The Year’s Developments and Trends in State Early Childhood Policy and Advocacy
Dear Allies,
As the COVID caseloads declined and the masks came off, 2023 was a year for getting back to business. The question was whether we would return to old ways of thinking, and investing, and spending, or whether we would learn from the pandemic and respond accordingly. Most states were flush with strong revenues and remaining federal relief funds. What would they prioritize in their budget allocations? Would they (a) hold on to them for a future rainy day, (b) give them back as tax credits, or (c) invest in programs and systems that made their state stand out as a great place to raise a family?
The answer is: all of the above.
In this report we highlight the state investments advocates and their in-state partners successfully pursued to improve outcomes for young children and their families: from continuous coverage for children on Medicaid for the first six years of their lives, to universal, statewide paid family and medical leave, to historic increases in state funding for child care, to the creation and expansion of child tax credits that will dramatically reduce poverty in some states. And one state–Minnesota—did all of the above!
The past year showed that state governments can and do act to improve child well-being, but we know pendulums swing, federal relief funds disappear, and state economies cool. The future will test state commitment to prioritizing children and families. Will they sustain investments? Will there be a powerful, unified voice advocating for this and more?
At the Alliance for Early Success, our theory of change grounds all our work in pursuit of this precise outcome: a powerful, diverse, and durable constituency for early childhood issues. It is both the bold vision and the incremental strategy to achieve it. We work to build a formidable state advocacy voice that outlasts any particular political party in power and any particular budget cycle. The goal is to engage the workforce, parents, local philanthropy, community organizers, policymakers, and the faith community. The more the better, and the more diverse the better, so everywhere you turn in a state you hear that the early years are important, we need to think bigger about how we invest in them, and we are not going away.
This report provides a snapshot of what happened in 2023, but I encourage you to check out our state policy landscape webpages for state-by-state details on what happened, including who is working at the state level to make it happen. We know our grantees play an essential role in these accomplishments while also recognizing they cannot do it alone. That is why we are dedicating $10 million in the coming years to build the collective power that is necessary for every child, in every state, to have what they need in the early years to realize their full potential.
With hope for the future,
Helene Stebbins, Executive Director
Alliance for Early Success
Strong state economies, combined with expiring federal pandemic relief funds, led to some of the most significant investments in recent memory. Wins came from an array of policy areas–from maternal and child health to child care to family economic support–and from the executive and legislative branches, as well as from the people through ballot initiatives.
One of the big headlines of 2023 was the surge in states taking the option to extended Medicaid coverage to 12 months postpartum. Only four states have yet to do this since it became an option for federal matching funding in April of 2022. States are also following Oregon and Washington’s lead, offering continuous coverage for kids on Medicaid for the first 3 to 6 years of the child’s life. Congratulations to California, Colorado, Hawaii, Ohio, New Mexico, Minnesota, and North Carolina, who are on the path to do this in 2023.
In response to the threat to the Indian Child Welfare Act, six states passed laws, joining 10 others, that provide the same protections. Shout out to Colorado, Maine, Montana, Nevada, North Dakota, and Wyoming for not relying on the Supreme Court to affirm the federal law.
Maine and Minnesota join 12 other states providing universal, statewide paid family and medical leave.
Maryland, Minnesota, Oregon, and Utah created new, permanent child tax credits, and 7 other states expanded their existing child tax credits–some doubling or tripling the previous amounts, dramatically reducing child poverty in those states.
States also made some of the largest investments of their own general revenue funds in early childhood programs. And a handful of states established new, dedicated funding streams for young children. Vermont passed a payroll tax to fund child care, Alaska, Colorado, and Texas passed ballot initiatives that increase funding for early learning. And Kentucky, Ohio, and Oregon tapped into lottery and casino revenues.
We celebrate states that invested to continue the child care innovations and supports, some of which were initially funded through COVID-relief dollars. New state dollars increased child care subsidy rates, lowered copayments, and increased the compensation and benefits for the child care workforce.
In 2023, Alabama made its largest annual increase in state pre-k funding, Alaska made the largest increase in early childhood programs in decades, and North Dakota allocated state funds for child care for the first time ever. Our Child Care Policy Roadmap 2023 highlights actions states have taken to create more equitable and ambitious child care systems.
We also celebrate the administrative policy wins—like Louisiana‘s State Board of Elementary and Secondary Education, who codified social emotional development in the state’s early learning standards—and the systems-level wins—like South Carolina‘s permanent authorization of South Carolina First Steps, which ensures the future of a comprehensive, statewide, public-private partnership working to build a strong early childhood system so that young children have the best possible start in life.
Read on for more details on what Alliance grantees in all 50 states and the District of Columbia are sharing about what happened in 2023.
The end of the COVID public health emergency required states to redetermine eligibility for Medicaid and CHIP for the first time since early 2020. The redetermination process has meant more than two million children have lost Medicaid coverage, but advocates in every state are working to keep the public informed of this “unwinding” of coverage. Alliance ally Georgetown Center for Children and Families created a toolkit for states advocates to communicate about the renewal process, coverage loss, and reenrollment.
In spite of this headwind, states found bipartisan agreement on policies to advance child and maternal health, including extension of Medicaid coverage to 12-months postpartum, reimbursement of doula services as a Medicaid benefit, continuous Medicaid enrollment for young children, and more. Alliance state allies collaborated with communities disproportionally impacted by health disparities and enlisted the support of unusual allies, including faith communities, to push policymakers to make maternal and child health a priority.
States in 2023 Reporting Changes in State Funding
for Maternal and Child Health*
Access to health care coverage ensures that children can receive appropriate preventive and primary care as well as treatment for any health issues that arise. Continuous coverage for children has been shown to reduce financial barriers to care for low-income families, promote health equity, and provide states with better tools to hold health plans accountable for quality care and improved health outcomes. Starting January 2024, all children in Medicaid and CHIP will qualify for a full year of coverage, as required by the 2022 Consolidated Appropriations Act.
Over and above the upcoming 12-month requirement, a growing number of states – now 10 – are advancing multiyear continuous eligibility for young children. Continuous coverage legislation passed in 2023 in Colorado (3 years, up to age 4, also includes a state feasibility study looking at extending to age 6), Minnesota (5 years, up to age 6) and Ohio (3 years, up to age 4). Legislators in Rhode Island and Montana also considered multi-year continuous eligibility for young children and Texas and Maryland lawmakers introduced similar measures.
“State advocates have called for the common-sense change to make Medicaid coverage available continuously for young children from birth to kindergarten. This means they won’t miss out on check-ups, vaccines or screenings because of lost paperwork or long call wait times that disenrolled them from Medicaid even if the child remained eligible.”
According to the American Immigration Council, 1 in 4 children in the United States have at least one immigrant parent and roughly 6 million children under the age of 18 are living with an undocumented parent or caregiver. Children of undocumented immigrant parents comprise 7.25 percent of all children in the U.S. Undocumented immigrants are generally ineligible to enroll in Medicaid and CHIP or to purchase coverage through the ACA Marketplaces. Thirteen states and Washington, D.C., provide Medicaid or CHIP to income-eligible children, regardless of immigration status by using state dollars: Oregon, Washington, California, Colorado, Illinois, New York, New Jersey, Minnesota, Massachusetts, Vermont, Connecticut, Rhode Island and Maine. Michigan joined them in 2023 with $32.1 million and a Medicaid policy change to end the state’s five-year waiting period for immigrant children and pregnant individuals eligible to enroll in Medicaid or MIChild (CHIP).
Research suggests that state coverage expansions for immigrants can reduce uninsurance rates, increase health care use, and improve health outcomes.
Data from the Centers for Disease Control and Prevention shows that the maternal mortality rate for all women nearly doubled between 2018 to 2021, climbing from 17.4 maternal deaths per 100,000 births in 2018 to 32.9 maternal deaths per 100,000 live births in 2021. And as in years past, Black and Indigenous women continued to experience by far the highest rate of maternal mortality. (The rate for Black women is three times higher than White women and the rate for Indigenous women is two times higher.) The ongoing maternal health crisis has prompted policymakers across the political spectrum to take action to improve maternal health outcomes.
In 2023, lawmakers extended Medicaid coverage to 12-months postpartum in states including Alaska, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, South Dakota, Texas, Utah, and Wyoming.
We have seen unprecedented state uptake of any new Medicaid option with the extended coverage for pregnant women from 60 days to a full year postpartum—all but four states have taken the new federal option, which only became available in 2022. Beyond adopting the postpartum extension, state advocates have also called on state leaders to ensure the coverage works as intended—that pregnant people and their infants get the right care at the right time during high-stakes periods of family change and rapid early development. This has led to more states looking at Medicaid coverage for doulas and midwives to community health workers or parent-child services without a child mental health diagnosis.
Doulas are non-medical, trained health care workers who support pregnant people before, during, and after pregnancy. Doula care is among the most promising approaches to combating disparities in maternal health. Pregnant and birthing people receiving doula care have been found to have improved health outcomes for both themselves and their infants, including higher breastfeeding initiation rates, fewer low-birth weight babies, and lower rates of cesarean births. During the 2023 legislative session several states took action to include doulas as part of Medicaid coverage, including Alabama, Colorado, Connecticut, Delaware, Michigan, and Ohio. For a full accounting of state level efforts to reimburse doula services through Medicaid, visit the Doula Medicaid Project.
In proposing her Healthy Moms, Healthy Babies Initiative that includes doula coverage, Michigan’s Governor Whitmer said, “Expecting Michiganders deserve to have the care they need to have a healthy pregnancy. Yet, more than 63 percent of maternal deaths in Michigan are preventable, and Black women are nearly three times more likely to die from pregnancy-related causes than white women. By providing doula services we are helping address health disparities and ensuring access to high-quality health care that meets their individual needs.”
Nevada passed a bill to allow for Medicaid to reimburse for services provided by Community Health Workers who are supervised by another provider. Community health workers (CHWs) are lay members of the community who work in association with the local health care system. CHWs usually share ethnicity, language, socioeconomic status, and life experiences with the community members they serve. Indiana legislators approved several bills aimed at improving access to contraceptives, doulas and other programs to decrease maternal and infant mortality.
In 2023, states made progress towards reforming their child welfare state laws to prioritize keeping families together as they work to implement the federal Family First Prevention Act of 2018.
Policymaking in child welfare has a long history of bipartisanship and has sparked important reform efforts to promote child safety, well-being and family stability, among other goals. In 2023, more than 250 legislative proposals were introduced on topics ranging from child abuse and neglect prevention, reporting and investigating child abuse and neglect, recruiting and retaining foster families, supporting relatives and kinship caregivers, and more. Several bills were introduced on hot-button topics such as religious freedom and LGBTQ rights, areas where starkly different political viewpoints exist. Most child welfare topics received bipartisan attention and support. Proposals that generated the greatest bipartisan support in 2023 were bills to improve training for mandatory reporters of suspected child abuse or neglect, as well as bills to improve the quality and availability of services to children and youth in foster care, particularly mental health services.
Prior to the Supreme Court upholding the Indian Child Welfare Act (ICWA) in the case of Haaland v. Brackeen, the Alliance hosted a National Issues/ State Action webinar on Indigenous Sovereignty and the Indian Child Welfare Act. In the weeks surrounding the 7-2 decision, states moved to enact legislation to codify state versions of ICWA in whole or in part, as well as measures to enhance oversight of ICWA compliance and to support foster placements of Indian children. States that passed ICWA legislation include Colorado, Maine, Minnesota, Montana, Nevada, North Dakota and Wyoming.
Kinship care also received significant attention from state lawmakers in 2023. Kinship care is widely considered best practice given the positive benefits associated with children who are connected to family, culture and community. Lawmakers from both parties introduced bills to provide financial assistance for relative caregivers, including guardianship assistance, as well as measures to improve family finding and prioritize kinship placements and connections. States enacting kinship legislation in 2023 included Alabama, Arkansas, Colorado, Hawaii, and New Mexico. According to survey results, our allies in Pennsylvania identified improving and expanding kinship care and permanency as their best policy opportunity in 2024.
Overall, maternal health is a growing focus in the Alliance grantee network. Three quarters of states report* that they prioritize maternal health in their policy agendas and they want to learn more about infant mental health support and treatment, access to adequate coverage for quality maternal health services, racial disparities in maternal health and birth outcomes, and the impact of social determinants of health like economic security and housing on maternal health outcomes. To support this learning, the Alliance hosted a maternal health webinar series in partnership with national organizations including Georgetown Center for Children and Families, Elephant Circle, Black Mamas Matter Alliance, and Reproductive Health (RH) Impact.
State and national advocates started 2023 with an agenda focused on funding. The year started with significant increases in the federal budget for child care and Head Start, but without a federal plan to offset the gaps left by expiring COVID relief funds. At the national level, advocates continued to track the uses of the federal COVID relief funds to demonstrate the impact of the funds and the continued need and worked with state advocates to document the crisis coming in the child care system as the funds expire. For example, the Center for Law and Social Policy (CLASP) explored the impact of the COVID relief funds in four states—Louisiana, Michigan, New York, and Virginia—and found that they invested in innovation, supported the workforce, and aligned existing systems to better serve children and families. Child Care Aware of America continue to track state uses of American Rescue Plan Act (ARPA) funds.
To continue these efforts, most states explored new sources of funding for child care, partnered in new ways with business and other partners, and were able to address access, affordability and quality in their child care systems. States used increased resources to build on the policy innovations that were created with federal COVID relief funds. They raised reimbursement rates for providers and increased compensation for providers, increased eligibility to serve more low-income working families, decreased or eliminated copayments, and addressed supply issues in under-resourced communities.
As COVID relief funds expired, state advocates worked for new state investments, and many were successful.
Among all states and D.C. surveyed, 20 percent reported a relatively small increase, and 41 percent reported a relatively large increase in state funding to improve quality and access to child care.* While the majority of new funds came through general revenues, a number of states used tax revenue, lottery funds, or other sources to support their child care systems.
Earlier this year, the Alabama legislature passed the largest ever single year increase in funding for early care and education. The Alabama School Readiness Alliance, a coalition of business partners, parents, providers, philanthropy, and other advocates worked to make a strong case for the need for increased investments in the ECE system. With funds from the State Education Trust Fund, the state will increase funding for the Alabama Quality Stars Quality Rating and Improvement System for Child Care by $30 million.
Several states supported supply building efforts through new funding sources. Colorado continued the Child Care Contribution Tax Credit, which allows any taxpayer who makes a monetary contribution to promote child care in the state to take an income tax credit that is equal to 50 percent of the total value of the contribution. The act extends the long-standing credit for three years. Similarly, the state budget in Indiana includes $250 million for a tax credit that will help small employers recover up to 50 percent of the cost of starting their own child care facilities for employees, with a cap of $100,000. Oregon allocated
