We just got our first glimpse of how catastrophic Trumpcare would be for the most powerless Americans

New estimates from the Congressional Budget Office predicted that within a decade, the Republicans’ proposed American Health Care Act would increase the number of uninsured people in the United States by 24 million. That’s more than the entire population of New York state losing their insurance. An analysis from the White House puts the increase in the number of uninsured Americans even higher, at 26 million. That’s closer to the population of Texas.

Still, Paul Ryan is feeling pretty good. “Our plan is not about forcing people to buy expensive, one-size-fits-all coverage,” the House speaker said in a statement on Monday. “It is about giving people more choices and better access to a plan they want and can afford.”

Maybe you can call it a choice to ignore a lump in your abdomen or stop taking your diabetes medication because it just cost too much. But what choice does a kid have if they are born poor or sick or both and need to see a doctor?

Right now, more than 40% of Medicaid beneficiaries are children. The Ryan health care bill radically restructures that program, taking what is currently a dynamic funding process—which grows as the need grows—and turning it into a federal cap or set of state-managed block grants. Either way, the amount of money available to cover low-income people or people with chronic and long term health problems gets locked in regardless of circumstances.

This would impact kids in a few ways, all of them cruel.

The number of people on Medicaid goes up when the economy tanks. When an adult takes a hit at work—maybe losing their job and the health insurance that comes with it—their kid takes the hit, too. An analysis from the Center on Budget and Policy Priorities released this summer found that “during the last recession and its aftermath, more than 10 million additional people enrolled in Medicaid; more than half were children.”

A more recent report from the CBPP found the Medicaid cuts outlined in the Republican bill would mean $370 billion in lost federal funding over the next decade. (This is what Paul Ryan would call money “saved,” but the need doesn’t actually go anywhere—it just shifts the burden to the states.)

As noted by George Washington University health policy experts and professors Joan Alker and Kelly Whitener, about a third of those cuts—$116 billion—would come from what you could call the “non-expansion” side of Medicaid—the parts of the program that already covered kids, seniors, pregnant women, and people with disabilities.

Less money means there are certainly more choices to be made, which Paul Ryan and other Republicans talk about as a kind of liberation. But it might feel more like a hostage situation for people on Medicaid or states figuring out how to keep them there.

States could respond to the cuts by dramatically raising taxes, cutting other essential spending, or cutting access to care. Sara Rosenbaum, a professor of health law and policy at George Washington University, had a prediction about what choice states would make when I interviewed her last month about the proposal.

“Unless a state were to stop funding its roads, its schools, and big chunks of its other human services and activities,” it will not be able to make up enough of the difference to fund Medicaid at its current levels, Rosenbaum said.

This may all sound abstract, and the bill’s Republican backers likely want it to stay that way. But there are real kids reflected in the numbers in those Medicaid rolls, real kids being quantified as burdens or cost-neutral in the House Speaker’s calculations around deficit reduction.

Micaela Walker, a photographer and mother to two young children, knows this all too well. Writing at Time magazine about her daughter, Lula, who died of health complications when she was 18 months old, and her experience navigating the health care system with a child who had a disability, she explains how Medicaid shaped her and her daughter’s lives during those months.

“Lula’s life depended on a network of medical experts, therapists, supportive equipment and caregivers that we otherwise would not be able to afford. Deny a disabled person’s right to uncompromised care, and you might as well deny their right to exist,” she wrote.

That’s what it will mean to strip away access to affordable health care from another family, another kid. It would serve Ryan well to remember that.