Originally written by Jessica Bylander and published on Health Affairs on October 6, 2020.
School closures appear to slow the spread of the virus, but for many children the health ramifications are far broader.
For Naomi Shapiro of Chicago, Illinois, school closure meant a temporary loss of essential therapies for her child with special needs. Shapiro’s youngest son has an 18q deletion, a missing piece on chromosome 18, which caused some developmental delays and hearing loss. Pre-pandemic, her son attended a pre-kindergarten program through Chicago Public Schools for children who are deaf and hard of hearing.
“He gets speech therapy, occupational therapy, physical therapy all at school,” Shapiro says. So when the school closures hit the city, “all of his therapies were on hold,” she says.
The data on the risks of COVID-19 for children is evolving. Initial reports suggested that children were not getting infected at high rates or contributing greatly to the spread of the disease. Although most infections in children are mild or asymptomatic, the Centers for Disease Control and Prevention (CDC) has since found that one in three children hospitalized for COVID-19 were admitted to an intensive care unit.1 A Chicago study published in JAMA Pediatrics also found that children infected with COVID-19 had similar levels of the virus on their nasal swabs as adults, suggesting that kids can spread disease.2
Although early COVID-19 modeling studies predicted that school closures alone would prevent only 2–4 percent of deaths,3 a later analysis found that school closure was associated with a significant decline in both COVID-19 incidence and mortality.4 In short, closing schools made sense.
Yet beyond the health risks posed to children by the virus itself, there are well-known health risks of school closures and the loss of the essential health and social services that schools provide. The pandemic has highlighted the urgent need for policy reforms that strengthen the safety net and welfare system for children, relieving some of the pressure on schools.
“Schools are a huge safety net, and we have to protect them as a safety net,” says Rhea Boyd, a pediatrician and public health advocate. “But the pandemic is also telling us how vulnerable that safety net is.”
Initiatives at the federal, state, and local levels are attempting to fill the gap, with varying levels of success. But the piecemeal approach and lack of clear guidance, which has left many families to chart their own course, is likely to deepen existing inequities faced by disenfranchised groups, such as children of color and low-income kids.
“Nobody wants more COVID cases, obviously, but we do have to think a little broader about the health trade-offs,” says Taryn Morrissey, an associate professor at American University, in Washington, D.C.
“Children are going to pay for this for decades to come. They will with lower earnings, they will with less education, and they will with poorer health. And certain groups of children are going to pay more.”
FOOD INSECURITY AND SCHOOLS
Much attention has been focused on kids’ access to healthy food when schools are closed, given the outsized role schools play in providing food security. In fiscal year 2019, 29.6 million children were served by the National School Lunch Program, and 14.8 million children were served by the School Breakfast Program; both programs provide free and reduced-price meals to children who qualify.5 The health harms of food insecurity are many, including fatigue; reduced immune response; and long-term developmental, psychological, physical, and emotional harms.6
Beginning in the spring, school districts and states began implementing three main alternative methods of providing school meals during the closures: on-site food pickup sites, meal deliveries, and Pandemic-EBT (P-EBT) cards, which provide the cash value of the school meals to families who would have received them if schools were open. The US Department of Agriculture (USDA) has issued waivers to allow schools to bypass certain child nutrition program requirements (for instance, allowing meals to be served outside of standard meal times and in nongroup settings) but notably has not required schools to provide food service during closures.6
The USDA also partnered with the Baylor University Collaborative on Hunger and Poverty and others to deliver meals to low-income kids in rural areas across the country through a program called Meals to You; permitted more families to receive the maximum Supplemental Nutrition Assistance Program (SNAP) benefit ($768 per month for a family of five, for instance); and expanded access to a pilot program that allows SNAP beneficiaries to buy food online. As of August 2020, the USDA said that nearly 40 million meals had been distributed through Meals to You, more than 99 percent of eligible children were covered by Pandemic-EBT, and more than 78,000 locations were offering meals for children while schools are closed.7 The proposed Heroes Act would extend Pandemic-EBT through fiscal year 2021 and expand the program to young children who had been receiving meals and snacks from child care providers.
Yet some families who relied on schools for healthy meals will certainly fall through the cracks; when schools serve free meals at sites over the summer, for instance, they reach only one in seven children who usually receive meals during the school year.6 The Pandemic-EBT benefit of $5.70 per day in most states also doesn’t stretch very far at retail stores.8
“The amount of money that goes onto the P-EBT card is the equivalent of the cost of meals at school,” says Emily Broad Leib, clinical professor of law at Harvard Law School and faculty director of the Harvard Law School Food Law and Policy Clinic, in Boston, Massachusetts. “That amount doesn’t really equate to meals bought on the private market.”
In May 2020 recommendations, the Food Law and Policy Clinic urged Congress to “meaningfully increase” the Pandemic-EBT benefit amount, as well as meaningfully increase SNAP benefits in general.9
“One of the reasons families rely so much on schools is our other food benefits pay so little,” Leib says.
Cumbersome rules about who is eligible for free and reduced-price meals, and what geographic areas can deliver meals to all children in their area, have led to increased calls for a universal free meal program for all children in US schools.
“We’re so concerned that someone who doesn’t make a low enough amount of money will use a program that we make access to the program really, really administratively complicated,” Leib says. “It would be good for everyone if there were the expectation that healthy meals would be served to everyone.”
On July 30, Rep. Bobby Scott (D-VA), chair of the House Committee on Education and Labor, introduced the Pandemic Child Hunger Prevention Act, which would temporarily make all students eligible for free school meals during the 2020–21 school year, either in school, at grab-and-go sites, or through meal delivery.10
In Boston Public Schools, which Leib’s children attend, all students are eligible for free breakfasts and lunches regardless of their income status—part of the USDA’s Community Eligibility Provision for schools and school districts in low-income areas.11,12 So when the schools closed, Leib says there were grab-and-go sites “everywhere,” and every student’s family was sent a Pandemic-EBT card.
“It made it easier to make sure kids didn’t get lost along the way.”
Meanwhile, for the 4.5 million young children served meals at child care settings and after-school programs through the Child and Adult Care Food Program, there were significant gaps in food access while child care programs were closed because of the pandemic.13
“Schools continued to get funded during the closure, so they could do grab-and-go or whatever they were trying to do,” says Gina Adams, a senior fellow in the Center on Labor, Human Services, and Population and director of the Low-Income Working Families project and the Kids in Context initiative, all at the Urban Institute, in Washington, D.C. “Child care programs couldn’t. They were closed; they had no money.”
In a July 2020 brief the Urban Institute urged policy makers, communities, and other stakeholders to develop a coordinated approach to meeting young children’s nutritional needs during the pandemic; and to support child care and early education programs’ capacity to feed children, such as by providing grants to child care centers to purchase and provide food during closures.13 Alternatively, policies that provide money directly to parents, such as Pandemic-EBT, may be a better option in the face of child care closures, Adams says.
CHILDREN WITH SPECIAL NEEDS
When Louisiana public schools closed in March, Kathryne Hart’s four-and-a-half-year-old son lost access to a profound number of services. Hart’s son has a variation in the UBA5 gene that causes seizures, vision loss, and extreme developmental delays. In the spring he was in a public preschool program where he was provided with a nurse, physical therapy, occupational therapy, speech therapy, adaptive physical education, and a teacher for the visually impaired, in addition to the special education teacher for the class. The family had just ironed out the details of the new services he would be receiving through his Individualized Education Program (IEP), a document created annually for each child in public school who is eligible for special education, which spells out agreed-upon supports and services to be provided in school.14 Then, schools and therapy clinics closed due to COVID-19.
“At the time, we couldn’t do anything,” says Hart, of Baton Rouge.
Without therapy, Hart’s son physically regressed, and he ended up hospitalized twice for problems that would have been detected earlier or prevented. By June the clinics reopened and prioritized kids with the most severe needs, and the family started receiving therapies virtually. But Hart’s son is still not receiving the level of care he received at school.
“We want to go back,” she says. “For him the risk of hospitalization is getting to the point that sending him to school isn’t any less dangerous.”
The pandemic has shifted onto many families the burden for providing services that had been coordinated by school systems under an IEP, leaving parents with only hard choices. They might, like Hart and her husband, assist with their child’s virtual therapy, pay out of pocket for home health aides or other helpers, use Medicaid funding for personal care assistants if possible, or simply stop the child’s therapy.
“There are families who are doing nothing at all, and they’re having a lot of behavioral issues,” says Georgia Mueller, program coordinator of the Missouri Family to Family Program, a statewide network of families offering free supports to people with disabilities and their families. “Families have had decent access for so long to decent therapy [through schools,] they just don’t know what to do.”
Mueller, whose twenty-one-year-old son has level 2 autism and receives personal care assistance through a Medicaid community support waiver, says the pandemic provides an opportunity to spread out the responsibility for providing special needs services.
“There is so much about this COVID experience that is making us rethink our policies,” Mueller says. “I see the prime opportunity to spread the responsibility to a variety of entities instead of it being [concentrated] in schools.”
For one, health insurance plans could play a bigger role in ensuring that children with special needs receive the services they need, she says. Within Medicaid, the Early and Periodic Screening, Diagnostic, and Treatment benefit provides “comprehensive and preventive health care services” to children under age twenty-one, including developmental and specialty services if needed.15 The benefit has “no peer” among private and other health insurance plans.16 Mueller would like to see such coverage become standard for all children’s health plans through age twenty-six. She also advocates for policies that can support families with children with special needs financially, which in turn could free up time and resources to provide or pay for their care at home. For instance, Mueller’s family participates in the Health Insurance Premium Payment (HIPP) program in Missouri, which helps families with a Medicaid-eligible member pay employer-sponsored insurance premiums.
“HIPP could be the difference between a parent who can stay home and implement those therapies and one who cannot,” Mueller says. “In our family, it’s $700 cash flow that I wouldn’t have otherwise.”
Even before the pandemic, public schools struggled to fulfill their role as a public health and social safety net for children, particularly in the face of decreasing funding for many schools. This was particularly true of schools serving Black communities, says Sally Nuamah, an assistant professor at Northwestern University, in Evanston, Illinois, who has studied the impact of permanent school closures on children of color.
“When you take that and add a pandemic to it, we can predict who is going to end up bearing the brunt and the burden of this,” Nuamah says. “And that’s what we’ve seen.”
In addition to being more at risk for COVID-19 hospitalization,1 families and children of color and low-income families face disproportionate negative consequences when schools and child care centers close. According to a policy brief from the NAACP, women of color make up 40 percent of educators in child care centers and homes and half of home-based paid child care providers—a sector hard hit by pandemic closures.17 In addition, Black students account for 44 percent of students in high-poverty schools where more than two-thirds of students are eligible for free or reduced-price lunches, and many homes in low-income communities lack access to technology or high-speed internet to facilitate virtual learning.17
“I worry about kids that were already on the margins or vulnerable in some way,” says Nia Heard-Garris, a pediatrician and researcher at Northwestern University’s Feinberg School of Medicine. “I worry about all kids, but there are definitely some kids who I feel like are going to be hit a little harder.”
Time will tell what the health effects of the pandemic will be even for children who were not infected with the virus, Heard-Garris says, but prior research on major events such as 9/11 indicate that such major stressors can impact birth outcomes for pregnant women, children’s mental health, and obesity rates.
In addition, when schools are able to safely reopen, families and educators will need to contend with the loss of learning milestones while schools were closed or operating part time.
“It’s like leaving generations of kids behind,” pediatrician Boyd says. “After we get past ‘should schools reopen and how?’, the next stage is going to be massive remediation. What do we do for all the kids who were virtual drop-outs, who haven’t checked in when school went online, and who aren’t thriving in this virtual learning environment?”
Some families—especially those with flexibility, financial resources, or both—have begun to form learning “pods,” where families band together to facilitate online learning among a small group of children, perhaps by hiring a tutor, alternating taking time off work, or forming home-schooling pods with a paid teacher. Some advocates are concerned, however, that this approach will only deepen inequities.18
“They are absolutely going to reinforce the same racial and class divides that already exist in neighborhoods and then in classrooms,” Boyd says.
Whether outside organizations could intervene to make access to learning pods more equitable, and at a large enough scale, remains to be seen. Among some smaller efforts, researchers from the University of California Irvine are pairing education students to tutor and facilitate small-group learning.19 In addition, Harvard University student Evelyn Wong recently received funding from the Clinton Foundation for a COVID-19 student project to create an online platform that pairs underserved K–12 students with undergraduates and postgraduates from colleges and universities for mentorship and educational resources.20
As is clear, schools provide much more than academics for children; in the absence of those supports, Nuamah cautions against focusing narrowly on whether kids achieve learning milestones under new pandemic realities. Instead, the major focus should be on making sure the social and public health needs of children are equitably met.
“Achievement only has meaning in an equitable society,” she says. “What does it mean to achieve or to care about merit in a context where people are suffering such deep inequities related to their social conditions?”
Approaching equity in child outcomes and opportunity goes beyond the debate of whether to reopen schools so that children can access the safety-net services that schools were providing. Boyd argues that what’s really needed is a redistribution of wealth so that the safety net has fewer—if any—people to catch.
“Your family doesn’t need an EBT card if you make a living wage,” she says. “We don’t need a moratorium on evictions if everyone can afford rent and their mortgage. The government helped facilitate this gap; how can the government facilitate remediating it?”
- 1 Hospitalization rates and characteristics of children aged <18 years hospitalized with laboratory-confirmed COVID-19 – COVID-NET, 14 states, March 1–July 25, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1081–8. Crossref, Medline, Google Scholar
- 2. Age-related differences in nasopharyngeal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) levels in patients with mild to moderate coronavirus disease 2019 (COVID-19). JAMA Pediatr. 2020;e203651. Google Scholar
- 3 School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health. 2020;4(5):397–404. Crossref, Medline, Google Scholar
- 4 Association between statewide school closure and COVID-19 incidence and mortality in the US. JAMA. 2020:e2014348. Google Scholar
- 5Department of Agriculture, Food and Nutrition Service. Child nutrition tables [Internet]. Alexandria (VA): FNS; 2020 Sep 17 [cited 2020 Aug 26]. Available from: https://www.fns.usda.gov/pd/child-nutrition-tables Google Scholar
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- 8Department of Agriculture, Food and Nutrition Service. Pandemic EBT (P-EBT) questions and answers [Internet]. Alexandria (VA): FNS; 2020 Apr 15 [cited 2020 Aug 26]. Available from: https://fns-prod.azureedge.net/sites/default/files/resource-files/SNAP-COVID-PEBTQA.pdf Google Scholar
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- 10House Education and Labor Committee [Internet]. Washington (DC): The Committee; 2020. Press release, Chairman Scott introduces bill to provide free school meals to all students during COVID-19 pandemic; 2020 Jul 30 [cited 2020 Aug 26]. Available from: https://edlabor.house.gov/media/press-releases/chairman-scott-introduces-bill-to-provide-free-school-meals-to-all-students-during-covid-19-pandemic Google Scholar
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- 14Department of Education, Office of Special Education and Rehabilitative Services. A guide to the individualized education program [Internet]. Washington (DC): DOE; 2000 Jul [cited 2020 Aug 26]. (Archived information). Available from: https://www2.ed.gov/parents/needs/speced/iepguide/iepguide.pdf Google Scholar
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