WHITE HOUSE:

The White House focused this week on extending the timeline for TikTok to be sold, the situation with Iran, and signing an Executive Order implementing a new trade deal with the UK.

CONGRESS:

The Senate dropped a bombshell this week with the language in their version of the One Big Beautiful bill that cuts even deeper into Medicaid with significant cuts to provider taxes. In welcome news for SNF’s, the provider tax cuts only affect hospitals and other healthcare providers, while SNF’s are explicitly carved out of the provider tax cuts, although they won’t be able to increase or modify any provider taxes moving forward. From a political perspective, the Senate’s most vocal Medicaid defenders, such as Senator Josh Hawley, are making noise that the Medicaid cuts in the bill are simply too steep for the House to accept. With the White House still sticking to a July 4^th timeline for passage, there remains very little room for Senate Majority Leader John Thune to navigate the competing factions. It’s pedal to the metal in DC as we navigate the process:

Elsewhere in DC:

• • For those so inclined, the carve-out for SNF’s can be found on page 492 of the bill in Section 71220(b)(iii). The full bill is here and the section-by-section summary is here. It’s important to realize that while the provider taxes are excepted, there’s nothing in the bill that prevents state government from taking funds generated by PT and using them for other providers.

• • One other welcome change for SNF’s in the Senate bill is a modification of the retroactive eligibility period for applications. The Senate’s version allows for two months retroactive eligibility for traditional Medicaid applicants (i.e. the non-expansion population), an increase from the House’s version that limited eligibility to one month. However, the Senate’s version does still represent a decrease from the current law that allows for three months retro coverage. This change can be found in Section 71114 of the bill.

• • Meanwhile, hospitals are searching for their own path forward in dealing with the cuts.

• • As we’ve mentioned before, the Senate has strict rules for what may be included in Reconciliation. The ultimate arbiter is the Parliamentarian. She issued the first of her rulings removing items from the bill. These rulings have a material impact on the final version of what passes. The latest ruling, coming late Friday night, removes a provision that would have shifted SNAP costs to states, sending Republicans back to the drawing board to find an alternate source of savings.

• • Adding to the pressure to increase cuts was the latest dismal report on the financial outlook for Medicare and social security.

• • While work requirements are politically popular and a relatively easy sell, actually implementing them in practice will be a tall order for states. The Kaiser Family Foundation took a deep dive into the work requirement provisions and what it might look like.

• • The White House continues to push the boundaries of the typical appropriations process, and it’s making Senate Republicans antsy.

• • We’ve touched on this before, but Texas’ Senate seat is shaping up to be an unexpectedly tough race, and depending on the GOP primary, might represent a chance for a Democratic pickup.

AGENCIES:

CMS released two new QSO’s this week:

• • QSO-25-19: This affirms CMS’ commitment to make the 2567 publicly available within 14 days of the issuance of the 2567. You can download a copy here (PDF).

• • QSO-25-20: This makes several changes to the nursing home compare site, including utilizing more recent surveys to determine star rating and posting records for SNF “chains”. You can download a copy here (PDF)

The GAO recommended that the Department of Labor do a better job of tracking Union expenditures and financial reporting.

The formal announcement is expected tomorrow (Monday, June 23^rd), but the Wall Street Journal reported that AHIP, the trade association for insurance companies, is planning a joint press conference with CMS tomorrow to announce a series of changes to the prior authorization process, including standardization of submissions across companies and involving more humans in the process. We will update the Digest with specifics when more details are released.

FROM THE NOTEBOOK:

• • In yet another sign that folks are realizing MA plans are politically unpopular, NYC chose not to pursue a transition of their retirees from traditional Medicare to a MA plan, acknowledging that the switch was disliked by beneficiaries. Even more stunning was the fact that Mayor Adams made the decision after the city won a court case earlier in the week that said the city has the legal right to make the switch, over the objection of the retirees.

• • The immigration crackdown is really starting to hit home with more SNF’s than ever reporting workforce shortages.

• • The Arkansas Health Care Association is partnering with local schools to help SNF’s in the state deal with nursing shortages.

• • Add New Hampshire to the mix of states having a problem passing a state budget, as the Governor is threatening to veto the current proposal.

• • A new study in JAMDA confirms what is obvious to most SNF operators: the higher the Medicaid mix, the more a SNF is hampered by an inability to hire staff.

• • Another study released this week found that the Medicaid cuts in the One Big Beautiful Bill can lead to thousands of preventable deaths. Maybe it’s not a great idea to cut Medicaid…