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WASHINGTON — On July 30, 1965, President Lyndon B. Johnson signed legislation that launched Medicaid, creating a U.S. health care safety net for millions of low-income Americans — a crowning achievement of his domestic legacy.

A year earlier, he did the same for food stamps, drawing on President John F. Kennedy's first executive order for the development of "a positive food and nutrition program for all Americans."

This summer, President Donald Trump began to chisel away at the programs.

The Republican Party's big tax and spending law delivered not just $4.5 trillion in tax breaks for Americans but some of the most substantial changes to the landmark safety net programs in their history. The trade-off will cut more than $1 trillion over a decade from federal health care and food assistance, largely by imposing work requirements on those receiving aid and by shifting certain federal costs onto the states.

While Republicans argue the trims are needed to rightsize the federal programs that grew over the decades and prevent rising federal deficits, they also seek to shrink the federal government and the services it provides.

"We're making the first changes to the welfare state in generations," House Speaker Mike Johnson, R-La., said in a recent podcast interview.

As the tax breaks and spending cuts law begins to take shape, it is unleashing a new era of uncertainty for the safety net programs that millions of people in communities across the nation have grown to depend on, with political ramifications to come.

Big safety net changes ahead

Polling shows most U.S. adults don't think the government is overspending on the programs. Americans broadly support increasing or maintaining existing levels of funding for popular safety net programs, including Social Security and Medicare, according to the poll from The Associated Press-NORC Center for Public Affairs Research.

Local governments are scrambling to figure out how they will comply with the new landscape, calculating whether they will need to raise their own taxes to cover costs, trim budgets elsewhere or cut back aid.

"The cuts are really big, they are really broad and they are deeply damaging," said Sharon Parrott, president of the Center for Budget and Policy Priorities, a research institute in Washington.

"The consequences are millions of people losing health care coverage," she said. "Millions of people losing food assistance. And the net result of that is higher poverty, more hardship."

At the same time, certain people who receive aid — including parents of teenagers and older Americans up to age 64 — will have to work, take classes or do community service for 80 hours a month to meet new requirements.

The nonpartisan Congressional Budget Office estimates 10 million more people will end up without health insurance. About 3 million fewer people will participate in the Supplemental Nutritional Assistance Program, known as SNAP.

"People are really concerned what this means for their fiscal health," said Mark Ritacco, chief governmental affairs officer at the National Association of Counties, which held its annual conference the week after Trump signed the bill.

The organization pushed senators to delay the start dates for some Medicaid changes, and it hopes further conversations with lawmakers in Congress can prevent some of them from ever taking hold.

"We're talking about Medicaid and SNAP — these are people's lives and livelihoods," Ritacco said.

GOP cuts health care, food aid

Republicans insist the law is adhering to Trump's vow not to touch Medicaid as the changes root out waste, fraud and abuse. A memo from the House GOP's campaign arm encourages lawmakers to focus on the popularity of its new work requirements and restrictions on benefits for certain immigrants.

"Those safety nets are meant for a small population of people — the elderly, disabled, young pregnant women who are single," the House speaker said on "The Benny Show."

He said the years since the Affordable Care Act, or Obamacare, came into law, "everybody got on the wagon."

"All these young, able-bodied, young men who don't have dependents, riding the wagon," the speaker said.

Medicaid then and now

When President Johnson established Medicaid alongside Medicare, the health care program for seniors, as part of the Social Security Amendments of 1965, it was meant for low-income families as well as the disabled.

Nearly every state signed on to participate in Medicaid by 1970, according to KFF, an organization focused on health policy. The program soon expanded to include pregnant women, school-age children and not just the very poor but also those with incomes just over the federal poverty limit, which is now about $15,650 annually for a single person and $26,650 for a family of three.

In the 15 years since the Affordable Care Act became law under President Barack Obama, Medicaid grew substantially as most states opted to join the federal expansion. About 80 million adults and children are covered.

While the uninsured population tumbled, the federal costs of providing Medicaid soared — to more than $880 billion a year.

"There are a lot of effects Medicaid has on health, but the most stark thing that it does is that it saves lives," said Bruce D. Meyer, an economist and public policy professor at the University of Chicago who co-authored a pivotal study assessing the program.

The law's changes will save the federal government "a substantial amount of money," he said, but that will come at "substantial increases in mortality. And you have to decide what you value more."

Food stamps, which were offered toward the end of the Great Depression but halted during World War II amid rationed supplies, launched as a federal program when Johnson signed the Food Stamp Act of 1964 into law.

Today, SNAP provides almost $200 in monthly benefits per person to about 40 million recipients nationwide.

Democratic Leader Hakeem Jeffries of New York delivered the longest speech in House history while trying to stall the Republicans' spending bill.

"Who are these people?" he said. "Ripping health care away from the American people. The largest cuts in Medicaid in American history. Ripping food out of the mouths of children, seniors and veterans who are going to go hungry as a result of this one big, ugly bill."