Dr. Ezekiel J. Emanuel and Amaya Diana
President Joe Biden just released his American Families Plan focused on strengthening the country’s social safety net and investing in our children.
Surprisingly, the $1.8 trillion plan seems to be missing one essential component: scaling up successful, evidence-based and thus far dreadfully underfunded early childhood interventions for low-income families. In particular, it should include programs that provide regular home visits, such as nurse-family partnerships, for low-income families beginning at birth and going up to one or two years of age.
Having a baby is one of the most stressful events in life for even the most privileged parents. For those with limited income and social supports, it can be financially and emotionally taxing. A relationship with a knowledgeable, supportive coach through pregnancy and infancy should not just be a cushy luxury for well-off mothers who can afford doulas. As an entitlement for low-income parents, it would be a transformative public policy with a high return on investment.
Medicaid would stabilize financing
Home-visiting partnership programs began in the 1970s typically serving low-income, first-time parents. There are many such programs, but the common thread involves linking nurses, social workers, or other professionals with parents for regular meetings at the parents’ home, where they are guided through healthy child development, connected to important social services, and, importantly, educated on how to care for their newborns and coached through this crucial period of their lives.
Despite robust evidence of their benefits, home-visiting programs are grossly underutilized, chiefly due to a patchwork of funding. There are numerous home-visiting early childhood intervention programs throughout the country, but the largest federal funding source — the Maternal, Infant and Early Childhood Home Visiting Program run through the Health Resources and Services Administration –served only 150,000 families in 2019, while there are nearly 1.6 million births — 42% of all births — financed by Medicaid each year. Because states must cobble together funding every year from a variety of sources, long-term, sustainable coordination and planning is impossible, which limits enrollment and hinders the programs’ overall effectiveness.
Mandating that Medicaid cover nurse-family partnerships or similar evidence-based programs for every expectant mother as part of the American Families Plan would resolve the funding question — and create a substantial return on investment. The precise cost estimates vary by location, with studies in the last decade showing an average comprehensive cost of about $8,700 per family. Increasing costs to reflect inflation to $10,000 per family for one year, enrolling every newborn delivered on Medicaid would cost under $20 billion a year. This would represent about 3% of total Medicaid spending. Over the 10-year budget window, it would constitute under a 10% increase in the cost of the American Families Plan.
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Financing home-visiting programs should not be considered government spending but a worthwhile investment. Over the last 50 years, home-visiting programs have been extensively evaluated through randomized trials, and the results are overwhelming: they have a large positive return on investment.
It is well understood that the earlier the intervention in children’s lives, the better and longer-lasting the outcomes. The most effective partnerships reduce child abuse and infant deaths, increase rates of breast feeding and immunization, and reduce childhood asthma and obesity. Strikingly, they also have long-term life impacts on the children’s educational readiness, language acquisition, and behavioral development, all of which reduce enrollment in special education programs. Even more encouraging, these programs lower the children’s chances, years later, of being arrested and trapped in the criminal justice system.
Starting at age 3 is playing catch-up
Addressing the social determinants in infancy – or even in utero before delivery – saves society money. The most comprehensive cost-effectiveness analyses are older. They indicate that the societal financial savings of nurse-family partnerships to be over $17,000 per child through reduced health, education, criminal justice and welfare spending. Recent estimates also find that state and federal savings would greatly outweigh program costs. For instance, the Center for American Progress estimates a 5% annual return.
These programs also offer an important way to reduce existing social disparities. Medicaid pays for about half of all rural births, nearly all of which would be eligible for these early childhood interventions. Similarly, Medicaid funds a majority of births for Black and Hispanic mothers. Consequently, investing in these early childhood interventions would narrow the disparities in the health and other outcomes of these rural and minority children. And the impact on health, education, and income would be lifelong.
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There is a tremendous amount of good in the American Families Plan as it is written: augmenting child care, expanding paid family and medical leave, funding nutrition benefits, introducing universal pre-K, and extending the child tax credit that would lift over 40% of American children out of poverty. It is an enormous investment in the next generation, with the potential to bring the United States up to the child support standards of other wealthy countries.
But these proposals begin at age 3. We will be playing catch-up if we do not focus on the crucial first year of life. By adding early childhood interventions such as nurse-family partnerships to the American Families Plan, Biden can revive the promise of opportunity and upward mobility for American children, even those born into poverty.
Dr. Ezekiel J. Emanuel (@ZekeEmanuel) is co-director of the Healthcare Transformation Institute at the University of Pennsylvania and author of “Which Country has the World’s Best Health Care?” Amaya Diana (@amayahdiana) is the research coordinator at the University of Pennsylvania’s Department of Medical Ethics and Health Policy.