Republicans in the House of Representatives passed a significant budget resolution on Tuesday that sets up President Donald Trump‘s agenda of tax cuts for the wealthy and service cuts for millions of Americans. Democrats warn that the budget will lead to an unprecedented cut in Medicaid, and experts caution that the budget cannot be enacted without enormous spending and service cuts and trillion-dollar increases to the national debt.

Republicans pass budget with massive tax and spending cuts

The House voted Tuesday on a controversial budget plan Trump supported. The bill authorizes $4.5 trillion in tax cuts by extending temporary cuts Trump enacted in his first term. The bill also calls for $1.5 trillion in budget cuts to partially offset the lost tax revenue, with major cuts to Medicaid likely due to this savings requirement. The vote had been in doubt, with Republicans fielding constituents’ anger about the proposed service and benefit cuts. Speaker of the House Mike Johnson, R-La., had delayed and later canceled the vote, only to reverse course again and call the vote. Trump, meanwhile, reportedly reached out to hesitant Republicans to get their support.

In the end, the vote passed along party lines 217-213. All Democrats voted against the bill, as did one Republican. House Minority Leader Hakeem Jeffries, D-N.Y., condemned the budget as “unacceptable, unconscionable, un-American” and said, “The Republican Budget represents the largest Medicaid cut in American history.”

Rep. Thomas Massie, R-Ky., the only Republican to vote against the bill, expressed doubt concerning the GOP argument that the tax cuts would stimulate economic growth that would pay for the budget shortfall.

“The only way they get to this magic thing where it’s not going to kill our country is five years from now, they imagine that 2.5% growth accumulates,” Massie told reporters before the vote, HuffPost reported.

Slashing Medicare and possibly more

The bill requires the House Energy and Commerce Committee, which oversees programs like Medicare and Medicaid, to find the necessary budget cuts mandated by the legislation. A likely target of these cuts will be Medicaid, which provides health coverage for low-income adults. The program has been significantly expanded through federal spending due to the Affordable Care Act signed into law by President Barack Obama in 2010, and Republicans seem to be ready to roll back or significantly eliminate coverage for as many as 20 million Americans.

Other programs, such as food stamps, could also be targeted for elimination or deep cuts. One large budget item that could be cut is Medicare, which covers older Americans. Medicare and Social Security have typically been taken off the table in these discussions for fear of significant voter backlash if older and more politically active Americans see these benefits in danger of being rolled back. Eliminating the federal Children’s Health Insurance Program is another radical option that could be implemented, although that is currently not being proposed. Whatever policy changes are put into place would have to pass the House and the Senate to be executed.

Republicans in Washington, D.C., seem determined to push through this piece of Trump’s legislative agenda. For an administration that has been using its power to slash government spending and shutter entire agencies, the deep cuts being discussed seem like part of the plan. But for millions of Americans, this budget risks making their daily lives significantly harder.