Hospital units dedicated to treating the nation’s sickest kids are disappearing nationwide. In the past year alone, hospitals have closed pediatric intensive care units for critically ill kids in Montana, Oregon, and Missouri. Overnight hospital wings for kids have also shuttered in Illinois and California.
Depending on the hospital, pediatric units — which are separate from neonatal intensive care units — can serve patients ranging from a few weeks old to well into their teens or early adulthood. As hospitals look to cut costs, many are converting those beds into more services for newborns or adults. As a result, pediatric intensive care has become centralized in medical hubs, requiring critically ill children to travel farther for lifesaving care.
“You can’t expect that people will be fine if the next-closest children’s hospital is a flight away or an eight-hour drive,” said Elizabeth Mack, a pediatric critical care doctor and spokesperson for the American Academy of Pediatrics.
Hospitals cutting pediatric care tend to cite low patient volumes; it’s relatively rare for a child to need intensive care. It’s also hard to find doctors to treat those rare cases because the nation is short on pediatric subspecialists, who earn less than those focused on adults. Meanwhile, hospitals are often paid less to treat children than adults, and buying gear tailored to kids adds extra costs.
The gap in care is acute in rural places. Cutbacks are happening across community hospitals, whether owned by small nonprofits or massive private equity companies.
A recent analysis of pediatric inpatient units, hospital wings that provide overnight care, found they decreased by nearly 30% from 2008 to 2022 — down from 1,749 hospitals to 1,226. That left three-quarters of the hospitals without any pediatric inpatient services.
Medical researchers and organizations warn such gaps will widen due to cuts in federal Medicaid spending. The Trump administration has added administrative hurdles to access the low-cost health coverage and whittled down who qualifies. While those changes focus on adults, about half of the nation’s kids are covered by Medicaid or its related Children’s Health Insurance Program. Public aid researchers have said that when caretakers get tangled in paperwork, children can lose coverage.
Fewer people enrolled in Medicaid — adults or kids — means hospitals are about to see a financial hit.
Mack, who also works as a hospital consultant on patient quality, said cutting kids’ services for most hospitals is “a spreadsheet issue.”
“This is a very pricey endeavor, and it’s not sustainable,” Mack said. “There’s not a great answer here.”
“It’s about quality”
Even without recent closures, many sick kids already travel long distances to obtain care.
When Darby Waldbillig’s toddler struggled to wake up one morning in 2022, Missoula was the Montana family’s closest pediatric critical care option — a 100-mile emergency flight from their home at the time in Helena, the state capital.
“Her face was swollen. She was drifting in and out of consciousness,” Waldbillig said.
Her nearly 2-year-old daughter, Siobhan, had bacterial meningitis, a life-threatening infection that swells tissue around the brain and spinal cord. Local emergency room workers started antibiotics before transferring her to Missoula’s Community Medical Center, where Siobhan spent more than a week in the pediatric intensive care unit — the same unit that closed this month.
“I firmly believe it’s because of those doctors that she lived,” Waldbillig said.
Whether Community Medical Center can still take cases like Siobhan’s depends on how sick a child becomes.
Greg Cook, the hospital’s CEO, said most kids who come in the door will still be able to stay for treatment. The difference is that the sickest kids — those in critical care who, for example, need a ventilator or continuous monitoring for a seizure — would be stabilized, then sent elsewhere.
“We made the decision to take care of the kids that we could absolutely take care of,” Cook said. “It’s about quality more than it is about the dollars.”
In a later email, hospital spokesperson Megan Condra said the decision was driven by low patient volumes and long-standing staffing challenges. “Our decision was not driven by concerns about the quality of care currently being provided,” she said.
Cook said the hospital hasn’t been able to recruit pediatric critical care doctors to live in Missoula since its last local pediatric critical care doctor retired eight years ago. Instead, specialists have been flying in on rotations. Cook said, on average, the hospital saw approximately two kids a month who needed intensive care when the decision to close the unit was made.
Cook estimated the unit’s closure will impact roughly 25 patients a year. The next-closest option in the state is Kalispell — a pediatric intensive care unit about 150 miles north of Missoula.
Hubs for pediatric care
Not all hospitals are hurting in the same way.
Community Medical Center in Missoula is owned by for-profit Lifepoint Health, whose revenue is more than $10 billion a year, according to its website.
Cook said hospital leaders downgraded the unit after consulting with Lifepoint Health. “Asking Lifepoint to float the program” wouldn’t have solved its main issue, he said.
St. Vincent Medical Center, a Portland, Oregon, hospital that closed its pediatric intensive care unit last November, is part of Providence, a nonprofit health system operating across seven states. The latest financial records filed with the federal government show Providence Oregon had more than a $15 million shortfall as of 2024.
But St. Vincent, like Community Medical Center in Missoula, cited too few patients, not money, as the main reason for the unit’s closure. The four-bed unit was often empty, said St. Vincent Medical Center spokesperson Lisa Helderop.
Raj Basu is division chief of critical care medicine at the Ann and Robert H. Lurie Children’s Hospital of Chicago, a regional hub that can treat really sick kids. He said if hospitals take on complicated pediatric cases without the doctors or experience needed, they could put patients at risk.
Pediatricians have said some community hospitals have low pediatric volumes. The U.S. birth rate has declined. And doctors have gotten better at diagnosing and treating kids early, while the development of vaccines has reduced once-common hospitalizations. Better medicine means more kids are surviving complex illnesses that once were death sentences. So when kids do need critical care, Basu said, they can have far more complicated conditions that take a lot of expertise to treat.
With widening gaps in care, Basu said, doctors worry patients will get worse in the time it takes to reach a medical hub.
“From the front lines, there’s a creeping sense, a concern, that kids are showing up a little bit sicker,” Basu said. “I don’t know that we have enough data yet to prove that.”
Basu, who is also with the Society of Critical Care Medicine, said such medical organizations are exploring solutions — for example, specialty centers that work with community hospitals to establish regional training and protocols to transfer patients.
Other potential solutions are securing more federal funding to cover services in low-access places and raising Medicaid reimbursement rates, said Kenneth Michelson, lead author of the study on declining pediatric units. Michelson also directs emergency medicine research at Lurie Children’s Hospital.
“There’s a case to be made that we don’t need this capacity, but this can’t be viewed as a typical good that we get from, like, a grocery store,” Michelson said. “This is people’s lives, children’s lives. So I think it’s more of a national necessity.”
He said the disappearance of critical services seems to ripple into more routine care as pediatric services shift to medical hubs. For example, the number of hospitals performing appendectomies on a child — a common pediatric surgery — decreased by more than half from 2003 to 2022.
Regional centers could be overwhelmed, especially by spikes in demand. Michelson said that happened in 2022, when children’s hospitals were full.
“Small, community emergency departments were having to call 10, 15, 20 different hospitals to try to find a hospital that would accept a patient,” Michelson said. “That’s probably going to happen again.”
In some ways, he said, people who live in places like Missoula are lucky because Community Medical Center still provides most forms of pediatric care.
Lauren Wilson, a pediatrician at Community Medical Center, said the hospital maintains an intensive care unit for newborns and will still have inpatient pediatric services, emergency treatment, surgeons, therapists, and some subspecialists. Local doctors can consult with pediatric critical care specialists elsewhere to treat, stabilize, and transfer kids when needed.
“This is still the place I would take my child if they were sick and I was worried,” Wilson said.
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