Families have access to necessary services through expanded eligibility, reduced administrative burden, and identification of needs and connection to services.

Ensuring access to the resources and services that parents and children need is foundational to building a prenatal-to-3 system of care. States provide a number of benefits and programs to children and families, based on varying eligibility criteria and modes of delivery. However, use of services among families who are eligible varies considerably from state to state: Between two children in different states with identical needs, one may receive a benefit that the other does not, a situation leaving many without the services that help them to thrive. Families of color, in particular, are less likely to receive services even though they are eligible, as demonstrated by research on programs such as Medicaid, WIC, and Early Intervention (EI) services.1,2 For example, in a study about EI services, eligible Black children under age 2 were found to be 5 to 8 times less likely to receive services than White children, depending on the eligibility category.3

States have the ability to increase families’ and children’s access to services through three primary pathways:

  1. Expanding eligibility criteria;
  2. Reducing administrative burden, or the amount of effort that families must expend to receive an eligible benefit; and
  3. Screening for the specific needs that families and their children have and connecting them with the precise services they need.

Expanded Eligibility Criteria

States have the flexibility to determine who is eligible for many programs and services, including programs largely funded by the federal government. Determinations about who is eligible for a service can be driven by whether a state has adopted a specific policy (for example, paid family leave or expanded income eligibility for health insurance), the broad or narrow criteria the state uses to determine whether someone is eligible (for example, criteria for Early Intervention services or child care subsidies), or whether to include or exclude certain populations that are not automatically eligible (for example, some states use state funds to provide services to immigrant families and children). These decisions drive variation in whether two children or parents with similar needs, but in different states, receive similar help.

Reduced Administrative Burden

Administrative burden refers to the barriers that increase the costs—time, money, and psychological distress—of applying for and maintaining eligibility in a public assistance programs. Administrative burden policies come in many forms, such as requiring that recertification for benefits take place in person rather than remotely, or that recertification take place every 3 months rather than 12, or that a host of documents be presented to prove eligibility. Moreover, the policies can result from intentional or inadvertent features of regulations that states put in place.4 Regardless of the intentions, administrative burden policies are largely costly and inefficient, and they reduce the use of services among those who are eligible. Because state resources are generally scarce, reasonable policies are needed to ensure that only families who are eligible receive the intended services, but states have found methods to reduce fraud while also reducing unnecessary burdens on eligible families.

Screenings and Referrals to Needed Services

Identifying needs early and addressing them immediately helps to reduce the need for later services (and saves money).5 An adequate system for screening and referrals requires four components: (1) screening to identify the precise services that are needed, (2) referring and connecting the family to the needed services, (3) serving the family to address the need, and (4) monitoring outcomes to ensure the need is addressed. A breakdown in any of these links to services threatens the health of the system and may compromise improvements in outcomes. Our current systems often focus on screening, yet neglect to document the needs of the families, the services rendered, or the improvements made in family and child wellbeing.

Through our comprehensive reviews of rigorous research, we have identified policies and strategies that provide states with key opportunities to remove obstacles that prevent families from participating in the programs intended to help them thrive. Next is a closer look at these policies and strategies and an overview of important outcome measures that states should use to track their progress toward removing barriers to access.

Three outcome measures illustrate families’ access to services based on expanded eligibility, reduced administrative burden, and screenings for needed services: (1) health insurance access among low-income women of childbearing age, (2) access to the Supplemental Nutrition Assistance Program (SNAP) among eligible households with children under age 18, and (3) developmental screenings among children under age 3. These outcomes vary considerably across states, as well as by race and ethnicity.

All three outcome measures were calculated intentionally in the negative direction to demonstrate where states have room for improvement and to help states prioritize the PN-3 policy goals that are lagging. Out of 51 states, the worst state ranks 51st, and the best state ranks first. The median state indicates that half of states have outcomes that measure better than that state, whereas half of states have outcomes that are worse.


% of low-income women of childbearing age who do NOT have any health insurance coverage
Median state value: 18.0%

In the five worst states, a third or more of low-income women of childbearing age do not have health insurance, leaving them physically and financially vulnerable, and without access to pre- or inter-conception care. Expanded income eligibility for health insurance would provide health insurance to most of these uninsured women, but not one of the five worst states has adopted the policy. At the extremes, low-income women in Texas are 9 times more likely than similar women in Vermont to lack health insurance, and lower-income Hispanic women lack health insurance at twice the rate of all other women.

See the Prenatal-to-3 State Policy Roadmap Appendix for a table of state variation in Access to Needed Services outcomes and corresponding ranks for each state.
Source: 2018 American Community Survey (ACS) 1-Year Public Use Microdata Sample (PUMS); for additional information, please refer to Methods and Sources.


% of eligible families with children under age 18 NOT receiving SNAP
Median state value: 7.5%

SNAP is a vital resource for increasing families’ food security and improving nutrition. In the six best states, more than 95% of families with children under age 18 who are eligible for SNAP receive the benefit. In the five worst states, approximately 1 in 5 eligible families with children does not receive SNAP. SNAP receipt also reveals racial disparities: Among eligible families with children, 4.2% of Black families and 8.1% of White families do not receive the benefit, whereas 19.1% of Hispanic families go without.

Source: 2016-2018, Urban Institute’s TRIM3 project; for additional information, please refer to Methods and Sources.


% of children ages 9 to 35 months whose parent reports their child did NOT receive a developmental screening in the past year
Median state value: 61.7%

Nearly 3 out of 4 children in the five worst states do not receive a developmental screening assessment prior to age 3; but even in the five best states, up to half of children do not receive this important assessment for early detection of developmental delays. Black and Hispanic children are substantially less likely than White children to be screened at an early age for developmental delays.

Source: 2016-2018 National Survey of Children’s Health (NSCH); for additional information, please refer to Methods and Sources.

Effective policies have a demonstrated positive impact on at least one prenatal-to-3 goal, and the research provides clear guidance on legislative or regulatory action that states can take to adopt and implement the policy. By contrast, effective strategies have demonstrated positive impacts on prenatal-to-3 outcomes in rigorous studies, but the research does not provide clear guidance to states on how to effectively implement the program or strategy statewide.


Effective state policies and strategies to increase Access to Needed Services

Effective PoliciesExamples of Impact on Access to Needed Services
Expanded Income Eligibility for Health Insurance
  • Medicaid expansion led to an 8.6 percentage point increase in preconception Medicaid coverage (B)

  • Medicaid expansion led to 0.9 more months of Medicaid coverage postpartum (I)

  • Medicaid expansion led to a 5.1 to 8.4 percentage point increase in rates of recommended perinatal screenings (D)
Reduced Administrative Burden for SNAP
  • Recertification intervals longer than 12 months led to an 11.4 percentage point increase in SNAP participation among households with children (12 percentage points among female-headed households) (E)

  • The elimination of policies that added transaction costs and stigma to SNAP participation explained 14.6% of the SNAP caseload increase from 2000 to 2016 (A)

  • Policies lengthening recertification intervals to longer than 3 months were associated with a 5.8% increase in SNAP participation from 2000 to 2009 (K)
Paid Family Leave
  • Access to paid family leave increased leave-taking by 5 weeks for mothers and 2 to 3 days for fathers (B)

  • Among Black mothers, access to paid family leave led to a 10.6 percentage point increase in leave-taking; among White mothers, a 4 percentage point increase (N)
Effective StrategiesExamples of Impact on Access to Needed Services
Comprehensive Screening and Referral Programs
  • Family Connects families accessed between 0.7 (B) and 0.9 (D) more community resources

  • Healthy Steps families had 3.5 times higher odds of being informed about community resources (E)
Child Care Subsidies
  • Subsidy recipient families were 2.0 to 3.8 times more likely to choose center-based care over informal care due to subsidy policy changes (G)

  • A $1,000 increase in state subsidy spending per low-income child led to 86% higher odds of enrollment in center-based care than multiple care arrangements (B)
Group Prenatal Care
  • Group prenatal care led to a 10% increase in receipt of adequate prenatal care (G)

  • Group prenatal care led to 1.8 more prenatal visits among participating Black women with high-risk pregnancies (L)

Note: The letters in parentheses in the tables above correspond to the findings from strong causal studies included in the comprehensive evidence reviews of the policies and strategies. Each strong causal study reviewed has been assigned a letter. A complete list of causal studies can be found in the Prenatal-to-3 State Policy Roadmap Appendix. Comprehensive evidence reviews of each policy and strategy, as well as more details about our standards of evidence and review method, can be found at in the Prenatal-to-3 Policy Clearinghouse.



Have states adopted and fully implemented the effective policies to impact Access to Needed Services?

Expanded Income Eligibility for Health Insurance

37 states have adopted and fully implemented the Medicaid expansion under the Affordable Care Act (ACA) that includes coverage for most adults with incomes up to 138% of the federal poverty level (FPL).

Sources: As of October 1, 2020. Medicaid state plan amendments (SPAs) and Section 1115 waivers.

Reduced Administrative Burden for SNAP

32 states have a median recertification interval that is 12 months or longer among households with SNAP-eligible children under age 18.

Sources: As of 2018. United States Department of Agriculture (USDA) Fiscal Year 2018 Supplemental Nutrition Assistance Program Quality Control Database and the QC Minimodel.

Paid Family Leave

5 states have adopted and fully implemented a paid family leave program of a minimum of 6 weeks following the birth, adoption, or the placement of a child into foster care.

Sources: As of October 1, 2020. State statutes and legislation on paid family leave.


Have states made substantial progress toward implementing the effective strategies to impact Access to Needed Services?

Comprehensive Screening and Referral Programs

8 states have both evidence-based comprehensive screening and referral programs: Family Connects and Healthy Steps.

Sources: As of June 12, 2020. Family Connects and Healthy Steps national websites.

Child Care Subsidies

1 state’s base reimbursement rates (for infants and toddlers in center-based care and family child care) meet the federally recommended 75th percentile using a recent market rate survey.

Sources: As of July, 1 2020. State children and families’ department websites and state market rate surveys.

Group Prenatal Care

10 states have supported the implementation of group prenatal care financially through enhanced reimbursements for group prenatal care providers.

Sources: As of June 8, 2020. State health department websites and proposed and passed state legislation.

Note: Some states in the “no” category for Policy Variation Across States have adopted a policy, but they have not fully implemented it, or they do not provide the level of benefit, indicated by the evidence reviews, necessary to impact the PN-3 goal. Many states in the “no” category for Strategy Variation Across states have implemented aspects of the effective strategies, but states are assessed relative to one another on making substantial progress. For additional information, go to the State Data Interactives.

  1. Stuber, J. P., Maloy, K. A., Rosenbaum, S., & Jones, K.C. (2000). Beyond stigma: What barriers actually affect the decisions of low-income families to enroll in Medicaid? The George Washington University School of Public Health and Health Services. https://hsrc.himmelfarb.gwu.edu/sphhs_policy_briefs/53/
  2. Brien, M., & Swann, C. (1999). Prenatal WIC participation and infant health: Selection and maternal fixed effects. Deloitte Financial Advisory Services, LLP, and University of North Carolina, Greensboro. https://www.researchgate.net/profile/Michael_Brien/publication/241815776_Prenatal_WIC_Participation_and_Infant_Health_Selection_and_Maternal_Fixed_Effects/links/555b32b108ae6fd2d829a9cd.pdf
  3. Feinberg, E., Silverstein, M., Donahue, S., & Bliss, R. (2011). The impact of race on participation in Part C Early Intervention services. Journal of Developmental & Behavioral Pediatrics, 32, 284–291. https://dx.doi.org/10.1097%2FDBP.0b013e3182142fbd
  4. Herd, P., & Moynihan, D. P. (2018). Administrative burden: Policymaking by other means. New York, NY: Russell Sage Foundation.
  5. Heckman. (n.d.). Why early investment matters. https://heckmanequation.org/resource/why-early-investment-matters/