Facing Budget Uncertainties, States Seek New Opportunities to Fund Successful Home Visiting Programs

States have a long history of using home visiting programs to deliver cost-effective interventions to vulnerable children and families, and recent federal investments have been instrumental in the expansion of evidence-based home visiting programs across the United States.

Due to budget uncertainties at the state and federal level, states are exploring opportunities to maximize investments through a variety of sources in order to maintain and expand evidence-based home visiting programs. A new National Academy of State Health Policy (NASHP) issue brief, Medicaid Financing of Home Visiting Services for Women, Children, and Their Families, examines existing and emerging Medicaid financing mechanisms that states are using to support home visiting.

Evidence-based home visiting programs provide a comprehensive array of in-home services and supports to families and young children on a voluntary basis, and have been found to promote positive child and family outcomes, such as improved child and maternal health, increased school readiness, improved family economic self-sufficiency, and reductions in child maltreatment.

While the various evidence-based home visiting models vary in intensity and scope, all of them use trained providers, such as nurses, social workers, child development professionals, and other paraprofessionals, to deliver services to young children and families. The services typically include screenings, case management services, and family support and counseling. Additionally, evidence-based home visiting programs that target high-risk families have been shown to save states up to $5.70 for every $1 invested in the long run. These savings result from reduced health services utilization — including emergency department visits — and decreased special education placements and grade repetition, which leads to higher educational attainment and economic success later in life.

States typically use public and private funds, including Medicaid, to support evidence-based home visiting programs. While home visiting is not a mandated or a fully-defined set of services under Medicaid, there are numerous Medicaid financing pathways that states are using to implement, sustain, and expand home visiting programs. The NASHP brief examines these funding pathways, which include targeted case management, Early and Periodic Screening, Diagnostic and Treatment (EPSDT), and 1115 and 1915(b) waivers.

The NASHP brief also explores emerging opportunities to support home visiting as part of state payment and delivery system reform efforts. Several states, including Minnesota and Virginia, have partnered with Medicaid managed care organizations to cover home visiting services through contract requirements or other arrangements. New York is providing funding to support evidence-based programs through its Delivery System Reform Incentive Payment (DSRIP) Waiver program, which is designed to restructure Medicaid’s care delivery system and shift to primarily value-based payments.

To support the comprehensive services, rigorous staff trainings, and development of quality controls that make evidence-based home visiting programs successful, states use an array of federal and state funding sources. This is even more critical given current funding challenges at the state and federal level. Many states are experiencing gaps in their budgets, and a range of programs are facing large funding shortfalls.

In particular, the future of the federal Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) is uncertain. MIECHV, created by the Affordable Care Act, has provided grants to 50 states, Washington, DC, and five territories to establish or expand evidence-based home visiting programs. MIECHV is currently up for reauthorization in Congress, with funding slated to end Sept. 30, 2017.

Two reauthorization bills have been introduced in the House of Representatives (Home Visiting Works Act of 2017 and Increasing Opportunity through Evidence-Based Home Visiting Act), and the Senate is expected to introduce a MIECHV reauthorization bill on September 19. However, as of mid-September, it is not known if MIECHV’s funding will be reauthorized. States’ ability to use, leverage, and coordinate multiple funding streams, including Medicaid, will be even more critical to the future of this public health intervention.