Association of State Medicaid Expansion With Hospital Community Benefit Spending.

Importance: Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. Objective: To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. Design, Setting, and Participants: This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. Exposures: State Medicaid expansion between 2011 and 2017. Main Outcomes and Measures: Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Results: Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06). Conclusions and Relevance: In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children.

Importance: As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources. Objective: To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days. Design, Setting, and Participants: This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019. Exposures: Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers. Main Outcomes and Measures: Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017). Results: Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid. Conclusions and Relevance: In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

Families With TRICARE Report Lower Health Care Quality And Access Compared To Other Insured And Uninsured Families.

Children in military families, who receive health insurance through the TRICARE program, face barriers to care such as frequent relocations, unique behavioral health needs, increased complex health care needs, and lack of accessible specialty care. How TRICARE-insured families perceive health care access and quality for their children compared to their civilian peers' perceptions remains unknown. Using data from the Medical Expenditure Panel Survey, we found that TRICARE-insured families were less likely to report accessible or responsive care compared to civilian peers, whether commercially or publicly insured or uninsured. Military families whose children had complex health or behavioral health care needs reported worse health care access and quality than similar nonmilitary families. Addressing these gaps may require military leaders to examine barriers to achieving acceptable health care access across military treatment facilities and off-base nonmilitary specialty providers, particularly for children with complex health or behavioral health needs.

Growth Of Public Coverage Among Working Families In The Private Sector.

Working families have increasingly enrolled their children in Medicaid or the Children's Health Insurance Program in recent years. Parents' place of employment affects the availability and cost of family health insurance, making it a determinant of pediatric public insurance enrollment. We examined that enrollment in the period 2008-16 in families working full time and earning more than 100 percent of the federal poverty level at three types of employers. Among low-income families (100-199 percent of poverty), children's public health insurance coverage was highest for those with parents employed at small private firms, increasing from 53 percent to 79 percent, while the public insurance coverage rate also increased among children with parents working for large private firms (from 45 percent to 69 percent). Among moderate-income families (200-299 percent of poverty) working at small private firms, public coverage increased from 21 percent to 64 percent. Increases in the number of working families with pediatric public insurance were driven by employees of large private firms. Maintaining high pediatric insurance coverage rates will require policies that recognize the changing role of public insurance for working families as the cost of employer-based coverage grows.

Family Characteristics Associated With Child Maltreatment Across the Deployment Cycle of U.S. Army Soldiers.

OBJECTIVE: Soldier deployment can create a stressful environment for U.S. Army families with young children. Prior research has identified elevated rates of child maltreatment in the 6 months immediately following a soldier's return home from deployment. In this study, we longitudinally examine how other child- and family-level characteristics influence the relationship of deployment to risk for maltreatment of dependent children of U.S. Army soldiers. METHODS: We conducted a person-time analysis of substantiated reports and medical diagnoses of maltreatment among the 73,404 children of 56,087 U.S. Army soldiers with a single deployment between 2001 and 2007. Cox proportional hazard models estimated hazard rates of maltreatment across deployment periods and simultaneously considered main effects for other child- and family-level characteristics across periods. RESULTS: In adjusted models, maltreatment hazard was highest in the 6 months following deployment (hazard ratio [HR] = 1.63, p < 0.001). Children born prematurely or with early special needs independently had an increased risk for maltreatment across all periods (HR = 2.02, p < 0.001), as well as those children whose soldier-parent had been previously diagnosed with a mental illness (HR = 1.68, p < 0.001). In models testing for effect modification, during the 6 months before deployment, children of female soldiers (HR = 2.22, p = 0.006) as well as children of soldiers with a mental health diagnosis (HR = 2.78, p = 0.001) were more likely to experience maltreatment, exceeding the risk at all other periods. CONCLUSIONS: Infants and children are at increased risk for maltreatment in the 6 months following a parent's deployment, even after accounting for other known family- and child-level risk factors. However, the risk does not appear to be the same for all soldiers and their families in relation to deployment, particularly for female soldiers and those who had previously diagnosed mental health issues, for whom the risk appears most elevated before deployment. Accounting for the unique needs of high-risk families at different stages of a soldier's deployment cycle may allow the U.S. Army to better direct resources that prevent and address child maltreatment.

Under-ascertainment from healthcare settings of child abuse events among children of soldiers by the U.S. Army Family Advocacy Program.

In cases of maltreatment involving children of U.S. Army service members, the U.S. Army Family Advocacy Program (FAP) is responsible for providing services to families and ensuring child safety. The percentage of cases of maltreatment that are known to FAP, however, is uncertain. Thus, the objective of this retrospective study was to estimate the percentage of U.S. Army dependent children with child maltreatment as diagnosed by a military or civilian medical provider who had a substantiated report with FAP from 2004 to 2007. Medical claims data were used to identify 0-17year old child dependents of soldiers who received a medical diagnosis of child maltreatment. Linkage rates of maltreatment medical diagnoses with corresponding substantiated FAP reports were calculated. Bivariate and multivariable analyses examined the association of child, maltreatment episode, and soldier characteristics with linkage to substantiated FAP reports. Across 5945 medically diagnosed maltreatment episodes, 20.3% had a substantiated FAP report. Adjusting for covariates, the predicted probability of linkage to a substantiated FAP report was higher for physical abuse than for sexual abuse, 25.8%, 95% CI (23.4, 28.3) versus 14.5%, 95% CI (11.2, 17.9). Episodes in which early care was provided at civilian treatment facilities were less likely to have a FAP report than those treated at military facilities, 9.8%, 95% CI (7.3, 12.2) versus 23.6%, 95% CI (20.8, 26.4). The observed low rates of linkage of medically diagnosed child maltreatment to substantiated FAP reports may signal the need for further regulation of FAP reporting requirements, particularly for children treated at civilian facilities.

Low-Income Working Families With Employer-Sponsored Insurance Turn To Public Insurance For Their Children.

Many families rely on employer-sponsored health insurance for their children. However, the rise in the cost of such insurance has outpaced growth in family income, potentially making public insurance (Medicaid or the Children's Health Insurance Plan) an attractive alternative for affordable dependent coverage. Using data for 2008-13 from the Medical Expenditure Panel Survey, we quantified the coverage rates for children from low- or moderate-income households in which a parent was offered employer-sponsored insurance. Among families in which parents were covered by such insurance, the proportion of children without employer-sponsored coverage increased from 22.5 percent in 2008 to 25.0 percent in 2013. The percentage of children with public insurance when a parent was covered by employer-sponsored insurance increased from 12.1 percent in 2008 to 15.2 percent in 2013. This trend was most pronounced for families with incomes of 100-199 percent of the federal poverty level, for whom the share of children with public insurance increased from 22.8 percent to 29.9 percent. Among families with incomes of 200-299 percent of poverty, uninsurance rates for children increased from 6.0 percent to 9.2 percent. These findings suggest a movement away from employer-sponsored insurance and toward public insurance for children in low-income families, and growth in uninsurance among children in moderate-income families.

Hospital Utilization Among Children With the Highest Annual Inpatient Cost.

BACKGROUND AND OBJECTIVES: Children who experience high health care costs are increasingly enrolled in clinical initiatives to improve their health and contain costs. Hospitalization is a significant cost driver. We describe hospitalization trends for children with highest annual inpatient cost (CHIC) and identify characteristics associated with persistently high inpatient costs in subsequent years. METHODS: Retrospective study of 265 869 children age 2 to 15 years with ≥1 admission in 2010 to 39 children's hospitals in the Pediatric Health Information System. CHIC were defined as the top 10% of total inpatient costs in 2010 (n = 26 574). Multivariate regression and regression tree modeling were used to distinguish individual characteristics and interactions of characteristics, respectively, associated with persistently high inpatient costs (≥80th percentile in 2011 and/or 2012). RESULTS: The top 10% most expensive children (CHIC) constituted 56.9% ($2.4 billion) of total inpatient costs in 2010. Fifty-eight percent (n = 15 391) of CHIC had no inpatient costs in 2011 to 2012, and 27.0% (n = 7180) experienced persistently high inpatient cost. Respiratory chronic conditions (odds ratio [OR] = 3.0; 95% confidence interval [CI], 2.5-3.5), absence of surgery in 2010 (OR = 2.0; 95% CI, 1.8-2.1), and technological assistance (OR = 1.6; 95% CI, 1.5-1.7) were associated with persistently high inpatient cost. In regression tree modeling, the greatest likelihood of persistence (65.3%) was observed in CHIC with ≥3 hospitalizations in 2010 and a chronic respiratory condition. CONCLUSIONS: Most children with high children's hospital inpatient costs in 1 year do not experience hospitalization in subsequent years. Interactions of hospital use and clinical characteristics may be helpful to determine which children will continue to experience high inpatient costs over time.

Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families.

IMPORTANCE: An increasing diversity of children's health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Children's Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children. OBJECTIVE: To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes. DESIGN, SETTING, AND PARTICIPANTS: A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Children's Health, comprising 80,655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015. EXPOSURES: Insurance type was ascertained using a caregiver-reported measure of insurance status and each household's poverty status (percentage of the federal poverty level). MAIN OUTCOMES AND MEASURES: Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care. RESULTS: Among the 80,655 children, 51,123 (57.3%) had private insurance, 11,853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P < .01; CHIP, 88% [87%-89%]; P < .01) and dental (Medicaid, 80% [78%-81%]; P < .01; CHIP, 77% [76%-79%]; P < .01) visits than were privately insured children (medical, 83% [82%-84%]; dental, 73% [72%-74%]). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% [24%-32%]), problems obtaining a referral (23% [18%-29%]), and frustration obtaining health care services (26% [23%-28%]). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% [26%-33%]) and frustration obtaining health care services (36% [32%-41%]) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the child's needs (63% [60%-67%]) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% [75%-78%]) than were caregivers of children insured by Medicaid (26% [23%-28%]; P < .01) or CHIP (38% [35%-40%]; P < .01). CONCLUSIONS AND RELEVANCE: This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.

Risk Adjusting Survival Outcomes in Hospitals That Treat Patients With Cancer Without Information on Cancer Stage.

IMPORTANCE: Instituting widespread measurement of outcomes for cancer hospitals using administrative data is difficult owing to lack of cancer-specific information such as disease stage. OBJECTIVE: To evaluate the performance of hospitals that treat patients with cancer using Medicare data for outcome ascertainment and risk adjustment and to assess whether hospital rankings based on these measures are altered by the addition of cancer-specific information. DESIGN, SETTING, AND PARTICIPANTS: Risk-adjusted cumulative mortality rates of patients with cancer were captured in Medicare claims data from 2005 through 2009 nationally and assessed at the hospital level. Similar analyses were conducted using Surveillance, Epidemiology, and End Results (SEER)-Medicare data for the subset of the United States covered by the SEER program to determine whether the inclusion of cancer-specific information (only available in cancer registries) in risk adjustment altered measured hospital performance. Data were from 729 279 fee-for-service Medicare beneficiaries treated for cancer in 2006 at hospitals treating 10 or more patients with each of the following cancers, according to Medicare claims: lung, prostate, breast, colon, and other. An additional sample of 18 677 similar patients were included from the SEER-Medicare administrative data. MAIN OUTCOMES AND MEASURES: Risk-adjusted mortality overall and by cancer category, stratified by type of hospital; measures of correlation and agreement between hospital-level outcomes risk adjusted using Medicare data alone and Medicare data with SEER data. RESULTS: There were large survival differences between different types of hospitals that treat Medicare patients with cancer. At 1 year, mortality for patients treated by hospitals exempt from the Medicare prospective payment system was 10% lower than at community hospitals (18% vs 28%) across all cancers, and the pattern persisted through 5 years of follow-up and within specific cancer categories. Performance ranking of hospitals was consistent with or without SEER-Medicare disease stage information (weighted κ ≥ 0.81). CONCLUSIONS AND RELEVANCE: Potentially important outcome differences exist between different types of hospitals that treat patients with cancer after risk adjustment using information in Medicare administrative data. This type of risk adjustment may be adequate for evaluating hospital performance, since the additional adjustment for data available only in cancer registries does not seem to appreciably alter measures of performance.

Changes in Young Adult Primary Care Under the Affordable Care Act.

OBJECTIVES: We sought to describe changes in young adults' routine care and usual sources of care (USCs), according to provider specialty, after implementation of extended dependent coverage under the Affordable Care Act (ACA) in 2010. METHODS: We used Medical Expenditure Panel Survey data from 2006 to 2012 to examine young adults' receipt of routine care in the preceding year, identification of a USC, and USC provider specialties (pediatrics, family medicine, internal medicine, and obstetrics and gynecology). RESULTS: The percentage of young adults who sought routine care increased from 42.4% in 2006 to 49.5% in 2012 (P < .001). The percentage identifying a USC remained stable at approximately 60%. Among young adults with a USC, there was a trend between 2006 and 2012 toward increasing percentages with pediatric (7.6% vs 9.1%) and family medicine (75.9% vs 80.9%) providers and declining percentages with internal medicine (11.5% vs 7.6%) and obstetrics and gynecology (5.0% vs 2.5%) providers. CONCLUSIONS: Efforts under the ACA to increase health insurance coverage had favorable effects on young adults' use of routine care. Monitoring routine care use and USC choices in this group can inform primary care workforce needs and graduate medical education priorities across specialties.

Childhood Asthma Hospital Discharge Medication Fills and Risk of Subsequent Readmission.

OBJECTIVE: To assess the relationship between posthospitalization prescription fills for recommended asthma discharge medication classes and subsequent hospital readmission. STUDY DESIGN: This was a retrospective cohort analysis of Medicaid Analytic Extract files from 12 geographically diverse states from 2005-2007. We linked inpatient hospitalization, outpatient, and prescription claims records for children ages 2-18 years with an index hospitalization for asthma to identify those who filled a short-acting beta agonist, oral corticosteroid, or inhaled corticosteroid within 3 days of discharge. We used a multivariable extended Cox model to investigate the association of recommended medication fills and hospital readmission within 90 days. RESULTS: Of 31,658 children hospitalized, 55% filled a beta agonist prescription, 57% an oral steroid, and 37% an inhaled steroid. Readmission occurred for 1.3% of patients by 14 days and 6.3% by 90 days. Adjusting for patient and billing provider factors, beta agonist (hazard ratio [HR] 0.67, 95% CI 0.51, 0.87) and inhaled steroid (HR 0.59, 95% CI 0.42, 0.85) fill were associated with a reduction in readmission at 14 days. Between 15 and 90 days, inhaled steroid fill was associated with decreased readmission (HR 0.87, 95% CI 0.77, 0.98). Patients who filled all 3 medications had the lowest readmission hazard within both intervals. CONCLUSIONS: Filling of beta agonists and inhaled steroids was associated with diminished hazard of early readmission. For inhaled steroids, this effect persisted up to 90 days. Efforts to improve discharge care for asthma should include enhancing recommended discharge medication fill rates.

Use of preventive dental care among medicaid-enrolled, school-aged US children in immigrant and nonimmigrant families: trends in Pennsylvania From 2005 through 2010.

OBJECTIVES: We describe trends in receipt of preventive dental care among Medicaid-enrolled children in Pennsylvania between 2005 and 2010, comparing the US children of immigrants with their co-ethnic peers in nonimmigrant families. METHODS: We analyzed Pennsylvania Medicaid claims, birth records, and census data for children born in Pennsylvania and enrolled in Medicaid for 10 or more months during any of the calendar years assessed. RESULTS: Receipt of preventive dental care was more likely among Latino children in immigrant families than among their peers in nonimmigrant families; also, it was more likely among White children in immigrant families than among their peers in nonimmigrant families. Rates of preventive dental care use among African American and Asian children in immigrant and nonimmigrant families were comparable. From 2005 to 2010, the percentage of Latino children in nonimmigrant families who received preventive dental care increased from 33% to 61%. Changes in other groups were significant but less dramatic. CONCLUSIONS: Receipt of preventive dental care has increased among Medicaid-enrolled children in Pennsylvania, with marked gains among Latino children. Within each racial/ethnic group, the children of immigrants were either more likely than or equally likely as children in nonimmigrant families to receive care.

Growth in the concurrent use of antipsychotics with other psychotropic medications in Medicaid-enrolled children.

OBJECTIVE: Second-generation antipsychotics (SGAs) have increasingly been prescribed to Medicaid-enrolled children; however, there is limited understanding of the frequency of concurrent SGA prescribing with other psychotropic medications. This study describes the epidemiology of concurrent SGA use with 4 psychotropic classes (stimulants, antidepressants, mood stabilizers, and α-agonists) among a national sample of Medicaid-enrolled children and adolescents 6 to 18 years old between 2004 and 2008. METHOD: Repeated cross-sectional design was used, with national Medicaid Analytic eXtract data (10.6 million children annually). Logit and Poisson regression, standardized for year, demographics, and Medicaid eligibility group, estimated the probability and duration of concurrent SGA use with each medication class over time and examined concurrent SGAs in relation to clinical and demographic characteristics. RESULTS: While SGA use overall increased by 22%, 85% of such use occurred concurrently. By 2008, the probability of concurrent SGA use ranged from 0.22 for stimulant users to 0.52 for mood stabilizer users. Concurrent SGA use occurred for long durations (69%-89% of annual medication days). Although the highest users of concurrent SGA were participants in foster care and disability Medicaid programs or those with behavioral hospitalizations, the most significant increases over time occurred among participants who were income-eligible for Medicaid (+13%), without comorbid ADHD (+15%), were not hospitalized (+13%), and did not have comorbid intellectual disability (+45%). CONCLUSION: Concurrent SGA use with other psychotropic classes increased over time, and the duration of concurrent therapy was consistently long term. Concurrent SGA regimens will require further research to determine efficacy and potential drug-drug interactions, given a practice trend toward more complex regimens in less-impaired children/adolescents.

Longitudinal association of county-level economic indicators and child maltreatment incidents.

To evaluate the association between economic indicators (unemployment and mortgage foreclosure rates) and volume of investigated and substantiated cases of child maltreatment at the county level from 1990 to 2010 in the Commonwealth of Pennsylvania. County-level investigated reports of child maltreatment and proportion of investigated cases substantiated by child protective services in the Commonwealth of Pennsylvania were compared with county-level unemployment rates from 1990 to 2010, and with county-level mortgage foreclosure rates from 2000 to 2010. We employed fixed-effects Poisson regression modeling to estimate the association between volume of investigated and substantiated cases of maltreatment, and current and prior levels of local economic indicators adjusting for temporal trend. Across Pennsylvania, annual rate of investigated maltreatment reports decreased through the 1990s and rose in the early 2000s before reaching a peak of 9.21 investigated reports per 1,000 children in 2008, during the recent economic recessionary period. The proportion of investigated cases substantiated, however, decreased statewide from 33 % in 1991 to 15 % in 2010. Within counties, current unemployment rate, and current and prior-year foreclosure rates were positively associated with volume of both investigated and substantiated child maltreatment incidents (p < 0.05). Despite recent increases in investigations, the proportion of investigated cases substantiated decreased by more than half from 1990 to 2010 in Pennsylvania. This trend suggests significant changes in substantiation standards and practices during the period of study. Economic indicators demonstrated strong association with investigated and substantiated maltreatment, underscoring the urgent need for directing important prophylactic efforts and resources to communities experiencing economic hardship.