A contingent of House Republicans is trying to push the nation’s health insurance program for poor and vulnerable Americans deep into conservative territory, past a firewall that the Obama administration maintained for eight years.

A partisan vote Thursday by the House Budget Committee would require able-bodied adults to hold a job to qualify for Medicaid. That profound change has long been touted on the far right as a way to promote personal responsibility but opposed by Democrats who fear that it would deny health care to many people who need it most.

Compelling people to work, which would align Medicaid with a similar requirement in the nation’s main welfare program, was one of three moves committee Republicans recommended as they approved the legislation they hope will begin to dismantle the Affordable Care Act.

Over protests from Democratic lawmakers, the panel also recommended that the expansion of Medicaid under the ACA be ended sooner than the GOP’s American Health Care Act envisions. And committee members voted that states should be able to convert Medicaid from an entitlement program — covering anyone who is eligible — into a block grant, under which the government would provide a state a fixed annual sum and free it from federal rules on which people qualify and what benefits must be provided.

On Friday, President Trump declared he was “100 percent” behind the work requirement and the block-grant option. The bill could be on the House floor by late next week.

A legacy of Lyndon Johnson’s War on Poverty in the 1960s, Medicaid always has been a shared responsibility of the federal government and the states. The current tug of war is likely to shift that balance and affect how generous the program will be for today’s 68 million low-income beneficiaries.

The Budget Committee’s votes Thursday did not formally alter the AHCA, which House Speaker Paul D. Ryan (R-Wis.) and his allies are trying to rush through the chamber amid a political obstacle course. The committee merely puts forward changes to be considered at the next stage before full House debate on the bill.

Still, its Medicaid recommendations further highlighted the ideological cross-pressures on Ryan — and the Trump administration — in forging a set of Republican health policies that might pass both the House and the Senate. While the committee is trying to nudge the program toward the right, moderate GOP governors and senators are fighting to ward off the loss of millions of dollars in federal aid to the 31 states, plus the District of Columbia, that expanded their Medicaid programs.

[Medicaid exposes rifts within the GOP over the program’s future after the ACA]

GOP governors from Arkansas, Michigan, Nevada and Ohio sent their own health reform proposal Thursday to Ryan and Senate Majority Leader Mitch McConnell (R-Ky.). The four worked behind the scenes on their proposal for weeks with several other Republican governors, though the others did not sign the public letter.

The current House bill “provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states,” they wrote. In their proposal, the governors urged Congress to preserve the increased level of federal payments that the ACA provides for adults in the Medicaid expansion group — and, if necessary for fiscal reasons, tighten the eligibility limits rather than cutting out the higher reimbursements.

Michigan Gov. Rick Snyder said Friday that Medicaid changes in the legislation would cause many in his state’s expansion group to lose coverage, while the bill’s shift to per capita payments would leave states without enough money for costly specialized pharmaceuticals developed in the future.

“If they don’t address that in some fashion, I’m not sure how we sustain even traditional Medicaid,” he said.

For now, the House GOP’s plan would provide states a fixed sum for each beneficiary, no matter how much of the costs it covered. The block grants recommended by the Budget Committee would give states a choice of funding method — an option that Diane Rowland, executive vice president at the Kaiser Family Foundation, expects “would no longer provide the safety valve to increase federal funds to support Medicaid during recessions or other surges in enrollment.”

The legislation would allow the expansion states to keep enrolling people until the end of 2019, and the federal government would continue paying for nearly all their costs. After that, the government would not provide the higher funding level for anyone new on the Medicaid rolls, presumably prompting states to retreat to their previous income thresholds.

The budget panel, however, recommended that the extra funding end right away. Calling Medicaid’s expansion “a cruel joke” because not everyone who joins can find doctors, Rep. Matt Gaetz (R-Fla.) said that waiting until 2020 “would be like a diet strategy, if I said I needed to lose weight but [would] start 2½ years from now and in the meantime eat everything in sight.”

[Affordable Care Act revision would reduce insured numbers by 24 million, CBO projects]

Rachelle Schultz, president and chief executive of Minnesota’s Winona Health, predicted Friday that many patients at her hospital could lose coverage. “If the Medicaid cuts go through, essentially, these people have no insurance,” she said at a Washington roundtable organized by the American Hospital Association. And uninsured people, she said, often delay treatment for chronic conditions until a problem worsens. “What happens is they stay home, and they show up at the emergency room” later.

The sharpest exchange during the committee’s debate was over making able-bodied adults on Medicaid hold or train for a job. Republicans suggested that such a requirement would save the government money and foster self-reliance. “Let’s prevent idleness,” said Rep. Jodey Arrington (R-Tex.), who contended that requiring people to work would “make this not so much of a seductive entitlement.”

Rep. Jan Schakowsky (D-Ill.) countered, saying that “most people on Medicaid who can work, work” and that Republicans’ “ultimate goal is to simply kick people off Medicaid and not actually help people find employment.”

The program covers Americans in low-income households, including children, pregnant women, people who are older or disabled, and others who are merely poor. About 11 million are people with somewhat higher incomes who joined in the past three years through the ACA expansion.

A Kaiser analysis last month found that 8 in 10 adult Medicaid recipients live in working families, and 59 percent who are not disabled have a job. Most who do not work have major obstacles, such as an illness, disability or caregiving responsibility for a relative.

During the Obama administration, at least a half-dozen states, including Indiana, Pennsylvania and Arizona, sought permission to include work or job-training requirements as part of their Medicaid programs. In each case, the request was denied.

At least one conservative authority on welfare opposes such efforts. “Making cash assistance or food stamps contingent on work participation is one issue,” said Robert Rector, a Heritage Foundation senior fellow in domestic policy studies. “Denying medical care to sick, poor people is another matter.”