The U.S. House of Representatives approved billions in cuts to Medicaid that advocates warn would undermine the nation’s already fragile system of services and supports for people with disabilities.

Republicans in the House pushed through a bill designed to follow through on President Donald Trump’s domestic agenda early Thursday by a vote of 215 to 214 after intense negotiations.

The legislation known as the “One Big Beautiful Bill Act,” which now heads to the Senate, would impose work requirements on many Medicaid beneficiaries and mandates that states check individuals’ eligibility for the program more frequently, among other changes.

The Congressional Budget Office estimated earlier this week that the changes called for in the bill would lead to $698 billion less in federal Medicaid subsidies between 2026 and 2034. Savings from Medicaid and other areas would help pay for an extension of tax cuts from Trump’s first term and support other administration priorities.

Republicans said the measure will end “waste, fraud and abuse” in Medicaid.

“Today, the House has passed generational, nation-shaping legislation that reduces spending, permanently lowers taxes for families and job creators, secures the border, unleashes American energy dominance, restores peace through strength, and makes government work more efficiently and effectively for all Americans,” House Speaker Mike Johnson, R-La., said. He indicated that the measure “strengthens our essential programs like Medicaid for the people who need it the most.”

Disability advocates, however, say that’s not the case.

“No matter what some Congressional leaders repeatedly deny, this budget contains some of the largest cuts to Medicaid in history,” said Nicole Jorwic, chief program officer at Caring Across Generations, an organization advocating for caregivers and people who rely on them. “This will impact disability service systems. Providers will close, wages will go down for an already underpaid (direct support professional) workforce, and disabled people will be at risk of losing their coverage if they don’t break through red tape and jump through the hoops being created by eligibility checks and work requirements.”

While disability services are not explicitly mentioned in the bill, chopping billions in federal investment for Medicaid would put financial pressure on states, advocates say.

“Community-based services for people with disabilities are not federally mandated and are especially vulnerable to Medicaid funding reductions at the state level,” 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. “Historically, when states face Medicaid funding shortfalls, non-mandatory services like home and community-based services are among the first to be scaled back, restricting access to essential supports people with disabilities need to live, work and thrive in their communities.”

The push for cuts comes at a time when the Medicaid home and community-based services system is already struggling. Over 700,000 people are on waiting lists for Medicaid waivers, which provide such services, according to KFF, a nonprofit that conducts health policy research. And a survey of almost 500 community-based services providers across the country late last year found that nearly all had experienced moderate or severe staffing shortages in the previous year. As a result, 69% had declined new clients and 39% closed programs or services, with over a third saying they were considering further cuts.

Lydia Nunez Landry with the disability rights group ADAPT said that waiting lists will only increase under the House bill forcing people with disabilities into institutions.

“The cuts are draconian and will have a catastrophic impact on people with disabilities, older Americans, children and poor people,” Nunez Landry said. “Disabled people will be socially removed into institutions and die.”

There are also concerns that more frequent eligibility checks and work requirements will mean increased paperwork and greater chances for people who qualify for Medicaid to be inadvertently lobbed off. Meanwhile, states will be obligated to allocate resources toward establishing systems to verify the new requirements are met, said Katy Neas, CEO of The Arc of the United States.

“These cuts are devastating,” said Neas who urged the Senate to reject the cuts. “And we won’t be silent while our community is pushed past the brink.”