At the age of 62, Marya Parral knows that her, and her husband’s, years of being able to care for their two developmentally disabled sons are numbered, and so they have done everything they can to ensure their children can continue to live independently.

For their oldest, Ian, that’s meant placing him in a program on an organic farm that caters to people diagnosed with autism. For Joey, their youngest, who has both autism and Down syndrome, Parral has found a caregiver who can help him deliver newspapers and run errands around their community of Ocean City, New Jersey.

Parral said none of this would be affordable without help from Medicaid, the federal government’s insurance program for poor and disabled Americans. But this week, the Republican-controlled House of Representatives  that would make deep cuts to the program, and Parral worries her sons will lose what she has worked so hard to build.

“We’re not going to be alive forever. We’re trying to set up a life for them, but that entire life that we’re working so hard to set up for them is dependent on ,” Parral said. “So it’s really devastating to think about cuts.”

Producing a budget is the first step in the Republican-controlled Congress’s drive to enact legislation that will pay for Donald Trump’s priorities. House lawmakers will now spend weeks working to write and pass a bill that is expected to approve $4.5tn in extended tax cuts, as well as funding for Trump’s plan for mass deportations of undocumented immigrants.

To pay for it, Republicans are considering a rollback of the federal social safety net, particularly Medicaid, which has nearly 80 million enrollees in all 50 states. The budget plan proposes an $880bn reduction in funding for the insurance over the next 10 years, an amount that experts warn would hollow out the program and have ripple effects across the entire American healthcare system.

Megan Cole Brahim, a professor at Boston University School of Public  and an expert on Medicaid, said the cut was the largest ever proposed, and if enacted would “have far-reaching impacts not just for those who rely on Medicaid, but for entire communities and economies”.

“These changes mean millions of Americans – including the low-income, elderly, persons with disabilities, children – will lose health insurance coverage,” she said. “Others may see significant reductions in benefits or limited access to care. The impact on hospitals and health systems will be significant, particularly for safety-net and rural hospitals, which are already on the brink of closure. Patient revenues will fall, uncompensated care will rise. There will be staff layoffs and site closures.”

John Driscoll, a healthcare executive and chair of the board of UConn Health in Connecticut, said: “The scale of the buzzsaw cuts to Medicaid would undermine every hospital’s ability to actually support its mission to care for the community, and would be a dangerous cut to the nursing-home infrastructure in the country.”

Republican leaders backed the cuts to Medicaid, as well as to similar programs such as one that , as a way to mollify lawmakers in their party who want the US’s  addressed. Still, not everyone is pleased. As the budget was being debated, eight Republican representatives, some of whom Democrats are keen to unseat in next year’s midterm elections, , warning that their districts’ large Hispanic populations would be harmed.

“Slashing Medicaid would have serious consequences, particularly in rural and predominantly Hispanic communities where hospitals and nursing homes are already struggling to keep their doors open,” they said.

All eight ultimately voted for the resolution, but the dissent may be a warning sign for the budget’s prospects of enactment, particularly in the House, where the GOP has a mere three-seat majority. It also remains unclear whether Republicans will try to pass all of Trump’s priorities in one bill, or split them into two.

The GOP has made clear they want to fully pay for the extension of Trump’s tax cuts, and Elyssa Schmier, vice-president of government relations for advocacy group MomsRising, said Medicaid and social safety programs are the party’s prime targets for cost savings.

“If you’re not going to go after, say, the Pentagon budget, if they’re only going to go to some of these big mandatory spending programs, there’s only so many places that Republicans feel that they can go,” she said.

In the days since the budget’s approval, Johnson and Trump have scrambled to downplay the possibility of slashing Medicaid, insisting they intend only to root out “fraud, waste and abuse.”

“The president said over and over and over: ‘We’re not going to touch social security, Medicare or Medicaid.’ We’ve made the same commitment,” Johnson told CNN in an interview.

Democrats have little leverage to stop the budget, which can be passed with simple majorities in both chambers. But the Democratic senator Ruben Gallego warned that gutting the social safety net to extend tax cuts that have  will alienate voters who sided with the GOP last November.

“It will be on Donald Trump and Republicans, the fact that he’s going to side with the ultra-rich versus the working poor,” said Gallego, who won election to his seat in Arizona even as Trump captured the state’s electoral votes. “Families that are barely making a living, scratching a living, they’re now going to get kicked off healthcare to give tax cuts to the mega-rich.”

The proposed cut to Medicaid would remove billions of dollars in funding from congressional districts nationwide that are represented by lawmakers from both parties, according to  by the liberal Center for American Progress.

In California’s San Joaquin valley, the Democratic representative Jim Costa’s district would lose the third-largest amount of funding, according to the data, and Medicaid coverage would be imperiled for more than 450,000 residents.

“This reckless budget prioritizes the wealthy while devastating those who need help the most,” Costa said. “I voted no because this resolution is bad for our valley and a threat to the wellbeing of the people I represent.”
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