Health Care Reform

We were bitterly disappointed to learn that the Early Learning Challenge Fund didn’t survive the rough and tumble of the health care reform effort. It represented much that was good about the Obama approach to education. Using competitive grants to fund better quality, better-coordinated services for children from birth to age 5, as the program proposed, would go a long way toward addressing the many deficiencies in our early childhood system.

We hope the administration finds another way to meaningfully fund the challenge grant concept for the early childhood years but can’t help wondering if this will actually happen. Obviously, it didn’t help that Congress had to resort to the reconciliation process for passage and that the amount saved from reforming the student loan program was revised downward. One worry is that the costs of health care reform, war, and other big budget items will simply squeeze early childhood programs out of the budget. In any case, this session in Congress will be a test of the early childhood community’s clout on the Hill.

The news wasn’t all bad for the early childhood community, however. The health care reform legislation does contain a $1.5 billion federal grant program for evidence-based home visitation for new and expectant families. Engaging families at home to deliver parenting education and child development guidance is not new. Programs like Parents as Teachers (PAT), Home Instruction for Parents of Preschool Youngsters (HIPPY) and Even Start have been around since the 1980s. They use home visits to deliver parent education intended to promote better cognitive and socio-emotional development of at-risk children. In the 1990s, programs like Healthy Families America and Healthy Start began using home visits in an effort to prevent child abuse.

For years, these programs have been plagued with questions about how well they work. The quality of research on them is mixed, as are the findings. For the most part, when positive effects have been found, they have tended to be modest. One exception is the Nurse Family Partnership. Begun in the 1970s, it targets low-income, first-time mothers with visits from trained nurses. Randomized trials have found the program produced positive outcomes that, among other things, included fewer childhood injuries, fewer subsequent pregnancies, and improved school readiness among the children of parents visited.

If a major expansion of home visitation is to be effective, policymakers need to realize that success with this service delivery model depends heavily on the quality of the intervention. As with high-quality preschool education, much depends on the quality of the professional doing the teaching and the pupil — in this case the home visitors and parents.

A good deal more high-quality research needs to be done on home visitation to identify what works for given sets of circumstances and to inform various aspects of the policy process. Among those calling for that is John Schlitt who directs the Pew Home Visiting Campaign at The Pew Center for the States. His initiative is looking at what each state is doing in this arena and will publish initial findings this year. It is working in partnership with states that take different home visitation approaches in order to better develop scenarios from which other states may benefit. Meanwhile, a number of states are funding programs that don’t have much in way of compelling evidence that they are working. That needs to change.