The NCSL Blog


By Emily Heller  

First, the Putting Evidence to Work in State Decision Making blog series provided information for state policymakers looking for ways to invest in programs that have documented evidence of their effectiveness.

stethescope on moneySecond, the series provided state policymakers with information to determine the cost effectiveness of different programs, through Return on Investment (ROI) analysis.

We’re ready to circle back to the first blog in this series, which asked “What convinced South Carolina Governor Nikki Haley to expand her state’s home-visiting program with an additional $30 million investment to reach more families?” It was likely that she knew of the research showing that home-visiting programs have a strong evidence base, and document widely accepted, credible information on cost effectiveness (ROI).

For example, several high-quality studies have documented the cost-effectiveness of the Nurse-Family Partnership, a nurse home-visiting program for low-income, first-time mothers.

A 2009 analysis of data from Memphis, Tenn., found reductions of 9 percent in Medicaid costs and 11 percent in food stamps—now called Supplemental Nutrition Assistance Program—costs among participants over 10 years. The net return on total investment for the federal government was approximately 54 percent.

A 2005 RAND Corporation analysis found a net savings, mostly in government costs, of $34,148 for each higher-risk family participating in the program, or $5.70 for every dollar spent.

Other successful home-visiting models support nurses, social workers, early childhood educators or other trained professionals who visit families in their homes during pregnancy and early childhood to provide health education, screenings, connections to other services and more. Additional research shows that evidence-based home-visiting programs lower the risk of child abuse and neglect, improve both mothers’ and children’s health and promote child development and school readiness.

Home-visiting programs also demonstrate a positive return on investment. While the programs require initial investment, they achieve long-term savings to states through reduced costs in areas such as emergency room visits, child protective services, foster care and special education, and increased tax revenues from parents’ earnings.

States support home-visiting programs through a combination of federal, state, local and private funds. The federal Maternal, Infant and Early Childhood Home Visiting Program (MIECHV, also known as the Federal Home Visiting Program) provides funding for states to operate home-visiting programs for at-risk pregnant women and parents with infants or young children.

In a cross-cutting federal effort, MIECHV is administered by the Health Resources and Services Administration (HRSA) in partnership with the Administration for Children and Families (ACF). In fiscal year 2015, the state grantee programs served approximately 145,500 parents and children in all 50 states, the District of Columbia and five territories.

HRSA and the Center for Medicaid and CHIP (Children’s Health Insurance Program) Services released an informational bulletin in March 2016 encouraging state health officials to improve access to health services for home-visiting beneficiaries. The bulletin includes information on federal funding options for state home-visiting programs through HRSA and Medicaid. 

By law, state and territory grantees must spend the majority of their Federal Home Visiting Program grants to implement evidence-based home-visiting models that meet rigorous standards for proof of effectiveness. Currently, states may choose from 17 proven models to find the program that best suits their goals and populations. These include Early Head Start-Home-Based Option, Healthy Families America and SafeCare Augmented.

New Mexico, as part of an effort to use evidence to guide investment decisions, examined home-visiting programs within the state. Officials conducted a cost-effectiveness evaluation of the Nurse-Family Partnership, Healthy Families America, SafeCare and other home-visiting models in New Mexico, using the Results First Initiative, a program of the Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation that provides states with data-driven cost-benefit analyses.

Using the Results First evaluation model, state leaders determined that New Mexico spends $113 million each year on child maltreatment, including investigation, foster care, adoption and other costs. Each foster care placement in New Mexico costs approximately $21,000 per year, while evidence-based, in-home services cost approximately $3,700 per year.

The Results First analysis in New Mexico compared returns on investment for various strategies aimed at addressing the costly issue of child welfare. In the New Mexico state-specific evaluation, evidence-based home-visiting models were found to be a cost-effective investment. Following this analysis, New Mexico chose to allocate $6.1 million during fiscal years 2013-2014 and 2014-2015 to evidence-based home-visiting programs.

While cost data and public health priorities will vary state to state, policymakers may want to consider this type of cost-effectiveness evaluation to guide decision making as they choose how to invest limited dollars.

In the final installment of the Putting Evidence to Work in State Decision Making for Health blog series we will look at another example of evidence-based programming to address an issue estimated to cost taxpayers $9.4 billion annually.

This blog is part of a four-part series that is intended to clarify evidence-based policy for state leaders. The series:

Emily Heller is a research analyst with NCSL's Health program.

Email Emily

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About the NCSL Blog

This blog offers updates on the National Conference of State Legislatures' research and training, the latest on federalism and the state legislative institution, and posts about state legislators and legislative staff. The blog is edited by NCSL staff and written primarily by NCSL's experts on public policy and the state legislative institution.