This week’s update on the reconciliation bill — it passed the House.

The main point: Early Thursday morning, the House passed the bill in a 215-214 vote, after weeks of internal conflict and last-minute intervention from President Trump.

The details: Before the bill reached the House floor for this vote, it had to be advanced by the House Rules Committee, which made several changes to the bill in a 21-hour markup.

• Medicaid work requirements will start earlier on Dec. 31, 2026 (instead of Jan. 1, 2029). The bill includes waivers states can pursue if they can’t implement them that quickly. The accelerated timeline could lead to additional savings of tens of billions of dollars but also cause more people to lose coverage.
• New cost-sharing requirements won’t apply to some types of care, including primary care, mental health care, and addiction treatment.
• Non-Medicaid expansion states will receive higher payments for uncompensated care, incentivizing those states not to expand Medicaid.
• The criteria were expanded for states that could lose a portion of their federal payments if they offer coverage to undocumented people.
• Additional executive actions to reduce “waste, fraud and abuse” in Medicaid were promised by President Trump.

Next steps: The bill now heads to the Senate, where changes are expected.

• Some senators are demanding greater spending reductions, while others want to soften the House’s proposals to cut Medicaid and food aid.
• Senate Majority Leader Thune can lose three GOP senators and still get the bill through the chamber. Thune wants to get the bill through the Senate by July 4.
• The bill would then need to be approved by the House again, meaning it still needs to ensure enough support from House members.

Our commentary: The changes to the Medicaid program in this bill will cause millions of people with substance use disorder to lose their health care coverage. See, for example, this analysis from the Legal Action Center on the impact of work requirements.