I 
115TH CONGRESS 
1ST SESSION H. R. 3291 
To amend title XIX of the Social Security Act to provide for a State option 
to provide for maternal, infant, and early childhood home visiting pro-
grams, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 18, 2017 
Mr. RYAN of Ohio (for himself and Mr. BEN RAY LUJA´N of New Mexico) in-
troduced the following bill; which was referred to the Committee on En-
ergy and Commerce 
A BILL 
To amend title XIX of the Social Security Act to provide 
for a State option to provide for maternal, infant, and 
early childhood home visiting programs, and for other 
purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Alleviating Adverse 
Childhood Experiences Act’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
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(1) Adverse childhood experiences include emo-
tional and physical neglect and abuse, sexual abuse, 
intimate partner violence, household substance 
abuse, household mental illness, parental separation 
or divorce, and having an incarcerated household 
member. 
(2) Findings from the adverse childhood experi-
ences study conducted by the Centers for Disease 
Control and Prevention have shown that adverse 
childhood experiences predispose children toward 
negative trajectories from infancy into adulthood. 
(3) As the number of adverse childhood experi-
ences increases so does the risk for myocardial in-
farction, asthma, mental distress, depression, smok-
ing, disability, unemployment, lowered educational 
attainment, opioid abuse, coronary heart disease, 
stroke, and diabetes. 
(4) According to the Centers for Disease Con-
trol and Prevention, adults who had been exposed to 
more than one adverse childhood experience were 
significantly more likely to be unemployed, to be liv-
ing in poverty, and not to have graduated high 
school than adults who had not experienced an ad-
verse childhood experience. 
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(5) The Centers for Disease Control and Pre-
vention also found that just one year of confirmed 
cases of child maltreatment costs $124,000,000,000 
over the lifetime of the traumatized children. These 
include increases in childhood health care costs, 
adult medical costs, productivity losses, child welfare 
costs, criminal justice costs, and special education 
costs. 
(6) Home visiting programs, pediatric-based 
services and informed, evidence-based approaches 
have been proven to prevent and mitigate the nega-
tive effects of adverse childhood experiences on chil-
dren and families. 
(7) Participants in the Nurse-Family Partner-
ship’s home visiting program have shown a 48 per-
cent reduction in State-verified reports of child 
abuse and neglect by age 15, a 67 percent reduction 
in behavioral and emotional problems by age 6, and 
a 59 percent reduction in arrests by age 15 among 
many other improved child health and development 
outcomes compared to counterparts in a control 
group. 
(8) Participants in the Nurse-Family Partner-
ship’s programs have also shown increased self-suffi-
ciency by family members (and less utilization of 
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Federal programs), generating a $12,300 savings in 
the supplemental nutrition assistance program under 
the Food and Nutrition Act of 2008 (7 U.S.C. 2011 
et seq.) and savings of $11,511 (valued with respect 
to 2006) under the temporary assistance for needy 
families program under title IV of the Social Secu-
rity Act (42 U.S.C. 601 et seq.) with respect to chil-
dren between the ages of 0 through 12. 
(9) HealthySteps, an interdisciplinary pediatric 
primary care model has been shown to increase child 
safety, on time vaccinations, age-appropriate paren-
tal engagement, school readiness, and connections to 
community resources. 
(10) Several States finance part of their home 
visiting programs through the Medicaid program 
under title XIX of the Social Security Act (42 
U.S.C. 1396 et seq.), but such program could be uti-
lized to support more eligible families. One study 
showed that if all eligible children and families were 
enrolled in evidence-based programs, States could 
save up to $2,400,000,000 combined and the Fed-
eral Government could save up to $813,000,000 over 
10 years. 
(11) Pediatric-based settings that incorporate 
developmentally oriented services such as promoting 
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early reading, connection to community-based serv-
ices, positive parent-child interaction, and guidance 
on behavior management have shown to increase 
participation in well-child visits and are associated 
with high levels of parent satisfaction. 
(12) Families participating in the Healthy 
Families America home visiting program have seen 
impacts within one year or less, including a 48 per-
cent reduction in babies born with low birth weight 
and increased healthy parent behaviors, such as a 41 
percent reduction in alcohol use. Mothers partici-
pating in such program were more than five times 
as likely to continue their education. 
SEC. 3. STATE OPTION TO PROVIDE FOR MATERNAL, IN-
FANT, AND EARLY CHILDHOOD HOME VIS-
ITING PROGRAMS. 
Title XIX of the Social Security Act (42 U.S.C. 1396 
et seq.) is amended by adding at the end the following 
new section: 
‘‘SEC. 1948. STATE OPTION TO PROVIDE FOR MATERNAL, IN-
FANT, AND EARLY CHILDHOOD HOME VIS-
ITING PROGRAMS. 
‘‘(a) 
IN
GENERAL.—Notwithstanding 
section 
1902(a)(1) 
(relating 
to 
statewideness), 
section 
1902(a)(10)(B) (relating to comparability), and any other 
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provision of this title for which the Secretary determines 
it is necessary to waive in order to implement this section, 
beginning on January 1, 2018, a State, at its option as 
a State plan amendment, may provide for medical assist-
ance under this title to eligible families through services 
furnished under early childhood home visitation programs 
or pediatric-based services that satisfy the requirements 
of subsection (b) in order to promote improvements in ma-
ternal and prenatal health, infant health, child health and 
development, parenting related to child development out-
comes, school readiness, and the socioeconomic status of 
such families, and reductions in child abuse, neglect, and 
injuries. 
‘‘(b) PROGRAM REQUIREMENTS.—The requirements 
of this subsection for an early childhood home visitation 
program conducted pursuant to this section are as follows: 
‘‘(1) QUANTIFIABLE, MEASURABLE
IMPROVE-
MENT IN BENCHMARK AREAS.— 
‘‘(A) IN
GENERAL.—The early childhood 
home visitation program establishes, subject to 
the approval of the State, quantifiable, measur-
able 3- and 5-year benchmarks for dem-
onstrating that the program results in improve-
ments for the eligible families participating in 
the program in each of the following areas: 
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‘‘(i) Improved maternal and newborn 
health. 
‘‘(ii) Prevention of child injuries, child 
abuse, neglect, or maltreatment, and re-
duction of emergency department visits. 
‘‘(iii) Improvement in school readiness 
and achievement. 
‘‘(iv) Reduction in crime or domestic 
violence. 
‘‘(v) Improvements in family economic 
self-sufficiency. 
‘‘(vi) Improvements in the coordina-
tion and referrals for other community re-
sources and supports. 
‘‘(B) DEMONSTRATION OF IMPROVEMENTS 
AFTER 3 YEARS.— 
‘‘(i) REPORT TO THE SECRETARY.— 
Not later than 30 days after the end of the 
3rd year in which the State conducts the 
program, the State submits to the Sec-
retary a report demonstrating improve-
ment in at least 4 of the areas specified in 
subparagraph (A). 
‘‘(ii) TECHNICAL ASSISTANCE.— 
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‘‘(I) IN
GENERAL.—The Sec-
retary shall provide a State required 
to develop and implement an improve-
ment plan under clause (ii) with tech-
nical assistance to develop and imple-
ment the plan. The Secretary may 
provide the technical assistance di-
rectly or through grants, contracts, or 
cooperative agreements. 
‘‘(II) 
ADVISORY
PANEL.—The 
Secretary shall establish an advisory 
panel for purposes of obtaining rec-
ommendations regarding the technical 
assistance provided to States in ac-
cordance with subclause (I). 
‘‘(iii) NO IMPROVEMENT OR FAILURE 
TO SUBMIT REPORT.—If the Secretary de-
termines after a period of time specified by 
the Secretary that a State has failed to 
demonstrate any improvement in the areas 
specified in subparagraph (A), or if the 
Secretary determines that a State has 
failed to submit the report required under 
clause (i), the Secretary shall withdraw ap-
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proval of the State plan amendment in-
volved. 
‘‘(C) FINAL REPORT.—Not later than De-
cember 31, 2022, the State shall submit a re-
port to the Secretary demonstrating improve-
ments (if any) in each of the areas specified in 
subparagraph (A). 
‘‘(2) IMPROVEMENTS IN OUTCOMES FOR INDI-
VIDUAL FAMILIES.— 
‘‘(A) IN GENERAL.—The program is de-
signed, with respect to an eligible family partici-
pating in the program, to result in the partici-
pant outcomes described in subparagraph (B) 
that the State identifies on the basis of an indi-
vidualized assessment of the family, are rel-
evant for that family. 
‘‘(B) PARTICIPANT OUTCOMES.—The par-
ticipant outcomes described in this subpara-
graph are the following: 
‘‘(i) Improvements in prenatal, mater-
nal, and newborn health, including im-
proved pregnancy outcomes. 
‘‘(ii) Improvements in child health 
and development, including the prevention 
of child injuries and maltreatment and im-
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provements in cognitive, language, social- 
emotional, and physical developmental indi-
cators. 
‘‘(iii) 
Improvements 
in 
parenting 
skills. 
‘‘(iv) Improvements in school readi-
ness and child academic achievement. 
‘‘(v) Reductions in crime or domestic 
violence. 
‘‘(vi) Improvements in family eco-
nomic self-sufficiency. 
‘‘(vii) Improvements in the coordina-
tion of referrals for, and the provision of, 
other community resources and supports 
for eligible families, consistent with State 
child welfare agency training. 
‘‘(3) CORE
COMPONENTS.—The program in-
cludes the following core components: 
‘‘(A) SERVICE DELIVERY MODEL OR MOD-
ELS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the program is conducted using one or 
more of the service delivery models de-
scribed in item (aa) or (bb) of subclause 
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(I) or in subclause (II) selected by the 
State: 
‘‘(I) The model conforms to a 
clear consistent home visitation model 
that has been in existence for at least 
3 years and is research-based, ground-
ed 
in 
relevant 
empirically-based 
knowledge, linked to program deter-
mined outcomes, associated with a na-
tional organization or institution of 
higher education that has comprehen-
sive home visitation program stand-
ards that ensure high quality service 
delivery and continuous program qual-
ity 
improvement, 
and 
has 
dem-
onstrated significant (and in the case 
of the service delivery model described 
in item (aa), sustained) positive out-
comes, as described in the benchmark 
areas specified in paragraph (1)(A) 
and the participant outcomes de-
scribed in paragraph (2)(B), when 
evaluated using well-designed and rig-
orous— 
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‘‘(aa) randomized controlled 
research designs, and the evalua-
tion results have been published 
in a peer-reviewed journal; or 
‘‘(bb) quasi-experimental re-
search designs. 
‘‘(II) The model conforms to a 
promising 
and 
new 
approach 
to 
achieving the benchmark areas speci-
fied in paragraph (1)(A) and the par-
ticipant outcomes described in para-
graph (2)(B), has been developed or 
identified by a national organization 
or institution of higher education, and 
will be evaluated through well-de-
signed and rigorous process. 
‘‘(ii) MAJORITY
OF
GRANT
FUNDS 
USED FOR EVIDENCE-BASED MODELS.—A 
State may not use more than 25 percent of 
the amounts paid to the State for a fiscal 
year under section 1903(a) for purposes of 
conducting a program described in sub-
section (a) using the service delivery model 
described in clause (i)(II). 
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‘‘(iii) CRITERIA FOR EVIDENCE OF EF-
FECTIVENESS OF MODELS.—The Secretary 
shall establish criteria for evidence of effec-
tiveness of the service delivery models and 
shall ensure that the process for estab-
lishing the criteria is transparent and pro-
vides the opportunity for public comment. 
‘‘(B) ADDITIONAL REQUIREMENTS.— 
‘‘(i) The program adheres to a clear, 
consistent model that satisfies the require-
ments of being grounded in empirically- 
based knowledge related to home visiting 
and linked to the benchmark areas speci-
fied in paragraph (1)(A) and the partici-
pant outcomes described in paragraph 
(2)(B) related to the purposes of the pro-
gram. 
‘‘(ii) The program employs well- 
trained and competent staff, as dem-
onstrated by education or training, such as 
nurses, social workers, educators, child de-
velopment specialists, or other well-trained 
and competent staff, and provides ongoing 
and specific training on the model being 
delivered. 
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‘‘(iii) The program maintains high 
quality supervision to establish home vis-
itor competencies. 
‘‘(iv) 
The 
program 
demonstrates 
strong organizational capacity to imple-
ment the activities involved. 
‘‘(v) The program establishes appro-
priate linkages and referral networks to 
other community resources and supports 
for eligible families. 
‘‘(vi) The program monitors the fidel-
ity of program implementation to ensure 
that services are delivered pursuant to the 
specified model. 
‘‘(4) PRIORITY FOR SERVING HIGH-RISK POPU-
LATIONS.—The State gives priority to providing 
services under the program to the following: 
‘‘(A) Eligible families who reside in com-
munities in need of such services, as identified 
in the statewide needs assessment required 
under subsection (d)(1)(A). 
‘‘(B) Low-income eligible families. 
‘‘(C) Eligible families who are pregnant 
women who have not attained age 21. 
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‘‘(6) An assurance that the State will obtain 
and submit documentation or other appropriate evi-
dence from the organization or entity that developed 
the service delivery model or models used under the 
program to verify that the program is implemented 
and services are delivered according to the model 
specifications. 
‘‘(7) Assurances that the State will establish 
procedures to ensure that— 
‘‘(A) the participation of each eligible fam-
ily in the program is voluntary; and 
‘‘(B) services are provided to an eligible 
family in accordance with the individual assess-
ment for that family. 
‘‘(8) Assurances that the State will— 
‘‘(A) submit annual reports to the Sec-
retary regarding the program and activities car-
ried out under the program that include such 
information and data as the Secretary shall re-
quire; and 
‘‘(B) participate in, and cooperate with, 
data and information collection necessary for 
the evaluation required under subsection (f)(2) 
and other research and evaluation activities car-
ried out under subsection (h)(3). 
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‘‘(9) A description of other State programs that 
include home visitation services, including, if appli-
cable to the State, programs carried out under title 
V with funds made available from allotments under 
section 502(c), programs funded under title IV, title 
II of the Child Abuse Prevention and Treatment Act 
(relating to community-based grants for the preven-
tion of child abuse and neglect), and section 645A 
of the Head Start Act (relating to Early Head Start 
programs). 
‘‘(10) Other information as required by the Sec-
retary. 
‘‘(d) REQUIREMENT FOR ALL STATES TO ASSESS 
STATEWIDE NEEDS
AND IDENTIFY AT-RISK COMMU-
NITIES.— 
‘‘(1) IN GENERAL.—Not later than 6 months 
after the date of the enactment of this section, each 
State shall conduct a statewide needs assessment 
(which shall be separate from the statewide needs 
assessment required under section 505(a)) that iden-
tifies— 
‘‘(A) communities with concentrations of— 
‘‘(i) premature birth, low-birth weight 
infants, and infant mortality, including in-
fant death due to neglect, or other indica-
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tors of at-risk prenatal, maternal, newborn, 
or child health; 
‘‘(ii) poverty; 
‘‘(iii) crime; 
‘‘(iv) domestic violence; 
‘‘(v) high rates of high-school drop- 
outs; 
‘‘(vi) substance abuse; 
‘‘(vii) unemployment; or 
‘‘(viii) child maltreatment; 
‘‘(B) the quality and capacity of existing 
programs or initiatives for early childhood home 
visitation in the State including— 
‘‘(i) the number and types of individ-
uals and families who are receiving services 
under such programs or initiatives; 
‘‘(ii) the gaps in early childhood home 
visitation in the State; and 
‘‘(iii) the extent to which such pro-
grams or initiatives are meeting the needs 
of eligible families described in subsection 
(k)(2); and 
‘‘(C) the State’s capacity for providing 
substance abuse treatment and counseling serv-
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ices to individuals and families in need of such 
treatment or services. 
‘‘(2) COORDINATION
WITH
OTHER
ASSESS-
MENTS.—In conducting the statewide needs assess-
ment required under paragraph (1), the State shall 
coordinate with, and take into account, other appro-
priate needs assessments conducted by the State, as 
determined by the Secretary, including the needs as-
sessment required under section 505(a) (both the 
most recently completed assessment and any such 
assessment in progress), the communitywide stra-
tegic planning and needs assessments conducted in 
accordance with section 640(g)(1)(C) of the Head 
Start Act, and the inventory of current unmet needs 
and current community-based and prevention-fo-
cused programs and activities to prevent child abuse 
and neglect, and other family resource services oper-
ating in the State required under section 205(3) of 
the Child Abuse Prevention and Treatment Act. 
‘‘(3) SUBMISSION TO THE SECRETARY.—Each 
State shall submit to the Secretary, in such form 
and manner as the Secretary shall require— 
‘‘(A) the results of the statewide needs as-
sessment required under paragraph (1); and 
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‘‘(B) a description of how the State in-
tends to address needs identified by the assess-
ment, particularly with respect to communities 
identified under paragraph (1)(A), which may 
include submitting a State plan amendment 
with respect to an early childhood home visita-
tion program in accordance with the require-
ments of this section. 
‘‘(e) PAYMENTS.— 
‘‘(1) IN
GENERAL.—Expenditures made with 
respect to providing services described in subsection 
(a) shall be treated as medical assistance for pur-
poses of section 1903(a). 
‘‘(2) MAINTENANCE OF EFFORT.—Amounts re-
ceived by a State under section 1903(a) for expendi-
tures with respect to providing the services described 
in subsection (a) shall supplement, and not supplant, 
funds from other sources for early childhood home 
visitation programs or initiatives. 
‘‘(f) EVALUATION.— 
‘‘(1) 
INDEPENDENT, 
EXPERT
ADVISORY 
PANEL.—The Secretary, in accordance with sub-
section (g)(1)(A), shall appoint an independent advi-
sory panel consisting of experts in program evalua-
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tion and research, education, and early childhood de-
velopment— 
‘‘(A) to review, and make recommendations 
on, the design and plan for the evaluation re-
quired under paragraph (2) within 1 year after 
the date of enactment of this section; 
‘‘(B) to maintain and advise the Secretary 
regarding the progress of the evaluation; and 
‘‘(C) to comment, if the panel so desires, 
on the report submitted under paragraph (3). 
‘‘(2) AUTHORITY TO CONDUCT EVALUATION.— 
On the basis of the recommendations of the advisory 
panel under paragraph (1), the Secretary shall, by 
grant, contract, or interagency agreement, conduct 
an evaluation of the statewide needs assessments 
submitted under subsection (d) and the grants made 
under subsection (h). The evaluation shall include— 
‘‘(A) an analysis, on a State-by-State 
basis, of the results of such assessments, in-
cluding indicators of maternal and prenatal 
health and infant health and mortality, and 
State actions in response to the assessments; 
and 
‘‘(B) an assessment of— 
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‘‘(i) the effect of early childhood home 
visitation programs on child and parent 
outcomes, including with respect to each of 
the benchmark areas specified in sub-
section (b)(1)(A) and the participant out-
comes described in subsection (b)(2)(B); 
‘‘(ii) the effectiveness of such pro-
grams on different populations, including 
the extent to which the ability of programs 
to improve participant outcomes varies 
across programs and populations; and 
‘‘(iii) the potential for the activities 
conducted under such programs, if scaled 
broadly, to improve health care practices, 
eliminate health disparities, and improve 
health care system quality, efficiencies, and 
reduce costs. 
‘‘(3) REPORT.—Not later than March 31, 2020, 
the Secretary shall submit a report to Congress on 
the results of the evaluation conducted under para-
graph (2) and shall make the report publicly avail-
able. 
‘‘(g) INTRA-AGENCY
COLLABORATION.—The Sec-
retary shall ensure that the Maternal and Child Health 
Bureau and the Administration for Children and Families 
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collaborate with respect to carrying out this section, in-
cluding with respect to— 
‘‘(1) reviewing and analyzing the statewide 
needs assessments required under subsection (d), the 
awarding and oversight of grants awarded under 
this section, the establishment of the advisory panels 
required under subsections (b)(1)(B)(iii)(II) and 
(f)(1), and the evaluation and report required under 
subsection (f); and 
‘‘(2) consulting with other Federal agencies 
with responsibility for administering or evaluating 
programs that serve eligible families to coordinate 
and collaborate with respect to research related to 
such programs and families, including the Office of 
the Assistant Secretary for Planning and Evaluation 
of the Department of Health and Human Services, 
the Centers for Disease Control and Prevention, the 
National Institute of Child Health and Human De-
velopment of the National Institutes of Health, the 
Office of Juvenile Justice and Delinquency Preven-
tion of the Department of Justice, and the Institute 
of Education Sciences of the Department of Edu-
cation. 
‘‘(h) RESEARCH AND OTHER EVALUATION ACTIVI-
TIES.— 
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‘‘(1) IN GENERAL.—The Secretary shall carry 
out a continuous program of research and evaluation 
activities in order to increase knowledge about the 
implementation and effectiveness of home visiting 
programs, using random assignment designs to the 
maximum extent feasible. The Secretary may carry 
out such activities directly, or through grants, coop-
erative agreements, or contracts. 
‘‘(2) REQUIREMENTS.—The Secretary shall en-
sure that— 
‘‘(A) evaluation of a specific program or 
project is conducted by persons or individuals 
not directly involved in the operation of such 
program or project; and 
‘‘(B) the conduct of research and evalua-
tion activities includes consultation with inde-
pendent researchers, State officials, and devel-
opers and providers of home visiting programs 
on topics including research design and admin-
istrative data matching. 
‘‘(3) REPORT
AND
RECOMMENDATION.—Not 
later than December 31, 2020, the Secretary shall 
submit a report to Congress regarding the programs 
conducted with grants under this section. The report 
required under this paragraph shall include— 
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‘‘(A) information regarding the extent to 
which States with a State plan amendment ap-
proved under this section demonstrated im-
provements in each of the areas specified in 
subsection (b)(1)(A); 
‘‘(B) information regarding any technical 
assistance 
provided 
under 
subsection 
(b)(1)(B)(iii)(I), including the type of any such 
assistance provided; and 
‘‘(C) recommendations for such legislative 
or administrative action as the Secretary deter-
mines appropriate. 
‘‘(i) ELIGIBLE FAMILY DEFINED.—The term ‘eligible 
family’ means— 
‘‘(1) a woman who is pregnant, and the father 
of the child if the father is available; or 
‘‘(2) a parent or primary caregiver of a child, 
including grandparents or other relatives of the 
child, and foster parents, who are serving as the 
child’s primary caregiver from birth to kindergarten 
entry, and including a noncustodial parent who has 
an ongoing relationship with, and at times provides 
physical care for, the child.’’. 
Æ 
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