Republicans are cutting Medicare. Not only Medicaid, Medicare.

It’s always appropriate to bet on the House Freedom Caucus caving to their leader Donald Trump. That’s what happened at 3:20 a.m. this morning, when various assurances, including a potential second reconciliation bill for the 2026 fiscal year, flipped all of them to yes on the Republican mega-bill, which takes food and medicine away from the most vulnerable people in America to give the wealthiest a tax cut.

Those Freedom Caucus members, and all but one member of the Republican caucus, voted early this morning on the rule governing debate on the bill. Before the vote on final passage, House Minority Leader Hakeem Jeffries unleashed an epic speech that has passed the six-hour mark and is still going. It is a kind of talking filibuster, afforded through the tradition of the “magic minute” granted to the opposition leader. But it is just delaying the inevitable: Republicans have the votes in the House to pass the Senate bill unchanged, after several members spent a week railing against the betrayal of changes made that added more debt, weakened the phaseout of clean-energy tax credits, inserted a corrupt deal that will incentivize states to make more payment errors in their SNAP program, and deepened cuts to Medicaid, which will bring the health system to the brink of devastation.

But now Republicans have created another problem. They didn’t just cut Medicaid; they also have forced nearly half a trillion dollars in cuts to Medicare, the health program for the elderly.

Because of a statutory requirement to automatically impose budget cuts when legislation increases the deficit, the Big Beautiful Bill would require automatic sequestration cuts across the board, something that has been confirmed by the Congressional Budget Office (CBO) but has been largely absent from the debate over the bill. Medicare is one of the programs that will face the axe, and the damage sums to $490 billion over the next ten years, starting in the next fiscal year that begins in October. While many of the safety-net cuts in the bill are delayed to help Republicans with their re-election campaigns, the Medicare cuts must begin next year.

The Statutory Pay-As-You-Go (PAYGO) Act of 2010 requires the Office of Management and Budget to keep scorecards that track the cumulative effects of legislation on the budget deficit, based on estimates from the CBO. The Senate version of the Big Beautiful Bill adds roughly $3.3 trillion in debt over the next ten years. That will have to be made up through automatic sequestration cuts.

As CBO confirmed in a letter to the top Democrat on the House Budget Committee, Rep. Brendan Boyle (D-PA), OMB’s calculation is mandatory, and unless Republicans manage to also pass massive deficit-reducing legislation within this fiscal year, something that is incredibly unlikely to happen, the cuts would follow.

Republicans could have waived the inclusion of the Big Beautiful Bill on the PAYGO scorecard, averting the sequestration cuts, but they did not do so. Future legislation could waive the cuts as well, but that has yet to be discussed.

Therefore, OMB would be required to issue an order reducing spending by $330 billion by January 2026. Many accounts are exempted from sequestration, including Social Security and several programs affecting low-income Americans. But Medicare is not.

There is a limitation on Medicare cuts of 4 percent of the program. In fiscal year 2026, that would come out to $45 billion. These cuts would increase with the growth of the program, hitting $75 billion by 2034 according to CBO. The total ten-year cuts would equal $490 billion.

President Trump has promised that he would not touch Medicare over the course of his presidency; of course, he said yesterday that Medicaid wouldn’t be touched either, something he was told was untrue by House Republicans.

Large Medicare cuts, which would have to be applied across the board, would worsen a hit to the health care system that already projects at least 17 million people losing their insurance coverage, with higher costs for people who retain their insurance. Several House Republicans balked at the Medicaid cuts in the bill, including physician Rep. Greg Murphy (R-NC) and Rep. David Valadao (R-CA), whose district has the highest concentration of Medicaid recipients in the country.

But both Murphy and Valadao voted for the rule to the Big Beautiful Bill, and quietly set the country on the path to large Medicare cuts. Indeed, these Medicare cuts have barely been part of the overall debate in Congress. Other issues, like capping and cutting state provider taxes that give them more resources for their Medicaid programs, have dominated the discussion.

There are other Medicare cuts in the bill as well, as Jonathan Cohn has pointed out. In particular, the bill changes the enrollment process for the Medicare Savings Program, which helps poor seniors (who also qualify for Medicaid) afford their prescriptions. This could lead to more than 1.3 million poor seniors losing access to this program, incurring thousands of dollars in new costs that they will not be able to afford, and likely leading to them receiving fewer prescriptions and increasing their mortality rates.

So Medicare patients will die even without the mandatory sequestration cuts. But if you add that $500 billion slash to the program, you could be talking about serious damage to access to doctors and hospitals, fewer providers able to survive, higher premiums for seniors, and a host of other problems. Health care was in trouble even before this bill, and big trouble with the provisions in it. The Medicare cuts put the system on the fast track to oblivion.