Saturday night into Sunday, the entire text of the bill was read in the chamber due to Democrat demands, followed by a 20-hour maximum debate period. At the end of that debate, members of both parties could offer proposed amendments and force floor votes. A final vote could come as soon as Monday, June 30. Senators hope their final bill will pass the House without changes in order to avoid a lengthy and contentious negotiations between both chambers and meet the GOP’s self-imposed deadline before the Fourth of July recess.
If passed, the bill—a draft text was released after midnight on Saturday—would slash many domestic programs that benefit poor and working-class people—in order to provide more than $4 trillion in tax breaks for billionaires, multimillionaires and wealthy corporations. Rural America would face deep cuts and economic damage due to reduced federal spending in Medicaid, food assistance, research, affordable housing, clean energy, local farm and food programs and other rural economic development initiatives. Even with the proposed spending cuts, the Republican reconciliation draft explodes the federal debt and deficit by trillions of dollars.
Public pressure and organizing are growing as people learn more about the GOP’s unpopular agenda. A recent Associated Press poll, for instance, found that a majority of Democrats, Republicans and Independents think that funding for Medicaid and the Supplemental Nutrition Assistance Program, or SNAP, is currently either “too little” or “about the right amount.” A recent Fox News poll found that about 60% of voters opposed the budget bill, with about half of respondents saying it would hurt their family.
The largest spending cut in the Senate reconciliation proposal is for Medicaid, with the Senate draft cutting the low-income health insurance program by approximately $1 trillion over the next decade according to the latest estimates from the independent Congressional Budget Office. Health care researchers estimate that between 11-16 million people currently on Medicaid would lose their health coverage if the bill passes the Senate and House.
Medicaid is a major source of revenue for many rural hospitals that are already struggling financially. Among other provisions, the Senate draft would cut the provider tax that states use to pay a large portion of their required Medicaid 10% cost-share. By charging providers like rural hospitals a tax and reimbursing them for that money through higher payments for their services, all states (except for Alaska) take advantage of this provider tax to boost the money they receive from the federal government from Medicaid. Another major provision would establish new strict national work requirements.
“Medicaid is a substantial source of federal funds in rural communities across the country. The proposed changes to Medicaid will result in significant coverage losses, reduce access to care for rural patients and threaten the viability of rural facilities,” said Alan Morgan, CEO of the National Rural Health Association (NRHA), in a June 23 statement on how the budget cuts would impact rural hospitals. “It’s very clear that Medicaid cuts will result in rural hospital closures resulting in loss of access to care for those living in rural America.”
The NRHA report, “Estimated Impact on Medicaid Enrollment and Hospital Expenditures in Rural Communities,” finds:
[O]n average, rural hospitals are slated to lose 21 cents out of every dollar they receive in Medicaid funding. Total cuts in Medicaid reimbursement for rural hospitals—including both federal and state funds—over the 10-year period covered by the bill would reach almost $70 billion for hospitals in rural areas. The Senate bill’s cuts to rural hospitals are more than 15% greater than the already highly damaging $60 billion in cuts under the House bill.
The draft bill now includes a $25 billion “rural hospital fund” to help win the votes of rural-state Senators concerned about rural hospital closures in their states. The provider tax change remains in the bill, though its implementation has been delayed by one year.
With respect to holdouts, Sen. Josh Hawley (R-Mo.), predictably, said he now supports the bill given the $25 billion rural hospital fund. Same with Sen. Susan Collins (R-Maine). Collins had initially called for a $100 billion rural fund, which Sen. Majority Leader John Thune (R-S.D.) rejected.
On Saturday, Tillis released a statement saying he’s a clear “no vote” on the bill because “it would result in tens of billions of dollars in lost funding for North Carolina, including our hospitals and rural communities.” President Trump exploded with rage at Tillis on his social media platform, saying he will be working to replace Tillis with a more MAGA Republican in the 2026 GOP primary election. (Tillis later announced he would not seek reelection.)
Last week, Democrats organized a “Save Our Hospitals Week of Action” highlighting the impact of proposed Medicaid cuts on local hospitals they represent. Democrats focused on rural hospitals include Rep. Bennie Thompson (D-Miss.—02) who toured Greenwood Leflore Hospital in Itta Bena, Ochsner Watkins Hospital in Quitman, Greenwood and Batesville to meet with local officials.
“I have several hospitals that are in bankruptcy. I have another hospital that’s about to close. I have three counties where there’s no hospital at all,” says Thompson, whose district includes the vast rural Mississippi Delta, during a rural health care tour press conference. “So, what some people in other parts of the country take for granted, here in Mississippi, we struggle.”
Advocacy group Protect Our Care also issued a report on the devastating impact the proposed Medicaid cuts on would have on rural hospitals, finding that hundreds of rural hospitals could either cut back on services or shut down altogether:
From 2010 to 2022, over 130 rural hospitals have closed. Since 2020 alone, 36 rural hospitals have closed, and as of 2024, over 700 rural hospitals were found to be at risk of closing in the near future, almost all of which were within non-Medicaid expansion states. In Medicaid expansion states, rural hospitals are 62 percent less likely to close, though Republicans are dead set on ripping expansion away from nearly 14 states and stopping 10 states from ever expanding. A 2025 analysis from the University of North Carolina at Chapel Hill found that over 338 rural hospitals are at particular risk of closure, conversion, or service reduction from substantial health care cuts because the hospitals either take a high relative share of Medicaid patients, or have experienced 3 years of negative total margins, or both. Republican cuts will force these hospitals to gravely cut back on services or close entirely, shutting entire communities off from health care.
A recent analysis by the American Hospital Association found that rural hospitals would lose $50.4 billion in federal Medicaid funding over the next decade if Republicans pass the current provisions in their budget bill.
In addition to the ongoing Medicaid negotiations, the Senate updated their reconciliation draft to comply with parliamentarian rulings. The Senate Agriculture Committee tweaked their SNAP cuts slightly, making some changes to proposed state cost-share payments based on error rates for the nation’s largest anti-hunger program. The updated GOP SNAP plan allows some flexibility in determining error rates and extends the timeline for enacting state cost-share mandates until 2028. The new plan also zeroes out state cost-share requirements for states with less than 6% error rates. Nearly $300 billion in SNAP cuts would likely remain in place, as would a more than $55-$67 billion increase in government payments to commodity rowcrop farmers. The Senate Environment and Public Works committee also made some changes, dropping their plan to sell off U.S. Forest Service and Bureau of Land Management public land and mandate drilling in the Arctic, at least for now. Public land selloff architect Senator Mike Lee (R-Utah) is already pursuing a scaled back plan that the Parliamentarian might allow.
In addition to the Medicaid holdouts in his GOP caucus, Thune is also facing pushback from fiscal hawks in the House and Senate who say the cuts are not deep enough, as well as Republicans opposed to clean energy cuts. The size and scope of the state and local tax (SALT) deductions are also an important factor for many Republicans, especially GOP House members whose districts are in Democratic states like New York and California. Blue state Republicans want to raise the SALT deduction from $10,000 to $40,000.
Another group of Republican Senators, Ron Johnson (R-Wis.), Rick Scott (R-Fla.), Cynthia Lummis (R-Wyo.) and Mike Lee (R-Utah), held out because they are “concerned” about the enormous increase in debt and deficit increases due to the bill. They are claiming to have voted to advance the bill to debate only and are not necessarily “yes votes” for the final bill. They plan to offer amendments to reduce the cost of the reconciliation bill, though they tend to focus on spending cuts rather than the $4.5 trillion increase due to tax cuts.
Senator Lisa Murkowski (R-Alaska) predictably voted in favor of advancing the bill due to some special giveaways to her state, including protections against SNAP cuts and an increased state share of revenue from drilling in the Arctic National Wildlife Refuge.
Lee pulled his controversial provision to sell of public lands, given five Western Republican House members saying they would not vote for the Senate bill in the House if the public lands selloff was included.
This “work-in-progress” legislative process means that things are still likely to change. Once the reconciliation package proceeds to the full Senate chamber, many amendments are likely to be debated and voted on.
In their effort to pass the legislation by July 4, Senate Republicans have openly defied the chamber’s rules.
Last week, the Senate parliamentarian ruled that several provisions, including the plan to limit the provider tax, violated Senate budget rules and was not eligible to avoid the 60-vote filibuster threshold on the Senate floor.
The Senate parliamentarian is an independent official appointed to enforce the chamber’s rules and precedent. To determine what is relevant and allowed under the specific budget rules, referred to as the “Byrd rule,” the Senate parliamentarian issues an opinion assessing budget relevance to specific provisions within proposed legislation.
While the special reconciliation process allows the GOP to bypass Democratic opposition in the Senate, thus avoiding the 60-vote filibuster threshold, it also comes with limitations for how the bill can affect the budget. For one thing, reconciliation bills cannot add to the deficit in the long term (after 2034 in this case), a rule that is enforced by the Senate parliamentarian. All Democrats are expected to vote against the budget bill. If more than three Republican Senators vote against the reconciliation bill, President Trump and Republican leaders would have to go back to the drawing board.
Bryce Oates writes The Cocklebur on Substack and is a Contributing Editor (Rural Community Organizing) at Barn Raiser. He writes about rural policy, people, places and politics. His work includes narrative nonfiction, opinion pieces and Q&A interviews. Bryce studies how the federal budget affects rural counties, farm and food policy, public lands and conservation issues, racial and gender equity in rural areas, climate change, economic inequality, rural demographic data and rural politics. A former farmer, rural economic developer and community organizer, he lives and works in Oregon’s Willamette Valley.
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