Beyond those budget numbers, negotiators included other provisions, some popular, others that may never have survived a full and open debate. The deal would repeal a powerful provision in the Affordable Care Act that empowered an independent medical advisory board to control the spiraling costs of Medicare. It would extend for one year 48 different tax credits that expired at the end of 2016, including credits related to mine safety, energy efficiency, rum imports, horse racing and economic development in American Samoa.
It would exempt a small private college in Kentucky from a tax on large higher education endowments that was included in last year’s tax law. Senate Democrats had used a parliamentary objection to strip that exemption, for Berea College, from the tax measure in December, only to see it return two months later.
And it would reauthorize funding for community health centers for two years with a $600 million increase as part of a new budget deal. Funding for the health centers, which serve more than 27 million people, had expired in October.
Speaker Paul D. Ryan of Wisconsin expressed confidence on Thursday morning that the bill would pass the House. But he also signaled that Republicans would not be able to muster enough votes to pass the measure on their own.
Graphic
Budget Deficits Would Balloon Under the Bipartisan Spending Deal
The two-year budget agreement reached by Senate leaders would contribute hundreds of billions of dollars to federal deficits.
“Part of it depends on the Democrats,” Mr. Ryan told the radio host Hugh Hewitt. “This is a bipartisan bill. It’s going to need bipartisan support. We are going to deliver our share of support. I feel very good about Republicans.”
A sizable number of House Republicans are likely to rebel against the deal because of its huge increase in spending. The conservative House Freedom Caucus, which has roughly three dozen members, formally opposed the deal on Wednesday night.
“It was pretty much a smorgasbord of spending and policy that got added to this,” said Representative Mark Meadows, Republican of North Carolina and the chairman of the Freedom Caucus. “Normally, people who eat at smorgasbords all the time are not the healthiest.”
On the other side of the political spectrum, some House Democrats could vote against it because it does nothing to move Congress closer to protecting undocumented young immigrants brought to the country as children, known as Dreamers.
Representative Nancy Pelosi of California, the House Democratic leader, said on Wednesday that she would oppose the budget deal unless Mr. Ryan offered a commitment to hold a vote on legislation in the House that would address the fate of the Dreamers. Lawmakers are seeking action to protect them because Mr. Trump is ending an Obama-era program that shields them from deportation, known as Deferred Action for Childhood Arrivals, or DACA.
On Thursday morning, Ms. Pelosi said she hoped Mr. Ryan would “man up” and make such a pledge, along the lines of one made by Senator Mitch McConnell of Kentucky, the majority leader. Nonetheless, Ms. Pelosi called the budget deal “a good bill.”
“I’m pleased with the product,” she said. “I’m not pleased with the process.”
Later Thursday, Mr. Ryan stressed his desire to address the fate of the young immigrants. But he did not offer the kind of open-ended commitment that might assuage Ms. Pelosi. Instead, he signaled that whatever bill the House considers would be one that Mr. Trump supports.
“To anyone who doubts my intention to solve this problem and bring up a DACA and immigration reform bill, do not,” he said. “We will bring a solution to the floor, one that the president will sign.”
The budget bill goes far beyond just raising federal spending to make permanent and temporary policy changes with far-reaching impacts. Perhaps most significantly, it would repeal the Affordable Care Act’s 15-member panel known as the Independent Payment Advisory Board, created to get Medicare spending under control.
President Barack Obama and his first budget director, Peter R. Orszag, as well as some health economists, championed the board as one of the most significant cost-control provisions of the 2010 health care law. But health care providers and some advocates for Medicare beneficiaries opposed the board, saying it could threaten patients’ access to care. Republicans said the panel symbolized much that was wrong with “Obamacare.”
Credit
Erin Schaff for The New York Times
With bipartisan opposition, however, members of the panel have never been appointed. Under the Affordable Care Act, the board was intended to recommend specific savings if Medicare spending per beneficiary was projected to grow faster than certain benchmarks. That has yet to happen.
The Congressional Budget Office estimated that eliminating the cost-control board would increase federal spending by a total of $17.5 billion over 10 years, because its recommendations would take effect in some years. Spending cuts recommended by the panel would take effect automatically unless Congress voted to block or change them.
Another provision buried in the bill makes a tweak to the sweeping tax overhaul that Congress approved in December, changing the language that spells out which colleges and universities are subject to an excise tax on their investment income.
The bill adds language that makes the excise tax applicable only to schools with “tuition-paying” students, shielding a school in Mr. McConnell’s home state, Berea College, that does not charge tuition.
The deal would also cut $1.35 billion in funding to an Affordable Care Act program meant to improve public health and prevention funding for states and municipalities. But it would give $6 billion in new funding to states to use fighting the opioid epidemic.
It would extend funding for the Children’s Health Insurance Program, which provides health insurance to children in low-income families, for an additional four years. Last month’s spending bill had already extended the program for six years, so now CHIP will be funded for an entire decade.
The bill extends a number of special payment bonuses for different Medicare providers, many of which were once intended to be temporary, but are regularly extended by Congress. Those include extra payments for rural hospitals, a higher payment rate for ambulances, and increased payment rates to certain Medicare doctors. It preserves loan repayment programs for health providers who choose to work in underserved areas, and preserves funding for hospitals that train residents.
The bill expands pilot programs meant to test the value of in-home care for some Medicare patients. And it expands the ability of private Medicare Advantage plans to offer so-called “telehealth,” where doctors treat patients over the phone or internet. It would allow Medicare providers who are part of an accountable care association to offer patients cash bonuses as incentives for healthy behaviors.
The bill increases discounts that pharmaceutical companies must give seniors enrolled in the Medicare Part D drug plans, by making the so-called “doughnut hole” smaller. This was a policy that was part of the Affordable Care Act, but the new legislation would speed up implementation by one year.
The bill would also extend funding for abstinence-only sex education programs.
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