4

Potential Policy Challenges and Opportunities

The early childhood workforce includes people employed in a variety of roles and in different types of settings, all working on behalf of young children, said Jacqueline Jones, the president and chief executive officer of the Foundation for Child Development and session moderator. There is now an extraordinary effort by those in the early childhood field as well as those in the philanthropic community and government to better understand the needs of the early childhood workforce and to support them through professional learning opportunities and improved compensation, Jones said. The early childhood workforce is generally poorly compensated, which presents challenges for maintaining staffing. Every state has a set of competencies for early childhood teachers, Jones said, but the requirements vary from state to state. There are two national certifications in the field of early childhood education, the Child Development Associate credential for entry-level teachers and the National Board for Professional Teaching Standards for accomplished teachers. However, Jones added, in the middle tier, which accounts for most of the early childhood workforce, there is no national certification that defines what should be known and what skills should be required.

In this session the panel considered policy challenges and opportunities at the intersection of early care and education and health as they relate to such issues as finance, workforce, and equity. Marcy Whitebook, the director of the Center for Study of Child Care Employment at the University of California, Berkeley, who spoke remotely via phone, described the early care and education system in the United States, including work-

force and economic issues. Rolf Grafwallner, the program director for early childhood initiatives at the Council of Chief State School Officers, discussed incorporating social-emotional learning (SEL) into state policies and into school and early childhood curricula. Gloria Higgins, the executive director of Executives Partnering to Invest in Children (EPIC), discussed opportunities to engage the business community in supporting early care and education. Aly Richards, the chief executive officer of the Permanent Fund for Vermont’s Children, described the various approaches being used to reach the organization’s goal of high-quality, affordable early care and learning for all who need it in Vermont by 2025. Finally, Danielle Ewen of EducationCounsel, LLC, discussed intentional and opportunistic approaches to changing policy and practice at the intersection of early care and education and health.

Following the presentations and discussion, participants moved to the adjacent gallery to reflect on the panel discussion with other attendees and to consider specific questions that were posed on posters around the gallery. After the participants reconvened in plenary session, a discussion of the responses to the questions was moderated by Paula Lantz, the associate dean for academic affairs and a professor of public policy at the Gerald R. Ford School of Public Policy of the University of Michigan. (Session highlights are presented in Box 4-1.)

POLICY HIGHLIGHTS AT THE INTERSECTION OF HEALTH AND EARLY CARE AND EDUCATION¹

The current early care and education system in the United States is less than optimal, Whitebook said. The scientific evidence about human development, early experiences, and long-term health outcomes that has been amassed over recent decades underscores the individual and societal long-term consequences of tolerating what is a suboptimal and, in many ways, dangerous status quo for some children, she continued. From its inception, the Head Start program has considered the health needs of children and has seen that those needs went hand in hand with the educational focus of the program. That is not the case for most early care and education services, however. The health and well-being of early education teachers is also fundamental to the quality of their teaching, but many experience burnout and other occupational health and safety issues.

There are clear areas of progress, Whitebook said, but there are systematic barriers to efforts to coordinate between health and early child-

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¹ This section is the rapporteur’s synopsis of the presentation by Marcy Whitebook, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.

hood care. As a case example, she described First 5 California, an initiative to improve early childhood outcomes in the areas of health and nutrition, early literacy and language development, high-quality child care, and smoking cessation. The program was launched in 1998 and is funded by a voter-approved tobacco tax. First 5 California brought together health and early childhood practitioners from every county to determine how best to use the resources from the tobacco tax. An immediate challenge, Whitebrook said, was that the different disciplines had long been siloed, and there was a lot of “talking past each other.” This stemmed, she said, from the complexity of each discipline, socialization and terminology that differed from profession to profession, and differences between the institutions where services were delivered. Communication was further complicated by different assumptions and different levels of status and authority. Although progress has been made, Whitebrook said, these

issues still need to be taken into account when those from different disciplines work together today. The First 5 California collaboration was strengthened by shared issues, she said. Both the health and the early childhood communities had tended to divorce child policy issues from their wider environment of relationships. Together they began to craft more multi-generational approaches. There was a focus on co-location of services, bringing mental health and other health practitioners into child care centers and homes, and thinking more holistically about the families and the communities in which children develop. In the process, Whitebook said, each discipline gained more respect for and understanding of the unique contributions made by other disciplines.

U.S. Early Care and Education System

The benefits of high-quality early care and education are often discussed in terms of “how it can ameliorate the effects of poverty, level the playing field for young children, provide support to families, and promote healthy behaviors and development,” Whitebook said. Those promises are coming to fruition in most other industrialized countries, Whitebook added, but despite tremendous effort, most children in the United States are not experiencing those benefits. Too often, she said, the design and financing of the U.S. early care and education system causes poverty for many families because of the cost. The system may ameliorate the cost burden for some families, but not for all who need help. The way that the early care and education system is structured reinforces and sometimes accentuates inequities, Whitebook added, because children do not necessarily have equal access to high-quality services. Economic stress undermines the health and well-being of the adults in children’s lives, including their parents, as well as of the poorly paid teachers and care providers.

An underlying cause of the state of early care and education is that the United States does not have a system of early care and education in which the government, either national or state, has assumed leadership responsibility for ensuring that services are available, affordable, and of high quality for all children and families. Early care and education is not defined as a public good in the same way that K–12 education is, Whitebook said. Rather, it is usually considered a private family responsibility. The structure assumes that the demand for early care will be met by a diverse and centralized private market. This structure contributes to inequity, Whitebook explained, because those with a greater ability to pay typically obtain the best services in a private market. In essence, early care and education has been monetized and is treated as a commodity. Except for in a handful of communities, she said, early care and education is not treated as part of the infrastructure of the educational system.

The federal government does intervene in the market on behalf of low-income families by offering each state a limited public subsidy based on the size of its low-income child population, Whitebook said. There are not enough resources, however, and only a fraction of children who qualify for subsidized child care are currently receiving it. For example, in 2014, 6.4 million children under the age of 6 lived in low-income working families, but only 1.41 million received a child care subsidy. Similarly, there is limited provision of state-funded public preschool, and less than half of the children who qualify for Head Start nationally are being served. Whitebook said that the United States devotes a much smaller percentage of its gross domestic product than other industrialized countries to early childhood services (see Figure 4-1). The United States also puts a smaller amount of its gross domestic product into health services than other industrialized countries. As a result, early childhood services are under-resourced compared with those in many other countries.

Impact of Early Care and Education on Health and Well-Being

Whitebook noted that much of the conversation in the early care and education field has focused on the types of qualifications that should be required of people working with young children (e.g., foundational knowledge of early development, bachelor’s degree with specialized training). The 2015 Institute of Medicine (IOM) and National Research Council (NRC) consensus report on transforming the early childhood workforce also highlighted the importance of the well-being of the adults in children’s lives, she said. The day-to-day interactions between caregivers and young children builds the initial architecture of the children’s brains and establishes their patterns of thinking and feeling. As such, the health and well-being of the people providing those early experiences are critical, Whitebook said. The IOM and NRC consensus report states the following:

The Economics of Early Care and Education

Early care and education policies in the United States can create stress for parents from the start, Whitebook said. In addition to the stress of arranging and paying for child care, most parents do not have paid family leave. They are left to choose between leaving their babies in care at a very young age or losing job security and income during this crucial period for the family. The burden is greatest on low-income families, she said. The cost burden for families is significant. Fifty-four percent of families pay more than 10 percent of their income for child care. In 32 states and the District of Columbia, center-based infant care costs are greater than one-third of a typical preschool worker’s earnings. For child care teachers who are also parents of young children, the stresses brought on by their low wages and high care costs are even greater.

The lack of sufficient financing of subsidies for early care and education means that rates for care are usually held low, so that more children can be served, Whitebook said. Because so many parents have difficulty covering the cost of care, there is significant market pressure to keep the cost low as well. It is the early care teachers who end up assuming the burden of this lack of financing through their low wages. The 2015 IOM and NRC workforce consensus report emphasized that most early educators suffer from deeply substandard compensation, which fails to reward their investments in education and

training and which ultimately threatens their well-being. Whitebook told participants that a related National Academies study on financing high-quality early care and education in the United States is currently under way.²

Educational interventions during the early years have the highest returns on investment because they provide the highest returns on learning, Whitebook said. The compensation structure of the early care and education system is inverse to the brain development curve (see Figure 4-2). People often assume that wages are low because those workers have not invested in education and training. Actually, about one-third of

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² Information about this National Academies consensus study and resulting report (released in 2018) can be found at http://sites.nationalacademies.org/DBASSE/BCYF/Finance_ECE/index.htm (accessed accessed August 9, 2018).

the early childhood workforce (including those working with infants and toddlers in center-based care) have college degrees. Of those working with 3- to 5-year-old children, close to 40 percent have college degrees.

Whitebook said that much of the conversation in the early care and education field has focused on the types of qualifications that should be required of all people working with young children (e.g., foundational knowledge of early development, bachelor’s degree with specialized training), while little attention has been focused on the need for professional support and appropriate financial rewards.

Wages for some early care and education teachers are very low compared to wages for teachers working with kindergarten age and early elementary age children, Whitebook said. In 2012 the average annual salary for an early care and education teacher with a bachelor’s degree or higher was about $27,000 for those working with children ages birth to 3 years and about $29,000 for those working with ages 3 to 5 years. Public pre-K teachers and school-sponsored pre-K teachers fared better, at about $34,000 and $43,000, respectively. Kindergarten and elementary teachers earned about $53,000 and $56,000, respectively.

As a result, economic insecurity is a significant concern among those in the early care and education workforce, Whitebook said. Forty-six percent of child care workers participate in some kind of federal income support (e.g., the Earned Income Tax Credit, Medicaid, food stamps), and many receive state- or local-level subsidies (e.g., child care subsidies, housing support). Many also hold down second jobs. Whitebook mentioned a study from several years ago in which teachers were asked to rate what they worry about and their level of financial security through their job. The resulting data showed that those who were earning more were worrying less, which is not unexpected, Whitebook said. People with more education worry less than those who do not have as much education (which is likely related to earnings). However, a substantial portion of people with degrees were still worrying about their monthly bills and providing food for their own families, and the worry was greater for those with young children.

An important skill for teachers, Whitebook said, is the ability to have intentional interactions with children. This requires them to remain focused and present in the moment. Economic insecurity can cause significant stress and can distract teachers from focusing on children’s needs. That stress, brought on by low pay and inadequate benefits, can be exacerbated by job conditions (many responsibilities, little down time, physical demands, etc.) and job instability. Whitebook mentioned the work of Megan Gunnar of the University of Minnesota, who has said that to be a good preschool teacher, one must have good executive function, but stress affects the areas of the brain and the capacities that teachers need to be most effective. Whitebook also referred participants to a study by

Whitaker and colleagues, which found that signs of poor physical and mental health occurred at a much higher rate among Head Start staff in Pennsylvania than among others in the United States with comparable sociodemographic characteristics (Whitaker et al., 2013).

In closing, Whitebook quoted the IOM and NRC workforce consensus report as saying that

Society in turn has a great responsibility to these early childhood teachers, of whom so much is expected, but to whom so little is given, Whitebook said. Maintaining and developing better health for children and families requires the expertise and the support of these professionals.

EMBEDDING SOCIAL-EMOTIONAL LEARNING INTO STATE POLICIES

Grafwallner began by pointing out that Brotman’s discussion of ParentCorps and its emphasis on self-regulation, Askew’s description of early childhood mental health consultation in New York City, and Whiteman’s and LeMoine’s overview of the workforce competencies needed to support children’s healthy development all have one common topic—ensuring children’s ability to have equitable access to SEL opportunities. The Council of Chief State School Officers (CCSSO) has been working with the Collaboration of Academic, Social, and Emotional Learning to incorporate aspects of SEL into schools and early childhood programs. Language in the Every Student Succeeds Act (ESSA) (the latest iteration of the Elementary and Secondary Education Act) provides an opportunity for a stronger emphasis on “soft skills” (i.e., SEL) to be incorporated into the ESSA plans, including into accountability plans. Over the last year, most of the chief state school officers have been focused on developing and implementing ESSA plans in their states.

Competencies of SEL

The competencies of SEL, Grafwallner said, include self-awareness (i.e., the identification of emotions and self-confidence); self-management skills (e.g., self-regulation, impulse control, self-motivation, goal setting, organizational skills); responsible decision making (making choices based

on respect and empathy for others); relationship building (social engagement); and social awareness (identifying problems and being able to solve them) (for more information, see Gayl, 2017).

These competencies apply to early childhood education as well as to K–12. Interestingly, Grafwallner said, the research on these skills is extremely rich and robust for early childhood education, but there is a dearth of research on SEL in elementary and secondary education. A question that needs attention, he added, is how to sustain work on SEL competencies beyond early care and education and on through K–12.

ESSA Plans

ESSA calls for integrating SEL into “well-rounded education.” Grafwallner discussed several aspects of the ESSA plans that CCSSO works on and provided examples of actions that states are taking.

How do states define well-rounded education in their plans? States define SEL skills to reflect children’s need to understand and manage emotion, set goals, and build positive relationships. Illinois, for example, has established pre-K to grade 12 SEL standards, and the implementation of these standards is supported by integration into multi-tiered support systems (MTSSs) in public schools. Grafwallner said that five other states are also in the process of establishing standards.

How is SEL represented in the plans? States can provide professional development on SEL competencies. For example, Massachusetts is including sustained professional development for teachers and guidance to local school districts and schools on how they can incorporate SEL into their curricula.

How is SEL being implemented and operationalized? State education agencies have programs to support the behavioral needs of students, such as positive behavioral interventions and supports (PBISs), MTSSs, and wrap-around services. There is an emphasis on supporting students on all fronts, Grafwallner said. Delaware is working with low-performing schools in high-need communities to establish more comprehensive services for early childhood mental health support, with wrap-around services to sustain support through the primary grades.

Finally, how is SEL connected to the various issues related to accountability for schools? For the first time, ESSA has given states the opportunity to evaluate soft skills (i.e., not academic skills) to help identify low-performing schools and to also consider other areas that are very important to families and parents. State accountability systems may now include indicators of school quality, such as school climate or school discipline (e.g., suspensions). States are promoting alignment of early childhood mental health consultation with PBIS or MTSS for K–12. As an

example, Iowa is establishing data systems to follow a variety of indicators (e.g., emotional safety conditions) using the Safe and Supportive Schools Condition for Learning Index. These states are trailblazers, working to sustain SEL across the board, Grafwallner concluded.

PARTNERING WITH THE BUSINESS COMMUNITY

There are many opportunities for collaboration to apply early childhood learning to improve public health. Higgins shared a figure from the 2014 roundtable workshop that illustrates potential health and development trajectories from early childhood to later life as well as the impacts of both stressors and interventions, including education, on a child’s trajectory (see Figure 4-3). She emphasized the need to broaden the audience of individuals and organizations that participate in these collaborations and discussed the role of the business community. EPIC, she said, is a business advocacy organization that works to enlighten the business community, at the highest levels, to be aware of the importance of early childhood education, and get the community to engage.³

Employers, whether public, private, or government, are very motivated to support early childhood education, Higgins said, and she encouraged participants to engage with the business community and business leaders. There are some businesses that are very generous, philanthropic, and community-minded, she said. Most, however, have arrived at a position of “enlightened self-interest,” realizing the impact that early childhood education has on the future availability of skilled employees. She noted that the millennial generation is entering the workforce, and she said that they have different commitments and needs from their employers. Another aspect that businesses have come to recognize is the costs due to employee child care challenges. Statistical analysis can estimate the costs of child care–related absenteeism, staff turnover, lost productivity, and inability to fill open job positions. In some cases, employers are willing to make a commitment to help support early care and education in a way that makes sense to them and their business.

There are other motivations for the business sector to become engaged in early care and education issues, Higgins said. In particular, there are tax-advantaged opportunities, such as tax credits or tax deductions, which are ways to share the cost of partnering to support early childhood education. Higgins offered these three examples:

1. The Cafeteria Plan (under Section 125 of the Internal Revenue Code) allows employees to choose from a menu of benefits to

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³ See http://www.coloradoepic.org (accessed October 30, 2017).

2. create a package that is best for their needs and to pay for those benefits with pre-tax income (e.g., health care, flexible spending accounts to pay child care expenses). This results in tax benefits for both employee and employer. Higgins said that these types of benefits can be very beneficial for the significant share of working-class individuals who could be defined as working class poor.

3. Dependent Care Assistance Programs (under Section 129 of the Internal Revenue Code) allow employers to contribute to an employee’s child care cost through the Cafeteria Plan mechanism, up to $5,000 per year. The employee receives that benefit income tax free. Higgins noted that the total annual contribution for the child care flexible spending account is capped at $5,000, which dates back to a 1982 law. She is currently advocating that the cap be updated to adjust for inflation.
4. The Colorado Child Care Contribution Tax Credit (a Colorado statute) provides a 50 percent tax credit for qualified contributions to child care programs. For example, if an employer has many workers who use a particular child care center and the employer chooses to support that center, the employer will get a Colorado tax credit for half of what it donates.

EPIC advocates at the federal level and at the business level for family-friendly workplace policies, Higgins said. At the business level, the goal is to enlighten employers about ways they can support work–life balance for their employees by providing simple solutions at low cost to the employer. Such solutions might include flex time, job sharing, or perhaps combining funding sources (vacation time, sick time, disability insurance, corporate generosity) to maximize paid, or partially paid, maternity or paternity leave.

In conclusion, Higgins said, EPIC works to engage businesses and to allow them to use their voice, at the policy level and the workplace level, to make a difference for their employees.

HEALTH CARE AND CHILD CARE INTEGRATION

The Permanent Fund for Vermont’s Children is the largest nonprofit organization for early childhood work in the state of Vermont, Richards said.⁴ Vermont is a small state, with a population of about 626,000 and an annual state budget of $5 billion. About 6,100 babies are born each year. Vermont is very rural and has deep pockets of poverty. There are also areas of great diversity, Richards said, and 45 languages other than

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⁴ See http://www.permanentfund.org (accessed October 30, 2017).

English are spoken in the Burlington-area school district. The state is using its small size to its advantage, working to break down silos and grow partnerships.

When the Permanent Fund was founded in 2000, it worked on adult-to-child mentoring and small, early childhood grants. Over the years it became more sophisticated, and several years ago all of the diverse funding was pulled together into one collaborative. The intent was to use philanthropy as an agent for sustainable, permanent change, Richards said. The Permanent Fund chose the most ambitious, but achievable goal it could identify and established a deadline. That goal is high-quality, affordable early care and learning for all who need it in Vermont, and the deadline is 2025. The entire endowment is committed to achieving this goal by this date, she said, and then the Permanent Fund will “go out of business.”

It is not possible to accomplish such a huge societal change without linking to health care, Richards said, and the Permanent Fund is working on integrating health care and child care. The health community in Vermont is moving to a fee-for-outcomes payment system and a focus on prevention. Most children are in some form of out-of-home care, and an accessible, high-quality, affordable system of care could provide both a safe environment for children and a huge population for primary prevention activities. This would also be a cost-effective, streamlined platform on which to co-administer other health services.

Stakeholders from all sectors in Vermont are coming together to discuss issues of importance for the state, such as caring for today’s workforce, training tomorrow’s workforce, curbing health care costs, the developmental origins of health and disease, opioid abuse, and resiliency. Brain science has shown that significant brain architecture is built early in a child’s life. The return on investment from early childhood development interventions is clear. And yet, Richards lamented, the pattern of actual spending is exactly opposite to the return on investment—in Vermont and everywhere else. In Vermont the public investment per child for infants and toddlers (age 0 to 2 years) is $903; for preschoolers (age 3 to 5 years) is $3,578; and for school-aged children (6 to 19 years) is $18,000.

The logical conclusion from this reality is simple: invest now or pay more later. A supply-and-demand analysis revealed that seven out of ten children under age 6 in Vermont have all available parents in the labor force, which means that they are likely to need some form of child care while a parent is working. Of these children likely to need child care, 47 percent of infants and toddlers do not have access to regulated child care, and 70 percent do not have access to high-quality, regulated child care. Furthermore, Richards said, child care is not affordable. The cost of child care, without subsidy, accounts for 40 percent of the gross household income of a single parent at median income.

The approach to tackling these issues includes public awareness, policy, and research and development innovation incubators, Richards said. She briefly described several initiatives the Permanent Fund is working on, including Vermont Birth to Five, which is focused on strengthening quality and systems, and the Let’s Grow Kids public awareness campaign. One example of linking health care to child care is work the Permanent Fund has done with the health care system to have the medical community train child care providers to conduct developmental screens and referrals. They have blanketed the entire state, and child care providers in every region of the state have now been trained, she said. In addition, trust and communication have been built between these sectors.

CHANGING INSTITUTIONS AND THEIR CULTURES

At its core, improving population health by leveraging early childhood care and education is about institutional change and about changing institutional cultures, Ewen said. Everyone in attendance is all working at the intersection of early care and education and health, she continued. Regardless of position or title or program, people working in early childhood education should be considering health to improve outcomes for children, and people working in health should be considering early childhood education to improve outcomes for children. Everyone is a potential partner in this work. Child care providers, schools, pediatricians, family practitioners, community health workers, trainers and those in workforce development, workers in welfare offices, and those working on domestic violence, bullying prevention, and gun violence prevention are all part of the conversation about early care and education and health. There are roles for the public, policy makers, political leaders, and the private sector (business community, foundations). The philanthropic community, for example, can lead the way by funding data collection, pilot programs, communication strategies, and advocacy activities.

Ultimately, this issue is about assuring equity for children, Ewen said. Assuring equity for early care and education providers is also a core principle. Ewen emphasized that all voices are relevant and have a role in these collaborative conversations, from the executive directors of the largest organizations to the family child care providers serving children and families with special needs. It is also time, she said, to think differently about what outcomes matter at the intersection of early care and education and health. Efforts to close the achievement gap have long focused on language and math skills, but the achievement gap also stems from health and developmental factors.

Ewen offered several examples of changing policy and practice at the intersection of early care and education and health, which she presented

in two categories: the intentional creation of new programs, practices, and policies; and seizing opportunities to “get on the train that is leaving the station.”

Intentional Creation of New Programs, Practices, and Policies

Intentionality, Ewen said, is building a system, putting the pieces children need into it, and then seeing what happens. One example of intentionality is the universal pre-K program in New York City. A key component of the Pre-K for All program was building developmental screenings of all children into the program design. Early care providers have the resources and training to conduct developmental screenings. There is a process for tracking screenings, and there are now several years’ worth of data available. The data show an increase in children being referred for supports and early intervention and also some specific health outcomes, including a significant decrease in asthma among young children. Asthma, Ewen noted, keeps a large number of children out of school. If these children can be identified and given the medical resources they need, they can stay in school and have a better chance at success. Head Start (discussed by Shinn-Brown in Chapter 3) and the SEL standards required by ESSA (discussed by Grafwallner) are other examples of intentionally creating new programs, practices, or policies that bring health and early education together.

Get on the Train That Is Leaving the Station

Good advocates often find ways to incorporate their issue into existing initiatives, Ewen said. Many communities are very invested in data collection. One example is the Early Development Instrument to measure school readiness (mentioned by Groginsky in Chapter 3), which is being implemented in a number of communities around the country. How can the volumes of data being collected be used to understand which children have access to high-quality early care and education in a community, where the family support programs are in that community, or where the pediatricians are in that community? How can these data be leveraged to create a community that is more supportive of children and families?

There are many opportunities to get on the train, Ewen said. Many communities, for example, have funders that want to build playgrounds, but if nobody uses them, they are of little value. There is an opportunity when those resources are being planned and built to bring policy makers together to make sure that children will be able to use them. In every state, children with disabilities who are in school systems are being assessed on a series of outcome measures. In many school districts and programs

that are serving young children with disabilities (infants, toddlers, preschoolers), those outcome measures are only looked at for that population. How can those policy levers be pushed to expand those outcome measures to all children and their families? The Head Start program is required to conduct developmental and other screenings (e.g., hearing, vision). Often those screenings are donated. How can those screenings be provided to all children before they enter kindergarten?

Ewen concluded by emphasizing that a small group of people can come together around a common goal and make a big change in public perceptions. The DC Public Libraries had heard about the word gap research and saw an opportunity to use some of their public service money to educate families about how communicating with their children builds their vocabulary. They launched a public awareness campaign, and now, for example, people riding in a taxi cab in Washington, DC, will hear a public service announcement about Sing, Talk, and Read. Ewen encouraged participants to make sure that every action they take is about bringing early care and education and health together.

DISCUSSION

During the open discussion that followed the panel presentations, participants discussed the cost of providing high-quality care, from economic analyses and funding to the training and compensation of staff. Participants were particularly interested in the forthcoming National Academies consensus study on financing early care and education with a highly qualified workforce (mentioned by Whitebook, earlier). There was also interest in further information about the tax credits for businesses discussed by Higgins.

Paying for Quality

Kindig asked about any economic analyses in the early care and education sector that might help identify targets and whether excess spending in health care might be reallocated to meet some of the needs. Ewen responded that there are cost analyses of, for example, child care, universal child care, and universal paid leave. The costs of pre-K programs for all 3- and 4-year olds have been analyzed in DC and New York—the figures are large, and there are tradeoffs. She observed that there are many cultural and political reasons why people do not want to invest large sums of money in early childhood care and education. And even if additional investment in Medicaid does not increase affordable child care, it is worthwhile because it can be used to create preventive systems that serve mother and baby together. She emphasized the need for uni-

versal child care in the United States, arguing that child care should be considered a public good, similar to K–12 education, and should be paid for in the same way. Richards added that one way to move a huge public policy issue forward is to have a public body talk about it. The Vermont legislature established the Blue-Ribbon Commission on Financing High-Quality, Affordable Care, which over a period of 1.5 years held public discussions on the costs of providing high-quality early care for those who need it. They concluded that an additional $206 million per year would be needed to provide high-quality care for the 70 percent of the population likely to need care. That might sound small, she said, but for a state with a $5 billion budget, it is significant. The numbers and details are needed for advocacy efforts, she said.

Participants discussed the ongoing National Academies study on the cost of high-quality early care and education. Helene Stebbins of the Alliance for Early Success said that it will be important for advocates to get together in preparation for the release of the report in order to begin to gather support for and take action on the findings and recommendations. Richards emphasized the importance of working with the business community, adding that it is easier to justify public investment if it can be demonstrated that the private and philanthropic sectors are already doing their parts. She also spoke of the need for shared services and creating economies of scale around the micro units of child care providers in order to demonstrate efficiency to legislatures when seeking money. Finally, she said, it is very effective to explain that 100 percent of this money goes to people; it is not just for buying things. Jones agreed and said that the National Academies study is based on the notion that high-quality care is provided by well prepared, well trained, well compensated teachers. The cost of quality is due to the cost of having teachers with appropriate compensation and appropriate skills. Others agreed with the need to be prepared for the release of the report and to create momentum concerning the recommendations. Jones said that perhaps that is a charge for the workshop participants.

Marthe Gold asked about the level of training needed and the salaries required to ensure a high-quality workforce for early care and education. Jones, who was a member of the National Academies consensus committee on transforming the workforce, said that a well-prepared workforce would have a wide range of competencies related to child development, partnering with parents and other professionals, and other skills and might perhaps require a bachelor’s degree or higher. She noted that the Boston Public Schools preschool program requires teachers to have a master’s degree. The field must reach the point where it is acknowledged that this work is real, that training is required, and that compensation must be appropriate. Ewen emphasized that there will be a wide range of

skills, all of which are professional. Someone caring for infants, for example, needs different skills, not fewer skills, than someone caring for 4-, 5-, or 6-year-olds.

Tax Credits

In response to a question, Higgins provided more details about the tax credits in Colorado. The tax credit has existed for nearly 20 years and is up for reauthorization again in 2018. Businesses are taking advantage of the credit, although the details of this are difficult to assess definitively as about 80 percent of businesses are small businesses that file their tax returns as partnerships. The Department of Revenue cannot identify the difference between an individual and a partnership because the cash flows through the business entity to the individual. About $50 million per year has been contributed to child care centers, which is a meaningful amount of money, she said. The money is very broadly used. For example, it can be used to open a new child care center, to pay salaries, to pay for scholarships for families, or to pay for scholarships for the workforce. Colorado has tried to pass tax increases that would benefit early childhood education, but taxpayers have not been willing to entrust the spending of their dollars to the state legislature.

GALLERY WALK REFLECTIONS

Participants were presented with four questions in the final gallery walk.

1. What are the main policy levers that could support the spread and scale of health/early care and education coordination?
2. What does it mean to be ready for spread and scale, conceptually and practically? Or, what are guiding principles for jurisdictions deciding how to support early care and education/health connections?
3. How can policy create incentives for cross-sector collaboration?
4. Can you offer any new insights?

After everyone had reconvened, Lantz summarized individual participants’ responses to the questions posed in the gallery and moderated the discussion. She recalled the point made by Whitebook that the way child care is set up in the United States is misaligned with what is well-understood about child development. Child care in the United States is, for the most part, a private market, and most people pay out of pocket for early care and education. The subsidies that are available are not reaching

all of those who need them. The market also pays a very low wage to its workers. This system reinforces and exacerbates inequalities for children and creates psychosocial and financial stress for families and caregivers.

As a demographer, Lantz observed that the U.S. system is not pronatalist in its support of families as are many other countries around the world. The number of women giving birth has declined, and fertility rates are lower. Rates differ according to socioeconomic status. In many countries, women with higher levels of education are not having as many babies. A country’s policies on support for families and young children affect birth rates, especially for women who are in the labor force. When countries have lower rates of reproduction, it alters the dependency ratio, which is the ratio of the number of children and older people (the dependent population) to the working-age population. Arguments about the need to invest more in children often seem to fall on deaf ears, Lantz said, or do not motivate the needed investments. In many countries, what has motivated policy makers to take more policy action in support of families and children has been the realization that there might not be enough children being born to support the population as its ages.

In reflecting on the comments that were made in the gallery, Lantz highlighted several main topic areas:

• Partnerships. Many of the comments posted called for investing in initiating and strengthening partnerships and collaborative approaches among the early care and education sector, the health sector, businesses, government, criminal justice, community organizers, and community members, to make the case for why more investments are needed and to develop specific plans. Lantz reported that one comment suggested looking to tobacco control and obesity prevention for successes from these kinds of partnerships and collaborations that could serve as models.
• Special issues and insights. Comments posted raised a range of topics and questions that had not yet been discussed at the workshop, including whether there is a role for respectful family planning to help women better plan, time, and space their pregnancies. Investments in this area might have positive impacts in terms of early childhood outcomes. Other topics raised included special issues for children in foster care, the impact of sleep on early childhood and development, and the impact of school absenteeism, Lantz reported. There were also comments about the community benefit investments required of nonprofit hospitals, including suggestions that early care and education be considered in every community health needs assessment.

• Social impact bonds. Lantz suggested that social impact bonds (pay-for-success financing) could be used to spread and scale interventions that would have a positive impact on early childhood development and population health. Chicago, for example, has a social impact bond initiative where private funders are investing in a pilot test of high-quality pre-K. The program is being evaluated, and the investors are receiving payments when success milestones are met.

Sources of Funding

During the discussion, a participant pointed out that South Carolina has a social impact bond for the Nurse–Family Partnership home visiting program and suggested that development issues, such as closing the word gap thorough talking and reading to children, could be incorporated into the visits. Robert McLellan of the Dartmouth-Hitchcock Medical Center pointed out that engaging private investors has been helpful in driving energy conservation and environmental sustainability efforts, as investors saw better returns from investing in energy efficiency than other marketplace efforts. Lantz suggested that there is a parallel between that example and social impact bond projects.

Following up on the point about hospital community benefit investments, Mary Pittman of the Public Health Institute said that much more money goes into the community from banks through the Community Development Fund. There are examples of investments in housing and transportation centers that have also had some linkage to education. She suggested exploring whether early care and education investment strategies could be incorporated into new initiatives from this fund.

Terry Allan of the Cuyahoga County Board of Health pointed out that some of the income from the Philadelphia sugar-sweetened-beverage tax is used to fund early childhood development and education programs. He noted that a similar tax initiative in Ohio in the late 1990s failed at the state level because the income was designated to go into the state general fund and was not tied to a specific use. Use taxes tied to a specific use, where there is a demonstrated need, appear to be more successful.

Chang said there is great potential for innovative funding in this area. She suggested, for example, urging the Center for Medicare & Medicaid Innovation to focus on children’s health.

Sustainability of Funding

Ewen said that piecemeal approaches will not secure the funding needed. About 15 states have done economic impact studies of how

much child care contributes to their state economy. In California, for example, child care is the third-largest generator of income to the state, after agriculture and tourism. Still, there have not been significant funding increases from the public sector in early childhood programs. The return on investment for early childhood investments ranges from $6 to $52 per $1 spent, depending on the study. She emphasized that sustainable approaches to funding are needed. During the last election cycle, for example, Ohio had passed a tax proposal to create 4-year-old pre-K programs. Although this is a great first step, she said, it is not clear if it will be sustainable (e.g., if it will need to be voted on periodically, or if it can be overturned). Various innovative and sustainable funding approaches are needed, including putting early childhood programs in school funding formulas and ensuring that tax policies pay for high-quality early care and education at the time when families need it. Lantz added that pay-for-success or social impact bonds are generally a proof-of-concept approach and are not themselves sustainable. The potential of the model is to fund innovative programs with private investor dollars to demonstrate to the government that a program or intervention is effective, at which point then government would assume financial responsibility for implementing such a program or intervention.