I am in a hospital room in San Antonio, Texas, and a young mother is begging me—quietly, politely, and in front of her preschooler, whom I’ll call Dani—to make her child well enough to leave the hospital today. “We’ll do whatever Dani needs,” she says.
“Of course,” I say.
“But could it be today?” she asks.
Her child has a serious infection and is not ready to go home. In fact, Dani may need surgery. The mother only wishes they could leave because Dani is uninsured: every night of hospitalization means thousands of dollars in additional costs.
Dani used to be covered by the Children’s Health Insurance Program, or CHIP, a program that—similar to Medicaid—provides health coverage to patients who can’t afford it. But a person must reënroll every year or risk losing coverage. During the pandemic, the federal government required states to automatically reënroll people in CHIP and Medicaid. But the requirement ended in 2023. After that, Texas set about disenrolling poor children from benefits with such cold vigor that the Biden Administration’s Department of Health and Human Services threatened to take action. According to a joint investigation by ProPublica and the Texas Tribune, more than two million Texans, most of them children and most of them eligible for Medicaid or CHIP, lost their coverage. Some were disenrolled because they filled out forms incorrectly or turned them in late.
Social workers at my hospital are helping this family reënroll, but they aren’t hopeful: there are many applications under review and processing currently takes three to six months. There’s not much I can offer, as a doctor, that won’t cost them. Dani clings to their mother, crying when I approach. I lean back against the handwashing sink and listen to the mother’s worries. Eventually, Dani falls asleep. The family stays overnight, and by morning the child is in the operating room.
What is happening to Texans is about to happen to millions of people in other states. Last week, in President Trump’s One Big Beautiful budget bill, Republicans in Congress voted to cut nine hundred and thirty billion dollars in health-care spending, according to the Congressional Budget Office. Medicaid and CHIP face large cuts, as does coverage under the Affordable Care Act. Even Medicare, which provides health care to seniors, is affected. The bill will achieve most of these savings by setting up paperwork and procedural barriers to coverage; Medicaid recipients will be expected to find work, volunteer, or attend school unless they are pregnant, parenting, or disabled. (Texas has demonstrated just how “effective” a bureaucratic barrier can be: about half of the state’s uninsured children are thought to be eligible for some form of coverage.) Experts estimate that between eleven million and seventeen million Americans will lose coverage nationwide, which they predict may lead to more than fifty thousand new preventable deaths each year. Supporters of the bill say the cuts will refocus federal funds on children, pregnant women, people with disabilities, low-income families, and seniors. This is akin to slicing up an umbrella with kitchen scissors and claiming that the cuts will help the umbrella refocus on its mission of keeping out the rain.
One of my first patients to be affected by the disenrollment crisis was a child with epilepsy. The child’s mother discovered a lapse in Medicaid coverage when she went to the pharmacy and was asked for thousands of dollars to pay for anti-seizure medicines. She couldn’t pay, and without the medicines, my patient ended up in the emergency room. Colleagues stopped a seizure, but our care was anything but efficient. I could not safely discharge the child without the appropriate meds, and reënrollment would take months. A charity program agreed to cover the medicines, but it took days to fill prescriptions. And so a preventable seizure led to a days-long hospital stay that was both expensive and avoidable.
When I was a medical student in Galveston, in the twenty-tens, almost a quarter of Texans were uninsured. The medical school I attended, like many of its peer institutions, had a free student-run clinic that serves such patients. Some drove for hours to get there, while others simply walked in off the street. When they arrived, they’d unbutton their shirts and show how poverty ravages the human form—particularly when there’s no medical care to blunt it. I saw workers with broken limbs who had been splinted in an E.R., only to be denied access to costly orthopedics appointments and surgeries. Others had received emergency stents and blood thinners after heart attacks, but had carried on with their lives because they had no ability to follow up with a cardiologist. The clinic saw people with treatable cancers whose cases were turned away from local hospital after local hospital. We students learned how to explain to them that they would die because they couldn’t pay for care.
I now work as a hospital pediatrician in San Antonio—a big-hearted city that, despite being one of the poorest major metropolitan areas in America, robustly supports medical care for local families living in poverty. Practicing pediatrics here has often felt like an escape from the economic brutality of American medicine. The county health-care program is a sliding-scale system supported by property taxes. Most of my patients are on Medicaid or CHIP; some are privately insured. Even when we treat patients who are totally unfunded, we can usually find some kind of financial support, in part because local, state, and federal programs have seemed unified by a commitment to looking after children. For the poorest kids, the hospital often eats the bill.
After years of watching my Galveston patients suffer and die from treatable diseases, simply being able to offer this standard of care to Texas children, regardless of a family’s income, has been a profound relief. When a Spanish-speaking toddler from the South Side presents with an infection in a leg bone, I can call up a pediatric orthopedic surgeon. When a new mother toughs it out on methadone throughout her pregnancy, as a treatment for opioid dependency, I can teach care for her newborn through opioid withdrawal. I can order all the labs a little girl needs to find out what’s causing the pain in her joints.
The difficult lessons of my early training have never left me, however. I know that these resources can be exhausted. They can be stripped away by law and policy. When that happens, a brutal cycle intensifies. Poverty makes people unhealthy; meanwhile, the cost of medical care often ruins families financially. Children who spend their first five years in poverty are more likely to struggle with learning, more likely to have asthma and obesity, more likely to suffer burns or gunshot wounds, and more likely to die of abuse. When they grow up, they will typically earn less, be more likely to spend time incarcerated, and have higher burdens of diabetes and heart disease. Generally speaking, they will die at a younger age than those who grew up with more resources.
Poverty is common among American children; kids under five are more likely than any other age group to be poor. It is also treatable. In recent decades, the most effective sustained policy for alleviating child poverty was the earned-income tax credit, which has bipartisan support and provides tax money back to families with children. During the pandemic, an expanded child tax credit reduced child poverty to a record low. Renewing this credit in 2022 would have insured economic stability for some three million children. The new budget bill increases the current child tax credit from two thousand dollars to twenty-two hundred dollars—and creates a “baby bond” program to build savings for young people. I believe that these aspects of the bill are good news for families. But I worry that their beneficial effects will be overshadowed by the costs of health care.
Hospitalizations imperil poor families, and not only because of the bills. A parent can lose her job during her child’s stint at a hospital, or miss so many shifts that she can’t pay for the family’s basic needs. One such mother apologized to me because she had to leave her daughter alone for the evening—they’d missed rent, she said, and she had to clear their things out of their apartment. She did not want me to call her landlord or invoke a legal-advocacy team; she had her own reasons for wanting to leave quietly.
“We’ll keep a close eye on your daughter,” I promised. “We’ll leave the door open, so we can hear if she needs anything.” I could promise to protect that girl for a single night. But I knew that I would be discharging her into a life made more tenuous, and more dangerous, by the costs of American medicine.
Access to medical care is often framed in terms of the lives it saves in the moment. But programs such as Medicaid are not simply tickets into the hospital; they are also some of the most effective anti-poverty programs for children. Like the social programs that support access to food, early-childhood education, and housing, Medicaid reduces costs and prevents debt. This last point is critical. Medical expenses can plunge people into poverty. Even families with private coverage run financial risks when seeking care for their kids.
When important medical care is deferred because of cost, kids suffer. I’ve witnessed infections that could have been treated early, in a primary-care clinic, instead spread and worsen because a child had no such clinic to go to. I’ve cared for newborns whose mothers missed weeks or months of prenatal care after coverage lapsed. Ironically, outpatient care—which is more affordable than hospital care—is often the hardest to get. Uninsured kids are likely to be turned away from clinics when they can’t pay out of pocket. One of our pediatric patients needed to see an ear, nose, and throat specialist because his tonsils were so big that he could barely eat. A free-clinic team sent him to ENT, but he was turned away because of lack of funding. He couldn’t get his tonsils out until he was admitted to the hospital with malnutrition.
I fear that what Texas pediatricians are encountering now will grow more common nationally, as Trump’s cuts are enacted over the next decade. The changes will be insidious, and bureaucracy may make them difficult for doctors to see. We cannot bear witness on behalf of children we never care for, whether because they do not show up to our clinics or because they are turned away for lack of funds. I am afraid of looking away for too long and finding myself a part of the machinery of injustice—blithely filling my own children’s lunchboxes on the income from a system that fails poor kids.
Cuts to CHIP and Medicaid could eventually affect care for all children. Even before the bill, many rural hospitals were closing their pediatric units. Such units often fail to make ends meet, in part because Medicaid and CHIP pay hospitals less than other insurers for the same care. More than three hundred U.S. hospitals, most of them in rural areas, may close altogether as a result of Trump’s bill. Patients who are newly uninsured, or who can no longer find care where they live, will be forced to look elsewhere—perhaps to hospitals like mine, which aim to offer care to any child in the community. I worry that even mission-oriented health systems will eventually face a tipping point, and will begin turning away unfunded children in order to prevent collapse.
I was once so compelled by medicine’s commitment to the worth of each human life that I set out to live by it. Now I know that a doctor’s ability to fulfill this commitment—to live a moral life in medicine—depends on the systems of care that we as a society build. I still want to be of use. I was a working-class kid from Texas, and I want to care for children like that. But I do not want to play a part in driving families into poverty or grinding children’s futures into dust. For doctors who care for poor families, cuts to Medicaid and CHIP threaten our ability to make the oldest promise in medicine: that we will do no harm. Day after day, I meet parents who are willing to sacrifice anything to save their children’s lives. They shouldn’t have to. ♦
