What to watch as the House takes up the One Big Beautiful Bill

Modern Healthcare – Wednesday, July 2, 2025
By Michael McAuliff

Now it’s the House’s turn to take another crack at President Donald Trump’s tax-and-spending-cuts package after the Senate narrowly advanced the legislation Tuesday.

Although the House approved an earlier version of the One Big Beautiful Bill Act of 2025 by a single vote in May, the Senate made significant changes, including deeper Medicaid cuts, that require the lower chamber to reconsider the measure.

The House Rules Committee, which prepares legislation for floor debate, acted swiftly to take up the Senate-passed bill Tuesday with an eye toward a vote as soon as Wednesday, as Trump continues to push for final action by Friday.

Some of the revisions that emerged from the Senate — where Vice President JD Vance needed to cast a tiebreaking vote — threaten to upend the delicate balance House Speaker Mike Johnson (R-La.) struck between two GOP camps in May.

Far-right Republicans wanted steeper spending reductions while other GOP lawmakers expressed concern about its $1 trillion in healthcare cuts, the lion’s share of which would come from Medicaid. There are also internal GOP disputes over other matters, such as the legislation’s effects on the budget, state and local tax deductions, and green energy tax credits.

“This bill is President Trump’s agenda, and we are making it law. House Republicans are ready to finish the job and put the One Big Beautiful Bill on President Trump’s desk in time for Independence Day,” Johnson and other House Republican leaders said in a news release Tuesday.

The Senate-passed bill would cause 11.8 million people to become uninsured, compared with 10.9 million under the House measure, according to the nonpartisan Congressional Budget Office.

The healthcare sector opposes the legislation virtually uniformly.

These are the major healthcare policies that could jeopardize the July 4 deadline and force Trump and the GOP-led Congress to make further amendments to the One Big Beautiful Bill.

Medicaid cuts

Perhaps foremost among Johnson’s challenges is soothing swing district lawmakers who were already concerned about the roughly $800 billion in Medicaid cuts the House OK’d. The Senate version would cut the program by at least $940 billion over 10 years, according to a CBO analysis issued Sunday that doesn’t include last-minute changes to the bill.

Sixteen House Republicans wrote Senate Majority Leader John Thune (R-S.D.) last week urging him to pull back on the Medicaid cuts.

“Protecting Medicaid is essential for the vulnerable constituents we were elected to represent,” Rep. David Valadao (R-Calif.) and colleagues wrote. “We cannot support a final bill that threatens access to coverage or jeopardizes the stability of our hospitals and providers.”

A key objection is that the Senate went further than the House in curtailing provider taxes states use to help cover their Medicaid expenses and trigger higher federal funding along with limits to state-directed payments they employ to dictate provider reimbursements to Medicaid managed care companies.

While the House bill would tighten the rules around those policies, the measure merely would freeze provider taxes and bar states from creating new ones. The Senate legislation would force states to reduce the taxes so they represent no more than 3.5% of a provider’s net patient revenue, down from the 6% cap currently in place.

“We’re going to debate it, and see which way it goes,” House Energy and Commerce Committee Chair Brett Guthrie (R-Ky.) said during the Rules Committee session Tuesday.

The federal budget

A group of more conservative Republicans are upset about the Senate bill’s ramifications for the budget. The lower chamber’s measure would add about $2.4 trillion to the national debt, compared with $3.3 trillion under the upper chamber’s legislation.

Rep. Ralph Norman (R-S.C.), who sits on the Rules Committee and belongs to the conservative Freedom Caucus, declared he opposed the Senate bill after supporting the House version.

“What the Senate did is unconscionable. What they did to our bill was unconscionable,” Norman said Tuesday. “I will vote against it here. I will vote against it on the floor,” he said.

Rep. Chip Roy (R-Texas), another hardliner on the Rules Committee and a Freedom Caucus member, made a similar vow. “My colleagues in the Senate failed us,” he said Tuesday.

Johnson can only afford to lose a handful of GOP lawmakers. In May, the bill passed 215 – 214, with Rep. Dr. Andy Harris (R-Md.), who chairs the Freedom Caucus, voting “present” and Rep. Andrew Garbarino (R-N.Y.), who signed the Valadao letter, missing the vote.

Johnson relied on Trump to push the bill over the line, and likely will need to again.

Process concerns and other issues

While the budget and Medicaid are the top issues dividing House Republicans, several other matters could drive opposition.

For example, while the House rolled back green energy policies and tax breaks, the Senate cut even deeper, and some members in conservative states that benefit from billions of dollars in green energy investment have raised objections.

Process could also be a stumbling point.

Roy highlighted how little anyone understood the Senate bill, which was being modified almost until it passed. He asked Guthrie and other committee chairs testifying before the Rules Committee whether they’d read the new measure before arriving to explain it. All of them said they had not finished.

Several House Republicans were caught unaware by provisions in their own bill, and could insist they have time to assess the latest version.

Republicans were expected to meet Tuesday and Wednesday to work out a path forward. If too many find the Senate’s work unpalatable, they would have to amend it, which would require it to go back to the Senate, instead of the president.

Norman predicted the House would rework it, and make it more like the House-passed bill.

Sen. Lisa Murkowski (R-Alaska), whose support after securing funding for rural healthcare providers was decisive, said she wanted the House to give the Senate another go.

“My hope is that the House is going to look at this and recognize that we’re not there yet,” Murkowski said Tuesday. “I would hope that we would be able to actually do what we used to do around here, which is work back and forth between the two bodies to get a measure that’s going to be better for the people in this country.”

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