When the bill arrived in the Senate, the Medicaid cuts passed by the House were a major sticking point for a handful of GOP senators, including Sens. Josh Hawley of Missouri, Lisa Murkowski of Alaska and Susan Collins of Maine . Though the Medicaid cuts in the Senate version are even more severe than in the House iteration, Hawley quickly said he would vote for them and Murkowski secured the addition of several provisions specific to Alaskans , though some were stripped out because they did not comply with parliamentary rules.

The largest spending cuts in the Senate version come from Medicaid, the popular government health insurance program that covers more than 70 million lower-income Americans .

The nonpartisan Congressional Budget Office said over the weekend that the Senate package is projected to add $3.3 trillion to the national deficit over the next decade and lead to nearly 12 million Americans losing health care coverage.

President Donald Trump wanted it all in “one, big, beautiful bill,” and Republicans are aiming to get it to the president ahead of the July 4 holiday. The package has now returned to the House, which must approve the same version of the legislation after passing a different version in May.

After more than 24 hours of deliberations, the U.S. Senate approved a sweeping package of tax cuts Tuesday that largely benefit the wealthy, financed by what advocates call “historic” cuts to government health insurance and nutrition programs that serve lower-income Americans.

Over the weekend, Sen. Thom Tillis of North Carolina said he opposed the bill over concerns about how the Medicaid cuts would impact his state; Trump promised to primary him and Tillis said instead he would not seek reelection. Republican Sen. Rand Paul of Kentucky voted against the package due to deficit concerns. Collins remained opposed, forcing Vice President JD Vance to cast the tie-breaking vote.

Democrats were largely on the sidelines because Republicans in the Senate used a process called reconciliation, which allows the majority party to bypass the 60-vote filibuster requirement and approve legislation by a simple majority vote. There are 53 Republicans in the 100-seat Senate.

It has become common for both parties to take advantage of reconciliation when they control the White House and both chambers of Congress. Republicans used reconciliation to enact the 2017 Trump tax cuts that they are now attempting to renew. Democrats used it to enact President Joe Biden’s COVID-19 stimulus bill and the Inflation Reduction Act.

Here are the programs serving women, children and LGBTQ+ Americans that the tax bill would change:

Medicaid

The Senate legislation would cut federal spending on Medicaid and the Children’s Health Insurance Program (CHIP) for low-income infants and children by more than $1 trillion over the next decade — an 18% larger cut than the House-approved version, according to Georgetown University’s McCourt School of Public Policy.

The federal-state Medicaid health insurance program covers more than 40% of all births in the country, and about 37% of those enrolled are children. Nationally, CHIP covers about 7 million children and several hundred thousand pregnant people.

READ MORE: A closer look at who relies on Medicaid

Like the legislation approved by the House, the Senate package would cut Medicaid spending in part by imposing a strict 80-hours-a-month work requirement for adults without children or disabilities — this change must be implemented by the end of 2026, after the midterm elections, but states have the option of doing it sooner. Three million Americans enrolled in Medicaid report that they are unable to work due to caregiving responsibilities, according to an AARP analysis. The 19th has reported on how these stepped-up work requirements would disproportionately impact middle-aged and older women.

The Senate bill would create new limits on Medicaid coverage for immigrants in the country legally. It would also require states to charge Medicaid recipients above the poverty line for co–payments for some health care.

A provision that would have prohibited Medicaid from covering gender-affirming care for transgender people — minors and adults — was stripped out by the Senate parliamentarian. But the Senate parliamentarian approved a provision that would prevent Planned Parenthood and other reproductive health care clinics from receiving Medicaid reimbursements for the provision of non-abortion care.

Some of the largest savings would come from the stepped-up work requirements and the reduction in the amount that states are able to tax Medicaid providers, impacting Medicaid expansions in as many as 22 states, according to KFF, a nonpartisan health policy organization.

The Senate legislation would also trigger the rollback of Medicaid expansions in some states that have passed laws that end the expansion if the federal government changes the federal-state funding formula.

SNAP

Like the package passed by House Republicans, the Senate version would require more SNAP recipients in their 50s and 60s to work and provide fewer exemptions for parents.

The proposal would lower the age at which work requirements end by a decade, to 54. Right now, parents with dependent children under 18 are exempt from working; the House bill lowered that age to 7 but the Senate version would only lower the age to 14.

WATCH: Provision in GOP budget bill puts millions at risk of losing SNAP benefits

Additionally, the Senate legislation would shift some SNAP costs to states — since its inception, SNAP benefits have been fully funded by the federal government.

Under the Senate’s SNAP proposal, the federal government would continue to fund SNAP for states that have a payment error rate below 6%, but starting in 2028, states with error rates above that would have to contribute 5% to 15% of the cost. Alaska and Hawaii would receive a temporary exemption from the cost-sharing requirement.

Changes to SNAP could also affect school nutrition programs, as many students qualify for free meals based on whether they and their families are eligible for food stamps.

Child tax credit

The Senate version would permanently increase the child tax credit to $2,200 from $2,000. The House tax bill approved in May would increase the amount of the child tax credit to $2,500, but only through 2028, the last year of Trump’s term. The tax credit would then drop back down and be indexed to inflation.

The Senate version tweaks a provision in the House-approved version that would require both of a child’s parents to have a Social Security number to access the credit, even if the child also has a Social Security number. The Senate version requires only one parent to have a Social Security number to claim the credit.

Both versions cap the refundable portion of the child tax credit, limiting the ability of the country’s lowest-income parents to access the credit.

President Donald Trump’s sweeping spending and tax cuts package returned to the House Wednesday, after the Senate narrowly passed a new version of the bill with steeper cuts to social safety-net programs like Medicaid.

Congressional Republicans argue an 18% reduction in Medicaid funding over the next decade is necessary to improve the stability of the program, which provides insurance for low-income households. But for health care providers — many of whom already face soaring drug and labor costs, staff shortages and insufficient reimbursement rates — the cuts leave a hole big enough to sink a community hospital.

“Every hospital is going to feel the effects of this,” said Nicole Stallings, CEO of the Hospital and Healthsystem Association of Pennsylvania (HAP), a statewide organization that represents 235 hospitals. “Services will be reduced, and some won’t be able to survive.”

More than half of the state’s hospitals are already operating in the red, according to HAP. About one-third of Pennsylvania hospitals have consistently posted losses in the last three years.

Stallings said that’s because Medicaid’s reimbursement to hospitals only amounts to 82 cents for each dollar of care the facility provides. In rural communities, where there are fewer patients, the reimbursement is just 74 cents on the dollar.

Under the Senate plan, Stallings said reimbursements could drop as low as 53 cents for every dollar of care provided.

“It’s not sustainable,” she said. “An already struggling hospital won’t be able to absorb a cut of this magnitude.”

Some Pittsburgh-area providers say the hit would come even as hospitals are still recovering from the financial damage of the COVID-19 pandemic.

Among the providers feeling the squeeze is the East Liberty Family Health Care Center, a federally qualified health center. FQHCs offer a range of primary-care services regardless of a patient’s ability to pay.

Arsenial Runion, CEO of the East Liberty center, said his staff of 100 were critical front-line health care workers during the pandemic, treating the underserved and uninsured during a time of strapped resources and soaring costs.

“Things have just now started to rebound a little bit,” he said. “And here comes another setback.”

About 30% of the 10,000 patients the center serves each year are on Medicaid, Runion said. Though the center receives other federal support, a large drop in Medicaid payments could leave a significant funding gap. He said it’s too early to say whether any of the center’s four clinics would close or if staff would be laid off, but those actions are under consideration.

“Everything is on the table,” he said. “I would say that’s the consensus for a lot of FQHCs.”

Two recent studies — one commissioned by Congressional Democrats and another by the Pennsylvania Health Access Network — found that if the cuts take effect, dozens of Pennsylvania hospitals could face a significant risk of closing or reducing services.

The Congressional evaluation listed five rural Pennsylvania hospitals, all on the western side of the state, as at-risk sites due to their volume of Medicaid patients or as a result of having posted three consecutive years of operating losses.

Four of the rural Pennsylvania hospitals listed in the congressional report are owned by UPMC: Jameson Hospital in New Castle, Northwest Hospital in Seneca, Kane Hospital in Kane, and Horizon Hospital in Greenville.

UPMC declined to answer financial questions about specific hospitals but acknowledged that rural and underserved communities will face a greater impact under Medicaid cuts.

“UPMC is closely following the proposed Medicaid changes, which could have a disproportionate impact on hospitals serving rural and other underserved communities,” a spokesperson said in a statement. “We remain committed to supporting access to essential care for all our patients across the communities we serve.”

A fifth hospital deemed at risk in the Congressional report is Highlands Hospital in Connellsville, Pa. Penn Highlands Healthcare, which owns the hospital, did not respond to a request for comment.

The Senate bill poses other financial challenges as well.

The nonpartisan Congressional Budget Office estimates that nearly 12 million people will lose health insurance if the Senate plan, and its $1 trillion in Medicaid cuts, becomes law. That would leave hospitals treating more uninsured patients, and not being reimbursed for the cost of care.

State officials estimate that the bill’s passage could mean roughly 500,000 Pennsylvanians would lose their coverage. And Gov. Josh Shapiro warned earlier this week that Harrisburg would not be able to make up for the federal funding losses.

Hospitals will also be impacted by a reduction in federal matching dollars that some states use to leverage their contributions to the Medicaid program.

Pennsylvania and other states levy a tax on Medicaid providers to help cover the cost of the program, and those revenues have been matched by the federal government. In Pennsylvania, the provider tax funds roughly 5% of the state’s Medicaid program, according to health research group the Hilltop Institute.

Pennsylvania’s tax rate is 5.9%, but the Senate bill would cap the tax nationwide at 3.5% by 2028. The change is estimated to save the federal government $183 billion, but it means less revenue for states.

The House version of the budget sought to freeze provider tax rates rather than lower them. Under the Senate plan, HAP estimates that Pennsylvania hospitals will see billions fewer dollars over the next 10 years.

In the Pittsburgh region, the tax-rate cut would mean a loss of $476.7 million to facilities in Congresswoman Summer Lee’s district, which includes the region’s flagship hospitals. Congressman Chris Deluzio’s district in Beaver County and Pittsburgh’s northern suburbs would see a $14 million revenue loss.

“Not only are there going to be more uninsured, but there’s going to be less money to go around to pay for the kinds of care that we need to provide,” said Patrick Keenan, policy director for the Pennsylvania Health Access Network.

And as hospitals are forced to operate with fewer resources, Keenan suggested that some hospitals may see doctors leave for bigger systems. He warns that could result in longer wait times for the providers who remain in rural areas.

At the same time, Runion said health care costs will be driven up as more patients rely on emergency rooms for care. Without insurance, he said patients will be reluctant to seek preventative care, delaying treatment until an issue becomes an emergency.

“Individuals are going to start flooding the emergency departments,” Runion said. “And a bill that may cost you less here could cost you a fortune there.”

Runion says the Senate bill’s passage would have broad and “devastating” effects. But, he said, “I’m committed as the leader of this organization to lay it all out on the field and do whatever I have to do to make sure that this operation continues to move forward.

“At the end of the day,” he added, “we are called to serve the people.”

Julia Zenkevich contributed to this report.

From higher grocery bills to fewer health care options, millions of everyday Texans could soon feel the ripple effects of President Donald Trump’s sweeping tax and spending proposal — known as the “Big, Beautiful Bill.”

Both John Cornyn and Ted Cruz, the state’s two Republican U.S. Senators, supported the bill as it narrowly cleared the U.S. Senate on Tuesday. It’s now being fast-tracked through Congress.

“This bill will do wonderful things for the 31 million people in my state,” Cornyn said.

The bill offers deep tax breaks for the wealthy while shifting significant costs onto states. For Texas, that could mean billions in new costs — or deep cuts to safety-net programs.

“At the end of the day, what the bill wants to do is to push a lot of the cost onto state governments,” said Brandon Rottinghaus, a political science professor at the University of Houston. “Texas is going to have to choose whether it wants to be as generous or less generous than it has been.”

Food aid on the chopping block

Among the most significant impacts of the bill for Texas families would be cuts to the Supplemental Nutrition Assistance Program, or SNAP. The federal food assistance program helps low-income households buy groceries. Texans received more than $7 billion in SNAP benefits in fiscal year 2024, according to the nonprofit Feeding Texas, an association of statewide food banks.

Historically funded by the federal government, SNAP could become a financial burden for Texas. The bill would require states with high payment error rates to cover a share of food assistance costs. Because Texas must balance its budget each year, lawmakers would need to raise taxes, cut other programs or reduce SNAP benefits statewide to absorb the potential cost.

“That, combined with the tightened eligibility rules, could potentially create a problem for people who are food insecure in Texas,” Rottinghaus said.

The bill also expands work requirements for SNAP recipients, raising the age limit for “able-bodied adults” from 52 to 64 and narrowing how states can waive those rules. Parents with children under 14 would be exempt.

With stricter eligibility rules and a lack of guaranteed funding, about 32,000 Texans could be pushed into poverty, according to the Urban Institute. These changes would take effect in 2028, if the bill is passed.

Medicaid faces deep cuts in federal funding

The proposal also targets Medicaid, the joint federal-state health insurance program that covers low-income children, pregnant women, people with disabilities and many elderly Texans. As of November 2024, more than 4 million Texans were enrolled, according to the latest state data.

Under the bill, federal Medicaid funding would drop sharply, with tighter eligibility rules and new work requirements aimed at cutting “waste, fraud, and abuse,” according to the Trump administration. Recipients would need to work 80 hours a month until age 65 to qualify, with exemptions for parents of children under 14 and people with disabilities.

The Congressional Budget Office’s latest cost estimate shows the bill would cut federal Medicaid spending by $1 trillion and leave nearly 12 million more people uninsured nationwide by 2034. An analysis by KFF projects Texas could lose up to $50 billion.

Rural hospitals face the greatest risk, according to Rottinghaus. Many operate on thin margins and depend heavily on Medicaid reimbursements. And many are already struggling to survive: A 2022 Kaufman Hall report found 26% of rural hospitals in Texas were at risk of closure, compared to 16% in 2020.

“The fact that the state is really struggling in rural areas to provide healthcare means that any kind of dramatic cuts to Medicaid could create some problems in staffing those institutions and delivering care,” he said.

The U.S. House of Representatives passed an earlier version of the bill in May, but changes made by the Senate now require House approval. Lawmakers are racing to finalize the deal before their self-imposed July 4 deadline, aiming to send it to Trump’s desk for final approval.

Daniel Payne reports on how the health industry and Washington influence and impact each other. He joined STAT in 2025 after covering health care at POLITICO. You can reach Daniel on Signal at danielp.100.

Chelsea Cirruzzo is a Washington correspondent at STAT, where she covers HHS. You can reach Chelsea on Signal at chelseacirruzzo.42.

John Wilkerson is a Washington correspondent for STAT who writes about the politics of health care. He is also the author of the twice-weekly D.C. Diagnosis newsletter .

This article was updated on July 3 with House passage of the bill.

WASHINGTON — House Republicans passed President Trump’s landmark tax bill Thursday, putting transformational health provisions on the cusp of enactment.

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The vote was 218-214, with two Republicans joining all Democrats in opposing the measure. Trump has said he will sign the legislation.

The Senate passed their version of the reconciliation bill on July 1, which differs from the version that passed the House on May 22. The Congressional Budget Office’s (CBO) latest cost estimate, which corresponds to the Senate Budget Committee’s version of the bill, shows that the bill would reduce federal Medicaid spending by $1 trillion and increase the number of uninsured people by 11.8 million. Building on prior KFF analysis of the House-passed reconciliation bill, this analysis allocates CBO’s federal spending reductions in the Senate reconciliation bill across the states. The Medicaid reconciliation provisions are numerous and complicated, but the majority of federal savings stem from work requirements for the expansion group, limiting states’ ability to raise the state share of Medicaid revenues through provider taxes, increasing barriers to enrolling in and renewing Medicaid coverage, and restricting state-directed payments to hospitals, nursing facilities, and other providers.

This analysis allocates the CBO’s estimated reduction in federal spending across states based on KFF’s state-level data and where possible, prior modeling work; and shows the federal spending reductions relative to KFF’s projections of federal spending by state under current law. KFF allocates the spending reductions provision-by-provision, pulling in a variety of data sources on which states are estimated to be most affected by each provision (see Methods). CBO has not yet provided estimates of the Senate-passed reconciliation bill, so KFF adjusted the prior CBO estimates by removing CBO’s estimated spending reductions for the three sections that were removed from the Senate Budget Committee bill by an amendment, which included a federal match rate penalty for states that have expanded coverage for immigrants, a prohibition on gender affirming care, and increased federal matching funds for Alaska and Hawaii. KFF did not include the $50 billion in funding for state grants through a Rural Health Transformation Program in the Senate-passed bill and did not account for other changes to the legislative language that were more complicated, including: appropriating new implementation funding for several provisions, retaining some elements of Biden-era regulations that had already taken effect, and applying new restrictions on provider taxes to local government taxes in expansion states.

CBO has not published updated estimates of the number of people who would lose Medicaid under the Senate’s reconciliation bill, so this analysis does not include updated enrollment estimates like those included in KFF’s analysis of the House-passed reconciliation bill. CBO’s most recent estimate of Medicaid enrollment loss from an earlier version of the House reconciliation bill was 10.3 million people in 2034, which was associated with a $625 billion decrease in Medicaid spending (reflecting preliminary estimates prepared for the House Committee on Energy and Commerce). Given the Medicaid spending reductions are considerably larger, more than 10.3 million people are likely to lose Medicaid from the Senate bill.

This analysis does not predict how states will respond to federal policy changes, and anticipating how states will respond to Medicaid changes is a major source of uncertainty in CBO’s cost estimates. Instead of making state-by-state predictions, CBO generates a national figure by estimating the percent of the affected population that lives in states with different anticipated types of policy responses. For example, different states might choose to implement a work requirement with reporting requirements that are easier or harder to comply with. In estimating the costs of the legislation, CBO assumes that in aggregate, states would replace half of reduced federal funds with their own resources in response to provisions that reduce the resources available to states, such as limits on provider taxes. For provisions that reduce enrollment but don’t affect the division of costs between the federal and state governments, such as work requirements, CBO estimates that the federal and state Medicaid spending would go down. However, those assumptions reflect states’ responses as a whole and are likely to vary and may not apply in all states.

To the extent that states’ responses are far different from the overall average response, changes in federal Medicaid spending will be larger or smaller than what is shown here. States could make further Medicaid cuts, which would result in spending reductions greater than is estimated here and further reduce states’ Medicaid spending. Alternatively, states could increase their spending on Medicaid to mitigate the effects of federal cuts, which could result in spending reductions that are smaller than is estimated here. This analysis illustrates the potential variation by showing a range of spending effects in each state, varying by plus or minus 25% from the CBO estimated midpoint.

Key Take-Aways

KFF estimates that the Senate reconciliation bill would reduce federal Medicaid spending by $1 trillion.

The five biggest sources of Medicaid savings in the Senate reconciliation bill sum to $896 billion in savings, which is 87% of the total, and include: Mandating that adults who are eligible for Medicaid through the ACA expansion meet work and reporting requirements ($326 billion), Repealing the Biden Administration’s rule simplifying Medicaid eligibility and renewal processes ($167 billion), Establishing a moratorium on new or increased provider taxes and reducing existing provider taxes in expansion states ($191 billion), Revising the payment limit for state directed payments ($149 billion), and Increasing the frequency of eligibility redeterminations for the ACA expansion group ($63 billion).