On Tuesday, Senate Republicans passed President Donald Trump’s intensely contested budget bill for the coming fiscal year, returning it to the House in a form that would slash $93 billion from annual federal Medicaid spending across the next decade, require states to implement Medicaid work requirements for adults (with limited exemptions), and strip health insurance from approximately 12 million people.

Trump’s success in attacking Medicaid represents a change from 2017, when disability advocates were able to convince politicians not to repeal the Affordable Care Act, which expanded Medicaid to low-income adults in the 40 states that implemented it. The new bill will undo much of that work in order to fund tax cuts that principally benefit the ultra-rich, with extreme consequences for millions of Americans kicked off insurance rolls.