Explaining state variability in pediatric hospitalizations and reported child maltreatment - children from families with low socioeconomic status (SES) have diminished health and well-being compared…

The National Institute of Child Health and Human Development awarded Children's Mercy Hospital $1.907 million on September 15, 2025, under the Child Health and Human Development Extramural Research program (CFDA 93.865) to examine state-level safety net policies and their association with pediatric hospitalizations and reported child maltreatment among low-income families. The project runs through July 31, 2030, with place of performance in Kansas City, Missouri.

The research will create a publicly available dataset of four state safety net policies, exploit variability in state policies to determine their associations with two dimensions of child well-being—physical and mental health hospitalizations and adverse childhood experiences—and test whether policy form as either "bolus" (annual one-time) or "continuous" (ongoing annual) income support affects outcomes. The investigators will conduct sub-state-level analyses at census public-use microdata areas and counties to overcome limitations of prior ecological approaches, then perform econometric analyses including dynamic difference-in-differences estimation and microsimulation of safety net benefits.

Sub-recipients include the National Association of Children's Hospitals and Related Institutions (analytical support including dataset merging and factor analysis), the University of Kansas Center For Research Inc. (econometric methods, TAXSIM model implementation for estimating exposure and eligibility, and manuscript preparation under principal investigator Donna Ginther), Temple University's Center for Public Health Law Research (development and validation of a legal scoring criteria index for state laws across a multi-year pilot and full-state rollout), and Kaiser Foundation Research Institute (health services research guidance and analysis interpretation under principal investigator Paul Chung).

Explaining state variability in pediatric hospitalizations and reported child maltreatment - children from families with low socioeconomic status (SES) have diminished health and well-being compared to children from families with higher SES, including higher rates of hospitalizations and child maltreatment. SES is multidimensional and, for children, includes family income. The investigators recently discovered substantial variability across states in the relationship of family income with rates of both pediatric hospitalizations and child maltreatment. State safety net policies, by supporting families with low income, may explain this variability. However, there has been no previous research on whether state safety net policies are associated with hospitalizations for either children or adults. Along with others, the investigators demonstrated at the state level that safety net policies are associated with reduced rates of child maltreatment, but the precision of that work was limited by state level ecological approaches. Their preliminary data suggests that the form of these policies - as either "bolus" or "continuous" supports - may be a critical and modifiable aspect of their impact. Three state policies act as an income "bolus" for families via annual one-time income support. In contrast, state minimum wage policies act as a "continuous" income support across the year. The investigators will exploit the variability in these state policies to determine their associations with two dimensions of child well-being: physical and mental health (hospitalizations) and adverse childhood experiences (child maltreatment). Their approach overcomes the limitations of prior state level ecological analyses, allowing them to examine the impact of the policies at the level of census public-use microdata areas (pumas) and counties. They have three specific aims: (1) create a publicly available dataset of four state safety net policies that adheres to the highest standards of legal research in all 50 states from 2000- 2020. Then, to determine if state variability in three "bolus" policies and one "continuous" policy are associated with (2) all pediatric hospitalizations by merging 225 ahrq hcup state inpatient databases from all states that have the patient's home ZIP code (n=15) every year during a 15-year period (2005-2019) and (3) all reports of child maltreatment investigated by child protective services from all 50 states in the national child abuse and neglect data system (ncands) every year during a 15-year period (2005-2019). The study will also explore the relationship of these policies with pediatric ED visits and specific diagnoses which may be more sensitive to the policies' effects. The proposed research is significant because IT will fill a critical knowledge GAP on the relationships of specific safety net policies with pediatric hospitalizations and maltreatment. The proposed research is innovative because IT is the first study to examine the impacts of safety net policies on hospitalizations, the first to examine the form of such policies (i.e., bolus VS. Continuous), and IT overcomes imprecise state-level methodological limitations through the examination of outcomes at the puma and county levels.