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Congress’ health deal still has hurdles

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After months of fruitless negotiations to extend Affordable Care Act subsidies that have since expired, congressional leaders announced Tuesday they’d notched a rare bipartisan win to overhaul other parts of the health care system.

Now they just have to hold onto it.

The agreement, attached to a government spending bill, would implement long-sought changes to the way pharmacy benefit managers operate, as well as extensions of public health programs and increased funding for community health centers. But even with strong support in both chambers, the bill faces significant hurdles.

Lawmakers must navigate around the powerful lobbyists for pharmacy benefit managers, or PBMs — the intermediaries who negotiate drug prices on the behalf of employers and insurers — who have handily defeated similar proposals in the past.

They also must reckon with conservative hard-liners who don’t like some of the provisions and could be prepared to weaponize the House GOP’s perilously slim margins to tank the effort by opposing a party-line procedural rule that would bring the funding measure to the floor.

One such provision in the health care package, championed by Sen. Bill Cassidy (R-La) and Bernie Sanders (I-Vt.) — the chair and ranking member of the Senate HELP Committee, respectively — would prevent PBMs from getting revenue from drug rebates. This proposal, which has buy-in from Senate and House GOP leadership, has infuriated the industry and its allies.

“Especially in the time in which we’re seeing health insurance premiums go up, this is just going to make it worse,” said Rep. Eric Burlison (R-Mo.) in an interview Wednesday. “What Senator Cassidy has done has gone, I think, way too far over the line.”

PBMs negotiate rebates, or discounts, with drugmakers for employer health plans and other payers in an opaque process that has drawn scrutiny over whether discounts are passed on to consumers or retained to boost profits. Drugmakers, under pressure to reduce high prescription drug prices, have been pointing the finger at PBMs as the culprit.

A spokesperson for Cassidy declined to comment.

If the health care package passes as part of the government funding measure, Democrats will have helped Republicans with a major health victory at a time when the GOP is particularly vulnerable on the issue.

Democrats have been hammering Republicans for months over their inaction on extending the enhanced Obamacare subsidies that lapsed at the end of last year. They have made the premiums that have skyrocketed as a result the centerpiece of a nascent midterm campaign assailing Republicans on “affordability.”

Talks for a subsidy extension remain ongoing in the Senate, but lawmakers left last week for a 10-day recess without reaching a deal. Abortion restrictions and minimum premium payments are the biggest impediments to landing a compromise.

For many Republicans, the health care bill they want to pass now as part of legislation to fund several government agencies —including Health and Human Services — also answers President Donald Trump’s demands that Congress end kickbacks to PBMs and require more transparency from insurers. Those elements were included in the president’s health care proposal released last week.

Some Democrats said the policy goal was too important to pass up, even though the deal did not include an extension of the ACA subsidies. A similar effort at the end of 2024 was torpedoed when billionaire Elon Musk blasted government funding legislation that contained the PBM measures, and there’s a desire not to squander the same opportunity this time around.

“We’ve wanted to clean up PBMs. We have to believe that not everything they do is wrong,” said Rep. Don Beyer (D-Va.) Wednesday.

Rep. Kathy Castor (D-Fla.), meanwhile, warned that while Republicans did the right thing on PBMs, it doesn’t mean healthcare will not be a major issue in the midterms.

“Do they get credit for doing the right thing [that] they should have been doing all year long? Okay,” she said.

The GOP and free-market healthcare 

Cassidy, in a statement, said the health package delivers “real, conservative reforms that rein in healthcare middlemen, make prescription drugs more affordable and increase access to lifesaving treatments for children.”

The rebate provision in the bill he authored with Sanders does have support from traditional GOP allies in the business sector. The ERISA Industry Committee, which represents self-funded large employer health plans, has repeatedly pushed for targeting PBM rebates among other reforms.

Rep. Chip Roy (R-Texas) said earlier this week he is still reviewing the package, but mainly wanted more transformational overhauls as insurers who own PBMs could potentially negate any changes.

“I am for the reforms, but at the end of the day insurers own the PBMs and they are just going to shuffle the deck chairs around and keep doing what they want to do,” he said.

For Washington’s influence sector, Republican support for the PBM changes mark a shift within the party away from its free market orthodoxy.

“It’s really like Congress dictating how two private companies can contract … From a historical context, Republicans are not big on interfering with the present marketplace,” said one insurance lobbyist granted anonymity to speak candidly.

Making a deal 

Lawmakers have pushed to return to PBM overhaul legislation since the Dec. 2024 package’s collapse.

“These should have been passed, a lot of them, last year,” said Castor. “They were poised to pass until Elon Musk got involved.”

House Republicans have also been eager to make up for failed attempts to include several health care provisions in their sweeping tax and spending megabill last summer, but they were stripped out in the Senate for not complying with the rules governing the budget reconciliation process.

January offered an enticing opportunity for lawmakers to try again as efforts to craft full-year appropriations bills picked up steam. Normally a health package runs as part of a larger, must-pass government funding measure to help ensure its success.

But the government has been running on stopgap spending bills since March 2024. House Republican leadership has been reluctant to add policy riders to such bills to ensure enough support from fiscal hawks.

This health care package came together relatively quickly this month as most of the items had already been considered – and vetted – previously, chiefly in the scrapped Dec. 2024 government funding legislation. There also were markups and committee hearings on the package’s contents, including regarding PBMs, throughout 2025, giving lawmakers a chance to become familiar with the policies. including on PBM reform, according to a Senate aide familiar with the negotiations.

Pharmacy benefit managers “hate” the reforms “but they … should not be surprised, because it’s been baked,” said another Senate GOP aide familiar with the health care package, granted anonymity to speak candidly of the PBM provisions. “And the cake has been sitting on a shelf in a deep freezer, perfectly maintained for like three years.”

Industry evasion 

Even with the latest proposed changes designed to bring accountability to PBMs and how they operate, lobbyists representing insurers, pharmaceutical companies and pharmacies say that PBMs have still largely outmaneuvered Congress.

The industry has spent years evading bipartisan congressional scrutiny, even as state legislatures moved in to reign in the sector. Since calls for reform took off in 2023, the Pharmaceutical Care Management Association, a major trade group, spent $47 million lobbying elected officials against placing guardrails on PBMs — about twice its spending from the prior three-year period.

“The market has outpaced Congress on this by a pretty wide margin,” said Adam Colborn, associate vice president at the Academy of Managed Care Pharmacy, which counts UnitedHealth, CVS Health, and Express Scripts as members. “There’s been a lot of emotion on both sides of the debate, but getting down to the nuts and bolts, there’s a relatively low ceiling for change.”

In October, Cigna announced that it would overhaul its pricing model and remove its system based on rebates, following a commitment from UnitedHealth to pass through 100 percent of rebates in January and a decision from CVS to do so in 2019 — a move analysts view as an effort by industry to get ahead of reform efforts on Capitol Hill.

“I don’t think anybody’s gonna be shooting off fireworks here … It’s not going to be a game changer,” said one pharmaceutical lobbyist, granted anonymity to share internal discussions of the health care deal currently pending before lawmakers.

On Tuesday, PCMA slammed the Cassidy-Sanders PBM provision, warning that such a proposal would limit companies’ ability to use alternative payment models and raise prices and urging Congress to shift its scrutiny on the pharmaceutical industry instead.

“PBMs are innovating business models to lower costs and meet employer demands far more quickly than Congress could ever implement,” Brendan Buck, PCMA’s chief communications officer, said in a statement. “It makes no sense to ban flexibility and choice and lock employers into a single system that will lead to higher drug costs.”

In September, PCMA launched a six-figure ad campaign in Washington accusing pharmaceutical companies of keeping prices high, following a similar campaign targeting PBMs from the Pharmaceutical Research and Manufacturers of America, which represents brand-name drugmakers in May.

Lobbyists and experts predict the PBM overhauls proposed by Congress are likely only the beginning as lawmakers ramp up scrutiny of the health care sector over high prices – and seek more opportunities to show voters in an election year they care about lowering health care costs.

“This is the opening salvo in what is going to be a long battle for reform,” said Sujith Ramachandran, an assistant professor at the University of Mississippi School of Pharmacy.

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Congress

Trump met with Coinbase CEO before bashing banks over crypto bill

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President Donald Trump met privately on Tuesday with Coinbase CEO Brian Armstrong before publicly backing the company’s position in an ongoing lobbying clash with banks that has derailed a major cryptocurrency bill, according to two people with knowledge of the matter who were granted anonymity to discuss a closed-door matter.

It is unclear what was discussed during the meeting, but it came just before Trump wrote on social media that banks “need to make a good deal with the Crypto Industry” in order to advance digital asset legislation that has stalled on Capitol Hill. He wrote that a recently adopted crypto law is “being threatened and undermined by the Banks, and that is unacceptable” — echoing Coinbase’s position.

A spokesperson for Coinbase declined to comment. The White House did not immediately respond to a request for comment.

The policy clash centers around whether crypto exchanges like Coinbase should be able to offer rewards programs that pay an annual percentage yield to customers who hold digital tokens known as stablecoins that are designed to maintain a value of $1. Wall Street groups are warning that allowing yield-like payments on stablecoins could lead customers to pull deposits from bank accounts and threaten lending that is critical to the economy.

Banks are pushing to ban any type of stablecoin yield payments as part of a sweeping crypto regulatory bill that is currently pending in the Senate. But a wide array of digital asset firms have fought back, and the rift helped derail the so-called crypto market structure legislation bill earlier this year. The legislation would establish new rules governing how crypto tokens are overseen by market regulators — a longtime lobbying goal for digital asset firms, which say they need “regulatory clarity” from Washington.

Coinbase, the largest U.S.-based crypto exchange, has played a key role in the spat. On the eve of a scheduled Senate Banking Committee markup in January, Armstrong came out against the most recent publicly released draft of the crypto bill. He warned in part against “Draft amendments that would kill rewards on stablecoins, allowing banks to ban their competition.” The markup was later postponed, and the bill has remained stalled ever since.

Since then, White House officials have sought to mediate a compromise between the two sides. The White House hosted a series of meetings with representatives from the banking and crypto sectors, but significant differences remain between the two sides and no deal has emerged.

Coinbase has become a major player in Trump’s Washington, thanks in part to massive political spending that is already beginning to shake up the 2026 midterm elections. The exchange, which was co-founded by Armstrong, is a leading backer of a crypto super PAC group known as Fairshake that is armed with a war chest of more than $190 million. Coinbase also donated to Trump’s inaugural committee and to the president’s White House ballroom renovation effort.

In his post on Truth Social Tuesday, Trump included a line that Armstrong has uttered verbatim in interviews about the stablecoin yield fight: “Americans should earn more money on their money.” Separately, on Tuesday night, Trump also posted a picture of an X post from Armstrong praising him for delivering “on his campaign promise to make America the crypto capital of the world.”

The crypto “Industry cannot be taken from the People of America when it is so close to becoming truly successful,” Trump wrote in the initial post.

Declan Harty contributed to this report.

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Lawmakers anticipate Trump will seek emergency funding for ‘open-ended’ Iran war

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Lawmakers given classified briefings Tuesday evening on the U.S. military conflict in Iran expect President Donald Trump will ask Congress for emergency cash to finance the war.

During the closed-door meetings on Capitol Hill, top Trump administration officials said only that they are considering a supplemental military funding request, according to lawmakers who attended the briefings. But senior intelligence and defense officials described a vast military operation that many members anticipate will require extra funding on top of the nearly $1 trillion Congress has already given the military over the last year.

“I think there will be a supplemental coming,” Sen. Lindsey Graham (R-S.C.) told reporters upon leaving his classified Senate briefing. “We’ll have to approve that.”

Sen. Chris Murphy of Connecticut, the top Democrat on the Senate committee overseeing funding for the Department of Homeland Security, said after the briefing that the military operation “feels like a multitrillion-dollar, open-ended conflict with a very confusing and constantly shifting set of goals” because top Trump administration officials “are refusing to take off the table ground operations.”

Sen. Josh Hawley (R-Mo.) also described the U.S.-Iran conflict as “a massive operation” that’s “rapidly changing.”

“It sounded very open-ended to me,” he added.

Some lawmakers typically opposed to increased spending are open to the idea of providing extra money to fuel the U.S. military’s operation against Iran. “I think it would have support of Republicans,” Sen. Ron Johnson (R-Wis.) said about a supplemental funding request Tuesday night.

“Everybody always wants money, any excuse, whether they’ll need it or not. My guess: They’ll need it,” Johnson continued. “We’re shooting off a lot of ammo. Gotta restock.”

But Democratic votes will be needed to pass any emergency funding package in the Senate, and minority party leaders say they will need far more details from the Trump administration if they are going to consider support for new Pentagon cash.

“Before you can feel satisfied about a supplemental — and I haven’t seen it — you have to know what the real goals are and what the endgame is,” Senate Minority Leader Chuck Schumer told reporters Tuesday.

Delaware Sen. Chris Coons, a senior Democratic appropriator, said he expects the Pentagon will send Congress a supplemental funding request and vowed to “make sure we are making all the investments we can” to keep U.S. troops safe.

But Coons said Trump administration officials need to testify at an open hearing so “the American people can get questions answered about the failures in planning that led to some of the challenges, losses and mistakes in this war.”

Any supplemental spending package to support the Iran war effort would come on top of the more than $150 billion the Pentagon got from the party-line tax and spending package Republicans enacted last summer and nearly $839 billion in regular funding Congress cleared last month.

The House’s lead Democratic appropriator, Connecticut Rep. Rosa DeLauro, said lawmakers have yet to receive information about how much the Pentagon has spent already.

“They’re talking about a supplemental, but we haven’t got a clue,” DeLauro told reporters after Trump administration officials briefed House lawmakers later Tuesday. “There’s no cost estimate of what they have spent so far. Is there anybody writing down what the hell they’re spending? No.”

Senate Majority Leader John Thune said Tuesday that Republicans “forward-funded” military operations with the party-line package enacted last summer but that lawmakers will be “paying attention” to any need for extra money.

“Not only do we have the resources to conduct the operations right now, but a lot of our allies in the region also have capabilities that are coming to bear now,” Thune said.

Even before the strikes on Iran, Trump was eyeing a massive hike in military spending for the upcoming fiscal year. He pledged to pursue a $1.5 trillion Pentagon budget, a roughly 50 percent increase to military spending.

The president said Tuesday, however, that U.S. military resources are far from depleted.

“We have a virtually unlimited supply of these weapons,” Trump said on social media. “Wars can be fought ‘forever,’ and very successfully, using just these supplies.”

Jordain Carney, Meredith Lee Hill, Connor O’Brien, Joe Gould and Calen Razor contributed to this report. 

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House Republicans are publicly cheering Trump’s Iran war. Privately, many are worried.

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The vast majority of congressional Republicans are publicly supportive of President Donald Trump’s decision to launch a war on Iran. But many are harboring private misgivings about the risks to American troops and global stability — as well as their own political fortunes — should the military campaign drag on indefinitely.

Trump’s comments this week that the bombing could last “four to five weeks” or more, that he doesn’t care about public polling and that the U.S. will do “whatever” it takes to secure its objectives are among the factors that have put lawmakers on edge.

Some of the anxieties have started emerging publicly.

“The constitutional sequence is, you engage the public before you go to war unless an attack is imminent. And imminent means like, imminent — not like something that’s been over a 47-year period of time,” Rep. Warren Davidson (R-Ohio), a former Army ranger, said Tuesday.

Rep. Eli Crane (R-Ariz.), a combat veteran who served in the Iraq War and has cautioned in the past against regime change efforts, called it “a very dicey, a very dynamic situation right now” on the Charlie Kirk Show Monday while also making clear he would give Trump deference.

“I hope it works out,” he added. “Military operations like this can go sideways so fast, you know, it will make your head spin.”

But a wider group of House Republicans granted anonymity to speak candidly shared deeper concerns about the strikes. All said they would stand with Trump and Speaker Mike Johnson this week to oppose a largely Democratic effort to force votes on restraining the president. But they said their support was not guaranteed over the long term.

“Most Republicans want clear objectives, clearer than they are now,” said one House Republican, who added members have pressed GOP leaders and White House officials to be more consistent in articulating the administration’s military goals.

Another was troubled by Trump’s own shifting statements on when the bombing campaign might wrap up, whether he is seeking the fall of the Islamic regime and whether ground troops might ultimately be necessary.

“Sounds a little bit like President Lyndon Johnson going into Vietnam, doesn’t it?” the lawmaker said.

Trump officials and top House GOP leaders have already moved to ease potential member concerns. Johnson, for instance, said leaving a classified briefing Monday that “the operation will be wound up quickly, by God’s grace and will.”

“That is our prayer for everybody involved,” he added.

A White House memo sent to congressional Republicans Monday outlined several military objectives for the bombing campaign and said Trump should be “commended” for taking on a hostile state sponsor of terrorism.

But despite denying that Trump had acted in pursuit of regime change, the document also said the Iranian regime “would be defeated” and included other contradictory statements about the reasons for the strikes — while trying to sidestep the question of whether the strikes constituted a “war,” a word Trump himself has used.

Beyond the fears of a prolonged military engagement that could be costly in dollars and American lives, Republicans are also facing the prospect of a stock market tumble and rising gas prices that could fall hardest on vulnerable incumbents ahead of the midterms. Many of those members promised their constituents, much as Trump did, that they would not engage in endless war.

The planned Thursday vote on a bipartisan war powers resolution has surfaced some of the GOP discomfort, even as party leaders and White House officials whip members against it — including those most at risk of losing their seats.

Rep. Thomas Massie (R-Ky.), who is co-leading the war powers push with Rep. Ro Khanna (D-Calif.), pointed to the White House memo as further evidence of incoherence on the administration’s part.

“So they’re going to defeat a terrorist regime that rules a country of 90 million people, but that’s not war?” he said in an interview.

Johnson argued Monday it would be

Also raising concerns in advance of the vote is Davidson, who has long railed against extended U.S. wars abroad. He said in a social media post Monday it was “troubling” that Secretary of State Marco Rubio said Monday that an imminent Israeli attack on Iran forced the U.S. to strike. He also raised concerns to reporters Tuesday about some of the administration’s claims.

House Intelligence Chair Rick Crawford (R-Ark.) said in an interview Tuesday he didn’t think the war powers vote was necessary and that Trump was operating within his legal authority.

The vote, he said, was “a way for individuals to sort of register their displeasure or make a political statement.”

Even if the war powers measure is defeated, some Republicans say an effort to restrain Trump could reemerge if the conflict drags on or Trump commits ground troops to the conflict. “If we’re talking months, not weeks, then you will see another vote,” said a third House Republican who added that Trump had some “leeway” for now.

Johnson, meanwhile, is channeling any intraparty concerns about Trump’s war into another vote this week on a stalled Homeland Security spending bill — an attempt to keep the focus on Democrats’ opposition to funding for TSA, FEMA and other agencies as a department shutdown approaches the three-week mark.

He is also arguing, as he told reporters after a classified briefing Monday, that the war powers vote is “dangerous” at a moment when U.S. troops were in harm’s way and that Republicans would act to “put it down.” The strikes, Johnson added, did not need advance congressional approval because they were “defensive in nature.”

Those arguments have resonated with most House Republicans, who say they’re willing to give the president time.

“I think so far, the Pentagon seems to have a good plan,” said Rep. Jeff Crank (R-Colo.), a member of the Armed Services Committee who said he would give Trump “six weeks or … eight weeks or whatever we need to accomplish the missions that we set out.”

“The worst thing we could do is go in and then … to pull back or cut short, whatever our objectives are,” he added. “We’re there. We need to get the objectives finished.”

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