The giant tax and spending bill President Donald Trump signed into law over the weekend includes the biggest health care spending cuts in U.S. history. In response, states are scrambling to shield their hospitals from the looming loss of hundreds of millions in federal funding.

The “Big Beautiful Bill," as Trump has called it, includes a $1 trillion reduction in spending over the next decade for Medicaid, the government insurance program for low-income Americans. Trump signed the bill on July 4.

A Republican megabill cuts $1 trillion from Medicaid, risking closures for hospitals that serve some of America’s most vulnerable. Rural hospitals in the U.S. already operate on a razor’s edge, but new cuts to Medicaid in the Republican appropriations bill could tip many of them into failure.