The U.S. House of Representatives passed the “One Big Beautiful Bill Act” on May 22 by a narrow 215-214 vote. The legislation addresses spending across healthcare, social programs, technology, taxes and education, and it now moves to the Senate.

The Senate will go through its own process of drafting text with a goal to get 51 votes before the House and Senate negotiate a final bill that can pass both chambers.

President Trump’s agenda is largely focused on tax, defense and immigration issues. This includes extending key provisions from the 2017 Tax Cuts and Jobs Act, expanding tax exemptions such as for tips and overtime, making changes to certain social programs including Medicaid and SNAP and modifying student loan payments. Additional priorities include major funding for border security and defense and restrictions on undocumented immigrants' access to benefits.

The Process

Budget reconciliation is a process used by the U.S. Congress to pass certain budget-related provisions with a simple majority vote in both the House of Representatives and Senate, bypassing a Senate filibuster.

It is a tool used to implement key parts of the president’s domestic policy agenda when a political party controls the House, the Senate and the White House. The reconciliation legislation is specific to changes in federal spending, revenues and/or the debt limit and is limited to changes lasting for a 10-year window.Identical language must be passed by the House and the Senate before it can be sent to the president for his signature.

It is important to note that this process is independent of the appropriations process, which addresses government funding. Fiscal Year (FY) 2025 funding expires Sept. 30, while the House Appropriations Committee will officially begin the FY2026 process June 5.

Current Status of the One Big Beautiful Bill Act

It is unclear to what extent the Senate is expected to make changes to the House-passed bill, but there isn’t enough support to pass the bill in its current form.

Further complicating things, the Senate faces a parliamentary quirk known as the Byrd Rule, which limits what provisions can be included in any reconciliation bill. If the bill passes the Senate, it will return to the House, where Republicans will either approve the Senate’s version and send it to President Trump, or the House will negotiate further to resolve differences between the two chambers.

The Senate aims to pass its version of the bill and send it to the president by July 4, but the senators have a lot of work ahead of them to meet that deadline.

Inside the House Bill

At a high level, the legislation has topline spending at around $4 trillion dollars and includes cuts totaling$2 trillion over 10 years. However, it is projected to add $2.4 trillion to the national debt over that same period.

Healthcare

• Medicaid
  • Establishes work requirements for Medicaid (at least 80 hours per month of work, community service or qualifying participation in an educational program) to start Dec. 31, 2026, using guidance from Secretary of HHS that is to be developed by Dec. 31, 2025
  • Provides for a reduction in the expansion match rate (FMAP) for states that “provides any form of financial assistance" whether Medicaid or other state program for undocumented immigrants, except for children and pregnant women
  • Requires states to do eligibility redetermination for Medicaid expansion populations every six months
  • Prohibits the use of federal Medicaid funds for gender-affirming care for minors and adults as well as prohibits federal funding for Planned Parenthood and other abortion providers
    
• Affordable Care Act (ACA)
  • Reinstates ACA cost-sharing reduction (CSR) payments, which are federal subsidies that allow insurers to assist for medical care or prescriptions for those enrolled in silver tier health plans
  • Ends “silver loading,” where insurance companies increase premiums for silver-tier plans to offset the cost of cost-sharing reductions (CSRs)
  • Establishes eligibility and income verification for ACA enrollees
  • Prohibits states from establishing new provider taxes or from increasing rates on existing provider taxes
  • Reforms PBM practices in Medicare Part D by limiting compensation to flat “bona fide service fees” (banning payment based on drug prices or rebates) and establishing transparency requirements
  • Provides funding for HHS for utilization of AI to identify and reduce Medicare improper payments
  • Changes to how Medicare determines provider reimbursement by creating a single conversion factor for all clinicians
  • Expands households’ ability to contribute to Health Savings Account (HSAs) and use those funds with less restrictions

Supplemental Nutrition Assistance Program (SNAP)

• Cuts $260 billion from SNAP
• Imposes new SNAP cost-sharing requirements on states starting in FY 2028, requiring states to cover at least 5% of benefit costs—rising to 15–25% if states exceed certain error rates—and cuts federal reimbursement for administrative costs from 50% to 25%
• Tightens work requirements for recipients

AI/Technology

• Proposes a 10-year moratorium on states' ability to regulate artificial intelligence
• Invests $500 million into U.S. AI Infrastructure, including $25 million specifically to HHS to identify waste, fraud and abuse in Medicare payments

Taxes/Economic Growth

• Extends 2017 Trump set tax rates
• Increases State and Local Tax (SALT) deduction from $10,000 to $40,000 and includes an income ceiling for beneficiaries of $500,000
• Raises the maximumChild Tax Credit
• Establishes no tax on tips or overtime
• Terminates Biden-era clean energy credits
• Raises the nation's debt limit by $4 trillion

Anticipated Impacts if the House-Passed Reconciliation Bill Were Enacted as is

Healthcare

• Slashes around $800 billion in funding for Medicaid and the ACA
• Approximately 16 million Americans could lose health insurance by 2034
• The provider tax moratorium will shift costs to statesas provider taxes account for at least 17% of the state's share. This shift in funds will either cause benefits or coverage to be cut or cuts in other budget lines to accommodate
• Healthcare providers may face increased financial strain from reduced federal support and more complex administrative requirements under new work rules

AI/Technology

• The proposed federal AI moratorium is unlikely to survive reconciliation due to the Byrd Rule, which restricts non-budgetary provisions. However, the issue remains a legislative priority. Sen. Ted Cruz (R-TX) is considering standalone legislation.

SNAP

• An estimated 3 million Americans could lose access to food assistance under the proposed changes.
• Shifting SNAP benefit costs to states may cause a budgetary dilemma

If the Senate were to pass the House reconciliation bill without significant changes — an outcome considered unlikely — the impacts would be far-reaching.

Impacts are most likely to disproportionately affect low income, rural and marginalized communities. New Medicaid work requirements and reduced coverage would heighten administrative demands on health IT systems, requiring enhanced tools for eligibility tracking, compliance and care coordination amid rising uncompensated care.

While federal interest in AI remains strong, the proposed AI moratorium highlights persistent regulatory uncertainty — an area where HIMSS members must remain adaptive.

At the same time, expansions in HSAs and federal preemption of AI rules could spur innovation, even as broader cuts to social benefits intensify operational and financial pressures on healthcare providers and on states which are likely to look to other budget lines to balance.