The Senate GOP's budget bill is even worse than the House version

It's not a continuation but a dangerous escalation of the assault on American health care.

By Jeff Nesbit

Republican leaders in Congress sure seem determined to cut taxes for the ultra-wealthy at the expense of Medicaid and Medicare, which will destroy health care for millions of Americans.

If you thought the House Republican assault on health care in the hideous reconciliation tax cut reconciliation package President Donald Trump demanded was bad, just wait until you see the Senate Republican plan. It’s worse, if that’s even possible.

Last week, the Senate Finance Committee’s Republican leadership unveiled legislative text that represents not a continuation but a dangerous escalation of the assault on American health care. It would make “Trump’s tax cuts” for those making more than $400,000 a year permanent at the expense of Medicaid, Medicare and food assistance.

Groups around the country are beginning to learn just how awful both the House and Senate versions of Trump’s “big, beautiful bill” really are for Medicaid and Medicare. In a letter to ranking Senate leaders, public health and policy researchers at Yale University and the University of Pennsylvania, for instance, warned that provisions in the House-passed federal budget reconciliation bill could lead to more than 51,000 deaths annually if enacted.

The Senate Republican version will take a wrecking ball to the Medicaid program and the Affordable Care Act across the country.

The text explicitly says that it’s designed to make Trump’s tax cuts for the ultra-wealthy permanent and makes clear that its primary funding mechanism is the dismantling of health security for millions of the nation's most vulnerable citizens.

“Senate Republicans (are seeking) deeper Medicaid cuts that slash provider payments, especially so for hospitals, and worsen cost shifts to states,” Democratic staff on the Senate Finance Committee wrote in an assessment of the new GOP text. “These cost shifts will force states to cut Medicaid benefits, like home-based care, mental health care, and school-based services, and K-12 education, nutrition, and public safety.”

Building on the House-passed bill, the Senate Republicans' vision is more severe, promising deeper cuts that would trigger devastating consequences for families, communities, and the nation's health infrastructure, Senate Democrats charged.

At its core, the proposal is an exercise in stark priorities. It seeks over $1 trillion in cuts to Medicaid and the Affordable Care Act (ACA). According to a Congressional Budget Office estimate, these historic cuts would directly result in 16 million Americans losing their health insurance.

This is not a peripheral consequence; it is a central feature of a plan that shifts resources away from public health and toward tax giveaways. There is only way to describe this: It’s a form of "class warfare" in which tax handouts for corporations and the wealthy are paid for by slashing Medicaid benefits and gutting ACA marketplaces.

The result is a future in which tens of millions of Americans face the impossible choice between their health and financial ruin, while rural hospitals and essential clinics are forced to close their doors.

The Senate bill deepens the already severe cuts proposed by the House, with a particular focus on Medicaid. It strategically targets states that expanded Medicaid under the ACA, effectively punishing them for providing coverage to low-income adults and families.

One key mechanism is the drastic reduction of the provider tax threshold from 6% to 3.5%. This seemingly technical change constitutes a major cut to hospital payments and shifts significant costs back to the states.

Similarly, the bill imposes new caps on Medicaid state-directed payments, tying them to a percentage of Medicare rates, which will further slash payments to hospitals and behavioral health providers.

Forced to absorb these new costs, states will inevitably have to cut essential services, including home-based care for seniors, mental health support, and even school-based health services for children.

The legislation also takes direct aim at specific populations and services. Senate Democrats, in a rebuttal of the GOP plans, calls this a "poorly veiled attempt" to defund Planned Parenthood because it lowers the federal funding threshold for certain family planning providers, threatening access to basic reproductive health care and cancer screenings for over two million Americans.

It further extends burdensome "work reporting" requirements to parents of older children, a policy known to cause eligible individuals to lose coverage because of the amount of red tape involved. The Senate GOP text also targets immigrant communities by reducing federal funds for emergency care for those ineligible for Medicaid because of their immigration status and restricting states from using their own funds to cover undocumented adults.

Beyond Medicaid, the Senate proposal retains the House's destabilizing policies for the ACA marketplaces. By imposing new enrollment and verification hurdles, the bill would make coverage harder to access, more expensive, and more difficult to keep for the millions of gig workers, small-business owners, and other Americans who rely on these plans.

According to a Kaiser Family Foundation analysis, over 90% of individuals in the ACA marketplaces depend on premium tax credits to afford their coverage. The Republican plan refuses to extend these credits, a decision that, combined with other administrative attacks, threatens to make state-based marketplaces fold and hasten the closure of more hospitals due to uncompensated care.

Also notable is what the Senate bill omits. While advancing the largest health care cuts in history, Senate Republicans chose to drop policies that had some bipartisan support. They abandoned reforms to pharmacy benefit managers, a policy to prevent a payment cliff for physicians, and funding for rural emergency hospitals.

Also discarded were policies to delay cuts to Medicaid disproportionate share hospital payments and a massive $41 billion expansion of health savings accounts that primarily benefit higher-income individuals.

Ultimately, the Senate Finance Committee's Republican proposal is a blueprint for a sicker, less secure America. It sacrifices the health of seniors, children, veterans, and working families to finance tax cuts for the wealthy.

By doubling down on the most harmful aspects of the House bill, Senate Republicans are charting a reckless course that will lead to millions of Americans losing coverage, skyrocketing costs, and the shuttering of essential health providers across the country. It is a stark vision of a nation that prioritizes the fortunes of a few over the foundational well-being of the many.

Jeff Nesbit was the assistant secretary for public affairs at HHS during the Biden administration.

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