WASHINGTON – Republican Sen. Josh Hawley has been clear about his red line as the Senate takes up the GOP’s One Big Beautiful Bill Act: no Medicaid cuts.

But what, exactly, would be a cut?

Hawley and other Republicans acknowledge that the main cost-saving provision in the bill – new work requirements on able-bodied adults who receive health care through the Medicaid program — would cause millions of people to lose their coverage. All told, estimates are 10.9 million fewer people would have health coverage under the bill’s proposed changes to Medicaid and the Affordable Care Act. That includes some 8 million fewer in the Medicaid program, including 5.2 million dropping off because of the new eligibility requirements.

“I know that will reduce the number of people on Medicaid,” Hawley told a small scrum of reporters in the hallways at the Capitol.

“But I’m for that because I want people who are able bodied but not working to work.”

Hawley and other Republicans are walking a politically fine line on how to reduce federal spending on Medicaid while also promising to protect a program that serves some 80 million Americans and is popular with the public.

As the party pushes ahead on President Donald Trump’ s priority package, Republicans insist they are not cutting the vital safety net program but simply rooting out what they call waste, fraud and abuse. Whether that argument lands with voters could go a long way toward determining whether Trump’s bill ultimately ends up boosting — or dragging down — Republicans as they campaign for reelection next year.

Republicans say that it’s wrong to call the reductions in health care coverage “cuts.” Instead, they’ve characterized the changes as rules that would purge people who are taking advantage of the system and protect it for the most vulnerable who need it most.

What’s in the bill

House Republicans wrote the bill with instructions to find $880 billion in cuts from programs under the purview of the Energy and Commerce Committee, which has a sprawling jurisdiction that includes Medicaid.

In the version of the bill that the House passed on a party-line vote last month, the overall cuts ended up exceeding that number. The Kaiser Family Foundation projects that the bill will result in a $793 billion reduction in spending on Medicaid.

Additionally, the House Ways & Means Committee, which handles federal tax policy, imposed a freeze on a health care provider tax that many states impose. Critics say the tax improperly boosts federal Medicaid payments to the states, but supporters like Hawley say it’s important funding for rural hospitals.

“What we’re doing here is an important and, frankly, heroic thing to preserve the program so that it doesn’t become insolvent,” Speaker Mike Johnson said on NBC’s “Meet the Press.”

House Democratic leader Hakeem Jeffries, meanwhile, has denounced the bill as an “assault on the healthcare of the American people” and warned years of progress in reducing the number of uninsured people is at risk.

Who would lose health coverage

The nonpartisan Congressional Budget Office estimates that the GOP’s proposed changes to federal health programs would result in 10.9 million fewer people having health care coverage.

Nearly 8 million fewer people would be enrolled in Medicaid by 2034 under the legislation, the CBO found, including 5.2 million people who would lose coverage due to the proposed work requirements. It said 1.4 million immigrants without legal status would lose coverage in state programs.

The new Medicaid requirements would apply to nondisabled adults under age 65 who are not caretakers or parents, with some exceptions. The bill passed by the U.S. House stipulates that those eligible would need to work, take classes, or record community service for 80 hours per month.

The Kaiser Family Foundation notes that more than 90% of people enrolled in Medicaid already meet those criteria.

The legislation also penalizes states that fund health insurance for immigrants who have not confirmed their immigration status, and the CBO expects that those states will stop funding Medicaid for those immigrants altogether.

Why Republicans want Medicaid changes

Republicans have cited what they call the out-of-control spending in federal programs to explain their rationale for the changes proposed in the legislation.

“What we are trying to do in the One Big Beautiful Bill is ensuring that limited resources are protected for pregnant women, for children, for seniors, for individuals with disabilities,” said Rep. Erin Houchin, R-Ind., in a speech on the House floor.

Senate Majority Whip John Barrasso argued that Medicaid recipients who are not working spend their time watching television and playing video games rather than looking for employment.

Republicans also criticize the CBO itself, the congressional scorekeeper, questioning whether its projections are accurate.

The CBO score for decades has been providing non-partisan analysis of legislation and budgetary matters. Its staff is prohibited from making political contributions and is currently led by a former economic adviser for the George W. Bush administration.

What polling shows

While Republicans argue that their signature legislation delivers on Trump’s 2024 campaign promises, health care isn’t one of the president’s strongest issues with Americans.

Most U.S. adults, 56%, disapproved of how Trump was handling health care policy in CNN polling from March. And according to AP VoteCast, about 6 in 10 voters in the November election said they wanted the government “more involved” in ensuring that Americans have health care coverage. Only about 2 in 10 wanted the government less involved in this, and about 2 in 10 said its involvement was about right.

Half of American adults said they expected the Trump administration’s policies to increase their family’s health care costs, according to a May poll from KFF, and about 6 in 10 believed those policies would weaken Medicaid. If the federal government significantly reduced Medicaid spending, about 7 in 10 adults said they worried it would negatively impact nursing homes, hospitals, and other health care providers in their community.

For Hawley, the “bottom lines” are omitting provisions that could cause rural hospitals to close and hardworking citizens to lose their benefits.

He and other Republicans are especially concerned about the freeze on the providers’ tax in the House’s legislation that they warn could hurt rural hospitals.

“Medicaid benefits for people who are working or who are otherwise qualified,” Hawley said. “I do not want to see them cut.”