The Senate Finance Committee split upon party lines in a Thursday vote on the nomination of Chiquita Brooks-LaSure, President Joe Biden's pick to head the powerful agency overseeing Medicare and Medicaid, voting 14-14 to move to a full Senate vote without a recommendation for confirmation.
Panel Republicans said their dissent was not due to her background or qualifications, but objected to the Biden administration's decision to pull a Texas Medicaid waiver that gave the state more than $100 billion in federal funding over the next 10 years and more flexibility in structuring the program.
The vote comes after Sen. John Cornyn, R-Texas, said he would hold up the confirmation using a process allowing a sitting senator to temporarily block a nomination from advancing to a full-body vote. It's likely Cornyn's hold will slow the vote but not stop it, as Senate rules allow Majority Leader Chuck Schumer, D-N.Y., or Minority Leader Mitch McConnell, R-Ky., to make a motion to force a vote.
Brooks-LaSure, despite having a mostly frictionless committee hearing, isn't the only HHS nominee to have some difficulty getting through the process. HHS Secretary Xavier Becerra was grilled by committee Republicans earlier this year over his abortion views, though he ultimately was approved by a single-vote margin.
Cornyn's decision to slow Brooks-LaSure's confirmation process is due to the Biden administration rejecting his state's request to extend a Medicaid waiver that helped reimburse Texas hospitals for care given to uninsured patients, approved by the Trump administration, the senator said.
On Thursday, Cornyn asked the chairman of the Senate Finance Committee, Ron Wyden, D-Ore., to postpone the vote, giving him time to talk to White House Chief of Staff Ron Klain. Klain has offered to speak to Cornyn on the issue, according to the senator.
Wyden denied the request. In his comments at the markup, Cornyn noted his inclination would normally be to vote for Brooks-LaSure, who worked at CMS during the Obama administration and is widely considered a solid pick for the role.
But "until Texas can receive an assurance that this action will be rectified and the rug will not be pulled out from under our poorest patients, I cannot support the nominee at this time. I don't know what else to do," Cornyn said.
On April 16, White House officials told Texas it was denying the state's $100 billion-plus request to extend its existing Medicaid program for the next 10 years. Acting CMS Administrator Liz Richter said the Trump administration hadn't followed the rulemaking process in approving the request Jan. 15, scant days before Biden assumed office.
The approval was one of a flurry of last-minute policy actions from the Trump administration, many of which Biden has paused for review or walked back, including Trump's controversial approval of work requirements, programs tying Medicaid coverage to work or volunteering hours.
Ex-CMS Administrator Seema Verma, in her approval of Texas' waiver, said the state didn't have to go through the traditional comment-and-answer process due to the coronavirus pandemic. The Biden administration disagreed.
"Upon further review, we have determined that CMS materially erred in granting Texas's request for an exemption from the normal public notice process," Richter wrote in her Friday letter to Texas' Medicaid director.
However, two Biden administration officials told the Washington Post the move was meant to push the state to expand its Medicaid safety-net insurance program to a larger swath of its low-income residents, as allowed under the Affordable Care Act. Texas is one of 12 majority-red states that have elected not to receive additional federal funding in exchange for expanding Medicaid coverage.
Democrats in Congress attempted to nudge the holdouts in a COVID-19 relief package passed in mid-March. The American Rescue Plan provides additional financial incentives for states that haven't adopted the ACA's Medicaid expansion by upping the federal match rate.
However, Texas has proved unswayed, despite its poor coverage statistics.
More than 18% of Texans don't have health insurance — more than double the national average — making it the state with the highest percentage of uninsured residents in the nation, according to U.S. Census data.
The current Texas waiver, which allows the state to funnel Medicaid dollars into nontraditional programs that typically aren't allowed by the federal government, lasts through September 2022, so the state has time to re-up its waiver request through the rulemaking process.
But Cornyn said the decision threatens the state's most vulnerable patients by undermining its safety net and the ability of hospitals to care for Medicaid patients, calling it a "sucker punch" from the Biden administration.
However, progressives generally view the Section 1115 waiver as a stop-gap measure that doesn't actually help low-income or needy patients, as it pays hospitals for uncompensated emergency care but doesn't provide funds for investing in preventative or primary care that could prevent high-acuity needs in the first place.
Also Thursday, the Finance Committee voted 20-8 in favor of the nomination of Andrea Palm for HHS deputy secretary, moving her nomination to the full Senate for a vote.