Title: Alleviating Adverse Childhood Experiences Act
Policy area: Health

Summary:
Alleviating Adverse Childhood Experiences Act
This bill amends XIX (Medicaid) of the Social Security Act to allow a state Medicaid program to cover, as medical assistance, services furnished under an early-childhood home-visitation program that:
A state Medicaid program that opts to cover such services must establish procedures to ensure that the participation of each eligible family is voluntary.
In addition, the bill requires each state to conduct a statewide needs-assessment to identify:
The Centers for Medicare & Medicaid Services must carry out specified research and evaluation activities related to the implementation and effectiveness of home-visitation programs.

[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3291 Introduced in House (IH)]

<DOC>






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 programs, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 18, 2017

  Mr. Ryan of Ohio (for himself and Mr. Ben Ray Lujan of New Mexico) 
 introduced the following bill; which was referred to the Committee on 
                          Energy 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 Representatives 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:
            (1) Adverse childhood experiences include emotional 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 experiences 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 experiences 
        increases so does the risk for myocardial infarction, asthma, 
        mental distress, depression, smoking, disability, unemployment, 
        lowered educational attainment, opioid abuse, coronary heart 
        disease, stroke, and diabetes.
            (4) According to the Centers for Disease Control and 
        Prevention, adults who had been exposed to more than one 
        adverse childhood experience were significantly more likely to 
        be unemployed, to be living in poverty, and not to have 
        graduated high school than adults who had not experienced an 
        adverse childhood experience.
            (5) The Centers for Disease Control and Prevention 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 negative effects of adverse childhood 
        experiences on children and families.
            (7) Participants in the Nurse-Family Partnership's home 
        visiting program have shown a 48 percent 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 Partnership's programs 
        have also shown increased self-sufficiency by family members 
        (and less utilization of 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 Security Act (42 U.S.C. 601 et seq.) 
        with respect to children 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 parental 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 utilized 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 Federal Government could save 
        up to $813,000,000 over 10 years.
            (11) Pediatric-based settings that incorporate 
        developmentally oriented services such as promoting early 
        reading, connection to community-based services, 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 percent reduction in babies born with low 
        birth weight and increased healthy parent behaviors, such as a 
        41 percent reduction in alcohol use. Mothers participating in 
        such program were more than five times as likely to continue 
        their education.

SEC. 3. STATE OPTION TO PROVIDE FOR MATERNAL, INFANT, AND EARLY 
              CHILDHOOD HOME VISITING 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, INFANT, AND EARLY 
              CHILDHOOD HOME VISITING PROGRAMS.

    ``(a) In General.--Notwithstanding section 1902(a)(1) (relating to 
statewideness), section 1902(a)(10)(B) (relating to comparability), and 
any other 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 assistance 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 maternal and 
prenatal health, infant health, child health and development, parenting 
related to child development outcomes, 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 improvement in benchmark 
        areas.--
                    ``(A) In general.--The early childhood home 
                visitation program establishes, subject to the approval 
                of the State, quantifiable, measurable 3- and 5-year 
                benchmarks for demonstrating that the program results 
                in improvements for the eligible families participating 
                in the program in each of the following areas:
                            ``(i) Improved maternal and newborn health.
                            ``(ii) Prevention of child injuries, child 
                        abuse, neglect, or maltreatment, and reduction 
                        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 coordination and 
                        referrals for other community resources 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 Secretary a report demonstrating 
                        improvement in at least 4 of the areas 
                        specified in subparagraph (A).
                            ``(ii) Technical assistance.--
                                    ``(I) In general.--The Secretary 
                                shall provide a State required to 
                                develop and implement an improvement 
                                plan under clause (ii) with technical 
                                assistance to develop and implement the 
                                plan. The Secretary may provide the 
                                technical assistance directly or 
                                through grants, contracts, or 
                                cooperative agreements.
                                    ``(II) Advisory panel.--The 
                                Secretary shall establish an advisory 
                                panel for purposes of obtaining 
                                recommendations regarding the technical 
                                assistance provided to States in 
                                accordance with subclause (I).
                            ``(iii) No improvement or failure to submit 
                        report.--If the Secretary determines 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 approval of the State 
                        plan amendment involved.
                    ``(C) Final report.--Not later than December 31, 
                2022, the State shall submit a report to the Secretary 
                demonstrating improvements (if any) in each of the 
                areas specified in subparagraph (A).
            ``(2) Improvements in outcomes for individual families.--
                    ``(A) In general.--The program is designed, with 
                respect to an eligible family participating in the 
                program, to result in the participant outcomes 
                described in subparagraph (B) that the State identifies 
                on the basis of an individualized assessment of the 
                family, are relevant for that family.
                    ``(B) Participant outcomes.--The participant 
                outcomes described in this subparagraph are the 
                following:
                            ``(i) Improvements in prenatal, maternal, 
                        and newborn health, including improved 
                        pregnancy outcomes.
                            ``(ii) Improvements in child health and 
                        development, including the prevention of child 
                        injuries and maltreatment and improvements in 
                        cognitive, language, social-emotional, and 
                        physical developmental indicators.
                            ``(iii) Improvements in parenting skills.
                            ``(iv) Improvements in school readiness and 
                        child academic achievement.
                            ``(v) Reductions in crime or domestic 
                        violence.
                            ``(vi) Improvements in family economic 
                        self-sufficiency.
                            ``(vii) Improvements in the coordination 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 includes the following 
        core components:
                    ``(A) Service delivery model or models.--
                            ``(i) In general.--Subject to clause (ii), 
                        the program is conducted using one or more of 
                        the service delivery models described in item 
                        (aa) or (bb) of subclause (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, grounded 
                                in relevant empirically-based 
                                knowledge, linked to program determined 
                                outcomes, associated with a national 
                                organization or institution of higher 
                                education that has comprehensive home 
                                visitation program standards that 
                                ensure high quality service delivery 
                                and continuous program quality 
                                improvement, and has demonstrated 
                                significant (and in the case of the 
                                service delivery model described in 
                                item (aa), sustained) positive 
                                outcomes, as described in the benchmark 
                                areas specified in paragraph (1)(A) and 
                                the participant outcomes described in 
                                paragraph (2)(B), when evaluated using 
                                well-designed and rigorous--
                                            ``(aa) randomized 
                                        controlled research designs, 
                                        and the evaluation results have 
                                        been published in a peer-
                                        reviewed journal; or
                                            ``(bb) quasi-experimental 
                                        research designs.
                                    ``(II) The model conforms to a 
                                promising and new approach to achieving 
                                the benchmark areas specified in 
                                paragraph (1)(A) and the participant 
                                outcomes described in paragraph (2)(B), 
                                has been developed or identified by a 
                                national organization or institution of 
                                higher education, and will be evaluated 
                                through well-designed 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 subsection (a) using the service delivery 
                        model described in clause (i)(II).
                            ``(iii) Criteria for evidence of 
                        effectiveness of models.--The Secretary shall 
                        establish criteria for evidence of 
                        effectiveness of the service delivery models 
                        and shall ensure that the process for 
                        establishing the criteria is transparent and 
                        provides the opportunity for public comment.
                    ``(B) Additional requirements.--
                            ``(i) The program adheres to a clear, 
                        consistent model that satisfies the 
                        requirements of being grounded in empirically-
                        based knowledge related to home visiting and 
                        linked to the benchmark areas specified in 
                        paragraph (1)(A) and the participant outcomes 
                        described in paragraph (2)(B) related to the 
                        purposes of the program.
                            ``(ii) The program employs well-trained and 
                        competent staff, as demonstrated by education 
                        or training, such as nurses, social workers, 
                        educators, child development specialists, or 
                        other well-trained and competent staff, and 
                        provides ongoing and specific training on the 
                        model being delivered.
                            ``(iii) The program maintains high quality 
                        supervision to establish home visitor 
                        competencies.
                            ``(iv) The program demonstrates strong 
                        organizational capacity to implement the 
                        activities involved.
                            ``(v) The program establishes appropriate 
                        linkages and referral networks to other 
                        community resources and supports for eligible 
                        families.
                            ``(vi) The program monitors the fidelity of 
                        program implementation to ensure that services 
                        are delivered pursuant to the specified model.
            ``(4) Priority for serving high-risk populations.--The 
        State gives priority to providing services under the program to 
        the following:
                    ``(A) Eligible families who reside in communities 
                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.
                    ``(D) Eligible families that have a history of 
                child abuse or neglect or have had interactions with 
                child welfare services.
                    ``(E) Eligible families that have a history of 
                substance abuse or need substance abuse treatment.
                    ``(F) Eligible families that have users of tobacco 
                products in the home.
                    ``(G) Eligible families that are or have children 
                with low student achievement.
                    ``(H) Eligible families with children with 
                developmental delays or disabilities.
                    ``(I) Eligible families who, or that include 
                individuals who, are serving or formerly served in the 
                Armed Forces, including such families that have members 
                of the Armed Forces who have had multiple deployments 
                outside of the United States.
    ``(c) State Plan Amendment Requirements.--A State seeking the 
approval of a State plan amendment under this section shall submit the 
amendment to the Secretary for approval, in such manner as the 
Secretary may require. The State plan amendment shall include the 
following:
            ``(1) A description of the populations to be served by the 
        early childhood home visitation program involved, including 
        specific information regarding how the program will serve high 
        risk populations described in subsection (b)(4).
            ``(2) An assurance that the State, in carrying out the 
        program, will give priority to serving low-income eligible 
        families and eligible families who reside in at-risk 
        communities identified in the statewide needs assessment 
        required under subsection (d)(1)(A).
            ``(3) The service delivery model or models described in 
        subsection (b)(3)(A) that the State will use under the program 
        and the basis for the selection of the model or models.
            ``(4) A statement identifying how the selection of the 
        populations to be served and the service delivery model or 
        models that the State will use under the program for such 
        populations is consistent with the results of the statewide 
        needs assessment conducted under subsection (d).
            ``(5) The quantifiable, measurable benchmarks established 
        by the State to demonstrate that the program contributes to 
        improvements in the areas specified in subsection (b)(1)(A).
            ``(6) An assurance that the State will obtain and submit 
        documentation or other appropriate evidence 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 family in 
                the program is voluntary; and
                    ``(B) services are provided to an eligible family 
                in accordance with the individual assessment for that 
                family.
            ``(8) Assurances that the State will--
                    ``(A) submit annual reports to the Secretary 
                regarding the program and activities carried out under 
                the program that include such information and data as 
                the Secretary shall require; 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 carried out under subsection 
                (h)(3).
            ``(9) A description of other State programs that include 
        home visitation services, including, if applicable 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 
        prevention 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 Secretary.
    ``(d) Requirement for All States To Assess Statewide Needs and 
Identify At-Risk Communities.--
            ``(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 
        identifies--
                    ``(A) communities with concentrations of--
                            ``(i) premature birth, low-birth weight 
                        infants, and infant mortality, including infant 
                        death due to neglect, or other indicators 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 individuals 
                        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 programs 
                        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 services to individuals 
                and families in need of such treatment or services.
            ``(2) Coordination with other assessments.--In conducting 
        the statewide needs assessment required under paragraph (1), 
        the State shall coordinate with, and take into account, other 
        appropriate needs assessments conducted by the State, as 
        determined by the Secretary, including the needs assessment 
        required under section 505(a) (both the most recently completed 
        assessment and any such assessment in progress), the 
        communitywide strategic 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-focused programs and activities 
        to prevent child abuse and neglect, and other family resource 
        services operating 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 assessment 
                required under paragraph (1); and
                    ``(B) a description of how the State intends to 
                address needs identified by the assessment, 
                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 visitation program in accordance with the 
                requirements 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 purposes of section 1903(a).
            ``(2) Maintenance of effort.--Amounts received by a State 
        under section 1903(a) for expenditures 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 subsection (g)(1)(A), shall appoint an 
        independent advisory panel consisting of experts in program 
        evaluation and research, education, and early childhood 
        development--
                    ``(A) to review, and make recommendations on, the 
                design and plan for the evaluation required 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, including indicators 
                of maternal and prenatal health and infant health and 
                mortality, and State actions in response to the 
                assessments; and
                    ``(B) an assessment of--
                            ``(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 subsection 
                        (b)(1)(A) and the participant outcomes 
                        described in subsection (b)(2)(B);
                            ``(ii) the effectiveness of such programs 
                        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 paragraph (2) and shall make the 
        report publicly available.
    ``(g) Intra-Agency Collaboration.--The Secretary shall ensure that 
the Maternal and Child Health Bureau and the Administration for 
Children and Families collaborate with respect to carrying out this 
section, including 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 Development of the National 
        Institutes of Health, the Office of Juvenile Justice and 
        Delinquency Prevention of the Department of Justice, and the 
        Institute of Education Sciences of the Department of Education.
    ``(h) Research and Other Evaluation Activities.--
            ``(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, cooperative agreements, or contracts.
            ``(2) Requirements.--The Secretary shall ensure 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 evaluation 
                activities includes consultation with independent 
                researchers, State officials, and developers and 
                providers of home visiting programs on topics including 
                research design and administrative 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--
                    ``(A) information regarding the extent to which 
                States with a State plan amendment approved under this 
                section demonstrated improvements 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 determines 
                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.''.
                                 <all>