PITTSBURGH — The future of Medicaid, the nation’s largest public health insurance program, hangs in the balance as House Republicans push for deep budget cuts that could drastically reshape it.

In Pennsylvania, where 3 million residents rely on Medicaid, advocates like Shana Jalbert, communications director of the Pennsylvania Health Access Network, worry about the vulnerable populations that stand to lose coverage.

Statewide, Medicaid covers about 40% of children and 33% of seniors, pregnant women and people with disabilities. The remaining 25% are low-wage workers without employer-provided insurance.

“That’s kind of the population we’re talking about when we’re talking about cuts,” she said. “It’s not a done deal yet. But what do we know is that any cut to the program, regardless of where it falls, will hit those populations hard.”

Embroiled in a contentious budget reconciliation process, Congress is weighing how to cut federal spending by $1.5 trillion over the next decade, in part to finance President Donald Trump’s extended tax cuts and increased border enforcement.

Experts warn that cuts to Medicaid are likely. Medicaid is the main program providing comprehensive health and long-term care to one in five Americans.

Of significant concern are proposals to restructure Medicaid funding by imposing a per-capita cap or converting it into a block grant, either of which could reduce federal Medicaid funding from between $500 billion and $800 million over nine years, according to the Congressional Budget Office.

Laura Harker, a senior policy analyst with the Center for Budget and Policy Priorities, explained that a per-capita cap would force states to absorb “unpredictable” costs.

“Medicaid’s current structure ensures the federal government shares financial risk with states, which is especially crucial during economic downturns or public health crises,” Harker said.

As a result, states would likely cut eligibility and benefits. Optional services that states offer, such as community-based care for people with disabilities or even prescription drug coverage, could be among the first to be cut.

“The state would be on the hook for people with the most complex needs, and they can’t afford that,” Harker said. “Since states have to balance their budget and can’t go into a deficit, they would have to make cuts to coverage, cuts to benefits.”

Medicaid expansion, which extends coverage eligibility to more low-income adults, is also at risk. Pennsylvania opted into the expansion in 2015.

Currently, the federal government covers 90% of states’ costs for services covered under Medicaid expansion. But Congress is considering reducing the federal matching rate to the standard amount it provides for regular Medicaid services, which is 56% in Pennsylvania. According to the Center for Budget and Policy Priorities, Pennsylvania would need to find $2.6 billion in 2025 to maintain that coverage, Harker said.

“In Pennsylvania, we’re looking at least 832,000 people were enrolled in the expansion group,” Harker said. “So that is putting coverage at risk for all those folks.”

Advocates like Jalbert argue that Pennsylvania residents will feel the impacts of lost coverage, one way or the other.

“If there’s a huge hole in the budget, that has to be either filled by cutting people off their health care or somehow finding the money by raising taxes on all Pennsylvania taxpayers,” she said.

‘It can affect them for life’

The potential cuts raise serious concerns for Cristina Codario, health policy director at Pittsburgh’s Allies for Children. The high percentage of Pennsylvania children covered by Medicaid makes it one of the most essential safety nets for low-income families.

“We’re talking about kids from families who make less than $30,000 a year,” she said. “These are working parents, caregivers and even health care workers who don’t get employer-sponsored coverage.”

She highlighted that Medicaid ensures children receive critical screenings, including developmental and behavioral health assessments.

“One in three kids relies on Medicaid for early screenings that detect developmental delays and chronic conditions,” Codario said. “If we start cutting Medicaid, we risk missing these crucial windows for early intervention.”

Beyond individual health care, Codario said Medicaid funds school-based services in communities, including mental health care.

Should services and eligibility be scaled back, Pennsylvania does offer alternatives through its insurance marketplace Pennie, as well as the Children’s Health Insurance Program. But she said these programs can’t fully substitute for Medicaid.

“All kids can qualify for CHIP, but it operates on a sliding scale, meaning there are costs involved,” she said. “Not all families can afford those costs, even if they qualify.”

She said any instability in coverage could have long-term consequences for children’s health.

“We know that when kids experience gaps in coverage, it makes it harder for them to access preventive care, which can lead to worse health outcomes down the line,” Codario said. “Children are only young for so long. If they don’t get the care they need now, it can affect them for life.”

Mary Hartley, president of The Arc of Greater Pittsburgh, said Medicaid is essential for people with disabilities, providing medical services, therapy and other intensive supports.

She criticized proposals like per-capita caps, which would limit funding per individual, calling them unrealistic for families with complex health needs.

“I just spoke with somebody today who said, ‘My son was 9 months old when he hit his private insurance medical cap,'” Hartley said. “People don’t fit into caps. It doesn’t work that way.”

She also highlighted the strain already placed on Pennsylvania’s Medicaid system, with more than 12,000 people with intellectual disabilities and autism currently on waiting lists for services.

“Our state is already struggling to provide the services people need,” Hartley said. “We have older parents, 80 and 90-year-olds, caring for their senior adult children because they can’t get the supports they need. I can’t even imagine a cut. It would be devastating.”

For children with intensive medical conditions and disabilities, Medicaid covers early interventions like speech therapy, occupational therapy and sensory integration therapy — critical services that help them navigate school and social settings. Just over half of children with special health care needs have private insurance as their sole source of coverage.

The impact on adults would be just as severe. Many rely on Medicaid-funded home and community-based services, which allow them to live independently rather than being forced into institutional care.

“It ensure(s) they can be part of the community, to live, thrive, work, go to school and engage meaningful day activities,” she said. “These are individuals who used to go to segregated institutions. Not only is that not terrible care, it’s not the best option for any human being.”

“Years ago, most people with disabilities were sent to institutions, and families stood up and said, ‘No, we want our children to live in the community,'” Hartley said. “That’s what Medicaid’s services allow. It’s actually less expensive, and people have much improved lives knowing they can work, go to school, engage in meaningful everyday activities.”

And many families don’t have the financial resources to cover the high cost of private insurance, and even if they could, “there are no comparable services in the private industry,” she said.

Amid the fears of drastic rollbacks, Hartley emphasizes that public opinion remains favorable toward Medicaid and how it’s currently spent. A recent AP-NORC poll found that 55% of Americans believe the government spends too little on Medicaid, while only 15% think it spends too much.

“I think it’s politically thoughtful to consider why it’s so meaningful to voters,” she said. “We care about people we love who are funded and supported by Medicaid. Many people know the benefits and how it works in their lives.”

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