The Senate’s deficit hawks might be raising the loudest hue and cry over the GOP’s “big, beautiful bill.” But another group of Republicans is poised to have a bigger impact on the final legislative product.
The Power of ‘Medicaid Moderates’
Call them the “Medicaid moderates.”
They’re actually an ideologically diverse bunch — ranging from conservative Josh Hawley of Missouri to centrist Susan Collins of Maine. Yet they have found rare alignment over concerns about what the House-passed version of the GOP domestic-policy megabill does to the national safety-net health program, and they have the leverage to force significant changes in the Senate.
“I would hope that we would elect not to do anything that would endanger Medicaid benefits as a conference,” Hawley said in an interview. “I’ve made that clear to my leadership. I think others share that perspective.”
Besides Hawley and Collins, other GOP senators including Lisa Murkowski of Alaska, Jerry Moran of Kansas, and Jim Justice of West Virginia have also drawn public red lines over health care — and they have some rhetorical backing from President Donald Trump, who has urged congressional Republicans to spare the program as much as possible.
Based on early estimates from the nonpartisan Congressional Budget Office, 10.3 million people would lose coverage under Medicaid if the House-passed bill were to become law — many, if not most, in red states. That could spell trouble for Majority Leader John Thune’s whip count: He can only lose three GOP senators on the expected party-line vote and still have Vice President JD Vance break a tie.
Republicans already have one all-but-guaranteed opponent in Sen. Rand Paul of Kentucky so long as they stick to their plan to raise the debt limit as part of the bill. They also view Wisconsin Sen. Ron Johnson as increasingly likely to oppose the package after spending weeks blasting the bill on fiscal grounds.
Meeting either senator’s demands could be enormously difficult given the tight fiscal parameters through which House leaders have to squeeze the bill to advance it in their own chamber. That, in turn, is empowering the senators elsewhere in the GOP conference to make changes — and the Medicaid group is emerging as the key bloc to watch because of its size and its overlapping, relatively workable demands.
Heeding those asks won’t be easy. Republicans are counting on savings from Medicaid changes to offset hundreds of billions of dollars in tax cuts, and rolling that back is likely to create political pain elsewhere for Thune & Co., who already want to cut more than the House to assuage a sizable group of spending hawks. At the same time, Speaker Mike Johnson is insisting the Senate make only minor changes to the bill so as to maintain the delicate balance in his own narrowly divided chamber.
Thune and Finance Committee Chair Mike Crapo (R-Idaho) have already acknowledged that Medicaid, covering nearly 80 million low-income Americans, will be one of the biggest sticking points as they embark this month on a rewrite of the megabill. They are talking with key members in anticipation of difficult negotiations and being careful not to draw red lines publicly.
“We want to do things that are meaningful in terms of reforming programs, strengthening programs, without affecting beneficiaries,” Thune said, echoing language used by some of the concerned senators.
Crapo voiced support in an interview for one pillar of the House bill — broad new work requirements for Medicaid beneficiaries — but rushed to add that he’s “still working with a 53-member caucus to get answers” to how the program can be overhauled: “I can only speak for myself.”
Complicating their task is the fact that some in the group — namely Collins and Murkowski — have a proven history of bucking their party even amid intense public pressure. The pair, in fact, helped tank the GOP’s last party-line effort on health care in 2017.
Leaders view them as unlikely to be moved by the type of arm-twisting Republicans are planning to deploy to bring enough of the fiscal hawks on board. And then there’s Hawley, who is playing up Trump’s own warnings to congressional Republicans about keeping their hands off Medicaid.
Hawley and Trump spoke shortly before the House passed its bill, with the senator recounting that the president said “absolutely categorically, ‘Do not touch Medicaid. No Medicaid benefit cuts, none.’”
Hawley, like Crapo, has indicated he is comfortable with work requirements, but he is pushing for two major tweaks to the House language: undoing a freeze on provider taxes, which most states use to help finance their share of Medicaid costs, and new co-payment requirements for some beneficiaries that he has been calling a “sick tax.”
The provider tax changes would present an issue with multiple senators, who fear it would exacerbate the bill’s impact on state budgets and slash funding that helps keep rural hospitals afloat. Justice, a former governor, called it a “real issue.”
“They haven’t done anything to really cut into the bone except that one thing,” Justice added. ”That’s gonna put a big burden on the states.”
Moran grabbed the attention of his colleagues when he warned in a pointed April floor speech that making changes to Medicaid would hurt rural hospitals. A “significant portion” of his focus, he said, “is to make sure the hospitals have the capability and the revenues necessary to provide the services the community needs — Medicaid is a component of that.”
Collins, who is up for reelection in 2026, has also left the door open to supporting work requirements, depending on how they are crafted. She has also raised concerns about the provider tax provision, noting that “rural hospitals in my state and across the country are really teetering.”
Murkowski, meanwhile, isn’t as concerned about the provider tax because Alaska is the only state that doesn’t use it to help cover its share of Medicaid spending. But she has expressed alarm over the House’s approach to work requirements, including a decision to speed up the implementation deadline to appease House hard-liners. She said it would be “very challenging if not impossible” for her state to implement.
As it is, any effort to water down the House’s Medicaid language will face steep resistance in other corners of the GOP-controlled Senate, where lawmakers are pushing to amp up spending cuts, not scale them back. Some senators, in fact, want to further tighten the House’s work requirements or reduce, not just freeze, the provider tax.
“I’d be damned disappointed if a Republican majority with a Republican president didn’t make some reforms,” said Sen. Kevin Cramer (R-N.D.). “The provider tax is a money laundering machine. … If we don’t go after that, we’re not doing our jobs.”
Ron Johnson and a few others are continuing to push to change the cost split for those Medicaid beneficiaries made eligible under the Affordable Care Act. The federal government now picks up 90 percent of the cost, and House centrists nixed an effort by conservatives to reduce it.
One idea under discussion by conservatives is to phase in the change to appease skittish colleagues and state governments, but that is still likely to be a nonstarter for 50 GOP senators. Hawley warned that “there will be no Senate bill if that is on the table.”
Adam Cancryn contributed to this report.
