July 2025

Federal Policy on the Social Safety Net

Early Action for States in Response to Recent Changes  

Indira Dammu and Bonnie O’Keefe

Note: This memo is part of a Bellwether series designed to help education advocates and state leaders — including those in governors’ offices, state education agencies and boards, and state legislatures — respond to shifts in policy and power at the federal level. This memo reflects federal policy developments through July 4, 2025.

Summary

The U.S. government has a long-standing federal family safety net that supports individuals and their families experiencing economic hardship. Examples of these programs include Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), Medicaid, and the Supplemental Nutrition Assistance Program (SNAP). Programs such as Title I, Part A of the Elementary and Secondary Education Act and Head Start/Early Head Start also provide additional targeted supports for economically disadvantaged students and children in pre-k through Grade 12 schools and early learning settings. During President Donald Trump’s first term, the administration proposed several funding cuts and programmatic changes to these federal family safety net programs, many of which were enacted.1 Since President Trump’s reelection in 2024, his administration has proposed additional changes that would impact coverage and eligibility requirements for millions of individuals nationwide. These changes are included in H.R. 1, the 2025 Budget Reconciliation Bill (nicknamed the “One Big Beautiful Bill Act”), which passed both chambers of the United States Congress and was signed into law by President Trump on July 4, 2025.

This memo focuses on changes to two federal family safety net programs — Medicaid and SNAP — and the potential direct and indirect impact on K-12 public schools and their students. Medicaid provides health insurance coverage for low-income individuals and their families, and SNAP provides funding for families to supplement their grocery purchases. Both programs enroll millions of children, ensuring they have access to health services and nutritious food. Medicaid also provides additional funding to states to operate school-based programs. Although these school-based programs represent a very small share of total Medicaid funding, they are one of the largest sources of federal funding for school districts.

This memo outlines some key policy changes enacted by federal policymakers, including tightening enrollment, expanding work requirements, and, in the case of SNAP, newly requiring states to contribute a match for funding. This memo also explores the impact of these changes on K-12 students and proactive steps that state or local policymakers can take to plan.

Overview of Medicaid and SNAP for Children and Schools

Medicaid 

Signed into law in 1965 as part of the Social Security Act, Medicaid is the largest federal program that provides health services to low-income individuals.2 Federal law requires certain groups to be covered (e.g., individuals receiving SSI and children in foster care). States can choose to cover additional groups beyond these federal requirements as a result of the Affordable Care Act (ACA). Specifically, the ACA allows states to opt in to expand Medicaid eligibility to include more low-income adults, a group referred to as “expansion adults.”

About 71.4 million people in the U.S. are enrolled in Medicaid, and of those, approximately 30 million (42%) are children.3 A separate program, the Children’s Health Insurance Program (CHIP), provides health coverage for children in families with incomes that are too high to qualify for Medicaid, but not enough to afford private coverage.4 Medicaid is the fourth-largest source of federal funding for K-12 public schools, providing about $7.5 billion annually for school-based Medicaid services.5

School-based Medicaid services cover a broad range of health services for all Medicaid-eligible students. For example, Medicaid funding can be used to pay for eligible services for students with disabilities, based on their individualized education program (IEP).6 Examples of services that could be funded through Medicaid include speech-language pathology and physical therapy.7 Since 2014, a clarification in federal policy has allowed states to receive federal Medicaid reimbursement for all eligible health services provided to all Medicaid-enrolled students — instead of covering only services in a student’s IEP.8 As of October 2023, 25 states have taken advantage of this federal flexibility and amended their state plans or expanded coverage to include school-based services that are not part of a student’s IEP.9

School-based Medicaid also covers the Early and Periodic Screening, Diagnostic, and Treatment benefit that is provided to all Medicaid-eligible children under the age of 21, which includes vision services and dental care.10 Schools can also use Medicaid funding to cover certain administrative costs associated with delivering health services. Examples of such costs include outreach to eligible students and families, referrals, and transportation.11

Medicaid eligibility for children ages 6 to 18 varies by state, ranging from 133% to 319% of the Federal Poverty Line.12 Undocumented children are not eligible for Medicaid, but some states provide them with health coverage using state funds only.13

Medicaid is a federal-state cost sharing program, and the Federal Medical Assistance Percentage (FMAP) is used to determine the federal and state share of expenditures. FMAP rates have a statutory minimum of 50% and a statutory maximum of 83%.14 For states that choose to expand Medicaid coverage through the ACA, the federal government covers a higher match rate of 90% of the cost of Medicaid coverage.15 Overall, states spend about 15% of every state dollar on Medicaid.16 With respect to school-based Medicaid services, many states require K-12 districts to cover the state’s share of the cost, and districts are reimbursed for the federal government’s share.17 

SNAP

SNAP was authorized as part of the Food Stamp Act of 1964 and is administered by the U.S. Department of Agriculture.18 SNAP provides monthly funds to low-income individuals to pay for grocery purchases. In fiscal year (FY) 2023, the federal government allocated $112.8 billion in funding for SNAP.19 In FY22, 28% of SNAP participants were children ages 5 to 17.20 Children who live in households that receive SNAP benefits can be directly certified for free meals at school without the need for a separate application.21 States must directly certify at least 95% of school-aged children living in households receiving SNAP.22 A student household’s SNAP participation also counts toward a school or district’s participation in the Community Eligibility Provision (CEP). The CEP allows an eligible school or district to provide free meals to all enrolled students without the need for additional applications.23

The federal government covers 100% of the cost of SNAP benefits and reimburses 50% of a state’s administrative costs to run the program.24 Eligibility for SNAP is based on both gross income (total household income before deductions) and net income (gross income after deductions).25 For example, for a family household of four, the gross monthly income eligibility level for SNAP is up to $3,380 and net income is up to $2,600.26 To receive SNAP benefits, most adults (with exceptions written in law) must also meet a set of work requirements. 

Recent Federal Changes to Medicaid and SNAP

After months of debate in Congress, H.R. 1 was signed into law by President Trump on July 4, 2025. Among other things, it makes several changes to Medicaid and SNAP. These changes are summarized below, with a focus on those that impact children and K-12 public schools.

 
Program
 
Summary of Changes
 
Estimate of Federal Cuts

Medicaid

 
  • Implements stricter, mandatory Medicaid work reporting requirements in all states for most expansion adults ages 19 through 64, starting in FY27.27 Parents with children under the age of 13 would be exempt from these work reporting requirements.28 However, this requirement could still lead some parents or caretakers to lose their Medicaid coverage, which may also impact coverage for their children.29
  • Eliminates the temporary financial incentive that was part of the American Rescue Plan Act for states that had newly adopted ACA expansion.30 Currently, 40 states and the District of Columbia have implemented Medicaid expansion.31
  • Impacts school-based Medicaid programs and student eligibility. Most states currently carve their school-based Medicaid program out of traditional Medicaid, and the state Medicaid agency directly reimburses districts.32 For these states, schools will not be directly impacted by other Medicaid cuts. However, for the few states that use a school-based Medicaid program that is part of a contract with a managed care organization (California, Minnesota, South Carolina, Tennessee, and Washington), changes to Medicaid could have significant impacts on their school-based Medicaid programs. Additionally, in all states and the District of Columbia, schools will feel the impact of fewer students being Medicaid eligible.
  • Analysis based on Congressional Budget Office (CBO) estimates shows that federal Medicaid and CHIP spending would decline by $1.02 trillion over the next 10 years.33
  • A preliminary CBO estimate shows that approximately 11.8 million additional people could be uninsured in 2034.34 Specific impacts on school-aged children are not yet known.
 SNAP
  • Expands work requirements, including adults with children ages 14 or older.35 The increase in population affected by work requirements would lead to some households with children losing SNAP benefits.
  • Requires states to contribute to the costs of SNAP benefits based on their payment error rates, which measures the accuracy of states’ eligibility and benefit determinations.36 Beginning in FY28, states will be required to pay between 5% and 15% of SNAP benefits based on their error rates, while states with an error rate of less than 6% would continue receiving 100% of the federal share.37 In FY24, only nine states reported an error rate of less than 6%.38 Starting in FY27, the federal government’s reimbursement of administrative costs would decrease from 50% to 25%.39 States could choose to modify benefits or eligibility to reduce costs, which could lower SNAP participation among households with children.
  • Eliminates Nutrition Education and Obesity Prevention Grant Program (also known as SNAP-Ed), which delivers formula grant funding for states to provide nutrition and fitness education programs in various community sites including public schools.40
  • The CBO estimates that federal funding for nutrition programs, which includes SNAP, would reduce by around $186 billion between 2025 and 2034.41
  • Increased work requirements could reduce SNAP participation by around 900,000 parents and other caregivers, which could also impact 800,000 children ages 14 to 17 who live with them.42

 

 

 

 

 

Impact of Federal Changes on Children and K-12 Public Schools

Cuts to the federal share of Medicaid spending would have some downstream effects on state budgets, which would in turn affect K-12 public school funding. Given that federal law requires states to provide certain benefits for all eligible Medicaid enrollees, regardless of economic outlook, federal Medicaid reductions would shift costs to states and crowd out state revenues available for other expenditures, including public education.43 An analysis by the CBO found that federal cuts to Medicaid could lead to states responding in four general ways:44

  • Spend more state revenues on Medicaid to cover the funding gap, through a mix of increased revenue and reduced spending on other programs.
  • Reduce payment rates to health care providers.
  • Limit the scope or amount of optional benefits.
  • Decrease overall enrollment in Medicaid.

A May 2025 CBO analysis on the U.S. House of Representatives’ version of the reconciliation bill found that state spending would increase by $78 billion to account for changes in state contributions to SNAP and Medicaid and for state tax and spending policies necessary to finance this additional spending.45 Because states will have to take on the burden of financing a greater share of Medicaid and SNAP spending under the new law, advocates are concerned about the impact on children from low-income households. Some of the concerns include states possibly cutting eligibility, services, and benefits for children.46

Apart from the impact on state budgets and K-12 education budgets, cuts to Medicaid and SNAP would also impact students and their opportunity to learn in school. Research has found that access to health care and nutrition has a positive impact on students’ education outcomes, in addition to their overall health.47

  • School-based health care access reduces the likelihood that a student is chronically absent by 29% and reduces the number of days absent by about 10%.48
  • Children who receive health services through Medicaid have positive outcomes that extend long past their coverage. For example, Medicaid-eligible children are more likely to graduate from college and have increased earnings in adulthood.49
  • Universal free meal programs in schools have a positive impact on math and English language arts scores for all students.50
  • SNAP participation reduces the likelihood of heart disease and diabetes in adulthood and increases the likelihood of completing high school.51

Beyond the changes to Medicaid and SNAP that directly affect children and families, provisions in H.R. 1 also impact state programs that rely on federal data and definitions to determine funding and eligibility for other school-related programs. For example, several states use SNAP and Medicaid participation to directly certify students for free meals in schools, a process called “direct certification.” Direct certification lowers barriers to participation by removing additional paperwork. Direct certification also reduces the stigma associated with a child’s eligibility for free or reduced-price meals in school.52 An early analysis by the Urban Institute on the U.S. House of Representatives’ version of the reconciliation bill showed that at least 832,000 students would no longer automatically qualify for free school meals through direct certification of SNAP eligibility if the proposed changes were enacted, and they would have to fill out a meal application form instead.53

Several states also rely on direct certification counts to qualify students as low income in their state school funding formulas. In those states, eligibility restrictions for Medicaid and SNAP would reduce counts of students in need, and public schools serving those students would qualify for less state formula funding. To preserve school funding targeting low-income students and communities, these states must either adjust formulas or determine alternate ways of estimating student poverty.

Actions State Leaders Can Take

As specified in H.R. 1, cuts to Medicaid and SNAP will impact children, their families, and K-12 districts across the country in a variety of ways. State leaders — including policymakers, district leaders, and advocates — can take a range of actions now in anticipation of these future cuts:

  • Strengthen or pursue additional revenue sources to strategically plan for federal cuts. Most states are expected to meet their revenue forecasts for FY25, but there is a likelihood that more states will experience budget deficits than in the past few years.54 Rainy day funds will allow states to address only temporary funding gaps, not the long-term ones posed by Medicaid and SNAP cuts. State policymakers should consider how to shore up revenue sources, which could include avoiding cuts to critical state revenue sources (e.g., the personal income tax or sales tax).
  • Improve state counts of economically disadvantaged students. All states currently use SNAP enrollment data to directly certify students as low income, and a handful of states use Medicaid data as well. Some states also allow districts to use additional data points, such as the number of children who live in households receiving TANF, participate in the Food Distribution Program on Indian Reservations, are enrolled in foster care or Head Start, or experience homelessness or are migrant, to determine eligibility for free school meals and other additional state funding for schools.55 More states should consider incorporating additional data into their counts of economically disadvantaged students to accurately identify eligible students, even with federal cuts or eligibility changes, and align that with their state’s funding for economically disadvantaged students.
  • Expand school-based Medicaid programs to address health care coverage gaps for children. Cuts to Medicaid overall could lead to households losing health care coverage, making children even more reliant on school-based health services. Because most states carve the school Medicaid program out of the rest of Medicaid, expanding the school-based program may be an important way to add additional services that will not be directly impacted by Medicaid cuts. Twenty-five states have also taken advantage of federal flexibility and now reimburse school districts for delivering health services to all students enrolled in Medicaid, not just those with an IEP.56 In 2023, the Centers for Medicare & Medicaid Services (CMS) issued guidance on this federal flexibility and required states to submit state plan amendments detailing compliance by July 2026.57 In 2024, CMS also announced a $50 million grant program that provides states with additional funding to expand school-based health services, although it is unclear if this grant will continue with the Trump administration.58 States should take advantage of this increased flexibility and develop plans to expand school-based Medicaid programs. For states that have already expanded services, there are continued opportunities to improve processes such as billing and reimbursement.59
  • Strengthen collaboration between state education agencies (SEAs) and state Medicaid agencies. SEAs and state Medicaid agencies often experience challenges with collaboration because they are navigating complex policies with different data systems. Some strategies to improve collaboration between SEAs and state Medicaid agencies include bringing together a team to review and revise state Medicaid plans and develop joint guidance for K-12 districts.60

Additional Considerations for State Policymakers

Medicaid and SNAP cuts will place additional pressure on state policymakers as they work to balance fulfilling federal mandates for coverage while also funding other public services. Over the coming months and years, state policymakers will likely have to make difficult decisions that could impact students, their families, and public schools. In preparation for these decisions, policymakers should consider the following set of strategic questions:

Stakeholder Engagement

  • How are state policymakers informing K-12 district leaders about changes at the federal level and the impact on students? 
  • What opportunities are available for social service agencies and other community partners to provide input on state Medicaid plans and help address gaps in the social safety net for students and their families? 

Policy and Budget

  • How does the state currently identify students from low-income households? Are there alternative measures that could better determine students in need? Which state programs rely on federal data and eligibility for critical pieces of state-run programs?
  • How might states find alternative or supplementary data and calculation methods if federal program eligibility shifts?

Implementation and Assistance

  • What are all the funding streams available at the state and federal levels to support student services, and does the state provide a single source document on how to access and intertwine them all?
  • What is the existing state capacity to support K-12 districts in taking advantage of federal flexibility, including reimbursement for providing school-based services to Medicaid-enrolled students?

 

OTHER RESOURCES

Endnotes

  1. Robert Greenstein, Trump Administration Budgets and Programs for People of Limited Means (Brookings, September 3, 2024), https://www.brookings.edu/articles/trump-administration-budgets-and-programs-for-people-of-limited-means/.
  2. “Program History and Prior Initiatives,” Centers for Medicare & Medicaid Services, Medicaid.gov, https://www.medicaid.gov/about-us/program-history.
  3. January 2025: Medicaid and CHIP Eligibility Operations and Enrollment Snapshot (Centers for Medicare & Medicaid Services, January 2025), https://www.medicaid.gov/resources-for-states/downloads/eligib-oper-and-enrol-snap-january2025.pdf.
  4. Medicaid and Children’s Health Insurance Program (CHIP) Overview (Department of Health & Human Services, September 2024), https://www.cms.gov/marketplace/technical-assistance-resources/fast-facts-medicaid-chip.pdf.
  5. Jessie Mandle, Alison Paxson, and Lena O’Rourke, How Medicaid Cuts Will Harm Students & Schools: Results of a Nationwide Survey of School District Leaders (AASA: The School Superintendents Association, March 2025), https://www.aasa.org/resources/resource/how-medicaid-cuts-will-harm-students-schools.
  6. Delivering Services in School-Based Settings: A Comprehensive Guide to Medicaid Services and Administrative Claiming (Centers for Medicare & Medicaid Services, 2023), https://www.medicaid.gov/medicaid/financial-management/downloads/sbs-guide-medicaid-services-administrative-claiming.pdf.
  7. “FAQs About Medicaid in Special Education,” Frontline Education, https://www.frontlineeducation.com/blog/medicaid-special-education/.
  8. Memorandum, “Re: Medicaid Payment for Services Provided Without Charge (Free Care),” from Cindy Mann, director of Centers for Medicare & Medicaid Services, Department of Health & Human Services, to state Medicaid directors, SMD# 14-006, December 15, 2014, https://www.medicaid.gov/federal-policy-guidance/downloads/smd-medicaid-payment-for-services-provided-without-charge-free-care.pdf; Getting to Know Your State’s School Medicaid Program: Overview for State Education Agencies and Other Partners (Healthy Schools Campaign, May 2024), https://healthystudentspromisingfutures.org/wp-content/uploads/2024/05/Getting-to-Know-Your-States-School-Medicaid-Program.pdf.
  9. School Medicaid Expansion: How (and How Many) States Have Taken Action to Increase School Health Access and Funding (Healthy Schools Campaign, October 17, 2023), https://healthystudentspromisingfutures.org/wp-content/uploads/2023/10/Status-of-School-Medicaid-Expansion_-How-and-How-Many-States-Have-Taken-Action-to-Increase-School-Health-Access-and-Funding.pdf.
  10. Centers for Medicare & Medicaid Services, Delivering Services.
  11. School-Based Services for Students Enrolled in Medicaid, MACPAC Issue Brief (Medicaid and CHIP Payment and Access Commission, March 2024), https://www.macpac.gov/wp-content/uploads/2024/04/School-Based-Services-for-Students-Enrolled-in-Medicaid.pdf.
  12. “Medicaid, Children’s Health Insurance Program, & Basic Health Program Eligibility Levels,” Centers for Medicare & Medicaid Services, Medicaid.gov, https://www.medicaid.gov/medicaid/national-medicaid-chip-program-information/medicaid-childrens-health-insurance-program-basic-health-program-eligibility-levels.
  13. Leonardo Cuello, “The Truth About Medicaid Coverage for Immigrants – and the Looming Threats,” Say Ahhh! (blog), May 21, 2025, https://ccf.georgetown.edu/2025/05/21/the-truth-about-medicaid-coverage-for-immigrants-and-the-looming-threats/.
  14. Alison Mitchell, “Medicaid’s Federal Medical Assistance Percentage (FMAP)” (CRS Product No. R43847), Congress.gov, April 2, 2025, https://www.congress.gov/crs-product/R43847.
  15. Elizabeth Williams, Anna Mudumala, Robin Rudowitz, and Alice Burns, Medicaid Financing: The Basics (KFF, January 29, 2025), https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/.
  16. Justin Theal and Riley Judd, “The Share of State Budgets Spent on Medicaid Posts Largest Annual Increase in 20 Years,” Pew, June 16, 2025, https://www.pew.org/en/research-and-analysis/articles/2025/06/16/the-share-of-state-budgets-spent-on-medicaid-posts-largest-annual-increase-in-20-years.
  17. Healthy Schools Campaign, Getting to Know.
  18. Institute of Medicine and National Research Council, “2, History, Background, and Goals of the Supplemental Nutrition Assistance Program,” in Supplemental Nutrition Assistance Program: Examining the Evidence to Define Benefit Adequacy, ed. Julie A. Caswell and Ann L. Yaktine (National Academies Press, 2013), 27–56, https://www.ncbi.nlm.nih.gov/books/NBK206907/.
  19. Jordan W. Jones, “SNAP Benefit Spending Varied From FY 2020 to FY 2023 With Changes to Maximum Benefit Amounts and Emergency Allotments,” Charts of Note, July 31, 2024, https://www.ers.usda.gov/data-products/charts-of-note/chart-detail?chartId=109660.
  20. Jordan W. Jones, “Children Accounted for About 40 Percent of SNAP Participants in Fiscal Year 2022,” Charts of Note, July 22, 2024, https://www.ers.usda.gov/data-products/chart-gallery/chart-detail?chartId=58386.
  21. Emily Gutierrez, Changes to SNAP Could Reduce Student Access to Free School Meals (Urban Institute, May 20, 2025), https://www.urban.org/research/publication/changes-snap-could-reduce-student-access-free-school-meals.
  22. Direct Certification in the National School Lunch Program State Implementation Progress Report to Congress School Year 2017-2018 & School Year 2018-2019, June 2021 Research Summary (Food and Nutrition Service, U.S. Department of Agriculture, 2021), https://fns-prod.azureedge.us/sites/default/files/resource-files/NSLPDirectCertification2017-1.pdf.
  23. Memorandum, “Community Eligibility Provision: Guidance and Updated Q&As,” from Heather Hopwood, acting director of the School Meal Policy Division, Child Nutrition Programs, to the regional and state directors of the Child Nutrition Programs, SP 09-2024, Food and Nutrition Service, U.S. Department of Agriculture, February 6, 2024, https://www.fns.usda.gov/cn/cep-guidance-updated-qas#:~:text=FNS%20published%20a%20final%20rule,of%20CEP%20prior%20to%20electing.
  24. Randy Alison Aussenberg, “Supplemental Nutrition Assistance Program (SNAP) and Related Nutrition Programs in the House-Passed Budget Reconciliation Bill: In Brief” (CRS Product No. R48552), Congress.gov, May 30, 2025, https://www.congress.gov/crs-product/R48552.
  25. “SNAP Eligibility: Frequently Asked Questions,” Food and Nutrition Service, U.S. Department of Agriculture, updated June 2, 2025, https://www.fns.usda.gov/snap/recipient/eligibility#WhataretheSNAPincomelimits.
  26. Food and Nutrition Service, “SNAP Eligibility.”
  27. “Health Provisions in the 2025 Federal Budget Reconciliation Bill,” KFF, updated July 1, 2025, https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/.
  28. One Big Beautiful Bill Act, H.R. 1, 119th Cong. (2025), https://www.congress.gov/bill/119th-congress/house-bill/1/text.
  29. Edwin Park, Medicaid and CHIP Cuts in the House-Passed Reconciliation Bill Explained (Georgetown University Health Policy Institute, Center for Children and Families, May 27, 2025), https://ccf.georgetown.edu/2025/05/27/medicaid-and-chip-cuts-in-the-house-passed-reconciliation-bill-explained/.
  30. One Big Beautiful Bill Act, H.R. 1, 119th Cong. (2025).
  31. KFF, “Health Provisions.”
  32. Healthy Schools Campaign, Getting to Know.
  33. Edwin Park, “Congressional Budget Office Confirms Senate Republican Reconciliation Bill’s Medicaid Cuts Are More Draconian Than the House-Passed Bill,” Say Ahhh! (blog), June 29, 2025, https://ccf.georgetown.edu/2025/06/29/congressional-budget-office-confirms-senate-republican-reconciliation-bills-medicaid-cuts-are-more-draconian-than-the-house-passed-bill/.
  34. Cynthia Cox, “About 17 Million More People Could Be Uninsured Due to the Big Beautiful Bill and Other Policy Changes,” Quick Takes, KFF, July 1, 2025, https://www.kff.org/quick-take/about-17-million-more-people-could-be-uninsured-due-to-the-big-beautiful-bill-and-other-policy-changes/.
  35. One Big Beautiful Bill Act, H.R. 1, 119th Cong. (2025).
  36. “SNAP Payment Error Rates,” Food and Nutrition Service, U.S. Department of Agriculture, updated June 30, 2025, https://www.fns.usda.gov/snap/qc/per.
  37. One Big Beautiful Bill Act, H.R. 1, 119th Cong. (2025).
  38. “Supplemental Nutrition Assistance Program: Payment Error Rates Fiscal Year 2024,” Food and Nutrition Service, U.S. Department of Agriculture, June 30, 2025, https://fns-prod.azureedge.us/sites/default/files/resource-files/snap-fy24QC-PER.pdf.
  39. One Big Beautiful Bill Act, H.R. 1, 119th Cong. (2025).
  40. One Big Beautiful Bill Act, H.R. 1, 119th Cong. (2025).
  41. Avery Lotz, “Where SNAP Cuts in Trump’s ‘Big Beautiful Bill’ Could Hit Americans Hardest,” Axios, July 3, 2025, https://www.axios.com/2025/07/03/trump-big-beautiful-bill-snap.
  42. By the Numbers: Senate Republican Leadership’s Reconciliation Bill Takes Food Assistance Away From Millions of People (Center on Budget and Policy Priorities, updated June 30, 2025), https://www.cbpp.org/research/food-assistance/by-the-numbers-senate-republican-leaderships-reconciliation-bill-takes.
  43. Theal and Judd, “Share of State Budgets.”
  44. Phillip L. Swagel, director of the Congressional Budget Office, to Ron Wyden, ranking member, Committee on Finance, United States Senate, and Frank Pallone Jr., ranking member, Committee on Energy and Commerce, U.S. House of Representatives, “Re: Estimates for Medicaid Policy Options and State Responses,” May 7, 2025, https://www.cbo.gov/system/files/2025-05/Wyden-Pallone_Letter.pdf.
  45. Phillip L. Swagel, director of the Congressional Budget Office, to Brendan F. Boyle, ranking member, Committee on the Budget, U.S. House of Representatives, and Hakeem Jeffries, Democratic leader, U.S. House of Representatives, “Re: Preliminary Analysis of the Distributional Effects of the One Big Beautiful Bill Act,” May 20, 2025, https://www.cbo.gov/system/files/2025-05/61422-Reconciliation-Distributional-Analysis.pdf.
  46. Medicaid in Schools Coalition to Mike Johnson, John Thune, Hakeem Jeffries, and Chuck Schumer, “Re: Reconciliation Efforts Impacting School Based Medicaid Programs,” February 17, 2025, https://www.aasa.org/docs/default-source/advocacy/medicaid-in-schools-coalition-letter-feb-17-2025.pdf?sfvrsn=e5c086ac_3.
  47. Jane Rochmes, School-Based Healthcare and Academic Performance: Implications of Physical Health Services for Educational Outcomes and Inequality (Stanford, 2016), https://cepa.stanford.edu/content/school-based-healthcare-and-academic-performance-implications-physical-health-services-educational-outcomes-and-inequality; Jeannette R. Ickovics et al., “Health and Academic Achievement: Cumulative Effects of Health Assets on Standardized Test Scores Among Urban Youth in the United States,” The Journal of School Health 84, no. 1 (2014): 40–48, https://pmc.ncbi.nlm.nih.gov/articles/PMC4058503/; “Dietary Behavior and Academic Grades,” Healthy Schools, Centers for Disease Control and Prevention, July 19, 2024, https://www.cdc.gov/healthy-schools/health-academics/diet-grades.html.
  48. Sarah Komisarow and Steven W. Hemelt, “School-Based Health Care and Absenteeism: Evidence From Telemedicine,” Education Finance and Policy 19, no. 2 (2024): 252–282, https://doi.org/10.1162/edfp_a_00398.
  49. Elizabeth Ash, William Carrington, Rebecca Heller, and Grace Hwang, “Exploring the Effects of Medicaid During Childhood on the Economy and the Budget,” Working Paper No. 2023-07 (Congressional Budget Office, November 2023), https://www.cbo.gov/system/files/2023-10/59231-Medicaid.pdf; Alisa Chester and Joan Alker, Medicaid at 50: A Look at the Long-Term Benefits of Childhood Medicaid (Georgetown University Health Policy Institute, Center for Children and Families, July 2015), https://ccf.georgetown.edu/wp-content/uploads/2015/08/Medicaid-at-50_final.pdf.
  50. Amy Ellen Schwartz and Michah W. Rothbart, “Let Them Eat Lunch: The Impact of Universal Free Meals on Student Performance,” Working Paper No. 203 (Maxwell School Center for Policy Research, Syracuse University, revised July 2019), https://www.maxwell.syr.edu/docs/default-source/research/cpr/working-papers/wp-203-let-them-eat-lunch.pdf?sfvrsn=efae783d_8.
  51. Long-Term Benefits of the Supplemental Nutrition Assistance Program (Executive Office of the President of the United States, December 2015), https://obamawhitehouse.archives.gov/sites/whitehouse.gov/files/documents/SNAP_report_final_nonembargo.pdf.
  52. “What Is Direct Certification?,” Healthy School Food Collaborative (blog), https://www.thehealthyschoolfoodcollaborative.com/blog/what-is-direct-certification/.
  53. Gutierrez, Changes to SNAP.
  54. Erica MacKellar, “The State of State Budgets Is Stable for Now,” NCSL, May 6, 2025, https://www.ncsl.org/state-legislatures-news/details/the-state-of-state-budgets-is-stable-for-now.
  55. Direct Certification Improves Low-Income Student Access to School Meals: An Updated Guide to Direct Certification (Food Research & Action Center, November 2018), https://frac.org/wp-content/uploads/direct-cert-improves-low-income-school-meal-access.pdf.
  56. Healthy Schools Campaign, School Medicaid Expansion.
  57. “Federal Guidance on School Medicaid,” Healthy Students, Promising Futures, Healthy Schools Campaign, https://healthystudentspromisingfutures.org/federal-support/.
  58. Medicaid & CHIP, “CMS Announces $50 Million in Grants to Deliver Critical School-Based Health Services to Children,” press release, January 24, 2024, https://www.cms.gov/newsroom/press-releases/cms-announces-50-million-grants-deliver-critical-school-based-health-services-children.
  59. A Guide to Expanding Medicaid-Funded School Health Services (Healthy Schools Campaign, March 2022), https://healthystudentspromisingfutures.org/wp-content/uploads/2022/04/A-Guide-to-Expanding-Medicaid-Funded-School-Health-Services-2022-Update.pdf.
  60. Lisa Eisenberg and Ruthie Caparas, “Strategies for Expanding School-Based Health Services Through Medicaid,” Insights & Impact (blog), WestEd, February 16, 2024, https://www.wested.org/blog/expanding-school-based-health-services-through-medicaid/.

Acknowledgments, About the Authors, About Bellwether

Acknowledgments

Special thanks to Bellwether Senior Adviser Sarah Broome for her input and expertise specific to Medicaid. We would like to thank our Bellwether colleagues Jennifer O’Neal Schiess and Sophie Zamarripa for their input and Ashlie Scott and Dwan Dube for their support. Thank you to Amy Ribock, Kate Stein, Andy Jacob, McKenzie Maxson, Zoe Cuddy, Julie Nguyen, Mandy Berman, and Amber Walker for shepherding and disseminating this work, and to Super Copy Editors.

The contributions of these individuals and entities significantly enhanced our work; however, any errors in fact or analysis remain the responsibility of the authors.

About the Authors

Linea Koehler

Indira Dammu

Indira Dammu is an associate partner at Bellwether in the Policy and Evaluation practice area. She can be reached at indira.dammu@bellwether.org.

Alex Spurrier

Bonnie O'Keefe

Bonnie O’Keefe is a senior associate partner at Bellwether in the Policy and Evaluation practice area. She can be reached at bonnie.okeefe@bellwether.org.

Bellwether is a national nonprofit that exists to transform education to ensure systemically marginalized young people achieve outcomes that lead to fulfilling lives and flourishing communities. Founded in 2010, we work hand in hand with education leaders and organizations to accelerate their impact, inform and influence policy and program design, and share what we learn along the way. For more, visit bellwether.org.

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