New home visiting funds are on the horizon
By Adam Sonfield
Senior Public Policy Associate
With partisan fighting increasingly the norm in Washington, one of the few potential points of agreement might be federal funding for so-called home visiting programs.
By having nurses or other experts visit new and expecting low-income families to provide information, guidance, and support, these programs can lead to numerous long-term health and social benefits for children and families, according to research compiled and analyzed by Heather Boonstra, senior public policy associate for the Guttmacher Institute.1 Of particular note for family planning providers and advocates, some programs have demonstrated reductions in unplanned pregnancy, improved birth spacing and resulted in fewer preterm births.
Numerous models for home visiting have been tested over several decades across the country. It is difficult to generalize about them, because they vary widely in the breadth of their goals, their program design, staffing, and implementation, and the extent of their demonstrated impact. Despite this variation, the American Academy of Pediatrics concluded in 2009 that home visiting programs can be important tools for preventing child abuse and neglect and for improving children's health, school readiness, and development.2
Perhaps the most famous and best-studied model, first developed in the 1970s by David Olds and known today as the Nurse-Family Partnership, serves nearly 20,000 families in 28 states.3 The visits provided under that model are designed to emphasize not only healthy behaviors and parenting skills, but also educational and economic achievement and the importance of pregnancy planning. It is by helping young mothers understand the value and importance of delaying future pregnancies and providing contraceptive counseling that programs such as the Nurse-Family Partnership have helped improve young mothers' reproductive health outcomes.
Economic analyses of home visiting programs have shown promise, despite their considerable expense. A 2005 meta-analysis conservatively estimated the net savings at about $6,000 per child, or $2.24 per dollar invested.4 In fact, contraceptive counseling might contribute greatly to such savings: Recent Guttmacher Institute estimates find that by helping women avoid unplanned pregnancies, every public dollar spent on family planning services saves four dollars in Medicaid-funded maternity and infant care.5
Most states today — 40 of them, according to a 2009 study from the National Center for Children in Poverty — provide at least some public funding for home visiting initiatives.6 In addition to state revenues, most of those programs draw on existing federal funding streams, including Medicaid, the Maternal and Child Health Block Grant, and Temporary Assistance for Needy Families (TANF). In that same survey, 31 of the 40 states were able to report their annual expenditures for home visiting, amounting to $250 million in federal and state dollars.
Nevertheless, this funding is not nearly sufficient to serve the 600,000 low-income women each year who give birth for the first time7, and program advocates have long pushed for a dedicated federal funding stream to change that equation. They have important new support for that agenda from President Obama, whose FY 2010 budget proposed a new, 10-year, $8.6 billion home visiting program, which would help states fund established and promising initiatives. Although it was not explicitly labeled as such, the president's proposal fits squarely within his broader agenda of finding "common ground" on the issue of abortion. It is attractive both to those who argue for increased support for family planning as a means to prevent unplanned pregnancy and thereby abortion, and to those who argue that additional support for low-income parents will encourage more pregnant women to carry a fetus to term. Those benefits are, of course, in addition to the numerous direct benefits for women and children — health, social, and economic, short- and long-term — that have for many years attracted broad-based support outside of the contentious abortion debate.
These programs also have found support in Congress over the past year, with proposals to dedicate new TANF funding for home visiting or to explicitly authorize Medicaid spending for that purpose. Indeed, home visiting initiatives were included in the House- and Senate-passed health care reform legislation late in 2009. As of this writing, one or more such initiatives are expected to be included in whatever bill the two chambers finally agree upon, if agreement can be reached. None of the congressional proposals meet President Obama's funding target, however, and fiscal pressures and small-government skeptics remain the most significant obstacles to fully meeting the need that home visiting advocates have identified.
- Boonstra HD. Home visiting for at-risk families: A primer on a major Obama administration initiative. Guttmacher Policy Review 2009, 12:11-14.
- American Academy of Pediatrics, Council on Community Pediatrics. The role of preschool home-visiting programs in improving children's developmental and health outcomes. Pediatrics 2009; 123:598-603.
- Nurse-Family Partnership. Nurse-Family Partnership, Snapshot, January 2009. Accessed at http://www.nursefamilypartnership.org/assets/PDF/Fact-sheets/NFP_Snapshot_Oct_09.
- Karoly LA, Kilburn MR, Cannon JS. Early Childhood Interventions: Proven Results, Future Promise. Santa Monica, CA: RAND Corp.; 2005.
- Frost JJ, Finer LB, Tapales A. The impact of publicly funded family planning clinic services on unintended pregnancies and government cost savings. J Health Care Poor Underserved 2008; 19:777-795.
- Johnson K. State-based Home Visiting: Strengthening Programs through State Leadership. New York City: National Center for Children in Poverty; 2009.
- Nurse-Family Partnership. Public funding: A sound investment that can yield substantial public and private gains, December 2009. Accessed at http://www.nursefamilypartnership.org/assets/PDF/Fact-sheets/NFP_Public_Funding.