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Jonathan Rivera had to get his foot, and part of his leg, amputated in January. Rivera lives in Florida—one of ten states which has declined federally backed Medicaid expansions through the Affordable Care Act, meant to patch state-level coverage gaps and allow more low-income people to qualify for care.

With House Republicans fielding Medicaid cuts in the range of hundreds of billions of dollars—at Trump’s behest—the income limits that determine eligibility, which already vary by state, could drop, putting Rivera and his wife at risk of losing health coverage despite their minimal income. Rivera’s wife, Dani, is also disabled, with nerve and cervical spine damage; her husband has been her caregiver since before his own medical emergencies. Their twelve-year-old son is autistic. If the couple did not have a child, in addition to being low-income, they wouldn’t have qualified for Medicaid at all under Florida’s strict eligibility requirements.

Without Medicaid, Rivera would not be able to afford prosthetics and associated care. A few years ago, he wasn’t on any insurance, and couldn’t afford diabetes medication, which led to the debilitatingly painful nerve condition Charcot foot. Unable to work, Rivera had surgery to rebuild his right foot in 2022. But returning to work as a cook led to further pressure on the foot, which he was forced to amputate. Now, the prospect of Medicaid cuts—and the possibility of losing coverage—loom over him.

“Getting kicked off it,” Rivera said, “would probably destroy me.”

Georgetown University public policy professor Edwin Park said that there are similarities between the current attacks on Medicaid and ones in 2017, during Trump’s first term, which also focused on “shifting the federal cost to states.” There are around 70 million Americans enrolled in Medicaid, half being children; 20 million of those enrollees only qualify due to Medicaid expansions—almost a third of the program. In a state like Florida, where there are 4.3 million people on Medicaid, around one million people are locked out by its refusal to take part in the expansion. (Required federal Medicaid eligibility groups also include disabled and aging people receiving Supplemental Security Income, pregnant people, and low-income children, all of whom Medicaid has to extend some level of coverage to in all states.)

The Riveras have been on private insurance in the past, but they faced high premiums, and—having had both—Rivera trusts Medicaid more for his post-amputation health care.

“States could restrict enrollment in some of the mandatory categories by lowering income thresholds or making it harder to keep,” said David Machledt, a senior health policy expert with the National Health Law Program. “The end result is people will lose coverage, and that will have major health impacts on those individuals.”

Elon Musk and Republican House Speaker Mike Johnson have been among many Medicaid opponents loudly promoting false, stereotyped accounts of widespread waste and fraud among its low-income recipients. But nearly two out of three working-age adults on Medicaid who aren’t on SSI—some seven million people—work. The truth of the matter is that most disabled people on Medicaid qualify due to income, which puts them at the highest risk for losing coverage if Republicans decide they’re not “poor enough” to cover. The approval process for SSI can take years, with tens of thousands of applicants dying annually while on wait lists. That leaves many disabled people too sick to work before the government agrees they’re “disabled enough,” if they end up qualifying at all.

“I don’t see how any state could protect people with disabilities from these kinds of cuts,” Park told me. “Two-thirds of people with disabilities who are on Medicaid aren’t eligible under the SSI pathway.”

And while cuts to Medicaid will be devastating for tens of millions of Americans, said Meg Comeau of Boston University’s Center for Innovation in Social Work and Health, “We won’t be able to get a good handle for a while on how many people are in those optional categories whose coverage has been taken away.” 

Harper Phillips, who lives outside Raleigh, North Carolina, qualified for Medicaid in late 2023 thanks to North Carolina’s Medicaid expansion—a vast improvement from Phillips’ previous coverage through their husband’s job at Target, which cost the couple $500 in monthly premiums against his take-home pay of just $1,700 per month. After launching in December 2023, North Carolina saw 600,000 enrollees under the expansion in its first year alone.

Medicaid meant Phillips, who lives with Hypermobile Ehlers-Danlos Syndrome and dysautonomia, is no longer afraid to visit medical specialists. “I’ve seen five or six specialists,” Phillips said. “That’s just not something I have to worry about.” But that’s also why Phillips is scared about having Medicaid being taken away from them. 

Machledt said that changes in people’s lives can be seen quickly in states that have taken part in Medicaid expansion: less medical debt, better access to health care, and improvements in health outcomes. On a macro level, Machledt says that expansions have led to more stabilization of rural health care and more health care jobs; he is concerned that rollbacks on Medicaid expansion will lead rural hospitals to close, given that nearly 14 million Medicaid enrollees live in rural areas.

Comeau is also concerned about the impact of Medicaid rollbacks on even middle-class children with disabilities. “Those fundamental changes in the optional categories of Medicaid enrollees will have a huge impact on kids who otherwise would not have access to the kind of life-saving and life-sustaining care that they need,” she added.

Some Republicans in Congress and state governments have raised work requirements as a way to cut down on how many people qualify for Medicaid, which would put around 36 million Medicaid enrollees at risk of being booted. 13 states had enacted Medicaid work requirements during the first Trump presidency; Georgia currently has the only active Medicaid program with such requirements. A recent investigation by ProPublica and the Current also found that Georgia’s program “cost federal and state taxpayers more than $86.9 million, three-quarters of which has gone to consultants.” In Arkansas alone, 18,000 people were kicked off Medicaid rolls during the first seven months of the state implementing work requirements in 2018.

Park cautions people to be wary of claims from some politicians that Medicaid work requirements will not impact disabled people. “The work requirements [don’t] include exemptions for people with SSI,” he said, “let alone all the other people with disabilities who are covered by Medicaid.” 

Kim Musheno, the Arc‘s senior director of Medicaid policy, said that medical exemption processes for work requirements are also flawed. “Exemptions required frequent documentation and verification, which created administrative barriers,” Musheno said. “Many individuals lost coverage simply because they couldn’t submit paperwork on time.” An October 2021 study also found that, of primary care providers in the first four states to enact Medicaid work requirements, one in five said they wouldn’t fill out paperwork signing off on work requirement exemptions, regardless of the circumstances.

Both Comeau and Machledt agree that it is not feasible for states to cough up the difference to make up for federal Medicaid cuts.

An April 2023 Congressional Budget Office analysis also predicts that enacting Medicaid work requirements will cost states a lot of money. “The CBO predicted it would increase state spending by $65 billion,” Machledt said. “So you’re shifting these costs onto the state budget that has to be balanced every year.”

There are avenues that states may likely take to reduce expenses, Comeau said, which include cutting provider costs. But, Comeau adds, “If they reduce provider rates, then fewer providers are interested in being enrolled.”

It also seems a likely possibility, Comeau explained, that states would roll back on optional Medicaid benefits, which includes a wide range of services people need, including physical therapy, prostheses like those Jonathan Rivera needs, hospice care, and certain prescription medication.

The right’s attacks on Medicaid, Machledt believes, “seem to be designed to trip people up and then blame them for falling.”