Bulwark Takes - 11: GOP FLIPS OUT As Trump’s Healthcare Cuts GUTTED

Episode Date: June 26, 2025

Jonathan Cohn joins Sam Stein to go inside the GOP’s latest healthcare debacle, after the Senate parliamentarian blocks up to $400 billion in Medicaid cuts. Can Republicans recover—or are they out of options?

Hey guys, me Sam Stein, managing editor of The Bullwork, and I'm joined by Jonathan Cohn, author of The Breakdown, and today, author of Morning Shots. Just the most prolific man in the business. Jonathan, thanks for doing this. We are talking a couple hours after a fairly major ruling from the Senate Parliamentarian with regards to President Trump's one big, beautiful bill. We're going to get into that. We're also going to be talking about the future stakes of that bill. But before we do subscribe to the feed, we appreciate it. All right, so Jonathan, let's just lay out what happened this morning.

Hard to sort of understand the larger ramifications, the immediate ramifications, though, strike me and I guess everyone else on the Hill as fairly consequential. Why don't you just tell the viewers what we're looking at? Yeah, we'll try to do this as simply as possible. So, yes, hold on. Let's warn the viewers. This is going to get really technical and boring. You might want to like, you know, take a sip of your coffee, up your energy levels a little bit, get the calcium Celsius,

whatever they're called. All right, go ahead. Okay. Headline is that somewhere between $250 and $400 billion in cuts to healthcare out of a bill that's going to, you know, that's like 25 to 40% of the total healthcare cuts in this bill that they're trying to pass just got ruled basically, there's rules for what you can and can't do in this kind of bill. And basically the person who decides those rules just said they're in violation. So Republicans have to scramble and figure out what to do about this whole now of $250 to $400 billion in cuts they want.

Slightly longer explanation. We're going to go slightly here, right? Desperate. So to get a bill through the Senate, nowadays, almost everything you need 60 votes, right, to overcome the filibuster. Not this one. To avoid that. Not this one. through the Senate. Nowadays, almost everything, you need 60 votes, right, to overcome the filibuster. Not this one. Not this one.

If you want to get around that, you can use this special procedure, this fast track privileged procedure that's called reconciliation. That's why everyone calls this the budget reconciliation bill. It's a procedure that's been around since the 70s. It was originally designed to make it easier for Congress to kind of adjust spending on the margins and taxes to kind of take account,

keep the budget balanced. It sort of got used in many different ways over the years. So they developed these rules to limit it. And they're very clear rules on what you can and well, I don't know if they're that clear, but there's very specific rules on what you can and can't. It has to be germane to the budget. The stuff that you're considering can't just be,

you know, I want to do massive climate policy. Or for instance, as Democrats tried, we want to raise the minimum wage to $15. Those will be ruled non-germane, and you can't do them in reconciliation. Now, who's the person who makes the ruling? Here's where we get interesting. Yeah. If it wasn't already interesting.

There's a position called the Senate Parliamentarian who is appointed on staggered, and this is definitely one of the things I wish I had gone back and looked because it's been years since I've had to get into the details of reconciliation. But I believe is appointed every couple couple years on staggered terms. The proletarian is basically like a lawyer, like a judge also, who sort of says, all right, this is my interpretation of the rules for reconciliation. You bring me a bill and then I tell you, yeah, this satisfies the rules. No, this does not. They call this if you may hear the phrase, bird bath.

And that's because Senator Robert Bird. Senator Robert Bird of West Virginia is the one who developed these rules because he was annoyed at the way people he thought that people the Senate was using reconciliation to do too much that wasn't really about the budget. So they're called the bird rules. You go through a bird bath and then it comes out the other side and your legislation sometimes, to use another phrase that they love to use upon capital, can look like Swiss cheese because this piece got taken out and that piece got taken out and now you got a different bill. Now, the parliamentarian has been doing this for a couple days now, taking out fairly modest

and then major pieces of the legislation. Why was this one this morning so significant compared to the others or was it? Well, it's definitely significant just based on the magnitude of the piece. Some of the other pieces that have come out and haven't come in. Some of them were expected and some were pretty small. So for example, there is a provision in the Republican bills that prohibit gender-affirming care, Medicaid from paying for any gender-affirming care.

I think most of us figured that was not going to get by. Yeah, there was one that was going to stop the ability of courts to issue nationwide injunctions. That had nothing to do with the budget. People were like, obviously it's kind of come out. No one was surprised when it did. There's barely a how.

The difference this morning is, I'm answering my own question, I suppose, but $200 to $400 billion of money that you now have to make up. This was for one of the bigger changes in Medicaid that they had put into the Senate version of the bill. They don't really feel like they have a lot of time here because they have the self-imposed deadline. First things first, talk about the provider tax, which is what this went after. What is the provider tax?

You really... I've already got one. I'm walking up. I'm walking up. Okay. I know. If we're gonna do this. Hold on. If we're gonna do this, we're gonna do this right.

We're going full. We're gonna do this right. That's right. Yeah. All right. So Medicaid, right? The big program, 80 million people, low income Americans. Federal government provides the majority of the money.

The rest states make up the rest. There's this complicated formula. There's different states get different matching formulas. Some time ago, states figured out there is a way, there's always this sort of tug of war, states want more money, federal government wants to give or not give more money, depending on who's in charge of the federal government. States figured out that the way the law was written, that there was basically a kind of gimmick they could do

where, try to sort of not get too in the weeds here, but basically they could charge a tax to their sort of healthcare providers in their state, so like their hospitals, and then pay them more so that the hospitals were basically held harmless and actually got more, and as a result of this, the state is able to draw more money down from the federal government. It's a gimmick. It's legal to be clear. It's not like illegal. I mean, it was all states do it except Alaska. That's right. That's right.

And some states depend on it more than others. Um, one of the reforms, one of the cuts in the Republican bills, both House and Senate, although there's a difference in the two of them, would basically clamp down on this and limit what states could do. There's a good government argument that, yes, you should do this, no, you shouldn't. That's a whole other conversation. But it's a lot of money for these states. Right.

And the end result, unless you figure out a way to replenish the Medicaid rolls from the feds to the states, is that there's just going to be less money from the feds going to the states for Medicaid, which means fewer people on Medicaid. All right, so big chunk rules non-Germane by the parliamentarian. The reaction on the Senate side has been a bit mixed. One is, okay, okay, we're going to rewrite this and we'll make it Germane. We can work with this or we'll have to work with this. We'll make it remain.

The other is we're going to have to look for other ways to make up this money with other Medicaid reforms. I'm going to come back to that in a second. The third is fuck the parliamentarian. We're going to overrule her and let's fire her. And I will say as of now, that last one doesn't appear to be gaining steam and the Senate Majority Leader John Thune has said he will not do it. I will also note there's precedent to do it.

People forget this because it's so long ago, but back during the Bush administration, Trent Lott, then the Majority Leader in a 50-50 Senate, relieved the parliamentarian of his duties because they issued some guidance on the Bush tax cuts that made it harder for them to pass. And so there is some precedent there, but it doesn't look like that's gonna be the case here. So let's go to option number two. Alternative ways to do this

if you aren't gonna go after the provider tax. What are they? So, first of all, let me just say, I am less convinced than you are that they're not going to overrule the parliamentarian. We'll see where this goes. I mean, didn't they just with the admissions rule

with California just a little while ago, they're willing to play. Yeah. Maybe I shouldn't be so convinced. I mean, I think they're saying that right now, I think with Trump championing the bid to get this done in this deadline, like that is the that is the path of that is the quickest way to get this done, because if they have to start reopening, finding money somewhere else, they're there. Yeah. I mean, so what else could they do? I mean, they could they could find other bigger

cuts in Medicaid. You may remember we were just a week ago, Ron Johnson from Wisconsin and Rick Scott from Florida, Rick Scott, great champion of government health care. Yes, profits from it. Yeah. How do you know that you know, we're happy, you know, they were talking about just a sort of much more straightforward reducing what the federal government pays for Medicaid. That would be a much bigger deal.

That would change this proposal in magnitude and what it does. As devastating as I think this could be, and we've talked about for people, it does not mess with the basic architecture of the Affordable Care Act or Medicaid expansion. It leaves the basic foundation is in place. And so this proposal would say is any state that expanded Medicaid off of Obamacare, which are many, there's a handful of Republican states that have not. We would basically take away a lot of that matching funds. You get the extra, you could no

longer get the extra matching funds or fewer. And a lot of states would have to automatically just get rid of expansion. I mean, it would immediately cause many states to... Would that qualify as a benefit reduction? I think so. I mean, I would call it. I mean, you know, you're reduced because, you know, people would lose coverage. I mean, absolutely.

And some states would. But let's be clear. In all these situations, people are going to lose coverage, whether it's through more paperwork or because you're messing with the provider tax. But they've been sort of rationalizing, or at least the Josh Hawes of the world have, by saying, well, these are like sort of technocratic changes. And what we're doing is we're making it more efficient. And this is not an actual benefit cut.

It's reform to Medicaid. But would cutting the actual federal matchdown qualify as a benefit cut its reform to Medicaid but would cutting the actual federal matchdown qualify as a benefit cut? I think so, right? I would say it's just coverage or coverage cut. I mean, just you know, people are going to lose them. Sure. All right.

So that's one option. I don't think that's going to pass the Senate. But who knows? I mean, I think that's a lot of red states that are going to lose. I mean, it's Hawley, North Carolina, Tillis, I mean, Tennessee, that I mean, it's Holly, North Carolina, Tilles, Tennessee, Kentucky and Ohio. I mean, you run down, there's a lot of states that really lose a lot from that. So probably not that.

But you know, I mean, there's not that many places to go. They've sort of maxed out. I mean, the whole game here, this whole bill, right, is to cut Medicaid, but package it as these efficiency abuse waste changes that don't look like cuts. And I think they kind of maxed out on what they can do that way. Right. So they got to figure out either how to convince the parliamentarian that the language they had around the fire taxes actually is germane or overrule the parliamentarian or maybe scale back somewhere, find cuts somewhere

else that's not Medicaid related or I don't know. I mean, there's two possibilities they could do if they wanted, right? So I mean, number one, and this got floated, remember a couple weeks ago, and it got shut down real quickly is Medicare Advantage. This is the private Medicare. Which is huge. Even lots of conservatives or Republicans say, there's basically a ton of corporate welfare baked into that system where insurers are just making huge profits. You can cut that. You're getting tons and tons of money because the government's subsidizing them for senior care basically.

Right, right. There is time. You could do the entire, you could get the full trillion dollars out of there if you really wanted to. And so they could go there Trump actually you know you know they've talked about it you know of course that's really that would be truly populist because you're going up against the insurance companies and that would be one way. That actually is a proposal that has democratic support now yeah

in a different context. Bernie Sanders will be there. Or Merkley I should say and they would do it but they would do it in a way the Democrats don't want which is to pay for tax cuts, but whatever. Okay. So that's one. Yes. That's one. And just, you know, just I just got, I know this is like a radical idea to throw out there, but they could not cut Medicaid so much.

You know, could let more people keep their health care as possible. I mean, they could, but they got to pass these tax cuts, man. They're already like, I mean, this is, they're already not paying for the tax cuts. They're already going to drive. See, this is where my familiarity with reconciliation is, I don't know, I admit I don't know. Do they have to have a certain amount of, you know, is there a level of deficit incursion that you suddenly do not qualify under the reconciliation rules. And I just don't know.

Yeah, I don't know either because the reconciliation resolution- They write the rules, yeah. They have certain instructions that they have to hit. So maybe there is some, again, I wish, you know, I'm not going to apologize for not knowing this. I'm not, there's a- These are the things you actually, when you call, this is the kind of question just for our viewers and listeners.

These are the kinds of questions where when people like Sam and I, we call up our sort of staff on Capitol Hill and ask them like, what is the deal? And you get like the chief of staff or you get the head health policy staffer and their answer is, I actually don't know. I need to ask one of our budget gurus. They go check the bigger nerds. All right, let's go to big picture for the close here, which is the timeline of this thing.

And you and I may be like screaming into the void on this one because it is so crazy to me. It is so crazy to me that even amidst all this, they're still chatting about a vote tomorrow. That we don't have a bill. We don't have final language, let alone a score of the bill or any analysis of what we do. We don't have a bill.

How can they vote tomorrow on this? And yet, the prevailing sentiment out there is that if not tomorrow, then it will be Saturday. And I can't fathom that self-respecting lawmakers would say, yeah, I'm comfortable doing that. It's crazy to me. But you and I both agree that we think that's probably what will happen. Well, I think you gave the answer there when you said you can't imagine self-respecting lawmakers.

These people have no respect for themselves. I'm convinced. I mean, this is so beyond the pale of responsibility. I mean, forget your policies. It really is. What is Congress there for? What are they doing up there? Wouldn't you want to know what you're about to vote on?

Like, I'm not even talking like three days. I know that's like the big metric. This is gonna be a day. Wouldn't you wanna have like an analysis of what might happen? Or at least some understanding of like what's in the bill? I don't know. Talk about the difference between this

and the Affordable Care Act. Cause people, that'll blow people's minds away. I know, I know. I just, I just. So Sam, you remember we were both there. They started writing the legislation for this in March, April of 2009. So Obama's in office like two, three months.

And this thing gets signed March, 2010. A year they spent on this bill. There were hundreds of hours of committee hearings. There were five different committees. They went through multiple drafts. They voted and there was lengthy floor debates. There were extensive CBO analysis every step of the way, a bazillion outside analysis.

I mean, this thing got exposed as much as legislation can. I mean, as you remember, this was an incredible source of frustration to the Obama White House. Rahm Emanuel, like every day that went past, he was like cursing the world because this thing wasn't done yet. Yeah. And they, you know...

It sucked up all the energy, all the oxygen. People forget that they spent months in bipartisan deliberations of this thing. I mean, bipartisan deliberations, hoping, praying that they could get a couple of Republican senators so they can hit the 60 vote threshold. It was a tedious, painstaking process. And then it looked like it was dead and they went through the whole thing all over again. It was just, it was wild to compare that to this. Yeah.

I mean, look, you can love it, you can hate it, you can think it's a mixed bag and you can think there were two, whatever you think about it. I mean, that's the way, you know There it was deliberated extensively in not just in private but in public everybody got to see what was there everyone got to judge it and I mean, that's the way you know for which makes sense for a law of that kind of you know Love magnitude is changes that it was going to usher into American society and this would be this is is not gonna be that magnitude

for healthcare specifically, but it will affect millions upon millions of people. Yeah, yeah, I mean, look, this is not full repeal. Like we were telling before, you know, leaves in place, this sort of big architecture, a lot of the changes it's making are sort of turning the dials on things. So, you know, we wouldn't expect it to have

as much attention, maybe as the Affordable Care Act or something equivalent, but surely half a quarter. We're like at point oh one percent. There's gonna be no debate on this. You know, why don't they just here's what they should do. They should just write a bill, put the title on and should be Donald Trump's tax and Medicaid bill. And it should be a one line bill. Whatever Donald Trump wants to do, he gets to do, period. Just vote on it. Why bother with the debate anymore?

That's crazy. Sorry. All right. Last, back then. So we brought, I think I know the answer, but we both, what's your certainty that they passed something this weekend on a scale of one to 10, 10 being completely certain? This weekend? This weekend. I don't know if I'm certain about this weekend on a scale of one to 10, 10 being completely certain. This weekend?

This weekend. I don't know if I'm certain about this weekend. Okay. I'll put myself at 50%. 50% this weekend. What's your certainty on them getting a bill to Trump's desk by July 4th, which is the goal, which means it passes the Senate and somehow passes the House. 75%.

I think they'll pass a bill. We got seven days or eight days. I think if you ask me, I think it passed a bill at some point in the next few weeks and like 99%. Although I think what's in the bill, what's in the bill, I think it is still very much, you know, I have to say all along, they're going to pass it because it's got tax cuts. You know, what else is in it is the question. Tax cuts and they got to deal with the debt limit at some point. Although, that is coming down the pike. All right, Cohn, I think we did pretty well there for about 15 to 18 minutes of wonkiness.

Yeah, I think it's still with us, hopefully. We'll find out when we look at the stats later today. All right, thank you, buddy. Appreciate it. Thank you guys for watching. Snipers of the Feed. Talk to you soon.