,i #aaeth ,,congress #ast ,session ,h4 ,r4 #cbia ,,in ,,the ,,house ,,of ,,representatives ,july #ah1 #bjag,mr4 ,ryan of ,ohio 7for himself and ,mr4 ,ben ,ray ,lujn of ,new ,mexico7 introduced the following bill2 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 maternal1 infant1 and early childhood home visiting programs1 and for other purposes4 #a4 ,short title ,this ,act may be cited as the ,alleviating ,adverse ,childhood ,experiences ,act4 #b4 ,findings ,congress finds the following3 7#a7 ,adverse childhood experiences include emotional and physical neglect and abuse1 sexual abuse1 intimate partner violence1 household substance abuse1 household mental illness1 parental separation or divorce1 and having an incarcerated household member4 7#b7 ,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 adulthood4 7#c7 ,as the number of adverse childhood experiences increases so does the risk for myocardial infarction1 asthma1 mental distress1 depression1 smoking1 disability1 unemployment1 lowered educational attainment1 opioid abuse1 coronary heart disease1 stroke1 and diabetes4 7#d7 ,according to the ,centers for ,disease ,control and ,prevention1 adults who had been exposed to more than one adverse childhood experience were significantly more likely to be unemployed1 to be living in poverty1 and not to have graduated high school than adults who had not experienced an adverse childhood experience4 7#e7 ,the ,centers for ,disease ,control and ,prevention also found that just one year of confirmed cases of child maltreatment costs #abd1jjj1jjj1jjj over the lifetime of the traumatized children4 ,these include increases in childhood health care costs1 adult medical costs1 productivity losses1 child welfare costs1 criminal justice costs1 and special education costs4 7#f7 ,home visiting programs1 pediatric-based services and informed1 evidence-based approaches have been proven to prevent and mitigate the negative effects of adverse childhood experiences on children and families4 7#g7 ,participants in the ,nurse-,family ,partnership's home visiting program have shown a #dh percent reduction in ,state-verified reports of child abuse and neglect by age #ae1 a #fg percent reduction in behavioral and emotional problems by age #f1 and a #ei percent reduction in arrests by age #ae among many other improved child health and development outcomes compared to counterparts in a control group4 7#h7 ,participants in the ,nurse-,family ,partnership's programs have also shown increased self-sufficiency by family members 7and less utilization of ,federal programs71 generating a #ab1cjj savings in the supplemental nutrition assistance program under the ,food and ,nutrition ,act of #bjjh 7#g ,u4,s4,c4 #bjaa et seq47 and savings of #aa1eaa 7valued with respect to #bjjf7 under the temporary assistance for needy families program under title ,,iv of the ,social ,security ,act 7#db ,u4,s4,c4 #fja et seq47 with respect to children between the ages of #j through #ab4 7#i7 ,healthy,steps1 an interdisciplinary pediatric primary care model has been shown to increase child safety1 on time vaccinations1 age-appropriate parental engagement1 school readiness1 and connections to community resources4 7#aj7 ,several ,states finance part of their home visiting programs through the ,medicaid program under title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq471 but such program could be utilized to support more eligible families4 ,one study showed that if all eligible children and families were enrolled in evidence-based programs1 ,states could save up to #b1djj1jjj1jjj combined and the ,federal ,government could save up to #hac1jjj1jjj over #aj years4 7#aa7 ,pediatric-based settings that incorporate developmentally oriented services such as promoting early reading1 connection to community-based services1 positive parent-child interaction1 and guidance on behavior management have shown to increase participation in well-child visits and are associated with high levels of parent satisfaction4 7#ab7 ,families participating in the ,healthy ,families ,america home visiting program have seen impacts within one year or less1 including a #dh percent reduction in babies born with low birth weight and increased healthy parent behaviors1 such as a #da percent reduction in alcohol use4 ,mothers participating in such program were more than five times as likely to continue their education4 #c4 ,state option to provide for maternal1 infant1 and early childhood home visiting programs ,title ,,xix of the ,social ,security ,act 7#db ,u4,s4,c4 #acif et seq47 is amended by adding at the end the following new section3 #aidh4 ,state option to provide for maternal1 infant1 and early childhood home visiting programs 7a7 ,in ,general ,notwithstanding section #aijb7;a77#a7 7relating to statewideness71 section #aijb7;a77#aj77;,b7 7relating to comparability71 and any other provision of this title for which the ,secretary determines it is necessary to waive in order to implement this section1 beginning on ,january #a1 #bjah1 a ,state1 at its option as a ,state plan amendment1 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 7b7 in order to promote improvements in maternal and prenatal health1 infant health1 child health and development1 parenting related to child development outcomes1 school readiness1 and the socioeconomic status of such families1 and reductions in child abuse1 neglect1 and injuries4 7b7 ,program requirements ,the requirements of this subsection for an early childhood home visitation program conducted pursuant to this section are as follows3 7#a7 ,quantifiable1 measurable improvement in benchmark areas 7,a7 ,in general ,the early childhood home visitation program establishes1 subject to the approval of the ,state1 quantifiable1 measurable #c- and #e-year benchmarks for demonstrating that the program results in improvements for the eligible families participating in the program in each of the following areas3 7i7 ,improved maternal and newborn health4 7ii7 ,prevention of child injuries1 child abuse1 neglect1 or maltreatment1 and reduction of emergency department visits4 7iii7 ,improvement in school readiness and achievement4 7iv7 ,reduction in crime or domestic violence4 7v7 ,improvements in family economic self-sufficiency4 7vi7 ,improvements in the coordination and referrals for other community resources and supports4 7,b7 ,demonstration of improvements after #c years 7i7 ,report to the secretary ,not later than #cj days after the end of the #crd year in which the ,state conducts the program1 the ,state submits to the ,secretary a report demonstrating improvement in at least #d of the areas specified in subparagraph 7,a74 7ii7 ,technical assistance 7,i7 ,in general ,the ,secretary shall provide a ,state required to develop and implement an improvement plan under clause 7ii7 with technical assistance to develop and implement the plan4 ,the ,secretary may provide the technical assistance directly or through grants1 contracts1 or cooperative agreements4 7,,ii7 ,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 7,i74 7iii7 ,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 7,a71 or if the ,secretary determines that a ,state has failed to submit the report required under clause 7i71 the ,secretary shall withdraw approval of the ,state plan amendment involved4 7,c7 ,final report ,not later than ,december #ca1 #bjbb1 the ,state shall submit a report to the ,secretary demonstrating improvements 7if any7 in each of the areas specified in subparagraph 7,a74 7#b7 ,improvements in outcomes for individual families 7,a7 ,in general ,the program is designed1 with respect to an eligible family participating in the program1 to result in the participant outcomes described in subparagraph 7,b7 that the ,state identifies on the basis of an individualized assessment of the family1 are relevant for that family4 7,b7 ,participant outcomes ,the participant outcomes described in this subparagraph are the following3 7i7 ,improvements in prenatal1 maternal1 and newborn health1 including improved pregnancy outcomes4 7ii7 ,improvements in child health and development1 including the prevention of child injuries and maltreatment and improvements in cognitive1 language1 social-emotional1 and physical developmental indicators4 7iii7 ,improvements in parenting skills4 7iv7 ,improvements in school readiness and child academic achievement4 7v7 ,reductions in crime or domestic violence4 7vi7 ,improvements in family economic self-sufficiency4 7vii7 ,improvements in the coordination of referrals for1 and the provision of1 other community resources and supports for eligible families1 consistent with ,state child welfare agency training4 7#c7 ,core components ,the program includes the following core components3 7,a7 ,service delivery model or models 7i7 ,in general ,subject to clause 7ii71 the program is conducted using one or more of the service delivery models described in item 7aa7 or 7bb7 of subclause 7,i7 or in subclause 7,,ii7 selected by the ,state3 7,i7 ,the model conforms to a clear consistent home visitation model that has been in existence for at least #c years and is research-based1 grounded in relevant empirically-based knowledge1 linked to program determined outcomes1 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 improvement1 and has demonstrated significant 7and in the case of the service delivery model described in item 7aa71 sustained7 positive outcomes1 as described in the benchmark areas specified in paragraph 7#a77;,a7 and the participant outcomes described in paragraph 7#b77;,b71 when evaluated using well-designed and rigorous-- 7aa7 randomized controlled research designs1 and the evaluation results have been published in a peer-reviewed journal2 or 7bb7 quasi-experimental research designs4 7,,ii7 ,the model conforms to a promising and new approach to achieving the benchmark areas specified in paragraph 7#a77;,a7 and the participant outcomes described in paragraph 7#b77;,b71 has been developed or identified by a national organization or institution of higher education1 and will be evaluated through well-designed and rigorous process4 7ii7 ,majority of grant funds used for evidence-based models ,a ,state may not use more than #be percent of the amounts paid to the ,state for a fiscal year under section #aijc7;a7 for purposes of conducting a program described in subsection 7a7 using the service delivery model described in clause 7i77,,ii74 7iii7 ,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 comment4 7,b7 ,additional requirements 7i7 ,the program adheres to a clear1 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 7#a77;,a7 and the participant outcomes described in paragraph 7#b77;,b7 related to the purposes of the program4 7ii7 ,the program employs well-trained and competent staff1 as demonstrated by education or training1 such as nurses1 social workers1 educators1 child development specialists1 or other well-trained and competent staff1 and provides ongoing and specific training on the model being delivered4 7iii7 ,the program maintains high quality supervision to establish home visitor competencies4 7iv7 ,the program demonstrates strong organizational capacity to implement the activities involved4 7v7 ,the program establishes appropriate linkages and referral networks to other community resources and supports for eligible families4 7vi7 ,the program monitors the fidelity of program implementation to ensure that services are delivered pursuant to the specified model4 7#d7 ,priority for serving high-risk populations ,the ,state gives priority to providing services under the program to the following3 7,a7 ,eligible families who reside in communities in need of such services1 as identified in the statewide needs assessment required under subsection 7d77#a77;,a74 7,b7 ,low-income eligible families4 7,c7 ,eligible families who are pregnant women who have not attained age #ba4 7,d7 ,eligible families that have a history of child abuse or neglect or have had interactions with child welfare services4 7,e7 ,eligible families that have a history of substance abuse or need substance abuse treatment4 7,f7 ,eligible families that have users of tobacco products in the home4 7,g7 ,eligible families that are or have children with low student achievement4 7,h7 ,eligible families with children with developmental delays or disabilities4 7,i7 ,eligible families who1 or that include individuals who1 are serving or formerly served in the ,armed ,forces1 including such families that have members of the ,armed ,forces who have had multiple deployments outside of the ,united ,states4 7c7 ,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 approval1 in such manner as the ,secretary may require4 ,the ,state plan amendment shall include the following3 7#a7 ,a description of the populations to be served by the early childhood home visitation program involved1 including specific information regarding how the program will serve high risk populations described in subsection 7b77#d74 7#b7 ,an assurance that the ,state1 in carrying out the program1 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 7d77#a77;,a74 7#c7 ,the service delivery model or models described in subsection 7b77#c77;,a7 that the ,state will use under the program and the basis for the selection of the model or models4 7#d7 ,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 7d74 7#e7 ,the quantifiable1 measurable benchmarks established by the ,state to demonstrate that the program contributes to improvements in the areas specified in subsection 7b77#a77;,a74 7#f7 ,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 specifications4 7#g7 ,assurances that the ,state will establish procedures to ensure that-- 7,a7 the participation of each eligible family in the program is voluntary2 and 7,b7 services are provided to an eligible family in accordance with the individual assessment for that family4 7#h7 ,assurances that the ,state will-- 7,a7 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 require2 and 7,b7 participate in1 and cooperate with1 data and information collection necessary for the evaluation required under subsection 7f77#b7 and other research and evaluation activities carried out under subsection 7h77#c74 7#i7 ,a description of other ,state programs that include home visitation services1 including1 if applicable to the ,state1 programs carried out under title ,v with funds made available from allotments under section #ejb7;c71 programs funded under title ,,iv1 title ,,ii of the ,child ,abuse ,prevention and ,treatment ,act 7relating to community-based grants for the prevention of child abuse and neglect71 and section #fde;,a of the ,head ,start ,act 7relating to ,early ,head ,start programs74 7#aj7 ,other information as required by the ,secretary4 7d7 ,requirement for ,all ,states ,to ,assess ,statewide ,needs and ,identify ,at-,risk ,communities 7#a7 ,in general ,not later than #f months after the date of the enactment of this section1 each ,state shall conduct a statewide needs assessment 7which shall be separate from the statewide needs assessment required under section #eje7;a77 that identifies-- 7,a7 communities with concentrations of-- 7i7 premature birth1 low-birth weight infants1 and infant mortality1 including infant death due to neglect1 or other indicators of at-risk prenatal1 maternal1 newborn1 or child health2 7ii7 poverty2 7iii7 crime2 7iv7 domestic violence2 7v7 high rates of high-school drop-outs2 7vi7 substance abuse2 7vii7 unemployment2 or 7viii7 child maltreatment2 7,b7 the quality and capacity of existing programs or initiatives for early childhood home visitation in the ,state including-- 7i7 the number and types of individuals and families who are receiving services under such programs or initiatives2 7ii7 the gaps in early childhood home visitation in the ,state2 and 7iii7 the extent to which such programs or initiatives are meeting the needs of eligible families described in subsection 7k77#b72 and 7,c7 the ,state's capacity for providing substance abuse treatment and counseling services to individuals and families in need of such treatment or services4 7#b7 ,coordination with other assessments ,in conducting the statewide needs assessment required under paragraph 7#a71 the ,state shall coordinate with1 and take into account1 other appropriate needs assessments conducted by the ,state1 as determined by the ,secretary1 including the needs assessment required under section #eje7;a7 7both the most recently completed assessment and any such assessment in progress71 the communitywide strategic planning and needs assessments conducted in accordance with section #fdj7;g77#a77;,c7 of the ,head ,start ,act1 and the inventory of current unmet needs and current community-based and prevention-focused programs and activities to prevent child abuse and neglect1 and other family resource services operating in the ,state required under section #bje7c7 of the ,child ,abuse ,prevention and ,treatment ,act4 7#c7 ,submission to the secretary ,each ,state shall submit to the ,secretary1 in such form and manner as the ,secretary shall require-- 7,a7 the results of the statewide needs assessment required under paragraph 7#a72 and 7,b7 a description of how the ,state intends to address needs identified by the assessment1 particularly with respect to communities identified under paragraph 7#a77;,a71 which may include submitting a ,state plan amendment with respect to an early childhood home visitation program in accordance with the requirements of this section4 7e7 ,payments 7#a7 ,in general ,expenditures made with respect to providing services described in subsection 7a7 shall be treated as medical assistance for purposes of section #aijc7;a74 7#b7 ,maintenance of effort ,amounts received by a ,state under section #aijc7;a7 for expenditures with respect to providing the services described in subsection 7a7 shall supplement1 and not supplant1 funds from other sources for early childhood home visitation programs or initiatives4 7f7 ,evaluation 7#a7 ,independent1 expert advisory panel ,the ,secretary1 in accordance with subsection 7g77#a77;,a71 shall appoint an independent advisory panel consisting of experts in program evaluation and research1 education1 and early childhood development-- 7,a7 to review1 and make recommendations on1 the design and plan for the evaluation required under paragraph 7#b7 within #a year after the date of enactment of this section2 7,b7 to maintain and advise the ,secretary regarding the progress of the evaluation2 and 7,c7 to comment1 if the panel so desires1 on the report submitted under paragraph 7#c74 7#b7 ,authority to conduct evaluation ,on the basis of the recommendations of the advisory panel under paragraph 7#a71 the ,secretary shall1 by grant1 contract1 or interagency agreement1 conduct an evaluation of the statewide needs assessments submitted under subsection 7d7 and the grants made under subsection 7h74 ,the evaluation shall include-- 7,a7 an analysis1 on a ,state-by-,state basis1 of the results of such assessments1 including indicators of maternal and prenatal health and infant health and mortality1 and ,state actions in response to the assessments2 and 7,b7 an assessment of-- 7i7 the effect of early childhood home visitation programs on child and parent outcomes1 including with respect to each of the benchmark areas specified in subsection 7b77#a77;,a7 and the participant outcomes described in subsection 7b77#b77;,b72 7ii7 the effectiveness of such programs on different populations1 including the extent to which the ability of programs to improve participant outcomes varies across programs and populations2 and 7iii7 the potential for the activities conducted under such programs1 if scaled broadly1 to improve health care practices1 eliminate health disparities1 and improve health care system quality1 efficiencies1 and reduce costs4 7#c7 ,report ,not later than ,march #ca1 #bjbj1 the ,secretary shall submit a report to ,congress on the results of the evaluation conducted under paragraph 7#b7 and shall make the report publicly available4 7g7 ,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 section1 including with respect to-- 7#a7 reviewing and analyzing the statewide needs assessments required under subsection 7d71 the awarding and oversight of grants awarded under this section1 the establishment of the advisory panels required under subsections 7b77#a77;,b77iii77,,ii7 and 7f77#a71 and the evaluation and report required under subsection 7f72 and 7#b7 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 families1 including the ,office of the ,assistant ,secretary for ,planning and ,evaluation of the ,department of ,health and ,human ,services1 the ,centers for ,disease ,control and ,prevention1 the ,national ,institute of ,child ,health and ,human ,development of the ,national ,institutes of ,health1 the ,office of ,juvenile ,justice and ,delinquency ,prevention of the ,department of ,justice1 and the ,institute of ,education ,sciences of the ,department of ,education4 7h7 ,research and other evaluation activities 7#a7 ,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 programs1 using random assignment designs to the maximum extent feasible4 ,the ,secretary may carry out such activities directly1 or through grants1 cooperative agreements1 or contracts4 7#b7 ,requirements ,the ,secretary shall ensure that-- 7,a7 evaluation of a specific program or project is conducted by persons or individuals not directly involved in the operation of such program or project2 and 7,b7 the conduct of research and evaluation activities includes consultation with independent researchers1 ,state officials1 and developers and providers of home visiting programs on topics including research design and administrative data matching4 7#c7 ,report and recommendation ,not later than ,december #ca1 #bjbj1 the ,secretary shall submit a report to ,congress regarding the programs conducted with grants under this section4 ,the report required under this paragraph shall include-- 7,a7 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 7b77#a77;,a72 7,b7 information regarding any technical assistance provided under subsection 7b77#a77;,b77iii77,i71 including the type of any such assistance provided2 and 7,c7 recommendations for such legislative or administrative action as the ,secretary determines appropriate4 7i7 ,eligible family defined ,the term eligible family means-- 7#a7 a woman who is pregnant1 and the father of the child if the father is available2 or 7#b7 a parent or primary caregiver of a child1 including grandparents or other relatives of the child1 and foster parents1 who are serving as the child's primary caregiver from birth to kindergarten entry1 and including a noncustodial parent who has an ongoing relationship with1 and at times provides physical care for1 the child4 4