Stephanie Armour, Kff Health News

Doctors, hospitals, and health insurers for weeks issued dire warnings to Republican lawmakers that millions of people would lose health coverage and hospitals would close if they cut Medicaid funding to help pay for President Donald Trump’s big tax and spending bill.

But Republicans ignored those pleas, made even deeper cuts, and sent the legislation on July 3 to the White House, where Trump signed it the next day.

The law’s passage marked a rare political loss for some of the health industry’s biggest players. When unified, doctors, hospitals, and insurers have stood among the most powerful lobbying forces in Washington and have a long track record of blocking or forcing changes to legislation that could hurt them financially.

But health industry lobbyists are catching their breath and assessing the damage after Trump’s massive bill raced through Congress in less than two months with only Republican votes.

Several lobbyists offered various reasons for being unable to stave off big cuts to Medicaid, a $900 billion state-federal health insurance program that covers an estimated 72 million low-income and disabled people nationally and accounts for 19% of all spending on hospital care, about $283 billion a year, according to the latest data. But nearly all agreed that GOP lawmakers were more worried about angering Trump than facing backlash from local hospitals and constituents back home.

“Members were more scared of Trump issuing a primary challenge than disappointing local voters who may find their hospital has to close or their insurance premium may go up,” said Bob Kocher, a partner with venture capital firm Venrock who served in the Obama administration, referring to election primaries leading into the midterms.

Consider what happened to Sen. Thom Tillis (R-N.C.). After he took to the Senate floor to announce his opposition to the bill because of its cuts to Medicaid, Trump threatened to support a challenger to run against Tillis next year. Shortly thereafter, Tillis announced his retirement from politics.

But other factors were at work.

The health industry’s warnings to lawmakers may have been dismissed because hospitals, health centers, and other health care provider groups are seen by Republicans as strong backers of the Affordable Care Act, the law known as Obamacare that’s considered Democrats’ biggest domestic achievement in decades.

The ACA expanded government health insurance coverage to millions of people previously not eligible. And no Republicans voted for it.

“Hospitals’ support of the ACA has frustrated Republicans, and as a result there is less a reservoir of goodwill to hospitals than in the past,” Kocher said.

Ceci Connolly, chief executive of the Alliance of Community Health Plans, said her lobbying team spent extra time on Capitol Hill with lawmakers and their staffers, raising concerns about how the legislation would imperil health care coverage.

“There was almost an overriding sense on the part of Republicans in Congress to deliver a major victory for President Trump,” she said. Her group represents health plans that provide coverage in about 40 states. “That superseded some of their concerns, reluctance, and hesitation.”

Connolly said she repeatedly heard from GOP lawmakers that the focus was on delivering on Trump’s campaign promise to extend his 2017 tax cuts.

She said the concerns of some moderate members helped lead to one concession: a $50 billion fund to help rural hospitals and other health providers.

The money, she said, may have made it easier for some lawmakers to support a bill that, in total, cuts more than $1 trillion from Medicaid over a decade.

Another twist: Many new lawmakers were clearly still learning about Medicaid, she said.

Republicans also seemed eager to reduce the scope of Medicaid and Affordable Care Act marketplace coverage after enrollment in both programs soared to record levels during the pandemic and the Biden administration, she said. Trump’s law requires states to verify eligibility for Medicaid at least every six months and ends auto-enrollment into marketplace plans — steps health policy experts says will reverse some of those gains.

Charles “Chip” Kahn, a longtime health lobbyist and CEO of the Federation of American Hospitals, which represents for-profit hospitals, said the industry’s message was heard on Capitol Hill. But because the bill dealt with so many other issues, including tax cuts, border security, and energy, lawmakers had to decide whether potential health coverage losses were more important.

It was very different than in 2017, when Republicans tried to repeal Obamacare but failed. Trump’s 2025 measure, Kahn said, isn’t a health reform bill or a health bill.

It “left us with an outcome that was unfortunate.”

There were some successes, however, Kahn said.

Industry lobbying did prevent the federal government from reducing its share of spending for states that expanded Medicaid under the ACA. Hospitals and other Medicaid advocates also persuaded Congress not to cap the program’s open-ended federal funding to states. Both measures would have tallied billions more in additional Medicaid funding cuts.

The new law doesn’t change eligibility rules for Medicaid or change its benefits. But it does stipulate that states require most Medicaid enrollees who gained coverage via the ACA’s expansion to document that they work or volunteer 80 hours a month, a provision the Congressional Budget Office predicts will lead to about 5 million people losing coverage by 2034.

The law also limits states’ use of a decades-old system of taxing health providers to leverage extra federal Medicaid funding. This was another loss for the hospital industry, which has supported the practice because it led to higher payments from Medicaid.

Medicaid generally pays lower fees for care than private insurance and Medicare, the program for people 65 and older as well as those with disabilities. But due to provider taxes, some hospitals are paid more under Medicaid than Medicare, according to the Commonwealth Fund, a health research nonprofit.

Kahn credits the Paragon Health Institute, a conservative think tank, and its CEO Brian Blase for pushing the argument that provider taxes amounted to legalized “money laundering.” Blase advised Trump on health policy in his first term.

One hospital executive who asked for his name to be withheld to avoid professional retribution said the message — that some facilities had used this play to increase their profits — resonated with GOP lawmakers. “They thought some hospitals were doing fine financially and did not want to reward them,” he said.

Still, Kahn, who is retiring at the end of the year, said he was pleased the Senate delayed implementation of the provider tax cuts until 2028. That will give the health industry a chance to revise the law, he speculated, possibly after the 2026 midterm election changes the balance of power in Congress.

In rural northeastern Louisiana, Todd Eppler, CEO of Desoto Regional Medical Center, had hoped Congress would pass the initial House version of the bill, which didn’t include cuts to provider-tax funding. But he said any impact on his hospital in Mansfield, located in House Speaker Mike Johnson’s district, will be offset by the $50 billion rural health fund.

“I am happy where we ended up,” Eppler said. “I think they listened to rural hospitals.”

Hospitals have argued for decades that any cuts in federal funding to Medicaid or Medicare would harm patients and lead to service reductions. Because hospitals are usually one of the largest employers in a congressional district, the industry often also warns of potential job losses. Such arguments typically give lawmakers pause.

But this time around, that message had little traction.

One health industry lobbyist, who asked not to be identified to speak candidly without risking professional repercussions, said there was a sense on Capitol Hill that hospitals could withstand the funding cuts.

But there’s also a belief that trade groups including the American Hospital Association, the largest hospital industry lobbying organization, could have been more effective. “There is lot of concern that AHA statements were too soft, too little, and too late,” he said.

AHA helped lead a coalition of hospital organizations that spent millions of dollars on television advertising against the GOP bill. Its president and CEO, Rick Pollack, said in a statement before the House voted on the legislation that the cuts to Medicaid would be a “devastating blow to the health and well-being of our nation’s most vulnerable citizens and communities.”

Pollack said in a statement to KFF Health News that the appeal of tax cuts drove Republican lawmakers to pass the law.

“Hospitals and health systems have tirelessly advocated to protect coverage and access for millions of people,” he said. “We will continue to raise these critical issues to mitigate the effects of these proposals.”

The nation’s largest trade group for doctors, the American Medical Association, also opposed the funding cuts to Medicaid and other federal health programs. Its president, Bobby Mukkamala, said in a July 1 statement that the changes “will shift costs to the states and specifically to physicians and hospitals to provide uncompensated care at a time when rural hospitals and physician practices are struggling to keep their doors open.”

But the AMA was also focused on securing higher Medicare fees for doctors. The law ultimately included a one-time 2.5% Medicare pay bump for doctors in 2026. This wasn’t a victory because it left out the House version’s permanent payment fix that would have tied doctor pay to the medical inflation rate. Mukkamala noted the temporary lift but described it as falling “far short of what is needed to preserve access to care for America’s seniors.”

Joe Dunn, chief policy officer at the National Association of Community Health Centers, said his organization worked relentlessly this year to prevent deeper Medicaid cuts that would financially hurt nonprofit clinics. Health center administrators visited Washington in February, made thousands of phone calls, and sent emails to members of Congress.

One payoff was that the health centers were exempted from the law’s requirement that providers charge some Medicaid enrollees up to $35 copayments for services.

But at the end of the day, Dunn said, many GOP House and Senate members simply wanted to finish the bill. “They went in a direction that satisfied the president’s timelines and goals,” he said.

Chief Washington correspondent Julie Rovner contributed to this report.

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This article first appeared on KFF Health News and is republished here under a Creative Commons license.

After the Senate voted to confirm Robert F. Kennedy Jr. as Health and Human Services secretary, supporters of his “Make America Healthy Again” movement cheered at having a champion in the federal government.

Now the grumbling has begun. Some of Kennedy’s allies say he’s become almost inaccessible since his confirmation and complain that he’s made glacial progress advancing MAHA goals, such as halting mRNA-based COVID shots and removing fluoride from drinking water.

The fractures underscore the clash between Kennedy’s movement and President Donald Trump’s “Make America Great Again” agenda. Kennedy is pulled between his supporters who want swift action to disrupt traditional health care and Trump, who is focused more on tariffs and increasing deportations than on disease, according to four people close to Kennedy who asked not to be identified because they weren’t authorized to speak to the press. Many of the priorities driving Kennedy’s MAHA program are not top priorities of his boss.

Kennedy’s capacity to navigate those tensions has been further strained by a measles outbreak and the threat of a bird flu pandemic, the people said.

Some of his deputies are still being vetted and other key positions remain unfilled. That, along with resignations of top HHS leaders and sweeping staffing reductions, has created a gap in expertise. Kennedy sometimes calls close informal advisers on the run before meetings, and the crises have put him in a reactionary stance, working on weekends and marshaling staff for Sunday meetings, according to the people.

More churn is coming because of an HHS reorganization set to eliminate about 20,000 jobs, including a 19% cut to the workforce at the FDA, which oversees food, nutrition, and vaccines.

HHS spokespeople didn’t respond to emails seeking comment.

To be sure, Kennedy’s ascendance represents a breakthrough for the MAHA movement, a broad collection of gadflies, groups, and wellness influencers who extol raw milk, metabolic health, and sustainable farming while lambasting Big Pharma, vaccines, and processed foods.

The coming months will test Kennedy’s ability to juggle the challenges and achieve Trump’s goals without losing the support of MAHA adherents, especially special interest and advocacy groups that helped him reach his influential perch overseeing one of the nation’s largest federal agencies. HHS, with a budget of almost $2 trillion, includes the Centers for Disease Control and Prevention, the National Institutes of Health, and the Centers for Medicare & Medicaid Services.

But the MAHA goals aren’t top agenda items for GOP voters, who tend to be focused more on the price of eggs than whether they’re organic.

The MAHA faithful “expect action” but their to-do list is not necessarily a high priority for voters or lawmakers, said Robert Blendon, a professor emeritus of health policy and political analysis at Harvard. “And should there be a big measles outbreak or avian flu, it would hurt the White House if there was a big conflict over vaccines going on,” he said.

An additional challenge for Kennedy is that not all MAHA and MAGA goals overlap. Trump wants to slash the workforce, which Kennedy has embraced. But fulfilling MAHA wishes will require more regulation, which runs counter to MAGA dogma favoring a smaller federal government.

MAHA wants fluoride out of water because followers say it leads to lower IQ levels in children, as well as arthritis and bone cancer. Kennedy said on X that fluoride is dangerous and that the Trump administration would recommend it be removed from America’s drinking water. Fluoridated water is credited for vastly reducing rates of tooth decay in the U.S. In 2015, the CDC called water fluoridation one of the 10 greatest public health achievements of the 20th century, and only 15% of Americans think fluoride is harmful or detrimental to the public, based on a poll in January by market research company Ipsos.

MAHA adherents believe in the debunked claim that vaccines cause autism, and Kennedy just tapped a vaccine opponent to work on a study on possible connections. In fact, HHS has launched an effort that Kennedy said will determine by September what has caused the “autism epidemic.” Many autism researchers say this timeline sows doubts about the study’s seriousness. Most voters support vaccines and believe in their benefits. Eight in 10 parents with children under age 18 say they normally keep them up to date with recommended childhood vaccines, according to a KFF poll in January.

And MAHA wants to replace seed oils, which the movement’s followers claim without evidence are unhealthy, with animal fats such as beef tallow, which is high in saturated fat, which can contribute to high cholesterol and heart disease. Only 13% of Americans believe seed oils are unhealthy to consume, based on a poll by the industry-backed International Food Information Council.

Perhaps no goal is more important to many MAHA followers, however, than banning the mRNA technology behind covid vaccines by Moderna and Pfizer.

“The big threat is that we still have covid-19 vaccines on the market,” said Peter McCullough, a former cardiologist who has been criticized for spreading covid misinformation and has informally advised Kennedy. “It’s horrendous. I would not hesitate; I would just pull it. What’s he waiting for?”

The FDA says covid shots are safe. They are credited for saving millions of lives worldwide during the pandemic, and two NIH-funded scientists who advanced mRNA technology were awarded the Nobel Prize in physiology or medicine in 2023.

Yanking authority for mRNA-based covid vaccines could backfire because Trump sees “Operation Warp Speed,” the federal effort to develop the shots, as one of his signature achievements, according to one of the people close to Kennedy. And it would have been impolitic to take action before the confirmation of an FDA commissioner, the person said. Marty Makary, a Johns Hopkins University researcher, was confirmed on March 25 to the post.

Kennedy also isn’t calling all the shots. He was initially unaware of the appointment of Gerald Parker, a veterinarian who recently chaired an NIH advisory board, to head the White House’s pandemic office, according to one of the people.

Kennedy did choose Susan Monarez, a former deputy director of the Advanced Research Projects Agency for Health, as acting CDC director. Trump nominated her for Senate confirmation to lead the agency on March 24. Kennedy felt she had worked well with Trump’s job-cutting Department of Government Efficiency and did a great job in her acting director position, one of the people close to him said.

Kennedy is also in a difficult position regarding Trump’s Make America Healthy Again commission, which Kennedy chairs. The panel’s charge to investigate and deliver an action plan on the nation’s decades-long increase in chronic illness, with a special emphasis on children, is a clear pitch to the MAHA movement. But Trump has told Kennedy, according to one of the people, that he wants to see measurable progress in a year to 18 months — which is hard both to define and to achieve.

While Kennedy is a scion of the country’s most famous Democratic family, he is widely distrusted in the medical community because of his fringe views on vaccines and his rejection of established science. Since taking office, he has tried to cultivate relationships with MAGA-leaning state officials, including West Virginia’s governor, Republican Patrick Morrisey. And his alliance with Trump is new. When Kennedy was running for president in 2024, Trump took to his Truth Social platform to say, “Kennedy is a Radical Left Democrat, and always will be!!!” — though Trump’s administration includes other onetime adversaries such as Secretary of State Marco Rubio.

Many of Kennedy’s nutrition and health goals would require regulation, which clash with Trump’s anti-regulatory agenda and his focus on a lean federal government.

Meanwhile, he’s relied on his principal deputy chief of staff, Stefanie Spear, a longtime Kennedy aide who has taken on the role of traffic cop in the department. He’s also leaned on HHS chief of staff Heather Flick Melanson for expertise. She was a senior adviser to former HHS Secretary Alex Azar in Trump’s first term.

Kennedy’s close circle of informal advisers includes nontraditional doctors, fellow vaccine opponents, media personalities, and self-appointed health gurus. Some have gained unprecedented influence and access to the innermost workings of federal health agencies.

Calley Means, for example, is a Kennedy ally whose business sells wellness products such as saunas and supplements. His statements have dismayed some scientists, such as when he called covid vaccine mandates for children a “war crime” and said without evidence that “metabolically healthy” people don’t die from covid. In March, Means joined the White House as a special government employee and MAHA adviser.

Others in Kennedy’s orbit include Del Bigtree, a television producer who founded the anti-vaccination group Informed Consent Action Network, and some officials from the previous Trump administration. Aaron Siri, a lawyer for Kennedy, is no longer involved in vetting candidates for HHS positions, one of the people said.

“‘Nontraditional’ as a description for these people is not enough. We’re talking about beyond the outer fringes of medicine,” said Irwin Redlener, senior adviser for the National Center for Disaster Preparedness at Columbia University, of Kennedy’s inner circle. “This faux expertise is really dangerous.”

Even as some MAHA adherents press for swifter action, Kennedy’s recent comments and actions suggest public health ideas once dismissed as fringe or unscientific now have an advocate at HHS.

Kennedy claimed without evidence that cod liver oil is an effective treatment for measles. He’s suggested letting the bird flu virus rip unchecked through infected chicken flocks even though scientists say that could unleash dangerous mutations.

And he’s backed cellphone bans in schools, saying phones cause cancer in kids. Most studies have found no such link.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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