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

Summary

Summary of "Bulwark Takes" Episode 11: "GOP FLIPS OUT As Trump’s Healthcare Cuts GUTTED"

Podcast Information:

• Title: Bulwark Takes
• Host/Authors: The Bulwark Team, including Sam Stein and Jonathan Cohn
• Release Date: June 26, 2025
• Description: Bulwark Takes brings you bite-sized takes on the news of the day from the entire Bulwark team, including Tim Miller, Sarah Longwell, and Bill Kristol, and more.

---

Introduction

In Episode 11 of Bulwark Takes, host Sam Stein is joined by political analyst Jonathan Cohn to discuss the immediate fallout from a significant Senate Parliamentarian ruling that has disrupted President Trump's ambitious healthcare reform bill. Released just a few hours after the ruling, the conversation provides a deep dive into the complexities of the budget reconciliation process, the specific healthcare cuts proposed, and the GOP's strategies in response.

The Senate Parliamentarian's Ruling and Its Immediate Impact

The episode kicks off with Sam Stein setting the stage about the recent major ruling by the Senate Parliamentarian that has thrown a wrench into Trump's healthcare plan.

Sam Stein [00:00]: "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."

Jonathan Cohn breaks down the essence of the ruling:

Jonathan Cohn [00:47]: "Somewhere between 250 and $400 billion in cuts to healthcare out of a bill that's gonna... 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."

This ruling means that a significant portion of the proposed healthcare cuts—constituting 25 to 40% of the total cuts—are now off the table, forcing Republicans to reassess their strategy to bridge a $250 to $400 billion funding gap.

Understanding the Budget Reconciliation Process

Cohn delves into the intricacies of the budget reconciliation process, a legislative procedure designed to expedite the passage of budget-related bills by circumventing the filibuster with a 60-vote threshold.

Jonathan Cohn [01:00]: "To get a bill through the Senate nowadays almost everything you need 60 votes. [...] It's a fast track privileged procedure that's called reconciliation."

He explains that reconciliation was originally intended to allow Congress to make adjustments to spending and taxes to maintain budgetary balance but is now being utilized for broader legislative changes, albeit under strict rules enforced by the Senate Parliamentarian.

The Role of the Senate Parliamentarian

Sam Stein introduces the critical role of the Senate Parliamentarian in ensuring that reconciliation bills comply with established rules.

Sam Stein [02:44]: "Now who's the person who makes the ruling?"

Jonathan Cohn [03:26]: "They're called the bird rules... you go through a bird bath and then it comes out the other side."

Named after Senator Robert Byrd, who established these stringent guidelines to prevent unrelated policy changes within reconciliation bills, the Parliamentarian’s ruling has now deemed substantial parts of Trump's healthcare cuts as non-germane, meaning they are outside the scope of the budgetary provisions and thus impermissible.

GOP's Immediate Reactions and Options

The GOP is now faced with three primary options to address the $250 to $400 billion shortfall caused by the Parliamentarian's ruling:

1. Rewrite the Bill to Make It Germane:

   • Adjust the language and provisions to fit within the budgetary constraints.

2. Seek Alternative Funding through Additional Medicaid Reforms:

   • Implement further cuts or changes to Medicaid to offset the deficit.

3. Attempt to Overrule the Parliamentarian:

   • Challenge or dismiss the Parliamentarian’s ruling, though this option faces historical resistance and low likelihood of success.

Sam Stein [04:12]: "The reaction on the Senate side has been a bit mixed... Or we'll have to work with this."

Cohn expresses skepticism about the GOP's willingness to overrule the Parliamentarian, citing historical precedents and the current political climate.

Jonathan Cohn [08:21]: "I am less convinced than you are that they're not going to overrule the parliamentarian... they are willing to do that."

The Provider Tax and Its Implications

A significant portion of the discussion centers around the "provider tax," a mechanism states use to generate additional federal Medicaid funds by taxing healthcare providers.

Jonathan Cohn [05:31]: "There's this complicated formula... they could charge a tax to their sort of health care providers in their state."

The Parliamentarian's ruling has targeted these provider taxes, deeming them non-germane, which means states can no longer utilize this method to bolster their Medicaid funding without violating reconciliation rules.

Sam Stein [06:59]: "Unless you figure out a way to like replenish the Medicaid rolls from the feds to the states, there's just going to be less money from the feds going to the states for Medicaid, which means fewer people on Medicaid."

Both hosts agree that this ruling effectively translates to significant reductions in Medicaid funding, leading to potential loss of coverage for millions of Americans.

Jonathan Cohn [10:22]: "People are going to lose insurance."

Alternative Strategies for the GOP

With the provider tax route closed, the GOP must explore other avenues to cover the budget shortfall:

1. Direct Cuts to Medicaid Federal Funding:

   • Reduce the federal government's contribution, forcing states to dial back Medicaid expansions.

2. Reforming Medicare Advantage:

   • Target the private insurance component of Medicare, potentially removing up to a trillion dollars in federal spending.

3. Scaling Back Medicaid Expansion Under the ACA:

   • Allow states to abandon Medicaid expansions, thereby reducing federal expenditures.

Jonathan Cohn [12:17]: "There is time. You could do the entire... you could get the full trillion dollars out of there if you really wanted to."

However, these options come with their own set of challenges and political pushback, especially reforms that directly reduce coverage and benefits for vulnerable populations.

Comparing to the Affordable Care Act (ACA) Passage

The hosts draw a stark contrast between the current GOP efforts and the meticulous, bipartisan process that led to the passage of the ACA.

Jonathan Cohn [16:54]: "That's the way it was deliberated extensively, not just in private, but in public."

They lament the rushed nature of the current legislative process, highlighting the lack of comprehensive debate, analysis, and transparency that characterized the ACA's development over months of committee hearings and public discourse.

Timeline and Prospects for Passage

Sam Stein expresses astonishment at the GOP's push to vote on the bill imminently despite its current state.

Sam Stein [14:03]: "We don't have a bill. How can they vote tomorrow on this?"

Jonathan Cohn acknowledges the chaotic approach but remains cautiously optimistic about the GOP's determination to pass the bill, primarily driven by the inclusion of tax cuts.

Jonathan Cohn [18:46]: "I think they'll pass it... What's in the bill, I think is still very much... tax cuts."

The duo discusses the slim likelihood of a fully polished bill reaching Trump's desk by the July 4th deadline, but they foresee eventual passage given the GOP's prioritization of tax legislation.

Conclusion

The episode concludes with a reflection on the high-stakes, fast-paced nature of the current legislative battle over healthcare, contrasting it with the deliberate and exhaustive process of past significant reforms like the ACA. Both hosts emphasize the potential widespread impact on millions of Americans' healthcare coverage and express concern over the GOP's strategies in navigating the budget reconciliation constraints.

Sam Stein [19:18]: "…We have about 15 to 18 minutes of wonkiness... Probably, we'll count on what it'll do."

---

This detailed summary encapsulates the key discussions, insights, and conclusions from the episode, providing a comprehensive overview for listeners who haven't tuned in.

Transcript

[Sam Stein]

Hey, guys. Me, Sam Stein, managing editor of the Bulwark. 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 is fairly consequential. Why don't you just tell the viewers what we're looking at?

[Jonathan Cohn]

Yeah, we'll try to do this as simply as possible. So, yes, hold on.

[Sam Stein]

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, get the calcium Celsius, whatever they're called. All right, go ahead.

[Jonathan Cohn]

Okay. Headline is that somewhere between 250 and $400 billion in cuts to healthcare out of a bill that's gonna, 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, do they, what to do about this 200, this hole now of $250 to $400 billion in cuts. They want slightly longer explanation. We're going to go slightly here. Right. Slightly desperate. So to get a bill 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. They developed these rules to limit it. And there are 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.

[Sam Stein]

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?

[Jonathan Cohn]

Ah, here's where we get interesting. Yeah, if it wasn't already interesting. There's a position called the Senate Parliamentari 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 years in staggered terms. The prolontero is basically a lawyer, like a judge almost, 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, yep, this satisfies the rules. No, this does not. They call this, if you may hear the phrase, bird bath.

[Sam Stein]

And that's because Senator Robert Byrd, Senator.

[Jonathan Cohn]

Robert Byrd 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 changes. Use another phrase that they love to use up on Capitol Hill. Can look like Swiss cheese because this piece got taken out and that piece got taken out and now you got a different bill.

[Sam Stein]

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.

[Jonathan Cohn]

Well, it's definitely significant just based on the magnitude of the piece. Some of the other pieces that have come out, Snapchat, you know, 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 bought.

[Sam Stein]

Yeah, there was one that was going to like stop the ability of courts to issue nationwide injunctions. Like that had nothing to do with the budget. And 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, $400 billion of money that you now have to make up. This was for the, one of the bigger changes in Medicaid that they had put into the Senate version of the bill. And 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?

[Jonathan Cohn]

You really.

[Sam Stein]

If we're gonna do this, we're gonna do this, we're gonna do this, right? We're going do this, right?

[Jonathan Cohn]

That's right.

[Sam Stein]

Yeah.

[Jonathan Cohn]

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 was 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 health care providers in their state, so like their hospitals, and then pay them more so that the hospitals were basically held, you know, harmless and actually got more. As a result of this, the state is able to draw more money down from the federal government. Gotcha. It's a gimmick. It's legal. To be clear. It's not like illegal. I mean, it was the.

[Sam Stein]

All states do it except Alaska.

[Jonathan Cohn]

That's right. That's right. And some states depend on it more than others. 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. You know, there's a good government argument that yes, you should do this, no you shouldn't. That's a whole other conversation. It's a lot of money for these states.

[Sam Stein]

Right. And the end result, unless you figure out a way to like 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 germane. 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 until the Senate Majority leader, John Th. 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 going to be the case here. So let's go to option number two, alternative ways to do this. If you aren't going to go after the provider tax, what are they?

[Jonathan Cohn]

So first of all, let me just say I, I, I am less convinced than you are that they're not going to overrule the parliamentarian. I, I, I, you know, we'll, we'll see where this goes. I, I mean, they didn't, they, I mean, they just, with the, with the, with the emissions rule, with California just a little while ago, they were, they're willing to do that.

[Sam Stein]

They did do that, yes.

[Jonathan Cohn]

Yeah, you're right. Okay.

[Sam Stein]

Maybe I shouldn't be so convinced.

[Jonathan Cohn]

I just, I mean, I just, I think they're saying that right now. I think with Trump, you know, 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, 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.

[Sam Stein]

Yes. When he profits from it. Yeah.

[Jonathan Cohn]

Had, 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. I just as that would be. That would change this, this proposal in magnitude in what it does. I mean, 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 that the basic, like the foundation is in place.

[Sam Stein]

And so their 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.

[Jonathan Cohn]

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.

[Sam Stein]

Would that qualify as a benefit reduction?

[Jonathan Cohn]

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.

[Sam Stein]

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 you know, what we're doing is we're making it more efficient. And this is not an actual benefit cut, its reform to Medicaid. But would, would, would cutting the actual federal match down qualify as a benefit cut? I think so. Right.

[Jonathan Cohn]

I, I would say it would or just it's just coverage or a coverage cut. I mean, just, you know, it's. People are going to lose insurance.

[Sam Stein]

All right, so that's one option. I don't think that's going to pass the Senate, but who knows?

[Jonathan Cohn]

I mean, I think that, I mean, it's Holly, North Carolina, Tillis, I mean Tennessee, Kentucky and Ohio. I mean, you run down. There's a lot of 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've kind of maxed out on what they can do that way. Right.

[Sam Stein]

So they got to figure out either how to convince the parliamentarian that the language they had around provider 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.

[Jonathan Cohn]

I mean, I mean, there's two possibilities they could do if they, you know, 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. Which is huge. Even, you know, lots of conservatives or in Pullmans say, you know, it's bait. There's basically a ton of corporate welfare baked into that system where insurers are.

[Sam Stein]

Just making huge profits, tons and tons of money because the government's subsidizing them for senior care, basically.

[Jonathan Cohn]

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, they've talked about it. Of course, that would be truly populous because you're going up against the insurance companies. But that would be one way that.

[Sam Stein]

Actually is a proposal that has Democratic support. Now, in a different context, Bernie will be there. Or Merkley, I should say. And they would do it, but they would do it in a way that Democrats don't want, which is to pay for tax cuts. Okay, so that's one.

[Jonathan Cohn]

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.

[Sam Stein]

I mean, they could, but they gotta pass these tax cuts, man.

[Jonathan Cohn]

They're already like, I mean, this is. They're already not paying for the tax cuts. They're already, you know, gonna drive what's.

[Sam Stein]

And 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.

[Jonathan Cohn]

Yeah, I don't know either, because the reconciliation resolutions, they write the rules.

[Sam Stein]

Yeah. They have certain instructions that they have to hit. So maybe there's some. Again, I wish, you know, I'm not going to apologize for not knowing this. I'm not. There's a more important.

[Jonathan Cohn]

These are 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.

[Sam Stein]

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. It's like 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.

[Jonathan Cohn]

Well, I think you gave away the answer there when you said, you can't imagine self respecting lawmakers. These people have no respect for themselves, I'm convinced. So beyond the pale of responsibility. I, I mean, forget your policy. This is not. What is Congress there for? What are they doing up there?

[Sam Stein]

Wouldn't you want to know, like, what you're about to vote on? Like, just, I mean, I'm not even talking like three days. I know, that's like the big metric. This is going to be a day. Wouldn't you want to 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 because people, that will blow people's minds away.

[Jonathan Cohn]

I know, I know. 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 analyses. 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.

[Sam Stein]

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 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.

[Jonathan Cohn]

Thing all over again.

[Sam Stein]

It was just, it was wild to compare that to this.

[Jonathan Cohn]

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 it was deliberated extensively, 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 which makes sense for a law of that kind of love. Magnitude changes that it was going to usher into American society.

[Sam Stein]

But this is not going to be that magnitude for health care specifically. But it will affect millions upon millions of people.

[Jonathan Cohn]

Yeah, yeah. I mean, look, this is not full repeal like we were saying 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, it's. We wouldn't expect it to have as much attention maybe as the Affordable Care act or something equivalent, but surely half a quarter, you know, we're like at 0.01%. 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 it 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. I mean, why bother with the debate anymore?

[Sam Stein]

That's crazy. Sorry. All right, last thing. So we both, I think I know the answer, but we both. What's your certainty that they pass something this weekend on a scale of 1 to 10, 10 being completely certain this weekend? This weekend?

[Jonathan Cohn]

I don't know if I'm certain about this weekend. Okay, how about myself at 50%? 50% this weekend?

[Sam Stein]

What's your certainty on them getting a bill to Trump's desk by July 4, which is the goal, which means it passes the Senate and somehow passes the house?

[Jonathan Cohn]

75%? I think they'll pass it.

[Sam Stein]

We got seven days or eight days.

[Jonathan Cohn]

I think, if you ask me. Are they gonna pass 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 is is still very much, you know, IOF said all along they're going to pass it because it's got tax cuts. You know, what else is in it? Is the question.

[Sam Stein]

Tax cuts. And they got to deal with the debt limit at some point, although. Oh, yeah, that thing that is coming down the pike. All right, Cohen, I think we did pretty well there for, you know, about 15 to 18 minutes of wonkiness.

[Jonathan Cohn]

Yeah. Is anyone still with us?

[Sam Stein]

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. Subscriber to the feed. Talk to you soon.