Introduction
The early childhood years are the foundation for lifelong well-being and healthy development. For children living in poverty, disproportionate exposure to negative experiences compromises this development. Early interventions like home visiting can mitigate the effects of adverse life events, improving outcomes for children and their families. In light of Governor Brown’s proposal to establish a home visiting initiative in the California Work Opportunity and Responsibility to Kids (CalWORKs) program — our state’s welfare-to-work program — this Brief explores the rationale behind home visiting, the underlying research, and the state of home visiting in California.
Adverse Experiences Harm Children in the Long Term
Research shows that exposure to stressful situations is damaging to children, particularly in the early years.[1] Chronic stress undermines children’s immune systems and impairs their neurological development, presenting long-term health, behavioral, and academic challenges. Living in poverty can create and exacerbate these stressful conditions, imposing substantial costs on children, their families, and society.[2] With California’s high rate of child poverty (23%), the state’s children face considerable obstacles.[3] These obstacles are particularly salient for children of color, who face higher poverty rates than white children.[4] Children living in poverty are more likely to experience barriers to success, including higher risk of being born prematurely or at a low birthweight, being abused, and achieving lower educational outcomes.[5] These experiences can limit children’s long-term chances for success and fuel intergenerational poverty. However, research also indicates that stable and supportive relationships with adults can mitigate and even reverse the effects of adverse life events.
Home Visiting Programs Can Improve Children’s Outcomes
Extensive research shows that early childhood interventions can reduce or prevent adverse life experiences and improve outcomes for at-risk families.[6] While later interventions can be successful, they are also likely to require more effort and public expenditures to address the harm.[7] Home visiting is one example of an early intervention. Home visiting programs offer parenting training and other assistance — such as help with navigating social services — to expecting parents and parents of young children, particularly those who are at risk of problems such as substance abuse, unemployment, or family violence.[8] These programs encourage positive parenting and can enhance child and maternal health, help prevent child abuse, and improve child development.[9]
Home visiting models vary widely in their target population, their home visitor qualifications, and their focus. For example, in the Healthy Families America (HFA) program, home visitors are social workers who serve low-income, at-risk families with children from birth to age 5. The Nurse-Family Partnership (NFP) supports low-income, first-time mothers through registered nurses who focus on child and maternal health. The variation in model design and the number of models could make it difficult to assess which models to trust and what outcomes they could yield. Fortunately, home visiting has generated an extensive body of research that identifies the impacts of each of the most commonly used models across eight broad areas:
- Child health
- Child development and school readiness
- Family economic self-sufficiency
- Linkages and referrals
- Maternal health
- Positive parenting practices
- Reductions in child maltreatment
- Reductions in juvenile delinquency, family violence, and crime.[10]
These areas align with the outcome categories specified in the legislation authorizing the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, which provides funds to states, territories, and tribes to support voluntary, evidence-based home visiting programs. Currently, the US Department of Health and Human Services (HHS) considers 20 models to be evidence-based, including the five largest national models (by enrollment): Early Head Start-Home Visiting, HFA, NFP, Home Instruction for Parents of Preschool Youngsters (HIPPY), and Parents as Teachers (PAT).[11] HFA and NFP have the strongest evidence base, with favorable outcomes in eight and seven areas, respectively.[12]
According to the research, home visiting produces demonstrable gains for parents and children. For example, home visiting can reduce low birth weight and premature births, help lower infant mortality, increase breastfeeding, and reduce parental stress.[13] These benefits may be particularly helpful in reducing racial health disparities, as children of color face lower rates of breastfeeding and higher infant mortality than white children.[14] Home visiting also can improve academic success and parent engagement, with participating parents more likely to read to their children and less likely to engage in harsh discipline.[15] Additionally, home visiting can improve family economic self-sufficiency through increased parental employment and improved family relationships. However, while studies point to differences in outcomes between families that received home visiting services and those that did not, these differences can be small.[16] Therefore, home visiting should be viewed not as a silver bullet, but rather as one tool among many possible early childhood interventions.
Yet research questions remain. There is little research on how effective home visiting is for some populations, such as military families and immigrant families with different cultural needs or for whom English is not their first language.[17] It is also unclear if home visiting can reduce or eliminate poverty for the child participants. The longest-term follow up study of NFP, which examined child outcomes at age 19, observed no significant effect on high school completion or economic productivity, though the authors did find reductions in teenage pregnancy and contact with the criminal justice system.[18] However, other research suggests that children’s earnings could increase due to reduced maltreatment, and some analysts have projected that NFP could raise lifetime earnings by more than $35,000 and help lift families out of poverty.[19]
In the Long Term, Benefits of Home Visiting Can Outweigh the Costs
Another way to evaluate home visiting’s value is to ask whether the benefits to families and society actually outweigh the fiscal costs of these programs. According to an evaluation of the MIECHV program, home visiting’s benefits are generally greater than its costs in the long term.[20] By preventing contact with the child welfare, criminal justice, and mental health systems, as well as increasing parental employment and earnings, home visiting can be a smart investment for the whole community. Targeting services to the most at-risk families also can pay off. In one 15-year study, benefits exceeded costs far more when services were targeted to the lowest-income families.[21]
Home Visiting in California: Fragmented and Insufficient Funding
In California, funding for home visiting comes from a patchwork of local and federal sources, with no state General Fund dollars.[22] Annual support totals at least $120 million, according to the Legislative Analyst’s Office (LAO).[23] The most significant investment in home visiting is through local First 5 commissions, which fund and coordinate services for children from birth to age 5.[24] First 5 revenue is generated by a state excise tax on cigarettes and other tobacco products imposed by Proposition 10 (1998).[25] First 5 supports both national evidence-based home visiting models and local models, with total investments at $86 million in 43 counties as recently as state fiscal year 2015-16.[26] In addition, federal grants support providers of local Early Head Start-Home Visiting programs and the state-administered MIECHV program, which allocated $16.3 million for the Nurse-Family Partnership and Healthy Families America programs in 2017-18, which began on July 1, 2017.[27]
Yet this funding environment is increasingly tenuous as falling tobacco consumption has reduced revenue for local First 5 commissions.[28] Declining revenue may mean that fewer families would benefit from a home visiting program even as current capacity already falls well short of need. Only 10% to 20% of at-risk families who would likely benefit from home visiting receive those services, according to the LAO.[29]
Governor Brown’s Proposal: Home Visiting in CalWORKs
Signaling new interest in home visiting, Governor Brown’s proposed 2018-19 state budget includes a three-year home visiting pilot initiative within CalWORKs. CalWORKs is supported with both state General Fund dollars along with federal Temporary Assistance for Needy Families (TANF) dollars. Beginning in January 2019, this program would provide up to 24 months of home visiting for first-time parents under age 25, who would have to be either pregnant or parenting a child under age 2. (CalWORKs parents’ participation in this new program would be voluntary.) The goal would be to “help young families reach self-sufficiency by improving family engagement practices; supporting healthy development of young children living in poverty; and preparing parents for employment.”[30] The Administration assumes that the program, which counties could implement at their option, would serve about 6,500 families on average each month. The Governor proposes a total of $158.5 million in federal TANF funds for this initiative, with no state General Fund support.[31] Specifically, $26.7 million in TANF dollars would be allocated during 2018-19, and the remaining $131.8 million would be available through calendar year 2021.[32] The Department of Social Services would be required to evaluate this initiative to determine if it should continue after 2021.
Though the Administration’s CalWORKs home visiting initiative would provide more families with access to these services, it excludes parents with more than one child and those age 25 or older. However, research suggests that home visiting is beneficial even for parents with multiple children.[33] Additionally, as the average CalWORKs household has two children and is headed by a 34-year-old caregiver, there are many families whom this initiative would overlook.[34] Including these families in the home visiting pilot would extend the reach of this initiative, but would also increase the cost. As a result, the state would likely need to invest General Fund dollars in this pilot program in addition to TANF funds. Moreover, extending this initiative beyond 2021 would likely require the state to provide ongoing — rather than temporary — General Fund support for home visiting within CalWORKs in order to supplement the available TANF dollars.
Home Visiting Programs Are Good State Investments
Given the substantial research on the benefits of home visiting, the Governor’s proposed CalWORKs home visiting initiative would be a promising, though limited, investment in California’s families. State policymakers should consider widening eligibility for the pilot program to parents age 25 or older and/or with more than one child. State leaders should also consider expanding state support for evidence-based home visiting beyond CalWORKs in order to reach substantially more families. Boosting access to home visiting would require a significant and ongoing state General Fund investment, particularly as California’s primary funders of home visiting — local First 5 commissions — face declining tobacco tax revenue. However, by committing ongoing state funding for home visiting, California would affirm its support for children in the crucial early years, helping protect them from the damaging effects of toxic stress, and strengthening families into the future.
Endnotes
[1] Ross Thompson, “Stress and Child Development,” The Future of Children 24:1 (2014), pp. 41-59.
[2] Center on the Developing Child at Harvard University, The Foundations of Lifelong Health Are Built in Early Childhood (July 2010) and US Department of Health and Human Services, Strengthening TANF Outcomes by Developing Two-Generation Approaches to Build Economic Security (April 12, 2016).
[3] This poverty rate is based on the Supplemental Poverty Measure. See Alissa Anderson, California’s Persistently High Child Poverty Rate Is Even Higher for Children of Color (California Budget & Policy Center: April 5, 2018).
[4] If the poverty rate for children of color were as low as that for white children, nearly 1 million fewer California children would be impoverished and the number of kids in poverty in our state would be cut by nearly half. See Alissa Anderson, California’s Persistently High Child Poverty Rate Is Even Higher for Children of Color (California Budget & Policy Center: April 5, 2018).
[5] Heather Sandstrom and Roxane White, Scale Evidence-Based Home Visiting Programs to Reduce Poverty and Improve Health (US Partnership on Mobility From Poverty: March 2018), pp. iv and 1.
[6] Lynn A. Karoly, Rebecca Kilburn, and Jill S. Cannon, Proven Benefits of Early Childhood Interventions (RAND Corporation: 2005).
[7] Ross Thompson, “Stress and Child Development,” The Future of Children 24:1 (2014), pp. 41-59.
[8] Charles Michalopoulos, et al., The Mother and Infant Home Visiting Program Evaluation: Early Findings on the Maternal, Infant, and Early Childhood Home Visiting Program — A Report to Congress (US Department of Health and Human Services: January 2015).
[9] US Department of Health and Human Services, The Maternal, Infant, and Early Childhood Home Visiting Program: Partnering With Parents to Help Children Succeed (no date), accessed from https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/pdf/programbrief.pdf on April 2, 2018.
[10] Through Mathematica Policy Research, HHS evaluates the research literature in the Home Visiting Evidence of Effectiveness (HomVEE) study. A model is “evidence-based” if at least one rigorous evaluation points to favorable and statistically significant impacts in two or more of the eight areas or if at least two rigorous evaluations with non-overlapping samples find one or more positive and significant impacts in the same area. See Emily Sama-Miller, et al., Home Visiting Evidence of Effectiveness Review: Executive Summary (US Department of Health and Human Services: August 2017), p. 6.
[11] Through Early Head Start-Home Visiting, low-income pregnant women and families with children up to age three receive home visits and group socialization opportunities. The Home Instruction for Parents of Preschool Youngsters program helps parents prepare their preschool-aged children for school. Parents as Teachers pairs parents with trained parent educators who focus on school readiness, child development, and abuse. Heather Sandstrom and Roxane White, Scale Evidence-Based Home Visiting Programs to Reduce Poverty and Improve Health (US Partnership on Mobility From Poverty: March 2018), p. 8.
[12] For a detailed breakdown of impacts by model type, see Emily Sama-Miller, et al., Home Visiting Evidence of Effectiveness Review: Executive Summary (US Department of Health and Human Services: August 2017), pp. 14-15.
[13] Heather Sandstrom and Roxane White, Scale Evidence-Based Home Visiting Programs to Reduce Poverty and Improve Health (US Partnership on Mobility From Poverty: March 2018), p. 2.
[14] Studies suggest that African-Americans have lower rates of breastfeeding than whites and higher rates of infant mortality. See Heather Sandstrom and Roxane White, Scale Evidence-Based Home Visiting Programs to Reduce Poverty and Improve Health (US Partnership on Mobility From Poverty: March 2018), p.9. For California-specific data, see The Annie E. Casey Foundation, Low Birth-Weight Babies by Race (updated May 2017), accessed from https://datacenter.kidscount.org/data/tables/16-low-birth-weight-babies-by-race?loc=6&loct=2&loc=6&loct=2#detailed/2/6/false/573,869,36,868,867/10,11,9,12,1,13/276,275 on April 2, 2018 and The Annie E. Casey Foundation, Infant Mortality by Race (updated May 2017), accessed from https://datacenter.kidscount.org/data/tables/21-infant-mortality-by-race?loc=6&loct=2&loc=6&loct=2#detailed/2/6/false/573,869,36,868,867/10,11,9,12,1,13/285,284 on April 2, 2018.
[15] Rachel Herzfeldt-Kamprath, Maura Calsyn, and Thomas Huelskoetter, Medicaid and Home Visiting: Best Practices From States (Center for American Progress: January 25, 2017).
[16] Congressional Research Service, Maternal and Infant Early Childhood Home Visiting (MIECHV) Program: Background and Funding (February 15, 2017), p. 2, downloaded from http://homevisitingcoalition.com/wp-content/uploads/CRS-Report.pdf, on April 20, 2018.
[17] Emily Sama-Miller, et al., Home Visiting Evidence of Effectiveness Review: Executive Summary (US Department of Health and Human Services: August 2017), p. 19.
[18] John Eckenrode, et al., “Long-term Effects of Prenatal and Infancy Nurse Home Visitation on the Life Course of Youths: 19-Year Follow-up of a Randomized Trial,” Archives of Pediatrics & Adolescent Medicine 164:1 (2010), pp. 9-15.
[19] Charles Michalopoulos, et al., The Mother and Infant Home Visiting Program Evaluation: Early Findings on the Maternal, Infant, and Early Childhood Home Visiting Program — A Report to Congress (US Department of Health and Human Services: January 2015), p. 10 and Heather Sandstrom and Roxane White, Scale Evidence-Based Home Visiting Programs to Reduce Poverty and Improve Health (US Partnership on Mobility From Poverty: March 2018), p. 10.
[20] MDRC assesses the effectiveness of different MIECHV-supported models, variation in program implementation, and cost-effectiveness through a random-assignment study called the Mother and Infant Home Visiting Program Evaluation (MIHOPE). See Charles Michalopoulos, et al., Evidence on the Long-Term Effects of Home Visiting Programs: Laying the Groundwork for Long-Term Follow-Up in the Mother and Infant Home Visiting Program Evaluation (MIHOPE) (US Department of Health and Human Services: September 2017), pp. 5-9.
[21] See Charles Michalopoulos, et al., Evidence on the Long-Term Effects of Home Visiting Programs: Laying the Groundwork for Long-Term Follow-Up in the Mother and Infant Home Visiting Program Evaluation (MIHOPE) (US Department of Health and Human Services: September 2017), p. 8.
[22] Children Now, Voluntary Evidence-Based Home Visiting in California (February 15, 2018).
[23] Legislative Analyst’s Office, The 2018-19 Budget: Analysis of the Health and Human Services Budget (February 16, 2018).
[24] Children Now, Early Childhood Home Visiting in California: The Right Place at the Right Time (September 2014).
[25] Excise tax revenue raised by Prop. 10 is used to support services that improve early childhood development. These funds are divided between the state First 5 Commission (which receives 20%) and local First 5 commissions (which receive the remaining 80%). See California Budget & Policy Center, How Much Does California Spend on Programs and Services for Children and Youth? (March 2006), p. 3.
[26] Email communication with First 5 Association of California (April 26, 2018).
[27] California administers federal MIECHV funds through the California Home Visiting Program, which supports NFP and HFA programs in 23 counties. See California Department of Public Health, Maternal, Child and Adolescent Health Division “Allocations,” https://www.cdph.ca.gov/Programs/CFH/DMCAH/Pages/Allocations.aspx accessed on April 18, 2018.
[28] Cigarette consumption has continued to decline in recent decades in California, particularly after public health campaigns and higher state excise taxes on cigarettes and other tobacco products. California Department of Public Health, California Tobacco Control Program, California Tobacco Facts and Figures 2016: Over 25 Years of Tobacco Control in California (October 2016).
[29] Legislative Analyst’s Office, The 2018-19 Budget: Analysis of the Health and Human Services Budget (February 16, 2018).
[30] Department of Finance, Governor’s Budget Summary 2018-19 (January 2018), p. 63.
[31] These federal TANF dollars would be “freed up” due to an anticipated decline in CalWORKs enrollment in the coming years. As California’s economy expands, more families are able to increase their employment and see their incomes rise. In turn, fewer families need or qualify for CalWORKs cash assistance, thus reducing the number of families enrolled in the program. Declining CalWORKs enrollment “frees up” funds — including TANF dollars — that can be used for certain other state purposes. The number of CalWORKs families has fallen by nearly 30% since 2010-11; the 2017-18 enrollment of 425,000 represents an historic 20-year low. See Legislative Analyst’s Office, The 2018-19 Budget: Analysis of the Health and Human Services Budget (February 16, 2018).
[32] The estimated 2018-19 expenditure level — $26.7 million — reflects a half-year cost (January through June 2019). The cost for a full fiscal year is estimated to be $52.5 million. Assembly Budget Subcommittee No. 1 on Health and Human Services agenda for April 4, 2018 hearing, p. 26.
[33] Joseph Galano and Lee Huntington, Comparison of Primiparous and Multiparous Mothers: Healthy Families Program Participation, Outcomes, Challenges, and Adaptations FY 1999-FY 2010 (June 2012).
[34] California Department of Social Services, CalWORKs Annual Summary: California Families on the Road to Self-Sufficiency (January 2017), p. 5.
