Congress is forging ahead with its budget for next year, but the most controversial program on the chopping block — Medicaid — is causing a rift within the Republican Party.

Earlier this year, Congress passed a budget blueprint that contains billions of dollars in cuts to federal spending, which House Speaker Mike Johnson (R-La.) promised did not touch Medicaid. But as lawmakers hammer out the details of the spending plan, changes to the popular government-funded healthcare program are looming.

Republicans are scrambling to find creative ways to fulfill budget cuts they voted on without gutting Medicaid, a politically risky move that would endanger healthcare for more than 71 million people nationwide and lead to cascading effects for hospitals and nursing homes.

So far, the options being floated — ramping up eligibility and work requirements and limiting access for immigrants — would have a drastic effect on Medicaid, even as Republicans brand their vision as tackling “waste, fraud and abuse,” a popular line used by Trump administration officials who are downsizing federal government departments and programs.

The GOP is “strengthening Medicaid for people who need it by eliminating things like fraud, waste and abuse, which is a huge problem in the program, including removing illegal aliens,” Johnson said at a news conference Tuesday.

Other options that lawmakers have considered involve drastically cutting how much money the federal government gives to states that expanded Medicaid coverage under the Affordable Care Act. If the minimum threshold were eliminated, California could lose as much as $156.5 billion in federal funding for the program over the next 10 years, according to an analysis by the Robert Wood Johnson Foundation.

“States can’t really raise that kind of revenue in general,” said Kathy Hempstead, senior policy officer at the foundation. “What states will do is maybe raise some revenue, but they’d have to start cutting services.”

Johnson indicated Tuesday that he’d moved away from that consideration.

Still, advocates warn that other options clamping down on eligibility will inadvertently disadvantage millions of people who qualify for the program.

The budget Congress passed included an order for the House Energy and Commerce Committee, which governs spending on Medicaid, to slash $880 billion over 10 years. The nonpartisan Congressional Budget Office has said that level of reduction is possible only by cutting into Medicaid.

In a letter to committee leaders Wednesday, the CBO outlined how federal changes to Medicaid would result in a shrinking of the program.

It anticipates that states would spend more themselves on Medicaid, reduce payment rates to healthcare providers, limit optional benefits and reduce enrollment.

Last week, the committee postponed a planned meeting on the bill over continued disagreements among its members. Matt Herdman, state director for Protect Our Care California, saw the delay as a partial win.

“They’ve clearly noticed they have a huge problem on their hands. They have a ton of vulnerable members,” Herdman said. “They would not have pushed this back if they thought this was a done deal.”

But Johnson dismissed the idea that the postponement was “a snag,” saying that after meeting with President Trump over the weekend and reviewing numbers, they decided “it just made sense for us to press pause for a week … to get it right.” The speaker said he is still aiming to pass the budget by Memorial Day.

In the meantime, Johnson is wrangling members from the far-right flank of the party, who support defunding and reforming Medicaid, and other Republicans, who are beseeching party leaders to avoid forcing them to vote for the cuts.

Twelve members who represent districts with high Medicaid populations — including California Reps. David Valadao (R-Hanford) and Young Kim (R-Anaheim Hills) — sent a letter to House leaders last month, warning that a vote to cut Medicaid would jeopardize their hard-won districts in future elections.

“We cannot and will not support a final reconciliation bill that includes any reduction in Medicaid coverage for vulnerable populations,” the letter read, adding that the lawmakers support reforming the program. It concluded: “Communities like ours won us the majority, and we have a responsibility to deliver on the promises we made.”

Valadao told Politico that he texts and meets with his colleagues in Congress regularly, working on alternative solutions. Valadao has serious motivation to save the program — he represents the California district with the highest percentage of Medicaid recipients, and he lost his congressional seat after voting to repeal the Affordable Care Act in 2017.

His office declined an interview for this article.

Protests to preserve Medicaid have been sweeping the nation for weeks. The Service Employees International Union, home to many care workers in the U.S., organized several demonstrations outside Republican congressional offices in recent weeks, including Kim’s.

“I’m seeing unbelievable energy about this,” Herdman said. “I don’t think I’ve seen anything quite as large in person since the pandemic on a legislative issue.”

Rep. Debbie Dingell (D-Mich.), who sits on the Energy and Commerce Committee, told reporters Tuesday that she’s been hearing from constituents in her district who rely on Medicaid to sustain their healthcare.

“Medicaid is a lifeline. It keeps children healthy, it helps parents work and it cares for seniors in nursing homes,” Dingell said. “The American people cannot afford Medicaid cuts, especially as the economy is being crashed around them by President Trump.”