Medicaid Cuts in Trump Tax Bill Spark Fears for Child Health, School Services

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In a few weeks, Felesia Bowen will hop in a van and begin driving across Alabama, visiting communities that struggle to access primary health care. As Bowen zigzags across the state, her vehicle — a mobile health care unit — will also serve as the nurse practitioner’s office as she brings medical services to women and children.

But after this weekend, when President Donald Trump signed into law the “One Big Beautiful Bill Act,” 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, nearly 900-page tax bill, 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 Congressional Budget Office.

Cuts to the Medicaid budget will have “just tremendous impacts,” Bowen added. Schools receive about $7.5 billion annually from Medicaid, 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 Children’s Health Insurance Program, 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 protecting the most vulnerable 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 Disability Justice Initiative 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 February letter opposing any proposed cuts that was spearheaded by the Medicaid in Schools Coalition and signed by 65 organizations.

Almost 70% of districts use Medicaid funding to pay for the salaries of health professionals, according to 2017 data. And about half of the nation’s kids — 40 million — are now insured through Medicaid or the Children’s Health Insurance Program.

In Alabama, where Bower sees patients, over 670,000 kids 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.”

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