12 EFFECTIVE SOLUTIONS TO HELP CHILDREN THRIVE
The prenatal to age 3 (PN-3) period is the most rapid and sensitive period of development, and it sets the foundation for long-term health and wellbeing. The science of the developing child points to eight PN-3 policy goals that all states should strive to achieve to ensure infants and toddlers get off to a healthy start and thrive.
Comprehensive reviews of the most rigorous evidence available identified four state-level policies and eight strategies that positively impact at least one of these PN-3 policy goals. The 12 effective solutions are profiled in this Prenatal-to-3 State Policy Roadmap. When combined, the policies and strategies create a system of care that provides broad-based economic and family supports, as well as targeted interventions to address identified needs.
The framework below illustrates the alignment between the eight policy goals, the 12 evidence-based policies and strategies that impact each goal, and selected outcomes that illustrate the wellbeing of children and families.
We also provide guidance below on how states can use the Roadmap to prioritize and meet their goals to help children thrive.
Visit the Prenatal-to-3 Policy Clearinghouse for more on the science behind each policy goal.
First, Prioritize Your Goals Based on the Wellbeing of Your State’s Infants and Toddlers
Tracking progress on the key PN-3 outcomes included in this Roadmap allows each state to determine the health and wellbeing of children and families in the state and to identify which PN-3 policy goals are lagging and should be prioritized. As states implement the solutions proven to impact their policy goals, assessing the wellbeing of infants and toddlers allows states to measure their progress toward achieving their goals.
View the wide variation across states on 20 outcome measures of child and family wellbeing illustrated at the end of this summary and on the state-level outcomes pages.
Second, Identify the Policy Solutions Proven to Impact PN-3 Policy Goals
Each of the 12 effective solutions in the Roadmap are proven to impact at least one of the eight PN-3 policy goals (highlighted in the framework above). This summary provides a snapshot of states’ progress on adopting and implementing each policy and strategy. The full Roadmap provides more detailed information on each effective solution in the policy and strategy profiles.
For each of the four policies, the evidence points to a specific policy lever that states can implement to impact outcomes. For the eight strategies, the evidence clearly links the strategy to PN-3 outcomes, but the current evidence base does not provide clear guidance on a specific policy lever that states should implement to provide access to services at scale and to positively impact outcomes. Therefore, for each Roadmap strategy, we identified a set of key policy levers that states can implement to increase access to the effective strategy.
The Roadmap helps each state monitor its progress on all 12 effective solutions and on 20 child and family outcome measures that illustrate the health, resources, and wellbeing of infants, toddlers, and their parents in each state.
The Roadmap also measures the progress states are making to reduce racial and ethnic disparities in access and outcomes. The 12 effective solutions are not implemented similarly across all states, leaving children and families across the US with a patchwork of benefits and unequal outcomes.
FEW STATES ARE DOING IT ALL, BUT MANY ARE MOVING FORWARD
7 States Have Newly Implemented At Least 1 Effective Roadmap Policy
Since the release of the 2022 Roadmap, seven states have fully implemented at least one of the four Roadmap policies – Michigan and South Dakota each newly implemented two policies.
Medicaid Expansion
South Dakota expanded Medicaid in November 2022 via a constitutional amendment, bringing the total number of states to 40 that have expanded Medicaid.
Paid Family Leave
Oregon and Rhode Island provided 12 and 6 weeks of paid family leave, respectively, for the first time this year, bringing the total to nine states that have fully implemented this effective policy, and 14 states that have enacted paid family leave programs.
State Minimum Wage
Four states – Michigan, Nebraska, Ohio, and South Dakota – increased their minimum wages to more than $10.00 per hour for the first time this year, such that 29 states have a minimum wage that meets the threshold. Michigan is scheduled to increase its minimum wage to $12.05 per hour in 2031 and Nebraska is scheduled to increase its minimum wage to $15.00 per hour by 2026. Ohio and South Dakota will continue to increase their wages based on annual indexing for inflation.
State Earned Income Tax Credit
Hawaii and Michigan implemented earned income tax credits (EITCs) that are now more than 10% of the federal credit and refundable. Hawaii passed legislation in 2022 to make its 20% credit refundable, and this year it expanded the credit to 40% of the federal EITC. Michigan implemented legislation this year to expand its refundable EITC from 6% of the federal EITC to 30%. In total, working families in 22 states now have access to a state earned income tax credit.
Most States Made Progress Toward Building a PN-3 System of Care
In addition to the progress states made to fully implement the four effective Roadmap policies, many more states enacted or seriously considered legislation to adopt one of the evidence-based policies, passed legislation to enhance the benefits, or will fully implement one of the policies in the next few years.
For example, in March 2023, North Carolina enacted legislation to expand Medicaid and plans to implement the expansion in December 2023. It will become the 41st state to expand Medicaid, which will increase access to health insurance for thousands of people in the perinatal period. Additionally, nine out of the remaining 10 states that have not expanded Medicaid considered legislation to do so this past year.
States also actively considered paid family leave policies. Maine and Minnesota successfully enacted 12-week paid family leave programs this past year that will be fully implemented in 2026. Colorado will implement its 12-week program in 2024, and Delaware and Maryland will implement their 12-week programs in 2026. Although other states were not successful, 23 states introduced legislation this past session to adopt a statewide paid family leave program of at least 6 weeks.
Legislative activity to strengthen minimum wage laws was also high. In the past year, 30 states introduced legislation to increase the state minimum wage, and several states were successful. Maryland enacted legislation to accelerate the incremental increase of its state minimum wage to $15.00 by 2024, rather than 2025; and New York enacted legislation to increase its state minimum wage to $16.00 by 2026. In total, the minimum wage increased in 13 states due to statutorily scheduled increases and in 14 other states due to annual indexing to inflation.
Voters are gathering signatures for ballot initiatives to expand the state minimum wage in Alaska and Missouri, but as of October 1, 2023, the outcome was not yet known. And in 2024, Montana will become the 30th state to have a minimum wage of at least $10.00 due to cost-of-living adjustment that will increase its current $9.95 wage to $10.30.
State earned income tax credits expanded in several states this past year. Montana enacted legislation this past year to expand its refundable EITC from 3% of the federal credit to 10% in tax year 2024, which will make it the 23rd state to implement a refundable state EITC that is at least 10% of the federal credit.
In total, 30 states introduced legislation this past year to establish or expand a state EITC; nine states successfully passed legislation to expand the generosity of their credit, and four states extended the benefits to additional populations, including workers that do not have a social security number.
9 States Have Fully Implemented All 4 Effective Policies
Because of the progress states made this past year, nine states have now adopted and fully implemented all four effective Roadmap policies. “Fully implemented” means that families in the state can currently access the level of benefits that rigorous research finds is necessary to impact PN-3 outcomes.
This year, Oregon and Rhode Island fully implemented their paid family leave programs of at least 6 weeks, which put them in the group of nine states that are providing all four of the broad-based economic and family supports in the Roadmap.
Ten states have fully implemented three out of the four Roadmap policies. Included in this group of states are Hawaii, which moved into this group because of its expanded refundable EITC; Nebraska, which substantially increased its state minimum wage; and Michigan, which fully implemented two Roadmap policies this past year – a state minimum wage that is greater than $10.00 and a refundable state EITC that is at least 10% of the federal credit.
Colorado is among this group, as well, and it will move to the top group when it fully implements its paid family leave program in 2024. Maine and Maryland will join the top group in 2026 when they each implement 12-week paid family leave programs.
Eleven states have fully implemented two of the four effective Roadmap policies. Ohio moved into this group by increasing its state’s minimum wage to more than $10.00 per hour. South Dakota fully implemented Medicaid expansion and a higher minimum wage, which added two policies to its system of care this past year. Minnesota and Delaware will move up from this group in 2026 when they each fully implement their 12-week paid family leave programs.
Twelve states have fully implemented only one of the effective Roadmap policies. Montana is currently part of this group, but next year the state is scheduled to increase its minimum wage and EITC, which will move it up to the group that has fully implemented three out of four policies in 2024.
To date, nine states have not fully implemented any of the effective policies, indicating that there is much work to be done to support children and families in the US. North Carolina, however, will move out of this group when it becomes the 41st state to implement Medicaid expansion in December 2023.
Importantly, even among states that have implemented a given policy, the generosity and reach of the policy varies considerably across states. We discuss this variation in detail in each of the policy and strategy profiles.
States Are Implementing Key Policy Levers to Expand Access to Effective Strategies
In addition to the four effective Roadmap policies, states also invested in the eight evidence-based strategies this past year through legislative or administrative action and are implementing many key policy levers to expand access to services.
Reduced Administrative Burden for SNAP
For example, Alaska increased its SNAP certification interval from 6 to 12 months, which will make it easier for eligible families in the state to remain on SNAP. Currently, 16 states offer 12-month certification periods to all families, and a majority of states allow all families to use simplified reporting and provide online case management services. However, only 10 states implement all three key levers for reducing the administrative burden for SNAP.
Comprehensive Screening and Connection Programs
Only three states – Connecticut, New Jersey, and Oregon –have a goal to implement comprehensive screening and referral programs statewide. But nearly half of states use Medicaid to fund services and/or provide state funding directly to the programs. For example, this year, New Jersey established a program for enhanced Medicaid payments for well-child and sick visits claims at HealthySteps sites, and Florida provided money directly to fund HealthySteps programs in its state.
Child Care Subsidies
States continue to make substantial investments in child care, however as federal stabilization dollars expire, permanent state investments will be necessary to maintain the great progress states have made toward making child care more accessible, affordable, and higher quality. In this past year, 18 states expanded eligibility for families to receive a subsidy, 5 states reduced copays to make child care more affordable, and 25 states increased reimbursement rates to providers to stabilize the market. However, only a handful of states have a permanent funding source for child care, which leaves these investments at risk.
Group Prenatal Care Services
Five states provide an enhanced Medicaid reimbursement and also direct state funding to support group prenatal care services. In this past year, Maryland became the eighth state to offer an enhanced Medicaid reimbursement rate, and North Carolina enacted legislation to establish an enhanced rate next year.
Community-Based Doulas
Because of new rigorous evidence that community-based doulas have a positive impact on perinatal health outcomes, we added this strategy to the Roadmap for the first time this year. Across the country, more than half of states introduced legislation to support doulas in some way, and 14 states successfully enacted legislation. Five states newly enacted legislation to provide Medicaid coverage for doula services. Among the 12 states currently implementing this key policy lever, Minnesota and Nevada made substantial increases to their Medicaid reimbursement rates. In addition, three states – Colorado, Missouri, and Nevada – newly provided funding to support the doula workforce, bring the total number of states that implement this key lever to nine.
Evidence-Based Home Visiting Programs
Fifteen states use Medicaid to fund elements of evidence-based home visiting programs that have a positive impact on parenting behaviors. The District of Columbia introduced legislation this past year to use Medicaid to fund home visiting services, but the bill did not pass. Eleven other states successfully enacted legislation to expand funding for home visiting programs.
Early Head Start
States continue to increase their investments in Early Head Start (EHS) programs. For example, this past year Colorado, Maine, and Minnesota made substantial investments in EHS. To date, 23 states directly invest in EHS in some way, either as an Early Head Start-Child Care Partnership grantee, direct state funding, or by providing a state-specific program that has similar quality standards as EHS.
Early Intervention Services
States have substantial latitude in how they implement their Early Intervention (EI) programs. Over the last year, several states took legislative or administrative action to enhance their EI services, specifically through increasing access to EI services for many families and improving the funding of their programs. To date, however, only four states – Florida, New Hampshire, New Mexico, and West Virginia – implement all three key levers that can expand access to care, which include allowing very low birthweight and at-risk for developmental delay to be used as qualifying conditions and eliminating family fees.
We will continue to monitor states’ progress toward implementing the effective strategies and investing in children and families.
Visit each of the policy and strategy profiles for more extensive information on the progress states have made over the last year toward full and equitable implementation of each of the 12 solutions.
HOW POLICY CHOICES IMPACT FAMILY RESOURCES ACROSS STATES
A state’s policy choices do not operate in isolation from one another. Instead, they interact to create a system of support of varying generosity for parents and children. Tax credits and near-cash supports, such as SNAP, provide valuable resources to families. However, state minimum wage, paid family leave, and child care subsidy policies are also significant drivers of the variation across states in the amount of resources a working parent has available to support their family.
For example, states that set a high minimum wage, but also require parents to pay a high copay or additional fees for a child care subsidy may leave families with a similar level of resources as parents in other states that provide a lower minimum wage, but do not require parents to pay a copay or fees for subsidized child care.
We simulate the minimum level of annual resources available to a single parent with an infant and toddler, who works full time at a minimum wage job, takes 12 weeks of leave under the Family and Medical Leave Act with benefits from paid family leave if available, and who uses a subsidy to leave their two children in center-based child care that charges the equal access target rate (which is the 75th percentile of the state’s market rate survey).
The figure below combines a state’s minimum wage, paid family leave, out-of-pocket child care expenses, nutrition benefits, and federal and state income taxes and credits to illustrate how the minimum level of resources available to a stylized family varies across states.
The figure illustrates wide variation in available resources due to state policy choices. In particular, the working parent has over $47,000 in annual resources to provide for their family in the District of Columbia, and the majority of these resources are their earnings from their minimum wage job. Importantly, the parent in the District of Columbia had access to paid family leave when their children were born, which protected a substantial portion of their wages when they took family leave. The parent in DC is also eligible for Medicaid.
By contrast, because of low minimum wages, no paid family leave, and high out-of-pocket child care expenses, this same working parent would have just over $20,500 in annual resources for their family if they live in Georgia, and most of the resources are benefits that the federal government provides. The parent also does not have access to Medicaid in Georgia.
For more information including how the level of resources varies across states once adjusted for the cost of living, visit the Policy Impact Calculator.
A PATCHWORK OF UNEQUAL OUTCOMES ACROSS STATES
The purpose of states’ implementing effective PN-3 solutions is to improve the wellbeing of infants, toddlers, and their parents, and to reduce long-standing disparities in outcomes by race and ethnicity.
Wide Variation Exists in the Wellbeing of Children and Families Across States
On some outcomes, such as preterm births, the percentage of children or families who are struggling in the states with the best outcomes is approximately half what it is in the states with the worst outcomes.
However, on other outcomes, the differences are much larger. For example, the percentage of low-income women of childbearing age who lack health insurance in Texas (46.1%) is nearly 50 times higher than it is in Vermont (1.0%); and the rate of child maltreatment per 1,000 children under age 3 is 16 times higher in West Virginia (33.4) than it is in Pennsylvania (2.0).
Even the “Best” States Have Room to Improve
Importantly, the “best” state does not necessarily indicate a target for all other states to strive toward; even in the states with the best outcomes, many children and families are struggling. For example, Massachusetts reports the lowest, or best, percentage of children who did not receive a developmental screening, but in that state still 40% of children are not screened for potential delays that can identify the need for intervention. Iowa has the best rate of children receiving all of their required immunizations, but more than 12% of infants and toddlers are not up to date on their immunizations.
The daily reading outcome measure provides another example of an outcome on which all states can improve; Oklahoma families report that over 73% of parents do not read to their infants and toddlers daily, which is the highest, or worst, percentage in the country. Maine families report the best rate of daily reading, but over 40% of young children are not read to daily in the state.
Examining Outcomes Across Race and Ethnicity is Essential, but the Data Are Often Lacking
In addition to measuring how states compare to one another, it is vital that states collect and share information on how families of different race and ethnic groups and socioeconomic statuses fare on these outcomes. For most of these measures, national data are not available that can adequately measure subgroup differences within a state, because of small sample sizes. The state-level outcomes pages and the demographic characteristics section of the Roadmap provide detailed information on these important measures, and where possible, the data are presented by race and ethnicity.
Prenatal-to-3 Outcomes to Measure Impact
THE SCIENCE IS CLEAR ON THE PATH FORWARD
The science clearly identifies the conditions necessary to help children thrive. The evidence now exists on how states can invest in effective policies and strategies to foster these conditions. This Roadmap is meant to serve as a guide for states as they undertake these important efforts to ensure all children thrive from the start.
View each state’s Roadmap summary for more state-specific information on the progress each state has made over the last year toward full and equitable implementation of each of the 12 solutions. Additionally, find extensive information on the impact that each solution has on the eight PN-3 policy goals, the choices that states can make to effectively implement them, the progress states have made in the past year toward implementation, and how states compare to each other in their generosity and reach of the policies and strategies in a profile for each policy and strategy.
