A partisan vote Thursday afternoon by the House Budget Committee would require able-bodied adults to hold a job in order to qualify for Medicaid. That profound change has long been popular on the far right as a way to promote personal responsibility but opposed by Democrats who fear it would deny health care to many people who need it the most.

Compelling people to work, which would align Medicaid with a similar requirement in the nation’s main welfare program, was one of a trio of moves that committee Republicans recommended as they approved the legislation they hope will begin to dismantle the Affordable Care Act.

Over protests from Democratic lawmakers, the panel also recommended that an expansion of Medicaid under the ACA be dismantled sooner than the GOP’s proposed American Health Care Act envisions. And committee members voted that states should be able to convert Medicaid from an entitlement program — covering anyone who is eligible — into a block grant, under which the federal government would provide a state a fixed annual sum and free it from federal rules spelling out which people qualify and what health benefits must be provided.

Friday morning, President Trump declared that he was “100 percent” behind the work requirement and block-grant option. The bill could be on the House floor late next week.

The three votes on Thursday did not formally alter the AHCA, which House Speaker Paul D. Ryan (R-Wis.) and his allies are trying to rush through the chamber amid a political obstacle course. The Budget Committee merely puts forward changes to be considered at the next stage before full House debate on the legislation.

Still, the Medicaid recommendations further highlighted the ideological cross-pressures on Ryan — and the Trump administration — in forging a set of Republican health policies that might pass both chambers of Congress. While the House Budget Committee is trying to nudge the program toward the right, moderate Republican governors and senators are fighting to ward off the loss of millions of dollars in federal aid to the 31 states, plus the District of Columbia, that expanded their Medicaid programs.

GOP governors from Arkansas, Michigan, Nevada and Ohio sent their own health-reform proposal on Thursday to Ryan and Senate Majority Leader Mitch McConnell (R-Ky.). The four had been working behind the scenes on the alternative proposal for some weeks with several other Republican governors, though these others did not sign onto the public letter.

The current House bill “provides almost no new flexibility for states, does not ensure the resources necessary to make sure no one is left out, and shifts significant new costs to states,” they wrote. As part of their proposal, the governors urge Congress to preserve the increased level of federal payments that ACA provides for adults in the expansion group — and, if necessary for fiscal reasons, cut back on the eligibility limits rather than cutting out the higher reimbursements.

A legacy of Lyndon Johnson’s War on Poverty in the 1960s, Medicaid always has been a shared responsibility of the federal government and states. The current tug of war is likely to shift that balance as well as affect how generous the program will be in the future.

For now, the House GOP’s health-care plan would provide each state a fixed sum for each beneficiary — no matter how much or little of the costs that funding covered. Committee Republicans would add an alternative to that per capita approach, and the block-grant option would give states more leeway to reshape Medicaid, according to Diane Rowland, executive vice president at the Kaiser Family Foundation. But block grants “would no longer provide the safety valve to increase federal funds to support Medicaid during recessions or other surges in enrollment.”

The legislation also would allow the expansion states to keep enrolling people until the end of 2019, and the government would continue paying for nearly all their costs. After that, the government would not provide the higher funding level for anyone new on the Medicaid rolls, presumably prompting most states to retreat to their previous income thresholds.

Rachelle Schultz, president and CEO of Minnesota’s Winona Health, said Friday that many of the patients her hospital serves could lose their coverage.

“If the Medicaid cuts go through, essentially, these people have no insurance,” Schultz said during a Washington roundtable organized by the American Hospital Association. The consequences will ripple outward, she added, since uninsured people often postpone treatment for chronic conditions until a problem worsens and requires more costly care. “What happens is they stay home, and they show up at the emergency room.”

The budget panel went further than the current bill, recommending that the extra funding end right away. Calling Medicaid’s expansion “a cruel joke” because not everyone who joins can find doctors, Rep. Matt Gaetz (R-Fla.) said that waiting until 2020 “would be like a diet strategy, if I said I needed to lose weight but [would] start 2½ years from now and in the meantime eat everything in sight.”

Rep. Debbie Wasserman Schultz (D-Fla.) countered, “That is simply code for deep cuts and fewer people covered.”

The sharpest exchange Thursday was over requiring able-bodied adults on Medicaid to hold or train for a job. Republicans suggested that such a requirement would save the government money and encourage those in the program to take greater responsibility for their own lives.

“Let’s prevent idleness,” said Rep. Jodey Arrington (R-Tex.), who contended that requiring people to work would “make this not so much of a seductive entitlement.”

Rep. Jan Schakowsky (D-Ill.) responded by saying that “most people on Medicaid who can work, work” and that Republicans’ “ultimate goal is to simply kick people off Medicaid, and not actually help people find employment.”

Medicaid now covers some 68 million low-income Americans, including children, pregnant woman, people who are older or disabled, and others who are merely poor. About 11 million of those beneficiaries are people with somewhat higher incomes who joined in the past three years through the ACA expansion.

A Kaiser analysis last month found that eight in 10 adult Medicaid recipients live in working families — and 59 percent who are not disabled have a job. Most who do not work have major obstacles, such as an illness or disability or caregiving responsibility for a relative, and nearly one in five are in school.

During the Obama administration, at least a half-dozen states sought permission to include work or job-training requirements as part of their Medicaid programs.

The requests ran the gamut: Indiana wanted to hinge eligibility on a work referral, while Arizona proposed that able-bodied adults work, seek work, or attend school or job training for at least 20 hours a week. Arkansas would have made Medicaid beneficiaries meet the same work requirements as welfare recipients, and Pennsylvania, Ohio and New Hampshire variously hoped to require part-time work, participation in a job training program or proof that a person was training for work.

In each case, the request was denied.

Many health industry officials say they remain confident the House legislation’s provisions for Medicaid will be significantly altered once the Senate weighs in.

“In many instances — not just with health care — the House does one thing, and the Senate tends to be a tempering institution,” Tom Nickels, the hospital association’s executive vice president for government relations and public policy, said Friday.

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