WASHINGTON — The U.S. Senate on Tuesday passed a sweeping Republican tax and spending bill that could reshape the nation’s healthcare landscape for years to come, narrowly approving the measure in a 51–50 vote with Vice President JD Vance casting the tiebreaker. Branded by former President Donald Trump as the “big, beautiful bill,” the legislation now heads to the House, where its path to final approval remains uncertain.
While the nearly $4 trillion package enshrines several of Trump’s top domestic priorities, including permanent extensions of the 2017 tax cuts and new tax relief for tipped income, overtime, and seniors, it also includes $1.1 trillion in healthcare cuts, with nearly $1 trillion targeting Medicaid, according to the nonpartisan Congressional Budget Office (CBO). The CBO estimates the legislation would result in 11.8 million Americans losing health insurance by 2034.
Republican leaders have touted the bill as a generational opportunity to reduce government waste and reinvigorate economic growth. Medicaid provisions, which include strict national work requirements and restrictions on state financing strategy, have sparked fierce debate within the GOP and drawn condemnation from Democrats, healthcare advocates, and others alike.
“We can’t be cutting health care for working people and for poor people in order to constantly give special tax treatment to corporations and other entities,” Senator Josh Hawley of Missouri said on Saturday. “If we’re going to be a working-class party, we’ve got to protect working people. The Medicaid stuff in here, I think is bad. We’ve delayed the worst of it; in the short term for my state, it’s going to be fine. But on a going-forward basis, we cannot go on like this.”
Some lawmakers were swayed by last-minute additions to the bill, including a $25 billion fund for rural hospitals intended to mitigate the impact of Medicaid reductions. Senator Lisa Murkowski (R-AK), a key holdout, secured Alaska-specific provisions before lending her support.
Yet other Republicans refused to back the legislation. Senators Thom Tillis (R-NC), Susan Collins (R-ME), and Rand Paul (R-KY) voted “no,” citing its healthcare impacts and deficit implications. Tillis, whose state stands to lose billions in Medicaid funding, warned, “What do I tell 663,000 people in two or three years when President Trump breaks his promise by pushing them off of Medicaid because the funding is no longer there?”
The bill also imposes new work requirements for the Supplemental Nutrition Assistance Program (SNAP) and shifts costs to some states, prompting concern among lawmakers representing low-income and rural districts. Representative David Valadao (R-CA), whose Central Valley district has high Medicaid enrollment, has signaled opposition, saying, “I will not support a final bill that eliminates vital funding streams our hospitals rely on.”
Democrats are already signaling that healthcare will be a central issue in the upcoming midterm elections. “The bill is the wrong answer for the American people,” said Democratic Senator Chuck Schumer of New York. “It’s not only a violation of how the Senate is supposed to work, it’s a violation of the promises that Republicans and Donald Trump, when they campaigned, made to the American people to look after their issues, not those at the very top.”
Despite intense intra-party negotiations and high-profile defections, Senate Republicans pushed the bill through under enormous pressure from Trump, who is going for a July 4 signing deadline. The House, where Republicans hold a narrow 220–212 majority, must now reconcile the Senate version with the earlier House-passed bill, a task that could prove difficult given objections from both fiscal conservatives and moderates.
If enacted, the bill would represent one of the most significant overhauls of U.S. healthcare policy in over a decade, rivaling the Affordable Care Act in scale, but moving in the opposite direction, with substantial implications for Medicaid, rural hospitals, and millions of low-income Americans.
