On May 22, the U.S. House of Representatives passed the One Big Beautiful Bill Act (H.R. 1), an extensive budget reconciliation package that advances President Trump’s plan to enact his economic agenda. After a series of ongoing negotiations with various factions within the Republican party, the bill passed narrowly by a 215-214-1 vote, with only Reps. Thomas Massie (R-KY) and Warren Davidson (R-OH) joining Democrats in opposition to the bill, and Rep. Andy Harris (R-MD) voting present.
Included in the highly anticipated bill was the House Energy and Commerce Committee’s title containing controversial health care-related provisions. The committee held a lengthy markup session on May 13 and 14. After nearly 27 hours of debate and consideration of dozens of amendments, the committee ultimately voted 30–24 along party lines to approve the package, including the health subtitle.
Among many other provisions, the health subtitle would impose work and community engagement requirements on Medicaid expansion populations, introduce copays at $35 for certain enrollees and reduce retroactive Medicaid and Children’s Health Insurance Program (CHIP) coverage from 90 days to 30 days. The bill would also enact limits on new provider taxes and state directed payments (SDPs), as well as a ban on Medicaid funding for gender transition therapies. It also includes notable reforms for pharmacy benefit managers (PBMs) and expands and clarifies the exclusion for orphan drugs under the drug price negotiation program.
The markup process revealed deep partisan divisions, particularly over proposed changes to Medicaid. Republicans, led by Chairman Brett Guthrie (R-KY), emphasized the need to rein in spending and prevent fraud by introducing work requirements, limiting retroactive coverage and restricting provider taxes. Republicans argued the reforms are necessary to protect Medicaid’s long-term viability and ensure resources reach the most vulnerable populations, pointing to protections and exceptions included in the bill’s work requirements provision. Democrats, led by Ranking Member Frank Pallone (D-NJ), denounced the legislation as a direct attack on low-income Americans. Democrats cited a report issued by the Congressional Budget Office (CBO) projecting that up to 13.7 million people could lose Medicaid coverage by 2034, warning of increased uncompensated care and strain on rural hospitals. Ultimately, Republicans rejected all amendments offered by Democrats.
The House Ways and Means Committee also adopted its section of the budget reconciliation bill on May 14 by a 26-19 vote. This section includes several significant health care provisions, featuring sweeping changes related to Health Reimbursement Arrangements (HRAs), Health Savings Accounts (HSAs), Medicare and Affordable Care Act (ACA) premium tax credits. The package also introduces structural reforms to Medicare and the ACA exchange. It expands eligibility for closed rural hospitals to reopen under the Rural Emergency Hospital (REH) designation and provides $25 million for the Department of Health and Human Services (HHS) to use artificial intelligence (AI) in identifying and recouping improper Medicare payments. Immigration-related restrictions are central to the bill’s health care provisions, eliminating Medicare and premium tax credit eligibility for undocumented immigrants and individuals with temporary immigration status. It also tightens ACA tax credit rules by requiring annual verification, eliminating special enrollment period access based on projected income, and removing caps on repayment of excess tax credits. Collectively, these provisions reflect a Republican strategy focused on limiting federal health spending, enforcing eligibility requirements and shifting coverage options toward market-based solutions.
During the markup, 38 Democratic-supported amendments were offered, but none were adopted. Notably, Rep. Steven Horsford (D-NV) offered an amendment to extend the enhanced Advanced Premium Tax Credits (eAPTCs) permanently, though the amendment failed. Reps. Terri Sewell (D-AL) and Lloyd Doggett (D-TX) also offered amendments to preserve the eAPTCs, though they too did not get approved.
All recommendations from the relevant House committees were ultimately combined and approved by the House Budget Committee after a weekend of continued negotiations. In a late night vote on Sunday, May 18, the committee voted 17-16 to advance the package, after four Republican holdouts—Reps. Ralph Norman (R-SC), Chip Roy (R-TX), Andrew Clyde (R-GA) and Josh Brecheen (R-OK)—who tanked the first vote on Friday, ultimately voted present.
The legislation then passed out of the House Rules Committee by an 8-4 vote on May 21 after more than 24 hours of debate. Several health care-related amendments impacting the House Energy and Commerce Committee subtitle were added. Notably, the committee approved: (1) moving the implementation date for biannual redeterminations of coverage for adults covered by Medicaid; (2) limiting retroactive coverage in Medicaid; and (3) requiring states to establish Medicaid work requirements by Dec. 31, 2026. The revised bill also moved to eliminate the discretion of future administrations to waive work requirements for various populations and ensure federal Medicaid does not fund gender transition therapies or procedures for minors or adults. Furthermore, it adjusted the limits on new SDPs, providing non-Medicaid expansion states with a cap of 110% of the Medicare rate for a given health care service, grandfathering in any existing SDPs above that rate in such states. Lastly, it inserted a new section to appropriate cost-sharing reduction payments (CSRs) for low-income beneficiaries in the individual market.
The Senate has yet to announce a formal schedule but is expected to take up the House-passed version in June. Final reconciliation between the House and Senate versions is anticipated later this summer, setting the stage for high-stakes negotiations, especially over Medicaid policy and federal spending priorities.
A full breakdown of the House-passed health care provisions under the jurisdictions of the Energy and Commerce and Ways and Means committees is linked here.
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