A high school senior learns that she’s pregnant — and she’s terrified. But a registered nurse comes to visit her in her home for about an hour each week during pregnancy, and every other week after birth, until the baby turns 2. The nurse advises her what to eat and not to smoke; looks around the house to advise her of any safety concerns; encourages her to read and talk to her baby; and counsels her on nutrition for herself and her baby.
This kind of support, with trained nurses coaching low-income, first-time mothers, is among the most effective interventions ever studied. Researchers have accumulated decades of evidence from randomized controlled trials — the gold standard in social science research — following participants for up to 15 years. They have consistently found that nurse coaches reduce pregnancy complications, pre-term births, infant deaths, child abuse and injury, violent crimes and substance abuse. What’s more, nurse coaches improve language development, and over the long term, cognitive and educational outcomes.
Nurse coaching is a vital tool that addresses both the liberal concern about income inequality and the conservative concern about inequality of opportunity. For fiscal conservatives in particular, nurse coaching sharply reduces long-term government spending on Medicaid, welfare and food stamps. And for advocates of good government, the independent Coalition for Evidence-Based Policy rates nurse coaching as “top tier” — meaning that it yields sizable, sustained effects.
This is why nurse coaching enjoys broad, bipartisan support. President Obama has long advocated for expanded funding for nurse coaching. House Speaker Paul Ryan’s plan to address poverty extols it as evidence-based and effective. And Gov. Nikki Haley (R) is expanding it in South Carolina.
Still, nurse coaching reaches only 2 to 3 percent of eligible families. Which raises the question: if it’s so successful — and people on both sides of the aisle support it — why can’t it be scaled to reach every eligible family?
There are two stumbling blocks.
First, states must cobble together disparate funding streams to support nurse coaching: the Maternal, Infant, and Early Childhood Home Visiting Program; the Maternal and Child Health Services Block Grant; foster care funds; welfare funding; and Medicaid funding. These funding sources can be unreliable and the need to apply for, administer and account for multiple funding streams can result in bureaucratic red tape.
Second, the billions of dollars in costs of nurse coaching must be paid for all at once, up front, while the savings and benefits to government and society accrue over time. If nurse coaching were fully scaled to reach every eligible family, the costs to state and federal governments would outweigh the savings for the first five years. But then the savings would start to outweigh the costs. Over 10 years, the net savings would be $2.4 billion for state governments and $816 million for the federal government.
The simple solution to this timing problem is to frontload future savings. Private investors, philanthropic foundations and the federal government could provide money to states to be used to set up nurse coaching programs. In the case of the federal government, this investment would be a single funding stream over five years.
Then, as savings start to materialize — as measured by an independent evaluator — states would gradually repay these investors (with a modest return on investment, in the case of private investors). Crucially, states would only need to repay investors if expected savings are achieved — thereby ensuring that taxpayer dollars yield results. In South Carolina, Haley is pioneering this “pay for success” model.
States that take up this option would save money — and the financial savings would be linked with positive outcomes for their budgets and society more generally. For instance, states could dramatically reduce pre-term births within six months. Pre-term and low birth weight infant hospital stays cost an average of $15,100, compared to $600 for uncomplicated newborns. And because 42 percent of pre-term and low birth weight infant stays are paid for by Medicaid, this one outcome would sharply reduce overall government spending.
As a matter of pragmatism, the policy choice is simple: Should we spend more money in the future on costly health care, welfare, food stamps, special education and criminal justice? Or should we take some of that money and invest it now in a way that’s proven to save money in the long run?
But something more than good government or financial prudence is at stake. The early years of life have a lasting impact. Differences in cognitive ability, for instance, emerge even before preschool and affect school readiness, academic achievement and lifetime earnings.
What’s at stake, in short, is whether we as a society want to give children born into poverty a better chance to succeed in life. Behind all of the evidence on return on investment are mothers who need support at the moment when it matters most. As one mother, Dinara Gabdula, said about her nurse coach, “In that moment after birth, you’re just lost and don’t know what to do, I don’t know what I would have done without Mrs. Beth.”
As we’re debating the future course our country will take, let’s seize the opportunity to make a real difference in the lives of children. During these polarized times, nurse coaching is one commonsense solution both parties can agree on.