Cuts to Medicaid that could cause millions of Americans to lose health insurance are on a list of budget options now circulating among House Republicans, according to a new report from Politico.

The list came from the office of House Budget Chairman Jodey Arrington (R-Texas), per Politico, whose sources stressed that the idea was just one item on a “menu” of possibilities for spending cuts. The ambitious list also proposes sweeping reductions in food assistance and a rollback of subsidies for clean energy that were a signature achievement of President Joe Biden.

Attempts to reach Arrington’s office over the weekend were not successful, but the list of options tracks closely with recommendations he issued through his committee last year.

All told, the new cuts together would reduce federal spending by $5.7 trillion over ten years. That would represent a significant shift in how much money the federal government spends — and what services provides for the American public.

But the potential scale of the cuts would also make the proposals difficult to pass, given Republicans’ slight, three-seat majority in the House and Democrats’ near certain opposition.

The Medicaid cuts in particular include two elements that will be familiar to anybody who remembers Republican attempts to repeal the Affordable Care Act, aka Obamacare, the first time Donald Trump became president back in 2017.

One of those elements is a call to “Equalize Medicaid Payments for Able Bodied Adults.” This is the kind of language many conservatives now use to describe ending the Affordable Care Act’s Medicaid expansion, under which the federal government provides states with extra money in order to make Medicaid available to anybody with income below or just above the poverty line.

The other familiar element is a call for “per capita caps” in Medicaid, which would effectively end the federal government’s commitment to funding the program at whatever level it takes to cover everybody who’s eligible. The GOP proposal is a version of something called “block granting” ― in effect, giving states a pre-determined chunk of money for programs, rather than giving them an open-ended funding commitment from Washington.

Republicans have long called for these sorts of changes, arguing that government-financed health care programs are wasteful, put excessive drain on taxpayers and ultimately do more harm than good ― even for people in need.

“We ought to look at whether we’re doing [Medicaid] the right way,” Sen. John Cornyn (R-Texas) said after the election in November, as Republicans were first starting to talk about their congressional agenda for this year. “Block grants make a lot of sense.”

But those arguments have rarely proven persuasive, thanks in no small part to independent projections showing consistently that enacting such policies would effectively strip millions ― maybe even tens of millions ― of Americans of their health insurance.

Those fears were a big reason Republican legislation to repeal Obamacare ultimately failed to pass, generating a political backlash against the party on health care policy that lingers to this day.

Still, Medicaid has remained the object of conservative criticism. Project 2025, the exhaustive Heritage Foundation document whose conservative authors hoped it would serve as a governing template for a second Trump term, called for radically revising the program.

And Medicaid may be a particularly tempting target now, given Republicans’ pledges to slash federal spending and to find offsets for the sweeping tax cuts they hope to enact.

Of course, taking so much money out of the program would have significant policy consequences, just as it would have back in 2017.

“Such a seemingly small and technical change [ending the extra funding for Medicaid expansion] would eliminate coverage for millions of people and put states at enormous financial risk,” Larry Levitt, executive vice president for health policy at the research organization KFF, told HuffPost.

The ACA [Affordable Care Act] extended Medicaid eligibility to all adults under age 65 (including parents and adults without dependent children) with incomes below 133 percent FPL [federal poverty level]. However, the Supreme Court ruling in June 2012 effectively made the expansion an option for states. As shown on this map, as of January 2021, 38 states and the District of Columbia have chosen to adopt the adult expansion, some through alternative approaches using Section 1115 waivers.