Republicans propose paring Medicaid coverage, but steer clear of deeper cuts

House Republicans released a plan late on Sunday that would cause millions of poor Americans to lose Medicaid health coverage and millions more to pay higher fees when they go to the doctor, but that stopped short of an overhaul that would make the deepest cuts to the program.

The proposal, which is one piece of a sweeping bill to enact President Trump's domestic agenda, including large tax cuts and increased military spending, omits the structural changes to Medicaid that ultraconservative Republicans have demanded. Instead, it bows to the wishes of a group of more moderate and politically vulnerable G.O.P. lawmakers whose seats could be at risk if they embraced deep Medicaid cuts.

It was published late Sunday night by the House Energy and Commerce Committee, which under the G.O.P. budget blueprint had to find $880 billion in savings over a decade. The panel is scheduled to meet on Tuesday afternoon to debate and refine the package.

Republicans have toiled to assemble a number of cuts large enough to meet that goal, which fiscal hawks have insisted upon, while appeasing lawmakers from districts where Medicaid enrollment is widespread.

Overall, the legislation would reduce federal spending by an estimated $912 billion over the decade and cause 8.6 million people to become uninsured, according to a partial analysis from the Congressional Budget Office that was circulated by Democrats on the committee. Most of those cuts —$715 billion — would come from changes to Medicaid and the Affordable Care Act.

The legislation's remaining savings would come largely from changes in energy policy, including the repeal of two Biden-era regulations that affect car pollution and auto efficiency.

But the Medicaid portion was the most divisive and is likely to continue to be the most hotly debated as the proposal — which must be approved by the committee this week and then pass the House and Senate — makes its way through Congress.

The legislation released on Sunday tries to split the difference between Republicans agitating for deep cuts to Medicaid and those eager to protect their states from changes that could force them to shoulder much higher costs. It excludes several policies under consideration that would create large holes in state budgets and instead focuses on policies that cause Medicaid beneficiaries to pay more fees and complete more paperwork to use their coverage.

It also adds a work requirement to Medicaid for poor, childless adults, mandating that they prove they are working 80 hours every month to stay enrolled. That is a less flexible version of a work requirement briefly imposed in Arkansas in 2018 that caused 18,000 people to rapidly lose coverage.

Even some Republicans in the Senate who have been vocal about their opposition to cutting Medicaid benefits, including Senators Susan Collins of Maine and Josh Hawley of Missouri, have said they are open to adding some work requirements to the program. Mr. Trump, who has been adamant that he did not want to do anything that could be characterized as a Medicaid cut, has also endorsed the policy.

But the legislation also ratchets up paperwork requirements across the program, by allowing states to check the income and residency of beneficiaries more often, and by permitting them to terminate coverage for people who do not respond promptly. The use of such strategies had been curtailed under a regulation published during the Biden administration.

An analysis of the paperwork change published by the Congressional Budget Office last week suggested that it would cause 2.3 million people to lose Medicaid coverage, many poor older and disabled people who are also enrolled in Medicare but use Medicaid to cover co-payments they cannot afford. Because this population is at special risk, the budget office found, the policy would cause only 600,000 more Americans to lose any form of health insurance, but it would cause many more to have trouble paying for medical care.

The bill would also require Medicaid beneficiaries who earn more than the federal poverty limit — around $15,650 for a single person — to pay higher co-payments for doctor visits. Typically, Medicaid requires very limited cost sharing from its beneficiaries, given their low incomes. The legislation would require co-payments of $35 for many medical services.

Democrats in Congress immediately assailed the package as an attack on health coverage for vulnerable populations.

"In no uncertain terms, millions of Americans will lose their health care coverage, hospitals will close, seniors will not be able to access the care they need, and premiums will rise for millions of people if this bill passes," Representative Frank Pallone of New Jersey, the top Democrat on the Energy and Commerce Committee, said in a statement.

The provision most likely to affect state budgets is a change to longstanding rules that allow states to impose taxes on hospitals, nursing homes and other providers and to use various accounting maneuvers to use the taxes to obtain more federal funding. The bill would freeze all state taxes at their current rates, and prevent states from using special related payments to pay hospitals higher prices for Medicaid services than Medicare pays.

The bill also takes direct aim at a handful of states controlled by Democrats that fund health coverage for undocumented immigrants, who are barred under the law from enrolling in Medicaid. The legislation would reduce federal funding for all childless adults without disabilities to 80 percent from 90 percent if the state subsidized coverage for such people. The change would mean significant funding cuts to states including California, New York and Washington unless they eliminated their state programs that enroll undocumented people.

The legislation includes numerous other small changes to Medicaid, including one to prevent owners of expensive homes from obtaining nursing home coverage, another barring coverage of gender-affirming care for transgender minors and several provisions meant to purge the program's rolls of ineligible immigrants and people who have died.

One provision is aimed squarely at reducing federal money for Planned Parenthood. The bill would prevent Medicaid from funding health providers that also offer abortion services. House Republicans inserted similar language into their unsuccessful legislation to repeal the Affordable Care Act — commonly known as Obamacare — in 2017.

The bill would also make numerous changes to enrollment processes for people who buy their own insurance coverage in Obamacare marketplaces. The legislation would shorten enrollment periods, tighten income verification, restrict access for immigrants in the Deferred Action for Childhood Arrivals program and make it harder for some people to automatically renew coverage at the end of the year.

On energy, scrapping the Biden-era environmental rules is projected to increase federal revenues because drivers of less-efficient cars pay more in gas taxes. It would also rescind unspent money in a number of environmental programs that were created as part of the Inflation Reduction Act and that made it easier to construct new energy pipelines, a change that generates fees to the government.

This article originally appeared in The New York Times.