-LRB- CNN -RRB- -- These are hard times in the United States . The government released its annual report on income , poverty and insurance coverage last week . The median income in the U.S. in 2010 was $ 49,445 , which is 2.3 % lower than it was in 2009 . But that 's just the median . To understand how bad things really are , we need to look at poverty . Let 's be explicit . To qualify as below the poverty line , you have to be really poor . A single person under the age of 65 has to earn less than $ 11,244 to be considered in poverty . That 's significantly less than a full-time minimum wage job . A single mother with a child has to make less than $ 15,030 to be considered in poverty . The percentage of people who met these criteria increased to 15.1 % in 2010 from 14.3 % in 2009 . It 's gone up steadily since 2007 when it was 12.5 % . What really hurts , however , is exactly who in America qualifies as living in poverty . Because of the social safety nets in place , relatively few people over 64 are very poor -LRB- 9 % -RRB- . Children , on the other hand , suffer greatly . About 22 % of Americans under 18 live in poverty . Let me say that again : More than one in five children in the United States is living in poverty . Children account for more than one-third of all such people in the U.S. right now . Think about that when we talk about how to save money in the future . I 'm a health services researcher , and incredibly invested in how we reform the health care system of this country . It 's why I 'd also like you to focus on the plight of the uninsured . In 2010 , the report said , the number of people in the United States who lacked insurance for an entire year was 49.9 million . This is the largest number of people without insurance since the passage of Medicare and Medicaid . Almost all of these people are below 65 . -LRB- Pretty much every American over 65 is on Medicare , after all . -RRB- It gets worse . The percentage of Americans who were covered by private health insurance decreased again -- to 64 % ; the number of people covered by employer-provided health insurance dropped to 55.3 % . Where did all of these people go ? Lots of them went to the government , as the number with Medicaid coverage increased to 15.9 % and those with Medicare coverage increased to 14.5 % . America is hurting . Unemployment is on the rise . Poverty is increasing . More people are losing or unable to get private insurance , and turning to our safety nets for coverage . Most of the benefits and improvements of the Affordable Care Act -- the large Medicaid expansion , the exchanges , the mandate , the subsidies -- wo n't go into effect until 2014 . -LRB- An early feature of the act that has already gone into effect has allowed hundreds of thousands of young people under 26 to remain on their parents ' insurance , and this group has fared better . -RRB- This is the truth we face as we talk about how to reform the health care system : Some claim we need to depend on the private market more and more , but it 's shrinking and unable to cover those who need it . Some want to cut Medicaid funding , but it 's responsible for covering more and more Americans . It 's important to face reality . Of the 75 million or so children in the United States right now , more than one third are covered by Medicaid ; an additional 10 % or so are uninsured . When we talk about cutting Medicaid funding , we 're talking about making things worse for these children . There 's no getting around that . I know that there 's a deficit problem , and I know that it 's important to get a handle on entitlement spending . But we ca n't ignore that right now Medicaid is one of the cheapest insurance programs around . People seem to have forgotten , but the reason the Affordable Care Act puts 20 million more people in Medicaid is that it was cheaper than putting them in the exchanges to get private insurance . Moreover , about 5 % of Medicaid enrollees account for more than 50 % of all Medicaid spending . That spending is almost all on elderly and disabled people . It 's unlikely these people will be cut from Medicaid . Poor children ? Poor adults ? Far more likely . There will be hard decisions ahead . No one can deny that entitlement spending , especially health care spending , is unsustainable on its current path . We must be able to look at the budget and talk about areas where we might spend less . That will inevitably lead to some groups getting less than they did before . Yet , as voting blocs and advocacy groups defend their piece of the pie , let 's not forget those who can not speak for themselves . The ranks of the poor are growing . They 're populated with children . And they depend on Medicaid for their health care in increasing numbers . Let 's not sacrifice their future while we 're trying to save it for the rest of us . The opinions expressed in this commentary are solely those of Aaron E. Carroll .