A vote that U.S. Rep. Tom Tiffany cast in June 2025 has become a centerpiece of healthcare advocates’ criticism of the Republican candidate for governor.

Tiffany, along with all Republican members of Congress and no Democrats, joined in the passage of the 2025 HR 1 — the legislation that President Donald Trump and U.S. House Republican leaders dubbed “The One Big Beautiful Bill Act.”

The measure made cuts to Medicaid and federal nutrition benefits over the next 10 years, along with a range of other changes to federal programs. The Medicaid changes alone have been projected to cut $900 billion to $1 trillion from the health insurance plan for people with low incomes.

The legislation also extended a series of tax cuts that were passed in Trump’s first term — cuts that primarily benefit wealthy Americans, according to the Center on Budget and Policy Priorities in Washington.

After the bill’s final passage in July 2025, Tiffany issued a statement praising the outcome for “providing tax cuts for seniors, parents, workers and small businesses” as well as for funding federal immigration agencies that have been deployed across the country.

Tiffany also said he would “remain committed to protecting Social Security, Medicare, and Medicaid for our seniors and the most vulnerable, while rooting out waste and curbing the reckless spending that threatens future generations.”

But in press conferences last week and Tuesday, healthcare advocates said that bill was central to their opposition to Tiffany’s healthcare record.

“When he voted for the one big beautiful bill, he essentially voted for a $1.1 trillion cut in healthcare,” U.S. Rep. Mark Pocan (D-Black Earth) said at a press conference Tuesday organized by the groups Main Street Action and Protect Our Care. “And that’s the biggest cut we’ve ever seen in this country.”

In addition to benefit cuts, advocates have focused on what HR 1 lacked. U.S. House Democrats tried to persuade the Republican majority to extend enhanced health insurance subsidies for people buying their health coverage on the Affordable Care Act marketplace.

The enhanced subsidies were enacted in 2021 and expired at the end of 2025. Democrats’ repeated attempts to extend them were rejected, not only during debate on HR 1 but several times later in 2025 as well as early in 2026.

Pocan said he’s spoken with small business owners across his South Central Wisconsin district who have been affected by the ACA premium increases that resulted.

“We’ve seen small business owners in Baraboo on the Affordable Care Act say that their monthly portion they pay in has doubled or even tripled,” Pocan said. One constituent he spoke with “just got out of the [insurance] system altogether,” setting aside the cash that would have gone to an insurance premium in hopes that it would be enough to cover a healthcare emergency.

“That’s not a healthcare plan,” Pocan said. “That’s not about making health insurance more affordable. That’s about taking insurance away from people.”

According to a July 28 report from KFF, a nonprofit healthcare policy analysis and news organization, coverage through the ACA fell nationwide by 2.6 million in 2026 from 2025 after seven years of steady increases. In Wisconsin, coverage fell 16%, by 45,000 people.

Gov. Tony Evers issued a statement Tuesday blasting Wisconsin’s Republican congressional delegation for letting the enhanced subsidies expire. 

“Congressional Republicans’ refusal to extend the tax credits caused healthcare coverage costs to skyrocket, pricing families in Wisconsin and across the country out of having coverage at all,” Evers said.

Macy Buhler, a De Forest childcare provider and Main Street Action member who joined the press conference with Pocan, said that without those additional subsidies, the cost of insurance for some of her employees rose to unsustainable levels.

Buhler said she can’t cover healthcare for her childcare teachers directly, but has been providing them a stipend to help teachers who need health insurance purchase it on the federal ACA marketplace, HealthCare.gov. She doubled that stipend for 2026, she said — a $40,000 increase in just that expense.

“Early childhood teachers deserve real access to healthcare and medication, not a Congress who makes it impossible for them to afford both,” Buhler told reporters. “Tom Tiffany voted for this bill. We cannot trust him with our healthcare.”

Buhler told the Wisconsin Examiner that she’s “lost some staff and closed a classroom because they can no longer afford to be an early childhood educator, a teacher.”

Nancy Higgs, a self-employed interior designer specializing in affordable approaches for her customers, has been in business since 2023. The ACA coverage made it possible to get health coverage, she told the Wisconsin Examiner.

After a good first year, the business struggled following the 2024 election. Because her net income was too low, she switched to enroll in Medicaid — called BadgerCare in Wisconsin — for her healthcare.

Higgs said she isn’t sure what will happen to that coverage under the HR 1 changes, which don’t take effect until January 2027.

During a virtual news conference on Thursday, Aug. 13, Dr. Sophie Kramer, a Madison internal medicine physician, said the loss of insurance coverage, whether from Medicaid or an ACA policy, will lead to poorer health. The news conference was sponsored by the Committee to Protect Health Care.

“So much of what we do depends on patients having consistent access to healthcare. I treat patients with chronic diseases like diabetes, cancer, heart disease, hypertension — and those don’t disappear when someone loses insurance, they just become harder to manage,” said Kramer. “I’ve seen too many patients suffer from treatable conditions simply because they didn’t have access to affordable care.”

Dr. Kristen Dall-Winther, another participant in that news conference, owns her own practice in Wisconsin’s 7th Congressional District. Tiffany has been her U.S. representative since 2019.

“I see first hand what happens when patients struggle to afford care, when rural hospitals are under financial pressure, and when people put off seeing a doctor because they are worried about what it will cost,” Dall-Winther said. “Tom Tiffany has repeatedly voted for policies that make those problems worse.”

Dall-Winther cited forecasts that HR 1 could eventually cost more than 250,000 Wisconsin residents their healthcare coverage.

Kramer also cited Tiffany’s vote against a federal bill that would have codified a right to abortion in September 2021. The measure passed the House on a party-line vote but stalled in the U.S. Senate.  

Nine months later, in June 2022, the U.S. Supreme Court overturned the nearly 50-year-old decision in Roe v. Wade that had legalized abortion nationwide. An 1849 Wisconsin statute that was interpreted as an abortion ban went into effect as a result.

“Tom Tiffany could have voted to protect that federal right to abortion in law, but he voted against it, allowing state bans like ours to interfere in personal medical decisions,” Kramer said.

The Wisconsin Supreme Court subsequently ruled that the Wisconsin law didn’t apply to elective abortion.

When Rob Stone finished high school in Bethesda, Maryland, in 2018, he was asked to identify three goals for his life. Stone loves art and baseball. He’s cheerful, sports a cheeky mustache, and he’s always up for an adventure.

Stone has a rare genetic movement disorder, dystonia-parkinsonism, that limits his mobility and speech. Setting specific goals would help him construct the life he wanted, and help his family identify the services he would need to live it to the fullest.

His parents suggested goals like “going on lots of walks” or “visiting state parks.” Stone just looked at them like they were ridiculous, said his mom, Jeneva Stone.

“We eventually discovered, through the right series of questions, that Robert wanted to protest,” she said. He’d watched disabled protesters dragged out of their wheelchairs from then-Senate Majority Leader Mitch McConnell’s office at the U.S. Capitol the year before, as they demanded the preservation of the Affordable Care Act.

Now 29, Rob has been a fixture on Capitol Hill and at the Maryland State House ever since, advocating alongside his parents for disability rights and healthcare. Earlier this year, he joined with other advocates to lobby the state legislature not to cut funding for services that help him and others live in their communities.

They weren’t able to prevent the cuts, but they did succeed in limiting them.

Disability advocates around the country are fighting a surge of federal and state actions that have eroded protections meant to keep people with disabilities living and working in their communities, rather than in institutions.

The federal government has walked away from decades-old requirements that states deliver disability services to people where they live. At the same time, state leaders, citing budget shortfalls, have rolled back community services the feds don’t require them to fund.

“It’s really hard,” said Rob Gorski, an Ohio father of three sons with autism who runs a popular social media account called TheAutismDad. “You try to wrap your head around one thing, and by the time you even figure out a path forward from there, they’ve thrown more stuff at you.”

In Maryland, state lawmakers were weighing cuts to Medicaid, the joint federal-state program that covers much of Rob’s care, which he receives at home. The federal government will be reducing its share of Medicaid funding as part of the One Big Beautiful Bill Act, the broad tax and spending measure President Donald Trump signed last summer.

Maryland ended up cutting $126 million from the agency that administers Medicaid for people with developmental disabilities — but that was less than the $150 million reduction that Democratic Gov. Wes Moore originally proposed. The final budget also scrapped a proposed cap on how much state funding a person in the program could receive per year.

“Medicaid itself isn’t just a budget line item,” Jeneva said. “It’s the mechanism through which the federal government ensures that people with disabilities have the civil right to live in their communities.”

Other threats to community-based disability services have emerged in Washington, D.C., and across the nation.

In June, the U.S. Department of Justice issued an opinion memo that says states don’t have to fund in-home or community-based services for people with disabilities who don’t want to live in institutions. The memo is a significant reinterpretation of federal law and represents a shift away from decades of civil rights protection.

The memo doesn’t change federal law, but it does signal a new focus for the DOJ, which is the primary enforcer of disability rights. Without enforcement, advocates worry, the civil rights protections they rely on could become moot.

In July, the DOJ published another notice saying it would no longer enforce its longstanding guidance on how to implement a landmark U.S. Supreme Court decision, Olmstead v. L.C., that requires public entities to provide community-based services, rather than institutional care, to people with disabilities whenever possible.

The federal spending reductions in the One Big Beautiful Bill Act are likely to spur more cash-strapped states to cut home- and community-based services, since the federal Medicaid law only requires them to provide institutional care. More than half a dozen states have already moved to limit such services for people with disabilities, according to an analysis of state actions by researchers at George Washington University.

And at least three states are suing to dismantle a section of disability law that requires states to provide community-based services.

Defenders of the changes say they will allow states to refocus their limited dollars on people with the most serious medical needs.

New Medicaid work requirements in the Trump law, which are expected to drop between 3 million and 7 million people from the rolls, “will free up more state funding for (home- and community-based services) recipients,” said Rachel Barkley, director of the Able Americans disability policy think tank, which is housed inside the conservative National Center for Public Policy Research.

But Jeneva Stone says the cuts in Maryland threaten her son’s ability to get the nursing and other services he needs to be able to live at home. She worries families like hers will be the first to face forced institutionalization.

“More and more burden falls on family caregivers to fill in the gaps, and that leads to unsustainable economic situations for families,” she said. “Once your job situation falls apart, your savings are gone, you’re faced with this ugly choice: I believe strongly in my son’s civil right to stay in his community, but I can’t keep a roof over his head.”

Everything feels uncertain, she said, as longstanding protections seem to be dissolving for her son and others like him.

“They’re happy, they’re living great lives,” she said. “Are they medically complicated? Yeah. But do they deserve to spend the rest of their lives lying in a bed in a facility just because it’s easier to care for them in a congregate setting?”

‘That’s what people want’

In the middle of the 20^th century, disabled activists and their family members demanded an end to systemic abuses suffered by many of the hundreds of thousands of disabled people who were hidden away in sprawling state institutions around the country.

In the following decades, presidents and lawmakers of both parties championed a national shift away from segregating disabled people in huge facilities and toward the provision of services — such as home health nurses, physical therapy or adaptive tools — that would enable them to live at home or in their communities.

The two most consequential landmark federal disability rights laws were signed by Republican presidents: Richard Nixon signed the Rehabilitation Act in 1973, and George H.W. Bush signed the Americans with Disabilities Act in 1990. Then, in its 1999 Olmstead ruling, the U.S. Supreme Court ruled that the unjustified institutionalization of people with disabilities was a form of discrimination.

“For decades we have very intentionally been shifting resources away from institutional care and into the community, because that’s what people want, and it’s more cost effective,” said Alison Barkoff, a health law and policy professor and director of the Hirsh Health Law & Policy Program at George Washington University.

“We can serve, generally, three people in the community for every one person in an institution. And it leads to better outcomes.”

More than 8 million Medicaid users receive such home- and community-based services across the country, while 1.5 million get services in institutions, such as nursing homes. Federal law requires state Medicaid programs to provide medical care and other support for people with disabilities.

People who live in institutions cost Medicaid an average of $54,462 per year, compared with $17,298 for people who get home and community services, according to the most recent Medicaid data.

State investments in home- and community-based services often result in short-term spending increases, but over time lead to long-term cost savings and a reduction in institutional spending, according to research from Brandeis University’s Community Living Policy Center.

The national shift to community-based services has been overwhelmingly popular. About 82% of people who receive community-based services prefer to live at home rather than in an institution, according to the most recent survey by the Medicaid and CHIP Payment and Access Commission.

That’s why, said Barkoff, “it is incredibly shocking, the approach that this administration is taking to something that has been so bipartisan and so much a part of American culture for decades.”

Some Republican-led states now want courts to adopt the Trump administration’s new interpretation of the Olmstead decision. Texas has already used the June DOJ memo in its lawsuit challenging federal requirements to provide community-based services. Florida also has used the memo as part of its appeal of a case involving medically complex children who were forced into nursing homes because the state refused to pay for in-home services.

Conservative state leaders say the federal government shouldn’t dictate how states offer support for people with disabilities, and argue that nursing shortages and other issues make it too difficult for states to care for some people outside of institutions.

Left behind

Barkley of Able Americans supports the shift away from institutionalization, but she says there should be more public investment in group homes or smaller facilities that can provide 24/7 oversight for people with more complex needs who can’t live safely at home.

“Unfortunately, it’s only when somebody with a serious mental illness hits the criminal justice system that they’re able to receive care,” she said. “And so for this sliver of the serious mental illness population, this movement has left them behind.”

VOR, a national disability rights nonprofit that supports “a full continuum of care options” for people with disabilities, argues that overly aggressive enforcement of the Olmstead decision and related federal law has, in some cases, resulted in people with disabilities being moved into community settings without adequate support. That broad-strokes application has contributed to poor outcomes, including homelessness, for some people.

The DOJ memo and other federal actions reducing community care have been driven in part by the Trump administration’s push to address homelessness, said Barkoff. Trump issued an executive order last July giving states a green light to commit people experiencing homelessness to treatment centers or hospitals, whether they want to go or not.

“They have created this narrative that Olmstead created this problem” of not enough beds for people who need higher levels of care, said Barkoff. But without Olmstead, “there was just a hollow promise to close institutions,” she said.

“What Olmstead did was create a tool to require states to follow through on that commitment.”

Gorski said it’s been more apparent this year than ever that there are people and families, particularly those with complex care needs, who feel that the shift away from institutional care hasn’t helped them.

Recent efforts by the Trump administration to roll back protections are “exploiting where we’ve failed to ensure that we’re taking care of our own people,” he said. “Everyone in this community should feel seen and heard and like they have a place at the table.”

But even VOR warned in a June statement that the DOJ memo “substantially weakens” protections and federal pressure on states to fund the community-based services many people with intellectual or developmental disabilities depend on.

States on their own

In June, Republican lawmakers in Ohio swiftly backtracked on a proposal that would have barred Medicaid recipients’ family members from being paid as caregivers. They pulled the controversial portion of the bill after backlash from residents who said it would hurt people with developmental disabilities whose caregivers are often relatives whose caregiving duties prevent them from taking other jobs.

Some states have recently expanded home and community-based services, including Georgia, Illinois, Ohio and Wyoming, according to George Washington University’s analysis. Others, including California, Idaho, Indiana, Maryland, Minnesota and Nebraska, have limited services.

Some, like Kansas and Virginia, have done both.

Ultimately, as the feds back away from enforcing civil rights protections, states are left to figure out how to offer services for people with disabilities in a way that balances civil rights with budget realities.

“At this point it’s kind of a state-by-state effort,” said Illinois state Sen. Julie Morrison, a Democrat who sponsored a bill this year, now law, that turned Illinois’s state disability commission into a cabinet-level agency.

“But at the end of the day we are obligated, morally I believe, to make sure we are taking care of people who need these services and who want to live in an independent environment.”

Rob Stone and his parents plan to continue meeting with state legislators in Maryland to push back against deeper cuts to services that help him remain with his family. His mother said she’s been doing a lot of explaining to lawmakers about how civil rights for people with disabilities fit into existing law.

“There’s a tremendous need for advocates to educate legislators at the state level about this because they’ve never had to think about these things before,” she said.

“It’s always been something the federal government takes care of.”

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.

After a 125-mile trip on his powered wheelchair, Carl Schulze rolled up just before noon Thursday to the Wisconsin Capitol.

The resident of Fox Crossing, near Neenah, made the journey to make a point: How Medicaid has helped him and thousands of other Wisconsin residents with disabilities — and how that help is being threatened in Washington, D.C.

A fall from a porch 19 years ago broke Schulze’s neck. He survived, but the accident left him unable to use his arms or legs.

Medicaid coverage for home care makes it possible for Schulze to hire aides who help him with virtually every activity of daily living. But with cuts to Medicaid totaling more than $900 million in 10 years because of the tax cut and spending law that President Donald Trump signed in July 2025, he worries that it may be harder to maintain his coverage, or pay the healthcare workers who support him.

And another initiative from the administration has angered — and worried — Schulze as well.

Since 1999, the U.S. Supreme Court’s Olmstead ruling has been interpreted to say that people with disabilities have a fundamental right to get their care at home or in the community instead of having to live in a nursing home or other institution. In June, however, the Trump administration U.S. Department of Justice issued a legal memo rejecting that long-held assumption.

“Apparently, it’s not a violation of my civil rights to put me in an institution against my will,” Schulze said to a bank of TV microphones on the sidewalk in front of the state Capitol. “The federal government is openly telling states, there will be no consequences if they defund the very services that keep disabled people living at home. They have effectively given states a green light to warehouse us again.”

As federal protections fade, disabled Americans fear a return to institutions

The looming Medicaid cuts could give states, which administer the health insurance program and cover some of its costs, “no choice but to cut programs,” Schulze said. “And when they decide on what’s cut, the programs that serve people with disabilities will be first up on the chopping block. That means people like me may soon be forced to choose between our physical health and even the rest of our life in the future.”

Other federal initiatives are cutting federal grants that “no longer align with the administration’s priorities,” Schulze said. “For Wisconsin, this means even more uncertainty and deeper potential cuts to independent living support.”

Schulze didn’t take his wheelchair ride alone. Starting in mid-July, he began the trip from his apartment in Fox Crossing, driving the chair until the battery needed charging, with drivers accompanying him in his van. With each successive day, they drove him and the chair to the point where he stopped previously and continued the trip. Along the way he recorded videos for social media.

Care in the community is first and foremost a human right, said Jenny Price, executive director of the Wisconsin Board for People with Developmental Disabilities, in an interview. But it’s also more economical than putting someone in an institution, she observed.

“When you look at these [home care] services on their own, they appear very expensive,” Price said. “What kind of gets lost when people look at that big dollar amount is what that dollar amount could be if it were provided in an institutional setting.”

The cuts’ impact doesn’t end with people who require Medicaid for their healthcare.

Jason Glozier, the co-chair of the Survival Coalition of Wisconsin Disability Organizations, is the executive director of the Wisconsin Coalition of Independent Living Centers, a network of agencies around the state that offer information resources, navigation assistance and advocacy for people with disabilities who want to remain in the community.

“Almost 50% of unpaid caregivers are providing as much or more care hours than a half-time job,” Glozier said, citing a survey that the Survival Coalition conducted last year. “And 31% of caregivers are providing care more than 60 hours per week. Under any sort of labor laws, that wouldn’t be fair treatment. It shouldn’t be fair to expect our families to provide that care unpaid.”

“Family members have been providing enormous amounts of uncompensated care, for decades in some cases, to keep people in their home,” Tami Jackson, a policy analyst for the Board for People with Developmental Disabilities and  the other Survival Coalition co-chair, told reporters. “Even small cuts to the number of hours [of healthcare coverage] that somebody like Carl and many others get can mean the difference between being in their home and being locked away in a nursing facility where you don’t have the freedom to decide what your hours are, when you eat, who you can see, whether or not you can commute to a job, and a thousand other daily things that most of us are not thinking about right now.”

The Trump administration announced Tuesday that it is freezing more than $1 billion in Medicaid payments to California and Minnesota in an effort to crack down on fraud.

Medicaid is the public health insurance for people with low incomes, including some disabled and elderly people, jointly funded by state and federal dollars.

The U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services deferred more than $867 million to California and $199 million to Minnesota. The feds say they need more documentation from those states to support some Medicaid claims for services that are at high risk for fraud.

The freeze marks the latest round of withheld payments as the Trump administration continues its crackdown on suspected fraud in publicly-funded social service programs, mostly focusing on Democratic-led states. Earlier this year, the Trump administration launched a fraud task force to look into potential waste or abuse in publicly-funded benefits programs, explicitly naming states such as California, Colorado, Illinois, Maine, Minnesota and New York.

The Trump administration has already deferred Medicaid payments in Minnesota twice this year, totaling nearly $400 million. The deferral process, under which the federal government can withhold funding when questioning claims already billed to Medicaid, had never been used to deny funding for entire service areas until a $243 million deferral in February, the Minnesota Attorney General noted.

A letter delivered Tuesday from CMS to the Minnesota Department of Human Services stated that $195 million of the deferred $199 million comes from specific providers that CMS identified as high-risk for fraud or “aberrant billing practices” based on historical billing and analysis. The money comes from services delivered from January through March and has already been paid. States will have to provide documentation backing up the claims or be forced to reduce future billing to the federal government.

The Trump administration has also threatened to withhold $2 billion in annual Medicaid funding to Minnesota in a separate process. The funding fight in Minnesota centers on 14 Medicaid services deemed high-risk to fraud and are largely designed to give long-term care for elderly and disabled people. But state officials have said that funding freezes could deliver a serious blow to the state’s Medicaid program more generally, which cost $18 billion in 2024 and covers other low-income Minnesotans.

John Connolly, temporary commissioner and state Medicaid director for the Minnesota Department of Human Services, said in a statement that Tuesday’s deferral reflects the federal government’s “unprecedented and punitive ways as part of their war on Medicaid and its recipients.”

“CMS touts their new fraud-detection capabilities, yet has not provided data or explanation on how the deferral amount was calculated or what it was based on. I respectfully ask the federal government to partner with us and share any information about their methods to identify potentially fraudulent providers in Minnesota,” Connolly said.

The federal-state fight over Medicaid funding has affected thousands of Medicaid providers in Minnesota, who were abruptly cut off from funding as the state raced to reach a federal deadline to screen all providers in the “high-risk” services. Providers and their advocates said the process was rushed and left legitimate providers unable to get paid for delivering services to vulnerable Minnesotans.

HHS Secretary Robert F. Kennedy Jr. said the Trump administration’s goal is to strengthen the integrity of the Medicaid program and make sure federal funds are spent appropriately.

“States that receive federal Medicaid funding must demonstrate that every dollar meets federal requirements,” Kennedy said in a news release on the deferred funds. “When they cannot, we will not release federal funds until they do.”

California Gov. Gavin Newsom, a Democrat, called the withheld funds a “recycled political stunt” in a post on X, and said his state was being targeted for political reasons.

Minnesota Democratic Gov. Tim Walz rejected the Trump administration’s framing of the situation in a post on X: “This isn’t about fraud — it’s about cutting your healthcare so that Trump can afford the tax cuts he gave to billionaires.”

CMS said it identified unusually high growth in spending on certain in-home care programs in California, triggering the hold on that state’s funds. It has not provided proof of fraud.

Newsom countered in his X post, arguing that California is saving taxpayer money “by keeping seniors and people with disabilities out of far more expensive nursing homes.”

In Minnesota, a CMS review flagged expenditures that raised “potential eligibility or billing concerns.”

“CMS is done trying to chase down stolen and misused funds after they’ve already left the building,” Dr. Mehmet Oz, CMS administrator, said in a news release, adding that the deferred payments are part of a “proactive new approach to program integrity.”

The pauses in funding don’t affect who is eligible for Medicaid, and they’re not permanent cuts.

Alyssa Chen of the Minnesota Reformer contributed to this story. Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org.