Last week, Republican members of Congress took the first step towards fulfilling their and President-elect Donald Trump’s campaign promise to “repeal and replace” the Affordable Care Act.
Despite the House and Senate passing a budget proposal that tees up the health care law’s evisceration, lawmakers on both sides of the aisle say that Obamacare’s legacy “home visiting” program will be reauthorized and perhaps even doubled in size.
Rep. Lloyd Doggett (D-Texas), a stalwart supporter of home visiting, told The Imprint that he plans to introduce legislation that would increase funding for the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) from $400 million to $800 million over the next five years.
MIECHV “is one of the few initiatives that seems to have enjoyed genuine bipartisan support,” Doggett said. “I view this really as empowering families legislation. It is about helping parents be the parents they want to be.”
When the Affordable Care Act was signed into law in 2010, it established MIECHV with a five-year authorization that totaled $1.5 billion. That constituted a massive increase in the federal home visiting budget, which began under the George W. Bush administration as a modest demonstration grant.
The program expanded the practice wherein nurses, social workers or other trained paraprofessionals help at-risk pregnant or parenting mothers with the difficult task of raising a baby. All of the 17 home visiting models approved for MIECHV funding are voluntary; visitation services can only be offered, not forced on the parent.
By 2014, MIECHV had tripled the number of families receiving these services to 115,545 participants, according to a 2016 report submitted to Congress. Despite these gains, the percentage of eligible families that the federal home visiting program touches is in the low single digits.
One of the approved models, the Nurse-Family Partnership (NFP), was identified last year by the Commission to Eliminate Child Abuse and Neglect Fatalities as the only program in the U.S. proven to reduce maltreatment-related deaths.
In Los Angeles, MIECHV funds four public health nurses in the County’s NFP program. Aurora Lopez, one of the county’s NFP nurses, works with as many as 25 first-time mothers at a time, teaching them parenting skills like how to breast feed, deal with the stress of a wailing infant and maintain a nutritious, nerve-calming diet.
This month, one of Lopez’ clients, 21-year-old Arjanae Carter, will celebrate her daughter Amaya’s second birthday. Lopez’ first visit to Carter’s Bellflower home was when she was five months pregnant.
Lopez beams, remembering visiting Carter two weeks after Amaya was born.
“Here is this life and you have so much hope for this person and it is valid hope because I know the mom,” Lopez said. “I know Arjanea and I know her strengths, so when I see Amaya and her mom I have so much hope.”
Despite its apparent success and bipartisan support, the program has not been reauthorized since its initial authorization ended in 2014. But Congress has maintained annual funding of $400 million through a pair of extensions. An initial extension was made under the Protecting Access to Medicare Act in 2015; another extension through fiscal 2017 came as part of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act.
MIECHV will face another funding cliff in September unless Congress reauthorizes the program or throws it another fiscal life preserver. Without MIECHV, the number of home visiting professionals around the country is certain to plummet.
“If states are realizing that funding is at risk and staff don’t know if they are going to have a job after September 2017, they are going to be concerned and in some cases start looking for new work,” said Stephanie Schmit, a senior policy analyst with the Center for Law and Policy.
But the National Home Visiting Coalition, of which Schmit is a member, is actually confident that MIECHV will survive. The coalition is gunning to double the program’s reach.
“We would like to see funding go from $400 to $800 million over a five year re-authorization,” said Teri Weathers, policy director at the NFP, another coalition member. “I think it has about as good of a chance of any reauthorization in this environment. It may have been easier if we had a different person in the White House. But it is always an uphill climb.”
The advocates derive their sanguine disposition from home visiting’s history on the Hill, evidence in support of the practice, and statements from current members of Congress who say they support the program and want to see it continue.
“Each time MIECHV needed to be extended, Congress has felt that it is important enough to protect as one of the cornerstone evidence-based policies,” said Karen Howard, vice president of early childhood policy with the First Focus Campaign for Children.
Long before MIECHV’s inclusion in the Affordable Care Act, the concept of home visiting had won champions on both sides of the aisle at both the state and federal level.
In 2004, two Republican senators introduced a bill that would have invested in expanding home visiting nationally. Four years later, under President George W. Bush, the federal government invested in the so-called “Evidence-Based Home Visiting Program.”
The most comprehensive Republican proposals put forward to dismantle the ACA have not mentioned MIECHV by name, according to advocates.
Those same advocates, lawmakers and congressional staff point to the strong evidence base that has made home visiting so popular.
That evidence base is largely built on the back of the Nurse-Family Partnership, which has been in existence for decades.
Widely publicized random control trials of the program show a broad range of positive outcomes for the children and mothers who accept the voluntary services. A 2015 study found that one-third of mothers involved with NFP who began the program without a high school diploma ended the program with one. And a 1997 study showed that NFP reduced reports of child maltreatment by 48 percent while emergency visits for accidents or poisonings dropped by 56 percent.
Part of the original MIECHV authorization included a comprehensive evaluation of the program. While the final results will not be in until next year, preliminary findings released in March of last year suggest the program is helping mothers and their children.
Eighty-five percent of the state and county programs funded through MIECHV demonstrated improvements in school readiness, more than two-thirds showed reductions in domestic violence and crime, and a similar number had reductions in child injuries.
David Olds, who designed NFP and led many of the random control trials that proved its effectiveness, sees the shifting political landscape in Washington D.C. and the imminent expiration of MIECHV as an opportunity for growth.
“Ideally, one would use this opportunity to deepen this program’s commitment to grounding policy and practice in solid evidence,” Olds said. “Where we have communities and families that are really hurting, let’s help them. Let’s make sure that they are served really well. That in my mind is the socially responsible thing to do.”
Both Republican and Democratic lawmakers agree.
“I’ve supported the Maternal, Infant and Early Childhood Home Visiting Program since its creation and look forward to its reauthorization,” said Senator Chuck Grassley (R-Iowa) in an email statement. “My staff already has met with interested groups and discussed working with them on the reauthorization. We haven’t discussed the exact terms, such as the dollar amount or the length of the reauthorization, yet. On David Olds’ ideas, accountability to measure results and make sure the money is well spent is always welcome. These ideas are something to consider as part of the debate.”
Staff for Senator Ron Wyden (D-Ore.), who was instrumental in the latest extension of MIECHV, said that he too was committed to seeing the program continue.
“Sen. Wyden will continue to be a strong supporter of extending and strengthening the Maternal, Infant and Early Childhood Home Visiting Program, as he has always been in the past,” said Wyden Press Secretary Samantha Offerdahl in an email statement.
Kevin Brady (R-Tex.) is the chairman of the House Ways and Means Committee, which holds the purse strings to many social policies including the federal home visiting program. In a January 11 op-ed that ran in The Hill, Brady called out his commitment to MIECHV directly.
“We will advance evidence-based reforms to fund more programs that actually work, such as the Maternal, Infant, and Early Childhood Home Visiting program, which has delivered positive results for families by empowering parents to achieve better outcomes for themselves and their children,” he wrote.
Members of the Ways and Means subcommittee who will have the first look at the home visiting program also showed support.
“As the newly-selected chairman for the Human Resources Subcommittee, Congressman Adrian Smith (R-Neb.) looks forward to discussing how to fund this important, evidence-based program when a new ranking member is chosen,” said Ways and Means Press Secretary Lauren Aronson in an email.
Rep. Doggett, who just stepped down as ranking member for the Human Resources Subcommittee, told The Imprint that his legislation doubling the funding over a five-year reauthorization was imminent. But he conceded that such an expansion might not have traction with the current leadership in Washington.
“I am working to see, given the current and unfortunate political climate and very dangerous period we have entered in American history, that we at least get this current level of funding reauthorized at the end of the fiscal year so that we don’t have a gap in the services that are out there now,” Doggett said.
Lopez, the Los Angeles public health nurse, thinks any disruption to federal funding would be unwise.
“An investment in mothers and infants and their families is an investment in our communities and our nation as whole,” she said. “It is a good investment, a smart investment and an ethical investment.”