The dismantling of Medicaid and children’s health insurance coverage continues.
Fifteen months after passage of President Donald Trump’s signature “One Big Beautiful Bill,” the Kaiser Family Foundation reports over 4.5 million people lost insurance — a drop largely attributed to discontinuation of tax credits created by the 2010 Affordable Care Act. A Department of Health and Human Services report places the number at approximately 3 million — a consequence of increasing plan costs and skyrocketing premiums. Estimates for a family of four earning $85,000 annually show health insurance premiums nearly doubling to over $7,500 per year.
Parental and child health insurance coverage are closely linked. The loss of millions of insured adults heralds losses in children’s coverage. As pediatricians, we are bracing for the impact the defunding of Medicaid will have on children’s hospitals and kids’ access to care.
Medicaid is the bedrock of health coverage for children. Nationally, almost 40% (28.2 million) of children are enrolled. Medicaid covers almost 50% of all high-risk births nationally. Cuts to the program, including limits on how states can fund their share of the cost, directly translate to missed health screenings, fewer vaccinations, reduced lead and autism screening for toddlers and less mental health treatment for adolescents.
Children are especially affected by these policies. Despite an insistence that children would be held harmless from austere cuts, more than 75% of Medicaid spending on child enrollees is threatened.
It wasn’t always this way. During the height of the COVID pandemic, the federal government incentivized keeping children in the Medicaid program by eliminating the need to reverify eligibility. Reducing this obstacle to being insured pushed the percentage of uninsured children downward to roughly 5% — among the lowest ever recorded and down from nearly 9% prior to passage of the Affordable Care Act. Buoyed by the federal example, states like Oregon and New York enacted Medicaid rules to maintain coverage of children from birth through school age — a policy undone by the current administration’s re-verification rules — eliminating 15 years of progress in children’s health coverage.
These preliminary increases in the uninsured population signal a complete reversal of past policies related to pediatric health coverage. States are now wrestling with the implications of a massive $1 trillion in Medicaid cuts. Cuts to eligibility, benefits and already-substandard Medicaid payments are inevitable — all of which threaten children’s care.
The new federal requirement to re-verify Medicaid eligibility every six months creates artificial hurdles to insurance and will turn our pediatric clinics into de-facto social work offices — as we assist parents with re-enrolling their children in coverage. This is especially true since most families will be unaware their coverage has lapsed. The inevitable result is churn — cycling in and out of public insurance based on health needs, a policy that increases administrative costs and leads to more expense from delayed or skipped preventive treatment.
These policies could not have come at a worse time for kids. Eroding vaccine confidence has resulted in the return of measles — with almost 4,500 cases this year alone, the highest level in 35 years. Years after the American Academy of Pediatrics declared a national emergency in pediatric mental health, too many children face difficulties finding mental health care.
Further, a 2-decade-long shortage of pediatric subspecialists has resulted in health deserts where children with chronic conditions — from diabetes to congenital heart issues — cannot obtain timely appointments with pediatric endocrinologists or cardiologists. The short supply of pediatric subspecialists stems from decades of systemic underinvestment in Medicaid payments, which averaged 75% of Medicare payments. These cuts can only worsen this situation.
The “One Big Beautiful Bill” also threatens your regional children’s hospital. Children’s hospitals represent only 5% of hospitals but, given the overrepresentation of children in Medicaid, are overly reliant on the program to keep our doors open. According to the Children’s Hospital Association, Medicaid payments cover only 80% of the actual costs of pediatric care, which is more specialized than adult medicine. The administration’s Medicaid policies are estimated to cut at least $1.7 billion from pediatric hospitals.
That means layoffs for physical and speech therapists and hiring freezes for nurses are on the table. Pediatric beds in local community hospitals will most likely become extinct, as administrators convert them to adult beds — paid for by higher-paying Medicare coverage, but further limiting pediatric health services for all patients — even those who are privately insured.
As midterm elections loom, voters can choose to continue to raze a program critical to children’s health or recognize that what hurts Medicaid ultimately harms all kids. During the pandemic, we made the conscious decision to keep kids covered; whether they remain insured will depend on what we choose on Nov. 3.
Shetal Shah, MD, FAAP, is a pediatrician, neonatologist and former chair of the National Pediatric Policy Council.
