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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 鈥� a mobile health care unit 鈥� 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 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.

鈥淏efore they had insurance, but then they couldn’t get to the provider,鈥� Bowen said. 鈥淣ow you’ll have providers coming out 鈥� but they won’t have the insurance.鈥�

Experts say Bowen鈥檚 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鈥檚 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 鈥渏ust tremendous impacts,鈥� 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鈥檚 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鈥檚 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鈥� ability to raise their share of Medicaid funding to new federal limits on eligibility 鈥� including work requirements for parents of kids 14 years or older 鈥� 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鈥檚 Center for Children and Families.

鈥淟ike many, we鈥檙e still unpacking exactly what this will mean for states and for individuals covered by Medicaid and for students in schools,鈥� Dwyer said. 鈥淪ome of these cuts are immediate and some go into effect over time.鈥� 

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

While there weren鈥檛 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 鈥� the more likely option, Dwyer said. They could also look to backfill budget shortfalls by slashing other school-based programs.

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

School-based Medicaid makes up less than 1% of the overall program鈥檚 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 鈥� state-based mechanisms that widen access to some people who wouldn鈥檛 normally qualify 鈥� are particularly at risk of losing services, since their eligibility isn鈥檛 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.

鈥淲hat 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 鈥� 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] 鈥� and they might miss a recertification process,鈥� Ives-Rublee added.

The changes could also result in fewer social workers or school-based psychologists and decreased access to health care 鈥� 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 鈥� 40 million 鈥� are now insured through Medicaid or the Children鈥檚 Health Insurance Program.

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

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

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

鈥淲e鈥檙e in for a long haul here,鈥� said Dwyer. 鈥淎 lot of these changes aren鈥檛 going to be overnight. They鈥檙e 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.鈥�

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