Infant Health Care Disruptions by Race and Ethnicity, Income, and Insurance During the COVID-19 Pandemic

Children's Continuous Medicaid Eligibility During COVID-19 and Health Care Access, Use, and Barriers to Care

Importance

National continuous Medicaid eligibility under the Families First Coronavirus Response Act (FFCRA) may have differentially affected children's health care depending on whether states had preexisting 12-month continuous Medicaid eligibility for children.

Objective

To estimate the association of states newly implementing continuous Medicaid eligibility under the FFCRA with children's health care access, health care use, and barriers to care.

Design, Setting, and Participants

This survey study used a difference-in-differences research design comparing states before (2017-2019) and during (2020-2022) the FFCRA overall, by caregiver-reported race and ethnicity, and among publicly insured children. Analyses used data from the National Survey of Children's Health (NSCH), an annual household survey on the health and well-being of children 0 to 17 years old in the US. Data were analyzed from September 2024 to March 2025.

Exposures

Whether states had pre-FFCRA 12-month continuous Medicaid eligibility for children.

Main Outcomes and Measures

Insurance coverage, gaps in coverage, unmet health care needs, any health care visits, preventive visits, emergency department visits, hospitalizations, any time spent weekly arranging children's health care, and problems paying medical bills.

Results

The sample included 215 884 children, with children in states with pre-FFCRA continuous eligibility being similar to children in states newly implementing continuous eligibility with respect to age (8.6 years old in both sets of states), gender (49.6% female compared to 48.5%), and nativity (66.7% third generation or longer with all parents born in the US vs 69.6%), with lower proportions who were non-Hispanic Black (11.9% compared to 13.8%) or non-Hispanic White (50.5% compared to 52.9%), and higher proportions who were Hispanic (25.5% compared to 23.9%). In adjusted difference-in-difference models, newly implementing continuous eligibility under the FFCRA was associated with a 0.7-percentage point (95% CI, -1.2 to -0.1 percentage point) reduction in children's unmet health care needs. There was no evidence of additional FFCRA-associated changes in outcomes overall. In subgroup analyses, there were reductions in coverage gaps, unmet health care needs, and time spent arranging care among Hispanic children and publicly insured children.

Conclusions and Relevance

In this survey study, newly implementing continuous eligibility for children under the FFCRA was associated with reductions in unmet health care needs and no additional changes in health care outcomes overall, with additional benefits for Hispanic children and publicly insured children. This could reflect expected changes under mandatory, national 12-month continuous eligibility for children implemented in January 2024.

Disproportionate Enforcement of a Hospital's Safe Sleep Policy for Racial and Ethnic Minority Families

OBJECTIVE

We aimed to evaluate the enforcement of a staff-initiated children's hospital safe sleep policy for evidence of systemic racism.

PATIENTS AND METHODS

Retrospective medical record review of staff-initiated safe sleep policy enactments was performed. Demographic data of infants aged 12 months or younger with an unsafe sleep event (USE) documented in the electronic health record were compared with logistic regression to infants without USEs. Time to escalation of USEs was analyzed using survival analysis. Descriptive statistics were used to compare median number of warnings and outcomes of escalation for each demographic group.

RESULTS

Of 233 infants with USEs, a disproportionate number were Non-Hispanic Black (NHB) (52%) compared with infants without USEs (23% NHB) (P < .01). When adjusting for confounding variables, NHB infants were 2.42 times more likely to have an USE compared with Non-Hispanic white (NHW) infants (OR, 2.42; 95% CI, 1.63-3.58; P < .01). NHW infants had a significantly longer median time between first and second warnings compared with all other groups (P < .01), and the time to fourth warning for NHW infants was over 6 times that for NHB infants. The only instances of USEs that escalated to hospital security involved NHB infants.

CONCLUSION

Disparities suggestive of systemic racism were identified in the enforcement of a children's hospital safe sleep policy. For hospitals looking to adopt or revise safe sleep policies, the authors suggest careful consideration of potential impacts on already systemically marginalized families. We suggest replacing punitive consequences of policy nonadherence with interventions to facilitate behavior change in the hospital and after discharge.