Upcoming Markups

House Republicans continue to work within their caucus to coalesce around specific deficit reduction policies that can be included in their budget reconciliation bill. Several committees marked up their budget reconciliation pieces the week of April 28, but House leadership has had to delay planned consideration of other reconciliation markups until the week of May 12.

The reconciliation markup for the House Energy and Commerce (E&C) Committee, where cuts and changes to Medicaid will occur, has been pushed to the week of May 12, as has the reconciliation markup for the House Agriculture Committee, where the Supplemental Nutrition Assistance Program (SNAP) cuts are being considered. These bills were expected to be marked up the week of May 5 but pressure to protect these safety net programs caused delay. The markup delays demonstrate effective efforts of advocacy to educate members of congress on the detrimental effects cuts to Medicaid and SNAP would have in their districts. When it occurs, the Energy and Commerce mark up will also include a reversal of the nursing home minimum staffing requirements.

The House Ways and Means Committee will also markup its portion of the reconciliation package, focused on extending the 2017 tax cuts during the week of May 12, perhaps on the same day as the Agriculture and E&C markups.

After all the committees’ pieces are put into one piece of legislation (popularly termed a “big, beautiful bill”) by the House Budget Committee, followed by the House Rules Committee’s final review, the full House could vote on its reconciliation bill the week before Memorial Day recess–if Republican leadership stick to their projected timelines.

LeadingAge Advocacy on Key Budget Reconciliation Issues

LeadingAge has been advocating since the fall of 2024 to protect Medicaid from cuts and to achieve other priorities in reconciliation, including reversing the Center for Medicare and Medicaid Services’ (CMS) nursing home minimum staffing requirements, protecting the tax exemption of municipal bonds, and expanding low income housing tax credits.

Prior to the forthcoming markups, the committees will release text to be considered by members on the committee 36 hours before the committee is set to meet. At that time, we will have our first real look at what policies the committee is lining up to implement and how those policies in E&C will cut Medicaid funding and access.

Because of the wide variation in each state’s Medicaid program, the impact of policy proposals under consideration in Congress to save federal funds will vary at the state level.  Members of Congress are considering how proposals impact their districts and states;  LeadingAge’s advocacy team is working to ensure members of Congress fully understand what is at stake.

As members of Congress assess how different policies to cut Medicaid will affect their constituencies, they are defecting from supporting some cuts. Some in states that have chosen not to expand Medicaid have little to lose voting for changes to federal funding for that group, though they may be unable to support reductions in provider tax revenue; still others will be unaffected by elimination of the Federal Medical Assistance Percentage (FMAP) floor, but won’t accept per capita caps.

CBO Scores on Policies to Cut Medicaid 

To help inform policy making, the non-partisan Congressional Budget Office (CBO) provides ‘scores’ or estimated costs or savings associated with enactment of potential legislation. On April 25, Ranking Members Ron Wyden (D-OR) and Frank Pallone (D-NJ) of the Senate Finance Committee and House Energy and Commerce Committee, respectively, requested CBO scores on five policy options to cut Medicaid that remain under consideration.

On May 7, CBO responded by providing 10-year scores on the federal savings achieved by these policy options, and also estimates of coverage losses and anticipated increases in the uninsured population. CBO’s estimates include consideration of assumptions as to how states will respond to the five options. These include an assumption that some states will backfill some of the lost federal funds, cut optional services, cut provider rates, and/or cut populations served. CBO assumes that states, though only calculated on the aggregate, will backfill approximately half of lost federal funding.

LeadingAge does not agree that states will have the latitude to do that for multiple reasons:

• States are facing budget cliffs as the tails of federal COVID stimulus and incentive dollars dry up.
• Collected revenues in states are coming in below projections because of decreased consumer spending and stagnation in economic growth from inflation.
• Other federal revenue streams for human services, human services-adjacent, and other programs have been cut, creating additional competition for limited resources where little previously existed.
• States are required to balance their budgets and don’t have the ability to borrow to fund short-term budget gaps caused from volatility in policy or revenues.

For these reasons, we believe the CBO estimate could be low in consideration of lost coverage and uninsured individuals at the 10-year mark.

Conservatives Restate the Need to Find Savings

As a rallying response to the CBO estimates, fiscal hawks in the House doubled down with a May 7 letter to House leadership reiterating their commitment to a bill that, by their interpretation, is fully offset. Their estimates include that tax cuts will generate $2.5 trillion in economic growth over 10 years, making the cost of extending these cuts $2 trillion over ten years. More than 30  signatories reiterate their red line: passage of any committee markups that fall short of budget resolution instructions will mean a reduction in the total tax cuts that Ways and Means can enact.

Medicaid Cuts Under Consideration: Moving Target

The list of cuts under consideration in the Medicaid program is a constantly moving target as Speaker Mike Johnson (R-LA) and House Energy and Commerce Chair Brett Guthrie (R-KY) attempt to bring the entire caucus into alignment on the need for the same level of cuts in the same ways. The budget resolution, which passed both the House and Senate earlier this year, directed Energy and Commerce to reduce spending by at least $880 billion over 10 years.

According to information LeadingAge has gleaned from Hill outreach and other sources, these Medicaid changes seem likely to be included in the E&C bill:

• Rescinding the Nursing Facility Minimum Staffing Rule and the Medicaid Eligibility and Enrollment Rule via an enforcement moratorium for 9 years.
• Codification of work requirements. This could be optional to allow for more state flexibility to adapt to their own economic conditions in the state and to make the policy more palatable or they could be mandatory which would garner more savings.
• Eliminating the temporary standard FMAP bump of 5% for states that have elected to expand Medicaid after the American Rescue Plan Act (ARPA) of 2021- this is for Medicaid claims other than those for which the state will receive 90% match for costs associated with coverage of the expansion population. The intent of this policy was to try to encourage non-expansion states to adopt Medicaid expansion.
• Normalizing Washington, D.C.’s statutory FMAP of 70% to the current FMAP floor of 50% which is what their FMAP would be under the standard FMAP formula.
• Cost sharing and premiums for expansion enrollees whose income is between 100 and 135% of the federal poverty level (FPL).
• Limitations on retroactive Medicaid eligibility to no more than 30 days prior to the date of application (currently set at 90).
• Increased eligibility checks – it is unclear whether this policy would only be for the expansion population or across all Medicaid covered populations.
• Limitations on coverages for: immigrants (unclear the parameters), states offering other coverage for undocumented immigrants, transgender care, and transgender care for minors. These policies may be linked to FMAP penalties for states that cover these services or populations.

Additional options remain on the table but the Republican caucus is struggling to reach consensus on these additional policies so they constantly seem to flow in and out of the conversation of what may be enacted. These include normalizing the FMAP for the expansion population, elimination of the FMAP floor, elimination of managed care provider taxes, and implementation of per capita caps on the expansion population.

What’s Next?

If House leadership is successful in clearing all reconciliation pieces from their respective committees and can pass a reconciliation package on the House floor, we have heard the Senate does not seem poised to complete the standard committee markups. This raises concerns for moderate House Republicans concerned about having to take a politically difficult vote if the Senate isn’t able or willing to coalesce around the same policy priorities and areas for cuts.

Follow this and related news in our Budget Reconciliation 2025 serial post.