The fate of the GOP’s reconciliation bill may very well come down to Medicaid.
The Trump administration is pulling out all the stops to convince holdouts — those who want more cuts and those who want fewer — but as of Tuesday, just over two weeks out from the GOP’s July 4 deadline, Senate Republican leaders don’t appear to have the votes for a bill that doesn’t even fully exist yet.
“I’m a ‘no,’” said Sen. Ron Johnson, who opposes the bill over deficit concerns. “I’m a ‘no’ for next week, for sure.”
Sen. Josh Hawley, another critic of the bill but because the cuts go too far, skipped the Senate GOP’s lunch on Tuesday.
“I just couldn’t take any more harangues about cutting Medicaid. I’ve had enough for a lifetime,” Hawley told NOTUS.
Asked what he’d want to see change in the Medicaid portion of the bill, Hawley expressed strong opposition to the provider tax adjustment for the effect it might have on health care in rural states like Missouri.
“I would recommend not defunding rural hospitals in order to pay for ‘Green New Deal’ subsidies,” Hawley said. “That might be my first suggestion, just as a matter of basic priorities.”
Both Vice President JD Vance and Mehmet Oz, the Centers for Medicare and Medicaid Services administrator, attended the Senate GOP’s closed-door lunch on Tuesday to dig into the legislation, hoping to sway holdouts.
Sens. Susan Collins, Lisa Murkowski and Hawley, among others, continue to have concerns about Medicaid provisions. Sen. Rand Paul objects to the bill’s inclusion of the debt limit. Sens. Rick Scott, Mike Lee and Johnson have all voiced concerns about spending levels in the bill.
Prior to the lunch, Oz told NOTUS that “the bill is very, very strong.” And lunch attendees lauded Oz’s visit. Sen. Mike Rounds said Oz did a “very nice job on explaining the path forward.”
“There were questions on it, and there are opportunities to make some modifications,” Rounds said. “But there’s reasons why those modifications haven’t occurred yet.”
Meanwhile, Vance came out of the lunch optimistic. He insisted Republicans have “broad alignment” on the Medicaid changes in the bill and simply need to fine-tune the details. He also told reporters he met with Collins just a day prior.
“She’s got some concerns, and other folks have concerns,” Vance told reporters. “You just have to work through them. You have to identify what are the ways that we can address those concerns. If we can’t address that concern in your preferred way, is there another way that we can fix it? That’s just part of the legislative process.”
Vance added there were “certainly some conversations about timing” among senators, with the July 4 recess rapidly approaching.
“I mean, look, I can’t make any promises, obviously,” he said. “I can’t predict the future. But I do think that we’re in a good place to get this done by the July 4 recess.”
The fight over Medicaid comes down to a few provisions that would cut how much the federal government spends on the program.
One area the Senate bill hits harder than the House is the provider tax, which is a state-imposed fee on hospitals meant to help fund the state’s share of Medicaid.
Rather than freezing the current federal cap on state provider taxes, as the House did in its reconciliation bill, the Senate Finance Committee is proposing lowering the tax that states can levy on medical providers to 3.5%, effectively shrinking the amount states can use to fund their share of Medicaid programs.
This could cause problems for rural hospitals especially, as Hawley has alluded to, which rely on a large share of that funding — especially in high Medicaid-enrollment states. Some rural health systems may be unable to make ends meet if the state has less funding coming from provider-tax revenue.
But fiscal conservatives who want to see the government spending less view the provider tax as a way states game the system to get more money out of the federal government. If states can charge higher provider taxes, they argue, they’ll ask for more in Medicaid matching funds from the federal government.
“We are broke,” Scott, one such critic, told reporters. “We’re running $2 trillion deficits. The states are scamming the system. They’re using provider taxes to scam the system.”
There’s only a few days left to reconcile what the spending critics want with the demands of other senators who are deeply against any constraints on the provider tax. Senators are scheduled to leave town Wednesday evening, and when they return Monday, it’ll be their last legislative week before their self-imposed Fourth of July deadline.
Senate Majority Leader John Thune has already threatened to keep members in town through the July 4 recess, something most would like to avoid. Members have parades, events and district work they’d like to get to — especially given how intense this year’s congressional schedule has been thus far. The Senate in particular has been in town far more than previous years, with Thune keeping the chamber in for 10 weeks straight earlier this year.
Still, the bill’s critics still think it has time to change.
When asked by reporters Tuesday if she could vote for the bill in its current form, Murkowski dodged the question.
But that might not be a problem.
“I don’t think it’s going to stay in this form,” she said. “Let’s just put it that way.”
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Ursula Perano is a reporter at NOTUS. Helen Huiskes is a NOTUS reporter and an Allbritton Journalism Institute fellow.