But after this weekend, when President Donald Trump Bowen, who specializes in primary care pediatrics, fears a new obstacle: her patients might lose access to the publicly funded health insurance that makes her work possible.

“Before they had insurance, but then they couldn’t get to the provider,” Bowen said. “Now you’ll have providers coming out — but they won’t have the insurance.”

Experts say Bowen’s concerns are not unfounded. The sweeping, which Republicans pushed through Congress last week without any Democratic votes, will cut federal spending on Medicaid and Children’s Health Insurance Program benefits by $1.02 trillion and increase the number of uninsured Americans by 7.8 million people over the next decade, according to estimates by the nonpartisan

Cuts to the Medicaid budget will have “just tremendous impacts,” Bowen added. Schools receive about $7.5 billion annually from , a popular joint federal and state health program that insures nearly 70 million Americans, most of whom are low income. For more than 30 years, it’s paid for services in schools for students with disabilities as well as low-income students.

If all provisions in the bill are enacted, it will lead to enrollment drops in the , which provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid, and a $125.2 billion reduction in Medicaid by 2034, the Budget Office predicted, though it’s not clear just how many kids would be impacted. 

The cuts will come through a variety of mechanisms over the next decade, ranging from immediately enacted provisions that curb states’ ability to raise their share of Medicaid funding to new federal limits on eligibility — including work requirements for parents of kids 14 years or older — which will go into effect in 2027. These, in particular, could harm children, who are less likely to be covered themselves if their parents lose access, according to Anne Dwyer, an associate research professor at Georgetown University’s Center for Children and Families.

“Like many, we’re still unpacking exactly what this will mean for states and for individuals covered by Medicaid and for students in schools,” Dwyer said. “Some of these cuts are immediate and some go into effect over time.” 

Republican lawmakers, though, argue they’re actually Medicaid recipients by removing undocumented immigrants and others they say never should have had access in the first place.

While there weren’t any provisions in the bill that directly slash school-based Medicaid services, the 20-plus Medicaid provisions it does include will ultimately place immense financial pressure on states to make up for the lost funds, which will have trickle-down impacts on schools, according to Dwyer.

In response, states will either have to raise taxes, or make further cuts within their Medicaid programs — the more likely option, Dwyer said. They could also look to backfill budget shortfalls by slashing other school-based programs.

“It’s just hard to imagine a scenario where states are faced with these levels of cuts, and individuals across the program aren’t impacted,” she said. 

School-based Medicaid makes up less than 1% of the overall program’s budget, but is still the fourth-largest federal funding stream for districts and allows them to pay for a swath of resources, including therapies for students with disabilities, school nurses, mental health care and specialized equipment, such as wheelchairs. 

The loss of funds will significantly impact how schools are able to cover mandatory services under the Individuals with Disabilities Education Act, according to Mia Ives-Rublee, the senior director for the at the Center for American Progress, a left-of-center think tank.

Kids who are eligible for Medicaid through expansions or waivers — state-based mechanisms that widen access to some people who wouldn’t normally qualify — are particularly at risk of losing services, since their eligibility isn’t required by federal law, said Ives-Rublee. 

But, she added, children will largely remain more protected than adults since a number of pediatric services are mandated at the federal level, including preventative screenings, check-ups and vision and hearing services. 

Still, if fewer children are enrolled in Medicaid overall, it will reduce the pool of money that goes towards school-based services leading to fewer resources and providers.

“What we will start seeing, and what we’ve seen in previous states, is that there will be a chunk of people who will just lose eligibility … because they either don’t get the information about the new paperwork requirements, they don’t understand that they now have to do check-ins twice a year [to determine eligibility vs. once a year] … and they might miss a recertification process,” Ives-Rublee added.

The changes could also result in fewer social workers or school-based psychologists and decreased access to health care — especially in rural and urban communities, according to a opposing any proposed cuts that was spearheaded by the Medicaid in Schools Coalition and signed by 65 organizations.

of districts use Medicaid funding to pay for the salaries of health professionals, according to 2017 data. And — 40 million — are now insured through Medicaid or the Children’s Health Insurance Program.

In Alabama, where Bower sees patients, over are enrolled in these programs.

“If you put all the kids in the country together, they’re the largest group of impoverished people,” said Bowen, who also serves as the president of the National Association of Pediatric Nurse Practitioners, “and they have no political voice … They rely on adults to hopefully do the right thing so that they can grow up and be healthy and contribute to this country …. but if they’re sick, they’re hungry, they can’t be educated. It’s an all-around impact.”

These impacts will be challenging to track, though, as they play out over the next decade, experts warn — especially less tangible ones like the amount of time states will spend trying to untangle how to implement the bill’s complex provisions.

“We’re in for a long haul here,” said Dwyer. “A lot of these changes aren’t going to be overnight. They’re going to be over the next months and years to come. And so I think just documenting what’s happening, what’s working [and] where pressures are coming up will be really important.”

The , signed by 65 organizations, was spearheaded by the Medicaid in the Schools Coalition, which advocates to protect and improve school-based Medicaid programs, which primarily serve students with disabilities and those living in poverty.

“Any cuts to Medicaid would reduce care for children with disabilities, undermine efforts to address the mental health crisis and exacerbate workforce shortages of school health providers,” said Jessie Mandle, the national program director at the and coalition co-chair. “Strong school-based Medicaid programs … rely on a strong Medicaid program overall, and so cutting Medicaid is equivalent to cutting school district budgets.”

Schools receive about $7.5 billion annually from , a popular joint federal and state health program that insures nearly 70 million Americans, most of whom are low-income. For more than 30 years, it’s paid for services in schools for students with disabilities as well as low-income students.

While President Trump said this week that Medicare, Medicaid and Social Security would in the GOP’s quest to deliver $4.5 trillion in tax cuts and beefed-up border security, in Medicaid funding decreases are being eyed in the House.

School-based Medicaid makes up less than 1% of the overall program’s budget, but is still the fourth-largest funding stream for districts and allows them to pay for a swath of resources, including therapies for students with disabilities, school nurses, mental health care and specialized equipment, such as wheelchairs. 

of districts use Medicaid funding to pay for the salaries of health professionals, according to 2017 data. New data forthcoming from The Healthy Schools Campaign suggests that the number is now even higher, Mandle told ����Ӱ��. 

And — 40 million — are now insured through Medicaid or the , which provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. Previous that improving children’s health improves their classroom performance.

Meanwhile, the political confusion over whether Medicaid will be protected has done little to quell anxiety that the funding might be in jeopardy. 

A Feb. 19 statement to from White House spokesperson Kush Desai attempted to reconcile Trump’s comments shielding Medicaid with his support for the proposed House budget that targets it: “The Trump administration is committed to protecting Medicare and Medicaid while slashing the waste, fraud, and abuse within those programs — reforms that will increase efficiency and improve care for beneficiaries.”

Any spending caps or reductions to the federal match would shift the bulk of the mandated costs of providing health care coverage to states, according to the coalition’s letter. This could have “devastating” effects, leading to a cut in services for all students — not just those with disabilities — or increased local taxes. 

On the ground, this could result in fewer social workers or school-based psychologists, decreased access to health care — especially in rural and urban communities, a loss of critical supplies that allow children with disabilities to access the same curricular as their peers and noncompliance with the Individuals with Disabilities Education Act, the coalition states.

“We have a very underfunded special education system,” said Sasha Pudelski, director of advocacy at and coalition co-chair, “and this Medicaid reimbursement is a critical source of funding.”

“Trying to find the money within our local education budget to fill in gaps where Medicaid currently reimburses districts would be — in this funding environment in particular — an enormous challenge,” she continued.

Silvia Yee, policy director at the , which co-signed the letter, said it’s particularly important that many of these health-related services are available in schools because they are widely trusted community hubs and family touchpoints. 

The burden of cuts would be felt particularly by vulnerable families, she added: “The more you reduce the available resources to a lower-income family, the more you’re potentially digging a pit for that family, and it’s very hard to dig out of.”

Yee also noted that a rollback in federal funding could make it more challenging for students with disabilities to learn in an integrated setting with their peers, setting them up for “segregation for the rest of their lives.”

“All of these services can and should work together to help us achieve integration that’s not a burden on teachers [and] not a burden on schools,” she said. “Helping take care of children’s medical needs in school is a step forward. Taking that away is such a step backward.”