A big problem for little people: the impact of proposed Medicaid reimbursement cuts and the fragility of pediatric rheumatology care

Abstract

Background

There is a significant shortage of pediatric rheumatologists in the United States with only about 420 practicing providers and more than 300,000 children with rheumatologic conditions. This shortage is compounded by regional maldistribution with large geographic areas lacking pediatric rheumatology providers and by the increasing prevalence of autoimmune diseases.

Main text

Medicaid was established in 1965 to provide coverage for low-income families, children, senior citizens and people with disabilities. About 50% of children in the US are insured through Medicaid or The Children’s Health Insurance Program (CHIP), programs that significantly increased access to health care for children. Pediatric subspecialists, including rheumatologists, see patients predominately covered through public insurance. However, the lower reimbursement rates have led to lower salaries for pediatric rheumatologists compared to peers with the same level of training. Medicaid cuts will potentially worsen this shortage by limiting reimbursement and recruitment of even fewer trainees. This will reduce access nation-wide and may result in worse outcomes for children living with rheumatologic conditions.

Conclusion

This paper poses some potential solutions including the recent American Board of Pediatrics decision to shorten the duration of subspeciality training for pediatric rheumatology, offering loan repayment, and expanding the role of advanced practice providers. It also highlights the importance of leveraging advocacy groups to fight for policies that promote the health and well-being of children living with rheumatologic conditions and advocate for policies that sustain reimbursement for specialty care.

Introduction

How a society cares for its children is an investment that safeguards its future. In the United States, there are approximately 70,000 board-certified pediatricians; pediatric rheumatologists represent well under 1% of this workforce [1, 2]. More than 300,000 children live with pediatric rheumatologic disease in the United States, yet there are only ~ 420 practicing pediatric rheumatologists, many of whom work part-time or devote a portion of their clinical effort to academic research, thereby limiting the clinical workforce [3–5]. In 2020, it was estimated that there were only 0.27 full-time pediatric rheumatology providers per 100,000 children, including advanced practice providers [2, 5]. Despite growing recognition of pediatric rheumatic diseases as a significant burden, the pipeline of new pediatric rheumatologists remains insufficient to meet current and projected demand [5].

Geographic maldistribution of pediatric rheumatologists further magnifies this crisis. Several U.S. states, particularly rural regions, currently have no pediatric rheumatologist, leaving children and caregivers to travel hundreds of miles to access specialty care and effectively creating pediatric rheumatology care deserts [5]. These gaps disproportionately affect children insured by Medicaid, especially those in rural areas, who are less likely to overcome the financial, logistical, and administrative barriers associated with long-distance subspecialty care [1, 2, 6].

Limited access to pediatric rheumatologic care places significant financial, emotional, and physical burdens on affected families, leading to higher rates of psychosocial distress and disability [7–9]. Unfortunately, in the setting of Medicaid cuts, pediatric rheumatology patients experiencing co-morbid depression and anxiety will have less access to mental health care.

Recent data from the American College of Rheumatology show that pediatric rheumatology fellowship positions continue to go unfilled. In the 2025 fellowship match cycle, 27 of 55 rheumatology trainee positions were filled and only 24 of 44 were filled in the following year. Exacerbating this shortage, the average pediatric rheumatologist is now in their early-to-mid 50s, reflecting an aging workforce with limited replacement capacity [2, 5]. Against the landscape of a fragile workforce, there is great concern that proposed reductions in Medicaid funding will worsen an already precarious system of care.

Understanding medicaid and CHIP

Medicaid, established in 1965, mandates coverage for low-income families, children, seniors, and individuals with disabilities. Although Medicaid is jointly funded by federal and state governments, it is administered by the states and U.S. territories within federal guidelines, resulting in 56 distinct Medicaid programs.

Today, approximately half of all children in the United States are insured through Medicaid or the Children’s Health Insurance Program [CHIP) [10]. Created in 1997, CHIP expanded coverage for children whose family income exceeded Medicaid eligibility thresholds but was insufficient to afford private insurance. Though similar to Medicaid with joint federal and state government funding, the federal government provides enhanced matching rates of 65–85% to encourage state participation. CHIP has contributed to a substantial decline in the number of uninsured children in the United States; from approximately 10 million in 1997 to < 3.8 million today [10].

For the providers, Medicaid reimbursement rates are substantially lower than those of Medicare (approximately two-thirds or less) and commercial insurers [10, 11]. Pediatric subspecialties, including pediatric rheumatology, care for a disproportionately high number of Medicaid insured patients, hence, these reimbursement disparities have a direct impact on pediatric subspecialty salaries. Pediatric rheumatology salaries are $80,000 to $120,000 below the average of their adult counterparts [12].

Proposed medicaid cuts

The One Big Beautiful Bill Act (OBBBA), signed into law on July 4, 2025, is projected to cut federal Medicaid funding by an estimated $911 billion to $1 trillion over a 10-year period. This reduction, combined with the resulting strain on state budgets, will have significant impacts on Americans and may result in substantial negative consequences for children and adolescents with rheumatologic disease.

Impact of proposed medicaid cuts

The proposed reductions in Medicaid funding would disproportionately affect children’s hospitals which derive more than half of their patient revenue from Medicaid dollars [11, 13].

The implications for pediatric rheumatology are significant. As a “cognitive” rather than procedure-based subspeciality, pediatric rheumatology is characterized by time-intensive visits and complex care coordination, which are poorly reimbursed under fee-for-service systems. When reimbursement rates decline while operational costs remain constant, institutions may struggle to maintain specialized pediatric services.

Reduced reimbursement could lead to fewer trainees entering the specialty, worsening the existing dearth of providers available to treat Medicaid patients. In a specialty plagued by workforce shortages, this would lead to further delayed diagnoses and initiation of therapies. The sequelae of irreversible joint damage, decreased physical function, and increased long-term health care utilization, would ultimately increase overall health system costs [8].

Beyond physician services, many children with rheumatologic diseases also rely on Medicaid for behavioral and mental health services, school-based therapy programs, and home health services; all essential for disease management and psychosocial support, allowing children to remain engaged in education while managing chronic illness.

Approved biologic medications, now central to the treatment of many pediatric rheumatic diseases, have an annual cost in excess of tens of thousands of dollars. Medicaid coverage, if reduced, would significantly limit their availability, and directly lead to worsening disease and increased disability.

In contrast, data indicate that Medicaid expansion under the Affordable Care Act improved survival outcomes for certain chronic pediatric diseases, underscoring the program’s broader role and importance for child health [14, 15].

Structural drivers of workforce fragility

Even in the absence of Medicaid cuts, pediatric rheumatology faces significant inherent structural challenges.

Pediatric rheumatology training typically requires ≥ 6 years of postgraduate education, yet compensation remains significantly lower than adult rheumatology and many other subspecialties despite shorter training pathways. These disparities are closely tied to Medicaid reimbursement structures, as pediatric rheumatology is a “cognitive” subspeciality and the lack of revenue generating procedures make it undervalued in current payment models [11]. Several strategies have been proposed to address these challenges.

Training pathway reform

One potential approach is shortening training duration by developing clinically focused fellowship tracks or combined pediatric residency-rheumatology pathways. This has recently been endorsed by the American Board of Pediatrics for rheumatology [16].

For physicians trained in internal medicine-pediatrics (Med-Peds), additional flexibility may be warranted. Under current models, Med-Peds physicians interested in combined rheumatology practice would require up to eight years of postgraduate training. Competency-based or abbreviated training pathways could enable Med-Peds and pediatrics physicians to also provide continuity of care across adolescence and adulthood, addressing critical gaps in transition care for patients with childhood-onset rheumatic disease.

Loan repayment programs

Educational debt continues to rise among medical trainees, exacerbated by accrued interest from prolonged subspecialty training [17]. Federal loan repayment programs have historically supported recruitment into pediatric subspecialties but are at risk given the recent uncertainties [18].

Strategic partnerships with philanthropic and community organizations capable of supporting targeted and fully funded loan repayment programs could play a critical role in addressing pediatric rheumatology workforce shortages and geographic maldistribution.

Expanding team-based care

The pediatric rheumatology workforce shortage is not solely a physician pipeline dilemma. Expanding the role and training of advanced practice providers (APPs), including nurse practitioners and physician assistants, represents a scalable solution to increasing clinical capacity [19].

Professional organizations such as the American College of Rheumatology have developed structured training curricula for APPs in rheumatology, helping to address knowledge gaps and facilitate integration into specialty practices. Team-based care models may allow practices to expand access to care while maintaining high-quality management of complex disease.

Workforce pathways and advocacy

Clinical exposure influences specialty choice [20]. Recruitment efforts should therefore begin earlier to engage trainees at multiple stages through structured pathway program to achieve a stronger workforce in pediatric rheumatology.

Importantly, the ACR Committee on Pediatric Rheumatology and ACR Committee Workforce Solutions are collaborating to target residents and medical students for earlier recruitment [21, 22].

Pathway initiatives such as The Academy for Workforce Advancement to Enrich Rheumatology Diversity (AWARD) [23], targeting medical students, undergraduate, and high school students from varied circumstances may help build a more diverse and sustainable workforce. These efforts can potentially be further supported through philanthropic campaigns and strategic partnerships with organizations such as the Arthritis Foundation, the Association of Women in Rheumatology, The Rheumatology Research Foundation, The Childhood Arthritis and Rheumatology Research Foundation (CARRA), and advocacy groups such as the Coalition of State Rheumatology Organizations (CSRO].

Although advocacy training has not been directly linked to workforce retention, preparing rheumatologists to navigate and influence reimbursement policy is essential to sustaining practice viability. Despite the field’s reliance on Medicaid reimbursement, trainees receive little formal education on Medicaid policy [24, 25]. Integrating advocacy training into fellowship curricula could help future rheumatologists navigate reimbursement systems and advocate for policies that sustain specialty care access. A workforce that understands the systems constraining practice is better positioned to achieve reform.

Conclusion

Pediatric rheumatology in the United States is at an intersection of workforce shortages, complex chronic disease management, and health policy vulnerabilities. The specialty faces an aging workforce, widespread fellowship vacancies, and geographic disparities in access to care.

Medicaid plays a central role in sustaining pediatric rheumatology services. Medicaid funding reductions risk broadening gaps in access and treatments and destabilizing an already fragile workforce. Sustainable access requires coordinated policy and workforce solutions. No single intervention will resolve this crisis. A multipronged strategy, as described, is required to safeguard care for children with rheumatic disease.

Abbreviations

CHIP

Children’s Health Insurance Program

Author contributions

Authors A.B.C. and G., contributed to the conception and design of the work, drafting of the manuscript, and critical revision for important intellectual content. All other authors contributed to the critical revision and editing of the manuscript. All authors approved the final version of the manuscript.

Funding

No funding was provided for this manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics and Consent to Participate declaration

Not applicable.

Competing Interest

Michelle V. Benjamin, MDNo relevant disclosures.Gail Kerr, MD, FRCP(Edin), MACRNo relevant disclosures.S. Amara Ogbonnaya, MDNo relevant disclosures.Gwenesta B. Melton, MDNo relevant disclosures.Sharon Dowell, MBBSAdvisory Board – AmgenAdvisory Board – Johnson & JohnsonGrace C. Wright, MD, PhD, FACRNo relevant disclosures.Mia T. Chandler, MD, MPHNo relevant disclosures.Disclosure Statement: The authors declare that they have no conflicts of interest relevant to this manuscript except as noted above.