House passes healthcare cuts in "One Big Beautiful Bill" by single vote

Congress created the budget reconciliationBudget ReconciliationA congressional process that allows spending and tax legislation to pass the Senate with 51 votes instead of the normal 60.Key ConceptBudget ReconciliationA congressional process that allows spending and tax legislation to pass the Senate with 51 votes instead of the normal 60.Open conceptBookmark process in the Congressional Budget and Impoundment Control Act of 1974, partly to reclaim legislative power from President Nixon, who had been refusing to spend money Congress appropriated. Reconciliation allows certain budget-related legislation to bypass the Senate filibuster and pass with a simple 51-vote majority, rather than the 60 votes required to end debate on regular bills.

Sen. Robert Byrd (D-WV) added his namesake Byrd RuleByrd RuleA Senate rule that bars non-budget provisions from being included in reconciliation bills, enforced by the Senate Parliamentarian.Key ConceptByrd RuleA Senate rule that bars non-budget provisions from being included in reconciliation bills, enforced by the Senate Parliamentarian.Open conceptBookmark in 1985, first as a temporary measure, then made permanent in 1990 as Section 313 of the Congressional Budget Act, after senators began stuffing reconciliation bills with controversial legislation unrelated to deficit reduction. Byrd warned the practice 'short-circuited the deliberative process' of the Senate. His rule allows any senator to raise a 60-vote point of order against provisions that don't produce a direct change in federal outlays or revenues.

House Republicans narrowly passed the One Big Beautiful Bill Act on May 22, 2025 by 215-to-214. The Senate passed an amended version 51-to-50 on July 1, 2025, with Vice President JD Vance casting the deciding vote. The House accepted Senate changes July 3, 2025 by 218-to-214, and Trump signed it into law on July 4, 2025 as Public Law 119-21. Not a single Democrat voted for the bill in either chamber.

MedicaidMedicaidA joint federal-state health insurance program covering more than 80 million low-income Americans.Key ConceptMedicaidA joint federal-state health insurance program covering more than 80 million low-income Americans.Open conceptBookmark was created on July 30, 1965, when President Lyndon B. Johnson signed the Social Security Amendments (H.R. 6675). Rep. Wilbur Mills (D-AR), chair of the House Ways and Means Committee, authored the bill, which passed the Senate 68-to-21. Johnson flew to Independence, Missouri to sign it at the Truman Presidential Library with former President Truman at his side, honoring Truman's 20-year push for national health insurance. In the program's first three years, nearly 20 million Americans enrolled.

Today MedicaidMedicaidA joint federal-state health insurance program covering more than 80 million low-income Americans.Key ConceptMedicaidA joint federal-state health insurance program covering more than 80 million low-income Americans.Open conceptBookmark covers approximately 90 million people, roughly one in four Americans, including 43 million children, 12 million elderly people, and 10 million people with disabilities. Congress tried to cut Medicaid through reconciliation three prior times. Reagan's 1981 Omnibus Budget Reconciliation Act restricted eligibility but didn't break the entitlement structure. Speaker Newt Gingrich's 1995 proposal to convert Medicaid to a block grant died when President Clinton vetoed it, triggering a 21-day government shutdown. The Senate's 2017 American Health Care Act failed when Sen. John McCain (R-AZ) cast the deciding no vote on July 28, 2017. The OBBBA is the largest statutory cut to Medicaid since the program's creation.

The 🏛️Congressional Budget Office's final score, published July 21, 2025, found the law adds approximately $3.4 trillion to the national debt over 10 years, pairing $863.4 billion in Medicaid and CHIP cuts with $295 billion in SNAP cuts to partially offset approximately $4 trillion in tax revenue foregone by making the 2017 Tax Cuts and Jobs ActTax Cuts and Jobs ActA 2017 federal law that lowered income tax rates for individuals and corporations, with most individual provisions written to expire after 2025 unless extended by a future Congress.Key ConceptTax Cuts and Jobs ActA 2017 federal law that lowered income tax rates for individuals and corporations, with most individual provisions written to expire after 2025 unless extended by a future Congress.Open conceptBookmark's expiring individual provisions permanent.

CBO projects 10.5 million people lose Medicaid or CHIP coverage by 2034 due to work requirementsWork requirementsRules requiring program recipients to work or participate in job training to receive benefitsKey ConceptWork requirementsRules requiring program recipients to work or participate in job training to receive benefitsOpen conceptBookmark, enrollment restrictions, and provider tax changes. Including ACA marketplace effects, total projected coverage loss rises to 11.8 million. An additional 5.1 million will lose coverage when enhanced marketplace premium tax credits expire at end of 2025. The law's work requirement applies to non-disabled adults ages 19 to 64 who aren't caregivers, requiring 80 hours per month of work, education, or community service to remain enrolled. Research from KFF finds 74% of non-disabled Medicaid adults already work; most who don't are caregivers, seasonal workers, or people with undiagnosed health conditions.

Arkansas was the first state to implement Medicaid work requirements in June 2018, after HHS approved a Section 1115 demonstration waiver. By January 2019, the state had disenrolled more than 18,000 people, mostly for failing to navigate the monthly online reporting system, not for failing to work. U.S. District Judge James Boasberg vacated the Arkansas program in Gresham v. Azar (March 27, 2019), ruling HHS had ignored Medicaid's core objective of providing coverage to the needy. The Biden administration withdrew all work requirement approvals in March 2021.

The OBBBA responds by codifying work requirements directly in the Social Security Act (42 U.S.C. § 1396a), rather than through administrative waivers. That shifts the legal basis away from the Administrative Procedure Act, the ground courts used to strike down prior requirements, though advocates argue constitutional and other statutory challenges remain viable.

Rural hospitals face a 21% projected decline in Medicaid reimbursement and 1.8 million rural Americans are projected to lose their Medicaid coverage by 2034. One in four rural residents relies on Medicaid, 28% more than in urban areas. The law creates a $50 billion Rural Health Transformation Fund over five years, but the National Rural Health Association projects the Medicaid cuts will reduce rural health spending by $155 billion over 10 years, a gap the fund can't fill, especially after FY2032 when the fund expires but the cuts are permanent.

The 2017 Tax Cuts and Jobs Act, passed December 20, 2017 by 224-to-201 in the House and 51-to-48 in the Senate, lowered the top marginal income tax rate from 39.6% to 37%, nearly doubled the standard deduction, and expanded the child tax credit. Most individual provisions were deliberately written to expire at end of 2025 to keep the 10-year cost estimate within the reconciliation budget window. Republicans openly intended to make them permanent before expiration. Without extension, approximately 62% of tax filers would have faced higher taxes in 2026. The OBBBA makes these provisions permanent, adds exclusions from taxable income for tips and overtime pay, and raises the estate tax exemption permanently to $15 million per individual ($30 million for couples).

The law cuts $295 billion from SNAP over 10 years and extends work requirements to adults up to age 64 (previously capped at 49). CBO projects average SNAP enrollment will fall by 4.7 million people annually. The law requires states to absorb a share of SNAP benefit costs for the first time in the program's history.

Commonwealth Fund researchers estimated the combined Medicaid and SNAP cuts would eliminate approximately 1.22 million jobs by 2029, equivalent to a 0.8-percentage-point rise in the U.S. unemployment rate. Nearly 500,000 of those jobs would be in health care. When the federal government cuts Medicaid payments to states, hospitals reduce staff, which reduces local consumer spending, which eliminates jobs across other economic sectors.

Two House Republicans voted no on final passage: Warren Davidson (R-OH) and Thomas Massie (R-KY), both citing insufficient fiscal restraint. Andy Harris (R-MD) voted present. In the Senate, Thom Tillis (R-NC) publicly warned that cutting Medicaid could cost Republicans the 2026 midterms. The American Hospital Association called the cuts 'devastating' and said many rural hospitals would face closure. Senate Parliamentarian Elizabeth MacDonough stripped several provisions during the Byrd Bath, including sections that would have barred HHS from implementing Biden-era Medicaid enrollment streamlining rules, ruling them extraneous to the budget process.

The law raises the federal debt ceiling by $4 trillion, from approximately $36 trillion to $40 trillion. The debt ceiling increase was bundled into the reconciliation bill to avoid a separate stand-alone vote. Sen. Rand Paul (R-KY) cited the debt ceiling increase as his primary objection to the bill.

The law creates 'Trump accounts,' tax-advantaged savings accounts for minors, with a $1,000 federal match per child born between 2024 and 2028, funded by up to $5,000 in annual parental contributions. It temporarily raises the child tax credit by $500 (to $2,500 per child through 2028) and the standard deduction by $1,000 for individuals and $2,000 for married couples filing jointly through 2028.