Jessie Mandle, National Program Director, Healthy Schools Campaign
“Due to the remote area we serve, our students have little to no access to medical services other than those provided in schools.” — Superintendent from a rural school district in Michigan
Schools are essential places for children to access health services. An estimated 40 percent of school-aged children have at least one chronic health condition (National Survey of Children’s Health, 2019). Among low-income children with special health care needs, approximately 87 percent do not receive necessary care, primarily due to financial costs and limited access (Child and Adolescent Health Measurement Initiative, 2022). Providing health care at school, where children spend most of their days, is crucial to addressing these concerns.
School health services encompass physical, behavioral, and mental health care that can be delivered by school health staff, such as school nurses, social workers and speech-language pathologists, as well as through school-based health centers and partnerships with local health organizations. Decades of research have shown that schools provide essential care that supports children’s short and long-term health and academic outcomes (Leroy et al., 2016).
Medicaid and School Health Funding
Medicaid plays a key role in funding school health services, spending more than $8 billion annually, according to an analysis of the most recent available data (Centers for Medicare and Medicaid Services, 2024).
Over the past decade, states and school districts have leveraged federal opportunities created with bipartisan support to increase Medicaid reimbursement (Mandle, 2024). This includes updating state Medicaid plans to 1) expand the types of Medicaid-covered school health services and providers eligible to bill Medicaid and 2) ensure schools can bill for all services provided to all Medicaid-enrolled students, not just the services included in a student’s Individualized Education Plan (IEP). This has led to a greater number of students receiving a broader range of care, including mental health services.
How Medicaid Cuts Will Impact Schools
The federal reconciliation bill signed into law in July 2025 (H.R.1) cuts almost $1 trillion in federal funding from Medicaid over the next decade. While H.R.1 does not place limits on the school Medicaid program, all states will face considerable decreases in the amount of federal Medicaid funding they receive, which is likely to cause significant budget gaps that will force states to draw from general funds, raise taxes, and/or cut Medicaid benefits. This puts the school Medicaid program at risk.
In 2025, Healthy Schools Campaign (HSC), partnering with four other national organizations, conducted a national survey of 1,400 school district leaders about the impact of Medicaid cuts on student access to health care, including mental and behavioral health services and substance use prevention services (Association of School Business Officials International et al., 2025). The majority of respondents stated that reduced federal funding would lead to reductions in school health staffing, health services, and supports necessary for learning, including fewer resources for students with disabilities, which would negatively impact the health and well-being of students and their communities.
Rural districts are particularly at risk, as they have a higher proportion of students covered by Medicaid compared to those in metropolitan areas, and schools are more likely to serve as the primary health care provider (Georgetown University McCourt School of Public Policy, 2025). “In rural Oklahoma, there are not adequate services for students outside the school system, especially for students with Medicaid,” a school psychologist shared in the survey. “Parents and students rely on the school districts to provide these services.”
Among the survey findings:
- 80 percent of respondents expect reductions to school health staff and personnel, including layoffs
- 70 percent expect reductions to mental and behavioral health services
- 90 percent expect reductions in programs and services across their district’s budget, including those outside of health services
Survey respondents also reported that Medicaid cuts would impact attendance and academic outcomes, as students with unmet health needs are more likely to miss school or have trouble learning, and add to families’ financial and emotional strain.
“Families are worried,” wrote a speech-language pathologist in rural Wisconsin. “It is hard enough to care for and support a student who has significant needs. Parents should not have to worry about losing financial support for necessary therapy services and access to appropriate medical care.”
Moving Forward to Support States, Schools & Students
Education and health advocates at all levels of government are working to promote and protect school Medicaid as a vital component of children’s health and well-being. At the national level, HSC is a proud co-convener of the Medicaid in Schools Coalition, representing more than 65 health and education organizations committed to advancing and protecting Medicaid and its critical role in schools.
The coalition educates policymakers about the role of school Medicaid in helping students access the health services they need (and may not otherwise receive), including health screenings for vision, hearing, and mental health issues, as well as the urgency of maintaining federal technical assistance to ensure states implement comprehensive and compliant school Medicaid programs.
Encourage Collaboration Among School Districts and State Medicaid and Education Agencies
At the state and local district levels, it is imperative for state agencies, school districts, and partners to collaborate across health and education sectors. Healthy Students, Promising Futures (HSPF), a national program led by HSC, has supported states and school districts for nearly a decade in leveraging Medicaid funding to meet the health needs of students.
The HSPF Learning Collaborative, which represents more than 30 states and 50 school districts, meets regularly for peer learning sessions and other meetings that enable members to ask questions of school Medicaid policy experts, share best practices and problem-solve common concerns. Each state team includes representatives from state Medicaid and education agencies and at least two school districts.
This coordination across agencies and levels of governance is a best practice for protecting Medicaid and strengthening school health services. The HSPF initiative also regularly develops reports, policy briefs, and webinars to help states and school districts implement, improve and sustain effective school Medicaid programs.
Help States Maximize School Medicaid Funding
As states face reductions in Medicaid and education funding, they must maximize school Medicaid reimbursement, especially since this funding can be reinvested in school health services and used to hire school health providers and offer more types of health services that students need.
Some states are well-positioned to receive maximum reimbursement (HSPF, 2023). They have updated their school Medicaid program in alignment with federal policy, which allows reimbursement of all medically necessary covered services, including mental and behavioral health services, for all students enrolled in Medicaid.
However, many states are still receiving only a trickle of the reimbursement funds for which they are eligible. These states have not yet allowed school districts to seek reimbursement for the full range of Medicaid-covered school health provider types and services.
HSPF has developed a series of policy actions to help states comprehensively expand their school Medicaid program and maximize Medicaid reimbursement (HSPF, 2024a). These policy actions, along with implementation resources, can help states and school districts sustain effective school Medicaid programs and mitigate the harms that federal cuts will cause (HSPF, 2024b).
Increase Medicaid Outreach and Enrollment Support
H.R.1 added new obstacles for Medicaid-eligible children to enroll in and maintain Medicaid coverage. It also created new eligibility requirements for immigrant children and children living in mixed-status families. These barriers will result in fewer students enrolled in Medicaid, putting children’s health at risk and leaving less money for the school Medicaid program.
School districts will need to increase their outreach and enrollment efforts to help students maintain coverage and ensure that schools receive reimbursement for the services they provide. To achieve this, school districts can utilize Medicaid funds for outreach and enrollment and build partnerships with health care advocates and Medicaid coalitions to share up-to-date information with families and support streamlined enrollment and renewal pathways.
Document the Impact of State and School District Budget Actions and Impact
Finally, as these changes and cuts occur, documenting the impact on student health and school district budgets is crucial. Because states and school districts will undergo and respond to cuts on different timelines, health and education advocates must stay closely engaged and involved as changes unfold. On-the-ground networks such as the HSPF Learning Collaborative can collect and share information, track trends, and utilize cross-state learning to identify strategies for combating these changes and strengthening programs.
Opportunity for Funders
We are at a pivotal moment, working not only to safeguard the public policies and systems necessary to protect children’s health, but to envision even stronger and more responsive policies and systems so we can effectively meet the needs of students and families.
Philanthropic organizations and leaders are essential partners in the work ahead. Protecting and strengthening school health services while championing Medicaid’s integral role in supporting children’s health is key to building an equitable and sustainable health care delivery system where all children can access the care they need to thrive.
References
Association of School Business Officials International, Council of Administrators of Special Education, Healthy Schools Campaign, National Alliance for Medicaid in Education, The School Superintendents Association. How Medicaid Cuts Will Harm Students and Schools: Results of a Nationwide Survey of School District Leaders. March 2025.
Centers for Medicare and Medicaid Services Financial Management Report for FY 2024; Medicaid Budget and Expenditure System/State Children’s Health Insurance Program Budget and Expenditure System (MBES/CBES).
Child and Adolescent Health Measurement Initiative. 2021-2022 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Accessed October 8, 2025.
Georgetown University McCourt School of Public Policy, Center for Children & Families. Medicaid Coverage in Metro and Small Town/Rural Area Counties, 2023. Jan. 14, 2025.
Healthy Students, Promising Futures. School Medicaid Expansion: How (and How Many) States Have Taken Action to Increase School Health Access and Funding. Oct. 17, 2023.
Healthy Students, Promising Futures. State Policy Actions: 10 Steps to Maximize Medicaid for School Health Services. Nov. 4, 2024a.
Healthy Students, Promising Futures. START: State Tools and Resources to Advance School Medicaid. 2024b.
Leroy ZC, Wallin R, Lee S. The Role of School Health Services in Addressing the Needs of Students With Chronic Health Conditions: A Systematic Review. The Journal of School Nursing. 2016;33(1):64-72. doi:10.1177/1059840516678909
Mandle J. HSC Documents Funding Boost for School Health Services. December 16, 2024.
National Survey of Children’s Health. NSCH 2018–19: Number of Current or Lifelong Health Conditions, Nationwide, Age in 3 Groups. Accessed February 24, 2021.