A single unelected bureaucrat has once again derailed a central piece of President Donald J. Trump’s pro-America agenda—this time by shielding illegal immigrants from being cut off from taxpayer-funded Medicaid benefits.

Senate Parliamentarian Elizabeth MacDonough, a holdover from the Obama-Biden era, ruled that a provision in the One Big Beautiful Bill (OBBB)—a sweeping piece of legislation being pushed by Senate Republicans—violates the rules of budget reconciliation and must be stripped out.

The provision would have barred illegal aliens from accessing Medicaid, a move widely supported by the conservative base and part of Trump’s broader push to end taxpayer-funded benefits for non-citizens.

Senate Republicans are advancing the bill using the budget reconciliation process, which allows legislation focused on federal spending and revenue to pass with just a simple majority, bypassing the usual 60-vote threshold needed to break a filibuster. But under the 1974 Congressional Budget Act, it’s up to the Senate Parliamentarian to determine whether each part of the bill is budget-related or just policy.

MacDonough—who has a long history of blocking conservative priorities—ruled against the GOP, forcing them to remove the Medicaid restriction targeting illegal immigrants, as well as provisions banning federal funds for transgender surgeries and limiting states from gaming the Medicaid system through so-called “provider taxes.”

The Wall Street Journal reported the decision last week, noting that MacDonough “blocked the GOP’s efforts to limit Medicaid and Medicare coverage for unauthorized migrants, ban the use of federal healthcare funding for transgender care and limit state ‘provider taxes.’”

The ruling triggered fierce backlash.

Sen. John Cornyn (R-TX) introduced an amendment Monday to waive the Budget Act for the Medicaid provision. It received a majority of votes but fell short of the 60 needed to override the parliamentarian, with the final tally at 56–44.

Turning Point USA CEO Charlie Kirk blasted the decision on X (formerly Twitter):

“Elizabeth McDonough stopped the Senate bill from blocking illegals from getting Medicaid.”
“An unelected Senate staffer is thwarting the will of 75 million people who voted to make sure foreign alien invaders aren’t getting taxpayer benefits. This is a red line. The Senate needs to CHANGE THE RULES, fire her, or find a solution.”

Though MacDonough blocked the ban on Medicaid benefits for illegals, she did allow a Medicaid work requirement to remain in the bill—one of the few wins for conservatives in her ruling.

“It is perfectly reasonable for taxpayers who are paying into the Medicaid program to insist that everyone in the program who can contribute do so, by working,” said Michael Cannon, director of health policy studies at the Cato Institute, in an interview with Fox Business.

MacDonough’s controversial influence is nothing new. Appointed in 2012 by former Democrat Senate Majority Leader Harry Reid, she has long been a wildcard in major legislative battles. She was kept in place by current Senate Majority Leader John Thune (R-SD), who took over the top role in January.

Even during the Biden administration, she wasn’t always favorable to the left. She famously blocked Democrats from using reconciliation to ram through a $15 minimum wage and a mass amnesty plan for 8 million illegal immigrants.

Still, many conservatives are asking why the Senate GOP continues to defer to a staff attorney with no electoral mandate, especially when her rulings consistently undermine the will of the American people.

The pressure is now on Republican leadership to find a path forward—either by removing MacDonough, challenging her rulings, or rewriting Senate rules to prevent unelected staffers from derailing conservative policy.