The summer heat wave blazing across the U.S. is set to endanger millions of infants and children, who are physiologically more vulnerable than adults to its impact. Unfortunately for American families, access to pediatric care is quickly evaporating from the healthcare landscape.
A variety of factors are exacerbating this problem, ranging from decreasing interest in pediatrics as a specialty to the closure of pediatric hospitals across the country. But no matter the cause, the picture is bleak.
The Landscape of Pediatric Care
Pediatric hospitals have been disappearing all across the country. During the decade before the COVID pandemic, data from the American Hospital Association survey showed an average of 407 pediatric inpatient beds were lost every year — either due to the closing of entire pediatric units or due to the redistribution of resources to more lucrative adult and subspecialty care units.
It wasn’t because there were significantly fewer children to fill these beds; in fact, the U.S. pediatric population decreased by less than 1% in this same period. Comparatively, in rural America where the stark decline in access has been even more drastic, pediatric inpatient capacity decreased by 26.1% between 2008 and 2018.
After the pandemic, children’s hospitals across the U.S. only struggled more, and a few pediatric medical centers — including the former Tufts Floating Hospital for Children — had to close down completely.
Most disconcerting, access to emergency and critical pediatric care has also become increasingly limited. Though children account for roughly a quarter of all emergency department (ED) visits in the U.S., 85% of children are seen in non-pediatric EDs.
While not every emergency department needs to sub-specialize in pediatrics, they do need to be able to stabilize a patient of any age. Unfortunately, on the most recent assessment by the National Pediatric Readiness Project — a program that regularly evaluates how prepared EDs across the nation are to care for children — the median score was 69.5/100.
In contrast, Pediatric Intensive Care Units (PICUs) provide highly specialized medical care to just children. While the overall number of PICU beds may have increased recently, the actual number of hospitals able to provide PICU-level care has declined.
Pediatric critical care is now nearly exclusively located in large academic medical centers — 63 hospitals in the nation account for about half of all the PICU beds. In the past few years, pediatric critical care has only continued to consolidate, requiring families outside of these hubs to travel further and further for desperately necessary services.
What’s Driving This Access Crisis?
Ultimately, the reason why access to pediatric care is disappearing is because the medical field has been systematically undervaluing care for children for years.
Across general practice and subspecialties, adult care providers have, on average, a $1.2 million higher lifetime earning potential compared to their pediatric counterparts.
Adult and pediatric residency programs also receive vastly different amounts of governmental support. An adult medicine program may receive nearly twice as much per-resident funding from Medicare as a freestanding children’s hospital does from Children’s Hospitals Graduate Medical Education (CHGME) — whose budget, unlike Medicare, is set by annual congressional approval.
Meanwhile, the number of applicants to U.S. pediatric residencies has fallen for the ninth straight year. A total of 252 positions across more than 60 pediatric programs went unfilled during this year’s residency match.
Even accounting for the overall increase in primary care residency spots in 2024, this discrepancy means that fewer physicians are going into pediatrics compared to last year. Moreover, trainees are not shifting their interest to other programs that can care for children; family medicine finished Match Day with 12% of its available training positions unfilled.
Reimbursements play a role too: the pediatric population is proportionally much more dependent on Medicaid, which reimburses inpatient care at a 22% lower rate than Medicare does (and a much lower rate than private insurers.)
Even when procedures and admissions have similar complexity, many state Medicaid/CHIP programs still reimburse pediatric care at lower rates. Many of the best pediatric hospitals in the U.S. still depend upon donors, grants, and philanthropic partnerships in order to keep their doors open.
Healthcare in America is expensive and hospitals have an impossible task trying to stay in the black. But with infant mortality, adolescent suicidality, and childhood chronic diseases all on the rise, pediatrics is not the place to cut corners.
Yet policymakers keep doing just that. Earlier this spring, Congress approved an $8 billion cut in the yearly budget for Medicaid Disproportionate Share Hospital payments, a program many children’s hospitals depend on to support lower-income families.
A judge recently dismissed Florida’s suit against CMS to disenroll children from its CHIP program for nonpayment of premiums, though the state is likely to seek an appeal. Meanwhile, over 22,000 Florida children have already been disenrolled due to unpaid premiums so far this year — a dangerous precedent that could open the door to the disenfranchisement of millions of American children.
The Health of Future Generations
The health of the next generation and the future health of this nation is in peril. It’s time to get serious about investing in the well-being of children.
Policymakers, healthcare administrators, educators, providers, and families need to oppose legislation that discounts the importance of pediatric care for all children. State and federal payment programs need to be restructured in order to stop short-changing children’s hospitals and their doctors.
Truthfully, healthcare for children is never going to be profitable in the short term. But it is worth the cost because, in the long term, the U.S. cannot afford to keep getting sicker.
Kristen Sparagna, MD, is a fellow with Massachusetts General Hospital Rural Health Fellowship and The OpEd Project Public Voices Fellowship.
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