Pediatric Care Levels in the United States: Definitions, Infrastructure, Staffing Models, and Implications for Access and Outcomes

Abstract

The landscape of pediatric healthcare provision in the United States has undergone profound and concerning transformations over the past two decades. A meticulous analysis reveals a significant decline in the number of hospitals equipped to deliver comprehensive ‘Level 1’ and ‘Level 2’ pediatric services, mirroring a simultaneous and substantial surge in facilities offering only minimal ‘Level 4’ pediatric care. This detailed research report comprehensively defines the various levels of pediatric care, elucidating the intricate infrastructure requirements, specialized equipment, and multidisciplinary staffing models intrinsic to each. It critically examines the evolving geographical distribution of these service levels across urban and rural settings, assessing the far-reaching implications of this stratification on patient access to specialized care, the quality of health outcomes for children, and the exacerbation of existing health inequities. Furthermore, this report synthesizes and proposes evidence-based best practices and policy interventions designed to optimize pediatric service delivery, foster resilient regional healthcare networks, and ensure equitable access to high-quality care for all children, irrespective of their demographic or geographical location. The ultimate aim is to provide a holistic understanding of the current challenges and to delineate a strategic roadmap for safeguarding the future of pediatric healthcare in the nation.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

1. Introduction

Pediatric healthcare in the United States is structured as a complex, tiered system, designed to categorize hospitals based on the intrinsic complexity and extensive range of services they are capable of providing to children. This hierarchical stratification, while conceptually sound, aims to meticulously match the medical needs of pediatric patients with the appropriate level of institutional capability, thereby striving to ensure that every child receives care precisely tailored to the severity and nature of their specific conditions. The theoretical underpinning of this system is to optimize resource allocation, enhance patient safety through specialization, and improve overall clinical efficiency. However, contemporary trends reveal a deeply concerning and systemic shift within this framework: a significant and precipitous reduction in the number of hospitals offering comprehensive, high-acuity ‘Level 1’ services, accompanied by an alarming proliferation of facilities providing only the most rudimentary ‘Level 4’ pediatric care. This evolving landscape warrants an urgent and comprehensive examination. Understanding the multifactorial implications of this profound shift is not merely an academic exercise but an essential imperative for policymakers, healthcare administrators, direct service providers, community leaders, and advocacy groups. Their collective efforts are critical in formulating robust strategies to not only maintain but also substantially enhance the quality, accessibility, and equity of pediatric care delivery across the nation (JAMA Network Open, 2023; Advisory Board, 2025).

The historical development of pediatric healthcare specialization emerged from a growing recognition that children are not simply ‘small adults’ but possess unique physiological, psychological, and developmental needs that necessitate highly specialized medical expertise and dedicated infrastructure. This led to the establishment of distinct children’s hospitals and specialized pediatric units within general hospitals, aiming to concentrate resources and expertise. The tiered system, initially conceived to rationalize this specialization, has inadvertently become a mirror reflecting broader systemic challenges within the US healthcare system, including economic pressures, workforce shortages, and geographical disparities. This report will meticulously delineate the characteristics of each care level, analyze the drivers behind the observed trends, explore their tangible impacts on vulnerable pediatric populations, and propose actionable strategies for systemic improvement.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

2. Definitions and Infrastructure Requirements of Pediatric Care Levels

The classification of pediatric care levels serves as a critical framework for delineating the capabilities of healthcare facilities in managing pediatric patients. These levels are generally defined by criteria encompassing staffing expertise, infrastructure, equipment availability, and the scope of services offered. A clear understanding of these distinctions is fundamental to appreciating the implications of the observed shifts in service distribution.

2.1 Level 1 Pediatric Care

Level 1 pediatric care represents the apex of pediatric services, embodying the highest possible standard of comprehensive and specialized care for children. These centers are almost exclusively found within large, freestanding children’s hospitals or as highly integrated departments within academic medical centers. Their fundamental mission is to manage the broadest spectrum of pediatric conditions, including the most acutely complex, critically ill, and technologically dependent cases, often requiring multi-organ support and highly specialized interventions. They serve as regional or even national referral centers for the most challenging patient populations (Frontiers in Public Health, 2024).

Infrastructure Requirements:

• Advanced Diagnostic and Therapeutic Modalities: These facilities boast state-of-the-art diagnostic imaging capabilities specifically adapted for children, including pediatric MRI, CT scans, advanced ultrasound, and nuclear medicine, often with child-friendly environments and sedation services. Therapeutic tools extend to advanced cardiac catheterization labs, interventional radiology suites, neurosurgical operating theaters equipped for microscopic and robotic procedures, and extensive rehabilitation facilities.
• Specialized Intensive Care Units: A cornerstone of Level 1 care is the presence of fully staffed and equipped Pediatric Intensive Care Units (PICUs) and Neonatal Intensive Care Units (NICUs). These units typically feature a high nurse-to-patient ratio (often 1:1 or 1:2 for critical cases), sophisticated monitoring systems, advanced mechanical ventilation including high-frequency oscillatory ventilation and extracorporeal membrane oxygenation (ECMO) capabilities, continuous renal replacement therapy (CRRT), and advanced hemodynamic monitoring. The NICUs are further specialized for extremely premature infants, those with complex congenital anomalies, and infants requiring prolonged intensive support (Wikipedia, 2024 – PICU).
• Dedicated Operating Theaters and Procedural Suites: Multiple operating rooms are specifically designed for pediatric surgery across all subspecialties, including cardiac, neuro-, orthopedic, general, plastic, and transplant surgery. These are outfitted with pediatric-sized instruments, anesthesia equipment, and monitoring devices.
• Comprehensive Laboratory and Pharmacy Services: In-house laboratories capable of performing highly specialized pediatric tests, genetic diagnostics, and rapid turnaround times for critical results are essential. An on-site pediatric pharmacy with expertise in compounding and administering medications for varying pediatric weights and physiologies is also critical.
• Emergency Department: A dedicated Pediatric Emergency Department (PED) staffed by board-certified pediatric emergency medicine physicians, offering 24/7 access to specialized emergency care, rapid diagnostic capabilities, and immediate access to all pediatric subspecialties.

Staffing Models:

• 24/7 Availability of Pediatric Specialists and Subspecialists: This is a defining feature. On-site presence or immediate availability (within minutes) of a vast array of board-certified pediatric subspecialists including intensivists, neonatologists, cardiologists, neurologists, oncologists, gastroenterologists, endocrinologists, nephrologists, pulmonologists, infectious disease specialists, geneticists, and many others. This typically involves robust fellowship programs contributing to continuous coverage.
• Multidisciplinary Support Teams: An extensive team of allied health professionals is integral. This includes pediatric anesthesiologists, certified pediatric nurses (CPN), respiratory therapists, child life specialists, social workers, nutritionists, physical, occupational, and speech therapists, developmental specialists, psychologists, and palliative care specialists. These teams collaborate in daily rounds and care planning.
• Academic and Research Focus: Level 1 centers often serve as major teaching hospitals, training the next generation of pediatricians and subspecialists through accredited residency and fellowship programs. They are also hubs for clinical research, participating in national and international trials to advance pediatric medicine.

2.2 Level 2 Pediatric Care

Level 2 centers provide a substantial range of pediatric services, capable of managing many common conditions and a significant number of complex cases. They often function as regional referral centers for less complex cases from Level 3 and 4 facilities but will transfer the most critical or specialized cases to Level 1 centers. These facilities are typically larger community hospitals or mid-sized children’s hospitals.

Infrastructure Requirements:

• Specialized Pediatric Units: Presence of PICUs and NICUs, though with potentially fewer beds and less comprehensive capabilities compared to Level 1 centers. They can manage moderately complex respiratory failure, sepsis, and common surgical recovery, but may lack capabilities for ECMO or highly specialized cardiac surgery.
• General Pediatric Wards: Dedicated pediatric inpatient wards with experienced nursing staff trained in pediatric care.
• Diagnostic Capabilities: Access to pediatric-appropriate imaging and laboratory services, though perhaps not 24/7 for all specialized tests.
• Pediatric-Equipped Operating Rooms: Operating rooms capable of performing a wide range of common pediatric surgeries.
• Emergency Department: A dedicated pediatric section within a general emergency department or a children’s emergency department with pediatric-trained staff.

Staffing Models:

• Availability of Pediatric Subspecialists: On-site or readily accessible pediatric subspecialists, often through on-call rotations rather than continuous in-house presence. Common subspecialties available might include cardiology, pulmonology, gastroenterology, and general surgery.
• Pediatric Hospitalists: In-house pediatric hospitalists providing 24/7 coverage for general pediatric admissions and consultations.
• Support Services: Access to pediatric anesthesiologists and respiratory therapists. Some child life services are typically available, alongside social workers and basic rehabilitation therapists.
• Referral Network: A robust system for rapid consultation and transfer to Level 1 centers for cases exceeding their capabilities, including specialized pediatric transport teams.

2.3 Level 3 Pediatric Care

Level 3 facilities offer basic pediatric services, primarily handling common pediatric conditions, providing immediate stabilization for more complex or critical cases, and preparing them for transfer to higher-level centers. These are typically smaller community hospitals or general hospitals with a pediatric unit.

Infrastructure Requirements:

• General Pediatric Units: Standard pediatric wards without specialized intensive care units. Monitoring capabilities are generally limited to non-invasive methods.
• Basic Diagnostic Services: Access to general imaging (X-ray, basic ultrasound) and a general hospital laboratory capable of common pediatric blood tests.
• Emergency Department: A general emergency department that may not have dedicated pediatric bays or staff but can stabilize pediatric emergencies.
• Limited Pediatric Equipment: Basic pediatric-sized equipment for resuscitation, intravenous access, and monitoring.

Staffing Models:

• General Pediatricians or Family Medicine Physicians: Pediatric care is primarily provided by board-certified general pediatricians or family medicine physicians who may have additional training in pediatrics.
• Limited Pediatric Subspecialty Services: Access to pediatric subspecialists is often limited and typically available through teleconsultation or referral only. They are rarely on-site.
• Basic Support Services: Availability of general anesthesiologists and respiratory therapists, who may have some experience with pediatric patients. Child life services are minimal or non-existent. Social work support is often generalized rather than pediatric-focused.
• Transfer Protocols: Clear and efficient transfer protocols and established relationships with Level 1 or Level 2 centers for patients requiring advanced care are crucial for patient safety.

2.4 Level 4 Pediatric Care

Level 4 centers provide minimal pediatric services, often found in rural, underserved areas, or as smaller critical access hospitals. They are equipped to handle only the most basic pediatric needs, such as routine well-child visits, minor illnesses, and injuries. They are typically not equipped for intensive care or complex medical management and serve primarily as points of initial contact for stabilization before transfer.

Infrastructure Requirements:

• Basic Pediatric Care Facilities: General medical wards or observation areas without specialized pediatric units or equipment. Outpatient clinics are the primary setting for pediatric care.
• Limited Diagnostic Tools: Access to basic X-ray and standard laboratory services for common blood tests.
• Emergency Services: A general emergency department that can provide initial stabilization for life-threatening pediatric conditions but must rapidly transfer any patient requiring more than immediate, temporary support.
• Minimal Pediatric Equipment: Very basic pediatric resuscitation equipment and supplies.

Staffing Models:

• General Practitioners or Family Medicine Physicians: Pediatric care is predominantly provided by general practitioners, family medicine physicians, or advanced practice providers (NPs, PAs) who may not have specialized pediatric training. They rely heavily on their general medical knowledge and the ability to consult with or refer to pediatric specialists.
• Limited or No Pediatric Subspecialty Services: Pediatric subspecialty access is virtually non-existent on-site and usually involves distant teleconsultations or direct patient transfers.
• Minimal Support Services: Limited or no access to dedicated pediatric anesthesiologists, respiratory therapists, or child life specialists. Nursing staff may have varied experience with pediatric patients but are not specifically pediatric-trained (Advisory Board, 2025).
• Robust Transfer Systems: An absolute necessity is a highly efficient and well-practiced transfer system, including agreements with higher-level facilities and access to regional transport services, often including air ambulance for critical cases.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

3. Trends in Pediatric Care Service Levels

The period between 2003 and 2022 has witnessed a dramatic and concerning reconfiguration of pediatric healthcare service levels across the United States. These shifts reflect underlying economic, demographic, and systemic pressures that have profound implications for patient access and health equity (JAMA Network Open, 2023).

3.1 Decline in Level 1, Level 2, and Level 3 Services

Between 2003 and 2022, the proportion of hospitals offering the broadest range of comprehensive pediatric services, classified as Level 1, experienced a substantial decrease of 38%. This reduction signifies a significant contraction in the availability of highly specialized, tertiary, and quaternary pediatric care. Concurrently, facilities categorized as Level 2 and Level 3, which offer moderate to basic comprehensive services respectively, also saw substantial declines, decreasing by 54% and 48%, respectively (JAMA Network Open, 2023). This pervasive trend indicates a broad consolidation of pediatric services into fewer, more centralized, and often geographically isolated specialized centers.

Drivers of the Decline:

Several interconnected factors contribute to this erosion of higher-level pediatric services:

• Economic Pressures and Financial Sustainability: Pediatric services are often less profitable than adult services due to lower reimbursement rates from public payers (Medicaid and CHIP, which cover a significant portion of pediatric patients) and the high fixed costs associated with maintaining specialized staff, equipment, and infrastructure. Level 1 and Level 2 centers require immense capital investment and ongoing operational expenses for advanced technology, round-the-clock subspecialist coverage, and comprehensive support services. Many hospitals, particularly smaller community hospitals, find it economically unsustainable to maintain these services (Advisory Board, 2025).
• Workforce Shortages: There is a critical and worsening shortage of pediatric subspecialists, including intensivists, neonatologists, surgeons, and various medical subspecialists. Recruiting and retaining these highly trained professionals, especially in non-urban areas, is exceedingly challenging. Burnout among existing staff, exacerbated by demanding schedules and increasing patient loads, further compounds the problem. The pipeline for training new subspecialists is insufficient to meet demand (Frontiers in Public Health, 2024).
• Consolidation and Mergers: The healthcare industry has seen a significant trend of hospital mergers and acquisitions. In this process, larger health systems often centralize specialized services, leading to the closure or downgrading of pediatric units in acquired hospitals to eliminate redundancy and achieve economies of scale. While this can streamline operations for the parent system, it reduces the overall number of accessible high-level facilities.
• Regulatory Burden and Accreditation Standards: Maintaining higher-level pediatric designations involves stringent regulatory compliance and accreditation standards, which can be costly and resource-intensive. Smaller hospitals may opt out of these designations to reduce administrative and financial burdens.
• Technological Advancements and Shifting Care Models: Advances in medical technology have enabled some procedures once requiring inpatient care to be performed in outpatient settings. While beneficial for certain conditions, this can reduce inpatient volumes for some services, making dedicated units less financially viable for hospitals with lower patient throughput.

3.2 Increase in Level 4 Services

In stark contrast to the decline in higher-level services, the proportion of hospitals providing the lowest pediatric capabilities, classified as Level 4, witnessed an alarming increase of 137%. In 2003, Level 4 facilities constituted 27% of all hospitals, but by 2022, this figure had soared to 65% (JAMA Network Open, 2023). This surge signifies a profound shift towards facilities offering minimal pediatric care, predominantly in rural or medically underserved areas.

Implications of the Increase in Level 4 Services:

• Default Option for Rural and Underserved Areas: The proliferation of Level 4 facilities is often a consequence of other hospitals closing their pediatric units or downgrading their capabilities. For many rural communities, a Level 4 facility may be the only local option for any pediatric care, necessitating extensive travel for anything beyond the most basic needs.
• Increased Reliance on General Practitioners: With fewer specialized pediatric units, the burden of initial pediatric assessment and stabilization falls disproportionately on general practitioners, family medicine physicians, and emergency room staff who may lack specialized pediatric training, potentially leading to diagnostic delays or suboptimal initial management.
• Strain on Higher-Level Centers: The increase in Level 4 facilities, coupled with their limited capabilities, means that Level 1 and Level 2 centers are likely to receive sicker patients who have experienced longer transport times and potentially less optimal initial stabilization. This places increased strain on their resources and contributes to bed shortages in PICUs and NICUs.
• Erosion of Regional Healthcare Ecosystems: This trend fragments regional pediatric healthcare ecosystems. While a referral system is crucial, an over-reliance on transfers from numerous Level 4 facilities to a few distant Level 1 centers creates logistical challenges, delays in care, and increased costs for families and the healthcare system (Medscape, 2025).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

4. Geographical Distribution and Impact on Access and Outcomes

The changing landscape of pediatric service levels has dramatically reshaped their geographical distribution, creating pronounced disparities that directly impact patient access to care and, consequently, health outcomes for children across the United States. The concentration of advanced services in urban centers, alongside the proliferation of minimal services in rural areas, exacerbates existing health inequities.

4.1 Urban vs. Rural Disparities

The distribution of pediatric care levels is markedly uneven across the United States. Urban and densely populated suburban areas predominantly host Level 1 and Level 2 centers, characterized by their capacity for highly specialized and complex pediatric care. Conversely, rural regions are overwhelmingly populated by Level 3 and, more significantly, Level 4 facilities (JAMA Network Open, 2023; Medscape, 2025). This disparity creates significant challenges related to access:

• Urban Areas: Children residing in urban areas generally benefit from a higher density of specialized pediatric services. This translates to better physical access, shorter travel times, and a broader choice of providers and facilities for both routine and complex care. The presence of multiple Level 1 and Level 2 centers fosters competition and innovation, potentially improving quality and service delivery.

• Rural Areas: Children in rural and remote regions face severely limited access to specialized pediatric care. These areas are frequently designated as ‘medical deserts’ or ‘maternity care deserts’ (Wikipedia, 2024 – Medical deserts; Wikipedia, 2024 – Maternity care deserts), meaning there is a severe shortage or complete absence of healthcare providers and facilities. For pediatric patients, this necessitates significantly longer travel times, often extending to several hours, to reach a higher-level facility. This burden falls heavily on families, imposing substantial logistical, financial, and emotional costs. Parents may need to take time off work, arrange childcare for other children, and incur expenses for transportation, lodging, and meals, often without adequate support. This ‘tyranny of distance’ not only delays diagnosis and treatment but also discourages families from seeking timely preventive or early intervention care, leading to conditions worsening before they are addressed.

4.2 Impact on Patient Outcomes

The stratification of pediatric services has profound and often detrimental implications for patient outcomes, particularly for children in underserved areas.

• Delayed Access to Specialized Care: Children in rural areas disproportionately experience delays in accessing specialized pediatric care. This is particularly critical for time-sensitive conditions such as pediatric trauma, acute appendicitis, severe infections, congenital heart disease requiring surgical correction, and pediatric cancers. For instance, studies indicate that rural residence is associated with worse surgical outcomes among infants at US children’s hospitals, largely due to delays in care access and transfer (PubMed, 2024 – Association of Rural Residence). Similarly, geographic access to pediatric cancer care in the US shows significant disparities, affecting treatment initiation and long-term survival (JAMA Network Open, 2023 – Geographic Access to Pediatric Cancer Care).

• Worsened Health Outcomes: Delays in receiving appropriate care can result in significantly worsened health outcomes. This includes higher rates of morbidity (e.g., increased complications from untreated infections, progression of chronic diseases) and, in critical cases, higher mortality rates. For pediatric trauma, delays in reaching specialized trauma centers can be fatal. Neonates requiring intensive care, particularly those with complex congenital conditions or extreme prematurity, face worse outcomes if transported long distances or if initial stabilization at a Level 4 facility is suboptimal due to lack of specialized expertise or equipment (ScienceDirect, 2024). Children with complex congenital heart disease in rural areas may experience greater preoperative morbidity due to prolonged waits for surgical evaluation (arXiv, 2024 – Transfer Learning Causal Approach).

• Exacerbation of Health Inequities: Disparities in access to pediatric care contribute significantly to broader health inequities, particularly affecting children from low-income, minority, and geographically isolated communities. These communities often face multiple barriers to care, including lack of insurance or underinsurance, language barriers, cultural insensitivity from providers, and limited health literacy. The absence of local specialized pediatric services forces these families to navigate complex and costly journeys for care, further entrenching health disparities. The Brookings Institution (2024) highlights how educational opportunity and access to pediatric care are intertwined, suggesting that communities with lower access to quality healthcare also often suffer from poorer educational outcomes, creating a vicious cycle of disadvantage (Brookings Institution, 2024).

• Mental Health Services: The impact is not limited to physical health. Pediatric mental health services are notoriously scarce across the US, and this problem is amplified in rural areas. Level 4 facilities rarely have mental health specialists, leaving children and adolescents with critical mental health needs without timely intervention, often leading to poorer long-term psychological outcomes and increased societal costs.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

5. Best Practices for Optimizing Pediatric Service Delivery

Addressing the evolving challenges in pediatric healthcare requires a multifaceted, collaborative, and innovative approach. Optimizing service delivery necessitates strategic interventions at the regional, policy, and community levels to bridge existing gaps and ensure equitable access to high-quality care for all children.

5.1 Strengthening Regional Networks

Developing robust, integrated regional networks is paramount for enhancing the delivery of pediatric services, particularly by connecting underserved areas with specialized care hubs. This ‘hub-and-spoke’ model is essential for rationalizing resource allocation and ensuring patient flow.

• Telemedicine and Telehealth Solutions: Implementing advanced telehealth solutions can significantly mitigate geographical barriers. This includes:

  • Real-time Interactive Telemedicine: Live video consultations between rural providers and urban pediatric subspecialists for diagnostic support, treatment planning, and monitoring chronic conditions. This allows for specialist input without requiring patient travel.
  • Store-and-Forward Telemedicine: Transmission of clinical data, images (e.g., dermatological lesions, radiological scans), and videos for asynchronous specialist review and consultation. This is particularly useful for non-urgent specialist opinions.
  • Remote Monitoring: Using wearable devices and home-based technology to monitor vital signs and other health parameters for children with chronic conditions, allowing for early detection of deterioration and timely intervention by a specialist located remotely.
  • Benefits: Telemedicine can reduce travel time and costs for families, improve access to specialist expertise, facilitate continuing medical education for rural providers, and support mental health consultations. Challenges include ensuring broadband access in rural areas, establishing clear reimbursement models, and navigating interstate licensing for providers.

• Mobile Clinics and Outreach Programs: Deploying mobile health units can directly provide services in underserved areas, bringing care closer to the patient.

  • Scope of Services: These units can offer well-child visits, immunizations, developmental screenings, management of common acute illnesses, chronic disease management (e.g., asthma education), and even basic dental or vision screenings.
  • Target Populations: Mobile clinics are highly effective in reaching geographically isolated populations, low-income communities, migrant families, and school-aged children.
  • Operational Considerations: Successful mobile clinic programs require strong community partnerships, culturally competent staff, efficient scheduling, and clear pathways for referral to higher-level care when needed.

• Standardized Referral and Transfer Systems: Establishing clear, efficient, and well-rehearsed referral pathways is crucial to ensure timely transfer of patients to the appropriate level of care. This involves:

  • Inter-hospital Agreements: Formalized agreements between Level 4/3 facilities and Level 1/2 centers outlining transfer protocols, communication channels, and clinical responsibilities.
  • Dedicated Pediatric Transport Teams: Specialized ground and air transport teams equipped with pediatric-specific monitoring and resuscitation equipment, staffed by pediatric critical care nurses, respiratory therapists, and paramedics, capable of stabilizing and safely transporting critically ill children. These teams act as an extension of the higher-level facility (ScienceDirect, 2024).
  • Shared Electronic Health Records (EHRs): Interoperable EHR systems across the network allow for seamless sharing of patient information, reducing diagnostic delays and ensuring continuity of care during transfers.

• Hub-and-Spoke Models of Care: Formalizing regional pediatric healthcare networks where Level 1 or Level 2 centers serve as ‘hubs’ supporting a network of ‘spoke’ Level 3 and Level 4 facilities. This model facilitates resource sharing, clinical guidelines dissemination, regular consultations, and coordinated patient movement.

5.2 Policy Interventions

Targeted policy measures are essential to address systemic disparities and support the maintenance and expansion of pediatric services.

• Incentivizing Pediatric Specialists in Underserved Areas: Financial and professional incentives can attract and retain pediatric subspecialists to rural and medically underserved areas:

  • Loan Forgiveness Programs: Expanding existing federal and state loan forgiveness programs for pediatricians and subspecialists who commit to practicing in designated underserved regions.
  • Scholarships and Grants: Providing scholarships for medical students and residents who commit to pediatric subspecialty training and subsequent rural practice.
  • Enhanced Reimbursement Rates: Increasing Medicaid and CHIP reimbursement rates for pediatric services, particularly for complex care and in rural areas, to make pediatric practice more financially viable.
  • Tax Credits and Housing Assistance: Offering tax credits or subsidized housing to specialists relocating to rural communities.

• Funding Support for Pediatric Services: Allocating dedicated resources to support the maintenance and expansion of pediatric services, especially in non-urban hospitals:

  • Rural Hospital Grants: Direct federal and state grants for rural hospitals to upgrade pediatric equipment, enhance infrastructure, and support specialized pediatric training for existing staff.
  • Telehealth Infrastructure Investment: Government funding for expanding broadband internet access in rural areas and providing telehealth equipment to underserved facilities.
  • Workforce Development Programs: Investing in expanding pediatric residency and fellowship programs, particularly those focused on general pediatrics and primary care, and supporting advanced practice provider (nurse practitioner, physician assistant) training with a pediatric focus.

• Data Collection, Research, and Policy Alignment: Enhancing robust data collection on pediatric care access, utilization, outcomes, and disparities is crucial to inform evidence-based policy decisions. This includes:

  • National Registries: Developing and maintaining national registries for specific pediatric conditions to track care patterns and outcomes across different service levels.
  • Health Equity Research: Funding research specifically targeting the social determinants of health affecting pediatric populations and the effectiveness of interventions in reducing disparities (Centers for Disease Control and Prevention, 2024).
  • Regulatory Reform: Reviewing and potentially revising state and federal regulations to facilitate regional network development, telemedicine adoption (e.g., cross-state licensing), and flexible staffing models for rural pediatric units.

5.3 Community Engagement

Engaging communities is vital for improving pediatric care, as it fosters local ownership, ensures relevance of services, and addresses non-medical barriers to care.

• Community Health Needs Assessments: Regularly conducting comprehensive community health needs assessments (CHNAs) to identify specific pediatric care needs, prevalence of chronic conditions, cultural preferences, and existing barriers to care. This ensures that services are tailored to the local population.

  • Methodologies: Employing a mix of surveys, focus groups, community forums, and analysis of public health data to gather insights directly from families and local leaders.

• Public Awareness and Health Literacy Campaigns: Educating communities about available pediatric services, the importance of preventive care, early intervention, and how to access different levels of care. This includes:

  • Digital Literacy: Training programs to help families navigate telehealth platforms and online health resources.
  • Disease-Specific Education: Campaigns for managing common pediatric conditions (e.g., asthma, diabetes) and recognizing signs of serious illness requiring immediate attention.
  • Child Life Program Awareness: Promoting awareness of child life services and their role in supporting children and families during healthcare experiences.

• Comprehensive Support Services: Providing non-medical support services to facilitate access to care and alleviate burdens on families:

  • Transportation Assistance: Collaborating with local non-profits, volunteer groups, or offering subsidized transportation for families needing to travel long distances for specialized care.
  • Childcare Support: Offering childcare for siblings when a parent must accompany a child for medical appointments or hospital stays.
  • Language and Cultural Navigation: Providing professional interpreters and cultural navigators to assist families from diverse linguistic and cultural backgrounds.
  • Housing Assistance: Partnering with Ronald McDonald Houses or similar organizations to provide affordable lodging for families whose children require extended stays at distant Level 1 centers.

• Partnerships with Schools and Local Organizations: Fostering strong collaborations with schools, community centers, faith-based organizations, and local government agencies to create a holistic support system for children’s health. School-based health centers, for example, can serve as crucial access points for primary pediatric care and early intervention services, particularly in underserved areas (Brookings Institution, 2024).

Many thanks to our sponsor Esdebe who helped us prepare this research report.

6. Conclusion

The evolving landscape of pediatric healthcare in the United States, marked by a disturbing decline in comprehensive ‘Level 1’ services and a dramatic increase in minimal ‘Level 4’ facilities, presents a profound challenge to the nation’s commitment to child health. This detailed analysis has illuminated the intricate definitions, extensive infrastructure, and specialized staffing required at each level of care, exposing the critical vulnerabilities introduced by the current trends. The uneven geographical distribution of these services, predominantly favoring urban centers while leaving vast rural areas underserved, has created significant disparities in access, leading to demonstrable negative impacts on patient outcomes and exacerbating existing health inequities among vulnerable pediatric populations (JAMA Network Open, 2023; Frontiers in Public Health, 2024).

Addressing these complex challenges necessitates a concerted, collaborative, and multifaceted approach. Strengthening regional networks through advanced telemedicine, strategic mobile clinics, and robust inter-facility transfer systems can bridge geographical gaps and ensure a continuum of care. Simultaneously, implementing targeted policy interventions, such as incentivizing pediatric specialists to practice in underserved areas, providing dedicated funding for pediatric services in rural hospitals, and enhancing data collection for evidence-based policymaking, is crucial for systemic reform. Furthermore, genuine community engagement, through needs assessments, public health education, and comprehensive support services, is vital to address the social determinants of health and non-medical barriers that impede access to care.

The future health and well-being of the nation’s children depend on our collective ability to reverse these concerning trends. It is an ethical imperative to ensure that every child, regardless of their zip code, socioeconomic status, or background, has equitable access to the highest quality of pediatric care. This requires sustained political will, innovative healthcare models, and a renewed commitment to investing in the specialized infrastructure and human capital necessary to safeguard the health of the next generation. The time for decisive action is now.

Many thanks to our sponsor Esdebe who helped us prepare this research report.

References

• Advisory Board. (2025). Fewer hospitals are offering pediatric services. Here’s what that means. advisory.com

• arXiv. (2021). COVID-19-Associated Orphanhood and Caregiver Death in the United States. arxiv.org

• arXiv. (2024). A Transfer Learning Causal Approach to Evaluate Racial/Ethnic and Geographic Variation in Outcomes Following Congenital Heart Surgery. arxiv.org

• Brookings Institution. (2024). Educational opportunity and access to pediatric care are more intertwined than you might think. brookings.edu

• Centers for Disease Control and Prevention. (2024). HHS Public Access. stacks.cdc.gov

• Frontiers in Public Health. (2024). Tiny patients, huge impact: a call to action. frontiersin.org

• JAMA Network Open. (2023). Geographic Access to Pediatric Cancer Care in the US. jamanetwork.com

• JAMA Network Open. (2023). Shifts in the Hospital Care of Children in the US—A Health Equity Challenge. jamanetwork.com

• Medscape. (2025). Rural Gaps Persist in Pediatric Trauma Care Access. medscape.com

• Pediatrics. (2024). A National Survey of Pediatric Post-Acute Care Facilities in the United States. journals.lww.com

• PubMed. (2024). Association of Rural Residence With Surgical Outcomes Among Infants at US Children’s Hospitals. publications.aap.org

• PubMed. (2024). Geographic access to care and pediatric surgical outcomes. pubmed.ncbi.nlm.nih.gov

• ScienceDirect. (2024). Disparities in access to healthcare services in a regional neonatal transport network. sciencedirect.com

• Wikipedia. (2024). Medical deserts in the United States. en.wikipedia.org

• Wikipedia. (2024). Maternity care deserts in the United States. en.wikipedia.org

• Wikipedia. (2024). Pediatric intensive care unit. en.wikipedia.org