Illustration: Aïda Amer / Axios
Much of the attention in the newly passed House reconciliation bill has focused on the big-ticket Medicaid changes like work requirements — but less-discussed provisions could vastly complicate the package's prospects in the Senate.
The big picture: The Senate is generally assumed to be a moderating force on the extent of Medicaid cuts, but some conservatives in that chamber, including Ron Johnson, are pushing for deeper spending cuts.
A few of the lesser-known changes:
1. Defunding Planned Parenthood. The measure would cut off Medicaid funding to the reproductive health group, a long-sought Republican goal.
- Past standalone measures aimed at that have been highly controversial, but the provision has received less scrutiny tucked in a giant tax-and-spending package.
- That could change in the Senate, where moderate Republicans Susan Collins and Lisa Murkowski support abortion rights and could raise roadblocks.
2. Cost-sharing in Medicaid. The bill is projected to cause 7.6 million Medicaid enrollees to lose health coverage. But others will keep coverage while having to pay more.
- The measure requires new cost-sharing, such as copays, for Medicaid enrollees making more than the federal poverty level, capped at $35 per service.
- Sen. Josh Hawley said on CNN last week that that provision is a "hidden tax on working poor people." He could emerge as a prominent player in the Senate debate on cuts to the safety net program.
3. ACA marketplace changes. The manager's amendment unveiled late Wednesday night added a major move: funding the ACA's cost-sharing reduction payments.
- That will have the effect of decreasing the subsidies that help people afford marketplace premiums (by lowering the benchmark silver plan premiums used to set the subsidy amounts).
- Other consequential ACA changes were already in the bill, such as preventing some groups of legal immigrants from getting subsidies and restricting automatic reenrollment in ACA plans.
- Whether Senate Republicans will seek changes to these measures isn't yet clear. One lawmaker to watch is Thom Tillis, who faces reelection next year and is open to renewing the enhanced ACA subsidies expiring this year.
What's next: The Senate could take a few weeks to work on the measure, with the Fourth of July as a possible deadline — or whenever hitting the debt limit gets close enough.
