The move to restrict coverage for legal immigrants comes as the Trump administration pushes ahead on its aggressive immigration campaign, delivering mass deportations, challenging birthright citizenship, and ending temporary protected status for hundreds of thousands of immigrants.

“These are the largest cuts to health coverage that we have seen, and this will be one of the largest cuts to immigrants in recent years,” said Drishti Pillai, director of immigrant health policy at KFF, a health policy think tank in Washington. The Congressional Budget Office, a nonpartisan scorekeeper, estimated similar provisions would leave 1.3 million lawfully present immigrants uninsured in 2034. Low-income green card holders in the five-year waiting period that applies to them for Medicaid, but who are currently eligible for subsidized Obamacare coverage, are expected to be the largest group hit.

The provisions have been overshadowed by broader Medicaid cuts, and the politically fraught nature of immigration has made Republicans reluctant to speak out about the restrictions. Still, they have raised concerns in both red and blue states because it would mean their already financially strained health care systems would have to bear the higher costs of uncompensated and emergency care.

“There is a lot of concern about how some of the immigration policies and some of the enrollment policies might play out throughout our patient population and our communities,” said Jonathan Chapman, chief executive of the Florida Association of Community Health Centers, who flew to Washington last week to lobby Congress and the White House on the megabill. Over 70 percent of patients at the state’s federally qualified health centers are uninsured or on Medicaid, and they have already reduced services due to insufficient funding.

Chapman added that Florida GOP Gov. Ron DeSantis’ support for Trump’s crackdown has already discouraged patients from seeking care at the community health centers, even though they typically do not ask about immigration status. “If my status was not clearly defined, I would be concerned about signing anything,” he added.

Vern Buchanan (R-Fla.), vice chair of the Ways and Means Committee, told POLITICO the megabill “ensures that federal health care dollars are prioritized for American citizens.” Buchanan led a letter with 11 members of the Florida Republican House delegation supporting the megabill.

Under fiscal pressure, blue states, including Minnesota and Illinois, have moved to roll back health care access for undocumented immigrants, who are not eligible for any federally subsidized health care programs. Last week, California Gov. Gavin Newsom, a Democrat, approved a state budget that will scale back free health care for undocumented immigrants.

One of the hardest-hit states from the megabill restrictions on immigrants will be New York, which is one of three states that have enacted a basic health program allowed under the Affordable Care Act known as the Essential Plan.

The Essential Plan offers low-cost health insurance for New Yorkers earning up to 250 percent above the federal poverty line and is funded by federal dollars that would otherwise be used for ACA tax credits. The GOP megabill will strip coverage for half a million immigrants covered by the plan and shift the cost to New York. The state must pick up the tab because of a 2001 state court decision that requires it to cover immigrants who are ineligible for Medicaid due to their immigration status.

The state’s hospital lobby, the Greater New York Hospital Association, believes the provisions as a whole will cost New York $3 billion annually and leave 225,000 immigrant New Yorkers uninsured.

“The downstream impacts are not just on immigrants,” said Elisabeth Wynn, executive vice president at the New York hospital group. “We don’t close services for a particular insurance category, those get closed for all.”

Earlier this month, five Republican House members from New York wrote a letter to Senate Finance Chair Mike Crapo (R-Idaho) urging a two- to three-year delay to the immigrant restrictions, warning an “abrupt elimination…will have drastically disruptive consequences for New York’s healthcare system.”

The bill will exclude lawfully present immigrants earning below the federal poverty level from the Obamacare marketplace starting next year. Marketplace restrictions for lawfully present immigrants earning above the poverty level will start in 2027.