WASHINGTON (AP) — One key unsettled issue stalling progress on President Donald Trump's big bill in Congress is particularly daunting: How to cut billions from health care without harming Americans or the hospitals and others that provide care?
Republicans are struggling to devise a solution to the health care problem their package has created. Already, estimates say 10.9 million more people would be without health coverage under the House-passed version of the bill. GOP senators have proposed steeper reductions, which some say go too far.
“The Senate cuts in Medicaid are far deeper than the House cuts, and I think that’s problematic,” said GOP Sen. Susan Collins of Maine.
Senators have been meeting behind closed doors and with Trump administration officials as they rush to finish up the big bill ahead of the president's Fourth of July deadline. Much of the package, with its tax breaks and bolstered border security spending, is essentially drafted. But the size and scope of healthcare cuts are among the toughest remaining issues.
It's reminiscent of the summer during Trump's first term, in 2017, when Republicans struggled to keep their campaign promise to “repeal and replace” the Affordable Care Act, or Obamacare, only to see the GOP splinter over the prospect of Americans losing health coverage. That legislation collapsed when then-Sen. John McCain famously cast a thumbs-down vote.
Senate Majority Leader John Thune is determined to avoid that outcome, sticking to the schedule and pressing ahead with voting expected by the end of the week.
“This is a good bill and it's going to be great for our country,” Thune said Wednesday, championing its potential to unleash economic growth and put money in people's pockets.
The changes to the federal health care programs, particularly Medicaid, were always expected to become a centerpiece of the GOP package, a way to offset the costs of providing tax breaks for millions of Americans. Without action from Congress, taxes would go up next year when current tax law expires.
The House-passed bill achieved some $1.5 trillion in savings overall, a large part of it coming from changes to health care. The Medicaid program has dramatically expanded in the 15 years since Obamacare became law and now serves some 80 million Americans. Republicans say that's far too high, and they want to shrink the program back to a smaller size covering mainly poorer women and children.
House Democratic Leader Hakeem Jeffries said Republicans are “trying to take away healthcare from tens of millions of Americans.” Democrats are uniformly opposed to what they call the “big, ugly bill.”
Much of the health care cost savings would come from new 80-hour-a-month work requirements on those who receive Medicaid benefits, even as most recipients already work.
But another provision, the so-called provider tax that almost all the states impose to some degree on hospitals and others that serve Medicaid patients, is drawing particular concern for potential cuts to rural hospitals.
Sen. Josh Hawley, R-Mo., said several senators spoke up Wednesday during a private meeting indicating they were not yet ready to start voting. “That’ll depend if we land the plane on rural hospitals,” he said.
States impose the taxes as a way to help fund Medicaid, largely by boosting the reimbursements they receive from the federal government. Critics decry the system as a type of “laundering” but almost every state except Alaska uses it to help provide the health care coverage.
The House-passed bill would freeze the provider taxes at current levels, while the Senate proposal goes deeper by reducing the tax that some states are able to impose.
“I know the states are addicted to it,” said Sen. Roger Marshall, R-Kan. But he added, “Obviously the provider tax needs to go away.”
But a number of GOP senators, and the hospitals and other medical providers in their states, are raising steep concerns that the provider tax changes would decimate rural hospitals.
In a plea to lawmakers, the American Hospital Association said the cuts won’t just affect those who get health coverage through Medicaid, but would further strain emergency rooms “as they become the family doctor to millions of newly uninsured people.”
“And worse, some hospitals, especially those in rural communities, may be forced to close altogether,” said Rick Pollack, president and CEO of the hospital group.
The Catholic Health Association of the United States noted in its own letter that Medicaid provides health insurance coverage for one in five people and nearly half of all children.
“The proposed changes to Medicaid would have devastating consequences, particularly for those in small towns and rural communities, where Medicaid is often the primary source of health care coverage,” said Sister Mary Haddad, the group’s president and CEO.
Trying to engineer a fix to the problem, senators are considering creating a rural hospital fund to help offset the lost Medicaid money.
GOP senators circulated a proposal to pour $15 billion to establish a new rural hospital fund. But several senators said that's too high, while others said it's insufficient. Collins has proposed that the fund be set at $100 billion.
“It won’t be that big, but there will be a fund,” Thune said.
Hawley, who has been among those most outspoken about the health care cuts, said he's interested in the rural hospital fund but needs to hear more about how it would work.
He has also raised concerns about a new $35 per service co-pay that could be charged to those with Medicaid, which is in both the House and Senate versions of the bill.
“Getting the fund is good. That’s important, a step forward,” Hawley said. But he asked: “How does the fund actually distribute the money? Who will get it to hospitals? ... Or is this just going to be something that exists on paper?”
A new analysis from the White House Council of Economic Advisers estimates the package would result in up to $2.3 trillion in deficit reduction over 10 years, a markedly different assessment from other analyses. In contrast, the nonpartisan Congressional Budget Office’s dynamic analysis of the House-passed measure estimates an increase in deficits by $2.8 trillion over the next decade.
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Associated Press writers Kevin Freking, Mary Clare Jalonick, Joey Cappelletti and Fatima Hussein contributed to this story.
Senate Majority Leader John Thune, R-S.D., center, joined at left by Sen. John Barrasso, R-Wyo., the GOP whip, speaks to reporters after Republican senators met with Treasury Secretary Scott Bessent and worked on President Donald Trump's tax and immigration megabill so they can have on his desk by July 4, at the Capitol in Washington, Tuesday, June 24, 2025. (AP Photo/J. Scott Applewhite)
WASHINGTON (AP) — Becky Pepper-Jackson finished third in the discus throw in West Virginia last year though she was in just her first year of high school. Now a 15-year-old sophomore, Pepper-Jackson is aware that her upcoming season could be her last.
West Virginia has banned transgender girls like Pepper-Jackson from competing in girls and women's sports, and is among the more than two dozen states with similar laws. Though the West Virginia law has been blocked by lower courts, the outcome could be different at the conservative-dominated Supreme Court, which has allowed multiple restrictions on transgender people to be enforced in the past year.
The justices are hearing arguments Tuesday in two cases over whether the sports bans violate the Constitution or the landmark federal law known as Title IX that prohibits sex discrimination in education. The second case comes from Idaho, where college student Lindsay Hecox challenged that state's law.
Decisions are expected by early summer.
President Donald Trump's Republican administration has targeted transgender Americans from the first day of his second term, including ousting transgender people from the military and declaring that gender is immutable and determined at birth.
Pepper-Jackson has become the face of the nationwide battle over the participation of transgender girls in athletics that has played out at both the state and federal levels as Republicans have leveraged the issue as a fight for athletic fairness for women and girls.
“I think it’s something that needs to be done,” Pepper-Jackson said in an interview with The Associated Press that was conducted over Zoom. “It’s something I’m here to do because ... this is important to me. I know it’s important to other people. So, like, I’m here for it.”
She sat alongside her mother, Heather Jackson, on a sofa in their home just outside Bridgeport, a rural West Virginia community about 40 miles southwest of Morgantown, to talk about a legal fight that began when she was a middle schooler who finished near the back of the pack in cross-country races.
Pepper-Jackson has grown into a competitive discus and shot put thrower. In addition to the bronze medal in the discus, she finished eighth among shot putters.
She attributes her success to hard work, practicing at school and in her backyard, and lifting weights. Pepper-Jackson has been taking puberty-blocking medication and has publicly identified as a girl since she was in the third grade, though the Supreme Court's decision in June upholding state bans on gender-affirming medical treatment for minors has forced her to go out of state for care.
Her very improvement as an athlete has been cited as a reason she should not be allowed to compete against girls.
“There are immutable physical and biological characteristic differences between men and women that make men bigger, stronger, and faster than women. And if we allow biological males to play sports against biological females, those differences will erode the ability and the places for women in these sports which we have fought so hard for over the last 50 years,” West Virginia's attorney general, JB McCuskey, said in an AP interview. McCuskey said he is not aware of any other transgender athlete in the state who has competed or is trying to compete in girls or women’s sports.
Despite the small numbers of transgender athletes, the issue has taken on outsize importance. The NCAA and the U.S. Olympic and Paralympic Committees banned transgender women from women's sports after Trump signed an executive order aimed at barring their participation.
The public generally is supportive of the limits. An Associated Press-NORC Center for Public Affairs Research poll conducted in October 2025 found that about 6 in 10 U.S. adults “strongly” or “somewhat” favored requiring transgender children and teenagers to only compete on sports teams that match the sex they were assigned at birth, not the gender they identify with, while about 2 in 10 were “strongly” or “somewhat” opposed and about one-quarter did not have an opinion.
About 2.1 million adults, or 0.8%, and 724,000 people age 13 to 17, or 3.3%, identify as transgender in the U.S., according to the Williams Institute at the UCLA School of Law.
Those allied with the administration on the issue paint it in broader terms than just sports, pointing to state laws, Trump administration policies and court rulings against transgender people.
"I think there are cultural, political, legal headwinds all supporting this notion that it’s just a lie that a man can be a woman," said John Bursch, a lawyer with the conservative Christian law firm Alliance Defending Freedom that has led the legal campaign against transgender people. “And if we want a society that respects women and girls, then we need to come to terms with that truth. And the sooner that we do that, the better it will be for women everywhere, whether that be in high school sports teams, high school locker rooms and showers, abused women’s shelters, women’s prisons.”
But Heather Jackson offered different terms to describe the effort to keep her daughter off West Virginia's playing fields.
“Hatred. It’s nothing but hatred,” she said. "This community is the community du jour. We have a long history of isolating marginalized parts of the community.”
Pepper-Jackson has seen some of the uglier side of the debate on display, including when a competitor wore a T-shirt at the championship meet that said, “Men Don't Belong in Women's Sports.”
“I wish these people would educate themselves. Just so they would know that I’m just there to have a good time. That’s it. But it just, it hurts sometimes, like, it gets to me sometimes, but I try to brush it off,” she said.
One schoolmate, identified as A.C. in court papers, said Pepper-Jackson has herself used graphic language in sexually bullying her teammates.
Asked whether she said any of what is alleged, Pepper-Jackson said, “I did not. And the school ruled that there was no evidence to prove that it was true.”
The legal fight will turn on whether the Constitution's equal protection clause or the Title IX anti-discrimination law protects transgender people.
The court ruled in 2020 that workplace discrimination against transgender people is sex discrimination, but refused to extend the logic of that decision to the case over health care for transgender minors.
The court has been deluged by dueling legal briefs from Republican- and Democratic-led states, members of Congress, athletes, doctors, scientists and scholars.
The outcome also could influence separate legal efforts seeking to bar transgender athletes in states that have continued to allow them to compete.
If Pepper-Jackson is forced to stop competing, she said she will still be able to lift weights and continue playing trumpet in the school concert and jazz bands.
“It will hurt a lot, and I know it will, but that’s what I’ll have to do,” she said.
Heather Jackson, left, and Becky Pepper-Jackson pose for a photograph outside of the U.S. Supreme Court in Washington, Sunday, Jan. 11, 2026. (AP Photo/Jose Luis Magana)
Heather Jackson, left, and Becky Pepper-Jackson pose for a photograph outside of the U.S. Supreme Court in Washington, Sunday, Jan. 11, 2026. (AP Photo/Jose Luis Magana)
Becky Pepper-Jackson poses for a photograph outside of the U.S. Supreme Court in Washington, Sunday, Jan. 11, 2026. (AP Photo/Jose Luis Magana)
The Supreme Court stands is Washington, Friday, Jan. 9, 2026. (AP Photo/J. Scott Applewhite)
FILE - Protestors hold signs during a rally at the state capitol in Charleston, W.Va., on March 9, 2023. (AP Photo/Chris Jackson, file)
