Missouri Republican Sens. Josh Hawley and Eric Schmitt voted in favor of a massive budgetary package on Tuesday that includes controversial restrictions on medical provider taxes.
Senators labored overnight on more than 45 amendments to the federal tax cuts, immigration restrictions and debt ceiling legislation. The bill passed when Vice President J.D. Vance supplied the tie-breaking vote, which sends the measure to the House.
Schmitt said in a statement that he proudly “voted to move forward with President Trump’s America First agenda today.” He pointed to provisions in the bill he crafted to make college savings accounts known as 529s more attractive, as well as a measure aimed at culling waiting lists for home- and community-based services for people with disabilities.
“The One Big Beautiful Bill will prevent the largest tax hike in American history, secure our border, fund deportations, create American jobs, and keep our country safe,” Schmitt said. “This is a win for families across Missouri, and I look forward to continuing to work with President Trump to usher in America’s Golden Age.”
Even though he voted for the so-called Big Beautiful Bill, Hawley said he had misgivings about some provisions around Medicaid.
One of the more controversial provisions in the reconciliation package would force states like Missouri to cap their medical provider taxes on entities such as hospitals. With the way the measure is structured, the 49 states like Missouri that have up to a 6% medical provider tax would gradually have to lower it to 3.5% by 2032.
Currently, Missouri’s medical provider tax is 4.2% – but has gone as high as close to 6%. The Missouri Hospital Association said capping the tax at 3.5% would cost Missouri hundreds of millions of dollars, which likely would force lawmakers to lower payments to medical providers.
In a statement, Missouri Hospital Association President Jon Doolittle said the Senate's bill "would harm those covered by Medicaid, all Missourians’ access to health care, the ability of hospitals to provide care and our state’s budget — especially when compared to the carefully constructed compromise crafted and adopted by the U.S. House of Representatives."
Doolittle was referencing how the House bill would bar states from raising or expanding medical provider taxes.
“Missouri’s hospitals are committed to working with state and federal leaders to mitigate impacts of these cuts and ensure all Missourians who are eligible for Medicaid coverage remain covered and enrolled,” Doolittle said.
Hawley had spoken out against the medical provider tax plan but ended up supporting the budgetary package after senators added a $50 billion rural hospital fund. He said in a statement that he “would continue to do everything in my power to reverse future cuts to Medicaid.”
“If Republicans want to be the party of the working class, we cannot cut health insurance for working people,” Hawley said.
Hawley was able to persuade senators to include what’s known as the Radiation Exposure Compensation Act in the legislation. That program, which expired last year, would be available to Missourians who became sick because of radioactive waste exposure in the St. Louis area.
“RECA is generational legislation for Missouri and will finally deliver justice for survivors in the St. Louis region,” Hawley said. “And when this reconciliation bill is signed into law, Missouri will also see new health care funding and big tax cuts for working families. I call on the House to quickly pass this legislation and send it to President Trump’s desk.”
A fund for safety-net hospitals
While Doolittle praised Hawley for pushing for more protections such as the $50 billion rural hospital fund, he and other advocates for rural health care said the provision was not enough to offset losses hospitals would experience because of the caps to the provider tax, requirements that Medicaid recipients provide work documentation and other blows to Medicaid funding.
Rural hospitals serve outsize numbers of Medicaid patients, said Sheldon Weisgrau, vice president of advocacy and public policy at the Missouri Foundation for Health, a St. Louis-based advocacy and philanthropic organization.
“They're very reliant on the funding, and they already operate on very thin margins,” he said. “And so any changes, any reductions to what funding is available to them – from any payer source, but most importantly, from their main payer sources – is going to cause problems.”
Hawley said in a press release that the rural hospital fund would add $1 billion to Missouri’s coffers over the next five years.
Heidi Lucas, of the Missouri Rural Health Association, wasn’t impressed with the changes, saying the added amendment just “prolongs the inevitable.”
“I think we're going to feel it,” she said. “It might take a little bit longer to feel it than what we were initially expecting, but we'll feel it. And the repercussions of that are going to be terrible, right? I firmly believe people are going to die because of this.”
Representatives from the Trump administration stress the bill “protects and strengthens Medicaid for those who rely on it – pregnant women, children, seniors, people with disabilities and low-income families – while eliminating waste, fraud, and abuse,” she said.
The White House notes, in an online fact sheet, that the bill “protects rural hospitals” by strengthening Medicaid.
Illinois Democrats condemn reconciliation package
Schmitt and Hawley's Democratic colleagues who represent Illinois voted differently.
Sen. Dick Durbin cited estimates that a combination of the medical provider tax curbs and requirements on Medicaid recipients turning in work-related documentation could prompt millions of people to lose their health care.
“Let’s make one thing clear – there is nothing ‘beautiful’ about slashing health care coverage for 17 million Americans all so President Trump can deliver a shiny tax cut to the wealthiest individuals and corporations,” Durbin said in a statement. “To make matters worse, Senate Republicans voted to close rural hospitals and take food off the table of millions of Americans, including children, seniors, and veterans, to pay for this outrageous giveaway.
“My Republican colleagues will now have to explain to their constituents why they chose to rip away health insurance from families so that millionaires and billionaires can enjoy a hefty tax break,” Durbin added.
Illinois Sen. Tammy Duckworth said in a statement, “Donald Trump and Republicans are proving they are intent on becoming the party of ‘well, we’re all going to die.’” That’s a reference to a flippant response Republican Sen. Joni Ernst of Iowa made during a town hall meeting when pressed about the impact of the bill on health care access.
“It’s downright shameful that by voting for this bill, Republicans are once again showing they would rather hurt middle-class families and our neighbors who are most in need than make the wealthy pay their fair share or show any backbone in the face of Donald Trump’s desire to enrich himself and his family,” Duckworth said.
Missouri Democrats were especially harsh toward Hawley, who had penned an op-ed in the New York Times calling on his colleagues not to make cuts to Medicaid. At least one Republican who voted against the bill, North Carolina Sen. Thom Tillis, said the medical provider tax plan would force states to kick people off Medicaid.
“Josh Hawley & Eric Schmitt just voted to sell out the people of Missouri,” said Missouri Democratic Party Chair Russ Carnahan in a statement. “Despite weeks of pretending to be undecided and voicing concerns about Medicaid cuts, Hawley weakly caved to GOP leadership and cast his vote in favor of the bill.”
Doolittle, however, praised Hawley for pushing for the medical provider tax cap to start phasing in after 2028 instead of 2027. He also said Hawley and Gov. Mike Kehoe played a key role in stopping Florida Sen. Rick Scott's amendment that would have slashed the federal contribution to states like Missouri that expanded Medicaid.
“MHA advocacy continues with Missouri’s representatives as [the budget bill] returns to the House for further consideration,” Doolittle said.
Turbulence in the House?
The bill now heads to the House, which is slated to take up the measure on Wednesday.
Whether that chamber will simply pass what the Senate approved is unclear. At least two members of the Missouri delegation, Reps. Bob Onder and Eric Burlison, said they were profoundly unhappy with the Senate’s version of the reconciliation package.
“The House gave the Senate a modest blueprint, but the bill they passed blows right past anything resembling an acceptable framework,” Burlison said in a post on X.
Onder was especially upset that the Senate parliamentarian excised a number of provisions from the bill. He said on Facebook that the “parliamentarian should stay out of the business of legislating.”
Onder and Burlison’s misgivings are important, since Republicans can only afford a few defections to send the budget bill to President Donald Trump.
And some House Republicans have a dim view of the Senate version of the medical provider tax plan.
