H.R.1’s Medicaid cuts threaten children’s health

Health Affairs – Tuesday, January 20, 2026
By Carlie N. Myers, Andrew Beck

Cuts to federal Medicaid funding pose a substantial risk to all children, regardless of their insurance coverage. H.R.1, the One Big Beautiful Bill Act, focuses on reducing federal spending, partly achieved through substantial changes to Medicaid and the Children’s Health Insurance Program (CHIP). According to the Congressional Budget Office, these provisions would increase the number of uninsured individuals by 9.1 million by 2034, a shift that would dramatically alter the pediatric health care landscape.

Medicaid and CHIP, which provide coverage for 38 million US children, are critical drivers of children’s access to health care services and promotion of improved, more equitable health outcomes. Although the Medicaid provisions in HR1 primarily target adults, several mechanisms in the legislation would directly and indirectly harm children. Medicaid serves as the backbone of the pediatric health care system, funding hospitals, preventive services, community health centers, and community health programs that provide healthy food and safe housing. Legislation that defunds coverage will have inevitable downstream consequences on all children.

Eroding The Foundation: HR1’s Impact On Pediatric Health Care

Insurance, including coverage through Medicaid and CHIP, is a primary mechanism for protecting families from financial hardship caused by medical expenses. HR1 introduces new cost-sharing requirements for some children included in Medicaid expansion, a change that has been linked to reduced use of high-value preventive care. For children, reduced health care use translates to delayed diagnoses, deferred treatment, and the rise of preventable illnesses that may increase costly emergency department and hospital use.

HR1 also penalizes Medicaid expansion states that extend coverage to certain noncitizens, creating avoidable gaps in health care coverage for children who already face substantial barriers to preventive and acute care services. By prohibiting the distribution of federal Medicaid funds without verification of citizenship or immigration status within narrow time frames, the bill places children without formal documentation at heightened risk of poor health outcomes. Downstream, these gaps in coverage will lead to more missed preventive care appointments, delayed diagnoses, and greater reliance on emergency department services for periodic pediatric care. Disruptions in coverage place disproportionate financial strain on families, increasing hardship and discouraging engagement with the health care system. At the population level, these disruptions increase preventable illnesses, avoidable health care use, and uncompensated costs, thereby straining safety-net hospitals, driving inefficiencies in health care delivery, and weakening public health capacity.

In addition, HR1 narrows the definition of “qualified” immigrants eligible for Medicaid and CHIP, excluding refugees, asylees, and others, further restricting health care access for children in these groups. Additional provisions explicitly exclude Deferred Action for Childhood Arrivals (DACA) recipients from Affordable Care Act Marketplace coverage and bar them from receiving premium tax credits, widening existing health care disparities among immigrant children.

Decreases in Medicaid funding through HR1 will also increase the administrative burden in applying for, accessing, and recertifying Medicaid and CHIP eligibility, disproportionately affecting children and families with low socioeconomic status and health literacy. The Centers for Medicare and Medicaid Services’ eligibility and enrollment final rules were initially designed to simplify and standardize Medicaid and CHIP application and renewal processes, reducing churn and increasing accessibility for vulnerable populations. HR1 will delay implementation and enforcement of these rules, effectively reinstating outdated practices that suppress enrollment, disrupt continuity of coverage (and care), and amplify disparities in receipt of child health care services.

HR1 also imposes constraints on how states pay pediatric clinicians. By restricting states’ ability to require Medicaid managed care plans to raise provider payment rates, the legislation encourages a stagnant, chronically underfunded pediatric workforce. Pediatrics is already one of the lowest-paid clinical fields, and low Medicaid reimbursement rates have long discouraged clinician participation, shrinking the workforce available to care for publicly insured children. Evidence shows that modest investments in pediatric provider payments translate directly into better health and educational outcomes for children. HR1 encourages the pervasiveness of historically low payment rates for pediatric clinicians, worsening barriers to access that children already face.

Federal funding cuts of this magnitude also jeopardize the stability of safety-net hospitals, particularly in rural communities, that rely heavily on Medicaid reimbursements. These hospitals care for children across insurance types; their closure would eliminate essential access points for emergency, inpatient, and subspecialty care for all children, regardless of insurance status. Over the past two decades, the capacity of US hospitals to deliver pediatric care has steadily declined. Reductions in Medicaid funding risk undermining the financial stability of hospitals that care for children, particularly in underresourced communities. When the safety-net hospital system fails, privately insured children lose access alongside publicly insured children, widening disparities in child health outcomes and increasing reliance on already strained regional referral centers.

Together, the HR1 provisions signal a change in the nation’s commitment to child health. Even children who are privately insured will feel the effects through reduced access, weakened community hospital infrastructure, and increased fragmentation of the health care system. Any federal legislation aimed at cost containment must account for the disproportionate and avoidable harm to children—harm that will ripple across education, family economic stability, and long-term health trajectories for all children.

Safeguarding Children In The Wake Of HR1

In the short term, health systems must brace for the profound disruptions HR1 could unleash on the pediatric health care environment. Hospitals and health systems should plan to strengthen financial assistance programs, expand philanthropic endowments, and build medical scholarship or relief funds designed to buffer families from new financial hardships. Proactive planning now is critical to prevent coverage losses from cascading into delayed care, worsening illness, and widening disparities in child health.

States will also need to play a central role in mitigating the fallout from federal funding cuts and the subsequent operational impact. State agencies should evaluate how changes to Medicaid and CHIP eligibility, payment structures, and administrative requirements influence child health outcomes. As the insurance landscape shifts, policy makers must prioritize strategies that protect all children’s access to preventive and high-value care while preserving continuity of coverage for eligible children. This includes maintaining streamlined enrollment processes, reducing administrative burdens, and strengthening partnerships between state agencies and health systems to ensure families can navigate the system without losing access to essential health services.

Additional state-level action will be necessary to stabilize pediatric health care infrastructure. Protecting safety-net hospitals, whether through targeted state grants or participation in initiatives such as the Rural Health Transformation Program, will be essential, particularly in communities where pediatric services are already scarce. Payment models that bolster pediatric clinician reimbursement can help offset projected cuts, ensuring that the workforce remains equipped to meet varied children’s needs.

Conclusion

Since the establishment of Medicaid and CHIP, federal investment has markedly improved children’s health across age groups and into adulthood. Strengthening these foundational programs is vital to ensuring that children can grow, learn, and participate fully in society. Investments in Medicaid for children generate immediate savings by reducing acute care use and school absenteeism and produce long-term returns by preventing avoidable hospitalizations and improving lifelong health trajectories. Expanding access to effective, evidence-based pediatric services through Medicaid and CHIP remains one of the most powerful strategies available to secure the well-being of today’s children—and the prosperity of the generations that follow.

States and policy makers must act now; without intentional mitigation strategies, HR1’s proposed Medicaid and CHIP reforms threaten to erode child health overall and widen existing disparities, unravelling decades of progress.

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