Harsh setback for Trump's mega bill: Medicaid reform does not comply with Senate rules
So ruled Elizabeth MacDonough, the current parliamentarian in the Senate. She is a nonpartisan staffer who serves as the Senate's top expert on parliamentary rules, advising leaders of the day on procedural matters.
John Thune during a press conference/ Saul Loeb.
Donald Trump's mega bill received a setback from the Senate on a key point: Medicaid reform. In the midst of negotiations between conservative and moderate Republicans, the Senate parliamentarian ruled that such reform does not comply with the Byrd Rule. This is the internal rule used to filter which provisions can enter budget reconciliation legislation, such as the "One Big, Beautiful Bill".
The decision was made by Elizabeth MacDonough, the current Senate parliamentarian, who serves as a nonpartisan official responsible for advising the leaders of the day on procedural matters.
In this case, she ruled that much of Medicaid reform does not comply with the Byrd Rule, a filter used to ensure that members of Congress do not over-include items in the budget reconciliation. Under the rule, so named by Sen. Robert Byrd (D-WV), a budget reconciliation bill can only contain provisions that increase or decrease federal government spending, increase or decrease federal government revenue, and change the public debt limit.
The filter passed by MacDonough will have a strong fiscal impact on the bill, as it eliminates a $250 billion savings in Medicaid cuts.
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What part of Medicaid reform was rejected?
Claiming that they did not meet the above requirements, MacDonough removed the following provisions from the "One Big, Beautiful Bill":
- The limitation on the Medicaid provider tax. This was one of the key provisions of the reform.
- The ban on Medicaid access for undocumented immigrants.
- The ban on federal coverage of gender transition care.
- The limitation of "spread pricing" within Medicaid. This is a practice used by pharmacy benefit managers, which Republican lawmakers say ends up increasing the price of drugs.
- The reduction of the Federal Medical Assistance Percentage (FMAP) for states that provide coverage to undocumented immigrants. The FMAP is the subsidy through which the federal government covers a percentage of total Medicaid spending in each state.
As for next steps for Trump and Senate leadership, they will need to either remove the cited provisions from the bill or rewrite them in a way that complies with the Senate's rules.
"We knew that it was going to be an interesting conversation and we didn’t know for sure how she was going to come down on it. But there are things that we can do, there are other ways of getting to that same outcome," Senate Republican Majority Leader John Thune (R-SD) said.
He also acknowledged that there is a chance that Republicans will not get "everything we want" on the health care provider tax. However, he remarked that he is confident that "most of the reforms" can be salvaged.
In addition, Sen. Tommy Tuberville (R-AL) publicly called for MacDonough to be fired. As he noted on his X account, the staffer is "blocking" the president's agenda.
"Did Harry Reid’s Senate Parliamentarian not get the memo? President Trump’s landslide victory was a MANDATE from 77 million Americans. The One Big Beautiful Bill delivers on that mandate. The Parliamentarian is trying to UNDERMINE the President’s mandate and should be fired," the Alabama Republican, who announced his candidacy for governor in 2026, wrote.
Can Trump fire the Senate parliamentarian?
The only precedent for firing occurred in 2001, when Trent Lott replaced Robert Dove with Alan Frumin, who held the position until 2012.
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