Critical Care Deserts Emerge as Hospitals Eliminate Pediatric Units

Hospitals across the nation have closed pediatric intensive care units at an alarming pace over the past year, shuttering specialized facilities in Montana, Oregon, and Missouri. Community Medical Center in Missoula, Montana, ended its pediatric intensive care services in October, continuing a national trend that forces critically ill children to travel farther for treatment. The hospital maintains a neonatal intensive care unit for newborns and continues to offer other pediatric services, but the loss of intensive care capacity marks a troubling shift.

Overnight hospital wings for children have also shuttered in Illinois and California. Pediatric units, which serve patients from a few weeks old to well into their teens or early adulthood, are separate from neonatal intensive care units. As hospitals seek to cut costs, many convert those beds into services for newborns or adults, centralizing pediatric intensive care in medical hubs and 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.

The number of pediatric inpatient units in hospitals fell 19% from 2008 to 2018, according to a study published in the journal Pediatrics in 2021. A more recent analysis found pediatric inpatient units decreased by nearly 30% from 2008 to 2022, dropping from 1,749 hospitals to 1,226. That left three-quarters of hospitals without any pediatric inpatient services.

Financial Realities Drive Hospital Decisions

Hospitals cutting pediatric care consistently cite low patient volumes, as it remains relatively rare for a child to need intensive care. The nation faces a shortage of pediatric subspecialists, who earn less than those focused on adults, making it hard to find doctors to treat rare cases. Meanwhile, hospitals receive lower payments to treat children than adults, and buying gear tailored to kids adds extra costs.

“It really has to do with dollars,” said Dr. Scott Krugman, vice chair of pediatrics at the Herman and Walter Samuelson Children’s Hospital at Sinai in Baltimore. “Hospitals rely on high-volume, high-reimbursement procedures from good payers to make money. There’s no incentive for hospitals to provide money-losing services.”

Hospitals optimize revenue by striving to keep their beds 100% full and filled with patients whose conditions command generous insurance reimbursements. Mark Wietecha, CEO of the Children’s Hospital Association, confirmed that a major factor in the bed shortage stems from a years-long trend of eliminating pediatric units, which tend to be less profitable than adult units.

The gap in care hits rural places hardest. Cutbacks occur across community hospitals, whether owned by small nonprofits or massive private equity companies. Just this year, hospitals have closed pediatric units in Boston and Springfield, Massachusetts; Richmond, Virginia; and Tulsa, Oklahoma.

Pandemic Aftermath Exposes Vulnerabilities

The COVID-19 pandemic accelerated changes in the healthcare industry that left many communities with fewer hospital beds available for children who are acutely ill, along with fewer doctors and nurses to care for them. When intensive care units flooded with older COVID patients in 2020, some hospitals began using children’s beds to treat adults. Many of those pediatric beds never returned to their original purpose.

The lockdowns and isolation that marked the first years of the pandemic left kids largely unexposed and still vulnerable to viruses other than COVID for two winters. Doctors now treat multiple years’ worth of respiratory ailments, with medical centers nationwide deploying triage tents, delaying elective surgeries, and transferring critically ill children out of state to cope with floods of young patients sickened by respiratory syncytial virus, influenza, and coronavirus.

Mental Health Crisis Compounds Access Problems

The shortage of pediatric beds extends beyond physical illness. Psychiatric “boarding,” when a patient waits in the emergency room after providers decide to admit the person, has increased because of a rise in suicide attempts and other mental health issues. A study of 40 hospitals in the journal Pediatrics found that cases in which children spent at least two days in pediatric hospitals before being transferred for psychiatric care increased 66% from 2017 through 2023, reaching 16,962 instances.

In St. Louis, leaders of Mercy Hospital and other local hospitals have described the shortage of beds for inpatient pediatric psychiatric care as a crisis for years. When a 14-year-old student expressed suicidal thoughts in January, providers at Mercy Hospital St. Louis reportedly told his parents they didn’t have beds available at their behavioral health center. The teen spent three days in a room in a secured area of the emergency department and saw a doctor twice, one time virtually.

St. Louis Children’s Hospital leaders aim to address that problem by opening a 77-bed pediatric mental health hospital in the suburb of Webster Groves. However, neighbors objected, worrying it would worsen safety and lower property values. Over the past decade, proposed psychiatric facilities for minors in California, Colorado, Iowa, Nebraska, and New York have also faced local resistance.

Federal Cuts Threaten to Widen Care Gaps

Medical researchers and organizations warn that gaps in pediatric care will widen due to cuts in federal Medicaid spending. The Trump administration added administrative hurdles to access the low-cost health coverage and whittled down who qualifies. While those changes focus on adults, approximately half of the nation’s kids rely on Medicaid coverage.

Behavioral health care advocates counter that concerns about psychiatric facilities are largely unfounded and rooted in stigma. Locating such facilities in remote areas, as neighbors sometimes suggest, reinforces the misconception that people with mental illness are dangerous and makes it harder to help them without their support system nearby, doctors explain. The same principle applies to pediatric intensive care units: proximity to family support systems remains crucial for children’s recovery and families’ ability to participate in care decisions.

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