With Vice President breaking the tie, the U.S. Senate just voted 50-50 “One Big Beautiful Bill Act”, the crown jewel of President Trump’s legislative agenda. With final text not even available to assess, and presumably not even read by the 50 Senators who voted for it, three Republican Senators voted no (Paul (KY), Collins (ME), and Tillis (NC)). We presume that the OBBB as passed cuts Medicaid by approximately $1 trillion – the largest cut in history to Medicaid and the biggest rollback to health care coverage in history.
One of those Republicans, Senator Thom Tillis (R-NC) took the floor to speak truth to power on what the OBBBA would do to Medicaid and shortly thereafter announced his retirement from politics. His words are:
Now Republicans are about to make a mistake on healthcare and betraying a promise. It is inescapable that this bill, in its current form, will betray the very promise that Donald J. Trump made in the Oval Office or in the Cabinet room when I was there with [the Senate Finance Committee], where he said: We can go after waste, fraud, and abuse on any programs.
Now those amateurs who are advising him—not Dr. Oz; I am talking about White House healthcare experts—refuse to tell him that those instructions that were to eliminate waste, fraud, and abuse all of a sudden eliminates a government program that is called the provider tax.
***
Over the course of the evening, I may look for an opportunity to speak again, but I am telling the President that you have been misinformed. Your supporting the Senate mark will hurt people who are eligible and qualified for Medicaid.
It’s almost unheard of for a Senator to draw a line in the sand against the top legislative priority of the President of their own party over Medicaid policy. Yet that is exactly what has happened, and for the right reason. As our colleague Edwin Park explains, the bill’s provisions relating to provider taxes and state directed payments will severely disrupt the ability of the 40 states that have taken up Medicaid expansion to finance their programs, resulting in large coverage losses and deep payment cuts to hospitals and other providers. Senator Tillis explained how he came to this conclusion:
Here is how I figured out the impact in North Carolina: I used to be speaker of the house. And I like the speaker and have a good relationship with the speaker and the President pro tempore, so I called them up. I had my staff ask them if they would do an impact assessment on what this proposed bill would do to the Medicaid Program in North Carolina.
But I didn’t want just the view of the Republican partisan staff that report to the speaker and the President pro tempore on how they are going to absorb this bill. I decided to go to Josh Stein, the Governor. I went to his Democrat staff for Medicaid. I asked them to prepare an estimate, independent of the estimate that I had done with fiscal research.
But I took it a step further. I went to the hospital association. I asked three different independent groups—a partisan Democrat group, a partisan Republican group of experts, and a nonpartisan group of the hospital association to develop an impact assessment, independent—not talking, not sharing, reporting to me. What I found is the best-case scenario is about a $26 billion cut. Now, we have got a delay, so it may be 2 years; it may be 1 year. All it does is make that $26 billion happen in year 1 or year 12. But the impact is the same, and it is indisputable.
Now, when I actually presented this report, that you can find on my website, I had people in the administration say: You are all wet. You don’t know what you are doing.
*** But after three different attempts for them to discredit our estimates, the day before yesterday, they admitted that we were right; that between the State-directed payments and the cuts scheduled in this bill, there is a reduction of State-directed payments, and then there is the reduction of the provider tax. They can’t find a hole in my estimate.
So, what they told me is that, yes, it is rough, but North Carolina has used the system; they are going to have to make it work. All right. So, what do I tell 663,000 people in 2 years or 3 years when President Trump breaks his promise by pushing them off of Medicaid because the funding is not there anymore, guys?
To be clear, Senator Tillis was not objecting to the OBBB overall, or even to Medicaid cuts. His political profile is one of “arch-conservative.” He supports the highly, highly problematic House-passed version, which KFF projected would cut federal Medicaid payments to North Carolina by $23 billion, or 11% over the next 10 years and cause 200,000 North Carolinians to become uninsured due to the loss of Medicaid coverage:
I love the work requirement. I love the other reforms in this bill. They are necessary, and I appreciate the leadership of the House for putting it in there. In fact, I like the work of the House so much that I wouldn’t be having to do this speech if we simply started with the House mark.
What’s so remarkable about this is that the Senator and his staff did their Medicaid homework (Medicaid matters!). They analyzed the version of the OBBBA posted by the Senate Finance Committee on June 16 to understand the implications for Medicaid enrollees and providers in North Carolina. Based on that analysis, the Senator decided that the version of the bill that reached the floor, with more than $1 trillion in Medicaid cuts, wouldn’t work for his constituents. As Senator Tillis emphasized:
…we owe it to the States to do the work to understand how these proposals affect them. How hard is that? I did it. How hard is it? How hard is it to sit down and ask the Medicaid office, ask the legislative staff, ask the independent hospital association what the impact is? If there is no negative impact, what is wrong with daylight? What is wrong with actually understanding what this bill does?
Good question. The OBBB will now go back to the House. Last week more than a dozen House moderates sent a letter saying that the Senate Medicaid cuts are too high. Rep. Don Bacon (R-NE) has announced his retirement and has expressed concerns about the Senate Medicaid cuts as well. Will enough House Members put the needs of their constituents at the top of their priority list? We shall soon find out.