Disability advocates are preparing to fend off potentially seismic cuts to Medicaid and community-based services now that President Donald Trump is back at the White House and Republicans are in control on Capitol Hill.

Republicans in the U.S. House of Representatives are reportedly circulating a “menu” of possible options to slash more than $5 trillion in spending in order to fund tax cuts and other Trump priorities. Options outlined in a document obtained by Politico show that up to $2.3 trillion could come from Medicaid.

If such cuts were to become reality, that would represent nearly a third of projected Medicaid spending over 10 years, according to KFF, a nonprofit that conducts health policy research.

That’s raising major concerns for disability advocates who have been pushing for years to see greater investment in Medicaid home and community-based services, the nation’s primary system of supports for people with developmental disabilities.

“It would be hard to overstate how serious these threats are,” said Zoe Gross, director of advocacy at the Autistic Self Advocacy Network. “Medicaid is a lifeline program for our community — we need to make it clear that it should be expanded, not looted to pay for tax cuts for billionaires.”

Advocates have been warning for years that the Medicaid home and community-based services system is under extreme pressure. A recent survey of hundreds of disability service providers nationwide found that 69% turned away new clients and 39% closed programs or services in the previous year and over a third said they were considering additional program cuts.

Among the options that Republicans are reportedly weighing is shifting Medicaid to a “per-capita cap system.” Currently, the federal government provides matching grants to states to help pay for the cost of care for anyone eligible for Medicaid, no matter how expensive. But, under a per-capita cap system, the government would provide a set amount of money for each enrollee leaving states to make up any difference in cost.

The draft document also lists lowering the matching funds that the federal government provides states for Medicaid, implementing work requirements for the program and other options to squeeze savings.

“We have concerns that when federal Medicaid funding is reduced, states must find new funding to balance the shortfall in state budgets. If new funding cannot be found, optional services like community-based services for people with IDD are often reduced, leading to longer wait lists for (home and community-based services) and higher rates of unnecessary and expensive institutionalization,” said Elise Aguilar, senior director of federal relations at the American Network of Community Options and Resources, or ANCOR, which represents disability service providers across the nation.

All of this has advocates experiencing déjà vu from Trump’s first term as president when Republicans in Congress tried to switch Medicaid to a per-capita cap system.

“Some of the proposals that we are hearing about are eerily similar to what was proposed in 2017, like fundamentally changing the structure of Medicaid,” said Nicole Jorwic, chief of advocacy and campaigns at Caring Across Generations, an organization advocating for caregivers and people who rely on them. “This would put access to home (and) community-based services at extreme risk, increase waiting lists and further exacerbate the direct care workforce crisis.”

A broad coalition of over 200 groups representing people with disabilities, family caregivers, seniors and care workers came together this month in a letter to leaders of the House and Senate to push back against any cuts to Medicaid.

“We are deeply concerned about recent statements from some Congressional leadership supporting proposals that would deeply cut Medicaid funding. Medicaid is already lean and efficient,” reads the correspondence organized by The Disability and Aging Collaborative and the Consortium for Constituents with Disabilities. “We strongly oppose per-capita caps, block grants, work requirements, restrictions on eligibility, barriers to enrollment and any other cuts or harmful changes to the Medicaid program. The result is the same: taking away coverage from people with disabilities, older adults, and others who cannot otherwise afford health care and long-term services and supports.”

Advocates now say they’re meeting with lawmakers and activating their members to speak up about the importance of Medicaid to this population.

“Whether the cuts come in the form of a work requirement (or) per-capita cap it all means lowering of the federal dollars going into Medicaid and there is not a state budget that could account for that loss,” Jorwic said. “People with disabilities and their caregivers should be tuned into any changes and cuts to Medicaid, as well as threats to special education services and prepared to share how any cuts would be detrimental.”