WASHINGTON — By a single, tiebreaking vote, Senate Republicans on Tuesday approved President Trump’s signature legislation, a major step toward passage of a bill that would expand tax cuts while cutting health care access to millions.

Just 50 Republicans supported the legislation, forcing Vice President JD Vance to cast the deciding vote.

GOP Sens. Rand Paul of Kentucky, Thom Tillis of North Carolina and Susan Collins of Maine joined all Democrats in the chamber in opposition to the bill.

The legislation passed with the support of a key skeptic of its most controversial provisions: Republican Sen. Lisa Murkowski of Alaska, who persuaded Senate leadership to include several provisions uniquely beneficial to her state to secure her support.

The bill extends tax cuts and benefits first passed in 2017 under Trump that were set to expire later this year, while creating new eligibility requirements for food stamps and Medicaid, raising barriers to health care access that could result in 11.8 million Americans losing coverage by 2034, according to the nonpartisan Congressional Budget Office.

The House of Representatives will now have a second vote on a reconciled version of the bill in the coming days. Should it pass, it will go to the president’s desk for his signature.

But final approval in the House is not guaranteed. A bloc of fiscal hawks and a handful of Republican lawmakers in districts that rely especially on Medicaid could still sink the vote. House Minority Leader Hakeem Jeffries, a New York Democrat, said he expects every member of his caucus will be in attendance to attempt to prevent passage of a bill he called a “disgusting abomination.”

The CBO estimates that the Senate version of the bill would add at least $3.3 trillion to the national debt — $1 trillion more than the House version — over the next decade, and even more if Congress votes later to remove several expiration dates built into the legislation.

The House Freedom Caucus, which was founded by several GOP lawmakers to advocate for fiscal discipline, had warned Senate Republicans on Monday to make major changes to the bill to “at least be in the ballpark of compliance with the agreed upon House budget framework.”

“It’s not what we agreed to,” the caucus wrote in a statement. “Republicans must do better.” After the Senate vote, several members of the bloc criticized its version of the bill for new language on green energy, and Rep. Marlin Stutzman of Indiana said it still included “unacceptable increases to the national debt and the deficit.”

Many Republicans voted for the bill with reservations and out of fear of the alternative: Tax cuts affecting millions of American households and businesses passed under Trump in 2017 are set to expire at the end of the year without a congressional extension.

Yet those tax cuts, as well as other tax breaks and incentives for senior citizens and tip workers, are expensive proposals, cutting into federal revenues. To offset a fraction of those costs, Republicans for the first time made funding cuts to Medicaid, the Affordable Care Act and the Supplemental Nutrition Assistance Program.

Even still, the CBO and other independent organizations assessed that the bill will increase borrowing by trillions, at a time when even Wall Street has begun to fear consequences from runaway debt.

Maya MacGuineas, president of the Committee for a Responsible Federal Budget, said in a statement that the Senate bill would add $600 billion to the deficit in 2027 alone and push deficits above 7% of gross domestic product.

“The level of blatant disregard we just witnessed for our nation’s fiscal condition and budget process is a failure of responsible governing,” MacGuineas said. “These are the very same lawmakers who for years have bemoaned the nation’s massive debt, voting to put another $4 trillion on the credit card.”

“The Senate took a bill that already borrowed way too much, and took it from bad to worse,” MacGuineas added.

Speaking with reporters after the vote, Murkowski said the choice was “agonizing,” but that she “had to look on balance, because the people in my state are the ones that I put first.”

“We do not have a perfect bill by any stretch of the imagination. My hope is that the House is going to look at this and recognize that we’re not there yet,” she said.

Collins, who is up for reelection in Maine next year, said she supported the bill’s provisions extending tax cuts and benefits.

“My vote against this bill stems primarily from the harmful impact it will have on Medicaid, affecting low-income families and rural healthcare providers like our hospitals and nursing homes,” she wrote on X. “The Medicaid program has been an important healthcare safety net for nearly 60 years that has helped people in difficult financial circumstances.”

Democrats in the Senate were swift in their condemnation of legislation that they believe will be deeply harmful to Republican prospects in the next election cycle, possibly costing them control of both houses of Congress.

“Every single Senate Republican is going to have to answer for these cruel and unpopular cuts this election,” said Sen. Kirsten Gillibrand of New York. “This is putting their majority at serious risk.”

Polling shows that Americans broadly support extending the 2017 tax cuts. Other expensive programs in the bill — including additional funding for border security and defense — also enjoy public support. But polls indicate that the public disapproves of the bill overall by a double-digit margin due to its cuts to core government programs.

“Republicans’ big ugly bill is one of the most shameful and selfish pieces of legislation I have ever seen,” California Sen. Adam Schiff said after the vote. “This bill will result in the closure of hospitals and clinics, kick millions of Americans off of their health care, slash food assistance for families, kill thousands of jobs, destroy the future of renewable energy and raise energy bills by hundreds of dollars every year — all to give a massive tax cut to wealthy people and big corporations, and to benefit polluters.

“And if that was not bad enough,” Schiff added, “it will skyrocket the national debt and deficit to help pay for tax cuts for the wealthy, leaving our children and grandchildren to pick up the tab. For any of the bill’s supporters to claim the mantle of deficit reduction or fiscal responsibility is hypocrisy of the rankest order.”

Trump was at an event in Florida when the vote occurred, touring a detention facility for migrants set in the Everglades. The president’s megabill also includes a significant increase in funding for border security and defense.

“Oh, thank you,” Trump said amid applause when he was told the news of the vote. “I was also wondering how we’re doing, because I know this is prime time.”

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