project

A Safety Net Unraveling: Feeding Young Children During COVID-19 Katherine W. Bauer, PhD, Jamie F. Chriqui, PhD, MHS, Tatiana Andreyeva, PhD, Erica L. Kenney, ScD, Virginia C. Stage, RDN, LDN, Dipti Dev, PhD, Laura Lessard, PhD, MPH, Caree J. Cotwright, RDN, LDN, PhD, and Alison Tovar, PhD, MPH

The emergence of COVID-19 in the United States led most states to close or severely limit the

capacity of their early child-care and education (ECE) programs. This loss affected millions of young

children, including many of the 4.6 million low-income children who are provided free meals and

snacks by their ECE programs through support from the federal Child and Adult Care Food Program

(CACFP).

Although Congress swiftly authorized waivers that would allow CACFP-participating ECE programs to

continue distributing food to children, early evidence suggests that most ECE programs did not have the

capacity to do so, leaving a fragmented system of federal, state, and local food programs to fill the gaps

created by this loss.

Critical steps are needed to repair our nation’s fragile ECE system, including greater investment in CACFP,

to ensure the nutrition, health, and development of young children during the COVID-19 pandemic and

beyond. (Am J Public Health. 2021;111:116–120. https://doi.org/10.2105/AJPH.2020.305980)

As COVID-19 took hold across theUnited States, most states ordered early child-care and education (ECE)

programs closed or severely limited

their enrollment.1 This loss affected

millions of families.2 ECE allows parents

to participate in the workforce3 and

supports children’s academic readiness

and social and emotional development.4

However, an additional and often for-

gotten role of ECE is that many child-

care centers and family child-care

homes provide healthy meals and

snacks to children for free or at a re-

duced cost to families. The federal Child

and Adult Care Food Program (CACFP) is

the primary source of funds for this

food.5

In 2019, CACFP reimbursed more

than 150 000 centers and homes for

meals and snacks fed to approximately

4.6 million children.6 Notably, because

CACFP eligibility is determined at the ECE

site level instead of the child level, CACFP

serves both low-income children and

other nutritionally vulnerable children

whose household incomes are too high

to qualify them for other forms of federal

food assistance.

CACFP clearly benefits young children.

CACFP-participating ECE programs pro-

vide healthier meals and snacks than

those served by nonparticipating

programs7–9 and in children’s own

homes.10 CACFP meals and snacks also

save families money and reduce food

insecurity.11 CACFP reimburses child-

care providers in the contiguous United

States up to $6.36 per child per day in

food costs,12 allowing families to use the

money that would have been spent on

these meals and snacks on other es-

sential expenses. The loss of CACFP-

supported meals, compounded by loss

of income during COVID-19, is likely

devastating for many families.

Recognizing the potential for harm

resulting from the loss of ECE-provided

meals, the Families First Coronavirus

Response Act,13 signed into law on

March 18, 2020, authorized the US

Department of Agriculture to offer sev-

eral waivers for CACFP implementation

that will continue through the 2020–

2021 school year. These waivers enable

CACFP-participating programs to dis-

tribute meals directly to families through

“grab and go” programs and provide

flexibility in monitoring compliance and

claiming reimbursements.

This rapid action allowed some ECE

programs to continue providing food to

children who had reduced their atten-

dance or stopped attending. However,

many ECE programs were already closed

or had limited operational capacity by the

time the waivers were provided. Na-

tionwide, there was a dramatic drop in

meals served once shelter-in-place or-

ders spread across the country, with 35%

fewer CACFP-reimbursed meals served in

child-care centers and family child-care

homes in April 2020 than in April 2019.14

For example, in Illinois, only approxi-

mately 60% of homes and 15% of

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RESEARCH & ANALYSIS A JP H

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centers continued to provide CACFP-

reimbursable food to children during

the state-mandated shelter-in-place or-

der. In Connecticut, approximately 80%

of CACFP-participating centers closed in

spring 2020, and only a small fraction of

those that closed (15%) continued to

provide CACFP-reimbursable food. Fi-

nally, in Rhode Island, all ECE programs

were ordered closed and only two

centers continued to provide CACFP-

reimbursable meals. Nationwide reim-

bursement data and state-specific

examples such as these can provide

some insight into the extent of the loss

of the CACFP benefit. However, because

there is a lack of consistent infrastructure

across states to monitor program or

child enrollment in CACFP, the full im-

pact of the loss of CACFP-sponsored

food on children and families may never

be known.

ECE programs’ limited ability to feed

young children during COVID-19 is a

result of a cascade of vulnerabilities in

our nation’s ECE system. First, most ECE

programs are privately funded and

operate on razor-thin margins. COVID-

19 led to not only ECE closures or dra-

matically reduced enrollment limits but

also unprecedented unemployment

among parents and fear of sending

children to group child care even if

available. The resulting loss of tuition for

ECE programs meant that many pro-

grams had to lay off employees,15 leav-

ing little or no staff to assist with food

distribution.

Second, the demographic makeup of

our nation’s child-care workforce, par-

ticularly individuals who own family

child-care homes, substantially overlaps

with populations at high risk for COVID-

19. Child-care workers are more likely

than the general population to be Black

and of older age, and the prevalence of

underlying chronic health conditions is

higher among these individuals.16,17

Some providers, therefore, closed or

limited enrollment beyond state re-

strictions to protect their own health

and the health of their employees.18

Third, CACFP reimbursements do not

fully cover food costs,19 and unlike

school food programs the reimburse-

ments do not cover administrative ex-

penses such as compliance paperwork,

staff training, menu planning, food

procurement, and meal preparation and

disbursement. Without tuition revenue,

many ECE programs simply do not have

the financial or human resources to

obtain food and distribute it to families,

even with the promise of eventual

reimbursement.

Federal, state, and local initiatives

have filled some of the gaps in food

access that resulted from scaling back

ECE programs, but by no means com-

pletely. In many communities, families

with young children are being directed

to school district–operated food distri-

bution programs. There are many ad-

vantages to relying on school districts to

distribute food; for instance, unlike most

ECE programs, school food service op-

erations typically can purchase and

safely distribute grab-and-go meals to

large numbers of families. However,

challenges with relying on school dis-

tricts to feed young children also exist.

As an example, families with young

children who are not yet in school may

be unaware of such services or un-

comfortable receiving food from

schools. Recent estimates indicate that

only between 11% and 36% of low-

income school-aged children partici-

pated in school meal distribution

programs during spring 202020; partici-

pation among families with younger

children is likely even lower.

In addition, schools provide meals

through the National School Lunch

Program (NSLP) and the School Break-

fast Program (SBP). The nutritional re-

quirements for these programs align

with the needs of school-aged children,

not infants and toddlers. CACFP reim-

burses providers for infant formula and

infant and toddler food, whereas the

NSLP and SBP do not offer reimburse-

ment for distributing these more ex-

pensive items.

Finally, and perhaps most important, it

is financially unsustainable for school

districts to be the primary source of food

for all children in their communities.

School districts providing families food

under the NSLP and SBP are not reim-

bursed for meals provided to young

children. As COVID-19 spread, many

districts transitioned to working under

the Summer Food Service Program and

the NSLP Seamless Summer Option,

which do reimburse districts for meals

for young children; however, the ex-

pense of providing families meals safely

still far exceeds reimbursement rates.

As a result, school districts that have

worked to ensure that food is available

and accessible for all who need it have

amassed millions of dollars of debt.21

Outside of school food distribution,

the Special Supplemental Nutrition

Program for Women, Infants, and Chil-

dren (WIC), which provides supplemen-

tal foods for pregnant women and

children 5 years or younger who meet

income eligibility requirements, can

partially fill the gap left by the loss of

CACFP-supported program closures or

enrollment restrictions. However, WIC’s

monthly benefits are limited, valued at

less than the replacement value of

CACFP for children 1 year or older.22 In

addition, families who participated in

WIC before COVID-19 already account

for the benefit in their food budgets.

Families newly eligible may not be

familiar with the program and, in

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particular, may not realize that this

federal food program does not assess

immigration status. Finally, families

served by CACFP may not be eligible for

WIC benefits if their household income

is above 185% of the federal poverty line

or their children are older than 4 years.

In short, COVID-19 has caused an

unraveling of the nation’s ECE programs

and access to CACFP-funded food, both

of which are critical to young children’s

nutrition and families’ economic stability.

The effects of this unraveling will con-

tinue beyond the present, as states

navigate reopening and continued high

rates of COVID-19, and will be dispro-

portionate among our nation’s most

vulnerable families who do not have the

resources to compensate for these

losses. To begin to repair the safety net

and help families with young children

avoid food insecurity, we recommend

the steps outlined subsequently.

IMPROVE EMERGENCY FOOD ACCESS

Although many communities acted

quickly to increase food access among

families with young children, soaring

food insecurity rates23 suggest that

these efforts may have been insufficient.

Given the fragility of the ECE market

system and the workforce, expecting

ECE programs to be a significant source

of food support for young low-income

children during a pandemic is untena-

ble. New, creative models are needed to

ensure that families with young children

who have lost access to CACFP have

sufficient food now and as we move

forward toward a “new normal” of un-

precedented unemployment and lim-

ited ECE opportunities. These solutions

must provide families with age-

appropriate food of high nutritional

quality for their children.

One approach to ensuring access to

nutritious meals during ECE closures is

to expand the Pandemic Electronic

Benefits Transfer (P-EBT) program to

consistently serve children 5 years or

younger. Motivated by the rapid, na-

tionwide closures of schools owing to

COVID-19, the Families First Coronavirus

Response Act13 authorized the disbursal

of financial assistance via P-EBT to

families whose children were no longer

receiving free or reduced-price meals at

school. A very limited number of chil-

dren enrolled in ECE programs received

P-EBT despite no longer receiving fed-

eral nutrition assistance through CACFP

either because of state-specific imple-

mentation of the law or because their

ECE program had been reimbursing

their meals through the NSLP, not

CACFP. However, early evidence sug-

gests that the vast majority of young

children did not receive this benefit.

Future uses of P-EBT for the COVID-19

pandemic or other emergencies should

make explicit that P-EBT will serve all

children participating in federal nutrition

assistance programs in school (NSLP or

SBP) and ECE (CACFP) settings alike.

IMPROVE ACCESS TO THE PROGRAM

Despite the essential role that CACFP

plays in feeding young children and the

financial stability it provides to ECE

programs and families, the program is

underused. Barriers to ECE programs’

participation in CACFP are well known.

Programs report that the CACFP ad-

ministrative requirements are too bur-

densome and reimbursements too low

to warrant participation.24 Administra-

tive conveniences that exist for school

meal programs, such as the community

eligibility provision that eliminates

the burden of collecting eligibility

applications from low-income families,

do not apply to CACFP. Eligible programs

may also not know about CACFP or their

eligibility. For example, 52% of non-

CACFP child-care centers in Connecticut

are not aware of CACFP even though

state licensing regulations require them

to adhere to the program’s nutrition

standards.25

As we rebuild our economy and food

systems within the United States, fund-

ing for CACFP must be prioritized. Efforts

are needed to support outreach and

expansion grants, reduce administrative

burdens, extend eligibility to unlicensed

programs, and increase reimbursement

rates to fill the gap between food

preparation costs and reimbursements.

One potential positive outcome of

COVID-19 is that new flexibilities in ad-

ministering and implementing CACFP

were tested through US Department of

Agriculture waivers, such as reducing

reporting requirements and increasing

the use of technology for program

monitoring. Research exploring how

states, CACFP sponsors, and ECE pro-

grams have made use of the federal

waivers, and the extent to which the

waivers have eased administrative

burdens while still ensuring program

integrity, is necessary to inform modifi-

cations that could improve program

uptake and implementation.

IMPROVE THE PROGRAM’S DATA SYSTEMS

Relative to most other federal food

programs, data regarding CACFP are

severely lacking, limiting the ability to

easily monitor program participation,

conduct needs assessments, and iden-

tify effects. Although aggregated state-

level data (e.g., number of meals and

snacks served) are disseminated to the

US Department of Agriculture, no single

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source has comprehensive data on

CACFP providers nationwide, their

characteristics, or the children they

serve. Provider-level information is also

not readily available in most states and

data collection systems vary widely state

to state, making it challenging to assess

CACFP across states or nationally.

Knowing to what extent CACFP is

reaching vulnerable populations, in-

cluding Black and Latinx families, immi-

grants, and families living in rural areas,

is critical to distributing needed re-

sources, ensuring families’ food security,

and advancing health equity, especially

during emergencies such as COVID-19.

SUPPORT EARLY CHILD CARE AND EDUCATION

Any efforts to address food insecurity

and improve nutrition among children

through ECE settings must begin with

ensuring that all children have access to

high-quality ECE. Without significant in-

vestment, such as the $50 billion in

emergency funding for ECE programs

proposed in the Child Care is Essential

Act (HR 7027), our country’s ECE infra-

structure will be irrevocably weakened

by COVID-19. Beyond this initial step,

ongoing support for the ECE workforce

is needed to increase pay and access to

benefits for providers, who for too long

have been essential workers providing

one of our country’s most important

services for barely minimum wage.17

Child Care Aware of America, a national

organization supporting the ECE field,

suggests several policy levers that could

improve the quality and stability of the

ECE system long term. For example,

expanding child-care tax credits would

help address the financial burden of

care for families, and income tax credits

for providers could help address the

shortage of ECE professionals by

incentivizing them to enter and remain

in the ECE workforce.17

CONCLUSION

ECE in the United States is both frag-

mented and fragile. For too long, we

have ignored the critical role of child-

care programs in promoting the health

and development of young children.

COVID-19 and its devastating impact on

the child-care infrastructure in the

United States have brought our reluc-

tance to prioritize young children into

sharp relief. Taking steps to repair our

previous underinvestment in these

areas is essential during the nation’s

pandemic recovery and beyond.

ABOUT THE AUTHORS

Katherine W. Bauer is with the Department of Nu- tritional Sciences, University of Michigan School of Public Health, Ann Arbor. Jamie F. Chriqui is with the Division of Health Policy and Administration, School of Public Health, University of Illinois, Chicago. Tatiana Andreyeva is with the Department of Agri- cultural and Resource Economics, Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford. Erica L. Kenney is with the Departments of Nutrition and Social and Behavioral Sciences, Har- vard T. H. Chan School of Public Health, Boston, MA. Virginia C. Stage is with the Department of Nutrition Science, College of Allied Health Sciences, East Carolina University, Greenville, NC. Dipti Dev is with the Department of Child, Youth and Family Studies, College of Education and Human Sciences, Uni- versity of Nebraska, Lincoln. Laura Lessard is with the Department of Behavioral Health & Nutrition, University of Delaware, Newark. Caree J. Cotwright is with the Department of Foods and Nutrition, Uni- versity of Georgia, Athens. Alison Tovar is with the Department of Nutrition and Food Sciences, Uni- versity of Rhode Island, Kingston.

CORRESPONDENCE

Correspondence should be sent to Katherine W. Bauer, PhD, Department of Nutritional Sciences, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109 (e-mail: [email protected]). Reprints can be or- dered at http://www.ajph.org by clicking the “Re- prints” link.

PUBLICATION INFORMATION

Full Citation: Bauer KW, Chriqui JF, Andreyeva T, et al. A safety net unraveling: feeding young children

during COVID-19. Am J Public Health. 2021;111(1): 116–120.

Acceptance Date: September 15, 2020.

DOI: https://doi.org/10.2105/AJPH.2020.305980

CONTRIBUTORS

K. W. Bauer drafted the article and finalized the submission. All of the authors contributed to the conceptualization of the article and data collection in addition to critically editing the article.

ACKNOWLEDGMENTS

All of the authors are members of the Nutrition and Obesity Policy Research and Evaluation Network (NOPREN) COVID-19 Early Childcare and Education Working Group. We thank the Centers for Disease Control and

Prevention and the Robert Wood Johnson Foun- dation’s Healthy Eating Research Program for their support of NOPREN.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to declare.

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