Chandra works as a nurse. She told me that she “grew up on the far right, and very staunchly in that pro-life, single-issue-voter camp.” “I had to confront the reality of being pro-life for the first time.” She decided against ending the pregnancy. The family chose to enroll in Medicaid because she and her husband had no money and had been volunteering on a medical ship off the coast of West Africa for the previous six months.
She told me, “I used to think Medicaid was only for leeches and moochers.” “Good people shouldn’t ever need Medicaid,” the statement goes. I found it quite difficult to enter that office and turn in my paperwork. However, she did. “It clearly altered the course of events because we could then seek the best care.” Her son’s birth, two open heart surgeries, and her prenatal visits were all covered by Medicaid. Her son is doing well eleven years later, and Chandra is a nurse in suburban Utah who specializes in caring for children with complex medical needs—children who, like her and her son, were once covered by Medicaid.
She may soon be unable to give that care. The One Big Beautiful Bill Act, Donald Trump’s comprehensive domestic legislation for his second term, was passed by Congress this summer. The White House maintains that the bill does not reduce Medicaid. By curbing what Republicans characterize as waste, fraud, and abuse in the health-insurance program, it lowers taxes and makes up for the revenue losses.
However, according to the Congressional Budget Office, the law will result in 11 million Americans losing their insurance coverage and deplete nearly $1 trillion of Medicaid’s funding over the course of the next ten years. Experts predict a series of consequences. Medical bankruptcy rates and private insurance premiums will increase. There will be longer wait times for specialist appointments. Care deserts will grow. Clinics and hospitals will have to close. Our health care system’s most vulnerable components could potentially fail. And perhaps at the top of that list is pediatric care.
Children’s health coverage and initiatives are not specifically targeted by the law. However, Medicaid or the associated Children’s Health Insurance Program covers almost half of all children in the United States. Sick babies will wind up footing the bill for tax breaks for the rich if the One Big Beautiful Bill Act is implemented as written.
Republicans claim that the bill “strengthens” Medicaid by denying adults insurance coverage. The nation is enforcing a nationwide work requirement for the program for the first time. Any state that has an expanded Medicaid program—one that provides coverage to all low-income adults, not just those with a disability or another qualifying condition—must confirm that enrollees are employed, volunteering, or enrolled in school. If they aren’t, they will be removed from the rolls.
Studies have shown that almost all Medicaid-eligible adults already work if they can, so the work requirement is not likely to encourage more people to find employment. However, implementing it will cost states millions of dollars, taking money away from providing real healthcare. Additionally, it is estimated that 8 million Americans will lose their insurance due to their inability to keep up with the paperwork.
A number of technical adjustments to Medicaid’s funding are also included in the bill, which will change the taxes that states impose on healthcare providers and the payments that they make to them. Even if children continue to qualify for Medicaid on their own, experts caution that removing parents from the program will also result in the removal of children. Parents who are enrolled in a public insurance program are twice as likely to enroll their children in one, and states that cover a small percentage of low-income adults also typically cover a small percentage of low-income children.
Over 4 million children in America do not have health insurance already. In a year or two, hundreds of thousands more could join them. The growing number of children without insurance is a crisis in and of itself. It is less common for children without insurance to have a pediatrician keeping an eye on their growth and well-being. They are more likely to be ill, receive fewer vaccinations and prescription drugs, receive less treatment for serious illnesses, and end up in the hospital. Additionally, they have a higher chance of passing away before becoming adults.
States are expected to reduce spending on “optional” or “nonessential” Medicaid programs, like in-home care for children with disabilities and chronic health conditions, at the same time that the number of children without insurance is increasing. Through these services, sick children can sleep in their own bedroom with their siblings, pets, and stuffed animals instead of in pediatric hospital wards, and disabled children can attend school in regular classrooms. Providing care at home lowers the number of hospital admissions and ER visits.
With a tone that wavered between measured despair and tempered rage, Chandra told me that it is also crucial for families. “Those are my patients,” she declared. “I love those kids.”
According to S.E. Smith, communications director of Little Lobbyists, an advocacy organization for kids with complex medical needs and disabilities, Medicaid already has a “institutional bias.” Compared to care given at home or in the community, the program provides a more thorough coverage of care in hospitals and clinics. In-home services are typically the first to be cut when state Medicaid programs experience financial difficulties. Smith informed me that the bill will result in far more significant cuts, separating children “from loving families, depriving them of a free and appropriate public education, and denying them an opportunity to participate in society.”
The bill will also make it more difficult for parents and caregivers to access institutional services as the demand for in-hospital treatment increases and at-home care decreases. Twenty percent of pediatric beds and thirty percent of pediatric-care units have been eliminated by health systems during the last fifteen years. Hospitals profit more from admitting adults than children because Medicaid offers lower reimbursement rates than Medicare and private insurance plans, and children are far more likely to be covered by Medicaid.
Because of this, pediatric care is now mostly provided in specialized children’s hospitals that are unable to handle the current demand. There are far too few pediatric health providers in low-income and rural areas, too few pediatric health specialists to diagnose and treat children, and too few hospital beds for infants and teenagers nationwide. Existing institutions are brittle: the profit margins of nonprofit children’s hospitals are 2.7%, while those of all hospitals are 6.4%.
The One Big Beautiful Bill Act is a hurricane-force windstorm, and the system is a shaky one. Hospitals will close, affecting not just Medicaid-eligible children but all children; demand will increase in the pediatric institutions that remain, as families will have fewer treatment options; and revenue per patient will decrease as fewer children are covered by Medicaid, giving health systems an even stronger incentive to concentrate on treating adults and seniors. Physicians predict that anxious parents will drive their sick and injured children to the children’s emergency room or intensive care unit for hours on end, only to discover that it is overcrowded.
Medical professionals expect the same dynamic to occur in rural healthcare. “This will affect 62 million Americans,” National Rural Health Association CEO Alan Morgan informed me. “If you live in a rural area, it affects your access to healthcare because it lowers the profitability of these facilities and their ability to remain in the community.” They also observe the same dynamic at work in long-term care, rehabilitation, and nursing homes. The country’s most vulnerable institutions could be destroyed, and those who provide health care to everyone could be weakened, by a law that was ostensibly designed to encourage adults to work.
The fact that the bill’s work requirements are postponed until after the 2026 midterm election may indicate that Republicans are aware of how disastrous and unpopular the party’s policies are. Hospital executives and Capitol Hill aides think that Congress may amend the bill or push back some of its provisions. However, there are tax cuts that need to be funded, and those who have cancer and disabilities can help with the cost.
“I have worked and resided in nations where access to healthcare is limited. I am aware of how that appears,” Chandra informed me. “I find it devastating that we may be dealing with some of the same issues that I have encountered in some of the world’s poorest nations. Anywhere, but particularly in the wealthiest nation on earth, it shouldn’t be the case.”
