Proposed Medicaid cuts would devastate pediatric health systems

Much of the dialogue surrounding the hundreds of billions of proposed Medicaid cuts passed by the Senate on Tuesday is centered on the impact on nearly 80 million Medicaid enrollees, half of whom are children. What does not receive as much attention, and which I’d argue is underappreciated, is how cuts to Medicaid would impact all children by devastating pediatric health systems, not just those in the program.

I have the privilege of working in a well-resourced pediatric intensive care unit (ICU) in a large freestanding children’s hospital. On a day-to-day basis, I take care of the sickest children locally and referred from across the country. I have no idea what insurance coverage my patients have — my team simply does everything to take care of the sick child in front of us.

What I have noticed is that pediatric health systems are fragile. During the Covid pandemic, I recall one state (not a hospital, a state) trying to transfer a group of patients because every pediatric ICU bed in their region was full. I’ve witnessed pediatric hospitals and ICUs across the country close, making it harder for children and families to access care. And, even in one of the largest ICUs in the country, we’ve had to develop a team that monitors deteriorating patients outside of the ICU while they await on an ICU bed.

What Americans don’t realize is that the funding structure and existence of pediatric health care is wholly dependent on Medicaid — and that proposed Medicaid cuts will topple this house of cards.

Approximately 37 million children (about 40% of all children in the country) are covered by of Medicaid or the Children’s Health Insurance Program (CHIP). Medicaid provides access to both preventative and acute care, which are essential to raising healthy children. We know that without insurance, children and families are more likely to delay care, to seek care in an emergency department, and to die in the hospital. Not only does uninsurance lead to worse health outcomes, but it is also more costly in terms of long-term health care spending. These costs are ultimately shared by everyone, not just the uninsured.

Cutting Medicaid will affect all children through a large toll on pediatric health systems, which have already been suffering from the low Medicaid reimbursement rates compared with private insurance (and Medicare). Suboptimal Medicaid reimbursement has been tied to the closures of pediatric units and hospitals — in fact, one in six hospitals that accepted pediatric patients in 2019 closed its services by 2021. This has also led to regionalization of pediatric health care, meaning that pediatric care is geographically limited and more likely to be centered in urban areas and/or freestanding children’s hospitals. As a result, families living in suburban and rural areas face increased time and distance to care, translating into decreased likelihood that children covered by any insurance program will be cared for by pediatric providers.

We also know that longer distance to care, delays in care, and lack of pediatric providers can lead to worse health outcomes. As a pediatric ICU doctor, I worry that the combination of sicker children and fewer pediatric centers will overwhelm existing systems. I can attest to the lack of pediatric hospital beds relative to demand, particularly when respiratory illnesses peak during winter months. In fact, our hospital created a team staffed by ICU doctors, nurses, and respiratory therapists to help support the care of critically ill patients who are waiting for an ICU bed to become available. I worry that this trend will worsen with Medicaid cuts, crowding the emergency department and referring hospitals with sick children who are awaiting definitive inpatient care.

The proposed cuts to Medicaid funding also remove a protective system that shields children from new threats. For example, Medicaid provides preventative care including routine vaccinations, which have been shown to be safe and effective at reducing pediatric hospitalization and death. With the current administration’s opposition to vaccine mandates, we’ve already seen our first deaths in a decade from measles, a vaccine preventable disease that was essentially eliminated in United States until the rise of vaccine hesitancy. Over 96% of children covered by Medicaid access essential routine preventative care, including vaccines.  We should worry that eliminating this care will further decrease individual and herd immunity against infectious diseases, again threatening the health of all children.

Lastly, even work requirements or other strategies to selectively decrease coverage of Medicaid-insured adults will ultimately hurt children. Medicaid funds almost 1.5 million pregnant women. This coverage is critical for prenatal and postpartum care, and has been shown to have crucial links to a safe and healthy delivery and decreased infant mortality. Moreover, studies have shown that public coverage of children is linked to parental coverage — parents are more likely to enroll their children in Medicaid when they themselves are covered. Thus, decreasing adult enrollment could still impact children’s coverage, even if the child remains eligible.

Medicaid is vital program that insures nearly half the children in the United States and millions of parents. It not only improves individual health outcomes for these children, but it critically supports already strained health systems that care for all children, including those covered by private insurance. Cuts to Medicaid will undoubtedly threaten the health of all children in this country.

Anireddy Reddy is a pediatric critical care physician at the Children’s Hospital of Philadelphia and senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania.