By Cristin Kumar
In this era, finding a federal program that elected officials from both political parties fervently support can be a daunting task. Yet no task is too daunting for the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. The MIECHV program, which provides voluntary, evidence-based home visiting services to at-risk pregnant women and parents with young children, is admired by members of Congress for its data-driven model and the positive results that participating parents and children have realized through its services. As the upcoming reauthorization deadline looms, states and local MIECHV providers wonder how this popular federal program (and their home visiting programs back home) might be affected.
Federal History of MIECHV
Though the MIECHV program is often associated with its enactment into law in 2010 through the Patient Protection and Affordable Care Act (PPACA), home visiting as a concept and method of addressing health and well-being in children through home visits has been in the U.S. since at least the 1960s; though it’s been argued that it actually began almost a century earlier, in the 1880s, with the Settlement House movement. By the 1990s, home visiting programs were growing in popularity across the country, with funding originating from a combination of sources, including private philanthropists and state governments.
Home visiting programs now exist in all 50 states, Washington, D.C., and five U.S. territories. States receive MIECHV funding through a federal funding formula, which takes into account the state’s highest-need counties. Funding may be supplemented by state and local governments, in addition to private foundations or health systems. In Florida, North Dakota, and Wyoming, because the states themselves do not accept funding, nonprofit organizations with “an established record of providing early childhood home visiting programs or initiatives in one or more states” are eligible to apply for funding directly to HHS.
Providing federal funding for home visiting has garnered strong bipartisan support at the federal level for at least the past two decades. In 2004, Missouri’s Republican Senators Chris Bond and Jim Talent introduced legislation to establish federal funding for home visiting, though it was never enacted into law. The program that immediately preceded MIECHV was launched by the Bush Administration as a pilot program in 2008 to build upon the existing state programs by providing approximately $10 million in grants to 15 states. The goal of the pilot was to determine what types of supports would be needed to scale home visiting at the federal level, replicating successful models with fidelity. One of the most significant elements of the Supporting Evidence-Based Home Visiting (EBHV) program (and one that has continued with MIECHV) was its requirement that the home visiting programs be evidence-based.
The PPACA officially authorized the MIECHV program, funding it at $1.5 billion over 5 years. The Medicare Access and CHIP Reauthorization Act of 2015 then renewed (or “reauthorized”) the program for two years at $400 million each through September 30, 2017 (though sequestration decreased the final amount of funding). Recently, MIECHV received a nod of approval from the Trump Administration in its FY 2018 budget proposal, which proposed continued (albeit, level) funding for the program. MIECHV is now administered at the federal level by the Department of Health and Human Services (HHS), under both the Health Resources and Services Administration (HRSA) and Administration for Children and Families (ACF).
In 2009, HHS and Mathematica launched an annual, comprehensive review of the evidence base for individual home visiting program models, called the Home Visiting Evidence of Effectiveness project (HomVEE). Per HHS, HomVEE “conducts a comprehensive review of the evidence of effectiveness of home visiting program models that support children’s health and development, school readiness, reductions in maltreatment, positive parenting practices, and improved family self-sufficiency (when in conjunction with child outcomes).” As of April 2017, HomVEE has classified 20 home visiting models as evidence-based, 10 of which are currently in use across the country. The various program models employ nurses, social workers, or parent educators in working directly with parents, sometimes up to the age of kindergarten entry. Some well-known models include Early Head Start-Home Visiting, Parents as Teachers and Nurse-Family Partnership.
In addition to the HomVEE study of program model effectiveness, and to grantee and sub-grantee continuous program evaluation, the MIECHV program itself is also undergoing a federal evaluation. The Maternal, Infant, and Early Childhood Home Visiting Evaluation (MIHOPE) is a legislatively-mandated evaluation of the MIECHV program, conducted by MDRC. MIHOPE requires: (1) an analysis of the needs assessments that states conducted in their initial MIECHV applications; (2) an implementation study to observe how programs are implemented and assess variations; (3) a cost-benefit analysis and effectiveness study to examine the costs of operating a program compared to its effectiveness; and (4) a random-assignment impact study to examine the effects home visiting programs have on the at-risk families they serve. The MIHOPE statewide needs assessment report was issued to Congress in 2015, while the additional three reports will be released in 2018. Also of note, HRSA updated the program’s performance standards in October 2016.
MIECHV Program Framework
The MIECHV program arose out of a growing understanding of the critical rate at which the brain develops in a child’s first years of life, as well as the importance of prenatal care to a child’s development. The program has been proven to prevent child abuse and neglect; premature birth, low birth weight, or infant deaths; and preventing the need for remediation, among other positive outcomes.
In order to qualify for initial funding, states conducted needs assessments in 2011 to identify communities with high concentrations of risk factors. States are required to establish benchmarks for demonstrating improvements in four of the six indicators and spend 75% of their funds on models considered evidence-based by HHS. States also use MIECHV funds for innovation pilots, such as Illinois’ project for very high-risk families, like parents who are homeless or in the child welfare system.
States are required to collect and report to HHS on a quarterly basis on the following benchmark areas for the eligible families in programs within their state:
- Improvements in maternal, newborn, and child health;
- Prevention of child injuries, child abuse, neglect, or maltreatment and reductions of emergency room visits;
- Improvements in school readiness and child academic achievement;
- Reductions in crime or domestic violence;
- Improvements in family economic self-sufficiency; and
- Improvements in the coordination and referrals for other community resources and supports.
In FY2015, the MIECHV program served 145,561 individual parents and children and provided 912,119 home visits across the U.S. In FY 2016, the number of parents and children served increased to 160,000. However, this likely does not capture the full picture, so to speak, as it does not take into account the greater impact on local communities that grows out of MIECHV providers’ partnerships with related community-based providers and programs. Because MIECHV is an outcomes-based program, leveraging other community resources through collaboration with, for example, other early childhood programs, workforce development programs, and healthcare providers to maximize community impact is key to a provider’s success. HHS and the Department of Education (ED) highlighted how this type of resource collaboration might work in its January 2017 guidance on the potential for collaboration between the Individuals with Disabilities Education Act (IDEA) Part C program providers and MIECHV providers. The guidance emphasized the benefit of timely referrals between programs and, more broadly, coordination of funding, policy and service delivery. These methods for collaboration could apply to a number of different types of federally-funded programs, such as Head Start, Child Care and Development Block Grant (CCDBG), or the Temporary Assistance for Needy Families (TANF).
State MIECHV Grant Administration
States apply to HHS directly for a MIECHV grant and then allocate the federal funding – often combined with state, local, private and other sources – often by issuing Requests for Proposal (RFPs). The specific RFP may ask for new programs, depending on funding levels, prioritized by need according to the 2011 statewide community needs assessments. A state may also issue grants to programs to expand the number of families served, or to sustain the services offered. Or, as in Illinois’ case, a state may also provide innovation funds for promising new approaches. A community action agency (CAA), or other community-based organization, is one of the types of eligible entities to apply to a state to administer a MIECHV-funded program – which could be in addition to its Head Start and/or Early Head Start programs, other programs for at-risk families, and even other home visiting models.
Each state has a distinct home visiting system with a distinct process for program procurement. Some states have rejected federal funding altogether, such as Florida, Wyoming, and North Dakota. In these states, a lead non-profit organization runs the state’s MIECHV program and grant administration. Florida receives approximately $11 million annually for its MIECHV grant. Because Florida is one of the 3 states that does not accept federal funds through its state agency, the Florida Association of Healthy Start Coalitions, Inc. applies directly to HHS for a MIECHV grant and disseminates funding to 11 projects with three models (Nurse-Family Partnership, Parents as Teachers, and Healthy Families Florida) across 14 communities. Most recently, in 2015 and 2016, Florida MIECHV released RFPs to expand services to a handful of the remaining high-need communities identified by Florida’s 2011 state assessment. One of the winners was the Manatee Community Action Agency, which was awarded funds to expand its services for at-risk families in Hardee and DeSoto counties through the Parents as Teachers model in March 2017. Manatee also offers the Healthy Families and the Home Instruction for Parents of Preschool Youngsters (HIPPY) home visiting models to other areas of the community it serves.
In Ohio, the Ohio Help Me Grow (HMG) home visiting program was created in 2001 to bring three separate programs for children birth-to-three, their families, and expectant parents, under a single system of coordinated services for home visiting and early intervention programs. The Ohio Department of Health administers the funding for HMG through the office of Central Coordination (CC), and counties will typically supplement funds through public and/or private moneys. In 2015, Cuyahoga County was the recipient of a $2 million grant from several private foundations to implement the Nurse-Family Partnership model, which was supplemented when Ohio allocated the county a $560,000 MIECHV grant in 2016. You can read Ohio’s HMG provider application here.
States recently went through their most recent round of applications, with HHS expected to announce awards by September 30. There is approximately $343 million in FY 2017 funding available to grantees for the two-year project period of September 30, 2017-September 30, 2019 (funds are available for expenditure for up to two years); of note, the award ceilings will be 0.8% less than in FY2016.
According to the federal government’s central grants forecasting page, grants.gov, HHS/HRSA is expected to release the next Funding Opportunity Announcement (FOA) for states to submit their applications in March 2018 with applications due May 2018. To learn more about the MIECHV program in your state, take a look at this interactive map which includes individual state fact sheets.
Legislative Status of the MIECHV Reauthorization
This past May, the House Committee on Ways and Means, one of the congressional committees overseeing the MIECHV program, held a hearing on reauthorizing the MIECHV program, with members on both sides of the aisle offering praise. The Senate Finance Committee (which oversees the program in the Senate) has not yet publicly introduced legislation. Both committees also oversee tax policy, and because tax reform is Congress’ number one priority right now, MIECHV is perhaps receiving less public attention. However, with strong support from both parties, the reauthorization is considered by Congress to be a “must-pass” bill.
In June of this year, House Republicans introduced the Increasing Opportunity through Evidence-Based Home Visiting Act (H.R. 2824), which would provide level funding for the program ($400 million) for each of five years through Fiscal Year 2022. The following month, House Democrats introduced their own version, The Home Visiting Works Act. This bill only makes changes to the program’s funding levels and set-asides. The bill would fund the program with annual escalations beginning at $600 million in FY 2018 and ending at $800 million in FY 2022. This increase in funding would allow for expansion to additional sites and high-need communities across the country. In a typical year, each of these two bills would be what are called “marker” bills, essentially marking the lines in the sand in preparation for later negotiations. Of course, it’s been anything but a typical year.
Based on the House Republican bill, substantive changes that could be included in the next reauthorization are: requiring each state to conduct a new state assessment by FY2020 (the last one was conducted in FY 2011); providing a third method by which a model may be made eligible; establishing a dollar-for-dollar funding match from grantees and their sub-grantees; and re-establishing a requirement around “self-sufficiency” benchmarks measuring improvement in employment, earnings, and receipt of means-tested benefits.
Should Congress fail to reauthorize the MIECHV program by September 30 of this year, its authorization will expire. Because of the recent discussions around raising the debt ceiling and the possibility of shutting down the government (which isn’t unheard of in the past five years), MIECHV reauthorization risks getting lost in the noise. Though the program’s popularity with Republicans (the majority in both chambers) makes it unlikely the program won’t be renewed, it remains to be seen what form the renewal will take.
- The Pew Charitable Trusts – States and the New Federal Home Visiting Initiative
- Committee on Ways and Means – Chairman Smith Opening Statement at Hearing on the Reauthorization of the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program
- Education Week – Head Start Down, Home Visiting Up in White House Budget Proposal
- Home Visiting History
- Parents as Teachers
- The Pew Charitable Trusts – States and the New Federal Home Visiting Initiative
- Zero to Three – Home Visiting: Looking Back and Moving Forward