The Senate narrowly passed the reconciliation bill on Tuesday, with Vice President Vance breaking a tie for a 51-50 vote.

• The vote followed nearly a full day of round-the-clock uncertainty over how the bill would come together, throughout a slow-moving vote-a-rama on amendments taking place on the Senate floor.
• The bottom line: The Senate passed a bill that would cut Medicaid for millions of Americans, raising particular risk for those with addiction.

Here’s a look at what happened in the past week leading up to this vote…

Parliamentarian rulings and bill changes: The Senate updated bill text after changes were made in response to Senate rules and disagreements among members.

• Reminder: To pass a budget reconciliation bill by a simple majority in the Senate, skirting the filibuster that requires 60 votes, the bill must meet certain requirements that limit what can be included. The Senate parliamentarian reviews bills to determine if provisions violate this Byrd rule.
• Provider taxes: The parliamentarian ruled that the provision to curtail provider taxes, a key source of Medicaid funding for states, did not meet the requirements. The Senate then changed the provision to delay the planned cuts, which the parliamentarian approved. It would still incrementally lower the cap for provider taxes from 6% to 3.5% in expansion states (and freeze the cap in non-expansion states), but the drawdown would begin in 2028, a year later than planned.
• Rural provider fund: To try to win over some holdout senators who had raised concerns about curtailing the provider tax, a provision was added to create a fund to help rural hospitals that would be impacted by the change. The bill passed includes a $50 billion stabilization fund over 5 years.
• Immigration provisions: The parliamentarian ruled against provisions to withhold federal funds from states that use their own funds to provide coverage to undocumented residents and to prohibit refugees and asylees from receiving Medicare. Senators tweaked these measures to preserve them in the bill. Provisions specifying that non-citizens cannot qualify for tax credits to purchase ACA marketplace plans were ruled compliant.
• Alaska funding: Senate leaders added provisions that would increase Medicaid payments in Alaska and Hawaii, in an effort to win Sen. Murkowski’s vote. But the parliamentarian ruled that these provisions violate the Byrd rule, and they were dropped.

New CBO score: A new analysis from the Congressional Budget Office found that the Senate version of the bill would lead to 11.8 million people losing health insurance over the next decade, 1 million more than the House version.

• The Senate bill would cut more than $1.1 trillion in health spending, with more than $1 trillion coming from Medicaid alone.

Vote to debate: The Senate voted 51-49 on Sunday to start debate on the bill after a daylong scramble by Senate leaders to win over several senators who were undecided or had vowed to block debate.

• This included promising a vote on an amendment to end the 90% federal cost-share for new enrollees under Medicaid expansion after 2030. This would have won over key deficit hawks but risked alienating those concerned about Medicaid cuts.

Debate and vote-a-rama:

• • Debate on the Senate floor began with the clerks reading the full 940-page bill out loud. The reading took over 16 hours on Sunday, with the rest of the process delayed until Monday morning.
  • On Monday, senators debated the legislation and had a “vote-a-rama,” a barrage of amendment votes. The amendment to reduce the federal match for expansion enrollees did not end up being brought up for a vote.
  • On Tuesday, the Senate voted to pass the bill.

Next steps:

• The bill is now with the House, which is expected to vote in the next day or two. Congress is still aiming for passage by July 4th, but the bill currently faces steep opposition among some sectors of the House for the changes the Senate made to the version carefully crafted to make it through the tightly divided House.
• If the House wants to make changes to the bill before passing it, that would require conferencing with the Senate, which would delay the bill.