I’m a pediatrician responsible for the health care of children across a large integrated health system spanning multiple states.

I’m also the mother of four, and I've been reminded annually for the past several years that my grandchildren will have to wait longer and travel further to receive medical care than my kids, as newly minted doctors choose not to train in pediatrics, particularly in pediatric medical subspecialties.

Already, severe shortages exist across every category of pediatric specialty care. And in the 2026 national fellowship match, no pediatric subspecialty filled all its available training positions.

Many filled less than half.

Even my field of neonatology — long considered one of pediatrics’ most competitive subspecialties — left nearly one in seven positions unfilled.

Across pediatrics, there are now more fellowship positions than applicants in several core subspecialties, clear evidence that the future workforce is shrinking at the same moment children’s medical needs are growing.

This is a dire crisis for pediatric care across the country, directly impacting children who depend on specialized medical expertise.

The consequences are already being felt. Children, particularly those with complex or chronic conditions, face extended wait times for appointments and often must travel long distances to access care. The lack of available subspecialists also increases the workload and burnout rates among existing pediatricians, leading to increases in early retirement and part-time work that further limit patient access.

The reasons behind this alarming decline are multifaceted, but one cause stands out.

Receiving less for doing more

Pediatric subspecialists receive strikingly low salaries compared to their adult medicine counterparts, with some earning less than half for same specialty. This disparity persists even though pediatric subspecialists complete up to three additional years of training and manage more complex, higher‑acuity patients.

That means they go to school longer, incur larger debt, deal with more difficult cases, and for all that receive a pay cut.

Why is this? The current system for valuing physician work, known as Relative Value Units (RVUs), disproportionately rewards adult medical care over pediatric care. 

For example, a colonoscopy performed on a child is reimbursed at approximately half of an adult colonoscopy — despite the fact that pediatric colonoscopies are both technically more difficult and performed only on ill patients with multiple other medical conditions while most adult colonoscopies simply screen healthy adults.

Likewise, when I place a thoracostomy tube in a 1-pound infant, my hospital receives about 30% less than an adult hospital for the same procedure. Again, the complexity, difficulty, and risk of my procedure is dramatically higher, yet my work is paid substantially less.

Exacerbating this financial challenge is the critical role of Medicaid, which insures nearly half of all children in the United States.  

Medicaid only covers a fraction of children’s hospitals’ costs to provide care, forcing them to take a loss on most pediatric patients. This underpayment directly results in lower revenue for all pediatric care, which in turn leads to lower salaries for pediatric subspecialists.

The result is a vicious cycle where financial instability disincentivizes talented medical students and residents from pursuing these critically important fields.

Solutions for our grandchildren

Four practical actions can break the cycle and restore the workforce our nations’ kids rely on — but we must act immediately.

1. Improve reimbursement rates

First and foremost, Congress must prioritize children’s health by allocating federal funds to increase reimbursement rates for pediatric services, achieving parity with adult care rates which are often benchmarked to Medicare.

2. Reform RVUs

The Centers for Medicare & Medicaid Services must reform the RVU system to accurately reflect the time, skill, and effort involved in pediatric care, particularly for non-procedural subspecialties, perhaps through a “pediatric booster” for relevant medical codes. These essential steps would stabilize the financial foundation of pediatric care.

3. Offer loan repayment

Increased funding for loan repayment programs specifically targeting pediatric subspecialties and those serving underserved populations is also vital to alleviate the crippling debt burden of medical education in the U.S.

4. Adopt “funds flow” models

Finally, pediatric departments and health systems must advocate for “funds flow” models that equitably support these critical subspecialties, ensuring competitive salaries and fostering an environment where pediatricians are not economically penalized for their commitment to children.

The future health of our children depends on a robust and well-supported pediatric workforce. It’s time for the public, policymakers, health care leaders, and academic institutions to recognize this crisis and act decisively to ensure every child has access to the specialized care they need. 

Our children and grandchildren deserve it.