Healing the Hidden Harm: Medicaid, Cortisol, and the Kids We're Missing

“Children are the future,” is a phrase that has been passed around for years, from the 31st President, Herbert Hoover, to Whitney Houston and everyone after that. There are books, classes, degrees, and even entire professions structured around the idea that children represent our hope for a better tomorrow. 

But what happens when the very systems that were designed to protect the future- healthcare, economic support, mental health services and so many others- fail the children who need them most? 

Biology & Poverty : The Two Unlikely Friends

For those who have been fortunate enough to not grow up in poverty, hearing the word brings a few images to mind. Children eating whatever they can to not be hungry or wearing whatever clothes their family could afford. However, one of the most overlooked and hidden consequences of poverty is chronic stress and its physiological marker: cortisol. 

The reality is, growing up in poverty actually changes their biology too. Children in low-income households are more likely to experience chronic stress. When a child experiences high levels of stress it activates their hypothalamic-pituitary-adrenal axis (HPA) and increases the release of cortisol, the body’s primary stress hormone. While cortisol is adaptive in short bursts, chronic elevation becomes neurotoxic, disrupting brain development and regulatory systems⁷. Research shows that socioeconomic disadvantage in early childhood is associated with dysregulation of cortisol rhythms, heightened reactivity to stressors and lasting alterations in brain structures involved in memory, emotional control and executive functioning ^2,4. 

These effects aren’t just theoretical - they manifest in measurable and observable developmental outcomes that persist across time. Children exposed to chronic stress and elevated cortisol levels are more likely to exhibit externalizing behaviors, such as aggression and hyperactivity, as well as internalizing symptoms, including anxiety and depression⁵. These behavioral disruptions often translate into academic difficulties, including poor attention regulation, impaired working memory, and reduced executive functioning. All of which are critical for classroom learning and social adaptation². As these children grow older, they also show an increased vulnerability to a wide range of physical and mental health disorders⁸ including cardiovascular disease, metabolic syndrome, substance use, and clinical depression. Fundamentally, early exposure to toxic stress biologically hardwires disadvantage, reinforcing health disparities that extend beyond childhood and well into adulthood⁹. These cortisol patterns can be directly observed in research comparing children across socioeconomic levels. As shown in Figure 1, children from high-poverty households tend to show slower recovery from stress, indicating that their physiological stress response system may be chronically overactivated². This kind of HPA-axis dysregulation is not only biologically taxing—it increases risk for a host of physical and mental health conditions later in life.

Figure 1. Cortisol recovery following stress exposure in children from high-poverty (Hi Pov) and low-poverty (Lo Pov) households.

Children living in high-poverty households exhibit blunted cortisol recovery, meaning their stress response remains elevated for longer periods compared to their peers in low-poverty environments. This pattern reflects dysregulation of the HPA axis and is associated with increased risk for long-term emotional and physiological health issues².

The Medicaid Gap: When Help Isn’t Reaching Who it Should

Medicaid and the Children’s Health Insurance Program (CHIP) were created to provide access to healthcare for low-income families. Unfortunately, not all families get access, even when they qualify. Some of the barriers include: 

• Optional Medicaid expansion for states, leading to unequal access across the U.S.

• Paperwork and red tape

• Language, literacy, and digital access challenges 

• Misinformation, especially in mixed-status immigrant families, preventing eligible children from receiving care due to fear or confusion about their status. This is known as the “welcome mat” effect, where coverage for adults through Medicaid expansion also increases enrollment among their children⁶.

Without adequate healthcare coverage, families often forego preventive care, mental health services, and developmental screenings, magnifying the effects of early adversity and reinforcing the chronic stress embedded within the home environment. 

Why This Matters - Biologically and Economically 

Chronic cortisol elevation in early childhood is associated with: 

• Elevated risk for anxiety, depression, and aggression⁵ 

• Lower school readiness and academic achievement² 

• Increased incidence of adult cardiovascular and metabolic diseases⁸

These outcomes generate long-term strain on public systems such as healthcare, education, welfare and the justice system. Investment in early prevention and preventive care is not only ethically sound- it is economically rational. 

Policy Recommendations

To mitigate these different tolls of poverty, the following policy actions are critical: 

• Expand Medicaid and CHIP eligibility and outreach, particularly in states that have not adopted Medicaid expansion⁶

• Simplify enrollment processes and reduce administrative churn, especially for families with fluctuating incomes¹

• Invest in early childhood health and mental health services, including home-visiting programs and trauma-informed pediatric care⁹

• Train providers in recognizing and responding to toxic stress, integrating behavioral health into routine care² 

More Than a Slogan

“Children are the future” is more than a slogan - it is a measurable truth. The biological embedding of poverty-related stress, particularly via elevated cortisol levels, is an urgent public health issue. Without reliable access to healthcare, these struggles don’t stop in childhood. They often grow worse over time, creating long-term cycles of hardship that can pass from one generation to the next. 

If we truly believe in protecting the future, then ensuring that every child has access to care, regardless of socioeconomic status, must be a national priority. We have the science. We know what works. What we need now is the will to act. 

References

1. Alker, J., & Roygardner, L. (2019). The number of uninsured children is on the rise. Georgetown University Center for Children and Families.

2. Blair, C., & Raver, C. C. (2016). Poverty, stress, and brain development: New directions for prevention and intervention. Academic Pediatrics, 16(3), S30–S36. https://doi.org/10.1016/j.acap.2016.01.010

3. Blair, C., & Raver, C. C. (2016). Poverty, stress, and brain development: New directions for prevention and intervention. Academic Pediatrics, 16(3 Suppl), S30–S36. https://doi.org/10.1016/j.acap.2016.01.010 

4. Evans, G. W., & Kim, P. (2007). Childhood poverty and health: Cumulative risk exposure and stress dysregulation. Psychological Science, 18(11), 953–957.

5. Gunnar, M. R., & Donzella, B. (2002). Social regulation of the cortisol levels in early human development. Psychoneuroendocrinology, 27(1–2), 199–220.

6. Hudson, J. L., & Moriya, A. S. (2017). Medicaid expansion for adults had measurable 'welcome mat' effects on their children. Health Affairs, 36(9), 1643–1651. https://doi.org/10.1377/hlthaff.2017.0347 

7. Lupien, S. J., McEwen, B. S., Gunnar, M. R., & Heim, C. (2009). Effects of stress throughout the lifespan on the brain, behaviour and cognition. Nature Reviews Neuroscience, 10(6), 434–445. https://doi.org/10.1038/nrn2639 

8. Miller, G. E., Chen, E., & Parker, K. J. (2011). Psychological stress in childhood and susceptibility to the chronic diseases of aging: Moving toward a model of behavioral and biological mechanisms. Psychological Bulletin, 137(6), 959–997.

9. Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: Building a new framework for health promotion and disease prevention. JAMA, 301(21), 2252–2259.

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Cami Howard, a Healthcare Representative at Summit, is a recent graduate of Purdue University where she obtained her degree in Brain and Behavioral Sciences. During her coursework, she learned more about hormones, trauma, and neuropsychology, which has sparked her interest in childhood trauma and the stress it has on hormones and development. Following graduation, she worked as a case manager at a nonprofit mental health center. She was able to take her passion and turn it into meaningful work after witnessing firsthand how trauma and systemic barriers can shape family dynamics, health outcomes and overall well-being. When she is not focused on her professional passions, Cami loves coaching solidcore classes part time as it gives her the opportunity to connect with different people in the community. She also loves to find ways to move her body, whether that be at the gym, playing tennis, or adventuring around outside. Cooking has also become a new found love as she has been trying to eat more GERD friendly meals.

Summit Managed Solutions is a management consulting and professional services firm that partners with healthcare organizations across the private, public, and social sectors to create value. By providing comprehensive solution management and inclusive business operation services, Summit helps deliver specific, transformative outcomes. With consulting and managed service offerings, Summit helps partners overcome the critical challenges associated with people, process, and technology, while providing partners with flexibility, reliability, and innovation that will propel growth.