Mark Swartz: What’s the immediate outcome of the new law?

Allison Gilbreath: It will allow for local departments of to come into a formal partnership with kinship families for children who would otherwise enter foster care. And now, the local agency will be able to offer them financial compensation that will be similar to what a foster parent would receive, which is around $800 in Virginia, depending on the child’s needs. And they will also be able to offer continual services that a typical foster family would receive. It also provides some opportunities for the family of origin to be on a path to reunification with the child.

(VPM)

Swartz: What do you hope will happen in the long term?

Gilbreath: What I hope to see is that all localities start a true kin-first model, which is especially important for young children, because we know for the developing brain from 0 to 5, that attachment is extraordinarily important to their lifelong development.

Swartz: This has been a 10-year journey for you. Did you ever want to give up?

Gilbreath: Never, but the approach has been, “Let’s take bites of the apples over the course of years,” to get here.

Swartz: For example?

Gilbreath: Virginia passed the program in 2018, which was for a small minority of children who were already placed with relatives. It allowed them to stay there and allowed the families to receive some compensation.

(ChildTrends)

Swartz: What kinds of objections did you hear to kinship care?

Gilbreath: Legislators would tell us, “Well, that’s just what families should do. We shouldn’t be compensating them for what’s just the right thing.” And we had to spend a lot of time educating them on, “Doing the right thing and taking on a child that has thousands of dollars of expenses annually aren’t the same thing.”

Swartz: How would you describe the historical roots of the how kinship care was treated in Virginia?

Gilbreath: I think that there are systems of oppression that permeate every system of which we live in. Black children are disproportionately represented in our foster care system. And as a response, the foster care system has been built around white dominant culture. The majority of our foster parents in Virginia are white. It’s not because folks of color don’t want to be become foster parents. They’re doing this informal system of kinship care, and there hasn’t been support for what is inherently cultural to Black families.

Swartz: How does the system put obstacles in the way of would-be Black foster parents?

Gilbreath: In Virginia, we go far beyond the federal requirements to become a foster parent. The requirement that is probably most talked about is the drug offenses. Basically, if you were caught with a certain amount of marijuana 10 years ago, but you’ve done nothing since then, you can’t be a foster parent in Virginia, and that disproportionately impacts families of color.

Swartz: So, a Black family in the first place might not be inclined to apply to be a foster family because of cultural issues, but then even if they were, there are these barriers preventing them.

Gilbreath: That’s very much the case.

Swartz: What about compensation for the attorneys? What we’re talking about is a legal process. A judge decides where a child goes, and if a family can’t afford their own representation, they’re going to have an attorney appointed by the state. But lawyers aren’t exactly lining up for that role, because the pay is so bad.

Gilbreath: The compensation for attorneys in child dependency cases is $120 for the entirety of the case, which is mind-boggling when I say it, but I always have to repeat. It’s the entirety of the case. So it’s almost always attorneys who are doing it as a part of their pro bono docket, which means two things happen. One, there’s poor representation. (This isn’t a matter of attorneys who don’t care, but the pay is low and the process can be traumatizing.) Two, because of the lack of adequate representation, those families are less likely to know all of their rights. They often have children removed who didn’t necessarily need to be removed in the first place.

Swartz: You’re a parent as well as an advocate, and you’re also a professor, teaching a course called Power, Privilege and Oppression in the . How do you weave all those strands together?

Gilbreath: has taught me extraordinary patience — for myself, for my children, for the sector, for the work. As a mom, you put in so much time, energy, into your children. And most days you don’t see any of the fruit of that. You might for one minute of a day, but then there are these glimmers where your child does something. For me, this year, my son started kindergarten, and he started to read. And seeing all the years that we put in from 0 to 5, just to try to build the building blocks for him to read, but that was five years of not just myself, but a lot of other people in his life through early intervention, through his teachers, to help us get there.

Swartz: And you get to see another kind of progress with your students.

Gilbreath: I’ve been teaching this class for four years now, and it is really one of the coolest things to see a student who’s now in the sector, and is looking back and saying, Professor Gilbreath, “What you said in your class helped shape the trajectory of my career, or the way that I show up in this work.” There are some things that I want to see changed in our system that perhaps I’m not going to see the change. I’m just going to lay the seed, and wait for the next person to fulfill the harvest.��

Swartz: Did you have a mentor or somebody who inspired you, along the way?

Gilbreath: One I would like to acknowledge is . She doesn’t do policy at all, actually, but that’s the way it goes. She’s an author. She was one of the first people to tell me I was special, which I don’t think people hear enough. I still talk to her all the time, when I’m faced with a hard decision or something like that. And she’s still supportive.

“Enrollment was down,” explains Franklin County Commissioner Erica Crawley, “and they couldn’t pay teachers a competitive wage.”

The City of Columbus supported early educators with $250 signing bonuses and made 250 scholarships available for families. It was a start, Crawley says, but it wasn’t impactful. As an Ohio state legislator at the time, Crawley was elected to the county leadership role and that’s when things started happening.

“T��� first thing I did,” she recalls, “was meet with our , and they had a list of things to invest in. I said, ‘Cool, let’s do all of them.’” Activating $24 million in American Rescue Plan Act (ARPA) funds, Franklin County approved:

• Sign-on bonuses for new staff
• Nearly 600 child care scholarships
• Incentive payments to programs that serve low-income families or care for children during nontraditional hours
• Bonuses for programs that increase their ratings from Ohio’s system
• Subsidizing wages for providers through pilots with YWCA and the Childhood League

“ARPA allowed us to really come from behind and move ahead of the pack,” Commissioner Crawley says. “We’re showing what investment from the government can make possible.”

But Wait, There’s More

When an additional infusion of cash in January, Franklin County board president John O’Grady said, “Our region is expected to add more than 700,000 people in the next few decades, which won’t be possible or sustainable unless we find ways to support high-quality early learning centers and help make child care more affordable for families.”

All told, Franklin County will invest $42 million of its ARPA funds in child care by 2026.

“T��� initiative is showing other counties how to be bold and strategic in child care investments, and we are seeing to use their federal relief dollars to support children,” says Reginald Harris of the. “Commissioner Crawley, and other visionary leaders like her, play a critical role as champions for funding for kids.”

Commissioner Crawley’s personal experience as a struggling mother of young twins fuels her dedication to child care. “I was on government assistance after I had my children,” she recalls. “When I started working, I didn’t qualify for publicly funded child care and had to pay for child care out of pocket. Without my children’s godmother, I couldn’t have afforded the thousand dollars per month.”

She’s also seen the adverse consequences of under-investment. “What I learned 20-something years ago,” she says, “is that this is how we divert our kids from the criminal justice system.”�� On the morning we spoke, Commissioner Crawley had just come from an administrative hearing about building a 2,200-bed, billion-dollar jail. “What would that money do for our kiddos that are 0 to 5? It would change their trajectory,” she asserts.

Little and Incredible

For Rae Stewart, founder of in Columbus, that money made the difference between closing down and thriving. “That sign-on bonus definitely helped get a lot of people in the door,” she says. “And if families tell me they don’t receive public funding, but that it still hurts them to pay so much, I can offer them the right scholarship.” In her neighborhood, she notes, there are many families who make a little bit too much to qualify for publicly funded child care but not enough to really pay out of pocket.

A former kindergarten teacher, Stewart knows the difference that early education can make. Some of her kindergarteners, she notes, “couldn’t even tell me their first and last name verbally. They didn’t know letters. They couldn’t hold pencils.”

She adds, “Once you get to five, sometimes it’s too late. It’s difficult to get children to develop a love for learning.”

From Blueprint to Blue Ribbon

In 2019, when Franklin County released its , the pandemic wasn’t on the authors’ minds, but the thought and planning that went into the document positioned the county to take action on behalf of its low-income residents. Many of the participants in listening sessions mentioned child care as a concern. “T���re aren’t any child care options to cover [my daughter] when she isn’t in school that I can afford,” said one. “T��� cost would wipe out my savings and make it hard to cover rent. I’m afraid I will have to quit working and go back on welfare.” The Blueprint calls for increased access to star-rated, quality child care

According to Trudy Bartley, associate vice president for Local and Community Relations, OSU, the Blueprint “enabled Commissioner Crawley to be a visionary. We’re not going to have universal child care, but what can we do in the interim until we get there?”

Bartley describes Franklin County as a “tapestry” of parents, schools, business and nonprofits. OSU engages in the tapestry via its , and , among other efforts.�� “How do we really come together and not be so territorial and divisive?” she asks.�� “And I think that when you look at the Rise Together Blueprint, that’s what the county has done.”

The question everyone is asking now is how Franklin County will sustain its investment after the ARPA money runs out in 2026. Commissioner Crawley mentions a ballot initiative as one possibility, building on precedents in , . and Kent County in Michigan.

For Little Incredibles’ owner Stewart, remaining afloat means she can focus on her goals of building her “dream team” of educators and getting her five-star rating. “Once I have that under my belt, I’ll seek to open up more five-star-rated centers around Columbus.”

Babies born to mothers on Medicaid died at almost twice the rate of babies born to mothers with private health insurance.

That may read like an indictment of the federal Medicaid program, but it isn’t. Rather, it’s a reflection of the program’s limitations, the complicated circumstances of mothers experiencing poverty, and sometimes a simple matter of geography.

“Medicaid is fantastic and undoubtedly has improved outcomes for mothers and babies. But even though it’s beneficial, it isn’t as good as private insurance,” says Dr. Colm P. Travers, neonatologist and assistant professor of pediatrics for the University of Alabama at Birmingham School of Medicine. “Babies don’t get to choose who their parents are, how much money their parents make or what they do for a living. The baby shouldn’t suffer because of their parents’ socioeconomic status.”

Travers led a recent study on how insurance status relates to infant outcomes in the U.S. The study, “,” was published in the October 2023 issue of JAMA Network Open. The study used data from the birth and infant death records database of the Centers for Disease Control and Prevention (CDC) from 2017 to 2020. Researchers analyzed data of more than 13 million infants; 54% born to mothers with private insurance and 46% to mothers with Medicaid. The study found that those with private insurance had a significantly lower risk of infant mortality — almost half the rate of mothers with Medicaid — as well as a lower risk of low birth weight, vaginal breech delivery and preterm birth. They were more likely to receive prenatal care in the first trimester compared with those with Medicaid.

Prenatal care is foundational for positive outcomes because the first trimester is such a crucial time for both mother and baby, says the study’s first author, Desalyn Johnson, a soon-to-be MD from the University of Alabama at Birmingham.

“From a biological standpoint for the fetus, that first trimester is when organogenesis occurs,” Johnson says. “T��� other two trimesters see more growth of the body, but the first trimester is when the heart, the lungs — all the organs — are formed. It’s also a time for recognizing the mother’s baseline risk factors that might put a pregnancy at risk, such as high blood pressure or diabetes. You really want mothers to have access to prenatal care at that critical time.”

Presumed Eligible

Because the prenatal period is so crucial, many states provide presumptive eligibility for low-income mothers, meaning that they can start prenatal care as early as possible in their pregnancy. General guidelines for Medicaid eligibility are set by the federal government, but each state sets up their own requirements for eligibility, which differ from state to state. In states that don’t allow presumptive eligibility, the process for approval can send applicants through an administrative tangle that takes weeks and involves multiple steps to navigate the bureaucracy — at a time when the clock is ticking for both mother and fetus.

“One of the big differences we found in infant outcomes was that the Medicaid population had delayed or inadequate prenatal care, possibly because of the process they have to go through before they can even get an appointment for their first prenatal visit. That can mean by the time they get approved, they’re delayed in their prenatal care, or they haven’t received adequate care in those first months. They’re already behind,” she says.

Sometimes whether an expectant mother can receive adequate care boils down to whether she can get to it, Johnson adds.

“Here in Alabama, a lot of our population is very rural,” she says. “Some must travel great distances to receive healthcare. When you’re trying to access Medicaid services, it adds to the barrier when you have to go to this county clerk or that building to fill out paperwork and then back and forth. It can be difficult.

“A lot of times, researchers look at urban health, which is very important, but we also need to consider this rural aspect, especially in the Southeast.”

Nowhere to Go

Once a pregnant person does get signed up for Medicaid, there is no guarantee that they will be able to find a health professional to care for them or their babies. According to a research letter published in JAMA Network Open, “,” in 2020, the number of general pediatricians in the entire U.S. was 56,800. Only 2,900 of these doctors worked in rural counties; 86 worked in completely rural counties, which the defines as a county with open countryside, fewer than 500 people per square mile and no towns with more than 2,500 population. Nationwide, 1,391 counties had no pediatrician; 1,156 of these were rural counties; 331 counties had neither general pediatricians nor family medicine physicians (FMPs).

The March of Dimes’ 2022 report, “,” finds that about 36% of all U.S. counties have no maternity care, whether obstetric providers, certified nurse midwives, or hospitals or birth centers offering obstetric care — a number that appears to be growing. Maternity care deserts are associated with a lack of adequate prenatal care during pregnancy, treatment of pregnancy complications and an increased risk of maternal death. More than 2.2 million U.S. women of childbearing age 15 to 44 live in maternity care deserts.

Among all highly industrialized countries, the March of Dimes report states, the U.S. is considered one of the most dangerous developed nations in the world in which to give birth.

, counties with neither general pediatricians nor FMPs were more likely to have higher percentage of non-Hispanic Black children, higher child uninsured rates, higher child poverty levels and fewer children enrolled in K-12. The issue of health professional deserts is so pervasive now in the U.S. it even gets its own acronym, HPSA (health professional shortage areas).

This shortage helps explain — though not entirely — why babies, especially post-neonatal intensive care unit (NICU) babies, born under Medicaid don’t receive the same level of postnatal care, such as oxygen monitors and ventilators, as babies born to privately insured mothers. The babies born on Medicaid also face increased risk of dying from trauma, accidents, and — a serious neonatal illness most common in premature babies, especially NICU babies who don’t get human milk.

Lifesaving Alternatives

These negative outcomes don’t have to be assumed for mothers living in poverty, the researchers say. Multiple studies have shown that expanding Medicaid prenatal care can dramatically improve things for both mothers and babies. For example, found that expanding Medicaid to cover prenatal care for undocumented immigrant women in Oregon was associated with more prenatal care visits and improved care, a reduction in the number of babies born with extremely low birth weight, and lower infant mortality rate. Additionally, the mothers’ access to prenatal care was associated with an increased number of well child visits and increased rates of recommended screening and vaccines during the child’s first year.

A study of Medicaid-sponsored provided strong evidence that the program improves the lives and health of mothers and babies. A team of nurses, social workers and other specialists work with the pregnant person’s doctor and local providers to care for mother and child throughout pregnancy and the child’s first year, including a well-regarded . The study found that enrollment in the program significantly reduced the odds of babies dying within their first year.

Ruling Out Race

Aware of important racial disparities in infant outcomes in the U.S., researchers adjusted their health insurance study for race, so the results reflected the difference between mothers on Medicaid and mothers with private insurance, not race-based differences.

“Race is largely a social construct,” Travers says. “Increasingly, medical and genomic studies are showing that there is little basis for race-based medicine in the U.S. In this study, we adjusted for the effect of race in our analysis, not to eliminate race, but to try to take it out of the equation. We purposely looked at insurance and adjusted for race so that we could get at the question of socioeconomic status and insurance specifically.”

For example, a recent from the National Institute of Child Health and Human Development found that newborns of Black patients had the worst perinatal outcomes. But once the study adjusted for insurance status, the difference was no longer significant.

The researchers also adjusted for sex of the newborn, maternal pregnancy risk factors, education level and tobacco use to analyze the differences between the two groups. The difference boiled down to who had the better health care. In other words, infant mortality outcomes are not fully explained by those external factors but are associated with the mother’s socioeconomic status, and access to insurance and adequate health care. Populations that are entirely self-pay, such as undocumented immigrants, may have even poorer outcomes than Medicaid patients —a subject for future study, the researchers say.

The results reflected in these studies don’t point to Medicaid’s failure but to the work remaining to be done to ensure that pregnant women of all socioeconomic circumstances receive the timely, adequate care they and their babies need.

“T��� draw of pediatrics for us as doctors is that when we’re working with children, we can lay the foundation for them to have healthy and successful lives,” Johnson says. “But if you don’t lay that foundation in the dawn of life, it can have repercussions for their entire lifespan. ��“We’ve now documented that, yes, these findings are what we expected. The next steps now are to decide how we as physicians, as policymakers, can address these issues and improve the outcomes for these babies.”

Further Reading

: In 2020, 42% of all births in the U.S. were covered by Medicaid. About one in nine women of childbearing age (11.6%) in the U.S. was uninsured. About one in 18 children younger than 19 was uninsured.

An interactive map showing which of the states have adopted Medicaid expansion coverage for nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 for an individual in 2024) and the 10 states that have not done so.

Over the course of any given day, Tiffany Jones manages all of these situations and a hundred more. Drawing upon her knowledge of child development, she recognizes and addresses diverse learning styles and abilities, cultivating a sense of belonging and curiosity within her program. “I see them growing into a generation of confident, empathetic and capable individuals,” she states.

As owner and operator of , Jones educates eight children in two large rooms of her home in Rockville, Maryland. And if it weren’t for American Rescue Plan Act (ARPA) funding, this dedicated and talented educator might have gone out of business, leaving the parents of these children unable to keep their jobs. And Precious Moments certainly wouldn’t be in these bright, capacious rooms without ARPA dollars.

Jones has plans for improving her business if and when more public investment comes — including a better outdoor space and a greater capacity to accommodate families who cannot normally afford child care — but first she has to make sure nobody swallows a Lego.

Jumping through Hoops

Originally from Bowie, Maryland, Jones aspired to be a doctor before motherhood and economics nudged her onto another career path. Enrolling in the rigorous pre-professional program in early care and education at Washington Adventist University meant bringing her three children along with her from 6:00 p.m. to 10:00 p.m. four nights a week.

“I had to learn the business and jump through all those hoops,” she recalls. Her administrative skills came in handy during the pandemic, when she secured ARPA funding to relocate Precious Moments. It cost $8,000 to move three blocks away and to furnish the new site. The rent is higher here, but it allows her to have separate areas for living and working.

“I was closed for 18 months during the pandemic,” she recalls, “So the funding had to last to pay the living expenses of a single mom to three kids.”

When a facility closes, she adds, it cannot open the next day in the new location, owing to licensing and fire marshal certification. “It was really closer to two years from when I closed to when I reopened and was fully operational. The parents were like, ‘We need this place and you need to open.’”

Since the pandemic, and thanks to ARPA funding, the racial makeup of Jones’s class transformed. “For 15 years,” she says, “I didn’t have one Black client. Child care is very expensive, and in Rockville it’s just really hard to find high-quality, affordable care. But when I started to accept pre-K funds, that was the first time that I had a client of color.”

The expanded space she secured helped her qualify for the pre-K expansion funds. On the day I visited, Margie Ryan, the pre-K coach assigned to Jones by the , was there to observe class.��“Tiffany is way ahead of the game,” Ryan told me, praising her vocabulary-building games centered on everyday household objects. Jones serves on the board of the Montgomery County and received a Montgomery County Innovative Leadership Excellence Award in October 2023.

Erica Phillips, executive director at the (NAFCC), praises Jones for “taking full advantage of ARPA to upgrade her program.” Thanks to the pre-K expansion and other factors, Phillips explains, Precious Moments is a more sustainable business today, which matters for Jones and her family, for the families she supports and for the local employers and economy that rely on her. Jones is the Maryland State Representative for NAFCC as well as an NAFCC policy fellow.

Jones’s financial situation is far from unique. “I know lots of providers that have used the ARPA funding,” she says, “and that’s what sustained their business.” Obstacles to receiving money included not having a separate bank account for their business or not having sufficient English-language skills to navigate the application. Montgomery County, Maryland has an unusually robust that helped providers with the process.

Beyond Precious Moments

Having learned to advocate for herself, Jones has proven effective at advocating for family care educators in Maryland. According to Phillips, “Peer leaders like Tiffany were incredible in disseminating information during the pandemic. Our child care leaders really stepped up, sharing information and making sure that no family child care program was left behind.”

Last year, care providers successfully lobbied Montgomery County to pilot a program for wellness benefits, including access to mental health counseling. A new goal on the horizon is what Jones describes as “a shared services model, where we’re all in a consortium of sorts to get access to benefits.” The vision includes business coaching, bulk purchasing and child care management software.

As Phillips points out, most family child care providers don’t have the means to save for retirement. Jones opened a self-employed pension at her credit union, but it is on her to make contributions to it. Given her slim profit margins, the account’s growth is slower than she would like.

What does the future hold for Precious Moments? “Any kind of funding would be helpful,” Jones says. “That outdoor classroom would be at the top of my list.” She also mentions curriculum upgrades, wraparound supports for her families and a backstop for her constant cash flow problem.

“I could resolve the cash flow issue by taking all privately paying families who pay before care is given,” Jones notes, “but then I wouldn’t be able to help families that really need care in order to work their jobs, and are looking for high-quality early education.”

Support for this reporting was provided by the Better Life Lab at New America.

It depends.

• Can incarcerated people be shackled during labor? It depends.
• Can women breastfeed or pump after delivery? Will anyone see to it that their infant receives this milk? It depends.
• Are pregnant people in custody with opiate addiction given medical assistance to detox, or are they left to go cold turkey on their own? It depends.
• Can an incarcerated woman have access to an abortion? It depends.
• Are pregnant, birthing and postpartum people treated with dignity and humanity while behind bars? It depends.
• Do we even know how many pregnant, birthing or postpartum people are behind bars in the U.S.? Actually, that answer is a straightforward No.

Whether incarcerated pregnant people have adequate nutrition, access to obstetric care or even such necessities as maternity clothing depends on what state they’re in, whether they’re in a prison or jail (more on that distinction later), and sometimes simply on the whims of jail staff or local sheriffs and deputies.

According to the , the capriciousness of reproductive care for pregnant, birthing and postpartum pregnant people in custody comes to us via a patchwork of decentralized and overlapping criminal legal systems throughout the U.S. comprising thousands of federal, state, local and tribal systems that together incarcerate more than 2 million people. Around 173,000 of that number are women or girls, primarily people of color, mostly young, and most arrested for non-violent offenses. The U.S. has the highest number of incarcerated people in the world and is second only to Thailand in the number of women behind bars.

Until recently, the pregnancy status of these incarcerated women had not been updated for decades, making it impossible to say with any certainty how many pregnant people were behind bars, how they were being cared for and the outcomes of their pregnancies. The federal First Step Act of 2018 now requires the U.S. Bureau of Justice Statistics to collect data on pregnancy outcomes from federal prisons, but no such requirement is in place for state prisons and jails. Any data at all on the thousands of women in local jails is spotty to nonexistent.

In 2019, Dr. Carolyn Sufrin, a national expert and advocate for reproductive care for incarcerated women, and her multi-sector research team at Johns Hopkins University School of Medicine and School of Public Health published , a significant study that collected data from 2016 to 2017 from 22 state prison systems, the Federal Bureau of Prisons, six jails and three juvenile justice systems, representing 57 percent of females in prison and 5 percent of those in jail. The study found that at any given time, 3 to 4 percent of females were pregnant when they entered U.S. jails and prisons.

An obstetrician-gynecologist with a doctorate in medical anthropology, Sufrin ran a women’s health clinic for six years as an OB-GYN at the San Francisco County Jail before going to Johns Hopkins. She found that the hard data she needed to study maternal health, including pregnancies, miscarriages and abortions behind bars, didn’t exist. She launched the initiative that became the PIPS study, the first-ever systematic study of pregnancy outcomes for women behind bars in the U.S.

“Part of why we know so little is that, as a society, we’ve just ignored these women,” Sufrin says. “We either pretend they don’t exist, or else people believe it’s such a small number of women, ‘Who cares?’ But how do we know it’s a small number unless we study it?

“T���re’s a saying, ‘Whoever isn’t counted doesn’t count,’ so the lack of data signifies how little we care about pregnant people, especially those at the margins of society.”

As the PIPS project concluded, Sufrin founded the (ARRWIP), which continues to conduct research on reproductive health care issues among incarcerated women. She says she became committed to this specialty as a first-year OB-GYN resident in Pennsylvania when she delivered the baby of a woman from the local jail who was shackled to the hospital bed throughout labor and delivery. Until that moment, she writes in her excellent book, “Jailcare: Finding the Safety Net for Women behind Bars,” like most Americans, she had given little thought to the idea that there were pregnant people behind bars, nor the complicated reality of that fact.

Shackles and Health Care

If the idea of shackling a pregnant woman in active labor seems medieval — or cruel and unusual punishment at the very least — welcome to large swaths of the U.S. Despite well-established medical risks, as of July 2023, only 40 states, the District of Columbia and the federal government have banned restraints in labor and delivery; some have banned the practice at other points in the pregnancy and postpartum period. In Maternal and Child Health Journal, November 2022), authors Camille Kramer et al. report that pregnancy policies and services in prisons and jails vary widely, with little consistency in compliance with anti-shackling legislation even in states where it’s banned. Most facilities station an officer inside the hospital room during labor and delivery, and nearly a third don’t even require that it be a female-identifying officer.

Though state prison systems hold twice as many individuals as jails, the PIPS study reports that more women are held in jails than in state prisons, a statistic that carries profound consequences for these women and their families. The distinction between prison and jail is that prisons are long-term confinement facilities the federal or state government monitors, often by an entity the government contracts. People in prison typically have been convicted of a felony and sentenced to one or more years. Jails are short-term facilities managed by a local or county government. More than 60 percent of women held in local jails have not been convicted of a crime and are awaiting trial, often because they can’t afford bail. A whopping 80 percent of women incarcerated in the U.S. are mothers, and most are their children’s primary caretakers.

The 1976 Supreme Court ruling in Estelle v. Gamble established health care as a constitutionally protected right for incarcerated people, but it didn’t prescribe mandatory services, standardization or oversight, creating the present system of health care roulette for those behind bars. Providing care for incarcerated women presents multiple unique challenges for any institution; caring for pregnant women in custody significantly raises the stakes. Pregnancies are often unplanned and complicated by a lack of prenatal care, a woman’s neglected health before incarceration, maternal trauma, poor nutrition, substance abuse, mental illness, limited social support and low socioeconomic status — all in a correctional system designed for men.

Post-Dobbs Pregnancy Behind Bars

Before the Supreme Court’s ruling in Dobbs V. Jackson Women’s Health, access to abortion already varied widely from state to state and among prisons. After the Court removed the constitutional right to abortion, the choices for pregnant incarcerated women have become even more precarious. Sufrin’s research found that even in states where abortion was legal, some prisons and jails had either official or unofficial policies that prevented incarcerated women from accessing abortion.

Under Roe v. Wade protections, incarcerated pregnant individuals at least had a constitutional right to abortion just like everyone else in the U.S. Despite this guarantee, abortion was not accessible to many in custody. Post-Dobbs, things are likely to get worse for those who are pregnant behind bars.

“We don’t know yet the full impact of the Dobbs decision because it’s hard to study this population,” Sufrin says. “But abortion access for incarcerated individuals was already constrained. How much this is going to impact abortion access in restrictive states is still to be determined.

“What I’m more concerned about is the ripple effect this is going to have on other aspects of pregnancy care in custody. We’ve already seen in abortion-restrictive states like Texas that non-incarcerated people brought to the hospital for obstetric emergencies like bleeding from a miscarriage or their water breaking early are being turned away from care where an abortion procedure would save their lives. They’re turned away because of how the law is written or because physicians fear what might happen if they misinterpret it. Women are basically being told to come back when they’re at death’s door.

“I’m concerned about the impact on incarcerated pregnant people with complications because they will be sent back to prison, which is ill-equipped to handle obstetrical emergencies. We’re likely going to see more pregnant individuals overall in the United States who are going to be sicker, and that may also be true in custody.

“None of this has been studied, so these are just hypotheses.”

When Jail Means Safety

Though it may not be intuitive, Sufrin says the “thorny reality” is that jail can improve outcomes for incarcerated pregnant people and their infants and can increase their chances for successful reintegration into the community. Jail is the new safety net, she writes in “Jailcare.” Women in jail represent one of the most marginalized and vulnerable groups in society. Indigent, addicted mothers too often can only access prenatal care behind bars. Though not all jails provide an environment that supports these women, those that do offer medical and prenatal care, treatment programs, improved nutrition and the relative stability that they’ve lacked can provide a safer, healthier alternative to the lives these women experienced on the outside.

Make no mistake, Sufrin says. Jail is still a place of punishment. The fact that it’s better behind bars for some people than being in the community isn’t so much an endorsement of jail as it is an indictment of our abandoned and ineffective social systems that have broken down and utterly failed these people relegated to society’s sidelines.

“That the system of incarceration has become an integral part of the country’s social and medical safety net is peculiar to the U.S.,” she writes, “and represents one of its greatest tragedies, the whittling away of public services for the poor coupled with an escalation in the number of jails and prisons with custody of that same population.”

“It’s still jail,” she says.

Going part time “cut my salary in half, so I needed help being able to afford some of the basics for my family,” she said. Even with her husband’s part-time work, the loss of income would have meant frequenting food pantries, and coping with whatever would be on offer there, if it weren’t for the Special Supplemental Nutrition Program for Women, Infants and Children, known as WIC. More than likely, without WIC she would have had to quit her job, give up her career and uproot her family to move closer to where she could get family support to help with child care. “I don’t think I could have made all the pieces fit in terms of time, support and finances,” she said.

Enrolling in WIC, though, has provided the help that she needed. “It just makes our life have a lot more convenience and dignity being able to shop for what I know my toddler will eat,” she said. “It’s been so great for our family.”

WIC’s supports have gone beyond financial help with buying food; Page said she’s shopping both more affordably and nutritiously for her family, adding more whole grains and protein to their diets. The program offers parenting services as well, and when she came home from the hospital after her baby was born and was having trouble breastfeeding, the program covered a lactation counselor who was able to sort out the issue, allowing Page to keep breastfeeding. She was connected with a curriculum that offers other parents’ experiences and ways to cope with stress and anger, as well as with a fellow mom who has coached her through breastfeeding. She got a starter kit of breastfeeding supplies like a hand pump and milk storage bags. “T��� support just felt amazing, it felt validating,” she said. With her first child, “I wish that I had this kind of coaching as a new parent, that would have been really helpful.”

“WIC met me in my special circumstance and was accessible for this particular need I had of being able to nourish two very small kids while not being able to work full time,” she said. She noted that she and her husband don’t have family nearby to help and support them; they moved to Utah so she could serve at her particular church. “Receiving food from WIC was the first time I’ve ever felt like, ‘Wow, my society sees what it takes to raise the next generation and actually values and supports this incredible investment that my little family is making into raising some good humans.’”

WIC’s financial, nutritional and moral support is now at risk of being pared back for the first time in a quarter decade. Although WIC is not an entitlement program—meaning that unlike Medicare or Social Security, it does not by definition serve everyone who is eligible—there has been a bipartisan commitment for more than 25 years to fund the program with enough money that it has been able to enroll everyone who applies. “WIC is unique,” noted Zoë Neuberger, a senior policy analyst at the Center on Budget and Policy Priorities. Congress has ensured “enough money so that nobody actually gets turned away for lack of funds.” But, thanks to the combined forces of more people enrolling than had been anticipated and much higher food costs, the program is unless Congress gives it more money.

If Congress doesn’t pass legislation early next year that includes enough funding for WIC by the summer, states will have to start putting people on waiting lists instead of accepting them immediately. Thanks to the program’s priority system, the first people who would be put on those lists would be postpartum people who aren’t breastfeeding and older children, as the program can serve kids up until they reach age five. Unlike other programs that serve people throughout their lives, the benefits of WIC can only be realized in a short window, so someone who languishes on a waiting list is likely to miss out entirely. States will also have to some people when they have to renew their benefits.

These changes will likely ripple out even to people who wouldn’t be put on a waiting list. “Once word gets out that not everyone who’s eligible is able to apply, then people just won’t show up,” Neuberger. Even as states prioritize breastfeeding parents and babies, those people may assume they can’t get on if they hear that there’s a wait. “It’s very hard to contain the effects.” Even if Congress passed enough funding to serve everyone the following year, any rebound in enrollment would likely be slow, she said.

In November, Congress passed and President Biden signed a continuing resolution that kept government funding steady until January 15. It didn’t include the extra money WIC needs, although it did include something important: the ability for the program to keep spending at whatever rate is needed to maintain its current operations and not turn anyone away or take away benefits.

But come January 15, lawmakers will once again debate how much to fund each federal government department and program. At that point it will need to come up with more money to stave off cuts. To keep serving all eligible families who enroll, WIC needs “a substantial increase from last year,” Neuberger said, estimating that it would take about $1 billion more.

And yet neither of the bills currently under consideration by either the House or Senate include nearly enough money to make sure WIC can keep enrolling and serving every eligible person. Instead, Neuberger and Katie Bergh, a senior policy analyst at the CBPP, estimate that under the Senate bill WIC would have to new parents and young children and, on top of that, under House Republicans’ steep spending reductions 4.7 million would have their benefits cut.

The need for extra funding is being fueled by two different factors colliding. WIC has never enrolled everyone who qualifies—there is a “very large group of low-income families that are eligible for WIC that have not enrolled in recent years,” Neuberger said, and in fact participation for a while. That trend has recently reversed, and participation over the second half of last year and all of this year. “That’s a very important, positive turnaround,” Neuberger said. It’s likely being driven by a coordinated effort to get more people to use the program combined with increased need among people who qualify—both thanks to higher food costs and expiring pandemic benefits like the expanded Child Tax Credit, universal free school meals and larger food stamp allotments. But it also means that the program needs more money to keep up in order to not have to turn anyone away.

At the same time, inflation and consistently higher price levels for food mean that each enrollee’s benefits now cost the program more. Unlike food stamps, which just give recipients a lump sum dollar amount, WIC covers most foods in quantities. That’s been very helpful for beneficiaries—they’ve been able to keep receiving the same amounts of grains and proteins, for example, even as prices have risen. But it’s meant the program is spending more. “It protected families, but it does increase the cost of providing those foods to families,” Neuberger said.

Neuberger was crystal clear that WIC is, for now, intact. “T��� program is fully open now, there aren’t waiting lists, there aren’t cuts,” she said. “But it’s really important for that final funding legislation to include enough money for everyone to continue to be served at the current benefit level.”

If WIC starts putting people on waiting lists, that would return it to how it operated in the 70s and 80s, when the program was new and states didn’t enroll everyone who applied. lawmakers in both parties committed to fully funding it so that everyone can be served. Since then, research has that WIC participation leads to the birth of healthier babies, better nutrition for babies and kids, less food insecurity, higher immunization rates, and higher scores of mental development for children later on. It also gets big returns; for every dollar it spends on prenatal services, it $2.48 in health care costs.

“Remarkably that commitment has held,” Neuberger said. “So, if there were a cut, it would be walking away from more than 25 years of precedent.”

On the other hand, studies estimate our current, broken child care landscape costs parents, employers and taxpayers billions of dollars a year. The Century Foundation estimates that with the loss of emergency pandemic funding for child care, , and taxpayers and businesses will lose $10.6 billion in revenue. A study by ReadyNation estimates those losses now total , more than double what they were pre-pandemic.

While some may debate the details of these estimates, no one who studies the issue seems to doubt the underlying premise that child care is an economic issue. In 2021, arguing for a massive national investment in early childhood.

Yet nearly three years later, a massive federal investment in child care remains politically out of reach, even after the COVID-19 pandemic and recovery have drastically weakened the child care sector and revealed just how critical child care is to a functioning economy.

Why haven’t arguments highlighting the billions of dollars on the line moved us to action?

“I think it has moved some folks, and that’s why it’s been our dominant argument. We’ve been making these arguments for twenty years,” said Eliot Haspel, senior fellow at the think tank Capita and author of the book “Crawling Behind: America’s Child Care Crisis and How to Fix It.”

“T��� economic argument for child care is an important one to be able to marshal for certain audiences,” Haspel acknowledged. “But at certain times I worry we’ve gotten just about as much mileage out of them as we’re going to. I don’t know how many people are left who are persuadable by economic data, who aren’t already persuaded.”

What’s more, Haspel worries the economic case for child care leads to solutions that prioritize the economy over kids and families. A child care system built for maximizing economic returns is not necessarily the best for the people involved.

“T���re is some danger to making the case for child care purely about its economic benefits,” said Haspel. “If what you’re trying to do is make sure that parents can get to work so that company productivity can continue to operate at the highest level, then you actually don’t want to invest in a really high-quality child care system that offers lots of good options and well compensated educators. All you need is a child care system that is minimally adequate.”

Haspel believes the economic case for child care has to be made in the larger context of an argument for family freedom and flourishing. “Every family deserves the opportunity to flourish and thrive and have the care situation that’s going to let them do that,” said Haspel.

My New America colleague Katherine Goldstein has spent the last year reporting on the care movement, including its strongest tactics and the hurdles it faces. Goldstein has seen economic arguments prove successful in garnering public investment in early childhood particularly at the state and local levels where the consequences of a lack of child care for work and economic opportunities are concrete and visible.

Goldstein reported on the success of a 2021 New Orleans ballot initiative that provided high quality through a small property tax increase. A few local business owners convinced of the need for a better-supported workforce became key champions of the initiative and helped defeat opposition from others in the business community.

As for the big economic numbers like the $122 billion ReadyNation says a lack of child care is costing the U.S., Goldstein is skeptical this kind of data alone will pull along any lawmaker who isn’t on board. “When you see those big numbers and you say, “Wow, that’s compelling. But it’s compelling because you’re already converted,” said Goldstein.

Unlike economic arguments specific to particular cities and their business and workforce communities, numbers in the billions can feel abstract. And policymakers at the federal level consider a whole slate of issues that have major economic implications. The question for the care movement is how to get legislative attention for this particular set of economically beneficial billion-dollar investments.

Goldstein thinks that the child care movement has all the evidence and sound arguments it needs. What it lacks is the political money and the voting blocs to force policymakers to care about and act for child care. For example, Goldstein found that when it came to the 2020 Build Back Better (BBB) legislation that would have massively overhauled the U.S.’s early care and learning systems, care organizations had just “1.4 percent of the lobbying spend compared to top business groups who opposed BBB.”

Jeannina Perez is director of Early Childhood for MomsRising, an online and grassroots advocacy organization that directly engages mothers to build a movement to influence and attract policymakers’ attention to these care issues. Perez says the economic data has different uses for different audiences, but that parents themselves are a key audience for it. “One of the key ways that we use this data is that it really helps working moms realize that the inability to find affordable child care isn’t a personal failing,” said Perez.

“People often don’t realize until they’re looking for child care, how incredibly difficult and expensive it is, and then they think, ‘What is wrong with me?’ And the economic data helps show that this is not a ‘you’ problem. This is a larger systemic failure.” When moms become convinced the problem they face is a systemic failure, Perez said, they are more confident to advocate for public policy solutions. It’s that growing movement of advocates for child care who ultimately will be tasked with not only convincing policymakers of the need for investment, but of pressuring them to take action.

All the advocates I spoke to about the economic case for child care agreed there’s no silver bullet argument that will get us to a well-funded, equitable and high-quality child care system. The economic data points are one of many tools the movement for child care has at its disposal, but they can’t replace a well-organized and well-funded political movement led by the people experiencing the crisis firsthand.

“T��� data tells us a story, but so do people,” said Perez. “People have a visceral experience of this day-in and day-out. We’ve made leaps and bounds in communicating what the cost of child care means for families. The good stuff takes time and care and love and energy. I have to believe that our elected leaders are going to do what’s right and come up with a comprehensive solution.”

But there was little to no empirical data on why this might be the case. So, Enchautegui, the chief knowledge officer for the Instituto del Desarrollo de la Juventud (translated to Youth Development Institute of Puerto Rico), set out to change that. “A lot of U.S. data sets do not include Puerto Rico,” she said. “For general U.S. sampling, such as the Current Population Survey, pulse surveys conducted during COVID or government-sponsored longitudinal surveys, Puerto Rico is not part of the sampling framework.”

Enchautegui and her team set out to create the “Socieconomic Survey of Families with Children,” which was conducted between December 2022 and February 2023, carried out through home visits in collaboration with the polling firm Ipsos. The sample represents the population of families with children ages 0-17, with incomes at or below $35,000 a year and with a head of household under age 60.

The report found that the most common characteristics of low-income families with children in Puerto Rico were headed by women who work and participate in social protection programs, and still have difficulties meeting basic household needs. Having a quality job was key to a family’s economic security and lifting the family out of poverty, and yet for 75% of families, not having child care was a major obstacle to employment. The child care obstacles were greater for mothers of preschool age children than those in elementary school or older.

“When we look specifically at people living in poverty, it is an overwhelmingly female-headed population, led by single women,” said Enchautegui. “When we talked to them in this report, we asked different questions about barriers to employment,” she said. “Most of it came down to access to child care.”

, published in September 2023, is the first empirical data on child care and employment in Puerto Rico. It feeds into both research and policy involving the overall quality of employment and how to promote an agenda for creating employment opportunities for families. And it shows how more women can and want to provide for their families, but need reliable child care to be able to do so.

The lack of reliable child care is the main reason that Kimberlyz Alvárez, a single mom of three kids in San Juan, is no longer able to work. For a while she was able to work, and had an aunt look after her kids. But after a time that situation became untenable and Alvárez had to quit to watch over her children. “It’s my responsibility and not my aunt’s to do that,” Alvárez said in an interview, translated from Spanish by Caridad Arroyo-Quijano, a research analyst with Instituto Del Desarrollo de la Juventud.

Alvárez, who is 27, previously worked at fast food restaurants like Burger King and Subway, either as a cashier or the drive through. She is no longer in a relationship with the father of her children, so she feels pressure to earn an income to support her family. She would like to go back to work, but she could only do so on a specific schedule that could accommodate her 5-year-old at school and her 3- and 1-year-old at Head Start, which ends at 2 p.m. “I trust the kids are secure in Head Start, but I don’t see that as a child care provider, it’s a school provider. Child care would be after that schedule, and I don’t know anyone in a child care center that I actually trust to leave my kids with so I can’t work full time.”

Women like Alvárez could benefit from additional child care offerings that would allow them to go back to work and earn a salary to support their families. But Puerto Rico faces additional barriers to providing child care support because of lack of local investment and limitations on federal funding. “Our funding is 100% federal dollars,” said Arroyo-Quijano. Unlike other states in the U.S., Puerto Rico does not contribute its own funding.

Arroyo-Quijano explained that there are both mandatory and discretionary funds for child care, but historically Puerto Rico has only received discretionary funds, which are allocated through the Child Care Development Block Grant. Mandatory child care funds are authorized through section 418 of the Social Security Administration and certain funds require state funding for the federal government to match. As a territory rather than a state, Puerto Rico has not had the same safety net programs or funding as other U.S. States.��Under the American Rescue Plan Act, Puerto Rico started receiving some mandatory funds permanently, but it still cannot access the funds that require state matching.

For Alvárez, even the availability of more funds may not change her situation. She wasn’t familiar with the American Rescue Plan Act funds and how they were impacting child care on Puerto Rico, but she felt that employers weren’t always aware of the needs of mothers. “Many of us are the main ones in our family in Puerto Rico,” Alvarez said. “Employers need to be more flexible in their work schedule so mothers can have more access to take care of their kids.”

One of 15 US Department of Agriculture programs aimed at reducing food insecurity and improving nutrition for America’s vulnerable populations, the is the primary federal program that helps feed the nation’s youngest children in a variety of child care settings. The program improves child nutrition, supports families, reimburses child care providers and infuses federal dollars into local economies, among other benefits.

And yet, the first nationwide analysis of data on CACFP just published in the American Journal of Preventative Medicine (AJPM) finds the program underused and unevenly accessed throughout the U.S. The study found that of all licensed child care centers in the U.S., just 36.5% participated in CACFP. In low-income areas, the number of child care settings using the program varied widely from state to state, ranging from 15.2% to 65.3%.

For the study, “,” researchers analyzed administrative data from the CACFP and child care licensing agencies in 47 states and the District of Columbia for 93,227 licensed child care centers. Alabama, Montana and North Carolina were not included due to incomplete data or non-response. In prior research, they found that many eligible child care providers were not taking advantage of the program; indeed, many had never heard of it.

Lead investigator Dr. Tatiana Andreyeva became aware of providers’ lack of participation as director of Economic Initiatives at the University of Connecticut’s Rudd Center for Food Policy and Health. The focus of her research has been the role of economic incentives in food choices, as well as the effects of federal assistance programs on food insecurity, diet quality and access to healthy food in at-risk communities. In earlier research, she had become aware of the CACFP’s surprisingly low provider participation in Connecticut; in surveying providers, she found multiple barriers to participation, including a lack of awareness and piles of paperwork. Supported by a grant from , a national program of the Robert Wood Johnson Foundation, Andreyeva and coinvestigators Dr. Timothy E. Moore, Lucas da Cunha Godoy and Erica L. Kenney were able to expand this research nationally.

Statistics Matter

The USDA does not keep statistics on eligible child care settings’ participation in the CACFP. It tracks the number of meals served and daily attendance for the program but doesn’t have a system that tracks participation among eligible programs, though it routinely estimates participation for its larger programs such as the Supplemental Nutrition Assistance Program (SNAP).

“As an economist, I can’t understand how this young population is so underfunded, underappreciated,” Andreyeva says. “T��� CACFP is about nutrition, but if you look at child care and education generally, this age group sees very little public funding. It’s the age where you can get such a positive return on investment, as has been shown in multiple studies. Somehow our society is ready to spend on K-12, but not on children zero to 5. This is the age when you can get a profound return on investment, as has been shown in multiple studies.

“So that’s what motivated me. With this grant, I could study provider child care participation nationwide — and nobody else has done it.”

The researchers collected data from state agencies that oversee licensing and CACFP and merged it with data that helped them identify CACFP-eligible child care centers and learn which of the eligible centers were participating. In other words, a mountain of data.

According to the , most U.S. children regularly are cared for by people other than their parents. Because all CACFP-subsidized meals and snacks must align with the USDA’s Dietary Guidelines for Americans, the children this program serves tend to eat more balanced, nutritious diets than they receive at home. A new study published in the concluded that compared with meals provided from home, children in low-income families who receive underwritten meals in child care settings experience greater food security, better health outcomes and are less likely to be admitted to the hospital from the emergency room. In a nation where most young children don’t meet dietary recommendations, child care centers and family daycare homes that participate in this food assistance program can play a unique role in improving the diets of millions of children.

Given those benefits, why wouldn’t these providers rush to sign up for this proven nutrition assistance?

Barriers To Participation

Andreyeva’s research highlights a variety of causes, with one key barrier as simple as no one knowing about it. More than half of non-CACFP centers in one state didn’t even know the program existed.

“Do a survey. Ask any parent, even low-income parents, nobody has ever heard about it,” she says. “A lot of child care providers don’t know about it. What we show in our studies is that participation varies by state, but it seems that for the federal government, CACFP is just not a priority.”

Even providers who are aware of the program often are challenged to take all the steps required to be a part of it. Most providers are already struggling to keep their heads above water and one more to-do list for one more program, even one with obvious benefits, can seem impossible.

“T���y’re already understaffed and overwhelmed, especially after the disaster of the last couple of years. They’re struggling financially and they just don’t have the staff to sort through it.

“I have a Ph.D. and we looked at the application with a nutritionist and we couldn’t figure out how to complete it,” she says. “For child care centers to track income eligibility — it’s a big pain and all the paperwork is just very complicated. No wonder they don’t want to do it.”

One of the complicating factors, she says, is that there have been a few instances of fraud with the CACFP, as recently as during the pandemic, in which millions of dollars were stolen from the government. What had already been a complicated process has become doubly so because of the number of T’s to cross and I’s to dot. The programs are administered through grants-in-aid to the states, which then manage the state program by designated agencies such as their departments of education, health, family and/or social services.

“Participants are usually small businesses, and there are so many of them, oversight can be really challenging for the state. Some states are so concerned with fraud prevention, and seeing that not a penny gets stolen, the feds and states have added so many layers of checks that it can be difficult for a provider to participate. So, a few bad apples have ruined it for others.”

Prior research by this team and others found that other barriers to participation include the complications of serving meals in child care centers, including the availability of food service companies able to provide CACFP-compliant meals at affordable rates; limited equipment and kitchen facilities and staff; local health and state regulations; a lack of parent interest in center-provided meals; and provider concerns about insufficient reimbursement.

“Many participating providers will say that CACFP, through meal reimbursements, pays for food costs, but doesn’t fully cover expenses, especially in more expensive areas with higher food costs,” Andreyeva says.

It Can Be Done

The high levels of CACFP participation in some states after accounting for income differences suggest that some have done an excellent job of getting providers to join the program. Andreyeva has another paper under review in which the researchers interviewed state agencies to see what they were doing — or not doing — to increase participation, so they can share best practices with state agencies, providers and policymakers.

The AJPM analysis has pinpointed multiple potential remedies that could boost participation in the CACFP. Among the researchers’ recommendations, the USDA, state agencies and advocates must:

• Understand why providers decide to participate or not in the CACFP, so solutions can be targeted to these issues.
• Simplify the application process and compliance requirements.
• Provide child care providers with small grants to cover the costs of applying for the program and/or remaining in compliance, such as updating kitchen facilities and equipment or helping them find service vendors.
• Increase the number of sponsoring agencies such as United Way, Catholic Charities and other nonprofits (required for family daycare homes to apply for CACFP), which could ease administrative challenges, particularly for smaller centers.

Policymakers could play a vital role in expanding access to CACFP, including providing adequate funding to administer the program effectively, modernizing data collection to assess and track participation, and conducting extensive outreach to raise awareness of the program.

Andreyeva points to the significant financial implications of failing to utilize this readymade, proven nutrition program. Previous research estimated that underutilization of CACFP in Connecticut left 20,300 children from low-income households without the program’s subsidized meals and cost the state $30.7 million in foregone federal funds. Multiply this figure by the number of qualifying child care centers and daycare homes nationwide that don’t apply, and it adds up to a huge amount of money left on the table.

How much better it would be for our nation’s youngest children if nutritious food were on the table instead.

Local officials continue to face difficult questions about their response. Why have the number and magnitude of wildfires on Maui increased so rapidly? Could more have been done to eliminate invasive grasses that are thought to increase wildfire susceptibility? Should the electric company have cut power on the morning of the fires due to the high winds? Why weren’t the community’s sirens, built originally to warn the community of tsunami danger, used to warn residents of the fire? There will plenty of blame to share.

The number of confirmed dead is now at 115 and is expected to climb, making it the deadliest wildfire in the U.S. in more than a hundred years. Meanwhile, at press time, 388 people are listed as missing. Hawaii governor Josh Green told the press that .

Those families whose lives were spared by the fires face other horrors. For many, their homes and all their possessions were destroyed in a matter of hours. Where will they sleep? Where will their children go to school? Who will care and educate their youngest children as they attempt to rebuild their lives and livelihoods? And by this week, as K-12 schools reopened, just how these children would recover from the trauma of returning to schools and child care centers with classmates and family members forever missing?

This is parenting in 2023. This is child care in the age of climate disasters. The tragedy in Maui raises a further question for not only our local, state, and government officials, but for all of us: With parents clearly unable to shield their children from the ever-expanding list of climate threats on their own, how can we rebuild our systems to promote young children’s safety, health and well-being?

More than 3,000 buildings were destroyed in the fires. According to national child care network Child Care Aware, that number includes four of the nine licensed child care centers in Lahaina. At least 150 child care slots were affected by the fires, according to PATCH, Hawaii’s child care referral network. PATCH began working immediately with local providers to create and publicize available slots, and to donate infant formula, diapers and financial resources to families and providers who need it.

PATCH’s Interim Executive Director Carol Wear said, “T��� impact of the fires has caused considerable distress among both the staff and the children under their care. To address this, local organizations specializing in infant mental health have been offering support to some of the affected centers.” PATCH is working with national partners who bring expertise and training when confronting such emergencies, and they’ve found they are not alone. They are leaning on a variety of local and national allies for support.

Climate Disruption and Children

According to a recent report by Inter-Agency Network for Education in Emergencies, an open network of representatives from NGOs, UN agencies, governments and academic institutions, the disruptions caused by climate disasters can have long-lasting and devastating impacts on children, including their health, both physical and emotional, their access to nutritious food, their access to responsive caregiving, learning opportunities, and their safety and security.

The United Nations’ World Meteorological Organization has found a in the past fifty years. UNICEF reports that over one billion children on the planet are , including fires, typhoons, cyclones and hurricanes.

Elliot Haspel, director of Climate and Young Children at the think tank Capita, says early education, like many of our systems, is underprepared for the consequences of climate change. “But unlike some other systems,” Haspel said, “early education is working with an acutely vulnerable population, a population that is essential to building a resilient and happy future.”

Haspel points to FEMA and other interagency disaster response plans as part of the reason young children are particularly vulnerable. That lack of inclusion of early education systems is at least in part a result of how fragmented child care and early education are in general in the United States. “Although there are over 100,000 schools in the United States, they’re organized into districts and have a central office that an agency can coordinate with. Unfortunately, that’s not the case for the early years,” said Haspel.

The millions of small, home-based child care centers and family child care providers across the U.S. are especially difficult to reach, meaning not only that they aren’t included in evacuation plans at the outset of a disaster, but may also not receive the critical resources they need to continue serving families during the recovery period or to sustain themselves beyond it.

Capita and the Aspen Institute co-convene a task force to draw attention to the relationship between climate and the early years of children’s lives. They recommend a strategy that mitigates climate change, adapts our current systems for our new climate realities, and prepares our systems for inevitable losses and damage that will result from them.

What kinds of changes might this result in, in practice? Experts have recommended numerous paths to act:

• focus on mitigation in communities of color, where extreme heat and pollutants are most impacting young children;
• adapt playgrounds and outdoor spaces to withstand climate changes, like providing shade in areas exposed to extreme heat;
• in the case of disaster, plan for what will happen to children when loss and damages occur, and for how to re-create stability for them as quickly as possible.

Moms Historically Have Led the Social Movements for Kids. Early Educators, too.

But accomplishing any of this will likely require a public groundswell to demand it. After all, despite majorities of Americans supporting federal investments in early education and child care, Congress has failed multiple times to renew pandemic-era funding for early learning and care even as we approach a funding cliff that could close 70,000 child care centers, and as the cost of child care is rising at double the rate of overall inflation. Our children are as vulnerable as they are in the face of climate change precisely because we have historically refused to invest in infrastructure they need.

Parents, especially moms, have forged some of the largest and most successful social movements in modern U.S. history, particularly by highlighting the threat to children’s lives. Since its formation in the 1970s, Mothers Against Drunk Driving (MADD) has from the local to the federal levels targeting drinking and driving. Moms Demand Action has galvanized a national movement against gun violence and won an impressive number of gun-safety victories, particularly at the state level.

At the local level, the connection between climate change and children’s lives is increasingly being made by : Science Moms, EcoMadres, Moms Clean Air Force, Mothers Out Front, Sunrise Kids NYC. As one mother and activist told the New York Times, “I want to be able to say to my kid, ‘We’re trying to do something.’”

Native groups have long drawn connections between protecting the natural environment and protecting the youngest members of our society. With the , for instance, Mohawk women led research to measure pollutants in their water sources, pointing out that toxins in water would become toxins in breastmilk.

Early educators are also a potentially powerful voice in advancing this struggle, as they have become an increasingly vocal bloc in the . Of all the institutions that young children and their families interact with, it is most often early educators who take on an outsized responsibility for the overall well being of children outside their families, even in the absence of adequate funding and infrastructure.

One of the buildings destroyed in the Maui blaze was a groundbreaking Hawaiian language immersion preschool serving about two dozen Lahaina families. ʻAha Pūnana Leo O Lahaina is part of a larger movement of native Hawaiian educators to preserve the language and culture by teaching children through traditional Hawaiian methods and in native Hawaiian language. According to the network of schools, Pūnana Leo means “nest of voices,” a learning philosophy in which children are “‘fed’ solely their native language and culture much like the way young birds are cared for in their own nests.”

ʻAha Pūnana Leo CEO Kaʻiulani Laehā says that same philosophy is driving the center’s response to the disaster. They are focused first and foremost on nurturing the families they serve, including enrolling displaced families in one of their other locations on Maui and other islands, and raising funds to provide them any resources they may need.

ʻAha Pūnana Leo is also working to provide security and resources to their five displaced staff members. “You can imagine, our staff are incredibly specialized,” said Laehā, “so doing whatever we need to retain them is a top priority.” Laehā added that while some of their educators have been reassigned to teach at their other sites, others are still on the ground on Maui helping with the rescue effort and caring for children impacted by the disasters. Those educators are part of the ʻAha Pūnana Leo “ohana,” or family, just like the children they educate and those children’s families.

The extent of the human loss in Maui is sadly still coming into focus, as search and recovery efforts continue. But the destruction of Lahaina, and so many of its most vulnerable people, will undoubtedly be remembered for years to come as among the most devastating tragedies in U.S. history.

As a public we are only beginning to grapple with what this tragedy means about where we stand as a country and planet, marking the dangers of our present climate, and laying bare our immense unpreparedness for an inevitably growing list of weather-related disasters. The fires should also force us to reckon with just how truly vulnerable so many of our youngest children are, specifically in a warming world, not currently built for them or for their needs.

Prior to the Bill de Blasio administration (2014-2021), free pre-K in New York City was a patchwork of means-tested, half-day programs that served just under 20,000 4-year-olds. In his first year in office, Mayor de Blasio delivered on a campaign promise to create an expansive universal pre-K program. By the time of de Blasio’s exit, his administration had created an immensely popular program that served 90,000 children, transformed New York City’s early childhood education infrastructure and was on track to add another 30,000 seats for three-year-olds.

But in the fall of 2022, current Mayor Eric Adams announced a preliminary budget that reallocated $568 million away from universal pre-K and halted the expansion of 3K For All.��So, where did things go wrong? Senior Adams administration officials have argued that mismanagement under de Blasio has resulted in the uneven distribution of seats, including the “opening tens of thousands of seats where there isn’t family need and failing to open seats where the need exists.” Nathaniel Styer, press secretary for the New York City Department of Education, claims that a has resulted in a large number of open slots in low-income, immigrant neighborhoods of the city like Highbridge in the Bronx, and few open seats in wealthy communities.

For my graduate capstone thesis at the Department of Urban Policy and Planning at Hunter College, I sought to understand why some of New York City’s most economically vulnerable residents are not making use of what should be an economic lifeline: free child care. I conducted research interviews with participants in four key stakeholder groups: parents, child care providers, former staff within the Division of Early Childhood Education, and policy experts.��My research aimed to unpack the “demand mismatch” theory and answer two questions:

1. Is there an unmet need for universal pre-K in low-income communities that is not captured by the way the Adams administration measures demand?
2. Are there barriers to information, access and enrollment that may be contributing to underutilization?

Here are my findings.

Finding: Universal pre-K may not have enough flexibility to match the diverse needs and preferences of New York City families.��

Many parents need child care before or after the traditional school day, on nights and weekends, and over the summer. In fact, of children in the United States have at least one parent who works non-traditional hours. The vast majority of New York City’s universal pre-K programs, however, are offered on a school-day/school-year calendar (6 hours and 20 minutes per day; 180 days per year) and only some community-based providers offer extended day and year programs primarily for families who meet Child Care Development Block Grant or Head Start eligibility criteria. found just 15% of 4-year-olds enrolled in universal pre-K received full-day, year round care and in some low-income communities less than 10% of pre-K seats were full-day, year-round.

Interviews confirmed that so few options for extended care may contribute to low utilization rates in low-income communities.��Elliot Haspel, author and expert on child and family policy, explained that “family needs for child care do not exist on a school-year, school-day basis. Often disproportionately, we know that lower income parents and parents of color tend to be those who are working shift jobs, and a high proportion of them are working non-traditional hours… So, the lack of flexibility can certainly be a barrier.”

A former staffer within the Division of Early Childhood Education, who requested anonymity in order to speak with me candidly, told me not being able to offer early or after-school hours was one of the biggest hurdles reported by principals. They also described the lack of extended hours as a “misalignment with what is being offered and what is needed in the community.”

For some parents, inflexible operation times can leave universal pre-K entirely out of reach. One mother, whose daughter is enrolled in a community-based center in Red Hook, said start times for some pre-K centers conflicted with the ferry schedule. Choosing to send their child to one of those programs would mean she or her spouse would be late to work every day, and therefore they did not apply.��

Finding: There may be demand for home-based family child care, but that need is not reflected in the composition of universal pre-K.

Enrolling in universal pre-K programs at district schools or formal child care centers may work for some families, but other families prefer different options. A argues that due to a “lack of multilingual staff, rigid schedules, and limited programming that is culturally and linguistically responsive, formal child care centers historically have not fully met the needs of immigrant communities, and particularly low-income immigrant communities.”

Julie Kashen, senior fellow and director for Women’s Economic Justice at the Century Foundation, said ��that home-based family child care is an option , especially those who are looking for a cultural or linguistic match and/or who require extended or nontraditional hours of care. These program options, however, are not offered for pre-K and are very much awith typically only a few hundred family child care seats.

A former DOE staffer, who requested anonymity, expressed that home-based family child care providers “are not technically excluded, but the way that the system is constructed ends up resulting in it being really difficult for them to be able to participate.”��He explained that New York City’s complex contracting process for its universal pre-K programs can shut family child care providers out, and thus, an arrangement that attracts low-income, immigrant communities remains out of reach.

Finding: Sustained outreach is necessary to engage low-income and immigrant communities, and scaling back the outreach initiatives could contribute to low utilization rates.��

The de Blasio administration focused heavily on outreach to reach families who may not typically have a high level of engagement with government agencies. There were borough- and neighborhood-specific outreach teams equipped with materials like palm cards and flyers available in all DOE languages, and there was on-the-ground support, including canvassing, days of action at shelters and events at libraries to bolster enrollment. Coordinated outreach and partnership with trusted community members has among “hard to reach” low-income and immigrant communities.

My interviews with former DOE staffers, however, revealed that the Division of Early Childhood Education under Adams has been plagued by understaffing and has significantly scaled back outreach initiatives. The Division of Early Childhood Education is across all divisions at City agencies. Members of the neighborhood and borough-specific teams have reportedly been and there is more focus on automated forms of outreach like , which are not nearly as effective in engaging low-income families, especially those who may have had previous negative experiences interacting with government agencies or who are undocumented.

After months of negotiation and just a few weeks after my capstone was published, the New York City Council voted to that restores universal pre-K funding and supports efforts to convert 1,800 3K seats from school-day/school-year seats to extended day/extended year seats. The final budget is a huge sigh of relief for early childhood education advocates who feared Adams’ proposed cuts, but the future of universal pre-K remains uncertain.

My research only begins to scratch the surface of this issue, but it does suggest that demand for universal pre-K is more complex than a simple measurement of seats vs. students. As the Adams administration continues to make staffing, strategic and budgeting decisions about universal pre-K, it should not assume that open seats means that there is no demand.

Instead of strategizing ways to reduce the size and scope of universal pre-K, it should invest in resources to help parents navigate the complicated enrollment process and ensure low-income communities can enroll in programs that fit their needs.

Working with organizations like to increase the number of licensed home-based family child care providers who participate in the program, reengaging the outreach teams and strengthening partnerships with on-the-ground trusted community organizations, and offering more extended day, full-year programming options could improve utilization rates in low-income communities.

At a December 2022 press conference, Mayor Adams stated “A true universal program prioritizes and serves every child, every day, in partnership with families and reflects the needs of the community.” It is up to the Adams administration to continue the legacy of universal pre-K and ensure that it is truly universal.

That is how Representative Dave Pinto explains it. The Democratic legislator, who chairs the state House Committee on Children and Finance Policy, explained that Minnesota’s legislators came to an agreement to prioritize children and families when spending the state’s . Support for a variety of early childhood programs will be included in the new funding, including scholarships to pay for child care, more money to pay the educators, the creation of a brand new statewide paid family and medical leave program, and a child tax credit for lower-income families.��Minnesota will also create a new Department of Children, Youth and Families to support child care and early learning opportunities, and oversee many of these new initiatives.

Minnesota is putting in new spending toward early childhood initiatives. An additional $252 million for , which is an annual scholarship worth up to $8,500, will go toward the child care or early education program for two years. The goal is to cap child care spending to 7% of a families’ income, the national standard set to deem child care affordable.

Such a dramatic sea-change came about through several factors — including changes in the electorate and the budget surplus.

“As President Obama said, elections matter, and we were so very fortunate, we had a trifecta of a Democratic governor, a Democratic Senate, and House,” said Nancy Jost, co-chair of the state’s Prenatal to Three Coalition and director of early childhood at .

The $17 billion surplus, which was initially $10 billion, had gone unused in 2022, when a split House and Senate couldn’t come to a agreement and a tentative arrangement fell apart. The initial surplus had swelled with the additional federal funds from the American Rescue Plan. By the time Democrats came to control all three branches of state government,��legislators were ready to take action.

Had the Republicans won, explained Pinto, they were expected to use the surplus to fund tax cuts. Instead, myriad social programs were able to see record gains. “This administration prioritized kids and families. When folks make lists of things from the session, this is one of many, many issues that won,” he said.

Jost credits state advocates working together to form a unified front, and knowing that having strong agreement among one another would yield better results than fighting among themselves for a smaller piece of the pie.

Democratic Governor Tim Walz’s Administration had to make Minnesota the best state in the country to raise a family. Now, the state will join the that have enacted paid family and medical leave. Such programs — including contributing to healthy cognitive and emotional development, improving maternal health and enhancing families’ economic security. Paid family and medical leave also reduces the demand for child care in the early months of an infant’s life if a parent is able to care for the child. (Infant care can be some of the costliest and hard to find child care for many families. for an infant is, on average, 6% higher than the cost of serving a preschooler.)

The state is also investing in improving compensation for educators alongside creating a stronger pipeline to hire more. Over a two-year period, $5 million in state funding will be allocated to award grants for early childhood educator programs that recruit and prepare community members to enter the teaching profession. For the past two years, Minnesota previously used funds provided by the American Rescue Plan to provide monthly payments to child care centers to increase compensation for providers under the “Great Start Compensation Supports” program. Under the new budget, such payments will become permanent.

“We need to establish the principle and recognition that this work is a public good,” said Pinto. “We pay for early learning and care once a child is five; there is no reason we shouldn’t be doing that when a child is younger.” The job of a child care provider, he says, is the lowest wage you can get with a high school diploma, and it shouldn’t be.�� Pinto estimates the extra funds from this program translates to $400 extra per month for a full time employee.

In addition, Minnesota has created that is expected to . This follows the success of the created through the American Rescue Plan during the COVID-19 pandemic. The NTC lifted 2.9 million children out of poverty nationally, down from 9.7% in 2020 to 5.2% in 2021, the lowest rate on record. As one posited: “Without additional action by Congress to renew the expanded Child Tax Credit, we should expect higher child poverty in future years.”

Both Jost and Pinto acknowledge that there is work still left to be done, but that this has been a sea-change in the field. Minnesota is now joining a handful of states, including and , whose historic investments in child care will be part of the national conversation and possibly serve as a map for success for others.

“I’ve been in the field for 50 years. When I first started, there wasn’t any talk about policy in early childhood. As the years have gone by, we have gotten more and more organized. We have found our voices and are encouraged to talk about the things that families need. I think all of the things have progressed over the years,” said Jost. “We have a long way to go, but boy have we come a long way.”

In a country that lacks any federal infrastructure for child care, state efforts like Vermont’s are charting a course forward on what a more universal care economy could look like for families.

How did it happen? Vermont’s efforts come after a decade of advocacy, lobbying efforts and coalition building to shore up a strong majority in favor of universal child care in the state. The state’s aging workforce meant incentives were needed to – and the availability of stable, affordable child care for longer periods of time.

The money for the child care plan will expand the subsidies to families with incomes up to 575% of the federal poverty guidelines. In addition, Aly Richards, CEO of Let’s Grow Kids, was also set aside to increase pay for child care workers. This will be funded from a .44% payroll tax, which is split between employers and employees.

Vermont has caught national attention, particularly among advocates and educators, for its bold and comprehensive approach. The process to get the initiative over the finish line was unique as Vermont is the only state with a Democratic veto-proof majority and a Republican governor.

“T��� dynamic that played out in Vermont shows what is possible when you have committed legislators, cultivated over years by grassroots organizers, advocates and community members speaking out on the importance of comprehensive investments in child care,” said Nina Dastur, director of state and local policy for Community Change, a national racial and economic justice organization. “We’re seeing the importance of grassroots organizing and everyday peoples’ participation in elections making real, tangible change for the better. The boldness of this veto override is backed by the community.”

In his comments explaining his reason for his Veto, Governor Scott that he had used the $390 million in surplus revenue “to fund many of these shared priorities like child care, voluntary paid family and medical leave, housing, climate change mitigation, and more.” But the initial child care funding had been primarily geared toward families paying less for care. And while the lack of affordability is a crucial piece of the child care crisis, another aspect is the low wages that the providers make, or the very thin or nonexistent profit margins that child care centers face. The additional payroll tax funding is designed to boost wages for providers and increase the subsidy amount they receive for each child enrolled – allowing centers to compete for and retain staff, and to be more financially soluble long term.

Many early childhood education programs in Vermont had been reducing hours and limiting spaces to try and stay open, explained Christina Goodwin, board president of the Vermont Association for the Education of Young Children and executive director of Pine Forest Children’s Center. “This bill means programs like ours can offer more spots to more families. It means financial relief for families who attend our school. It also means stability, as we can pay teachers closer to a living wage and retain our talented early childhood educators.”

will go into effect beginning in summer 2023 with $20 million in one-time “readiness payments” to support child care programs in preparing for the expansion of the child care subsidy system. Then through new public investment in January 2024, programs will receive a 35% reimbursement rate increase. Providers will also receive reimbursements based on enrollment and not attendance, which can be crucial for providers for staffing and planning purposes, and critical for more vulnerable populations that are subject to disruptions. More changes continue through 2024, culminating with the child care subsidies reaching the state population at 575% of the federal poverty level in October 2024.

The success in Vermont took over a decade to come to fruition, but it’s possible that — similar to policies like paid family leave — other states can see Vermont’s actions as a model to emulate. “T��� public demand for child care legislation in Vermont is loud and clear and legislators heard that cry,” said Julie Kashen, director of the Women’s Economic Justice and senior fellow at The Century Fund, where she writes about child care policy. “When the public demand meets the political will, elected officials can overcome obstacles to lead the way on child care.”

So when her sister offered to let Lerrga live in her basement and care for both her and her sister’s children, she took her up on the offer. Word got around that Lerrga was offering quality care, and more families came to her needing care for their children, too. She started taking on children outside of her own family.

It’s been a struggle ever since. Today she cares for three children who were referred to her by friends: a five year old, a three year old, and one who isn’t even yet two, “muy chiquitita,” she said: very little. She charges $30 a day for the youngest child since she requires more care and supervision, and $20 a day for each of the other two. “No me gano mucho,” she said: I don’t earn much. But that’s all that the parents can afford to pay her, and even as it stands parents complain about how much she charges. She once had a family that had so little money that they sent their baby to her with an empty bottle, and Lerrga had to spend her own money buying formula to make sure the baby was fed. She knew she had a duty to do it, even if it was a struggle for her — because it’s not the baby’s fault that its parents couldn’t afford to send supplies.

Even her low rates are an improvement. Before she recently took a course at the local United Way, she was only charging $10 a day per child. She also didn’t know how many children was too many to accept, and one summer watched eight by herself. But now she offers more enriching care — guiding the kids in her care to learn through play, teaching them colors, numbers, how to share.

Then there’s the lack of predictability. She often abruptly loses income when parents lose their jobs or their shifts. She once had a child whose father worked in construction, and every time it rained he stayed home with his kid and didn’t pay her.

She puts in long hours, starting at 5 in the morning and working until 3 every day. One parent works on a farm an hour away, another works an early shift at a tamale factory and another works an early shift at a meat processor. Lerrga makes so little, however, that she has to work a second job cleaning a restaurant at night after the children leave.

“Es difícil,” she said: it’s difficult. “No me descansa”: the work doesn’t let her rest. Even with the two jobs she lives paycheck to paycheck.

Lerrga’s struggle has recently gotten much easier. She is now part of a new program being piloted in her state: the Thriving Providers Project, which sends out regular, guaranteed payments to home-based child care providers like her. Now Lerrga receives $250 every two weeks, no strings attached. “Me ha ayudado mucho,” Lerrga said: It has helped me a lot.

Thriving Providers offers guaranteed, unconditional cash payments to home-based child care providers for between a year and 18 months. It grew out of the pandemic: in March of 2020, Home Grown, a national collaborative of funders, gave money to 13 emergency funds around the country to give cash payments to 2,500 home-based child care providers. Home Grown has always focused on these child care providers — including both those who care for other people’s children out of their own homes and family, friends and neighbors who offer care more informally — because it’s a frequently used form of care but it “is really under investigated, under invested in, and underappreciated,” said Executive Director Natalie Renew. These providers were among those most likely to stay open in the early shutdowns to care for the children of essential workers, but there was little support for them within existing systems.

Even though the recipients of the pandemic emergency payments were from many different kinds of places and weren’t necessarily like each other, it became clear that across the board “these relatively small amounts of cash were being used for very basic things: housing, utilities and food,” Renew said. Home Grown realized that, even outside of a crisis like the early days of the pandemic, these providers were living in a precarious financial state and needed financial support.

The current iteration “leverages what we’ve learned in the guaranteed income sector,” Renew said, and applies the lessons to child care, specifically care that’s provided by family members, friends and in people’s homes. Universal basic income pilots have essentially proven that “cash is best,” Renew said. “We think providers know best what they need to run the best possible programs.” Thriving Providers, therefore, offers the money without any conditions and “no expectations,” she said. It stands in stark contrast with other forms of support that are available to child care providers, particularly the government subsidy system, which has a multitude of rules and regulations providers have to meet to participate and typically doesn’t pay enough to cover the actual cost of care. Participation in the subsidy system also relies on parents to seek out funding, which is outside of providers’ control. Payments are made based on how many children are enrolled, not on the amount of labor a provider puts in nor what would add up to a living wage.

The goal is to “reduce income volatility and increase economic stability among home-based providers,” Renew said. By doing so, the organization wants to explore what the knock-on effects are: Does it improve the quality of care? Do families have a better experience? “Our theory is when child care providers are less stressed and less burdened by economic volatility and instability, they can be more valuable caregivers,” she said. They’ll be able to focus more on the care they provide and how they provide it when they’re not constantly worrying about how to cover costs and pay the bills.

Lerrga is part of the program’s first pilot in Colorado, which, in partnership with local nonprofit Impact Charitable, launched in the summer of 2022. It is now making payments to 100 providers. Many are similar to Lerrga: friends and family caring for children in a more informal way than a child care center. They are receiving the same payments as Lerrga, plus providers are offered access to tele-mental health services as a peer support group.

What Lerrga has experienced is typical: Joyceline Felix, a consultant on the Colorado pilot, said that what she charges is about average for family child care in Colorado. “A lot of families can’t afford to pay these rates,” Felix said. Home-based providers generally tend to have unstable incomes because they serve low-income families that are unstable themselves, and they also typically work second or third jobs to make ends meet, Renew said. Nationally, most earn a year from the care they provide.

The Colorado pilot is already having a big impact. Over 80 percent of participants say that it’s allowed them to continue being a child care provider, while over 86 percent say that it’s helped them manage the fluctuations in their incomes, according to recent findings from surveys conducted by the Center on Early Childhood at Stanford University. “I don’t have to work elsewhere,” one recipient said. “I’m not stressing out so much about monthly bills.” They’re having less of a hard time affording food and health care, and paying for the basics has gotten easier. Their housing instability has been greatly reduced and their schedules have become more predictable. “I feel very supported and with less financial stress,” a recipient said.

That, in turn, seems to be increasing the quality of care they can provide. The survey tracks seven measures of quality, including how often providers engage in back-and-forth exchanges with children or prevent difficult behavior, and all have steadily increased over the course of the program.

The goal, ultimately, is to get these kinds of programs in place in “as many places as possible,” Renew said. Her organization partnered with local providers in Colorado to design the pilot, and as they did, they created a toolkit to replicate the program as quickly and cost efficiently as possible in other places. Home Grown is “actively planning in several other places,” she said, including Nashville, New York City, Los Angeles and possibly statewide in Pennsylvania. King County in Washington is also partnering to build its own project.

Eventually, Renew said, she hopes to influence how all child care providers are paid — offering them more stability, predictability and financial security.

“Yo no creia caundo me dieron,” Lerrga said: when she was told she would be receiving the money, she couldn’t believe it.

But now with the money, “tengo suficiente por todos,” she said: she has enough supplies for all of the children she cares for. She’s able to buy the diapers and toilet paper she needs, as well as snacks and even some small toys for the children. She can buy ingredients for her sopita, a soup all of the children love whenever she makes it. It’s also given her peace of mind, alleviating the stress she used to feel about being able to cover all of her bills, especially the high gas bills in cold Colorado winters. As the weather gets hot this summer she’ll be able to afford to buy popsicles for the children — what was a luxury she couldn’t afford previously — to help them stay cool while they play.

The money also came at an important time her personally. She had a baby a month ago, and when she was pregnant she was able to use the money to cover the cost of prenatal care since she doesn’t have health insurance. After her baby was born, she was able to take a month off to recuperate while she had a friend watch her children. She didn’t get any payments from the parents during that time, but the Thriving Providers money kept her afloat. “No iba a vacaciones,” she said: I’ve never taken any vacations. She never took any time off at all before the payments — if she did she would lose money she couldn’t afford to forego. This was the first time she’d ever stepped away from her work.

“Esta ayuda es muy importante,” Lerrga said: this help is very important, and not just for her, but for all home care providers in her state receiving the funds. “Yo estoy muy agradecida,” she said: I am very grateful.

In the state House, 118 legislators voted in favor of the legislation, and only 100 are needed for an override. Twenty-four state senators voted for it and 20 are needed to override.

The child care program comes after almost a decade of work from state advocates and a desire to help shore up young families in the workforce in a state with an aging population. (Child care is still one of the for keeping people, notably women, out of the workforce). “A system transformation” is how Aly Richards, the CEO of Let’s Grow Kids, a Vermont-based agency that has lobbied and organized on behalf of this state’s universal child care movement, described it.

Child care funds will be created by a 0.44% increase in the state’s payroll tax, of which employers will pay three-quarters. It’s estimated that the tax will generate close to $80 million per year, which will be further boosted by an additional $50 million from the state’s general fund.

The payroll tax agreement has been after two weeks of an impasse between the chambers. The funds will go toward child care subsidies, and will provide generous increases both to families that pay for child care and for providers who receive the subsidies.

Previously, Vermont provided some form of child care subsidies to families whose income was at or below 350% of the federal poverty line — one of the highest eligibility thresholds nationwide. The new legislation would increase the eligibility threshold to 575% of the federal poverty level making it the highest in the nation. (New Mexico, another state that leads on providing child care, has increased their child care subsidies to 400%). In addition, low-income families that earn less than 175% of the federal poverty line will not have to make any child care co-payments.

Providers will also see a significant subsidy reimbursement increase. This July, all providers will be reimbursed at the current from the state, with another increase of 35% coming in January 2024. Also, Vermont will increase subsidy reimbursement rates for Family Child Care Home providers, so that the gap between family child care and center-based care reimbursement shrinks by 50%.

“This home-based provider increase emerged as a strategy to really support rural child care and to almost be a rural revitalization effort,” Richards said. “This would infuse additional funding into home-based providers in the area.”

Farm workers have very specific child care needs, such as non-standard hour care and many live in child care deserts. In addition to the subsidy bump, will now be . Tying subsidies to enrollment will keep more child care providers afloat. Payments by enrollment allows providers to��pay staff more reliably and plan for the future, rather than relying on a piecemeal approach. This is especially critical in a rural state like Vermont, where families are more likely to travel long distances to find care.

This distinction, explained Richards, is a matter of equity. “If you have a family that is missing days of school for a variety of reasons, especially for vulnerable families, the child care programs can no longer get payment for the program,” she said. “It was creating instability in an already fragile market. This creates more sustainable revenue for the educators and it supports the most vulnerable families that have absences that they cannot avoid.”

Support for such consistent funding increases for child care programs is notoriously difficult to achieve on a large scale. While polls show Americans want affordable, reliable child care — and such legislation has in our country — there has been little movement in individual states and on the federal level to create the required infrastructure to provide child care for more families. Vermont and New Mexico have made headlines for their pragmatic approach to child care — New Mexico as a way to uplift struggling families and Vermont as a way to bolster a young workforce. that are working to expand access to high quality child care include California, Michigan, and Minnesota, but this is hardly a unified approach for a wealthy developed country that treats child care as an individual problem and not a public good.

Julie Kashen, the director of the Women’s Economic Justice and Senior Fellow at The Century Fund, believes that the combination of public demand and political will helped spur policymakers to find a way to make child care and early learning a priority.

“What’s happened in these states will materially improve the lives of families and communities, while also creating models, momentum and mobilization for national progress,” Kashen said. “T��� progress in the states does not, however, negate the need for national action. We need a robust federal investment alongside state engagement to ensure that all families are able to choose the child care that works best for them.”

Despite the bipartisan support for the bill, Governor Scott announced his intention to veto the legislation. Richards explains that her coalition has a good working relationship with the Governor’s office, and the decision to veto can be traced back to a campaign promise not to raise taxes. Without the payroll tax increase, the program could not have afforded to pay providers more.

“It has come down to a fundamental difference in how you are going to think about affordability,” said Richards. “T��� Governor agrees child care is essential but won’t raise taxes. Those two things cannot live together. The solution is public investment. We know this is hard work. That is why we have a bipartisan movement. We are making hard choices together, but we are doing so responsibly.”

The legislative session for the veto override is scheduled for June 20 to 22.

With the state legislature approving $30 million in funding in April, TennCare will seek approval from the Centers for Medicare & Medicaid Services for the diaper benefit, which it hopes to receive in early January.

According to the (NDBN), one in three U.S. families is financially unable to provide all the diapers their children need, which exposes the child to potential health risks, makes it less likely for them to be accepted at child care where parents must bring diapers for each day, and increases the financial, physical and emotional stress on parents. The NDBN estimates that diapers for one Tennessee child for one month cost about $80, a crippling amount for struggling families — particularly those with two or more children.

Diapers are not covered by any federal assistance program, though they are a keystone for families’ health and financial well-being. For a parent or caregiver making minimum wage, roughly 8 percent of their income will go toward diapers. Most families who are challenged with diaper insecurity fall short by 20 diapers a month, a number that can make the difference between having a job and being unemployed.

A study by the noted an increase of $11 in personal income for every dollar’s worth of diaper aid that a family received, due to better health outcomes for babies and less time missed from parents’ work and school. It’s an investment that ultimately increases a state’s tax revenues as families’ financial picture stabilizes as they participate more fully in the workforce. The U.S. Health and Human Services’ , named unmet diaper need as a health equity issue. found that babies experienced 77 percent fewer days of diaper rash when funding for diapers and diapering supplies was provided.

In Tennessee, more than 300,000 of the state’s population are children under age 3 and about 49 percent live in families earning less than 200 percent of the federal poverty level (about $30,000 for a family of four). As part of its expanded services, TennCare will adjust its income threshold for pregnant women to 250 percent of the federal poverty level, making the program available to an additional 2,400 new mothers per year.

In addition to helping families afford diapers, TennCare’s additional benefits will establish continuous health coverage for children for at least their first year, regardless of changes in the parents’ circumstances or eligibility, helping an estimated 10,000 children remain enrolled. It will also make permanent Tennessee’s full year of postpartum coverage including dental and pharmacy benefits, which began as a pilot program in 2021, and will add lactation supports for enrollees.

“We’re able to provide all these benefits and add additional people to our TennCare program through a unique waiver that we negotiated with the federal government, TennCare III,” the program’s director, Stephen Smith said in a statement. “T��� concept of this waiver is that Tennessee is rewarded for its efficient management of our Medicaid program, and that reward comes in the form of shared savings. These are additional federal dollars that we can reinvest back into the program to enhance benefits and services, and serve more people to accomplish these important objectives.

“A real benefit of this approach,” Smith said, “is that we not only can provide more benefits and serve more Tennesseans, we can do it at no additional taxpayer expense.”

Medicaid waivers are vehicles that states can use to test new or existing ways to deliver and pay for health care services in Medicaid and the Children’s Health Insurance Program (CHIP). Tennessee is one of 10 states that has chosen not to expand Medicaid under the Affordable Care Act, electing to receive federal funds via a modified block grant. Under the waiver agreement negotiated with the federal government, the state will retain half of any federal savings its Medicaid program achieves. Tennessee’s waiver was approved in January 2021 and is valid for 10 years.

Tennessee received $330 million of shared savings in its first full year of the waiver, says Amy Lawrence, TennCare’s director of communications, savings that will be turned back into the Medicaid program.

TennCare recipients will not be taxed for the diapers they receive, Lawrence says. Tennessee’s tax rate on diapers is 7 percent to 10 percent depending on the locality — one of the highest rates in the country. A bill to eliminate the tax on diapers, formula and baby wipes for all Tennesseans was introduced this year but failed to make it out of committee.

Michele Johnson, executive director of the Tennessee Justice Center, said the diaper benefit is welcome as far as it goes, but it doesn’t go nearly far enough. The Nashville-based nonprofit advocates for Tennessee’s approximately 1.3 million low-income families through class-action lawsuits and works to shape public policy. Medicaid expansion has been one of the center’s key missions on behalf of the more than 300,000 uninsured Tennesseans.

“While we are grateful for any baby step towards a healthier state,” Johnson says, “the state’s investments in minor tweaks to the TennCare program are a far cry from meeting their moral responsibilities to the people who send them to Nashville to solve problems and lead.

“We continue to be at the bottom of the nation in most every metric of health and well-being due to leadership failures. We desperately need leaders willing to set aside politics and prioritize joining the rest of the industrialized world in choosing evidenced-based approaches to sound and equitable health policy.”

A spokesman for Tennessee’s House Democratic Caucus said that covering the cost of diapers and other provisions TennCare is promoting are necessary steps but, like Johnson, urged that Tennessee go farther.

“We know the need is there,” said Ken Jobe, press secretary for the caucus, in an email. “TennCare’s proposed funding numbers are encouraging. However, until the program is fully implemented, we will not know the full impact and actual number of families receiving these resources.

But in all that time she’s always lived paycheck to paycheck, frequently having to decide which bills to pay in full and which to skip. It wasn’t until last year, when she received funding from the American Rescue Plan, that she was finally able to give herself a paycheck that went beyond meeting basic expenses. “I’m just learning how to pay myself something,” she said.

She works from 6 in the morning to 6 at night every day, and she can only afford to take two weeks off a year. Recently when her husband, a disabled war veteran, wound up in the ICU, she lost a week of income because she had to stay with him. She had to borrow money from her mother to cover the lost pay. He’s still not fully recovered, so Johnson has to have other people go with him to his doctor appointments so she doesn’t lose more income.

It’s particularly hard to make the math work given that she accepts government subsidies, which she’s done since she opened. They don’t cover the cost of what it takes to care for the children, so she’s had to reduce her own bills and go without some things she wanted or needed. “T���y don’t give you full pay,” she said. “T��� government needs to step in, when [parents] can’t pay us in full the government needs to step in and pay the rest.”

All of those struggles are why she’ll be closing her doors on May 8 along with at least 725 other child care providers across the country as part of the second ever Day Without Child Care. Providers and organizers with Community Change Action will hold over 50 events across 15 states and Washington, D.C. to demand that the government ensure better pay for providers, make care affordable for all families, and build “an equitable child care system.”

In Austin, Johnson and others will head to the state capitol, where they’ll have food, bouncy castles, and will be hosting a “care-e-oke.” “We’re doing it big,” Johnson said. Providers in Minneapolis, Minnesota; Columbus, Ohio; and Indianapolis, Indiana will also gather at their state capitols to rally and make their demands heard.

Johnson’s parents, who all work, support her even if it means they’ll have to go without care for the day. “T���y say, ‘Go for it, we’re behind you,’” she said. Most will come with her to the event on the 8^th.

Johnson will be going without, too: she’ll forfeit a day of income by closing her doors. “It’s definitely worth it,” she said. She would know. She also closed last year during , when for the first time over 300 providers nationwide shut their doors and protested for better treatment. “It was awesome,” she said. “I was excited to actually be able to get out and advocate for our small ones that can’t talk.”

She believes they were heard, at least by the president, who the most sweeping set of executive actions on child care in history, including a call to lower or eliminate families’ co-pays for subsidies and the creation of model rights for domestic workers. President Biden also included $600 billion over ten years for child care and early childhood education in his most recent budget, the largest investment a president has ever called for, and his administration is requiring companies that seek funding from the CHIPS and Science Act to build semiconductor plans to ensure child care is available for their employees and consider defraying the cost. “T��� president heard us, but Congress, open your eyes,” Johnson said. “Listen to what we’re saying.” She wishes lawmakers would actually spend a day in a child care like hers to “see how it works.”

“I want our legislators and I want the public to know that without child care there’s no workforce. We are the workforce behind the workforce,” Johnson said. “Child care needs to be a priority. Child care needs to be up front.”

Without federal action, Johnson, like many providers across the country, is facing down the end of the pandemic-era funding that has helped keep her afloat. Most money for the sector in the American Rescue Plan has either been spent or will be in the next year or two. Democrats had originally included significant funding to reform the sector and keep it solvent in their Build Back Better reconciliation package, but it was all eventually stripped out. Johnson is already cutting back in an attempt to save up for when the end of the funding arrives. “I’m just pinching and trying to pay this and trying to pay what I can pay right now,” she said. “It’s very hard.”

The service is growing in popularity because it has been shown to make a dramatic difference in the birth experience for mothers, babies and families. A U.S. Department of Health and Human Services report published in December found that doula services drastically improved maternal health outcomes.�� “Doula-assisted mothers were four times less likely to give birth to a baby with low birth weight, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding,” the report states. According to the , the one-on-one emotional support provided by doulas has been shown to reduce cesarean births, help shorten the duration of labor and improve the rate of spontaneous vaginal birth.

American mothers need all the help they can get. Though rates of maternal deaths have been declining in most countries, the U.S. has the of any industrialized country in the world, and the Centers for Disease Control and Prevention reports that “stark and unacceptable” racial and ethnic disparities persist in this maternity crisis. A large body of research suggests that doula support is a promising strategy to mitigate these disparities.

Medicaid each year — roughly 1.5 million births — and among the CDC’s policy recommendations to address America’s maternity crisis is to extend Medicaid coverage to make sure that no one in this country dies because of pregnancy. Because states have some discretion in how to use their Medicaid funding, some have begun following the evidence and offering doula services as a benefit to their enrollees.

Michigan has now become the latest state to reimburse doula services for individuals covered by or eligible for Medicaid insurance, joining 15 other states that have done so or are in the process of providing this benefit. In taking this step, the Great Lake State has made it possible for the approximately 45,000 Michigan Medicaid enrollees who give birth each year to access the gift of childbirth assistance that for years has been a luxury enjoyed by those who could pay for the service out of pocket or had great insurance.

Though Michigan has made strides recently in improving maternal and infant health, it still suffers from one of the nation’s highest infant mortality rates, with infant deaths among its Black and Native American communities more than double those among white infants. Black women in Michigan are three times more likely to die from pregnancy-related causes than white women — in keeping with similar national disparities.

To address these inequities, Gov. Gretchen Whitmer launched her initiative, allocating millions of dollars to improve birth outcomes and support birth equity. As part of this initiative, Michigan expanded Medicaid coverage for a full 12-month postpartum period, providing access to critical physical and behavioral health services, dental care, treatment for substance abuse, and more throughout the first year after pregnancy.

In January 2023, Gov. Whitmer announced that announced that Michigan would begin supporting expecting mothers by covering doula services for Medicaid enrollees. In making the announcement, Gov. Whitmer stated that a whopping 63 percent of maternal deaths in Michigan are preventable. (Michigan is by no means an outlier in these numbers: The in 2020 that more than 80 percent of pregnancy-related deaths from 2017 to 2019 in the U.S. were preventable.) To powerfully impact that situation, the state has put together a comprehensive program, a sort of one-stop shop that will spread the word about doula services, build the workforce, and provide ongoing resources and support for Michigan’s doulas.

A Solid Platform for Success

Doulas practiced in Michigan before the launch of the initiative, says Dawn Shanafelt, director of the Michigan Department of Health and Human Services Division of Maternal & Infant Health, who is leading the . “But with the program, Michigan will have a central location where families that have Medicaid insurance can find doulas available in their communities.”

The initiative also provides a registry for doulas that offers webinars, training and continuing education, as well as for enrolling as a Medicaid provider and guidance on billing for doula services through Medicaid. To become a provider, individuals must have completed Michigan Department of Health and Human Services-approved (MDHHS) training, and they can find these approved programs on the website. The initiative provides scholarships for those who want to take the training and become professional doulas — a strategy that both builds the workforce and offers economic opportunity within local communities.

A key component of the program is the Doula Advisory Council comprising 29 individuals, all doulas from across the state who represent the diversity of Michigan’s communities, Shanafelt says. The council will work to promote advancement of doula services statewide and advise the MDHHS on policies, applications and resources, as well as providing advice on content for continuing education and reviewing training programs to ensure they meet Medicaid requirements.

The health department is hiring two doula specialists to work with Shanafelt’s division to serve different geographic areas of the state. She says one of these specialists has been hired — a doula with 22 years’ experience — and a second is on the way.

Medicaid policy includes a maximum of six doula visits during the prenatal and postpartum period, plus one visit for labor and delivery in a hospital setting. The flat reimbursement rate is $75 for each of the six visits, plus $700 for attendance through labor and delivery.

A stumbling block for states accessing Medicaid funding for doula services has been the requirement by the federal Centers for Medicare and Medicaid Services that doula services must be recommended by a licensed healthcare provider. To address this, Michigan’s chief medical executive Dr. Natasha Bagdasarian has issued a standing recommendation that doula services are medically necessary and should be offered to families covered by Medicaid insurance.��In her recommendation, Bagdasarian wrote that doula services should be offered “immediately and on an ongoing basis to Medicaid recipients until such time as determined no longer necessary.”

Results Speak Volumes

Since professional doula services were first offered in 1970s, friction has existed with the medical community, with some doctors and nurses viewing doulas as encroaching on their territory, or just one more body to get in the way of their efficiency during labor and delivery.

“T��� way to change the mindset regarding who’s a part of the care team is by seeing excellent outcomes,” Shanafelt says. “By seeing that the patient or birthing person’s well-being improved by having a doula as part of their care team, attitudes change.

“Having the American College of Obstetrics and Gynecology recommend having an emotional support person such as a doula present because it is associated with better outcomes for women in labor makes a difference,” she says. “Doulas have been serving birthing persons for decades, even hundreds of years, so this isn’t a new concept. The difference is the recognition of the value and importance of the doula profession.

“T��� shift is partly a result of the research that’s been published (about the benefit of doulas), but most importantly, it’s come from listening to families. Families tell us what works best for them. They’re the experts. So, if you listen to the experts, you’re going to hear time and time again that doulas make the difference.”

RESOURCES

• , a nonprofit organization connecting Black families to certified Black doulas throughout the U.S. The maternal mortality rate among Black women��, according to the Centers for Disease Control and Prevention (CDC).
• Survey of medical literature demonstrating significant benefit for birthing parents and their infants, notably for Black patients

FACT CHECK

• (Journal of Law, Medicine & Ethics)

“Biden has been the caregiver-in-chief in terms of championing these issues,” said Melissa Boteach, vice president for income security and child care/early learning at the National Women’s Law Center. “This administration has really been a standout leader on child care.”

Biden recently released his annual budget, which over 10 years to child care and early childhood education. , that funding would allow states to expand child care for more than 16 million children while ensuring that low-income families get care for free and families earning up to $200,000 would pay no more than $10 a day for each child. It would also send states money to provide high-quality, universal, free preschool in a variety of settings for all four-year-olds, and after states accomplished that they would also be able to expand it to three-year-olds.

On top of those funds, the budget would also spend $22.5 billion on existing child care and early education programs, including a $1 billion increase for the Child Care and Development Block Grant over what Congress approved at the end of last year. It puts an extra $1.1 billion into Head Start and $45 million into Preschool Development Grants to states.

It’s “the largest investment that’s ever been made in a president’s budget,” Boteach said. “This budget is setting a goalpost.” Despite the fact that Biden’s attempt to include for child care over three years in his Build Back Better plan ultimately failed, his budget calls for even more funding than that. “He’s building upon the commitment, not backing away from it,” she said.

The budget also “shows you can reduce the deficit,” Boteach pointed out, “and still invest in child care if you do the popular step of taxing corporations and wealthy individuals.”

Still, presidential budgets, while telegraphing an administration’s priorities and values, rarely get enacted as-is, and there is little chance that Congress will pass legislation to match the child care and early childhood education funding Biden’s included. Still, he has overseen some other concrete changes for the sector.

Last year, Congress passed the CHIPS and Science Act, which creates $39 billion in incentives to build semiconductor plans in the U.S. The Commerce Department has since for companies that seek those incentives, and is one that they outline how they will ensure child care for their employees and “strongly consider defraying the price of care such that it is within reach for low- and medium-income households.” Companies will be some of the subsidy money they receive to meet that requirement, such as building on-site child care facilities, giving workers money to afford care or investing in existing providers to ensure they have enough slots.

The effects of the requirement will be small. It’s not likely to do much to address the crisis roiling the sector in which providers can’t hire and retain enough employees, leaving people who need care .

Some worry that it will also misalign with policy goals. “This is not the optimal way to do child care policy,” said Chris Herbst, associate professor at Arizona State University who studies the child care industry. “Industry-targeted child care policy is not what the market needs.” He is concerned that, because the money goes to people who work at semiconductor plants, it will go to higher earning workers, “which is inefficient, and feels inequitable as well,” he said. They are likely already paying for child care out of pocket, so this money will just replace what they were already spending. “We’re not going to bring anybody new into the labor market as a result,” he said. “We’re not going to expose any new kids to high-quality child care.” It also leaves out anyone in school or training programs who need child care while they learn, even if their ultimate aim is to get a semiconductor job.

Boteach sees it as a worthwhile marker, however. “It sends an important message that child care is economic policy,” she said.

She acknowledges it won’t have an impact on the sector “at scale.” But many of the workers who will be employed at new semiconductor and other plants that get the CHIPS funding will need child care—especially if these companies plan to attract women to these jobs—and Boteach sees this requirement as a way to ensure that the increased demand doesn’t disrupt existing child care markets. “If all of a sudden you have all these workers coming in to build the plant and operate the plant,” she said, and they’re trying to find slots for their kids without any extra supply, “it’s going to drive up prices and push out some of the families who use child care locally.”

“This is about providing a point of planning,” Boteach said.

What is already having a much larger impact is funding that Biden signed into law at the start of his term: the American Rescue Plan Act, which included $39 billion for the sector, the amount of funding the child care industry had ever received in the country’s history. “It was huge,” Boteach said with a laugh. have received stabilization grants made possible by the money, and say it helped them stay open. An stayed open that would have otherwise closed.

The money also helped prompt states to with child care innovations, from giving providers healthcare and retirement benefits in Oregon to offering subsidies to nearly all residents in New Mexico to waiving parent copays in Indiana. “T��� amount of innovation on child care right now is really exciting,” Herbst said. Those experiments are at risk of being erased when the money runs out this year and next. Still, “T���re’s going to be a tremendous amount of learning that happens as a result of all of this experimentation that may work its way back up to the federal level and find its way into legislation,” Herbst said. “That will ultimately improve the quality of our debate whenever we have another serious debate about this at the federal level.”

States at least have one ongoing pot of money that they can turn to, a pot that’s even bigger now. In December, Biden signed an appropriations bill into law that included for the Child Care and Development Block Grant, a $1.9 billion increase over last year’s funding, representing the second-largest increase in the grant’s history. Boteach called it “historic.”

Ultimately, although child care and early childhood investments were stripped out of Democrats’ reconciliation package, both Herbst and Boteach remain positive about where the issue stands. “I’m actually more optimistic than I have been in a while,” Herbst said.

The pandemic forever changed the way the country views care. “Between parents and businesses and people who are caregivers in general, you can’t really unsee the last few years,” Boteach said.

The debate over Build Back Better, meanwhile, “changed the debate, and it moved it forward,” Boteach said. “We have moved from child care being a nice to have to a political imperative.” The country got closer than it had in a half century to investing in a robust, national child care system. It used to be that advocates like Boteach had to push candidates for office at both federal and state levels to “really embrace and have a plan on this,” she said. “It’s a default now that you need to have a robust and long-term plan to address this country’s child care crisis to be a serious candidate. That’s a huge step forward.”

“I really do think we’re having a moment,” Herbst said. “We are in a drastically different spot than we were even just a few years ago.” Child care legislation will keep getting reintroduced, he said, and each time it’ll improve on the last. “One of these days we’ll get it.”