Reducing Child Food Insecurity After COVID-19: Policy Innovations And Cross-Sector Partnerships

Childhood food insecurity rapidly increased in the first months of the COVID-19 pandemic, with the rate of food insecurity in households with children nearly doubling to almost 30 percent by the summer of 2020. The US Department of Agriculture (USDA) found that nearly 15 percent of children nationwide lived in households experiencing food insecurity by the end of 2020, which was the first rise in food insecurity rates since 2011, and Black and Hispanic families were disproportionately impacted. This substantial rise in demand for food support catalyzed rapid and much-needed changes in supplemental food systems that were previously hindered for decades by complicated enrollment procedures and outdated regulations. For example, federal waivers issued during the pandemic permitted remote issuance of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) benefits, extension of certification periods for the Supplemental Nutrition Assistance Program (SNAP), and replacement of school meals through the Pandemic Electronic Benefit Transfer (P-EBT) program. These temporary policy changes were accompanied by new or strengthened local community responses, ranging from greater investment in food banks to increased reach of programs providing supplemental weekend food to children.

Prior to these innovative policy and community-led efforts responding to the rise in food needs during the COVID-19 pandemic, children’s health care providers were already playing a role in screening for and addressing food insecurity among children and families. An increase in screening during clinical encounters is driven by robust evidence linking childhood food insecurity to poorer child health outcomes that persist across the life course. When families are identified as food insecure by screening, clinicians most often direct patients to outside resources, including government food assistance programs and community-based organizations (CBOs) providing direct food distributions to families. However, health care systems screening for food insecurity and organizations best positioned to provide resources addressing food insecurity often operate in siloes, with very limited collaboration across these sectors. Additionally, the capacity of CBOs to respond to food insecurity—in the context of increased referrals from clinical screening, economic hardships caused by the COVID-19 pandemic, and soaring inflation—is insufficient or tenuous at best.

COVID-19 has highlighted the imperative role of policy innovation and collaborative partnerships among clinical practices, government agencies, and CBOs in developing sustainable system-level changes to meet the food needs of children and families. To understand innovations developed within the fragmented supplemental food system for children, we talked with 34 informants representing government programs, school programs, and CBOs addressing food insecurity in North Carolina from December 2020 to March 2021. In these semi-structured interviews, we assessed the cross-sector response to rising food needs for children and the potential for programmatic sustainability in pandemic recovery. Here, we present three recommendations for policy makers, health care systems, and local stakeholders that build on key national and statewide policies implemented during the COVID-19 pandemic to promote collaborative efforts.

Recommendation 1: Facilitate Data Matching Across Benefit Programs

When schools closed in March 2020, the new P-EBT program gave states the option to provide nutrition benefits distributed on EBT cards for families with children receiving free or reduced lunch through the National School Lunch Act. In North Carolina, the enrollment and school attendance data needed to administer the P-EBT program were housed in two separate state departments—the North Carolina Department of Health and Human Services and the North Carolina Department of Public Instruction linking to the National School Lunch Program. Therefore, atewide administration required implementation of data-sharing agreements. The use of cross-program data sharing dramatically simplified enrollment and distribution of P-EBT benefits to families throughout the pandemic. While this type of data sharing was previously allowed under federal regulations, the required data-sharing agreements were challenging to create and were not always prioritized prior to the pandemic. In our interviews, this was noted as a major barrier preventing state program leaders from simplifying eligibility identification before the pandemic. The requirement for data-sharing agreements was also frequently mentioned by school social workers and nutrition program leaders as a barrier they continue to face when attempting to enrolling eligible children into school-based nutrition programs. However, the unique precedent set by cross-program data matching for the P-EBT program makes eligibility matching a feasible reality. In this process, which has been supported as a potential mechanism to ensure all families are enrolled in benefits for which they are eligible, data for beneficiaries enrolled in a program, such as Medicaid, are used to identify those who are adjunctively eligible but not participating in another program, such as WIC. For example, in data matching, a three-year-old child enrolled in Medicaid, who is also eligible for WIC but not enrolled, could be identified and targeted, outreach could then facilitate WIC enrollment. The unprecedented circumstances of COVID-19 accelerated momentum to overcome data-sharing barriers, resulting in policies that promoted effective cross-sector integration of child services between nutrition support programs and schools.

Informants involved in the rapid development of the P-EBT program in North Carolina noted the importance of a clearly articulated, shared priority of feeding children across social services and public instruction agencies, which served as a critical component to catalyze the coordination between these two state agencies. Representatives from these agencies reported meeting frequently to ensure alignment of goals and values, generate creative solutions to troubleshoot regulatory and data barriers, and build and maintain momentum to ensure cross-agency agreements were executed. The P-EBT program was a critical resource for many families during the pandemic, which reduced the number of families reporting child hunger by approximately 17 percent in the 2020–21 school year. State agencies should continue to build on these new collaborations and the agreements forged during the pandemic as well as identify additional partners who share the goal of ensuring no child goes hungry.

Cross-program data matching and adjunctive eligibility, which is automatic income-eligibility determination for families enrolled in another means-tested program, occur across various social programs and with wide-ranging success across the United States. Cross-program data matching and adjunctive eligibility are important tools to streamline eligibility determination, simplify the administrative burden of enrollment and recertification for families, and increase more equitable enrollment in currently underused federal benefit programs that have strong evidence supporting the improvement in child health and well-being. Therefore, consideration of additional data-sharing agreements for cross-program data matching, including Medicaid, SNAP, WIC, and the National School Lunch Program, is critical in the coming years. As demonstrated by the P-EBT program, these agreements take commitment and resiliency in the face of cumbersome approval processes that can slow momentum. The success of the P-EBT program in feeding children demonstrates that cross-sector collaboration and data sharing can be successful when prioritized by state leaders.

Recommendation 2: Integrate Systems Of Care By Identifying Social Needs In Health Care Systems And Creating New Financial Partnerships With Community-Based Organizations

While food insecurity screening is increasingly common in some clinical settings, in North Carolina, the recent transition to Medicaid managed care has included the rollout of universal, standardized social needs screening for all Medicaid beneficiaries. With clinicians already frequently referring to external food resources to address food insecurity identified during clinic visits, the systematic food insecurity screenings of all Medicaid beneficiaries could substantially increase referrals to CBOs. However, several community-based stakeholders we spoke with in the year leading up to implementation were unaware of plans to systematically screen all Medicaid beneficiaries for social needs. There is significant opportunity for health care systems to further partner with CBOs to integrate community-based referrals and resources into clinical settings, as CBOs have the needed expertise to address unmet social needs in the community. The development of intentional, long-term partnerships between health care entities and CBOs can allow for enhanced integration of services that address immediate social and health needs, while also creating opportunities to develop cross-sector upstream solutions.

Beyond partnering with CBOs to address social needs identified in clinical settings, collaborative nutrition support strategies between health care systems and CBOs are necessary to improve child food security. CBOs require financial support to address an increasing number of referrals, as almost all CBO informants we interviewed reported that a lack of funding threatened their long-term sustainability driven by the substantial increase in children and families served during the pandemic. One solution could be to coordinate partnerships that share finances and accountability for improved health outcomes among health systems, payers and CBOs. Value-based payment models, which go beyond typical fee-for-service payment structures and can provide reimbursement for addressing food insecurity or other drivers of health traditionally felt to be out of the scope of health care, provide an opportunity to better integrate health care-based food insecurity screening with CBOs food resources for families. With health systems not optimally situated to address social determinants of health that impact health care costs, and CBOs having the infrastructure to address these social needs, this type of partnership could mutually benefit both parties. 

The Healthy Opportunities Pilot is an innovative Medicaid-shared financial structure developed prior to the COVID-19 pandemic to better coordinate clinic-community efforts addressing social drivers of health, which is being piloted in North Carolina under a section 1115 Medicaid waiver. The Healthy Opportunities Pilot will provide reimbursement for evidence-based interventions that address the social drivers of health, such as housing, food, transportation, and toxic stress, to high-risk Medicaid beneficiaries. To address food insecurity, the Healthy Opportunities Pilot provides healthy food boxes and fresh produce prescriptions to families, with an additional option for delivery, and can also provide food and nutrition resource navigation. Health care structures that not only provide funding for identification of food insecurity in clinics, but also payments to CBOs addressing these identified food needs, are an essential next step as CBOs are relied upon to intervene on food insecurity identified in clinical settings.

The COVID-19 pandemic has accelerated the urgency to launch such supportive and innovative strategies to finance and develop collaborations for nutrition support. For example, North Carolina launched a support services program in August 2020, building upon the Healthy Opportunities Pilot infrastructure, in which community health workers identified needs and made referrals to social supports (for example, home-delivered groceries) for individuals isolating or quarantining during COVID-19. Community health workers facilitated social service distributions through the braided funding of Medicaid, FEMA, and COVID-19 funds. Other states also created new programs to address social determinants of health during COVID-19, such as California’s expansion of their “Whole Person Health” program providing housing and wrap-around services for enrollees who had contracted COVID-19 by leveraging existing community partnerships. More health system and CBO partnerships that share investments through braided or shared funding strategies will be essential to adequately address food and other social needs identified in health care settings among children. These integrated strategies developed during the COVID-19 pandemic should be leveraged to establish novel cross-sector financial partnerships to reduce child food insecurity.

Recommendation 3: Reduce Barriers To Federal Nutrition Program Use Through Policy Innovations

The partnerships developed to address childhood food insecurity were augmented by many policy flexibilities in nutrition support programs initiated due to COVID-19. The Families First Coronavirus Response Act in March 2020 allowed authorization of multiple waivers by the USDA to temporarily modify SNAP and WIC enrollment and utilization regulations, increasing access to these programs during the pandemic. These waivers have been extended through the ongoing pandemic, with many SNAP and WIC waivers ending shortly after the federal public health emergency ends, if not already ended by the state. The WIC physical presence waiver allows for certification without anthropometric and biochemical data and remote benefit issuance. With these waivers, more eligible families receive remote benefits so that barriers, such as lack of transportation or risk of COVID-19 exposure, are mitigated. Data provided to us from North Carolina WIC demonstrated a nearly 20 percent participation increase in 2020 compared to the prior year, a substantial increase considering the declining rates in use over multiple prior years.

Additional investments will further facilitate innovation in the WIC program. The American Rescue Plan Act provided nearly $880 million to facilitate modernization, innovation, and outreach within the WIC program, and the U.S. Department of Agriculture/Tufts Telehealth Intervention Strategies for WIC grant, provides $1 million to promote better telehealth integration. Using this grant, informants shared that some North Carolina counties anticipate piloting WIC kiosks in highly trafficked community areas to promote WIC enrollment and nutrition education with hopes to expand these kiosks statewide. The co-location of these services was one innovation accelerated during the COVID-19 pandemic, when telehealth and remote services became essential to address child needs, and transportation was highlighted as a major barrier to program access.

Similarly, SNAP flexibilities implemented during the COVID-19 pandemic allowed for extension of recertification periods and telephonic signature and waived the interview requirement upon enrollment. These temporary federal flexibilities allowed five million more participants to participate in SNAP nationally and receive much needed food benefits. The USDA also approved the expansion and acceleration of online purchasing and grocery delivery pilots through pre-approved retailers in many states, a process that was urgently needed to address rural food insecurity. The SNAP program has also benefited from further funds to assist states with the ongoing demand for SNAP benefits by temporarily allowing for maximum benefit distributions and, for the first time since 1975, undergoing a historic and permanent increase in benefits by approximately 25 percent. This increase in benefits through an update to the Thrifty Food Program was driven by the need to keep pace with the increasing cost of food, allowing families to have adequate funds to purchase food items consistent with a healthy diet. With significant inflation nationally in the wake of the COVID-19 pandemic leading to rising food, housing, and gas prices, this increase in monetary distributions may still fail to meet the complete needs of families.

The future of these waivers and pilots is uncertain beyond the COVID-19 national public health emergency declaration. The impact of these flexibilities and the operational lessons learned during the pandemic should inform longer-term reforms to streamline eligibility and enrollment processes in both the WIC and SNAP programs. If invested in a way that builds upon the shared goals, partnerships, and practices demonstrated to be effective during the pandemic, new federal and state funding policies could have transformative effects on reducing childhood food insecurity. Additionally, using more universal support programs, such the Child Tax Credit, to reduce child food insecurity should be explored in the post-pandemic period. Early evidence suggests the majority of families used their first credit on food, reducing the rates households with children experiencing food insecurity in the past seven days from 13.5 percent to 9.5 percent in early August 2021. Reinstatement of this innovative program alongside extension of program flexibilities would support a variety of children’s needs, including access to healthy foods.

Conclusion

The impact of the pandemic on childhood food insecurity will have consequences for many years. The pandemic has spurred widespread momentum to address long-standing inequities and improve child food security. Government agencies and CBOs have shown remarkable innovation, financial commitment, and resilience to address the rapidly worsening childhood food insecurity during the pandemic. Further investments and flexibilities, including cross-program data matching, increased investment in food support programs through value-based payment models, and innovations in federal food programs, will be needed to achieve the shared goal of no child going hungry. The COVID-19 pandemic has accelerated partnerships and collaborations among previously separate government, school, and health care sectors, but the need to create more sustainable and accessible cross-sector infrastructure that prioritizes equitable access to healthy and sufficient food for America’s youth remains.

Authors’ Note

We would like to thank all the key stakeholders whose viewpoints informed these recommendations. We would also like to acknowledge Michelle S. Franklin, Ainsley Buck, Emma Dries, Emma Garman, Sophie Hurewitz, Elizabeth Jones, Reed Kenny, Ellie Winslow, Beth Gifford, K.K. Lam, and Gillian D. Sanders Schmidler who completed key-stakeholder interviews informing these recommendations.