An insulting offer for a rural hospital fund is panned by Senate Republican holdouts.??? But the leadership is betting they'll give in soon enough.??? ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????

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Republicans Propose Fixing 1.5 Percent of Their Rural Hospital
Problem

An insulting offer for a rural hospital fund is panned by Senate Republican holdouts. But the leadership is betting they'll give in soon enough.

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Gene J. Puskar/AP Photo

By David Dayen

**Welcome to "Trump's Beautiful Disaster," a pop-up newsletter about the Republican tax and spending bill, one of the most consequential pieces of legislation in a generation.****Sign up for the newsletter** [link removed]

**to get it in your in-box.**

The desperation from the Republican leadership on the Big Beautiful Bill would be funny if I thought it would stick. The bill is clearly not ready for the Senate floor, with numerous Republicans saying they would not vote [link removed] to advance it. Yet Majority Leader John Thune (R-SD) is sticking to his
original plan of passing the bill this week, a bill that remains invisible, without final text, without CBO scores (which are critical for compliance with budget rules), without fixes to some of the items ruled not germane to a reconciliation bill, and without adjudication on many of the other items, including most of the all-important Senate Finance Committee language that covers taxes and Medicaid.

About Medicaid...

The more severe cuts in the Senate Finance version, especially restrictions on the Medicaid provider tax that would leave many states unable to afford the program, have really set off several Republicans, especially those in rural states who know that their hospitals will not survive [link removed] the carnage. This is probably now the biggest sticking point in the bill.

There were rumors of a rural hospital fund, to shore up those facilities most at
risk of closure. Then yesterday Senate Republicans made their offer: a $15 billion fund [link removed].

It's an unbelievably insulting number. The House Medicaid title cut about $907 billion, and with the added weight of the provider tax the number is more than $1 trillion. So this is less than 1.5 percent of the proposed cut. Sen. Thom Tillis (R-NC) estimated $38 billion in losses in his home state of North Carolina alone; that's nearly triple the total fund.

Keep in mind that Tillis's loss figures just come from the provider tax, not the work requirements and increased co-pays and other Medicaid changes in the bill, which will have the effect of 11 million fewer people on the rolls, at least. Republicans have tried to pinpoint just the expanded provider tax as the problem, not the destruction of Medicaid contemplated in the bill that goes well beyond that. And
this rural hospital fund doesn't even come close to dealing with the compartmentalized pain, let alone all of it.

This isn't even a Band-Aid on a gaping wound, it's a torn edge of a paper towel.

Sen. Susan Collins (R-ME) said she wanted a $100 billion fund, even while admitting that "I don't think that solves the entire problem." Collins has also floated a tax on people making over $100 million [link removed] to pay for it, and somehow I don't think a tax that would fall on Trump's cabinet is going to fly. But the fact that wild tax plans that have already been rejected are being tossed out at this late stage shows how unsettled this bill really is.

There's also talk of delaying the implementation of the ratcheting down of provider taxes, which currently begins in 2027. This merely delays rather than prevents the executioner's knife. But every dollar placed into
this fund, or every dollar lost due to delay, is a dollar that House and Senate deficit hawks don't want to see expended at all. Sen. Rick Scott (R-FL) is still pitching cutting the federal share for state Medicaid expansions from the Affordable Care Act, something that would only exacerbate the problems at the state level.

[link removed]

It's an impossible situation, yet one where Thune wants his caucus to take a leap of faith anyway. The consensus among the bill's supporters is to react to concerns over blowing a giant crater in the health system with, approximately, fuck 'em. "I know a lot of us are hearing from people back home about Medicaid. But they'll get over it," said the barely ambulatory former Senate leader Mitch McConnell (R-KY) in a closed-door meeting, according to reports.

This all makes it a gut check for Republican Senators. Several of them,
contra McConnell, are saying behind closed doors and even in public [link removed] that they won't advance the bill over the weekend as scheduled [link removed] without definitive answers to their concerns, or that they just want everything to slow down [link removed]. But clearly the Senate leadership doesn't believe them. They don't think anyone in the Republican Party has the guts to defy President Trump and vote down his agenda, even if temporarily. So they can settle that question by actually voting with their convictions, or cowering once again, bought off by some nonsense like a deficit commission
[link removed] (oh really, we're doing this again?).

I'll believe in the convictions when I see them.

More Parliamentarian Nixes

The parliamentarian ruled on the Health, Education, Labor, and Pensions part of the bill, which mostly includes the awful student loan changes [link removed]. The big one is that current borrowers will not be forced into the more expensive repayment options envisioned in the bill, stopping them from paying hundreds of dollars more per month. In addition, students in medical residencies will still qualify for Public Service Loan Forgiveness; and so-called "silver loading" (which is very complicated) will remain allowable, preventing a large potential spike in Affordable Care Act premiums for a certain group of people.

The repeal of
two rules, which allowed students to get loans canceled more easily if these schools defrauded them or if they close, is still under review by the parliamentarian.

All of the parliamentarian changes may have blown a $300 billion hole [link removed] in the bill, according to one senator, money that they don't have lying around in an easy-to-pass substitute. And that was before these changes.

[link removed]

Over in the House

Medicaid is not the only holdup. You have the SALT deduction cap, clean energy tax credits, a public land sale that was taken out by the parliamentarian [link removed] but may come back
[link removed] in some other form, and the controversial state AI regulatory ban, which survived the parliamentarian but which many Republicans don't like.

I've gone through all of these in this newsletter at one point or another. But here's a guy with a bigger list [link removed], and he has a vote in the House: Rep. Chip Roy (R-TX). His figures say that the Senate bill costs $1 trillion more than a House version that was already a $3.3 trillion operation. And his bill of particulars is much longer. He wants SALT expansion rolled back and clean energy tax credits phased out more quickly, yes; but he wants to tax remittances, and a bigger endowment tax (the Senate cut the top rate to 8 percent, down from the House's 21 percent; other Freedom Caucus members
have said this is a dealbreaker [link removed]), and maintain larger SNAP cuts, and close a tax break for cigarette companies, and expand health savings accounts.

The question, as ever, is "What are you going to do about it?" The fact that there had to be a headline reading "Chip Roy says he means it this time [link removed]" tells you everything you need to know about the expectation that he and everyone else will fall in line, again. The boastful talk is back ("I can vote no as many times as it takes and for as long as it takes, to do something actually big and beautiful," Roy told Politico [link removed]), but until it actually happens, these claims are simply not credible.

Timeline

As of Wednesday night, we were
still waiting on several rulings from the Senate parliamentarian, including the most important one, the current policy baseline [link removed]. Thune would give Senators less than 48 hours or less to read what will be a massive bill and vote to advance it, if he sticks to his original goal to start voting on Friday and carry it through the weekend.

We want to hear from you. If you're a Hill staffer, policymaker, or subject-matter expert with something to say about the Big Beautiful Bill, or if there's something in the legislation you want us to report about, write us at info(at)prospect.org.

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