Summary
As Senate Republicans enter the second week of closed-door negotiations over the One Big Beautiful Bill (H.R. 1), the debate has sharpened with new Congressional Budget Office (CBO) projections highlighting the bill’s health care implications, and with pressure building from both moderates and budget hawks within the GOP.
The latest CBO estimate finds that if the House-passed reconciliation bill were enacted, 10.9 million more Americans would become uninsured. This is in addition to 5.1 million coverage losses already expected due to the expiration of enhanced ACA subsidies and changes in CMS’ proposed 2026 Marketplace rule.
Key CBO findings include:
- Medicaid Work Requirements: CBO projects that 5.2 million individuals would lose Medicaid coverage due to new work mandates, with 4.8 million becoming uninsured because they would not qualify for ACA subsidies or have access to employer coverage.
- Federal Match Reductions: Lowering federal Medicaid matching funds for states covering undocumented immigrants would lead to 1.4 million additional uninsured.
- Eligibility Redeterminations: Increased eligibility checks and the rollback of streamlined Medicaid enrollment processes would add another 1.3 million to the uninsured.
- Provider Tax Freeze: Changes limiting states’ ability to use provider taxes would result in 400,000 fewer insured.
- Marketplace and CSR Policy Changes: Reinstating cost-sharing reduction (CSR) payments but prohibiting them for plans covering elective abortion would end “silver loading” in most states, resulting in 300,000 more uninsured, disproportionately impacting individuals earning 200–400% of the federal poverty level.
- Additional Marketplace Rule Changes: Stricter verification requirements and restrictions on immigrant eligibility for ACA tax credits would cause an additional 2.3 million to lose coverage.
Amid calls from fiscal conservatives to achieve greater deficit reduction, Senate Republicans are reportedly considering further Medicaid cuts and potentially changes to Medicare, something Republican leadership and the Trump Administration has previously pledged was “off the table.”
Possible additional Medicaid policies include those elevated by the Paragon Health Institute, which urges the Senate to cap state-directed payments at Medicare rates (something the White House announced it plans to do), phase-out the provider tax in Medicaid expansion states (with exceptions for nursing homes and rural providers), and limit intergovernmental transfers to private provider rates.
Medicare policy changes are also reportedly being considered. Senate Majority Leader John Thune (R-SD) said he is open to discussing “anything that has to do with tackling waste fraud and abuse.” Notably, Senator Marshall (R-KS) said he sees Medicare Advantage (MA) insurers’ upcoding practices as fraud, raising questions about whether Cassidy’s (R-LA) and Merkley’s (D-OR) No UPCODE Act (S.1105) could be included. Despite the chatter, odds remain slim for substantial policy changes with such little room for error.
Majority Leader Thune has suggested that Senate committees will fully release the revised text of the reconciliation bill by the end of this week. Despite Senate Democrats’ demands for a formal markup, Republican leadership appears poised to bypass committees, limiting Democrats’ ability to challenge provisions until the vote-a-rama amendment process expected the week of June 23. The House would then need at least a week to pass the Senate’s bill given the 72-hour rule, meaning the July 4 deadline is technically doable, but very ambitious. The more pressing deadline remains the August “X-Date,” when the Treasury Department has warned that the federal government will exhaust cash reserves and extraordinary measures, requiring congressional action to raise the debt limit.
Meanwhile, the House is voting on the White House’s recission package (H.R. 4) and the Senate’s HALT Fentanyl Act (S. 331) this week.
Regulatory Update
The Office of Management and Budget is reviewing the following:
- Proposed CY 2026 payment updates for physicians, hospital outpatient departments and ambulatory surgical centers, home health agencies, and end-stage renal disease facilities. These proposed rules are typically published in June or July.
- A final rule titled, “Medicaid Eligibility Changes Under the Affordable Care Act of 2010; Giving States Freedom to Use Immigration Information to Determine State Residency for Medicaid Eligibility.” The rule is part of the Trump administration’s efforts to increase federal oversight on states using Federal Medicaid funding for the health care of undocumented immigrants.
- ACA Marketplace. A final rule with a series of proposals intended to address improper enrollments in Marketplace coverage and reduce improper federal spending on advanced premium tax credits (IHPP summary). If finalized as proposed, 750,000 to 2 million fewer individuals would enroll in Marketplace coverage in 2026.
- 340B Program. A notice titled, “340 Rebate Guidance.”