Medicaid

Pregnancy centers in the U.S. that discourage women from getting abortions have been adding more medical services — and could be poised to expand further.

The expansion — including testing and treatment for sexually transmitted infections (STIs) and even providing primary medical care — has been unfolding for years. It gained steam after the Supreme Court overturned Roe vs. Wade three years ago, clearing the way for states to ban abortion.

The push could get more momentum with Planned Parenthood closing some clinics and considering shutting others after changes to Medicaid. Planned Parenthood is not just the nation’s largest abortion provider, but also offers cancer screenings, sexually transmitted infection testing and treatment, and other reproductive health services.

“We ultimately want to replace Planned Parenthood with the services we offer,” said Heather Lawless, founder and director of Reliance Center in Lewiston, Idaho. She said about 40% of patients at the antiabortion center are there for reasons unrelated to pregnancy, including some who use the nurse practitioner as a primary caregiver.

The changes have frustrated abortion rights groups, who, in addition to opposing the centers’ antiabortion messaging, say they lack accountability; refuse to provide birth control; and offer only limited ultrasounds that cannot be used for diagnosing fetal anomalies because the people conducting them don’t have that training. A growing number also offer unproven abortion-pill reversal treatments.

Because most of the centers don’t accept insurance, the federal law restricting release of medical information doesn’t apply to them, though some say they follow it anyway. They also don’t have to follow standards required by Medicaid or private insurers, though those offering certain services generally must have medical directors who comply with state licensing requirements.

“There are really bedrock questions about whether this industry has the clinical infrastructure to provide the medical services it’s currently advertising,” said Jennifer McKenna, a senior advisor for Reproductive Health and Freedom Watch, a project funded by liberal policy organizations that researches the pregnancy centers.

Post-Roe world opened new opportunities

Perhaps best known as “crisis pregnancy centers,” these mostly privately funded and religiously affiliated centers were expanding services such as diaper banks ahead of the Supreme Court’s 2022 Dobbs vs. Jackson Women’s Health Organization ruling, which overturned Roe.

As abortion bans kicked in, the centers expanded medical, educational and other programs, said Moira Gaul, a scholar at the Charlotte Lozier Institute, the research arm of SBA Pro-Life America. “They are prepared to serve their communities for the long term,” she said in a statement.

In Sacramento, for instance, Alternatives Pregnancy Center in the last two years has added family practice doctors, a radiologist and a specialist in high-risk pregnancies, along with nurses and medical assistants. Alternatives — an affiliate of Heartbeat International, one of the largest associations of pregnancy centers in the U.S. — is some patients’ only health provider.

When the Associated Press asked to interview a patient who had received only non-pregnancy services, the clinic provided Jessica Rose, a 31-year-old woman who took the rare step of detransitioning after spending seven years living as a man, during which she received hormone therapy and a double mastectomy.

For the last two years, she’s received all her medical care at Alternatives, which has an OB-GYN who specializes in hormone therapy. Few, if any, pregnancy centers advertise that they provide help with detransitioning. Alternatives has treated four similar patients over the last year, though that’s not its main mission, director Heidi Matzke said.

“APC provided me a space that aligned with my beliefs as well as seeing me as a woman,” Rose said. She said other clinics “were trying to make me think that detransitioning wasn’t what I wanted to do.”

Pregnancy centers expand as health clinics decline

As of 2024, more than 2,600 antiabortion pregnancy centers operated in the U.S., up 87 from 2023, according to the Crisis Pregnancy Center Map, a project led by University of Georgia public health researchers who are concerned about aspects of the centers. According to the Guttmacher Institute, 765 clinics offered abortions last year, down more than 40 from 2023.

Over the years, pregnancy centers have received a boost in taxpayer funds. Nearly 20 states, largely Republican-led, now funnel millions of public dollars to these organizations. Texas alone sent $70 million to pregnancy centers this fiscal year, while Florida dedicated more than $29 million for its “Pregnancy Support Services Program.”

This boost in resources is unfolding as Republicans have barred Planned Parenthood from receiving Medicaid funds under the tax and spending law President Trump signed in July. While federal law already blocked the use of taxpayer funds for most abortions, Medicaid reimbursements for other health services were a big part of Planned Parenthood’s revenue.

Planned Parenthood said its affiliates could be forced to close up to 200 clinics.

Some already had closed or reorganized. They have cut abortion in Wisconsin and eliminated Medicaid services in Arizona. An independent group of clinics in Maine stopped primary care for the same reason. The uncertainty is compounded by pending Medicaid changes expected to result in more uninsured Americans.

Some abortion rights advocates worry that will mean more healthcare “deserts” where the pregnancy centers are the only option for more women.

Kaitlyn Joshua, a founder of abortion rights group Abortion in America, lives in Louisiana, where Planned Parenthood closed its clinics in September.

She’s concerned that women seeking health services at pregnancy centers as a result of those closures won’t get what they need. “Those centers should be regulated,” she said. “They should be providing information which is accurate, rather than just getting a sermon that they didn’t ask for.”

Thomas Glessner, founder and president of the National Institute of Family and Life Advocates, a network of 1,800 centers, said the centers do have government oversight through their medical directors. “Their criticism,” he said, “comes from a political agenda.”

In recent years, five Democratic state attorneys general have issued warnings that the centers, which advertise to people seeking abortions, don’t provide them and don’t refer patients to clinics that do. And the Supreme Court has agreed to consider whether a state investigation of an organization that runs centers in New Jersey stifles its free speech.

Different services than Planned Parenthood

Choices Medical Services in Joplin, Mo., where the Planned Parenthood clinic closed last year, moved from focusing solely on discouraging abortion to a broader sexual health mission about 20 years ago when it began offering STI treatment, said its executive director, Karolyn Schrage.

The center, funded by donors, works with law enforcement in places where authorities may find pregnant adults, according to Schrage and Arkansas State Police.

Schrage estimates that more than two-thirds of its work isn’t related to pregnancy.

Hayley Kelly first encountered Choices volunteers in 2019 at a regular weekly dinner they brought to dancers at the strip club where she worked. Over the years, she went to the center for STI testing. Then in 2023, when she was uninsured and struggling with drugs, she wanted to confirm a pregnancy.

She anticipated the staff wouldn’t like that she was leaning toward an abortion, but she says they just answered questions. She ended up having that baby and, later, another.

“It’s amazing place,” Kelly said. “I tell everybody I know, ‘You can go there.’”

The center, like others, does not provide contraceptives — standard offerings at sexual health clinics that experts say are best practices for public health.

“Our focus is on sexual risk elimination,” Schrage said, “not just reduction.”

Mulvihill and Kruesi write for the Associated Press.

More than a thousand chanting healthcare workers, activists and local officials filled the Los Angeles Convention Center on Thursday afternoon to protest pending trillion-dollar healthcare cuts contained in Trump’s “Big Beautiful Bill.”

“Healthcare right now in America is bad,” said Romond Phillips, a mobile clinic driver, who attended the rally. “I’m out on the front lines, so I see the need for it.”

David Rolas, a community advocate from South L.A., came out to the rally to show his support. He says, growing up, he remembers how hard it was to get access to healthcare and how many people died because of it. He was diagnosed with diabetes over 20 years ago, and today, he gets healthcare through Covered California.

“It’s helped me get the medicine I need, like my insulin,” said Rolas. “As I get older, I want to make sure I’m around for my kids. But my insulin isn’t cheap, so thankfully, I have affordable healthcare right now, but I will be affected by these changes.”

Earlier this week, Democrats in the Senate refused to vote for a Republican short-term funding bill, which excluded an extension of enhanced premium tax credits. These credits, enacted in 2021, helped healthcare plans offered through the Affordable Health Care Act (known as Obamacare) to remain affordable. Without an extension, the credits will expire.

Trump’s “Big Beautiful Bill,” which was passed earlier this year, proposes nearly a trillion dollars in cuts to Medicare and Medicaid. With these changes, millions of Americans will face higher insurance premiums and possibly lose coverage. Democrats are fighting to get the subsidies extended and are demanding that Republicans reverse the Medicaid cuts.

The dispute over healthcare cuts led to the government shutdown this week.

At the rally, Holly Mitchell, a member of the Los Angeles County Board of Supervisors who represents the city’s 2nd District, says she’s fearful of going back to the days before Obamacare. Her district is made up of 2 million Angelenos, with 850,000 enrolled in MediCal.

“I don’t know about you, but I’m not going back there,” Mitchell said. “Those are horrible, inhumane, dangerous times. Black, brown and poor people die at a higher rate than they should have because they didn’t have access to healthcare.”

The rally was organized by St. John’s Community Health, a nonprofit aimed at providing healthcare to underserved communities.

Jim Mangia, president of the organization, announced that St. John’s plans to build a coalition of community-based organizations, labor unions, clinics and hospitals that would get an affordable healthcare measure on next year’s county voting ballot.

“It would go directly to voters and raise hundreds of millions of dollars to save healthcare for our most vulnerable neighbors,” said Mangia. “It would build a national example that can be replicated across the country, to undermine Trump’s billionaire tax cuts, and restore the programs and healthcare our communities need so desperately.”

The working title for the initiative is the Los Angeles County Emergency and Essential Healthcare Restoration Measure. It’s still in its early stages, with ballot language being drafted. Mangia expects that the county would need to gather around $500 million to fill the new gaps Trump’s “Big Beautiful Bill” will leave in residents’ healthcare plans.

Congresswoman Sydney Kamlager-Dove, who represents California’s 37th District, said cuts will hit her constituents hard, noting that there are 400,000 people who rely on Medicaid. About 3.5 million people in the state could lose their health insurance, she said.

“It’s about kicking people off of their healthcare benefits,” said Kamlager-Dove.

She blames the Republican party for the government shutdown, saying, “If they want to keep the government open, they would have, they would have negotiated with Democrats, but they chose not to.”

Republicans have, in turn, blamed Democrats for the closure and have said they are open to making changes to healthcare policy later.

Of all the finger-pointing and recriminations that come with the current federal government shutdown, one of the most striking elements is that the Trump administration blames it on Democratic support for granting taxpayer-funded healthcare coverage to undocumented immigrants. The White House has called out California specifically, saying the state exploits a legal “loophole” to pay for that coverage with federal dollars, and other states have followed suit.

“California utilized an egregious loophole — since employed by several other states — to draw down federal matching funds used to provide Medicaid benefits for illegal immigrants,” the White House said in a policy memo released Wednesday as a budget stalemate forced a shutdown of the U.S. government.

The administration said that the Working Families Tax Cut Act, which goes into effect in October 2026, closes the loophole by prohibiting the use of taxpayer money to provide healthcare coverage to undocumented immigrants and other noncitizens.

In the memo, the White House accused congressional Democrats of wanting to repeal those policy reforms as a condition to keep the government running.

Izzy Gardon, a spokeswoman for Gov. Gavin Newsom, said there’s nothing to the administration’s underlying assertion that California and other states have found some sort of loophole that enables them to funnel Medicaid money to noncitizens.

“This is false — CA does not do this,” Gardon said in a one-line email to the L.A. Times.

Healthcare policy experts agree. California is not exploiting a “loophole,” said Adriana Ramos-Yamamoto, a senior policy analyst at the California Budget & Policy Center, a nonprofit, nonpartisan organization that studies inequality.

“The state is making lawful, transparent budget choices to invest in health coverage with its own dollars,” Ramos-Yamamoto said in a statement to The Times. “These investments improve health outcomes, strengthen communities, and lower health care costs in the long run.”

At issue is Section 71117 of the Republican-backed “One Big Beautiful Bill Act,” which imposes nearly $1 trillion in reductions to federal Medicaid healthcare spending for low-income Americans over the next 10 years. The provision allows states “to finance the non-federal share of Medicaid spending through multiple sources, including state general funds, healthcare related taxes (or ‘provider taxes’), and local government funds,” as long as taxes on healthcare providers are imposed uniformly so as not to unfairly burden providers of Medicaid services.

The bottom line, analysts said, is the administration is citing a problem with the law that doesn’t seem to exist, at least not in California.

“The so-called California loophole references a provision in the law that ends a waiver of the uniformity requirements for provider taxes — this provision has nothing to do with using federal funds to pay for care for undocumented immigrants,” said Jennifer Tolbert, a healthcare expert at the nonprofit healthcare research, polling and news organization KFF.

“But the White House makes the claim that California uses the money they get from the provider tax to pay for care for undocumented immigrants,” Tolbert said.

Fact-checking the administration’s claim is all the more difficult because there are no official data on how states spend money collected from provider taxes, Alice Burns, another KFF analyst, added. What’s more, California is among several states that offer some level of Medicaid coverage to all immigrants regardless of status. And because California cannot be federally reimbursed for healthcare spending on people who are not in the country legally, those expenses must be covered at the state level.

The White House memo goes on to claim that if Democrats were to succeed at repealing the provisions in the Working Families Tax Act, the federal government would have to spend an additional $34.6 billion in taxpayer money “that would continue to primarily be abused by California to fund healthcare for illegal immigrants.”

This assertion also misconstrues the facts, according to KFF.

“What we do know is that the $35 billion in savings that is referenced in the White House Fact Sheet refers to the federal government’s estimated savings … resulting from states making changes to their provider tax systems,” KFF spokesperson Tammie Smith said. That is, the projected savings aren’t connected to healthcare for immigrants living in the U.S. illegally.

Political squabbling aside, California’s approach to medical coverage for low-income, undocumented immigrants is set to undergo a major shift thanks to provisions in the 2025-26 state budget that the Democrat-led legislature and Newsom approved in June.

Starting on Jan. 1, adults “who do not have Satisfactory Immigration Status (SIS)” will no longer be able to enroll in Medi-Cal, California’s Medicaid program, according to the state’s Department of Health Care Services webpage. Those who already have this coverage can keep it and continue to renew their enrollment. And starting on July 1, Medi-Cal enrollees who are age 19-59, undocumented and not pregnant will have to pay a $30 monthly premium to keep their coverage.

The changes, which Newsom called for in the spring to offset a ballooning Medi-Cal budget deficit, drew criticism from some immigrant rights groups, with the California Immigrant Policy Center describing the moves as “discriminatory.”

“In light of the militarized mass immigration raids and arrests causing fear and chaos across California, we are disappointed that the governor and the leadership in the Legislature chose to adopt a state budget that makes our communities even more vulnerable,” Masih Fouladi, the center’s executive director said at the time.

Everyone in California who qualifies for Medi-Cal will still be eligible to receive emergency medical and dental care, no matter their immigration status.

Ever since Elijah Maldonado was born at just 29 months, he has needed specialty treatments that his family could afford only with publicly funded healthcare.

Diagnosed with cerebral palsy as an infant, he spent his first three months at a public hospital where the family lives in Orange County.

Now 7, Elijah receives physical and speech therapy among a host of other services paid for through Medicaid. He relies on a wheelchair funded by the government. An assistant paid for with taxpayer dollars makes sure he’s safe on the bus ride to and from school.

Each month, he receives a $957 disability check that helps to cover his and his family’s living expenses.

Josephine Rios wipes her grandson Elijah’s face.

(Juliana Yamada / Los Angeles Times)

Still learning to speak on his own, he uses a Proloquo speech app on an iPad provided by his school to tell his family when he’s hungry, needs to use the restroom or wants to play with his favorite toys.

“It’s his voice — his lifeline,” his aunt and primary caretaker Cassandra Gonzalez says of the app. Her compensation for his in-home care comes from taxpayer dollars too.

Now that lifeline — and much of the government assistance Elijah receives — is at risk of going away.

With hundreds of billions of dollars worth of cuts to Medicaid and food aid kicking in this fall thanks to the passage of the Republican-backed “One Big Beautiful Bill Act” — on top of earlier cuts imposed by Elon Musk’s Department of Government Efficiency — a host of federally funded healthcare and nutrition programs that serve low-income Americans will be scaled back, revamped with expanded work requirements and other restrictions or canceled altogether if individual states can’t find alternate funding sources.

The budget reduces federal spending on Medicaid alone by about $1 trillion over the next 10 years nationwide, with initial reductions taking effect in the coming weeks.

Gov. Gavin Newsom responded by accusing the Trump administration of “ripping care from cancer patients, meals from children and money from working families — just to give tax breaks to the ultra-rich.”

L.A. public health officials called the cuts devastating for a county where nearly 40% of the population is enrolled in Medi-Cal, the state’s Medicaid program. L.A. County’s Department of Health Services, which oversees four public hospitals and about two dozen clinics, projects a budget reduction amounting to $750 million a year, and federal funding for the Department of Public Health, which inspects food, provides substance-use treatment and tracks disease outbreaks, will drop by an estimated $200 million a year. Spending cuts have prompted hiring freezes and projections of ballooning budget deficits, county health officials said.

Spending reductions, combined with recent changes to the Affordable Care Act and Medicare, could leave an additional 1.7 million people in California uninsured by 2034, according to an analysis by the nonprofit healthcare research organization KFF.

Cuts to the Supplemental Nutrition Assistance Program (SNAP), colloquially known as “food stamps,” will exceed $280 billion over the next decade, according to projections from the Congressional Budget Office.

It’s not just that the cuts to these programs are massive by historical standards.

The new rules and restrictions are confusing and states have been given little guidance from the federal agencies that oversee health and nutrition programs on how, or even when, to implement them, experts at the Center on Budget Policy and Priorities wrote in a recent report.

What’s clear, the CBPP said, is that millions of children, older adults, people with disabilities and veterans stand to lose not just Medicaid coverage but federal aid to access the type of healthy foods that could prevent illness and chronic conditions.

More than 5 million California households receive food aid through the state’s CalFresh program and 97% percent of them will see their benefits either slashed or eliminated because of federal spending cuts, changes to eligibility requirements or financial constraints at the state level, according to an analysis by the nonpartisan California Budget Policy Center.

Elijah plays with toy cars outside his aunt’s home in Tustin.

(Juliana Yamada / Los Angeles Times)

In Orange County, where Elijah’s family lives, public health officials were already reeling from federal spending cuts in the months before the budget bill passed, said Dr. Veronica Kelley, director of the OC Health Care Agency. For example, there was the $13.2-million cut to funding for family planning services in the county, and the $4-million reduction in funding to Women, Infants and Children nutrition (WIC).

The agency has worked to prevent mass layoffs by moving public-health workers in canceled programs to other departments or leaving some positions unfilled in order to save jobs elsewhere, and it has sought out nonprofit social service organizations and philanthropies to either take over programs or help fund them, Kelley said.

Now, Kelley is preparing for possible cuts to programs to combat obesity, maintain community gardens, help seniors make better healthcare decisions and reduce the use of tobacco. The agency also has to figure out how to make up for a $4.8-million reduction in federal funds for the county’s SNAP program that takes effect on Wednesday — another casualty of the federal spending bill.

The measures that the agency has leaned on to get through the year are not sustainable, Kelley said. “We can only do that for so long,” she said. “It’s chaotic. In terms of healthcare, it’s devastating… It feels like we’re taking so many steps backward.”

The looming cuts and changes have also set off alarm bells at Kaiser Permanente, California’s largest private healthcare provider with 9.5 million members statewide, 1.1 million of whom are enrolled in Medi-Cal, the state’s Medicaid program.

“Without the ability to pay, newly uninsured people will find themselves having to delay care, leading to more serious and complex health conditions, increasing the use of emergency services and more intensive medical services,” Kaiser Permanente Southern California Regional spokeswoman Candice Lee said in a statement to The Times.

“This will affect all of us as the cost of this uncompensated care leads hospitals and care providers to charge paying customers more to cover their costs. Some hospitals and providers, especially those in rural and underserved areas, will be unable to make up for these unreimbursed costs, and will be financially threatened by these changes.”

Standing in front of her sister Cassandra’s town home in Tustin, a quiet suburban city of 80,000 about 10 miles south of Disneyland, Elijah’s mother, Samantha Rios; grandmother Josephine Rios; and Aunt Cassandra are filled with worry.

Elijah points to a command on his Proloquo speech app, which he uses to communicate his needs.

(Juliana Yamada / Los Angeles Times)

Josephine, a nursing assistant who works at a Kaiser hospital in Orange County, said she hears the panic in patients’ voices when they describe rushing to schedule needed medical procedures in anticipation of losing their Medicaid benefits.

Earlier this year, Josephine joined delegations of unionized California healthcare workers who traveled to Washington with the aim of pressing lawmakers to oppose spending cuts.

Rep. Young Kim, the Republican who represents the Rios family’s district in Congress, was receptive to the delegation’s pleas to vote no on the budget bill, Josephine recalls. The congresswoman ultimately voted for the bill, saying on her official webpage the legislation was good for Californians because it would relieve the tax burden on families, ensure that government dollars are used effectively and “strengthen Medicaid and SNAP for our most vulnerable citizens who truly need it.”

Elijah’s Aunt Cassandra and grandmother Josephine look over his shoulder as he watches a TV show.

(Juliana Yamada / Los Angeles Times)

Now, Josephine looked on as Elijah, seated in his wheelchair, played on his iPad and watched a Disney program on his phone. He can press a tab on the touchscreen to make the tablet say “My name’s Elijah” if he’s feeling unsafe away from home, another to tell his family he needs space when upset.

Watching Elijah enjoy himself, the women said they feel awkward broadcasting their woes to strangers when all they desire is what’s best for him. They don’t need the public’s pity.

The family wants lawmakers and the public to understand how seemingly abstract healthcare decisions involving billions of dollars, and made 2,000-plus miles away in Washington, have brought new financial turmoil to a family that’s already on the edge financially.

Samantha, a single mom, works full time to provide a home for Elijah and his two sisters, ages 10 and 8. A subscription to the Proloquo speech app alone would cost $300 a year out-of-pocket — more than she can afford on her shoestring budget.

Due to changes in household income requirements, Samantha had already lost Medicaid coverage for herself and her two girls, she said, as well as her SNAP food assistance, leaving her at a loss for how to fill the gap. She now pays about $760 a month to cover her daughters and herself through her employer-based health plan.

The cut to food aid has forced her to compensate by getting free vegetables, milk, eggs and chicken from the food pantry at a local school, a reality that she said she was at first too ashamed to disclose even to relatives.

Then came the bad news Samantha recently received about Elijah’s monthly Social Security Insurance for his disability. She was stunned to hear that because of stricter income cut-offs for that type of aid, Elijah would no longer receive those checks as of Oct. 1.

“Before, he was getting $957 a month — obviously that’s grocery money for me,” Samantha said. The money also went to buy baby wipes, as well as knee pads to help him move more comfortably on the floor when not using his wheelchair.

“I don’t get food stamps. I don’t get Medi-Cal for my girls. I don’t get any of that,” Samantha said. “As of Oct. 1, now I’ve got to figure out how am I going to pay my rent? How am I going to buy groceries?”

Luckily, the sisters said, the physical, speech and behavioral-health therapies that Elijah receives are safe — for now.

And the women know they can lean on each other in tough times. The sisters and Josephine all live within minutes of each other in Tustin, close enough for Samantha’s children to eat at someone’s home when their own cupboards are bare.

Every few months, Samantha said, Elijah experiences severe seizures that can last up to 90 minutes and require hospitalization.

Cassandra and Josephine like that they can run over to help if Elijah has a medical emergency. Another sister who lives farther away is on hand when needed too.

“What’s going to happen to other families who don’t have that support system?” Samantha said.

Given the potential for further cuts to programs that pay for home-based healthcare and assistants for people with disabilities, Cassandra wonders what will happen to her own family if she can no longer work as Elijah’s caregiver.

Where would the family get the money to pay a new caregiver who is qualified enough to work with a special-needs child who can speak a few words thanks to speech therapy but who cannot eat, walk or use the restroom without supervision? What if funding is eliminated for the assistant who travels with Elijah to school?

“People think that cutting Medi-Cal, cutting food stamps or whatever isn’t going to affect that many people,” Cassandra said. “It’s affecting my nephew and nieces. It’s affecting my sister. But it’s not just affecting her household. It’s affecting my household.”

“We’re not saying we’re going to Disneyland or going out to eat every day,” Cassandra said. “This is just living. We can’t even live at this point, with things being cut.”

The women offered up principles they feel are in short supply lately in the discourse over the government’s role in public health — among them “morals” and “empathy.” Samantha adds one more word to the list.

“Humanity,” she says. “We lack it.”

WASHINGTON — The federal budget deficits caused by President Trump’s tax and spending law could trigger automatic cuts to Medicare if Congress does not act, the nonpartisan Congressional Budget Office reported Friday.

The CBO estimates that Medicare, the federal health insurance program for Americans over age 65, could potentially see as much as $491 billion in cuts from 2027 to 2034 if Congress does not act to mitigate a 2010 law that forces across-the-board cuts to many federal programs once legislation increases the federal deficit. The latest report from CBO showed how Trump’s signature tax and spending law could put new pressure on federal programs that are bedrocks of the American social safety net.

Trump and Republicans pledged not to cut Medicare as part of the legislation, but the estimated $3.4 trillion that the law adds to the federal deficit over the next decade means that many Medicare programs could see cuts. In the past, Congress has always acted to mitigate cuts to Medicare and other programs, but it would take some bipartisan cooperation to do so.

Democrats, who requested the analysis from CBO, jumped on the potential cuts.

“Republicans knew their tax breaks for billionaires would force over half a trillion dollars in Medicare cuts — and they did it anyway,” Rep. Brendan Boyle of Pennsylvania, the top Democrat on the House Budget Committee, said in a statement. “American families simply cannot afford Donald Trump’s attacks on Medicare, Medicaid and Obamacare.”

Hospitals in rural parts of the country are already grappling with cuts to Medicaid, which is available to people with low incomes, and cuts to Medicare could exacerbate their shortfalls.

As Republicans muscled the bill through Congress and are now selling it to voters back home, they have been critical of how the CBO has analyzed the bill. They have also argued that the tax cuts will spur economic growth and pointed to $50 billion in funding for rural hospitals that was included in the package.

Groves writes for the Associated Press.

The nation’s first mandated work requirement for Medicaid recepients, approved by the Republican-led Congress and signed by President Trump, is expected to have a seismic effect in California.

One estimate from state health officials suggests that as many as 3.4 million people could lose their insurance through what Gov. Gavin Newsom calls the “labyrinth of manual verification,” which involves Medi-Cal recipients proving every six months that they are working, going to school or volunteering at least 80 hours per month.

“It’s going to be much harder to stay insured,” said Martha Santana-Chin, the head of L.A. Care Health Plan, a publicly operated health plan that serves about 2.3 million Medi-Cal patients in Los Angeles County.

She said that as many as 1 million people, or about 20% to 40% of its members, could lose their coverage.

The work requirement will be the first imposed nationwide in the six-decade history of Medicaid, the program that provides free and subsidized health insurance to disabled and low-income Americans.

It’s relatively uncharted territory, and it’s not yet clear how the rules will shake out for the 5.1 million people in California who will be required to prove that they are working in order to qualify for Medi-Cal, the state’s version of Medicaid.

After the 2026 midterm elections, millions of healthy adults will be required to prove every six months that they meet the work requirement in order to qualify for Medicaid. The new mandate spells out some exceptions, including for people who are pregnant, in addiction treatment or caring for children under age 14.

Democrats have long argued that work requirements generally lead to eligible people l osing their health insurance due to bureaucratic hurdles. Republicans say that a work requirement will encourage healthy people to get jobs and preserve Medicaid for those who truly need it.

“If you clean that up and shore it up, you save a lot of money,” said House Speaker Mike Johnson of Louisiana. “And you return the dignity of work to young men who need to be out working instead of playing video games all day.”

Only three U.S. states have tried to implement work requirements for Medicaid recipients: New Hampshire, Arkansas and Georgia. One study found that in the first three months of the Arkansas program, more than 18,000 people lost health coverage.

People can lose coverage a variety of ways, said Joan Alker, a Georgetown University professor who studies Medicaid. Some people hear that the rules have changed and assume they are no longer eligible. Others struggle to prove their eligibility because their income fluctuates, they are paid in cash or their jobs don’t keep good payroll records. Some have problems with the technology or forms, she said, and others don’t appeal their rejections.

Of the 15 million people on Medi-Cal in California, about one-third will be required to prove they are working, the state said. Those people earn very little: less than $21,000 for a single person and less than $43,000 for a household of four.

The state’s estimate of 3.4 million people losing coverage is a projection based on what happened in Arkansas and New Hampshire.

But those programs were brief, overturned by the courts and weren’t “a coordinated effort among the states to figure out what the best practices are,” said Ryan Long, the director of congressional relations at the Paragon Health Institute, a conservative think tank that has become influential among congressional Republicans.

Long said advancements in technology and a national emphasis on work requirements should make work verification less of a barrier. The budget bill includes $200 million in grants for states to update their systems to prepare, he said.

Arguments from liberal groups that people will lose healthcare are a “straw man argument,” Long said: “They know that the public supports work requirements for these benefits, so they can’t come out and say, ‘We don’t support them.’”

A poll by the health research group KFF found this year that 62% of American adults support tying Medicaid eligibility to work requirements.

The poll also found that support for the policy drops to less than 1 in 3 people when respondents hear “that most people on Medicaid are already working and many would risk losing coverage because of the burden of proving eligibility through paperwork.”

In June, Newsom warned that some Californians could be forced to fill out 36 pages of paperwork to keep their insurance, showing reporters an image of a stack of forms with teal and gold accents that he described as “an actual PDF example of the paperwork that people will have to submit to for their eligibility checks.”

Many Californians already are required to fill out that 36-page form or its online equivalent to enroll in Medi-Cal and Covered California, the state’s health insurance marketplace.

Experts say it’s too soon to say what system will be used for people to prove their work eligibility, because federal guidance won’t be finalized for months.

Newsom’s office directed questions to the Department of Health Care Services, which runs Medi-Cal. A spokesperson there said officials are “still reviewing the full operational impacts” of the work requirements.

“The idea that you are going to get a paper submission every six months, I’m not sure people have to do that,” Long said.

Georgia is the only state that has implemented a lasting work requirement for Medicaid. Two years ago, the state made healthcare available to people who were working at least 80 hours per month and earned less than the federal poverty limit (about $15,000 for one person or $31,200 for a household of four).

More than 100,000 people have applied for coverage since the program’s launch in July of 2023. As of June of this year, more than 8,000 people were enrolled, according to the state’s most recent data.

The Medicaid program has cost more than $100 million so far, and of that, $26 million was spent on health benefits and more than $20 million was allocated to marketing contracts, KFF Health News reported. Democrats in Georgia have sought an investigation into the program.

The Inland Empire agency that provides Medi-Cal coverage for about 1.5 million people in San Bernardino and Riverside counties estimated that 150,000 members could lose their insurance as a result of work requirements.

Jarrod McNaughton, the chief executive of the Inland Empire Health Plan, said that California’s 58 counties, which administer Medi-Cal, “will be the ones at the precipice of piecing this together” but haven’t yet received guidance on how the eligibility process will be set up or what information people will have to provide.

Will it be done online? Will recipients be required to fill out a piece of paper that needs to be mailed in or dropped off? “We don’t really know the process yet, because all of this is so new,” Naughton said.

In the meantime, he said, the health plan’s foundation is working to make this “as least burdensome as possible,” working to improve community outreach and connect people who receive Medi-Cal insurance to volunteer opportunities.

California and a coalition of other liberal-led states sued the Trump administration Tuesday over a provision in the “Big Beautiful Bill” that bars Planned Parenthood and other large nonprofit abortion providers from receiving Medicaid funding for a host of unrelated healthcare services.

The measure has threatened clinics across the country that rely on federal funding to operate. California Atty. Gen. Rob Bonta, who is helping to lead the litigation, called it a “cruel, backdoor abortion ban” that violates the law in multiple ways.

The states’ challenge comes one day after Planned Parenthood won a major victory in its own lawsuit over the measure in Boston, where a federal judge issued a preliminary injunction blocking the ban from taking effect against Planned Parenthood affiliates nationwide.

Federal law already prohibits the use of federal Medicaid funding to pay for abortions, but the new “defund provision” in the bill passed by congressional Republicans earlier this month goes further. It also bars nonprofit abortion providers that generated $800,000 or more in annual Medicaid revenue in 2023 from receiving any such funding for the next year — including for services unrelated to abortion, such as annual checkups, cancer screenings, birth control and testing for sexually transmitted infections.

Attorneys for the U.S. Department of Justice have argued that the measure “stops federal subsidies for Big Abortion,” that Congress under the constitution is “free to decline to provide taxpayer funds to entities that provide abortions,” and that Planned Parenthood’s position should not hold sway over that of Congress.

In announcing the states’ lawsuit Monday, Bonta’s office echoed Planned Parenthood officials in asserting that the provision specifically and illegally targets Planned Parenthood and its affiliate clinics — calling it “a direct attack on the healthcare access of millions of low-income Americans, disproportionally affecting women, LGBTQ+ individuals, and communities of color.”

Bonta’s office said the measure threatened $300 million in federal funding for clinics in California, where Planned Parenthood is the largest abortion provider, and “jeopardized the stability” of Planned Parenthood’s 114 clinics across the state, which serve about 700,000 patients annually — many of whom use Medi-Cal, the state’s version of Medicaid.

During a virtual news conference Monday, Bonta noted that federal funds already don’t cover abortions. He said the new provision was “punishment for Planned Parenthood’s constitutionally protected advocacy for abortion” and “a direct attack on access to essential healthcare for millions who rely on Medicaid.”

“The Trump administration and Congress are actually gutting essential lifesaving care, like cancer screenings and STI testing, simply because Planned Parenthood has spoken out in support of reproductive rights,” Bonta said. “The hypocrisy is really hard to ignore. A party that claims to be defenders of free speech only seem to care about it when it aligns with their own agenda.”

Bonta added: “Rest assured, California will continue to lead as a reproductive freedom state, and will continue to defend healthcare as a human right.”

In their lawsuit, the states argue that the measure is unlawfully ambiguous and violates the spending powers of Congress by singling out Planned Parenthood for negative treatment, and that it will harm people’s health and increase the cost of Medicaid programs for states by more than $50 million over the next decade.

In its lawsuit, Planned Parenthood also argued that the measure intentionally singled it and its affiliates out for punishment, in violation of their constitutional rights, including free speech.

In granting Planned Parenthood’s request for a preliminary injunction, U.S. District Judge Indira Talwani wrote Monday that she was “not enjoining the federal government from regulating abortion and is not directing the federal government to fund elective abortions or any healthcare service not otherwise eligible for Medicaid coverage.”

Talwani, an Obama appointee, wrote that she also was not requiring the federal government “to spend money not already appropriated for Medicaid or any other funds.”

Instead, Talwani wrote, her order blocks the Trump administration from “targeting a specific group of entities — Planned Parenthood Federation members — for exclusion from reimbursements under the Medicaid program,” as they were likely to prove that “such targeted exclusion violates the United States Constitution.”

In a statement to The Times on Tuesday, White House spokesman Harrison Fields said the “Big, Beautiful Bill” was “legally passed by both chambers of the Legislative Branch and signed into law by the Chief Executive,” and Talwani’s order granting the injunction was “not only absurd but illogical and incorrect.”

“It is orders like these that underscore the audacity of the lower courts as well as the chaos within the judicial branch. We look forward to ultimate victory on the issue,” Fields said.

The White House did not immediately respond to a request for additional comment on the states’ lawsuit.

Jodi Hicks, president and CEO of Planned Parenthood Affiliates of California, joined Bonta during his news conference. She welcomed the states’ lawsuit, saying “an attack this severe requires a multi-pronged response with both short and long term strategies.”

Hicks said it’s particularly important that California is helping to fight back, given the huge stakes for the state.

“California is the most impacted state across the country because of the volume of patients that we have, but also because of the amount of Medicaid that our state takes,” she said. “It speaks to our values. And this defund provision is certainly [an] attack on values — most heavily on California.”

Bonta is leading the lawsuit along with the attorneys general of Connecticut and New York. Joining them are Pennsylvania Gov. Josh Shapiro and the attorneys general of Colorado, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, North Carolina, Oregon, Rhode Island, Vermont, Washington, Wisconsin and the District of Columbia.

Bonta noted the lawsuit is the 36th his office has filed against the Trump administration in the last 27 weeks.

News about U.S. Immigration and Customs Enforcement raids and arrests seems to flow as if emanating from an unending tap.

That makes it difficult, at times, to pick up on important topics and issues.

I’m going to use this space to highlight a few articles from my colleagues focusing on the potential growth of ICE in the coming years, new tools that federal agents can use to expand crackdowns, and what the actual numbers say.

Trump wants to hire 10,000 ICE agents

My colleague Andrea Castillo dove into the numbers and reality of an agent hiring spree.

The massive funding bill signed into law this month by President Trump earmarks about $170 billion for border and immigration enforcement, including tens of billions for new deportation agents and other personnel.

During his first term, when Trump called for ICE and U.S. Customs and Border Protection to hire 15,000 people collectively, a July 2017 report by the Homeland Security inspector general found significant setbacks.

In 2017, ICE hired 371 deportation officers from more than 11,000 applications and took 173 days on average to finalize hires, the news outlet Government Executive reported. According to Cronkite News, Border Patrol shrunk by more than 1,000 agents after Trump left office in 2021.

The Homeland Security inspector general concluded that to meet the goal of 10,000 new immigration officers, ICE would need more than 500,000 applicants. For CBP to hire 5,000 new agents, it would need 750,000 applicants.

Castillo added that past and potentially future corruption, the prospect of lowering hiring standards and competition with other police agencies make Trump’s hiring goal an uphill battle.

For more, check out her entire article here.

ICE is accessing Medicaid records

My colleagues Jenny Jarvie and Hannah Fry noted that the Trump administration is forging ahead with a plan to hand over the personal data of millions of Medicaid recipients to Homeland Security personnel seeking to track down people living in the U.S. illegally.

The huge trove of private information includes home addresses, Social Security numbers and ethnicities of 79 million Medicaid enrollees.

The plan, which has not been announced publicly, is the latest step by the Trump administration to deliver on its pledge to crack down on illegal immigration and arrest 3,000 undocumented immigrants a day.

California Sens. Alex Padilla and Adam Schiff warned last month of potential violations of federal privacy laws as Trump officials made plans to share personal health data.

Undocumented immigrants are not permitted to enroll in Medicaid, a joint federal and state program that helps cover medical costs for low-income individuals.

However, federal law requires states to offer emergency Medicaid, coverage that pays for lifesaving services in emergency rooms to everyone, including non-U.S. citizens.

Check out the full article here.

Homeland Security says it arrested 2,800 undocumented people between early June and July

Colleagues Michael Wilner and Rachel Uranga reported on the number of people picked up in the Greater Los Angeles area by Homeland Security.

Federal authorities said earlier that 1,618 undocumented immigrants had been detained between June 6 — the start of the U.S. Department of Homeland Security operation in Los Angeles — and June 22. That total increased by nearly 1,200 arrests in just over two weeks. Trump deployed the National Guard and U.S. Marines in the city days after the operation began amid heated protests.

Gov. Gavin Newsom and local officials have repeatedly criticized federal operations for terrorizing immigrant communities, where business has slowed and many have holed up in their homes.

The president’s immigration crackdown in Los Angeles has been a test case for his administration as it presses the bounds of executive authority, deploying federal agents and the military to a major metropolitan city with leadership hostile to its cause.

For more, here’s the complete article.

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Los Angeles County’s health system, which is responsible for the care of the region’s poorest, is careening toward a financial crisis because of cuts from a presidential administration and Republican-led Congress looking to drastically slash the size of government.

President Trump’s “Big Beautiful Bill,” which passed earlier this month, is expected to soon claw $750 million per year from the county Department of Health Services, which oversees four public hospitals and roughly two dozen clinics. In an all-staff email Friday, the agency called the bill a “big, devastating blow to our health system” and said a hiring freeze had gone into effect, immediately.

And the Trump administration’s budget for the next fiscal year will likely result in a $200-million cut to the county Department of Public Health, whose responsibilities include monitoring disease outbreaks, inspecting food and providing substance use treatment.

“I’m not going to sugarcoat it. I’m not going to say we survive this,” said Barbara Ferrer, head of the public health department, in an interview. “We can’t survive this big a cut.”

Both Ferrer and Department of Health Services head Christina Ghaly warned that the federal cuts will devastate their agencies — and the patients they serve — for years to come. Employee layoffs are likely.

In April, the White House announced it was ending infectious disease grants worth billions of dollars, including $45 million that L.A. County was supposed to use to combat the spread of measles and bird flu. California has joined other states in a lawsuit fighting the cuts, and the court has issued a preliminary injunction suspending the cuts.

A protest earlier this month in Anaheim, co-led by the California Nurses Assn., called on Rep. Young Kim (R-Anaheim Hills) to vote against President Trump’s spending bill.

(Allen J. Schaben/Los Angeles Times)

This month, the county public health department lost another $16 million after Trump’s bill cut funding for a program educating food stamp recipients about how to buy healthy meals.

And there’s more to come. The Trump administration’s proposed budget for 2026 will be the biggest blow yet, Ferrer warned, yanking $200 million from her department — a 12% cut.

“I’m old. I’ve been around for a long time,” said Ferrer, whose work in public health dates back to the Reagan administration. “I’ve never actually seen this much disdain for public health.”

Ferrer said the cuts mean she no longer has enough money for the county’s bioterrorism watch program, which monitors for outbreaks that might signal a biological attack. Soon, she said, county officials may have to stop testing ocean water for toxins year round, cutting back to just half the year.

“Like, you want to swim? You want to know that the water is safe where you swim, then oppose these kinds of cuts,” she said. “That affects everybody who goes to the beach.”

L.A. County Public Health Director Barbara Ferrer said she is bracing for $200 million in cuts to her budget.

(Al Seib/Los Angeles Times)

Layoffs are likely, said Ferrer. About 1,500 public health staffers are supported through federal grants. More than half the federal money the department receives is funneled to outside organizations, which would likely need to make cuts to stay afloat.

A similarly grim cost analysis is underway at the county Department of Health Services, where executives said they expect to lose $280 million this fiscal year because of the bill.

“I can’t make a promise that we will be able to avoid layoffs because of the magnitude of the challenges,” said Ghaly.

Ghaly said the bill slashed the extra Medicaid money the county typically gets to cover care for low-income patients. They expect many patients might be kicked off Medicaid because of new eligibility and work requirements. The federal government is pulling back on payments for emergency services for undocumented people, meaning the county will have to foot more of the bill.

The White House did not respond to a request for comment.

Department of Health Services officials said they expect to lose $750 million per year by 2028. By then, the agency’s budget deficit is projected to have ballooned to $1.85 billion.

In an attempt to pump more cash into the system, L.A. County supervisors voted on Tuesday to increase a parcel tax first approved by voters in 2002, which is expected to raise an additional $87 million for the county’s trauma care network.

After a long debate Tuesday, Supervisors Holly Mitchell and Lindsey Horvath worked to direct $9 million of the parcel tax money to Martin Luther King Jr. Community Hospital, a private hospital that serves as a critical safety net for South Los Angeles residents who would otherwise find themselves in a medical desert.

Without that cash infusion from the county, the cuts in Trump’s bill would have put the hospital at risk of closing, since the majority of patients in its emergency room are on Medicaid, said Elaine Batchlor, Martin Luther King’s chief executive officer.

“If they’ve lost their Medicaid coverage, we simply won’t get paid for those patients,” she said.

Dr. Elaine Batchlor, chief executive of MLK Community Healthcare, said her hospital was hanging by a thread financially. Then came more cuts.

(Francine Orr/Los Angeles Times)

Martin Luther King replaced a county hospital that closed after losing national accreditation in 2005 because of serious medical malpractice, landing it the nickname “Killer King.”

“The fact that that hospital closed in the first place I think is criminal, and I intend to do all I can to protect the integrity of the services,” said Mitchell, whose district includes the hospital and who pushed for it to get a cut of money from the parcel tax increase.

Local health providers said that changes at the state level have created additional uncertainty. The state budget for this fiscal year freezes enrollment in Medi-Cal, California’s version of Medicaid, for undocumented immigrants ages 19 and older starting in January. Medi-Cal recipients ages 19 to 59 will have to pay a $30 monthly premium beginning July 1, 2027.

“Most families [we serve] are making about $2,400 to $2,600 a month. They’re going to have to choose between paying their Medi-Cal fees for a family of four — that’s $120 a month — or paying rent or paying for food,” said Jim Mangia, head of St. John’s Community Health, who said the cuts will disrupt care for tens of thousands of low-income residents.

The St. John’s clinic, which gets most of its revenue from Medi-Cal reimbursements, serves more than 120,000 patients a year, most of whom live below the federal poverty line.

If the clinic doesn’t find a way to replace the lost revenue, Mangia warned, services will have to be reduced. The clinic recently started treating immigrant patients in their homes after realizing they had been skipping appointments because they feared being arrested by federal immigration agents.

“Then what we’re looking at is closing several health centers,” said Mangia. “We’re looking at laying off hundreds of staff.”

At Venice Family Clinic, a community health center that serves nearly 45,000 patients annually, 80% of patients rely on Medi-Cal. Roughly half the clinic’s revenue comes from Medi-Cal reimbursements.

Dr. Mitesh Popat, a family physician and head of the clinic, said that federal policy changes — especially more frequent paperwork and added work requirements — will likely push eligible patients off of Medi-Cal. He said the clinic is exploring ways to expand support for patients to navigate the paperwork and keep their coverage.

“This puts a bunch of barriers in the way of people who already have enough challenges in life,” Popat said. “They’re trying to make it, trying to survive, trying to put food on the table.”

SACRAMENTO — For nearly 20 years, Maria would call her sister — a nurse in Mexico — for advice on how to manage her asthma and control her husband’s diabetes instead of going to the doctor in California.

She didn’t have legal status, so she couldn’t get health insurance and skipped routine exams, relying instead on home remedies and, at times, getting inhalers from Mexico. She insisted on using only her first name for fear of deportation.

Things changed for Maria and many others in recent years when some Democratic-led states opened up their health insurance programs to low-income immigrants regardless of their legal status. Maria and her husband signed up the day the program began last year.

“It changed immensely, like from Earth to the heavens,” Maria said in Spanish of Medi-Cal, California’s Medicaid program. “Having the peace of mind of getting insurance leads me to getting sick less.”

At least seven states and the District of Columbia have offered coverage for immigrants, mostly since 2020. But three of them have done an about-face, ending or limiting coverage for hundreds of thousands of immigrants who aren’t in the U.S. legally — California, Illinois and Minnesota.

The programs cost much more than officials had projected at a time when the states are facing multibillion-dollar deficits now and in the future. In Illinois, adult immigrants ages 42 to 64 without legal status have lost their healthcare to save an estimated $404 million. All adult immigrants in Minnesota no longer have access to the state program, saving nearly $57 million. In California, no one will automatically lose coverage, but new enrollments for adults will stop in 2026 to save more than $3 billion over several years.

Cuts in all three states were backed by Democratic governors who once championed expanding health coverage to immigrants.

The Trump administration this week shared the home addresses, ethnicities and personal data of all Medicaid recipients with U.S. Immigration and Customs Enforcement officials. Twenty states, including California, Illinois and Minnesota, have sued.

Healthcare providers told the Associated Press that all of those factors, especially the fear of being arrested or deported, are having a chilling effect on people seeking care. And states may have to spend more money down the road because immigrants will avoid preventive healthcare and end up needing to go to safety-net hospitals.

“I feel like they continue to squeeze you more and more to the point where you’ll burst,” Maria said, referencing all the uncertainties for people who are in the U.S. without legal permission.

‘People are going to die’

People who run free and community health clinics in California and Minnesota said patients who got on state Medicaid programs received knee replacements and heart procedures and were diagnosed for serious conditions like late-stage cancer.

CommunityHealth is one of the nation’s largest free clinics, serving many uninsured and underinsured immigrants in the Chicago area who have no other options for treatment. That includes the people who lost coverage July 1 when Illinois ended its Health Benefits for Immigrants Adults Program, which served about 31,500 people ages 42 to 64.

One of CommunityHealth’s community outreach workers and care coordinator said Eastern European patients she works with started coming in with questions about what the change meant for them. She said many of the patients also don’t speak English and don’t have transportation to get to clinics that can treat them. The worker spoke to the AP on condition of anonymity to protect patients’ privacy.

Health Finders Collective in Minnesota’s rural Rice and Steele counties south of Minneapolis serves low-income and underinsured patients, including large populations of Latino immigrants and Somali refugees. Executive director Charlie Mandile said his clinics are seeing patients rushing to squeeze in appointments and procedures before 19,000 people age 18 and older are kicked off insurance at the end of the year.

Free and community health clinics in all three states say they will keep serving patients regardless of insurance coverage — but that might get harder after the U.S. Department of Health and Human Services decided this month to restrict federally qualified health centers from treating people without legal status.

CommunityHealth Chief Executive Stephanie Willding said she always worried about the stability of the program because it was fully state funded, “but truthfully, we thought that day was much, much further away.”

“People are going to die. Some people are going to go untreated,” Alicia Hardy, chief executive officer of CommuniCARE+OLE clinics in California, said of the state’s Medicaid changes. “It’s hard to see the humanity in the decision-making that’s happening right now.”

A spokesperson for the Minnesota Department of Health said ending the state’s program will decrease MinnesotaCare spending in the short term, but she acknowledged healthcare costs would rise elsewhere, including uncompensated care at hospitals.

Minnesota House Speaker Lisa Demuth, a Republican, said the state’s program was not sustainable.

“It wasn’t about trying to be non-compassionate or not caring about people,” she said. “When we looked at the state budget, the dollars were not there to support what was passed and what was being spent.”

Demuth also noted that children will still have coverage, and adults lacking permanent legal status can buy private health insurance.

Healthcare providers also are worried that preventable conditions will go unmanaged, and people will avoid care until they end up in emergency rooms — where care will be available under federal law.

One of those safety-net public hospitals, Cook County Health in Chicago, treated about 8,000 patients from Illinois’ program last year. Dr. Erik Mikaitis, the health system’s CEO, said doing so brought in $111 million in revenue.

But he anticipated other providers who billed through the program could close, he said. “Things can become unstable very quickly,” he said.

Monthly fees, federal policies create barriers

State lawmakers said California’s Medi-Cal changes stem from budget issues — a $12-billion deficit this year, with larger ones projected ahead. Democratic state leaders last month agreed to stop new enrollment starting in 2026 for all low-income adults without legal status. Those under 60 remaining on the program will have to pay a $30 monthly fee in 2027.

States are also bracing for impact from federal policies. Cuts to Medicaid and other programs in President Trump’s massive tax and spending bill include a 10% cut to the federal share of Medicaid expansion costs to states that offer health benefits to immigrants starting October 2027.

California health officials estimate roughly 200,000 people will lose coverage after the first full year of restricted enrollment, though Gov. Gavin Newsom maintains that even with the rollbacks, California provides the most expansive healthcare coverage for poor adults.

Every new bill requires a shift in Maria’s monthly calculations to make ends meet. She believes many people won’t be able to afford the $30-a-month premiums and will instead go back to self-medication or skip treatment altogether.

“It was a total triumph,” she said of Medi-Cal expansion. “But now that all of this is coming our way, we’re going backwards to a worse place.”

Fear and tension about immigration raids are changing patient behavior, too. Providers told the AP that, as immigration raids ramped up, their patients were requesting more virtual appointments, not showing up to routine doctor’s visits and not picking up prescriptions for their chronic conditions.

Maria has the option to keep her coverage. But she is weighing the health of her family against risking what they’ve built in the U.S.

“It’s going to be very difficult,” Maria said of her decision to remain on the program. “If it comes to the point where my husband gets sick and his life is at risk, well then, obviously, we have to choose his life.”

Nguyễn and Shastri write for the Associated Press and reported from Sacramento and Milwaukee, respectively. AP journalist Godofredo Vasquez in San Francisco contributed to this report.

The Trump administration is forging ahead with a plan that is sure to fuel alarm across California’s immigrant communities: handing over the personal data of millions of Medicaid recipients to federal immigration officials who seek to track down people living in the U.S. illegally.

The huge trove of private information, which includes home addresses, social security numbers and ethnicities of 79 million Medicaid enrollees, will allow officials with Immigration and Customs Enforcement greater latitude to locate immigrants they suspect are undocumented, according to an agreement signed this week between the Centers for Medicare and Medicaid Services and the Department of Homeland Security and obtained by the Associated Press.

“ICE will use the CMS data to allow ICE to receive identity and location information on aliens identified by ICE,” the agreement says.

The plan, which has not been announced publicly, is the latest step by the Trump administration to gather sensitive information about people living in the U.S. as it seeks to deliver on its pledge to crack down on illegal immigration and arrest 3,000 undocumented immigrants a day. It is certain to face legal challenges.

Critics have sounded the alarm ever since the Trump administration directed the CMS last month to send the DHS personal information on Medicaid enrollees, including non-U.S. citizens registered in state-funded programs in California, Illinois, Washington and Washington, D.C.

These states operate state-funded Medicaid programs for immigrants who are otherwise ineligible for federal Medicaid and had committed not to bill the federal government.

California Senators Alex Padilla and Adam Schiff warned last month of potential violations of federal privacy laws as Trump officials made plans to share personal health data.

“These actions not only raise ethical issues but are contrary to longstanding HHS policy and raise significant concerns about possible violations of federal law,” the Senators wrote in a letter to U.S. Health and Human Services Secretary Robert F. Kennedy Jr., DHS Secretary Kristi Noem and CMS Administrator Mehmet Oz.

“We are deeply troubled that this administration intends to use individuals’ private health information for the unrelated purpose of possible enforcement actions targeting lawful noncitizens and mixed status families,” Padilla and Schiff said in a statement. “The decision by HHS to share confidential health information with DHS is a remarkable departure from established federal privacy protections that should alarm all Americans.”

DHS spokesperson Tricia McLaughlin declined to answer questions about whether immigration officials are now accessing the personal Medicaid data or how they plan to use it.

“President Trump consistently promised to protect Medicaid for eligible beneficiaries,” McLaughlin said in a statement. “To keep that promise after Joe Biden flooded our country with tens of millions of illegal aliens CMS and DHS are exploring an initiative to ensure that illegal aliens are not receiving Medicaid benefits that are meant for law-abiding Americans.”

Undocumented immigrants are not permitted to enroll in Medicaid, a joint federal and state program that helps cover medical costs for low-income individuals. The program also limits benefits for other lawfully present immigrants, with some required to undergo waiting periods before they can receive coverage.

However, federal law requires states to offer emergency Medicaid, coverage that pays for lifesaving services in emergency rooms to everyone, including non-U.S. citizens.

A 2024 Congressional Budget Office report found that a total of $27 billion was spent on emergency Medicaid for non-citizens between 2017 and 2023. That number represents less than 1% of overall spending on Medicaid during that time period. Nevertheless, Trump and other federal leaders have pushed to reduce spending on Medicaid, alleging that undocumented immigrants have been taking advantage of the program.

Hannah Katch, a CMS advisor during the Biden administration who previously worked for California Medicaid, told The Times that the Trump administration’s plan to turn over Medicaid data represented “an incredible violation of trust.”

The data that states send to CMS has certain protections and requirements in statute and also by custom, Katch said. For CMS to share the information of Medicaid enrollees outside the agency, she said, would have a devastating impact on people who depend on emergency Medicaid to access critical care.

“Making people afraid to seek care when they are experiencing a medical emergency, or when their child is experiencing a medical emergency, it is an incredibly cruel action to take,” Katch said.

Elizabeth Laird, the director of equity in civic technology at the Center for Democracy & Technology, said the sharing of such data would further erode people’s trust in government.

“By turning over some of our most sensitive healthcare data to ICE, Health and Human Services has fundamentally betrayed the trust of almost 80 million people,” she said in a statement to The Times.

“This jaw-dropping development proves that the Administration’s claim of using this information to prevent fraud is a Trojan horse that instead will primarily advance their goal of deporting millions of people,” she said. “Over 90 percent of entitlement fraud is committed by U.S. citizens, underscoring the false pretense of sharing this information with ICE.”

The plan to share Medicaid data is not the first time the Trump administration has sought to share personal information across departments. In May, the Department of Agriculture told states they had to turn over data on the recipients of SNAP food benefits.

Last month, the California Medical Assn. warned that the Trump administration’s sharing of personal Medicaid data would put nearly 15 million patients and their families at risk statewide.

Dr. René Bravo, CMA’s president elect, said that sending sensitive patient information to deportation officials “will have a devastating impact on communities and access to care that all people need.”

“Our job is not protecting the borders, it’s protecting our patients and providing the best health care possible, “ Bravo said in a statement. “When patients come to us it’s often the most vulnerable times in their lives, and we offer a safe space for their care.”

Orange County’s Office of Immigrant and Refugee Affairs notified the public last month that the CMS had been directed to send DHS personal information of Medicaid enrollees, including non-citizens.

“This data, provided for the purpose of administering healthcare, may now be used to locate individuals for immigration enforcement or to challenge their future immigration applications,” the statement read.

The agency wrote that it had already heard of increased anxiety among clients who are fearful that their personal information could be used against them if they seek health care services.

“We are concerned this will further erode trust in public institutions and care providers,” the agency wrote.

Orange County Supervisor Vicente Sarmiento, who represents a large Latino population that includes Santa Ana and portions of Anaheim, said the families enrolled in Medi-Cal did so with the reasonable expectation their information would be kept private.

He called the action a “cruel breach” that erodes people’s trust in government.

“These actions discourage participation in healthcare and mean that some individuals may not seek needed medical services,” he said in a statement. “This hurts the overall community, creates serious public health concerns, and increases costs for our healthcare system.”

Jose Serrano, director of Orange County’s Office of Immigrant and Refugee Affairs, said certain information about those who sign up for benefits has long been shared with the state, which passes it along to the federal government for research, funding and eligibility purposes.

“The one thing that is different during this time is that the information is being used against people, especially those who are immigrants,” he said.

The situation has already caused anxiety among immigrant populations in Orange County, Serrano said. Some have reached out to the agency asking whether they can un-enroll from programs or change their addresses for fear that they or their families may be targeted by immigration officials.

“The truth is immigrants spend more and invest more in our communities and the economy then they take away,” Serrano said, adding that it’s unfortunate that this medical information is “going to be used against the same families that are already investing in our communities through the taxes they pay on a yearly basis.”

OK, I’ll say it. I’m sick of superheroes. I blame the Marvel Cinematic Universe (36 movies and counting over 17 years) and the DC Extended Universe (43 movies and counting, mostly since the late 1970s). Maybe Earth’s not big enough for two universes. They’re running pretty thin these days, down to rebooting reboots, making sequels for prequels and squeezing every ounce from the intellectual property tube to fill out streaming platform minutes.

But there’s always Superman. The Krypton-born alien, orphaned, sent off into space for survival and then raised by adoptive parents in Kansas. He’s now been with American pop culture for 10 decades (eight in film). Despite an outfit modeled after a circus strongman, he’s become a durable, transcendent symbol of the ultimate immigrant and somehow a simultaneous embodiment of “Truth, Justice, and the American Way.”

Superman’s the classic American good guy, and so this weekend’s opening of the new “Superman” with David Corenswet is a great time to think about the real good guys and gals in American life — that is, if you can find any. Where are all the good guys and gals in America? What qualifies someone for the title these days?

The idea has definitely shifted. It’s as if by sheer screen volume the fake superheroes overwhelmed the public consciousness. Superheroes are dialed up so high we can’t hear what real heroes sound like anymore. A 2008 poll in Britain found almost a quarter thought Winston Churchill was fake, while a majority of Britons believed Sherlock Holmes was real.

We’ve become confused: We prefer to watch fake heroes on screen rather than expect real ones to emerge in life. And so the fake ones become the only kind of hero we recognize.

The historian Daniel Boorstin described this transition from heroism to fame in his 1961 book “The Image.” He noted that heroes in American history were typically known for great public contribution through immense difficulty and danger. It didn’t matter much what they looked like because their deeds had saved lives and mattered to so many.

But pictures and movies changed everything in the 20th century. Heroes became celebrities. We traded away enduring contributions to the public good in exchange for flimsy, flashy fame that works for a paycheck. Value over values; money over all.

This isn’t hard to see. Look at how college sports has been conquered by contracts and name-image-likeness deals. How law firms kowtowed to an administration making unprecedented demands. How media heavyweights keep bending knees to the same. And let’s not get started with social media “influencers” except to say that doing the right and honest thing has been swept aside by the twin tsunamis of popularity and the Almighty Buck.

Where’s our real truth, our real justice, our real American way?

Not in Congress. The “Big Beautiful Bill” is a perfect example. It might take a Mt. Rushmore makeover to honor the profound contributions to cowardice in the votes surrounding this act. Rep. Jeff Crank (R-Colo.) couldn’t vote fast enough to add trillions to the national debt despite arguing, less than a year ago, that Congress is “turning a blind eye to this $35 trillion in debt,” that it’s “unsustainable” and that “we have to get our fiscal house in order, and we have to do this for our children and our grandchildren.”

Or Rep. Chip Roy (R-Texas), long-time fiscal hawk on the debt, who repeatedly railed against the Big Beautiful Bill’s deficit spending in the final stretch. And then he voted for it.

Or Sen. Josh Hawley (R-Mo.), known for saying “we must ignore calls to cut Medicaid” because “slashing health insurance for the working poor” would be “both morally and politically suicidal.” That was in May. But come July, Hawley voted to cut Medicaid.

The final vote came down to Sen. Lisa Murkowski (R-Alaska). In a mid-June town hall, she said, “I have made clear very early on that we cannot move forward with a bill that makes cuts to Medicaid.” And yet, despite the fact that nearly 40,000 Alaskans (more than 5% of the state’s population) will likely lose their healthcare coverage as a direct result of the bill, Murkowski caved.

Sarah Longwell, founder and publisher of the Bulwark, spared nothing in her criticism of Murkowski. She wrote that this one action “defines our pathetic political moment,” embodying:

“Selfishness: I’m taking care of me and mine, the rest of you can pound sand;

Lack of accountability: I know the bill is bad, hopefully someone else will fix it;

Cowardice: I’m scared of Trump and his voters and need to go-along to get along with my GOP colleagues;

Moral rot: I know the difference between right and wrong, and actively chose wrong.”

Not exactly Superman. Sounds more like Lex Luthor at his most self-serving and callous.

We don’t need someone faster than a speeding bullet in the House. We don’t need senators leaping tall buildings in a single bound. We don’t need Superman.

But we do need our Clark Kents and Lois Lanes to step up. We do need our real heroes right now. Maybe Crank or Roy or Hawley or Murkowski will see the movie this weekend. Maybe they’ll find some courage for the next vote.

Maybe.

ML Cavanaugh is the author of the forthcoming book “Best Scar Wins: How You Can Be More Than You Were Before.” @MLCavanaugh

SACRAMENTO — The federal safety-net healthcare system for low-income and disabled Americans, Medicaid, won’t be the only medical coverage devastated by the package of spending cuts and tax breaks signed into law by President Trump on the Fourth of July.

Covered California, the state’s Affordable Care Act health insurance marketplace, estimates that as many as 660,000 of the roughly 2 million people in the program will either be stripped of coverage or drop out due to increased cost and the onerous new mandates to stay enrolled. Those who do stay could be hit with an average monthly premium increase of up to 66%.

This is Phil Willon, the L.A. Times California politics editor, filling in for columnist George Skelton this week.

To find out more about how the millions of Californians who rely on Covered California for health insurance will be affected by Trump’s megabill, I spoke with Jessica Altman, the organization’s executive director.

We spoke on Thursday, while the Republican-led U.S. House of Representatives was voting to approve the reconciliation legislation. According to estimates by the nonpartisan Congressional Budget Office, the package will lead to 11.8 million more people going without health insurance nationwide over the next decade.

Price increase imminent

Covered California serves as a marketplace exchange for state residents seeking healthcare insurance under the federal Affordable Care Act, widely known as Obamacare, allowing them to select from name-brand insurance providers and choose from a variety of coverage plans.

“A quarter of the people we cover are sole proprietors. That’s everything from mom-and-pop Etsy shops to a consultant, a highly educated tech worker in San Francisco doing contract work. We really have that full spectrum,” Altman said.

Covered California also serves as a health insurance sanctuary for residents whose income rises enough for them to lose eligiblity for Medi-Cal, as Medicaid is known in California, or those who work for companies that don’t provide benefits.

The current cost for basic coverage ranges from $0 a month for individuals earning around $21,000 — just above the income eligibility for Medi-Cal — to 8.5% of the income of people making $75,000 or more, Altman said.

The vast majority of Californians receive federal subsidies to lower their premiums, including many middle-income families who had become eligible when Congress expanded the financial assistance in 2021.

Those subsidies were not renewed in the Trump megabill. In theory, the Republican-led Congress could remedy that before the end of the year but, given that Trump spent most of his first term in office trying to repeal the Affordable Care Act, the odds of that appear slim.

“We have many, many people paying less than $10 a month for their health insurance. We’re going to lose that price for sure,” Altman said. “We also have people, that person making $75,000 a year … they’re going to lose all of their tax credits and potentially pay hundreds more a month.”

And that price increase will start to hit home in four months, when Covered California’s open enrollment signup period begins for 2026.

Thousands of Californians will drop their coverage because they can no longer afford the expense, Altman predicts.

“This is a moment where Americans and Californians are so financially strained: Their rent, their food, their gas, their child care, all of their transportation, all of these things,” Altman said. “They are not in a position today where they feel like any of those costs can rise by 66%.”

Altman said the governor and California Legislature budgeted an additional $190 million for Covered California, which hopefully will help reduce the number of residents who will lose their healthcare coverage. But, she said, it’s nowhere near enough to make up for the federal cuts.

Targeting legal immigrants and ‘Dreamers’

Approximately 112,000 lawful immigrants in California also will be stripped of premium tax credits and cost-sharing support, essentially pushing health coverage out of financial reach, she said. That includes immigrant groups that have been eligible for assistance for years, including those with work and student visas, refugees, asylees and victims of human trafficking.

“They are limiting it so only green card holders and a couple of very nuanced categories of certain Cuban immigrants and certain immigrants from Pacific Island nations can get financial assistance,” Altman said.

Immigrants who grew up in the United States after being brought here illegally as children, a group known as “Dreamers,” will be stripped of their eligibility, Altman said.

Thousands more Californians likely will drop coverage because of new burdensome verification requirements, including increased tax filings, and bureaucratic hurdles that must be overcome to maintain eligibility.

Big picture

California Gov. Gavin Newsom already has warned that the cuts to Medicaid in what Trump calls the “Big Beautiful Bill,” a cornerstone of his second-term agenda, will lead to hospital and clinic closures, especially in the state’s underserved rural areas.

Altman said that impact will be exacerbated by the tens of thousands of Californians expected to lose their medical insurance they secured through Covered California. Medical facilities received higher compensation to care for patients who secured health insurance through Covered California than they do for patients on Medi-Cal. And hospitals and clinics will now take an even greater financial hit for caring for Californians with no health insurance, raising healthcare costs for everyone else.

“We know people will get less healthcare. They will not get their preventive care, they will not get their primary care at the rates that they do when they’re covered,” Altman said. “But when they really need care, they’re going to go get it. They’re going to get it at the emergency room, and our system is going to pay for it anyway.”

What else you should be reading

The must-read: Valadao votes for a Trump megabill expected to disrupt healthcare for many in the Central Valley
The TK: Gov. Newsom will visit South Carolina, a pivotal presidential primary state
The L.A. Times Special: Kidnappers or ICE agents? LAPD grapples with surge in calls from concerned citizens

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United States President Donald Trump’s signature piece of budget legislation, the “One Big Beautiful Bill”, will likely raise healthcare costs, experts have said. While the Medicaid cuts will directly impact those who depend on the programme, the consequences will extend to others as well.

The 869-page bill, which includes roughly $1 trillion in cuts to Medicaid over the next decade, passed in the House along party lines, with only two Republicans – Representatives Thomas Massie of Kentucky and Brian Fitzpatrick of Pennsylvania – breaking ranks. It will be signed into law by Trump on Friday.

In addition to patients, Medicaid funds also help financially strapped hospitals and other healthcare facilities, and the cuts could lead to their closures.

Apart from this, almost 12 million people could lose health insurance by 2034 due to reductions to both Medicaid and the Affordable Care Act marketplace, according to a Congressional Budget Office analysis.

Experts warn the new law will drive up costs elsewhere in the system. Patients may face higher out-of-pocket expenses, while hospitals could be forced to lower the quality of care, raise prices, or close entirely due to the financial strain.

“There is the mistaken belief that cuts in Medicaid will only affect those on Medicaid. Many hospitals, clinics, and healthcare organisations depend on Medicaid funding for their operations. Therefore, cuts in Medicaid can adversely affect the types and quality of services they provide,” Bruce Y Lee, professor of health policy at the CUNY Graduate School of Public Health and Health Policy, told Al Jazeera.

“In fact, a number of healthcare organisations depend so heavily on Medicaid funding that they could go out of business with significant cuts.”

The cuts would hit rural hospitals hard, according to an analysis from the National Rural Hospital Association (NRHA). About 20 percent of the US population lives in rural areas, where Medicaid covers one in four adults, a higher share than in urban areas, and plays a large part in financing healthcare services.

The cuts are expected to result in a 20 percent reduction in funding for rural hospitals in half of all states.

That will hurt patients like Martha Previte and her partner Jim Earl, who live in rural Maine. Both have type 1 diabetes and rely on regular hospital visits for a range of procedures, including blood tests and kidney treatment.

“I fear that these cuts are going to close hospitals that we rely on to get care, and we’re not going to have anywhere to go,” Previte told Al Jazeera.

This bill could result in as many as 338 hospitals closing around the US. There are already nearly 800 hospitals that are facing financial hardship.

“Our goal is to help ensure hospitals can remain open for their communities, and people can get the care they need when they need it. Our nation’s health and economic future depend on it,” the American Hospital Association said in a statement condemning the bill’s passage and calling it “an extremely disappointing and very difficult day for health care in America”.

Those that stay open could result in cuts to essential care like chemotherapy and behavioural health services.

The bill does include $50bn for rural hospitals to offset the additional financial strain they will face. But because of cuts to Medicaid, that funding will not make enough of a dent to keep healthcare costs from rising and healthcare facilities from shuttering.

Analysis from the Kaiser Family Foundation found that Medicaid cuts would still lead to a drop of $155bn in federal Medicaid spending on rural hospitals over the next 10 years.

“While the President promised to lower costs for Americans, this bill is set to spike premiums and other healthcare costs,” Elizabeth Pancotti, managing director of policy and advocacy at the Groundwork Collaborative, told Al Jazeera.

Rural hospitals in the state of Missouri will be the hardest hit and are expected to lose an average of 29 percent of Medicaid funding. While Missouri’s Senator Josh Hawley, in a May op-ed in the New York Times, said cuts to Medicaid would be “politically suicidal”, he and his fellow Missouri senator, Republican Eric Schmitt, voted in support of the bill before it moved to the House of Representatives on Tuesday.

The cuts are also expected to affect nursing homes disproportionately in urban areas, according to an analysis from Brown University School of Public Health, which forecast that 579 nursing homes could shutter. Those at highest risk have a Medicaid payer share greater than 85 percent. It was found that the Medicaid cuts overwhelmingly affected nursing homes in California, Georgia, Illinois and Texas.

Looming Medicare changes

Medicaid is not the only healthcare programme seeing cuts. While Medicaid is intended for those who are low-income, Medicare covers healthcare for those 65 and older, as well as some others who have disabilities. Some patients, like Previte, receive both.

“Medicare is my primary insurer, and Medicaid picks up what Medicare does not cover. I am a type 1 insulin-dependent diabetic of 41 years with serious complications. Medicare covered my recent hospitalisation and upcoming outpatient procedures,” Previte told Al Jazeera.

The Republican bill could also indirectly lead to cuts in Medicare services because of the statutory Pay‑As‑You‑Go Act of 2010. Under this, the White House’s Office of Management and Budget is required to keep a “scorecard” to track net increases to the deficit, with a goal to “eliminate the overage”.

Because of that, the programme may not get all of the money allocated to it, a potential $490bn loss in access to funds over the next decade, according to the Congressional Budget Office, affecting coverage for people who rely on Medicare.

“The whole thing [the tax bill] is a stark abandonment of human social responsibility,” Previte’s partner Earl said.

Affordable Care Act changes

The upcoming law also makes significant changes to the Affordable Care Act, otherwise known as Obamacare. It shortens the annual enrollment period for healthcare coverage by about a month and drives up premium costs for those who need it.

According to analysis from the Kaiser Family Foundation, insurance premium prices could increase on average by $1,296 a year.

Those who get their healthcare coverage through the exchange will also need to annually update their personal information, which includes income and immigration status, rather than being enrolled automatically.

The changes will cause a strain on the small business economy. Last year, as many as 3.3 million self-employed individuals and small business owners relied on the marketplace for health insurance.

“If you’re a young business owner, already stretched thin by housing costs, child care bills, and health premiums, this bill just made your future harder,” Richard Trent, executive director of Main Street Alliance, an advocacy group for small businesses, said in a statement.

Former President Barack Obama, in a post on X, weighed in as the bill strips parts of his signature policy, a key part of his legacy.

“It will increase costs and hurt working class families for generations to come,” the former president said in a post before the bill’s passage.

“This will be another branch of a limb of a disastrous tree. I’m concerned about what this means for our future care. The thing with diabetes, like many ailments, they’re livable if they’re treated properly. You can live a long, happy, healthy life, but when you’re deprived of healthcare, maintenance-of-health care, and things like that, then a whole Pandora’s box of disasters can happen to your health,” Earl added.

WASHINGTON — Republicans muscled President Trump’s tax and spending cut bill through the House on Thursday, the final step necessary to get the bill to his desk by the GOP’s self-imposed deadline of July 4th.

At nearly 900 pages, the legislation is a sprawling collection of tax breaks, spending cuts and other Republican priorities, including new money for national defense and deportations.

Democrats united against the legislation, but were powerless to stop it as long as Republicans stayed united. The Senate passed the bill, with Vice President JD Vance casting the tiebreaking vote. The House passed an earlier iteration of the bill in May with just one vote to spare. It passed the final version 218-214.

Here’s what’s in the bill:

Tax cuts are the priority

Republicans say the bill is crucial because there would be a massive tax increase after December when tax breaks from Trump’s first term expire. The legislation contains about $4.5 trillion in tax cuts.

The existing tax rates and brackets would become permanent under the bill, solidifying the tax cuts approved in Trump’s first term.

It temporarily would add new tax deductions on tip, overtime and auto loans. There’s also a $6,000 deduction for older adults who earn no more than $75,000 a year, a nod to his pledge to end taxes on Social Security benefits.

It would boost the $2,000 child tax credit to $2,200. Millions of families at lower income levels would not get the full credit.

A cap on state and local deductions, called SALT, would quadruple to $40,000 for five years. It’s a provision important to New York and other high tax states, though the House wanted it to last for 10 years.

There are scores of business-related tax cuts, including allowing businesses to immediately write off 100% of the cost of equipment and research. Proponents say this will boost economic growth.

The wealthiest households would see a $12,000 increase from the legislation, and the bill would cost the poorest people $1,600 a year, mainly due to reductions in Medicaid and food aid, according to the nonpartisan Congressional Budget Office analysis of the House’s version.

Money for deportations, a border wall and the Golden Dome

The bill would provide some $350 billion for Trump’s border and national security agenda, including for the U.S.-Mexico border wall and for 100,000 migrant detention facility beds, as he aims to fulfill his promise of the largest mass deportation operation in U.S. history.

Money would go for hiring 10,000 new Immigration and Customs Enforcement officers, with $10,000 signing bonuses and a surge of Border Patrol officers, as well. The goal is to deport some 1 million people per year.

To help pay for it, immigrants would face various new fees, including when seeking asylum protections.

For the Pentagon, the bill would provide billions for ship building, munitions systems, and quality of life measures for servicemen and women, as well as $25 billion for the development of the Golden Dome missile defense system. The Defense Department would have $1 billion for border security.

How to pay for it? Cuts to Medicaid and other programs

To help partly offset the lost tax revenue and new spending, Republicans aim to cut back on Medicaid and food assistance for people below the poverty line .

Republicans argue they are trying to right-size the safety net programs for the population they were initially designed to serve, mainly pregnant women, the disabled and children, and root out what they describe as waste, fraud and abuse.

The package includes new 80-hour-a-month work requirements for many adults receiving Medicaid and food stamps, including older people up to age 65. Parents of children 14 and older would have to meet the program’s work requirements.

There’s also a proposed new $35 co-payment that can be charged to patients using Medicaid services.

More than 71 million people rely on Medicaid, which expanded under Obama’s Affordable Care Act, and 40 million use the Supplemental Nutrition Assistance Program. Most already work, according to analysts.

The Congressional Budget Office estimates that 11.8 million more Americans would become uninsured by 2034 if the bill became law and 3 million more would not qualify for food stamps, also known as SNAP benefits.

Republicans are looking to have states pick up some of the cost for SNAP benefits. Currently, the federal government funds all benefit costs. Under the bill, states beginning in 2028 will be required to contribute a set percentage of those costs if their payment error rate exceeds 6%. Payment errors include both underpayments and overpayments.

But the Senate bill temporarily delays the start date of that cost-sharing for states with the highest SNAP error rates. Alaska has the highest error rate in the nation at nearly 25%, according to Department of Agriculture data. Sen. Lisa Murkowsk (R-Alaska) had fought for the exception. She was a decisive vote in getting the bill through the Senate.

A ‘death sentence’ for clean energy?

Republicans are proposing to dramatically roll back tax breaks designed to boost clean energy projects fueled by renewable sources such as energy and wind. The tax breaks were a central component of President Biden’s 2022 landmark bill focused on addressing climate change and lowering health care costs.

Sen. Ron Wyden (D-Ore.) went so far as to call the GOP provisions a “death sentence for America’s wind and solar industries and an inevitable hike in utility bills.”

A tax break for people who buy new or used electric vehicles would expire on Sept. 30 of this year, instead of at the end of 2032 under current law.

Meanwhile, a tax credit for the production of critical materials will be expanded to include metallurgical coal used in steelmaking.

Trump savings accounts and so, so much more

A number of extra provisions reflect other GOP priorities.

The bill creates a new children’s savings program, called Trump Accounts, with a potential $1,000 deposit from the Treasury.

The Senate provided $40 million to establish Trump’s long-sought “National Garden of American Heroes.”

There’s a new excise tax on university endowments and a new tax on remittances, or transfers of money that people in the U.S. send abroad. The tax is equal to 1% of the transfer.

A $200 tax on gun silencers and short-barreled rifles and shotguns was eliminated.

One provision bars for one year Medicaid payments to family planning providers that provide abortions, namely Planned Parenthood.

Another section expands the Radiation Exposure Compensation Act, a hard-fought provision from GOP Sen. Josh Hawley of Missouri, for those impacted by nuclear development and testing.

Billions would go for the Artemis moon mission and for the exploration of Mars, while $88 million is earmarked for a pandemic response accountability committee.

Additionally, a provision would increase the nation’s debt limit, by $5 trillion, to allow continued borrowing to pay already accrued bills.

Last-minute changes

The Senate overwhelmingly revolted against a proposal meant to deter states from regulating artificial intelligence. Republican governors across the country asked for the moratorium to be removed and the Senate voted to do so with a resounding 99-1 vote.

A provision was thrown in at the final hours that will provide $10 billion annually to rural hospitals for five years, or $50 billion in total. The Senate bill had originally provided $25 billion for the program, but that number was upped to win over holdout GOP senators and a coalition of House Republicans warning that reduced Medicaid provider taxes would hurt rural hospitals.

The amended bill also stripped out a new tax on wind and solar projects that use a certain percentage of components from China.

What’s the final cost?

Altogether, the Congressional Budget Office projects that the bill would increase federal deficits over the next 10 years by nearly $3.3 trillion from 2025 to 2034.

Or not, depending on how one does the math.

Senate Republicans are proposing a unique strategy of not counting the existing tax breaks as a new cost because those breaks are already “current policy.” Republican senators say the Senate Budget Committee chairman has the authority to set the baseline for the preferred approach.

Under the alternative Senate GOP view, the bill would reduce deficits by almost half a trillion dollars over the coming decade, the CBO said.

Democrats say this is “magic math” that obscures the true costs of the tax breaks. Some nonpartisan groups worried about the country’s fiscal trajectory are siding with Democrats in that regard. The Committee for a Responsible Federal Budget says Senate Republicans were employing an “accounting gimmick that would make Enron executives blush.”

Freking and Mascaro write for the Associated Press.

WASHINGTON — Confident that passage of President Trump’s signature legislation was all but assured, West Wing aides summoned holdouts in the House Republican caucus Wednesday to deliver a blunt message: Follow the president’s orders and get it done by Friday.

It was a call to action after House Speaker Mike Johnson (R-La.) directed his caucus to return to Washington from home districts around the country, braving flight delays due to storms in the capital to be back in time for a vote before the Fourth of July.

But the vote was in doubt, and signs emerged of cracks in a coalition otherwise firmly under Trump’s control.

“The president of the United States didn’t give us an assignment,” Rep. Derrick Van Orden, a Republican from Wisconsin, told reporters, using an expletive to suggest Trump was treating lawmakers like his minions. “I’m a member of Congress. I represent almost 800,000 Wisconsinites. Is that clear?”

Frustration within the Republican Party was coming from two disparate camps of a broad-tent coalition that have their own sets of grievances: fiscal hawks who believe the bill adds too much to the national debt, and lawmakers representing districts that heavily rely on Medicaid.

One GOP lawmaker who attended the White House meeting Wednesday, Rep. David Valadao of California, represents a Central Valley district with one of the highest percentages of Medicaid enrollment in the nation.

The president’s megabill, which he calls the “Big Beautiful Bill,” levies historic cuts to the healthcare program that could result in up to 12 million Americans losing health coverage, according to the nonpartisan Congressional Budget Office, gutting $1 trillion in funding and introducing a work requirement for enrollees of 80 hours per month until they turn 65 years old.

The legislation would also restrict state taxes on healthcare providers, known as the “provider tax,” an essential tool for many states in their efforts to supplement Medicaid funding. Several Republican lawmakers fear that provision could have devastating effects on rural hospitals.

House Minority Leader Hakeem Jeffries, appearing Wednesday with other Democrats on the Capitol steps, denounces President Trump’s tax and spending bill.

(Bloomberg via Getty Images)

A handful of Republican lawmakers from North Carolina have bristled at the president’s pressure campaign, with Rep. Chuck Edwards telling Punchbowl News that the White House meeting “didn’t sway my opinion.” North Carolina Sen. Thom Tillis was one of three Republicans who voted against the bill Tuesday, warning it would devastate his state. It still passed with a tie-breaking vote from Vice President JD Vance.

The vote was shaping up to be narrow in the House as well, where Johnson can afford to lose only three votes in order to pass the omnibus legislation.

A daylong debate on the House floor allowed for private negotiations to continue, ahead of a crucial procedural vote on rules that would be the last step before a final vote. But it was unclear whether the expressions of frustration and doubt Wednesday amounted to performance art in anticipation of the bill’s inevitable passage, or signaled a genuine threat to the bill.

Earlier Wednesday, after taking meetings at the White House, members of the House Freedom Caucus, a bloc founded to promote fiscal responsibility, also met with Johnson. The speaker emerged with a message of tempered optimism and later said he was hoping to secure a final vote Wednesday night.

“I feel very positive about the progress, we’ve had lots of great conversations,” Johnson told reporters, “but we can’t make everyone 100% happy. It’s impossible.”

“This is a deliberative body. It’s a legislative process by definition — all of us have to give up on personal preferences,” he said. “I’m never going to ask anyone to compromise core principles, but preferences must be yielded for the greater good. And that’s what I think people are recognizing and coming to grips with.”

Rep. Chip Roy of Texas, a member of the Freedom Caucus, had been highly critical of the Senate legislation. But he signaled an openness Wednesday afternoon to vote in favor of the bill, an indication that passage could be imminent.

Democrats are out of power across Washington and have no ability to stop the legislation. But many believe it could backfire on Republicans in the midterm elections next year.

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

Trump says the legislation encompasses his entire domestic agenda, extending tax cuts passed during his first term in 2017 and beefing up funding for border security, mass deportations and the Defense Department.

Cuts to Medicaid, as well as to the Supplemental Nutrition Assistance Program, better known as SNAP, are intended to offset a fraction of the costs. But the CBO still estimates the legislation will add $3.3 trillion to the national debt over the next decade, and hundreds of billions to the deficit, with other nonprofit budget trackers forecasting even higher figures.

July 2 (UPI) — California and 19 other states have filed a lawsuit challenging the legality of the Department of Health and Human Services permitting the Department of Homeland Security “unfettered access” to individual Medicaid health data, raising fears it could be used as part of President Donald Trump’s mass deportation plans.

According to the lawsuit, filed Tuesday in the U.S. District Court for the Northern District of California, the states are asking the court to declare HHS’ transfer of Medicaid data to DHS, which oversees Immigration and Customs Enforcement, was unauthorized and enjoin its use for the purposes of immigration enforcement. They are also seeking to prevent any further sharing of Medicaid data.

“The Trump administration has upended longstanding privacy protections with its decision to illegally share sensitive, personal health data with ICE,” California Attorney General Rob Bonta said in a statement. “In doing so, it has created a culture of fear that will lead to fewer people seeking vital emergency medical care.”

The lawsuit states that on June 13, the plaintiff states learned that HHS had transferred to DHS en mass Medicaid files from California, Illinois and Washington.

The states said the data transferred was personally identifiable, not anonymized and included Medicaid beneficiaries’ immigration status and addresses among other information.

According to the lawsuit, HHS provided neither the states nor the Medicaid beneficiaries with warning or notice of the transfer and the department has not identified the legal authorities under which it shared the personal Medicaid data with DHS.

HHS has said, the lawsuit states, that it gave the information to DHS “to ensure that Medicaid benefits are reserved for individuals who are lawfully entitled to receive them” but Congress has permitted coverage and federal fund for emergency Medicaid to all residents of the United States, including those without immigration status.

Among the consequences of the sharing of this information is that it could lead to noncitizens disenrolling or refusing to enroll in emergency Medicaid, which they are eligible for, thereby denying them healthcare they may need.

“The Trump administration’s use of Washingtonians’ private health information for its own political agenda is outrageous,” Washington Gov. Bob Ferguson said in a statement.

“This is a violation of trust for everyone whose data was inappropriately shared, but especially our immigrant communities and mixed-status families, who are already being targeted by the Trump administration.

Protesters railed on Tuesday against an Orange County congresswoman who could be a critical vote on President Trump’s proposal to cut more than $1 trillion in federal dollars that helped pay for healthcare for those in need and extend tax cuts for millions of Americans.

Trump’s proposed “One Big Beautiful Bill Act” narrowly passed the U.S. Senate hours before hundreds of people gathered in a cul-de-sac outside of the Anaheim field office of Republican Rep. Young Kim to protest those cuts. The legislation still needs to be voted on by the U.S. House of Representatives, which could happen before the end of the week.

“I don’t know why they call it beautiful, because there’s nothing about it that’s beautiful. It’s harmful, it’s reckless, and it’s cruel, and it’s going to hurt people,” said Melody Mendenhall, a nurse at UCLA who is active with the California Nurses Assn., which was among the groups that organized the protest. “Rep. Young Kim, hear our cry, hear our voices. We need our Medicaid. We cannot afford this type of reckless cuts and behavior.”

A security guard blocked the parking lot to Kim’s office and at least a half-dozen Anaheim police officers watched the protest unfold.

Several people who appeared to be Kim staffers watched the demonstration from outside the building before they dashed inside when protesters marched to the building, unsuccessfully sought to enter it and then began chanting “Shame! Shame!”

In a statement, Kim said that her door was always open to Californians in her district.

“I understand some of my constituents are concerned and know how important Medicaid services are for many in my community, which is why I voted to protect and strengthen Medicaid services for our most vulnerable citizens who truly need it,” Kim said. “I have met with many of these local healthcare advocates in recent months.”

Trump’s proposal would dramatically overhaul the nation’s tax code by making cuts approved during the president’s first term permanent, a major benefit to the corporations and the nation’s wealthy, while slashing funding for historic federal safety-net programs including Medicaid and the Supplemental Nutrition Assistance Program, which helps provide food to low-income Americans.

Roughly 15 million Californians, more than a third of the state, are on Medi-Cal, the state’s version of Medicaid, with some of the highest percentages in rural counties that supported Trump in the November election. More than half of California children receive healthcare coverage through Medi-Cal.

A version of the Republican bill was passed by the U.S. House of Representatives with Kim’s support. The U.S. Senate narrowly approved an amended version of the bill on Tuesday. The defection of three GOP senators meant Vice President JD Vance had to cast the tie-breaking vote for it to pass in that chamber.

The House and Senate will now work to reconcile their two different versions of the bill. This week was a district work week for members of Congress, but House Speaker Mike Johnson (R-Louisiana) ordered members back to Washington, D.C., for votes on the bill that could occur Wednesday or Thursday.

Republicans hope to get the legislation to President Trump’s desk for his signature by Friday, Independence Day, though there is some concern among its members about whether they will have enough votes to pass the bill because of potential defections and the united Democratic opposition.

An analysis released by the nonpartisan Congressional Budget Office on Sunday estimated that the Senate version of the proposal would increase the national deficit by nearly $3.3 trillion from 2025 to 2034 and would result in 11.8 million Americans losing health insurance in less than a decade.

Trump praised the passage of the bill on social media and urged House Republicans to support the Senate plan.

The proposal has caused a rift within the GOP, with and some House members have expressed reservations about the measure because of the amount it would add to the nation’s deficit and its impact on their constituents.

“I’ve been clear from the start that I will not support a final reconciliation bill that makes harmful cuts to Medicaid, puts critical funding at risk, or threatens the stability of healthcare providers” in his congressional district, Rep. David Valadao (R-Hanford) wrote on the social media site X on Sunday.

He represents more than half a million Central Valley residents who rely on Medicaid — the most of any congressional district in California, according to the UC Berkeley Labor Center. A spokesperson for Valadao on Tuesday didn’t respond to a question about how the congressman planned to vote.

Kim’s Orange County district is more affluent than Valadao’s, but roughly one in five of her constituents relies on Medicaid.

The congresswoman was en route to Washington at the time of the protest, according to a spokesperson.

Outside her Anaheim field office, protester after protester described how the bill would impact vulnerable Californians, such as disabled children, the elderly, veterans and those who would lose access to reproductive healthcare.

“The stakes have never been higher. We are living in a time when our rights are under attack,” said Emily Escobar, a public advocacy manager for Planned Parenthood of Orange and San Bernardino Counties.

She said that federal funds do not pay for abortions, but help pay for other vital healthcare, such as cancer screenings, preventative care, testing and treatment for sexually transmitted infections and access to contraception. More than one-third of Planned Parenthood’s patients nationwide reside in California.

These cuts will result in clinics being shut down, effectively reducing access to abortion, Escobar said.

“Let me make this clear, this bill is a backdoor abortion ban,” she said.

Shari Home, 73, said she and her husband were weighing how to divide their Social Security income on food, medication and medical supplies after her husband, who suffers several chronic health conditions, fell last year.

“The hospitalizations were so expensive, so we applied for and got Medi-Cal in January and food assistance, and it’s been such a lifesaver,” said the Laguna Woods resident. “Without Medi-Cal, I don’t know what we would do. Our lives would not be good. We would not have the medications that he needs.”

Michelle Del Rosario, 57, wore a button picturing her son William, 25, on her blouse. The Orange resident, one of Kim’s constituents who has previously voted for her, is the primary caregiver for her son, who has autism, epilepsy and does not speak.

Her son relies on his Medi-Cal coverage for his $5,000-a-month seizure medicine, as well as the home health support he receives, she said.

“He lives at home. He has desires, at some point, to live independently, to work, but he needs” these support services for that to happen, Del Rosario said.

WASHINGTON — President Trump’s megabill encompassing his domestic agenda on Monday inched closer to becoming law as Republican senators sifted through familiar procedural hurdles toward a final vote on legislation that would dramatically transform the tax code and Medicaid.

Throughout a day of marathon voting, senators offered amendments to the bill that could ultimately decide whether it secures passage through Congress. If the Senate approves the legislation — as it is expected to do by a slim, simple majority and with bipartisan opposition — then the House will have to vote for a second time on the final text before it goes to the president’s desk for his signature.

Anticipating Senate passage, the House Rules Committee has already scheduled a hearing on reconciling the two bills for Tuesday. The White House previously set July 4 as a goal to get the package, called the “One Big Beautiful Bill Act,” passed by both chambers.

But several Republicans are still criticizing the bill, including Sens. Rand Paul of Kentucky and Thom Tillis of North Carolina, who announced he will not seek reelection in 2026 over the weekend before ripping into the legislation as a “betrayal” to voters.

Although the legislation has hundreds of provisions, its most sweeping would make tax breaks passed in 2017 during Trump’s first term permanent — an expensive proposition — before they are set to expire at the end of this year, while attempting to offset some of those costs with historic cuts to Medicaid and the Supplemental Nutrition Assistance Program, social welfare programs that for decades had been seen as a political third rail.

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.

“What do I tell 663,000 people in two years or three years, when President Trump breaks his promise by pushing them off of Medicaid because the funding’s not there anymore?” Tillis said in a speech from the Senate floor. “The people in the White House advising the president are not telling him that the effect of this bill is to break a promise.”

Both Paul and Tillis voted against advancing the bill to a floor vote and have indicated they will vote “no” on its final passage.

“Republicans are about to make a mistake on healthcare, and betraying a promise,” Tillis continued. “It is inescapable that this bill in its current form will betray the very promise that Donald J. Trump made in the Oval Office, or in the Cabinet room, when I was there with Finance [Committee members] where he said, ‘We can go after waste, fraud and abuse on any programs.’”

Tillis and a handful of his colleagues, including Sen. Josh Hawley of Missouri, have expressed concern with elements of the bill that restrict state taxes on healthcare providers, known as the “provider tax,” an essential tool for many states in their efforts to supplement Medicaid funding.

The Senate parliamentarian has already determined that the provision, among others, fails to follow the rules of the chamber and must be removed or modified. Another passage crucial to the bill, which introduces a structure for work requirements for Medicaid, was halted by the parliamentarian.

Senate Minority Leader Chuck Schumer (D-N.Y.) speaks to reporters outside the chamber on June 30, 2025.

(Manuel Balce Ceneta / Associated Press)

Republicans efforts to prohibit the use of Medicaid funds on gender transition care, to cancel regulations that require a minimum staffing ratio at nursing homes and to limit Medicaid access to immigrants were also cut by the parliamentarian, who continued to review amendments to the bill as they were introduced Monday.

The parliamentarian’s moves eat into the stated cost savings of a bill that is already slated to add trillions of dollars to the debt over the next decade — a problem for fiscal hawks in both chambers whose votes will be crucial for passage.

They also gutted key provisions that were top priorities for Sen. Lisa Murkowski of Alaska, the focus of an intense lobbying campaign by Senate Republican leadership after expressing skepticism over several provisions of the legislation. Sen. Susan Collins of Maine, who is up for reelection next cycle, has also expressed concern over its cuts to Medicaid.

“This is an ongoing process — the president continues to be very much engaged with the leadership in both the Senate and the House,” Karoline Leavitt, the White House press secretary, told reporters in a briefing Monday. “He understands that legislators want to protect jobs in the communities and their districts.”

Democrats in the Senate have been united in their opposition to the bill, with Mark Kelly, of Arizona, warning Republicans of electoral repercussions.

“If they lose their health insurance,” he told MSNBC in an interview, “sure, they’re going to remember.”

But the potential political windfall for Democrats isn’t stopping the party from attempting to improve the legislation, he said, noting a number of amendments proposed by Democratic senators Monday that would roll back cuts to Medicaid and SNAP.

If the bill does ultimately clear the Senate, Republicans will have only a handful of votes in the House to spare in a final vote. And several are already suggesting they will vote against it, including Rep. David Valadao of California, whose constituents rely heavily on Medicaid.

“I’m not a ‘yes’ necessarily,” said Rep. Don Bacon, a Republican from Nebraska who has announced his retirement. Bacon added that he believes the Senate version has gone too far in gutting healthcare programs. “I think we’ll have a hard time passing.”

An intraparty fight has also broken out among Republicans over the fate of green energy tax credits, which several GOP senators — including Murkowski, as well as Chuck Grassley and Joni Ernst of Iowa — sought to preserve for several more years. A group of House Republicans had successfully lobbied in their version of the bill to speed up the termination of those credits.

Elon Musk, a co-founder of Tesla, and Trump’s close advisor and benefactor before the two men fell out this month, renewed his attacks on the legislation Monday, calling it “utterly insane and destructive” for its price tag.

“It is obvious with the insane spending of this bill, which increases the debt ceiling by a record FIVE TRILLION DOLLARS that we live in a one-party country — the PORKY PIG PARTY!!” Musk wrote.

“Time for a new political party,” he added, “that actually cares about the people.”

WASHINGTON — Senate Republicans voting in a dramatic late Saturday session narrowly cleared a key procedural step as they race to advance President Trump’s package of tax breaks, spending cuts and bolstered deportation funds by his Fourth of July deadline.

The 51-49 vote came after a tumultuous session with Vice President JD Vance on hand if needed to break a tie. Tense scenes played out in the chamber as voting came to a standstill, dragging on for hours as holdout senators huddled for negotiations. In the end, two Republicans opposed the motion to proceed to debate, joining all Democrats and independents.

It’s still a long weekend of work to come.

Republicans are using their majorities in Congress to push aside Democratic opposition, but they have run into a series of political and policy setbacks. Not all GOP lawmakers are on board with proposals to reduce spending on Medicaid, food stamps and other programs as a way to help cover the cost of extending some $3.8 trillion in Trump tax breaks.

Ahead of the expected roll call, the White House released a statement of administrative policy saying it “strongly supports passage” of the bill that “implements critical aspects” of the president’s agenda. Trump was at his golf course in Virginia on Saturday with GOP senators posting about it on social media.

“It’s time to get this legislation across the finish line,” said Senate Majority Leader John Thune (R-S.D.).

But as the day wore on, billionaire Elon Musk, a key Trump advisor for the first months of the administration, lashed out against the package — as he has in the past — calling it “utterly insane and destructive.”

“The latest Senate draft bill will destroy millions of jobs in America and cause immense strategic harm to our country!” he said in a post on X.

The 940-page bill was released shortly before midnight Friday, and senators are expected to grind through the hours of all-night debate and amendments in the days ahead. If the Senate is able to pass it, the bill would go back to the House for a final round of votes before it could reach the White House.

With narrow Republican majorities in the House and Senate, leaders need almost every lawmaker on board in the face of essentially unified opposition from Democrats. GOP Sens. Thom Tillis of North Carolina and Rand Paul of Kentucky voted against.

Senate Democratic leader Chuck Schumer of New York said Republicans unveiled the bill “in the dead of night” and are rushing to finish the vote before the public fully knows what’s in it. He was expected to call for a full reading of the text in the Senate overnight, which would take hours.

The weekend session could be a make-or-break moment for Trump’s party, which has invested much of its political capital on his signature domestic policy plan. The president is pushing Congress to wrap it up and has admonished the “grandstanders” among GOP holdouts to fall in line.

The legislation is an ambitious but complicated series of GOP priorities. At its core, it would make permanent many of the tax breaks from Trump’s first term that would otherwise expire by year’s end if Congress fails to act, resulting in a potential tax increase on Americans. The bill would add new breaks, including no taxes on tips, and commit $350 billion to national security, including for Trump’s mass deportation agenda.

But the cutbacks to Medicaid, food stamps and green energy investments, which a top Democrat, Sen. Ron Wyden of Oregon, said would be a “death sentence” for America’s wind and solar industries, are also causing dissent within GOP ranks.

The Republicans are relying on the reductions to offset the lost tax revenues, but some lawmakers say the cuts go too far, particularly for people receiving healthcare through Medicaid. Meanwhile, conservatives, worried about the nation’s debt, are pushing for steeper cuts.

Tillis, who said he spoke with Trump late Friday explaining his concerns, announced Saturday he cannot support the package as is, largely because he said the healthcare changes would force his state to “make painful decisions like eliminating Medicaid coverage for hundreds of thousands.”

The release of that draft had been delayed as the Senate parliamentarian reviewed the bill to ensure it complied with the chamber’s strict “Byrd rule,” named for the late Sen. Robert C. Byrd (D-W.Va.). It largely bars policy matters from inclusion in budget bills unless a provision can get 60 votes to overcome objections. That would be a tall order in a Senate with a 53-47 Republican edge and Democrats unified against Trump’s bill.

Republicans suffered a series of setbacks after several proposals, including shifting food stamp costs from the federal government to the states or gutting the funding structure of the Consumer Financial Protection Bureau, were deemed out of compliance with the rules.

But over the past few days, Republicans have quickly revised those proposals and reinstated them.

The final text includes a proposal for cuts to the Medicaid provider tax that had run into parliamentary hurdles and objections from several senators worried about the fate of rural hospitals. The new version extends the start date for those cuts and establishes a $25-billion fund to aid rural hospitals and providers. Sen. Josh Hawley (R-Mo.), who had opposed the cuts, vowed “to do everything I can” to make sure the reductions never go into effect.

The nonpartisan Congressional Budget Office has said that under the House-passed version of the bill, some 10.9 million people would lose their healthcare coverage and at least 3 million fewer would qualify for food aid. The CBO has not yet publicly assessed the Senate draft, which proposes steeper reductions.

Top income earners would see about a $12,000 tax cut under the House bill, while the package would cost the poorest Americans an additional $1,600, the CBO said.

The Senate included a compromise over the so-called SALT provision, a deduction for state and local taxes that has been a top priority of lawmakers from California, New York and other high-tax states, but the issue remains unsettled.

The current SALT cap is $10,000 a year, and a few Republicans wanted to boost it to $40,000 a year. The final draft includes a $40,000 cap but limits it to five years.

Many Republican senators say that is still too generous. At least one House GOP holdout, Rep. Nick LaLota of New York, has said that would be insufficient.

House Speaker Mike Johnson (R-La.) sent his colleagues home for the weekend with plans to be on call to return to Washington. But as the Senate draft was revealed, House GOP support was uncertain. One Republican, Rep. David Valadao of Hanford, said he was opposed.

Mascaro, Freking and Cappelletti write for the Associated Press. AP writers Ali Swenson and Matthew Daly contributed to this report.