The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programme in the US
The Patient Protection and Affordable Care Act, generally known as the Affordable Care Act (ACA) or ‘Obamacare' passed into law in March 2010. “The ACA created the first nationwide Maternal, Infant, and Early Childhood Home Visiting (MIECHV) programme, which allocated federal grants to states, tribal organisations, and non-profit organisations to support evidence-based home visiting services for at-risk pregnant women and parents with young children up to kindergarten entry. The [programme] targets communities with the highest need.” 
The MIECHV programme is “one of the most innovative government programmes ... Social workers, parent educators, or registered nurses to low-income families with pregnant mothers and babies in the home. The visitors provide health check-ups and referrals, parenting advice and guidance with navigating other government programmes”.  Its principal objectives are to:
- Improve coordination of services for the at risk communities.
- Identify and provide comprehensive services to improve outcomes for families who reside in at-risk communities.
The programme is administered by the Health Resources and Services Administration's (HRSA) Maternal and Child Health Bureau in collaboration with the Administration for Children and Families (ACF). Since 2010, HRSA has awarded grants to 47 state agencies, the District of Columbia, 5 territories, and 3 non-profit organisations. It is alternatively known as the federal home visiting programme.
In the 2000s, many parts of the US suffered from high rates of infant mortality, disadvantaged children living in poverty, low-weight births, and births to teenage mothers.
Scientific research had shown that there were ways of reducing the risks associated with birth and early childhood in these low-income areas. “Home visits by a nurse, social worker, early childhood educator, or other trained personnel during early parenting improve the lives of children and families by preventing child abuse and neglect, supporting positive parenting, improving maternal and child health, and promoting child development and school readiness.” 
The public impactThe MIECHV programme has provided more than 1.4 million home visits since 2012. According to a March 2016 report to Congress, “MIECHV-funded programmes provided nearly 750,000 home visits to 115,545 participants in 2014. The programme served one-quarter of US counties and approximately one-third of at-risk communities (274 counties)”. 
The federal government, along with state and local governments, are the major stakeholders in the MIECHV programme. The main department of state engaged is the Department of Health & Human Services. The main stakeholding agencies are the HSRA and the ACF.
The federal government supported the programme by incorporating it in the ACA and allocating USD1.5 billion. In addition, “Congress authorised an additional $400 million for fiscal year 2015”. 
Both main political parties were convinced of the merits of the MIECHV programme, “Partly because of the growing evidence for the efficacy of home visiting programme, politicians from both sides of the aisle have seen it as a good public investment ... MIECHV itself had bipartisan support: Senator Bond and Senator Hillary Clinton introduced it in 2009.” 
This commitment has been demonstrated by the ACA legislation, which allocated USD1.5 billion to the programme and by Congress's additional funding in 2015.
In general, the American public has moderate confidence in public health, with 17 percent of Americans strongly confident in the medical system and 22 percent quite confident, according to a 2016 Gallup poll. This is roughly comparable to its confidence in the Supreme Court and organised religion. However, it is relatively low compared to the military (41 percent strongly and 32 percent quite confident).
The ACA has polarised the American public, with opponents slightly outnumbering proponents. “Disapproval of the law, which has generated public opposition from its outset, is up four percentage points since July. Approval of the ACA now stands at 44%, down slightly from 47% this summer. Since early 2013, those opposed to the law have consistently outnumbered those in favour by varying margins.”  However, there is no evidence available as to public opinion on this specific initiative, and the lack of confidence in the ACA is more likely to reflect highly publicised changes to health insurance provision than home visits.
Clarity of objectives
The objectives of the MIECHV programme were clear and precise and targeted the desired outcomes. The immediate objective was to make more home visits to at-risk families with infant children. This was intended to contribute to six social goals :
- Improved maternal and newborn health.
- Prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits.
- Improvement in school readiness and achievement.
- Reduction in crime and domestic violence.
- Improvements in families' economic self-sufficiency.
- Improvements in the coordination and referrals for other community resources and supports.
Strength of evidence
Programmes based on home visits to new mothers had been conducted in the US before the MIECHV programme was set up, and the government looked at various programmes that existed around the country. “The … programme builds upon decades of scientific research showing that home visits by a nurse, social worker, early childhood educator, or other trained personnel during early parenting improve the lives of children and families by preventing child abuse and neglect, supporting positive parenting, improving maternal and child health, and promoting child development and school readiness.” 
It is unusual in the degree of emphasis it places on research. “The MIECHV programme has an unprecedented focus on evidence and evaluation. Participating administrators and home visiting programmes must use existing research about ‘what works', while being given space to develop new approaches.” 
One of the main sources of evidence was the Home Visiting Evidence of Effectiveness (HomVEE), which wa launched in 2009 to conduct a thorough and transparent review of the home visiting research literature. “HomVEE provides an assessment of the evidence of effectiveness for home visiting programme models that target families with pregnant women and children from birth to kindergarten entry (that is, up through age 5).” 
The MIEHCV programme has legal force, being created under the ACA. Its financial feasibility has been addressed under successive tranches of federal funding.
The HomVEE research validated the home visiting model as a means of achieving social benefits. The economic benefits were addressed by a number of studies, including one by the RAND corporation in 2005 “that examined the benefits and costs of various early childhood interventions, [and found that] when results are combined across multiple evaluations of home visiting programmes ... home visiting programmes are estimated to generate about $6,000 in net benefits per child, or $2.24 for every dollar invested”. 
The study concluded that the social benefits also led to economic benefits for the government: “importantly, changes in the lives of women who participated in the Nurse-Family Partnership programme - such as fewer months spent on welfare and increased tax revenues as women entered and remained in the workforce - accounted for much of the program's net savings to the government.” 
At the federal level, the programme is administered by the HSRA and ACF on behalf of the Department of Health & Human Services. The major task of these agencies is to disburse funds to the states after checking the robustness of the proposed models in each target state or counties. In addition, the management system envisages regular data gathering in order to assess the effectiveness and also to propose changes.
Much of the management support for the programme was given by Technical Assistance (TA) providers to organisations that received state funding to implementing the MIEHCV programme. “TA providers worked collaboratively with HRSA and ACF ... to meet each state grantee's individual needs and priorities. The developers of home visiting models have also been crucial partners in providing training and TA to grantees and LIA staff on programme administration, implementation, data collection, performance monitoring, and sustainability.” 
This has led to a greater effectiveness and efficiency of the programme. “In comparison to the first year of data collection in fiscal year (2012, in FY 2014 state grantees tripled the number of home visiting programme participants (115,545 participants) and quadrupled the number of home visits provided (746,303 home visits).” 
There are already positive reports on MIECHV home visits from 17 US states, from Arkansas to Utah. “In 2015, 17 [programme] grantees ... reported developmental/ behavioural screening rates of at least 75 percent, more than twice the national average of 31 percent in 2011-2012.” 
It has been established that quality home visiting programmes can have positive impacts on child and family outcomes. Three studies reported net taxpayer savings, through fewer emergency room visits, lower utilisation of child protective services, and increased tax revenue as a result of higher parental earnings. The following parameters are also used in analysing the value of the MIECHV:
- The number of injuries among infants up to the age of 50 months.
- Delayed childbearing among target population.
- Better test scores among children in the target population.
- Lesser requirement of welfare measures offered under the program as time progresses.
The federal government, along with state and local governments, were well aligned in supporting the MIECHV programme. The federal Department of Health & Human Services was aligned with the main actors, the HSRA and the ACF. The individual states were responsible for using grants from federal bodies to implement the programme at state level with support from external actors such as Medicaid and socioeconomic and medical NGOs.
For example, the Centre for Medicaid & CHIP Services and the HRSA “have been working collaboratively to inform states about resources available to help them meet the needs of pregnant women and families with young children, specifically with respect to home visiting services”. 
The services and individual visitors that carry out MIECHV home visits, such as educators and social workers, support at-risk mothers “by assisting them in accessing services and learning the necessary skills to raise children who are physically, socially, and emotionally healthy and ready to learn”. 
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