BAKERSFIELD, Calif. >> To understand the conundrum House Republicans have gotten themselves into as they try to pass their budget plan, look no further than Rep. David Valadao of California.

Almost nowhere in the nation relies as heavily on Medicaid as his district here in the Central Valley, where nearly two-thirds of the population depends on the program for health care, from low-income nursing home patients to the parents of developmentally disabled children to veterans with chronic conditions.

So it comes as little surprise that Valadao, one of the most politically vulnerable Republicans in the country, has appeared uneasy about the prospect of voting for his party’s budget blueprint, a measure that would pay for $4.5 trillion in tax cuts in part through deep cuts to Medicaid.

To pass their budget plan and smooth the way for enactment of President Donald Trump’s sprawling agenda, House Republican leaders will need to muster near unanimity from their members. Under the outline, Medicaid cuts would have to make up nearly half of the required $2 trillion in spending cuts, if Medicare is left untouched as Republicans have said it will be.

But they are finding it is one thing to hypothetically entertain spending cuts on a spreadsheet, and entirely another to ask lawmakers to cast a vote that would have real-life consequences in their districts.

In a recent letter to House Republican leaders, Valadao and other Hispanic lawmakers argued that such cuts “would have serious consequences, particularly in rural and predominantly Hispanic communities where hospitals and nursing homes are already struggling to keep their doors open.”

Valadao, who declined an interview request, is feeling the pressure from constituents at home. He did not attend a town hall this week in Bakersfield hosted by a local health care advocacy group on the potential impact of Medicaid cuts. But it was standing room only as people — some wearing cowboy hats and boots, others in scrubs, and some wearing vests identifying them as veterans — packed into the community room of a senior living center. Many of them were angry.

“Right now, we are counting on you to be the champion that you truly are,” said Grace Huerta, addressing Valadao. The mother of two adult children with autism, Huerta recounted to the audience how the congressman had met with her daughter and promised that he would do everything he could to help people with disabilities.

“You stand on your word,” she said. “Then why would you go back on it now, when you promised my children?”

Valadao is not the only one facing potential blowback from his constituents for backing the party’s budget plan. With the House in recess this week, angry constituents across the country, even in deep-red districts, confronted Republicans about the sharp cuts they are proposing and Trump is making to every corner of the government.

In southeastern Virginia, constituents protested the firings of federal workers outside Rep. Jen Kiggans’ office. In the northeast suburbs of Georgia, attendees at a town hall booed Rep. Rich McCormick over spending cuts spearheaded by Elon Musk. And in Pennsylvania, protesters urging Republicans to protect Medicaid marched in front of the offices of Reps. Ryan Mackenzie and Scott Perry.

Yet as early as Tuesday, when they hope to bring the budget plan to a vote, House Republicans will be asking their rank and file to go on the record supporting cuts to that program and many others.

The plan instructs the Energy and Commerce Committee, which has jurisdiction over Medicaid and Medicare, to find $880 billion in cuts. If all the cuts came from Medicaid, the country’s largest insurance program, it would represent an 11% reduction in spending, on average, over a decade.

The House Budget Committee estimated earlier this year that imposing work requirements on Medicaid would cut $100 billion — meaning lawmakers would need to approve more drastic measures to hit their spending targets, like shifting more of the costs to the states.

Further complicating the picture for Republicans, Trump promised on the campaign trail not to touch Medicare — and added in an interview that aired this week that he also did not want to lay a finger on Medicaid. The next day, he endorsed the House blueprint that calls for doing just that.

It all has left Valadao, who represents a Democratic-leaning district and is perpetually one of House Republicans’ most politically endangered members, with seemingly no good options or political cover.

He could oppose the budget plan and derail it, invoking Trump’s wrath and almost guaranteeing the prospect of a primary challenger. Or he could support it, guaranteeing a deluge of attacks from Democrats and jeopardizing his standing with voters like Angel Galvez, the chief executive of the Bakersfield American Indian Health Project.

Galvez, who voted for Valadao last year, runs a clinic that serves roughly 6,800 American Indians and Alaska Natives — 90% of whom, he said, are insured by Medicaid. His clients include Indian children in the foster care system, veterans and seniors with chronic health conditions.

“The services we provide are services that they can’t afford otherwise,” Galvez said in an interview, adding that his clinic had prioritized mental health services for the Native American community in Bakersfield.

“What you’re doing is you’re saving someone’s life, but simultaneously, you’re reducing the cost to the system,” he said, “because if they’re well, then they don’t need to have emergency services: hospital visits, psychiatric holds, things that cost the managed care plans billions of dollars. So as a leader of this organization, I’m just a little baffled as to why they would target such a health plan to eliminate funding for things that we see as a positive.”

Valadao knows firsthand the political perils of supporting legislation that aims to gut health care policies that are broadly popular. First elected in 2012, he was swept out in 2018, when Democrats won the House back by campaigning narrowly on Republican efforts to repeal and replace the Affordable Care Act.

Democratic leaders in recent days say it is a playbook they intend to repeat. In the 2018 midterm election campaign, they made a conscious decision to keep a tight focus on how Republican efforts to repeal the health measure and give tax cuts to the wealthy would hurt Americans, Rep. Hakeem Jeffries, D-N.Y., the minority leader, recalled in a recent interview on MSNBC.

“Those were the decisive issues that allowed us to take back the House in November of 2018,” he said. “And that’s a lesson that I think we can draw from that moment.”

Valadao’s seat has long presented a prime target for Democrats. His district leans Democratic but he has routinely been able to notch victories in his majority-Hispanic district, weathering challenges from the right after he voted to impeach Trump in 2020 and beating back efforts to oust him from the left.

But the issue of Medicaid cuts could carry a uniquely galvanizing power.

At the town hall, Kelly Kulzer-Reyes, a professor at a community college, described how her family relies on Medicaid to afford the services required by her 12-year-old daughter, Amelia, who has Down syndrome. They include support staff members who help teach Amelia basic skills in the hopes that she will be able to live independently as an adult after her parents can no longer care for her.

“I have to have a world where I can die, and losing Medicaid will make it so I don’t get to die,” Kulzer-Reyes said. “I have to know she’s OK.”