I 115th CONGRESS 1st Session H. R. 3291 IN THE HOUSE OF REPRESENTATIVES July 18, 2017 Mr. Ryan of Ohio (for himself and Mr. Ben Ray Luján 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.

1. Short title This Act may be cited as the Alleviating Adverse Childhood Experiences Act . 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. 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: 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. .