Public Benefit Programs and Differential Associations With Child Maltreatment by Race and Ethnicity.

Importance: Public benefit programs, including state spending on local, state, and federal-state partnership programs, have consistently been associated with overall reductions in child protective services (CPS) involvement. Inequities in eligibility and access to benefit programs may contribute to varying associations by race and ethnicity. Objective: To determine whether associations between state spending on benefit programs and rates of CPS investigations differ by race and ethnicity. Design, Setting, and Participants: This cross-sectional ecological study used repeated state-level measures of child maltreatment from the National Child Abuse and Neglect Data System and population estimates from the US Census Bureau for all Black, Hispanic, and White children. All 50 US states from October 1, 2009, through September 30, 2019 (fiscal years 2010-2019), were included. Data were collected and analyzed from May 13, 2022, to March 2, 2023. Exposures: Annual state spending on benefit programs per person living below the federal poverty limit, total and by the following subcategories: (1) cash, housing, and in-kind; (2) housing infrastructure; (3) child care assistance; (4) refundable earned income tax credit; and (5) medical assistance programs. Main Outcomes and Measures: Race- and ethnicity-specific rates of CPS investigations. Generalized estimating equations, with repeated measures of states, an interaction between race and spending, and estimated incidence rate ratios (IRRs) and 95% CIs for incremental changes in spending of US $1000 per person living below the federal poverty limit were calculated after adjustment for federal spending, race- and ethnicity-specific child poverty rate, and year. Results: A total of 493 state-year observations were included in the analysis. The association between total spending and CPS investigations differed significantly by race and ethnicity: there was an inverse association between total state spending and CPS investigations for White children (IRR, 0.94 [95% CI, 0.91-0.98]) but not for Black children (IRR, 0.98 [95% CI, 0.94-1.02]) or Hispanic children (IRR, 0.99 [95% CI, 0.95-1.03]) (P = .02 for interaction). Likewise, inverse associations were present for only White children with respect to all subcategories of state spending and differed significantly from Black and Hispanic children for all subcategories except the refundable earned income tax credit (eg, IRR for medical assistance programs for White children, 0.89 [95% CI, 0.82-0.96]; P = .005 for race and spending interaction term). Conclusions and Relevance: These results raise concerns that benefit programs may add relative advantages for White children compared with Black and Hispanic children and contribute to racial and ethnic disparities in CPS investigations. States' eligibility criteria and distribution practices should be examined to promote equitable effects on adverse child outcomes.

Clinic-Based Financial Coaching and Missed Pediatric Preventive Care: A Randomized Trial.

OBJECTIVES: Poverty is a common root cause of poor health and disrupts medical care. Clinically embedded antipoverty programs that address financial stressors may prevent missed visits and improve show rates. This pilot study evaluated the impact of clinic-based financial coaching on adherence to recommended preventive care pediatric visits and vaccinations in the first 6 months of life. METHODS: In this community-partnered randomized controlled trial comparing clinic-based financial coaching to usual care among low-income parent-infant dyads attending pediatric preventive care visits, we examined the impact of the longitudinal financial intervention delivered by trained coaches addressing parent-identified, strengths-based financial goals (employment, savings, public benefits enrollment, etc.). We also examined social needs screening and resource referral on rates of missed preventive care pediatric visits and vaccinations through the 6-month well-child visit. RESULTS: Eighty-one parent-infant dyads were randomized (35 intervention, 46 control); nearly all parents were mothers and more than one-half were Latina. The rate of missed visits among those randomized to clinic-based financial coaching was half that of controls (0.46 vs 1.07 missed of 4 recommended visits; mean difference, 0.61 visits missed; P = .01). Intervention participants were more likely to have up-to-date immunizations each visit (relative risk, 1.26; P = .01) with fewer missed vaccinations by the end of the 6-month preventive care visit period (2.52 vs 3.8 missed vaccinations; P = .002). CONCLUSIONS: In this pilot randomized trial, a medical-financial partnership embedding financial coaching within pediatric primary care improved low-income families' adherence to recommended visits and vaccinations. Clinic-based financial coaching may improve care continuity and quality in the medical home.

Systemic Determinants in Surgery: Nonclinical Factors Affecting Time to Operation for Incarcerated Ventral Hernias.

INTRODUCTION: We explore nonclinical factors affecting the amount of time from admission to the operating room for patients requiring nonelective repair of ventral hernias. METHODS: Using the 2005-2012 Nationwide Inpatient Sample, we identified adult patients with a primary diagnosis of ventral hernia without obstruction/gangrene, who underwent nonelective repair. The outcome variable of interest was time from admission to surgery. We performed univariate and multivariable analyses using negative binomial regression, adjusting for age, sex, race, income, insurance, admission day, comorbidity status (van Walraven score), diagnosis, procedure, hospital size, location/teaching status, and region. RESULTS: 7,253 patients met criteria, of which majority were women (n = 4,615) and white (n = 5,394). The majority of patients had private insurance (n = 3,015) followed by Medicare (n = 2,737). Median time to operation was 0 days. Univariate analysis comparing operation <1 day to ≥1 day identified significant differences in race, day of admission, insurance, length of stay, comorbidity status, hospital location, type, and size. Negative binomial regression showed that weekday admission (IRR 4.42, P < .0001), private insurance (IRR 1.53-2.66, P < .0001), rural location (IRR 1.39-1.76, P < .01), small hospital size (IRR 1.26-1.36, P < .05), white race (IRR 1.30-1.34, P < .01), healthier patients (van Walraven score IRR 1.05, P < .0001), and use of mesh (IRR 0.39-0.56, P < .02) were associated with shorter time until procedure. CONCLUSION: Shorter time from admission to the operating room was associated with several nonclinical factors, which suggest disparities may exist. Further prospective studies are warranted to elucidate these disparities affecting patient care.

Outcome prediction in bariatric surgery through video-based assessment.

INTRODUCTION: The relationship between intraoperative surgical performance scores and patient outcomes has not been demonstrated at a single-case level. The GEARS score is a Likert-based scale that quantifies robotic surgical proficiency in 5 domains. Given that even highly skilled surgeons can have variability in their skill among their cases, we hypothesized that at a patient level, higher surgical skill as determined by the GEARS score will predict individual patient outcomes. METHODS: Patients undergoing robotic sleeve gastrectomy between July 2018 and January 2021 at a single-health care system were captured in a prospective database. Bivariate Pearson's correlation was used to compare continuous variables, one-way ANOVA for categorical variables compared with a continuous variable, and chi-square for two categorical variables. Significant variables in the univariable screen were included in a multivariable linear regression model. Two-tailed p-value < 0.05 was considered significant. RESULTS: Of 162 patients included, 9 patients (5.5%) experienced a serious morbidity within 30 days. The average excess weight loss (EWL) was 72 ± 12% at 6 months and 74 ± 15% at 12 months. GEARS score was not significantly correlated with EWL at 6 months (p = 0.349), 12 months (p = 0.468), or serious morbidity (p = 0.848) on unadjusted analysis. After adjusting, total GEARS score was not correlated with serious morbidity (p = 0.914); however, GEARS score did predict EWL at 6 (p < 0.001) and 12 months (p < 0.001). All GEARS subcomponent scores, bimanual dexterity, depth perception, efficiency, force sensitivity, and robotic control were predictive of EWL at 6 months (p < 0.001) and 12 months (p < 0.001) on multivariable analysis. CONCLUSION: For patients undergoing sleeve gastrectomy, surgical skill as assessed by the GEARS score was correlated with EWL, suggesting that better performance of a sleeve gastrectomy can result in improved postoperative weight loss.

Objective assessment of robotic surgical skills: review of literature and future directions.

BACKGROUND: Evaluation of robotic surgical skill has become increasingly important as robotic approaches to common surgeries become more widely utilized. However, evaluation of these currently lacks standardization. In this paper, we aimed to review the literature on robotic surgical skill evaluation. METHODS: A review of literature on robotic surgical skill evaluation was performed and representative literature presented over the past ten years. RESULTS: The study of reliability and validity in robotic surgical evaluation shows two main assessment categories: manual and automatic. Manual assessments have been shown to be valid but typically are time consuming and costly. Automatic evaluation and simulation are similarly valid and simpler to implement. Initial reports on evaluation of skill using artificial intelligence platforms show validity. Few data on evaluation methods of surgical skill connect directly to patient outcomes. CONCLUSION: As evaluation in surgery begins to incorporate robotic skills, a simultaneous shift from manual to automatic evaluation may occur given the ease of implementation of these technologies. Robotic platforms offer the unique benefit of providing more objective data streams including kinematic data which allows for precise instrument tracking in the operative field. Such data streams will likely incrementally be implemented in performance evaluations. Similarly, with advances in artificial intelligence, machine evaluation of human technical skill will likely form the next wave of surgical evaluation.

Changing Who Has a Seat and Voice at the Table: How the Academic Pediatric Association is Responding to Systemic Racism.

The Academic Pediatrics Association has taken multiple steps over the last 2 years to incorporate the lenses of anti-racism and social justice into our mission and work. In this commentary, we discuss the creation and work of the Anti-Racism and Diversity Task Force, which was charged by the Academic Pediatrics Association's Board of Directors with identifying strategies to promote anti-racism and advance the diversity, equity and inclusion agenda.

State Spending on Public Benefit Programs and Child Maltreatment.

BACKGROUND: To determine the association between states' total spending on benefit programs and child maltreatment outcomes. METHODS: This was an ecological study of all US states during federal fiscal years 2010-2017. The primary predictor was states' total annual spending on local, state, and federal benefit programs per person living ≤100% federal poverty limit, which was the sum of (1) cash, housing, and in-kind assistance, (2) housing infrastructure, (3) child care assistance, (4) refundable Earned Income Tax Credit, and (5) Medical Assistance Programs. The main outcomes were rates of maltreatment reporting, substantiations, foster care placements, and fatalities after adjustment for relevant confounders. Generalized estimating equations adjusted for federal spending and estimated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: States' total spending was inversely associated with all maltreatment outcomes. For each additional $1000 states spent on benefit programs per person living in poverty, there was an associated -4.3% (adjusted IRR: 0.9573 [95% CI: 0.9486 to 0.9661]) difference in reporting, -4.0% (adjusted IRR: 0.903 [95% CI: 0.9534 to 0.9672]) difference in substantiations, -2.1% (adjusted IRR: 0.9795 [95% CI: 0.9759 to 0.9832]) difference in foster care placements, and -7.7% (adjusted IRR: 0.9229 [95% CI: 0.9128 to 0.9330]) difference in fatalities. In 2017, extrapolating $1000 of additional spending for each person living in poverty ($46.5 billion nationally, or 13.3% increase) might have resulted in 181 850 fewer reports, 28 575 fewer substantiations, 4168 fewer foster care placements, and 130 fewer fatalities. CONCLUSIONS: State spending on benefit programs was associated with reductions in child maltreatment, which might offset some benefit program costs.

Racial Disparities in Developmental Delay Diagnosis and Services Received in Early Childhood.

BACKGROUND AND OBJECTIVE: Racial disparities in diagnosis and receipt of services for early childhood developmental delay (DD) are well known but studies have had difficulties distinguishing contributing patient, healthcare system, and physician factors from underlying prevalence. We examine rates of physician diagnoses of DD by preschool and kindergarten entry controlling for a child's objective development via scoring on validated developmental assessment along with other child characteristics. METHODS: We used data from the preschool and kindergarten entry waves of the Early Childhood Longitudinal Study, Birth Cohort. Dependent variables included being diagnosed with DD by a medical provider and receipt of developmental services. Logistic regression models tested whether a child's race was associated with both outcomes during preschool and kindergarten while controlling for the developmental assessments, as well as other contextual factors. RESULTS: Among 7950 children, 6.6% of preschoolers and 7.5% of kindergarteners were diagnosed with DD. Of preschool children with DD, 66.5% were receiving developmental services, while 69.1% of kindergarten children with DD were receiving services. Children who were Black, Asian, spoke a primary language other than English and had no health insurance were less likely to be diagnosed with DD despite accounting for cognitive ability. Black and Latinx children were less likely to receive services. CONCLUSIONS: Racial minority children are less likely to be diagnosed by their pediatric provider with DD and less likely to receive services despite accounting for a child's objective developmental assessment. The pediatric primary care system is an important target for interventions to reduce these disparities.

Engaging Community and Academic Partners to Explore Adolescent Emotional Well-Being.

In an under-resourced area of the South Bay of Los Angeles, partnerships were formed between community advocates with extensive research experience, less experienced academic investigators, and an urban public high school without partnered research experience. This article outlines the process of developing these partnerships through a community-academic research conference addressing a priority area identified by the local community to define and understand the importance and relevance of adolescent emotional well-being. Teen participants from the high school identified support from the community as the most crucial ingredient for achieving adolescent emotional well-being.

Hospitals' Diversity of Diagnosis Groups and Associated Costs of Care.

BACKGROUND AND OBJECTIVES: Hospitals treating patients with greater diagnosis diversity may have higher fixed and overhead costs. We assessed the relationship between hospitals' diagnosis diversity and cost per hospitalization for children. METHODS: Retrospective analysis of 1 654 869 all-condition hospitalizations for children ages 0 to 21 years from 2816 hospitals in the Kids' Inpatient Database 2016. Mean hospital cost per hospitalization, Winsorized and log-transformed, was assessed for freestanding children's hospitals (FCHs), nonfreestanding children's hospitals (NFCHs), and nonchildren's hospitals (NCHs). Hospital diagnosis diversity index (HDDI) was calculated by using the D-measure of diversity in Shannon-Wiener entropy index from 1254 diagnosis and severity-of-illness groups distinguished with 3M Health's All Patient Refined Diagnosis Related Groups. Log-normal multivariable models were derived to regress hospital type on cost per hospitalization, adjusting for hospital-level HDDI in addition to patient-level demographic (eg, age, race and ethnicity) and clinical (eg, chronic conditions) characteristics and hospital teaching status. RESULTS: Admission counts were 383 789 (23.2%) in FCHs, 588 463 (35.6%) in NFCHs, and 682 617 (41.2%) in NCHs. Unadjusted mean cost per hospitalization was $10 757 (95% confidence interval [CI]: $9451 to $12 243) in FCHs, $6264 (95% CI: $5830 to $6729) in NFCHs, and $4192 (95% CI: $4121 to $4265) in NCHs. HDDI was significantly (P < .001) higher in FCHs and NFCHs (median 9.2 and 6.4 times higher, respectively) than NCHs. Across all hospitals, greater HDDI was associated (P = .002) with increased cost. Adjusting for HDDI resulted in a nonsignificant (P = .1) difference in cost across hospital types. CONCLUSIONS: Greater diagnosis diversity was associated with increased cost per hospitalization and should be considered when assessing associated costs of inpatient care for pediatric patients.

Economy-Sensitive Conditions: Are Some Pediatric Hospitalizations Triggered By Economic Recessions?

The impact of economic recessions on child health is complex and varied. Here we examine associations between county-level unemployment and pediatric hospitalizations in fourteen states every third year from 2002 to 2014. After adjusting for state-specific effects of unemployment across all counties and years, we found that increased unemployment was associated with increased pediatric hospitalizations for four potentially economy-sensitive conditions, such that a 1 percent increase in unemployment was associated with a 5 percent increase in hospitalizations for substance abuse, a 4 percent increase for diabetes mellitus, and a 2 percent increase both for children with medical complexity and for poisoning and burns. Mean pediatric all-cause hospitalizations increased by 2 percent for every 1 percent increase in unemployment (or 54,177 excess hospitalizations in 2011 compared with 2005). Hospitalizations for mental health, despite the increased severity of these conditions during recessions, were not associated with unemployment. Further research is needed to examine potential federal, state, and local policies that may mitigate the influence of unemployment on child health and pediatric hospitalizations.

Ambulatory quality, special health care needs, and emergency department or hospital use for US children.

OBJECTIVE: This study examined family-reported ambulatory care quality and its association with emergency department and hospital utilization, and how these relationships differed across levels of medical complexity. DATA SOURCES: The 2006-2013 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: Secondary analysis of MEPS data. Variables fitting the National Quality Measures Clearinghouse clinical quality measures domain framework were selected. Exploratory factor analysis grouped ambulatory quality into 12 access, experience, or process measures. Weighted negative binomial regression stratified by health status identified associations between ambulatory quality and ED visits or hospitalizations. DATA COLLECTION: 41,497 children ≤18 years were included. The 5-item special health care needs (SHCN) screener categorized health status as complex, less complex, or no SHCN. PRINCIPAL FINDINGS: Weighted SHCN proportions were 1.6 Percent complex, 18.2 Percent less complex, and 80.0 Percent no SHCN. Mean ED visits were 130 and 335 visits/1000 children/year for no/ complex SHCN, respectively. Mean hospitalizations were 20 and 175 hospitalizations/1000 children/year for no/complex SHCN, respectively. ED visits were associated with 8 of 12 quality measures for no/less complex SHCN. For example, usually/always receiving needed care right away was associated with 22 Percent lower ED visit rate (95% CI 0.64-0.96). Hospitalizations were associated with 4 of 12 quality measures for less complex SHCN. In complex SHCN, associations between ambulatory quality and ED/hospital use were weak and inconsistent. CONCLUSIONS: Ambulatory quality may best predict ED and hospital use for children with no or less complex SHCN. Whether and how ambulatory care predicts emergency and hospital care in complex SHCN remains an important question.

The Detrimental Influence of Racial Discrimination on Child Health in the United States.

BACKGROUND: The current literature describing the largely damaging effect of racial discrimination on child health is weakened by several confounding factors. We aimed to: 1) describe the relation between racial discrimination and child health and 2) evaluate the potential mediating role of mental health relating racial discrimination to child health, using methods that mitigate confounding. METHODS: Using the 2011-2012 National Survey of Children's Health (N = 95,677), we performed: 1) propensity score analysis, matching and comparing discrimination-exposed to non-exposed children and 2) structural equation modeling, examining mental health as a mediator of the pathway between discrimination and child health. RESULTS: In the first approach, the proportion of children with excellent health was 5.4% (95% Confidence Interval (CI), 3.6,7.2%) lower with exposure to racial discrimination. Among minority children, those with low income had the greatest decrements in general health associated with racial discrimination. Among white children, those with high income had the greatest decrements. In the structural equation model, minority children had higher odds of experiencing racial discrimination (Odds ratios (ORs) ≥ 5.47, [95% CIs, 4.92,10.6]); meanwhile, children who experienced discrimination were more likely to have anxiety and depression (ORs ≥ 3.58, [95% CIs, 2.87,4.58]), which were linked to lower odds of excellent health (ORs ≤ 0.44, [95% CIs, 0.41.52]). CONCLUSION: The negative health association of racial discrimination may be mediated by mental health and vary by racial, ethnic, or socioeconomic group. This work may stimulate the formation of targeted interventions to address these disparities.

Physical Health, Medical Care Access, and Medical Insurance Coverage of Youth Returning Home After Incarceration: A Systematic Review.

Youth reentry following incarceration is a subject of active health care policy innovation and debate. We systematically searched PubMed, CINAHL, Cochrane Library, and Google Scholar for research articles on physical health status or medical care access related to youth reentry (i.e., children and adolescents under 18 years of age). A total of 2,187 articles were identified in the search. After applying exclusion criteria, 10 articles remained. Those included covered general physical health (four articles), medical insurance coverage (five), noninsurance barriers to care and care utilization (five), and reentry youths' prioritization of needs (four). Despite vulnerable health status, the literature on youths' physical health status and medical care access during reentry is sparse, signifying a disconnect in research priorities. The findings suggest that intervention trials on youth reentry and health are needed and that that policy makers should be concerned with Medicaid policy reform.

Health System Research Priorities for Children and Youth With Special Health Care Needs.

OBJECTIVES: In this study, we sought to establish priorities for a national research agenda for children and youth with special health care needs (CYSHCN) through a structured, multistakeholder, mixed-methods approach. METHODS: Using surveys, we solicited responses from >800 members of expert-nominated stakeholder organizations, including CYSHCN families, health care providers, researchers, and policymakers, to identify what research with or about CYSHCN they would like to see in a national research agenda. From 2835 individual free-text responses, 96 research topics were synthesized and combined. Using an adapted RAND/UCLA Appropriateness Method (a modified Delphi approach), an expert panel rated research topics across 3 domains: need and urgency, research impact, and family centeredness. Domains were rated on 9-point Likert scales. Panelist ratings were used to sort research topics into 4 relative-priority ranks. Rank 1 (highest priority) research topics had a median of ≥7 in all domains. RESULTS: The RAND/UCLA Appropriateness Method was used to prioritize CYSHCN research topics and depict their varying levels of stakeholder-perceived need and urgency, research impact, and family centeredness. In the 15 topics that achieved rank 1, social determinants of health (disparities and rurality), caregiving (family resilience and care at home), clinical-model refinement (effective model elements, labor divisions, telemedicine, and system integration), value (stakeholder-centered value outcomes, return on investment, and alternative payment models), and youth-adult transitions (planning, insurance, and community supports) were emphasized. CONCLUSIONS: High-priority research topics identified by CYSHCN experts and family leaders underscore CYSHCN research trends and guide important directions. This study is the first step toward an efficient and cohesive research blueprint to achieve highly-effective CYSHCN health systems.

Barriers to Health Care for Latino Youths During Community Reentry After Incarceration: Los Angeles County, California, 2016-2018.

Objectives. To examine barriers to health care for Latino youths during reentry after incarceration.Methods. For this in-depth qualitative study, we conducted 69 semistructured interviews with 22 Latino youths and their parents at 1, 3, and 6 months after incarceration. We performed thematic analysis of interview transcripts, from which a preliminary conceptual model emerged describing barriers to care for Latino youths. We then conducted trajectory analyses of dyadic youth-caregiver pairs to test the conceptual model. We collected longitudinal interviews in Los Angeles County, California, from November 2016 to March 2018.Results. Beyond recognized stressors experienced by youths during reentry, most of which families related to poverty and neighborhood environment, Latino youths also experienced cultural barriers to care (i.e., self-reliance and pride, religiosity and reproductive care as taboo, preference for home remedies, language) as well as barriers to care because of undocumented status (i.e., fear of deportation, job insecurity).Conclusions. Reentry is challenging, and Latino youths face additional barriers to care during reentry related to culture and legal status, but have cultural strengths. Increased access to culturally sensitive, safety-net health care, regardless of immigration status, may reduce health inequalities for Latino youths undergoing reentry.

The Role of Parent Engagement in Overcoming Barriers to Care for Youth Returning Home After Incarceration.

We sought to understand the role of parent engagement in overcoming barriers to care for youth re-entering the community following incarceration. For this mixed methods study, we conducted quantitative surveys on healthcare needs and access with youth (n = 50) at 1-month post-incarceration, and semi-structured interviews with a subset of these youth (n = 27) and their parents (n = 34) at 1, 3, and 6-months post-incarceration (total 94 interviews). Differences by race/ethnicity and gender were assessed using Chi square test of proportions. We performed thematic analysis of interview transcripts to examine the role of parent engagement in influencing youths' access to healthcare during reentry. Most youth were from racial/ethnic minority groups and reported multiple ACEs. Girls, compared to boys, had higher ACE scores (p = 0.03), lower family connectedness (p = 0.03), and worse general health (p = 0.02). Youth-identified barriers to care were often parent-dependent and included lack of: affordable care (22%), transportation (16%), and accompaniment to health visits (14%). Two major themes emerged from the qualitative interviews: (1) parents motivate youth to seek healthcare during reentry and (2) parents facilitate the process of youth seeking healthcare during reentry. Parents are instrumental in linking youth to healthcare during reentry, dispelling prevailing myths that parents of incarcerated youth are inattentive and that youth do not want their help. Efforts that support and enhance parent engagement in access to care during reentry, such as by actively involving parents in pre-release healthcare planning, may create stronger linkages to care.

Insurance Coverage for Children Impacts Reporting of Child Maltreatment by Healthcare Professionals.

OBJECTIVES: Children's insurance coverage, through increased access and use of the healthcare system, may increase the likelihood that healthcare professionals (HCPs) will detect and report child maltreatment. We sought to estimate the association between insurance coverage for children and reporting of child maltreatment by HCPs. STUDY DESIGN: We conducted a cross-sectional study of US counties from 2008 to 2015 using data from the US Census Bureau's Small Area Health Insurance Estimates, National Center for Health Statistics, and National Child Abuse and Neglect Data System. The primary predictor was counties' percent of children insured. We controlled for counties' children living at ≤200% federal poverty level, race/ethnicity demographics, and urban-rural status. The primary outcome was the rate of maltreatment reporting from HCPs. Generalized linear mixed effects models with repeated measures across years tested associations. RESULTS: We included 5517 county-year observations involving 470 876 018 child-years. Counties' percent of children insured ranged from 74.6% to 99.2% with a median of 93.7% (IQR, 91.0-95.4). For every 1 percentage point increase in counties' percent of children insured, there was an associated 2% increase in child maltreatment reporting by HCPs (adjusted incidence rate ratio, 1.02; 95% CI, 1.02-1.03). If counties' percentage of insured children had been 1 percentage point greater in 2015, a predicted 5620 (95% CI, 5620-8089) additional reports would have been generated. CONCLUSIONS: Among its other benefits for children's well-being, insurance coverage may also contribute to child protection by increasing the reporting of maltreatment among HCPs.