Even before the Trump administration’s multipronged attacks on health programs, which have targeting diversity, equity and inclusion efforts but also ensnared spending on addiction recovery, vaccination efforts and infectious disease tracking, Massachusetts HHS faced grim fiscal realities, Walsh said. More people are in need of health services, and their needs are increasingly acute. Even with a proposed $2.8 billion increase, which would raise the HHS budget to $33.3 billion, departments are eyeing program cuts to accommodate mandatory payroll and rate increases.

“We’re left with hard choices,” Walsh said.

In the coming weeks the state House and Senate will introduce and vote on their own versions of the budget before sending their funding priorities for the governor’s signature.

State budget pressures aside, officials are terrified of Congress following through with a possible $880 billion cut to federal programs, including Medicaid, over the next 10 years that would likely reverse years of work to expand insurance access in the state. About two million people rely on MassHealth, the state’s Medicaid administrator, for health insurance, and that program relies on federal reimbursement for more than half its roughly $20 billion budget.

Congress is likely to implement some or all of four cost cutting measures, Mike Levine, assistant secretary for MassHealth, told the joint committee Monday. It could rescind Biden-era Medicaid regulations that would likely increase costs, impose per person spending limits, restrict states’ ability to raise money for Medicaid through taxes on health care providers, or impose a mandate to make Medicaid enrollment contingent on working, volunteering, or investing in education.

Work requirements, in particular, he said, are “very effective at keeping people from getting health insurance.”

With cuts all but certain, MassHealth is determining what core services it will attempt to protect. Among the most important to preserve are programs, such as home health care, that help people who could live independently to stay out of nursing homes, and preventative health care for children, Levine said during the Legislative hearing.

“I think we collectively have an obligation to protect core parts of the program,” he said. “It’s a matter of identifying our key populations and what we’re going to do to support them.”

The Department of Public Health is also taking steps to compensate for lost services or at-risk federal funds, said Dr. Robbie Goldstein, the state’s public health commissioner.

Cuts to the CDC Immunization Services Division and Robert F. Kennedy Jr.’s history of vaccine skepticism add urgency to a proposal for what is essentially a state version of the federal vaccine recommendation and purchasing infrastructure. A surcharge on health insurance carriers would support a state purchasing program to provide adults with free vaccines for illnesses such as COVID-19, influenza, and RSV. The state would also create its own vaccine recommendation panel and maintain “the vaccine infrastructure that’s necessary despite federal neglect,” Goldstein said during Monday’s hearing.

Massachusetts public health programs are among those most threatened by federal cuts. The Centers for Disease Control and Prevention is seeking to claw back tens of millions of uncommitted dollars from $118 million in health-related grants, including vaccination initiatives, substance use programs, and money for the state’s epidemiology labs, state officials said.

A lawsuit challenging the CDC trims prompted a court order that for now will keep the funds flowing, but the courts may eventually side with the Trump administration.

“These cuts are real. Our programs are at great risk,” Goldstein said. “People’s lives will be affected.”

As state officials warned of what could come, the trims already in the proposed budget sent ripples of concern through the state. Department of Mental Health officials are facing blowback after proposing the closure of several programs for children as well as the Pocasset Mental Health Center, one of just two adult residential mental health programs on Cape Cod. The Pocasset plan is on pause while a working group considers options, but staffers are concerned the state will ultimately decide to shutter the 16-bed facility.

“We’re already lacking on the Cape for resources for mental health,” said Alanna Stanley, an infection control nurse at Pocasset. “It sounds like low lying fruit by closing Pocasset, but the reality is it’s remote here, and we really have nothing.”

Similarly, workers at the DPH-run Pappas Rehabilitation Hospital for Children in Canton are concerned a pause on plans to close that facility is only a temporary reprieve. Many attended the joint committee’s public comment session at the State House Tuesday to push legislators to protect the campus.

Pappas housed 32 patients as of Monday, people ages 7 to 22 with developmental or physical disabilities who are difficult to support outside a hospital setting. In the past month, patient discharges have alarmed workers. They fear the state is depopulating the facility to justify its closure.

Goldstein disputed that, saying discharges are part of the routine churn of the hospital’s population. Pappas’s closure is under a working group’s consideration, he said, and in the meantime the facility is still admitting patients, with three taken in from January through March.

“There are no predetermined conclusions here,” he said.

About 800 Massachusetts children with severe medical needs, Goldstein said Monday, could benefit from a residential hospital program, and DPH is seeking ways to expand services for them. The aging Pappas buildings simply can’t accommodate some of these children, such as those who require ventilators, he said.

Kathryn Brewer, a Pappas teacher, said nowhere else in the state can offer the same mix of education, recreation, and camaraderie specifically tailored for people with significant disabilities.

“They are in a community of peers just like them on a campus that is accessible for their needs,” she said. “What happens when Pappas is their home and you’re taking that away from them?”

Jason Laughlin can be reached at jason.laughlin@globe.com. Follow him @jasmlaughlin.