House Mega-Budget Bill Moves Forward, Amid Conflict and Confusion

The fate of the Medicaid program remains hanging in the balance, as a massive 2026 federal budget bill careens wildly through the U.S. Congress, with unprecedented developments and legislative maneuvers that have made it difficult for political analysts to predict exactly what the bill, being pushed forward by House Republicans via the reconciliation process, will ultimately look like.

Very late on Sunday night, May 18, House Republicans pushed the budget bill—named the “One Big Beautiful Bill Act,” in deference to President Donald Trump, who has been referring to it as such—out of the Budget Committee along strict party lines, after it had failed in a Budget Committee vote on Friday evening, May 16, because of opposition from hardline right-wing Republicans in the House Freedom Caucus, who insisted that the projected $625 billion in cuts to federal support for the Medicaid program were not enough, even as that level of cuts could cause at least 8.6 million Medicaid recipients to be dumped from the program, according to the Congressional Budget Office (CBO), with some advocacy groups estimating that number to be even higher. There is also disagreement inside the House Republican caucus as to the final provision for work requirements under the program.

With regard to the enormous uncertainty surrounding the bill, The Hill’s Mychael Schnell and Mike Lillis reported early on Tuesday morning, May 20, that “the unfinished nature of the Trump agenda bill was on full display Monday morning, when House GOP leadership staff briefed reporters on the current state of play — the main takeaway of which was that ‘nothing is final until it’s final.’ Asked about the SALT deduction cap, Medicaid work requirements and repealing green energy incentives Democrats enacted in 2022, staffers demurred, underscoring that virtually every one of the hot-button issues have not been completely adjudicated.” And they quoted House Speaker Mike Johnson (R.-La.) as stating that “We’re going to have a lot of discussion among the conference over the next 48 hours” in order to try to achieve some level of consensus inside the House Republican caucus.

They wrote that “The Speaker did, to be sure, see some success late Sunday night, when the House Budget Committee advanced the bill following Friday’s failed vote. But the move only came after a quartet of spending hawks agreed to vote “present” to allow the legislation to move forward in the process — making a point not to vote “yes” as they push for more changes.

Indeed, Schnell and Lillis noted that “Some [hardline conservative House Republicans] were visibly frustrated that the discussions over the weekend didn’t bear more fruit, making clear that their decision to allow the bill to move through the Budget panel was no indication that they’re ready to back it the next time it comes up for a vote. ‘We made progress this weekend, but … we didn’t get nearly far enough,’ Rep. Chip Roy (R-Texas) told reporters late Sunday night. The group — including several members of the conservative House Freedom Caucus — are asking for an accelerated start date to the beefed-up Medicaid work requirements in the bill, in addition to an expedited rollback of several green energy tax credits that Democrats enacted in 2022.”

In the midst of the swirl of activity, President Trump on Tuesday met with the House Republican caucus on Capitol Hill; what he said was self-contradicting in terms of actual policy outcomes. As the New York Times’s Catie Edmondson wrote at midday on Tuesday, “ Mr. Trump insisted that the bill would not cut any benefits, telling reporters on Capitol Hill: ‘We are not doing any cutting of anything meaningful. The only thing we’re cutting is waste, fraud and abuse. With Medicaid: waste, fraud and abuse.’ That statement was not likely to sit well with the fiscal conservatives who are withholding their support for the legislation because they argue it does not make meaningful enough changes to Medicaid to substantially bring down its costs and rein in deficits. The legislation, as currently written, is predicted to result in at least 8.6 million Americans becoming uninsured, according to the Congressional Budget Office. But Republican leaders omitted two of the most aggressive options they had considered to cut Medicaid, bowing to Mr. Trump’s stated opposition and to more moderate Republicans, mostly from politically competitive districts, who said they could not accept such reductions.”

Uncertainty over the content of the bill

One challenge for the House Democrats opposing the Medicaid cuts and work requirements that Republicans are seeking is that large parts of the bill remain in flux, as the bill was pushed out of the Budget Committee with absolutely no committee hearings, in a breach of normal congressional protocol (though President Donald Trump’s first-term 2017 budget was passed in the same way, with zero committee hearings).

As the New York Times’s Catie Edmondson wrote late on Sunday night after the bill had passed out of the Budget Committee (it next goes to the House Rules Committee), “The four Republicans on the panel voted against the legislation the first time the budget panel met, protesting the timeline for the work requirements for Medicaid recipients — which the bill would not impose until 2029, after the next presidential election — and the provisions targeting the clean energy tax credits in the Inflation Reduction Act, which the measure would partially but not completely repeal. Work requirements are broadly popular among congressional Republicans, and even those who have balked at other cuts to Medicaid have said they could support such requirements. Mr. Johnson told reporters outside the hearing room minutes before the vote on Sunday night that he had agreed to move up work requirements for Medicaid recipients ‘as soon as possible,’” Edmondson reported.

“I think the desire of every Republican always has been to make work requirements real and actionable as soon as possible,” Johnson said. “We learned in the process that some of the states would needed a longer lag time to add in the implementation of the new policy. So we’re going to push it as far as we can.”

And, Edmondson reported, Chip Roy (R.-Tex.), one of the Freedom Caucus members who had initially voted against the bill on Friday evening but then switched his vote to “present” on Sunday night in order to allow the bill to move forward, “in his statement also suggested he wanted Republicans to reconsider proposals to cut Medicaid spending that party leaders had previously ruled out at the behest of more moderate members. One would limit the way states use a tax loophole to increase federal spending on Medicaid. Big chunks of those savings would come from reducing Medicaid spending in poorer, Southern states. The other would change the way Medicaid is financed. The federal government currently gives less money to richer states that can better support Medicaid with their own tax dollars. And it gives all states an exceptionally generous matching rate for anyone who signs up through the Obamacare Medicaid expansion,” she reported. And she quoted Roy as calling that a “perverse funding structure” that ultimately “increases the likelihood of continuing deficits,” and of states that have yet to expand Medicaid, like Texas, doing so in the future.

Key provisions of the budget bill remain in flux, even as it has passed out of the Budget Committee and into the Rules Committee, something that historically, would never have been allowed, especially for such sweeping and impactful legislation. On Monday, May 19, POLITICO’s Ben Leonard and Meredith Lee Hill reported that “Conservatives are still pushing for controversial changes to the federal share of Medicaid payments, which could lead to major benefit cuts, but House Republican leadership, moderates and the White House are all still resisting that effort, according to two Republicans granted anonymity to describe the private talks. Medicaid work requirements, though, are expected to be phased in two years, addressing the hard-liners’ push to speed up the previously planned 2029 implementation. The draft bill, however, includes multiple waivers of those provisions that states can pursue, and those waivers are not expected to substantially change, the Republicans said.”

Further, Leonard and Hill wrote, “Hard-liners also secured a rough agreement from the speaker over the weekend to speed up the phase-out of clean energy tax credits enacted under former President Joe Biden, though the parameters of how quickly that happens are still a major fight inside the GOP conference. One of the biggest battles is over whether so-called shovel-ready projects will be hit, as hard-liners are pushing for.”

As Healthcare Innovation has been reporting, the healthcare provider community has expressed solid opposition to the proposed massive Medicaid cuts, with association leaders predicting not only profound financial distress for physician groups, hospitals, and health systems, but also the inability of many physicians to take on Medicaid patients as a result.

Congress-watchers and policy experts agree that the legislative process taking place right now is nearly unprecedented, making it that much more difficult to predict specific policy outcomes.

This is a developing story. Healthcare Innovation will update readers on emerging developments.