Deals blows

Senate rulekeeper deals blows to revised ‘big, beautiful bill’

A Medicaid carveout for Alaska was among the “Byrd bath” casualties.

By Katherine Tully-McManus

The Senate’s rewritten domestic policy bill faces new hurdles after the parliamentarian advised senators Sunday that several provisions violate the chamber’s strict rules for budget reconciliation bills.

The rulings, released in a memo from Democrats on the Senate Budget Committee, come as Senate Republicans are still trying to ensure they have the votes for final passage of their signature legislation.

Two provisions added to the bill just days ago — and tailored specifically to boost Medicaid payments to Alaska and Hawaii — have been ruled to violate the Senate’s Byrd rule. That limits what can pass through the reconciliation process with a simple majority.

GOP leaders had hoped the Medicaid provisions focused on non-contiguous states, along with other Alaska-friendly changes, would be enough to win the vote of Sen. Lisa Murkowski (R-Alaska). She had voiced concerns over deep cuts to Medicaid and the Supplemental Nutrition Assistance Program (SNAP).

Murkowski voted to move forward with the bill Saturday night after making committee chairs and leadership sweat.

Elsewhere, Senate Republicans attempted to expand a Medicare drug-price negotiation exemption for “orphan” drugs to include medicines that treat multiple rare diseases. But the parliamentarian ruled it is not in compliance with rules and could threaten the ability to pass the megabill with a simple majority. The orphan drug provision was in the House-passed bill, but was not included in the first Senate Finance Committee’s proposal earlier this month.

The parliamentarian also ruled against provisions that sought to block implementation of two Biden-era regulations that seek to make it easier for older adults and individuals with disabilities to enroll in Medicaid and maintain coverage.

Also flagged by the parliamentarian was a provision that would prohibit implementation of a Biden Administration rule on nursing facility staffing, which was estimated to reduce federal Medicaid spending by $23 billion over 10 years.

“We have been successful in removing parts of this bill that hurt families and workers, but the process is not over, and Democrats are continuing to make the case against every provision in this Big, Beautiful Betrayal of a bill that violates Senate rules,” Ranking Member Jeff Merkley (D-Ore.) said in a statement.

The latest rulings also delivered some good news for Senate Republicans: A handful of provisions they tweaked to try to get them in compliance with the rules were green lit.

The Senate Republican proposal to delay planned cuts to provider taxes that fund state obligations to Medicaid survived the so-called “Byrd bath” and will not be subject to a supermajority vote. The changes would still incrementally lower the allowable provider tax in Medicaid expansion states from 6 percent down to 3.5 percent. But the drawdown would begin in 2028, one year later than planned.

A proposal to bar Medicare coverage for non-citizen immigrants was also deemed to be within the rules. It would remove the ability of refugees, asylum seekers, and people with temporary protected status from being able to enroll in Medicare.

Similarly, provisions specifying that non-citizens cannot qualify for tax credits and cost-sharing reductions to purchase health insurance through Affordable Care Act marketplaces were also ruled to be compliant with the rules.

Still under review by the parliamentarian is a provision that would bar Planned Parenthood from receiving federal Medicaid funds.