While lawmakers are bogged down on health care legislation, the Republican-led Congress has been unable to pass a budget, overhaul the federal tax code, or provide more more for infrastructure — all considered priorities for the new Trump administration. Since the election, it has had sealed no major legislative accomplishments.

Those services, which are provided at the discretion of individual states, include dental care for adults, long-term care for disabled and elderly people living at home, certain therapies that children with disabilities receive in school, prosthetic limbs, and even prescription drugs.

TUSCALOOSA, Ala. — Optional services that millions of Medicaid beneficiaries receive would be at risk under Republican proposals to scale back Medicaid as part of legislation to repeal and replace the Affordable Care Act.


The battle over replacing the Affordable Care Act has focused intensely on the future of Medicaid, the state-federal health insurance program for the poor and vulnerable created more than 50 years ago as part of President Lyndon B. Johnson’s Great Society.

Much of the debate has centered on Republican proposals to roll back the recent expansion of the program to millions of low-income adults without disabilities.

But the House and Senate bills would also make profound changes to the nature of Medicaid, shifting it from an open-ended entitlement to a program with strict federal funding limits.

Those changes would have far bigger consequences over time, affecting many more of the roughly 74 million Americans on Medicaid. The threat to optional services may be especially acute in states, like Alabama, that already spend far less than the national average on Medicaid and are averse to raising more revenue through taxes.

“In a poor state like Alabama, you are starting off with a baseline that’s already low,” said James A. Tucker, director of the Alabama Disabilities Advocacy Program, which provides legal services to people with disabilities here.


“There’s a fundamental antipathy to spending the public purse on health care services for poor people, and that would only get worse if the resources become capped and more limited,” Tucker said

The drain on Medicaid funding would worsen over time under the bill that Senate Republicans are working to pass. The nonpartisan Congressional Budget Office estimated that Medicaid spending would be 26 percent lower under the Senate plan than it would be under current law in 2026 — and 35 percent lower in 2036.

The office predicted that states would be forced to “eliminate optional services, restrict eligibility for enrollment or adopt some combination of those approaches.”

Under the Senate plan, states would receive a fixed annual amount for each Medicaid beneficiary.

The amount would increase every year by a formula that is expected to grow much more slowly than average medical costs, although the growth rate would be slightly higher for disabled and elderly beneficiaries. Disabled children would not be subject to the spending caps.

While the Republican-led Congress is bogged down on health care legislation since the election and has produced no major legislative accomplishments

Lawmakers have been unable to pass a budget, overhaul the federal tax code, or provide more more for infrastructure — all considered priorities for the new Trump administration.

Other must-do congressional business— chiefly lawmakers’ core responsibilities of passing a budget and spending bills, and keeping the government solvent — is sliding into an already daunting fall agenda that is looking more and more like it'll be a train wreck.


Friday brought more bad news for Speaker Paul Ryan, Republican of Wisconsin, and other House leaders as 20 GOP moderates signaled a revolt on the budget, writing a letter to Ryan announcing their opposition to an emerging plan to force cuts to government agencies and benefit programs such as food stamps.

The letter, authored by Representative Charlie Dent, Republican of Pennsylvania, warned that without an agreement with Democrats on increasing agency spending, moderates will be ‘‘reticent to support any budget.’’

‘‘It’s looking like they’re very disorganized. They got obviously a lot of conflict over spending preferences and it’s not just a two-way conflict,’’ said top House Budget Committee Democrat John Yarmuth of Kentucky. ‘‘It’s just a tough Rubik’s Cube they’re trying to solve.’’

The annual congressional budget measure — a prerequisite to this fall’s hoped-for tax effort — is languishing, as are the 12 annual spending bills that typically consume weeks of House floor time each summer.

But GOP leaders say all is going well. Ryan told a Wisconsin radio host Thursday that ‘‘it’s the most productive Congress since the mid-’80s’’ and issued a news release Friday titled ‘‘Despite What You May Hear, We Are Getting Things Done.’’

The release cites a bipartisan Department of Veterans Affairs accountability measure and 14 bills repealing Obama-era regulations as Congress’ top achievements.

‘‘It would be hard to fault the average American for thinking all that’s going on in Washington these days is high-drama hearings and partisan sniping,’’ Ryan said. ‘‘But amid the countdown clocks and cable news chatter, something important is happening: Congress is getting things done to help improve people’s lives.’’


Congress will have to act on measures to increase the nation’s borrowing authority, prevent a government shutdown, and lif budget ‘‘caps’’ that are hobbling efforts to beef up the military.

Unlike health care, the debt limit and a deal to fix the spending caps can only be resolved with Democratic help.