Federal Focus - Policy Design Principles
Principles of Policy Design for Leaders
Lessons from Home Visiting for Designing Durable Child and Family Policy
Access it here as a printable PDF
By Doug Steiger, Senior Contributor
Federal support for children and families is contracting, but not uniformly.
Medicaid and SNAP have absorbed significant cuts from H.R. 1.
The Social Services Block Grant and Head Start face serious threats. In this environment, the programs that thrive will be the ones that were built to last. Home visiting is worth studying because it was.
While other family programs have struggled to hold ground, home visiting has grown.
It’s been reauthorized twice, expanded in reach, and largely insulated from partisan attack.
That’s not a coincidence; its durability reflects specific structural choices about how the program was framed, funded, and governed that also reinforced its strength and persistence.
Understanding those choices matters now, when advocates and policymakers are deciding which programs to prioritize — and how to build the next generation of family supports.
What is Home Visiting?
Home visiting is not a single program. It is a category of services for parents and children that range from the prenatal through early childhood period.
Two dozen evidence-based models qualify for federal funding, ranging from intensive nurse-led interventions to parent education programs rooted in child development research.
The best-known models include Nurse-Family Partnership, which pairs nurses with first-time mothers, and Parents as Teachers, which focuses on parent education and child development.
Some models begin during pregnancy and continue through infancy. Others serve families with toddlers and preschoolers.
The age range and workforce varies, but early childhood is the consistent anchor.
How It Works
Across models, the core structure is similar: voluntary support to families from trained home visitors.
These visitors seek to build strong relationships with families, often providing parenting education and developmental screenings for the children. They also link families to resources and services.
Home visiting is funded by the federal government in multiple ways.
The primary federal vehicle is the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, which in 2025 distributed nearly $500 million to states, jurisdictions, and non-profit organizations for evidence-based home visiting programs.
In 2024 those funds reached 35 percent of U.S. counties, nearly two-thirds of them rural.
Several home visiting models also qualify for reimbursement under the Family First Prevention Services Act (FFPSA).
By 2023, at least 30 states had included at least one home visiting model in their FFPSA plans. But total FFPSA prevention claims that year barely exceeded $100 million nationwide, making this a secondary, and still emerging, funding source.
Medicaid provides another pathway.
As of 2022, 28 states financed some form of home visiting through Medicaid. Some states reimburse full models, while others only cover components, such as case management.
The most common model funded through Medicaid is the Nurse-Family Partnership.
States may also use TANF ($133 million in federal funds in 2024) and Social Services Block Grant dollars for home visiting.
Home Visiting Hasn’t Just Persisted, But Expanded
Many federal family programs fight to hold their funding flat. Home visiting has done something rarer: it has grown.
MIECHV launched in 2010 at $100 million for 2010. By 2013, it had reached $400 million.
It has since been reauthorized twice, demonstrating ongoing support.
The most recent reauthorization, passed with a strong bipartisan margin, authorizes $600 million in 2025 and $800 million in 2027, with a growing share structured as matching grants that draw in state and local dollars alongside federal funds.
That trajectory is not just a budget story. It reflects accumulated political capital — built through bipartisan sponsorship, a durable evidence base, and a program design that gave states and communities ownership rather than compliance obligations.
The sections below examine each of those advantages in turn.
Advantages of Home Visiting
Home visiting’s expansion over the past two decades was not accidental. Several structural features made it easier to grow than other prevention strategies.
Bipartisan Durability
Although MIECHV was established by the Affordable Care Act (ACA), federal support for home visiting predates it.
A demonstration program operated during the George W. Bush administration, and some states were offering home visiting before that. Republican policymakers, including Senator Kit Bond, were early champions.
The most recent MIECHV reauthorization was named for the late Republican Congresswoman Jackie Walorski.
That cross-party lineage has helped shield home visiting from the partisan swings that have unsettled other social programs.
Established Evidence Infrastructure
The home visiting field has long conducted evaluations of the various models.
The first randomized trial of the Nurse-Family Partnership was published in the 1980s. This extensive evidence base has given policymakers confidence to invest in home visiting.
That mattered. In a policy environment increasingly oriented toward “evidence-based” funding, home visiting had the kind of evidence Washington recognizes and finances.
And the evidence continues to build; most recently a 2025 HHS study found positive longer-term impacts including on family economic circumstances, maternal health, and “parent-child interactions.”
Voluntary Design
Home visiting does not involve coercive pressure or system involvement.
Families engage because they choose to, not because an agency has leverage over them.
That design choice reduces stigma, improves engagement quality, and makes the program easier to defend politically as a support rather than a surveillance mechanism.
Anchored to a Universal Life Event
Most family programs reach people at their most overwhelmed — in a housing emergency, a health crisis, a child welfare investigation.
Home visiting, by contrast, is typically offered around pregnancy or early parenthood.
Parenting is a common life experience for many adults, one that comes with joys as well as difficulties.
Even when the program is targeted, offering support at that moment reduces stigma and makes engagement easier than programs framed explicitly around risk or system involvement.
Positioned Within Maternal and Child Health
During the ACA debate, there were multiple ideas for home visiting funding.
Some wanted to support home visiting wholly within Medicaid; others thought it should be a child welfare prevention program with ACF.
In the end, MIECHV was established as a maternal and child health program.
This has separated it from partisan Medicaid fights and avoided the perception that it is solely for child welfare-involved families. It broadened its base, reduced partisan friction, and created a broader constituency of engaged stakeholders, including the administrators of state maternal and child health programs.
Multiple Models, Local Ownership
Home visiting is not a single federally imposed model. States can choose among approved evidence-based approaches and braid multiple funding streams.
The wide variety of approaches and funding streams allows states and communities flexibility to design their own version of home visiting to fit their available workforce and families in need of support.
This reduces resistance to implementation, since states are selecting from a menu rather than adopting a single mandated design.
Key Lessons for Leaders from Home Visiting
As policymakers and advocates seek to expand and improve child and family serving programs, there are lessons from home visiting to consider:
Institutional home matters. Where a program sits in the federal architecture shapes who defends it.
MIECHV's placement in HRSA rather than CMS wasn't just an administrative detail.
It shaped the program's political coalition, its beneficiary base, and its distance from the most contested policy fights.
Invest in the evidence before you need it. While expensive and time consuming, being able to point to quality research on the effectiveness of home visiting has been crucial to its growth.
For those prevention services less able to invest in research – or whose approach does not lend itself to traditional evaluation – consider how to use alternative methods to best demonstrate success.
This is also where flexibility of philanthropic investment can make a difference in early proof for innovation.
Collaborating with creative academics and state administrators could increase the chances of this working.
Design for state ownership and capacity, not compliance for capital. The MIECHV model — a menu of approved approaches, required performance measures, significant local design flexibility — created constituencies at the state level that now have political reasons to protect the program.
A pure block grant would have lost accountability; a single mandated model would have lost the local champions.
The balance between those two failure modes is worth studying carefully.
Build bipartisan relationships early and specifically. Generic bipartisan outreach rarely works; it has to connect to local success and leaders' values and priorities.
What worked for home visiting was identifying specific Republican champions at the state level first, then translating that into long-term federal support.
In the current environment, that means finding conservatives who care about early childhood, family stability, or rural access to services — and investing in those relationships before a reauthorization fight, not during one.
