Patrick Toomey, who represents Schmetterling in the Senate, said the health-care proposal only “slightly slows down the rate at which Medicaid will continue to grow so that this is actually a sustainable program.” Medicaid has grown in recent years and now makes up almost 10 percent of federal spending. The bill’s supporters say the cuts protect funding for people who really need it, like Schmetterling, by limiting Medicaid for the able-bodied adults who became eligible under the Affordable Care Act, and limiting per-capita expenditures, to put it on a sound financial footing. The Senate’s bill would reduce the deficit by $321 billion over a decade.

But the proposed changes to Medicaid go well beyond a budgetary trim. Right now, more than 80 percent of Medicaid’s budget funds health care for the disabled, elderly, and children. The plan “fundamentally changes Medicaid in a way that hasn’t been done before,” said MaryBeth Musumeci, a Medicaid expert at Kaiser Family Foundation. The Senate bill would reduce Medicaid’s budget by a projected 35 percent over the next two decades, compared to current policy, and because so much of its budget already goes to the neediest Americans, Musumeci said it would have “profound implications for all beneficiaries.”

That’s because such a large reduction leaves states little option but to raise taxes, pay doctors less, limit who gets coverage, cut back on services—or perhaps do all at once.

Some services, like hospital care and nursing homes, are mandated under federal law and can’t be cut. But advocates warn that because other services that are essential to disabled people are technically optional, they could be the first on the chopping block.

Chief among those optional benefits are the Medicaid-funded attendants who help about 3 million disabled Americans get out of bed, bathe, eat breakfast, drive to work, and go to sleep at night.

“When states are squeezed for money they are going to reduce those services or end them all together,” said Mary Lou Breslin, a policy analyst at the Disability Rights Education and Defense Fund, “and without that help they face institutionalization.”

* * *

Like a lot of people in the San Francisco Bay Area, Stacey Milbern got dressed in a plaid shirt, basketball shorts, and a Golden State Warriors cap on June 17. The basketball team had just won its second championship in three years, and earlier that week the streets along the team’s parade route were jammed with fans. An attendant who earns $12.50 an hour, Medicaid’s wage in Milbern’s area, tugged her shirt on and made sure her hat was angled just right.

Milbern had skipped the parade and was now celebrating in her own way instead. In her Medicaid-funded wheelchair, she rolled to a friend’s house almost two miles away. “It's not just about health care,” said Milbern, “it’s really about my ability to participate in society.” That night, another attendant would connect her to a respirator so she could sleep safely.