Elizabeth MacDonough: Medicaid Expansion, the Byrd Rule, and the Senate Parliamentarian's Tightrope

Published on: Jun 27, 2025

Elizabeth MacDonough: The Senate Parliamentarian's Tightrope Walk

The Senate Parliamentarian is a crucial, yet often unseen, figure in the U.S. legislative process. Tasked with interpreting and applying the Senate's rules, the Parliamentarian advises the presiding officer on points of order and procedural questions. Elizabeth MacDonough, the current Senate Parliamentarian, has faced particularly challenging situations, especially when dealing with complex issues like Medicaid expansion and the Byrd Rule. This article delves into MacDonough's role, the complexities of the Byrd Rule, and the implications for Medicaid expansion under reconciliation.

Understanding the Senate Parliamentarian's Role

The Senate Parliamentarian's office is non-partisan, providing impartial guidance to both parties. The primary duty involves interpreting Senate rules and precedents. These interpretations are advisory, not binding, but they carry significant weight and are rarely overturned by the presiding officer. The Parliamentarian's expertise is essential for navigating the Senate's often arcane procedures, ensuring that legislation adheres to the established rules.

Elizabeth MacDonough's background includes a law degree from Vermont Law School and experience as an attorney in the Department of Justice. She served as a staff attorney for the Senate Judiciary Committee before becoming a Senate Parliamentarian, ultimately rising to the top position. Her tenure has been marked by high-stakes debates and intense scrutiny, particularly concerning budget reconciliation and its impact on healthcare policy.

The Byrd Rule: A Key Obstacle in Budget Reconciliation

The Byrd Rule, named after former Senator Robert Byrd, is a provision within the Congressional Budget Act of 1974 that restricts the types of provisions that can be included in reconciliation bills. Reconciliation is a streamlined legislative process used to expedite budget-related legislation, requiring only a simple majority (51 votes in the Senate) for passage, thus avoiding the threat of a filibuster. However, the Byrd Rule acts as a safeguard against using reconciliation for extraneous policy matters.

Specifically, the Byrd Rule allows senators to raise points of order against provisions in a reconciliation bill that are considered "extraneous." A provision is deemed extraneous if it meets any of the following criteria:

It does not produce a change in outlays or revenues.
It produces changes in outlays or revenues that are merely incidental to the non-budgetary components of the provision.
It is outside the jurisdiction of the committee that reported the reconciliation bill.
It increases outlays or decreases revenues during a fiscal year after the years covered by the reconciliation bill (the “Byrd Rule window,” typically 10 years).
It contains recommendations with respect to Social Security.

The impact of the Byrd Rule is significant. It forces legislators to carefully craft reconciliation bills, ensuring that all provisions have a direct and substantial budgetary impact within the 10-year window. This constraint can significantly limit the scope of policy changes that can be enacted through reconciliation.

Medicaid Expansion and the Byrd Rule: A Collision Course

Medicaid expansion, a key component of the Affordable Care Act (ACA), has been a frequent subject of debate in the context of budget reconciliation and the Byrd Rule. Attempts to either expand or repeal aspects of Medicaid through reconciliation have often faced challenges related to whether these provisions are primarily budgetary or policy-driven.

The central question is whether Medicaid expansion provisions have a sufficient budgetary impact to be considered permissible under the Byrd Rule. Opponents often argue that certain provisions, while having budgetary consequences, are primarily aimed at achieving broader policy goals related to healthcare access and coverage. They contend that these provisions are therefore extraneous and should be struck from the reconciliation bill.

Elizabeth MacDonough, as Senate Parliamentarian, has played a crucial role in determining the fate of Medicaid-related provisions in reconciliation bills. Her interpretations of the Byrd Rule have been highly consequential, shaping the contours of healthcare policy and impacting millions of Americans.

Examples of MacDonough's Rulings on Medicaid and the Byrd Rule

Several instances highlight the complexities and significance of MacDonough's role. One notable example is the 2017 attempt to repeal and replace the Affordable Care Act (ACA) through reconciliation. The proposed legislation included significant changes to Medicaid, including repealing the ACA's Medicaid expansion. MacDonough was called upon to determine whether these provisions complied with the Byrd Rule.

In this instance, MacDonough advised that certain provisions of the proposed repeal were indeed in violation of the Byrd Rule. Her reasoning often centered on whether the provisions had a primarily budgetary impact or were driven by broader policy objectives. For example, some provisions related to essential health benefits and individual mandates were deemed extraneous because their budgetary impact was considered secondary to their policy implications.

More recently, during debates over additional COVID-19 relief packages and attempts to further expand healthcare access, MacDonough's opinions were again sought on Medicaid-related provisions included in reconciliation bills. These situations underscore the ongoing relevance of the Byrd Rule in shaping healthcare policy through the reconciliation process.

Specifically, consider the debates surrounding the inclusion of a Medicaid expansion incentive in the American Rescue Plan (ARP) of 2021. The ARP sought to encourage the remaining states that had not expanded Medicaid under the ACA to do so by offering them a temporary increase in the federal medical assistance percentage (FMAP). This proposal aimed to incentivize expansion by providing a significant financial boost to states that chose to participate.

Republican lawmakers challenged the inclusion of this provision under the Byrd Rule, arguing that the incentive was primarily a policy change aimed at coercing states into expanding Medicaid, rather than a purely budgetary measure. They argued that the incentive was extraneous because its primary purpose was to achieve a policy outcome (Medicaid expansion) rather than simply reducing the federal deficit or increasing revenue.

MacDonough ultimately ruled against the inclusion of the full incentive provision in the reconciliation bill, citing the Byrd Rule. While the exact details of her reasoning are not publicly available, it's likely that she found the policy objective of incentivizing Medicaid expansion to be a dominant factor, making the budgetary impact secondary. This decision forced Democrats to remove the provision from the final bill, demonstrating the significant power of the Byrd Rule and the Parliamentarian's interpretation thereof.

The Broader Implications of MacDonough's Rulings

Elizabeth MacDonough's interpretations of the Byrd Rule have far-reaching implications for healthcare policy. By limiting the scope of what can be achieved through reconciliation, she has effectively constrained the ability of Congress to make significant changes to Medicaid and other healthcare programs without bipartisan support. This has led to increased reliance on other legislative avenues, which often require 60 votes in the Senate to overcome a filibuster.

The Byrd Rule, as interpreted by the Senate Parliamentarian, therefore acts as a significant check on the power of the majority party to unilaterally enact major policy changes through the budget process. This can lead to greater gridlock and necessitate bipartisan compromise, but it also ensures that significant policy changes are subject to more thorough debate and consideration.

Furthermore, MacDonough's rulings have highlighted the inherent tension between budgetary and policy considerations in the legislative process. Many policy changes inevitably have budgetary consequences, and vice versa. Determining which aspect is primary and which is secondary can be a subjective and challenging task, placing a heavy burden on the Senate Parliamentarian.

Criticisms and Controversies

The role of the Senate Parliamentarian, and particularly Elizabeth MacDonough's tenure, has not been without controversy. Both Democrats and Republicans have, at times, criticized the Parliamentarian's rulings, particularly when those rulings have thwarted their legislative objectives. Some critics argue that the Byrd Rule is overly restrictive and that the Parliamentarian's interpretations have been too narrow, unduly limiting the ability of Congress to address pressing policy challenges.

For example, during the debates over raising the debt ceiling, some Democrats explored the possibility of using reconciliation to bypass the need for Republican votes. However, the Byrd Rule posed a significant obstacle to this strategy, as it would have required Democrats to identify specific budgetary changes that would offset the increase in the debt ceiling. Critics argued that the Byrd Rule was being used to obstruct a necessary action and that the Parliamentarian's interpretation was hindering the government's ability to function effectively.

Conversely, Republicans have sometimes criticized MacDonough for rulings that they perceive as favoring Democratic policy objectives. These criticisms often center on the argument that the Parliamentarian is not adhering strictly enough to the text of the Byrd Rule and is instead allowing policy considerations to unduly influence her interpretations.

These criticisms underscore the inherently political nature of the Senate Parliamentarian's role. While the Parliamentarian is intended to be a non-partisan advisor, her decisions inevitably have significant political consequences, making her a target for criticism from both sides of the aisle.

The Future of the Byrd Rule and Medicaid Expansion

The future of the Byrd Rule and its impact on Medicaid expansion remain uncertain. As long as the Byrd Rule remains in effect, it will continue to constrain the ability of Congress to make significant changes to Medicaid through reconciliation. This means that any future attempts to expand or repeal aspects of Medicaid will likely face significant procedural hurdles, requiring careful consideration of the Byrd Rule's limitations.

There have been calls from some quarters to reform or even eliminate the Byrd Rule. Proponents of reform argue that the rule is outdated and unduly restrictive, hindering the ability of Congress to address complex policy challenges in a timely and effective manner. They suggest that the Byrd Rule should be modified to allow for greater flexibility in the reconciliation process, enabling Congress to enact more comprehensive legislation without being constrained by overly narrow budgetary considerations.

However, opponents of reform argue that the Byrd Rule serves an important purpose in preventing the abuse of the reconciliation process. They contend that the rule ensures that reconciliation is used primarily for budgetary matters, preventing it from being used as a vehicle for enacting extraneous policy changes that would otherwise require bipartisan support. They argue that eliminating or weakening the Byrd Rule would undermine the Senate's traditions of deliberation and compromise, leading to more partisan gridlock and less effective governance.

Elizabeth MacDonough's successors will undoubtedly face similar challenges in navigating the complexities of the Byrd Rule and its impact on healthcare policy. The Senate Parliamentarian's role will continue to be a critical one, shaping the contours of legislative debates and influencing the fate of significant policy initiatives.

Conclusion: A Delicate Balance

Elizabeth MacDonough's tenure as Senate Parliamentarian has been marked by significant challenges and controversies. Her interpretations of the Byrd Rule have had a profound impact on healthcare policy, particularly concerning Medicaid expansion. While her decisions have been criticized by both sides of the aisle, she has consistently strived to provide impartial guidance based on her understanding of Senate rules and precedents. The role of the Senate Parliamentarian requires a delicate balance between legal expertise, procedural knowledge, and political awareness, and MacDonough has navigated this complex terrain with skill and dedication. The future of Medicaid expansion and other healthcare policies will continue to be shaped by the Byrd Rule and the interpretations of future Senate Parliamentarians.