The Senate has passed a $4.5 trillion tax cut bill after last-minute changes to its health care provisions, as Republicans scrambled to get their party on board.

A Republican megabill cuts $1 trillion from Medicaid, risking closures for hospitals that serve some of America’s most vulnerable. Rural hospitals in the U.S. already operate on a razor’s edge, but new cuts to Medicaid in the Republican appropriations bill could tip many of them into failure.