ATLANTA – Children’s health care advocates say proposed cuts to Georgia’s insurance program for the poor will jeopardize access to basic medical services for the state’s youngest residents.

That’s because children make up the bulk of Medicaid enrollees in Georgia. Since the state is one of 19 that did not expand Medicaid under the Affordable Care Act, the program is mostly limited to children, the elderly and the disabled.

And in several counties, including rural communities that helped put Donald Trump in the White House, the program provides coverage for more than half the local children.

Advocates say these young rural Georgians, in particular, stand to lose the most under the long-awaited GOP proposal to overhaul Obamacare – one of Trump’s signature campaign pledges.

The plan proposes to cap Medicaid funding based on historical enrollment numbers, costing Georgia an estimated $1.9 billion in federal funding over time as lawmakers attempt to rein in Medicaid spending.

“Small-town hospitals and small-town pediatricians who are in high-Medicaid areas won’t be able to stay in business,” said Dr. Ben Spitalnick, who is president of the Georgia chapter of the American Academy of Pediatrics.

“If there’s a Medicaid cut, these doctors go out of business and then even children with private insurance in these areas don’t have access to a doctor,” said Spitalnick, who is also a Savannah pediatrician.

In non-expansion states such as Georgia, Medicaid is primarily a children’s program, says Voices for Georgia’s Children. The nonprofit estimates the cuts would affect 15.6 million children in states that did not expand the program.

In Georgia, more than 1.3 million children were on Medicaid as of last year. Patients 19 years old and younger made up about 66 percent of the state’s nearly 2 million Medicaid enrollees.

Medicaid funds more than half of the state’s births. It also provides access to preventative services such as immunizations, checkups and screenings that can help catch developmental issues early when they can be more easily treated.

“They need those services to grow into healthy, productive adults, and if you’re missing one service – like if a kid doesn’t get hearing aids or dental services – that kid’s chances for success diminish rapidly,” said Polly McKinney, advocacy director for Voices for Georgia’s Children.

McKinney said she’s concerned that the number of uninsured children in Georgia will grow if the cuts to Medicaid are approved. Right now, about 166,000 children are believed to be uninsured.

“We can’t afford to have the number of children without health insurance as it is and we certainly can’t afford to have more kids without health insurance, nor can we afford to short them on benefits,” McKinney said.

Georgia is among the lowest spending states per person, but it spends slightly above the national average on its children. In 2014, the state on average spent $2,827 per child – about $250 more than the national average, according to the Kaiser Family Foundation.

The Peach State’s spending per enrollee for all groups, which was $4,398, is about $1,338 less the national average.

It would be difficult, McKinney said, for Georgia to run its program anymore efficiently. She said a provision in the Senate bill designed to help low-spending Medicaid states such as Georgia does not do enough to shield children from the effects of the cuts.

Groups such as McKinney’s organization and the Academy of Pediatrics are urging senators to leave Georgia’s Medicaid funding intact. So is the Georgia Hospital Association.

“Further cuts to this important program could greatly threaten access to care for our state’s most vulnerable population,” said Earl Rogers, the association’s president.

A revised Senate health care bill was unveiled Thursday that included an exemption from the spending cap in the case of public health emergencies. Senators have also sought to exempt children with disabilities from the cap.

Sen. Renee Unterman, R-Buford, who chairs the Georgia Senate Health and Human Services Committee, said she considers the latest version an improvement because of the inclusion of $45 billion for states to use for opioid treatment, which is a growing need in Georgia.

But she remains concerned about the potential Medicaid cuts, which will shift costs to the state.

“One thing is for sure, if someone is sick in the state of Georgia and they show up at a hospital, they’re going to get treated,” Unterman said Thursday. “The question is where does that reimbursement cost come from?”

A libertarian-leaning group, the Georgia Public Policy Foundation, has praised the Senate’s plan for putting the entitlement program on a budget and for proposing to bring all states closer to the national spending average through gradual cuts or increases.

Georgia could “enormously benefit” under the plan, Kelly McCutchen, the foundation’s president, wrote in a recent blog post.

But Laura Harker, a health policy analyst with the left-leaning Georgia Budget and Policy Institute, said while there might be an initial increase, the Senate plan would lead to a drop in federal funding in the long run.

“I think looking at the longer term picture is really important,” she said. “It would really lock us in for the long term. Even with an initial bump, it wouldn’t keep up with the cost of health care.”

Jill Nolin covers the Georgia Statehouse for CNHI’s newspapers and websites. Reach her at jnolin@cnhi.com.