Framework of the Organisation for Economic Co-operation and Development and the Nurturing Care Framework of the World Health Organization (WHO) and United Nations provide overarching guidance for global, evidence-informed actions for improving early child development (Black & Hurley, 2014; Black et al., 2016; World Health Organization et al., 2018).

More recent policy frameworks for early child development have built on the latest science of early childhood and the first 1,000 days (Black & Merseth, 2018; Shonkoff, 2010; Shonkoff & Fisher, 2013). Policymakers can consider investments that address small needs before they become more costly and complex, aiding in school readiness, better long-term health, lower incarceration costs, boosted earnings, and future tax payments. Many early childhood policies and interventions have demonstrated such returns well into adulthood and beyond. For example, in several studies, Heckman and his colleagues have detailed strong return on investment for high-quality early learning programs that lead to improved adult health and educational outcomes (see García et al., 2020).¹ Research on multiple evidence-based home visiting models has similarly demonstrated strong returns on investment based on future savings in public benefits, from health to child welfare to justice involvement (Minkovitz et al., 2016). Other studies have associated Medicaid health coverage during pregnancy and early childhood with long-term educational, earnings, and health outcomes into adulthood and to two generations in the future (Boudreaux et al., 2016; Goodman-Bacon, 2021). These types of programs and interventions can be scaled to serve more families. But, as described in Chapter 4, scaling programs need to permit adaptations to local contexts and cultures. Such adaptations need to be adequately resourced to account for additional costs, effort, and time. Continued and ongoing evaluations are also needed to ensure that promising interventions and programs align and adapt to the full range of child and family circumstances, cultures, and best practices.

Current national and state policies for economic security, health, early education and childcare, and family services in early childhood do not sufficiently promote and support early relationships between parents and their young children (Doyle et al., 2023; Johnson et al., 2023). Yet evidence-informed programs and practices, with proven effectiveness in nurturing early relationships, are available to guide policy change. Many also work to remove system-level barriers that have far too often burdened parents and disrupted their well-being (Damian et al., 2025; NASEM, 2016). Even when federal policies have expanded evidence-informed programs—such as through the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting (MIECHV)

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¹ Long-run evidence for such longitudinal studies may suffer from a changing-context problem. In the case of the Perry Preschool Project, for example, the conditions facing the children who were studied and their families were vastly different from the conditions for children today (Duncan & Magnuson, 2013).

program—they often reach only a small fraction of those who could benefit and cannot adequately garner full population-level impacts (Daro & Dodge, 2010; Yoshikawa et al., 2018).

A constellation of policies and systems, working together, is needed to support early relational health in homes, clinics, schools, communities, and states where young children and their families live, work, play, and ultimately flourish (Johnson et al., 2023). Interconnected federal and state policies and early childhood systems have significant potential to create the conditions for early relational health by aiding nurturing relationships in families and communities.

Aligned principles for action can sharpen the focus of policymakers and strengthen impact. Rather than list the full array of possible federal and

workforce-supportive policy is Medicaid reimbursements for home visitors, community health workers, and community-based doulas (Bakst et al., 2020).

Does the policy increase access to parent/maternal, infant, and early childhood mental health services, beginning prenatally and including promotion, prevention, and treatment for parents and children together? Relevant policies include the broad range of mental health and substance use disorder prevention, screening, and treatment for families (Drake-Croft et al., 2025; Horen et al., 2024). Policy and funding support is necessary so that health and mental health systems will be well equipped to ensure access to developmentally appropriate parent–child maternal, infant, and early childhood mental health services. In particular, such approaches, services, and treatments are needed to promote, nurture, and/or repair caregiver/parent–child relationships.

Does the policy strengthen and coordinate with other programs and systems that interface with young children and their families? Linkages and coordination are needed among health, family support, early care and education, home visiting, early intervention, mental health, housing, child welfare, and other services and informal supports.

FINANCING OPPORTUNITIES TO ADVANCE EARLY RELATIONAL HEALTH

This section describes opportunities for expanded local, state, and federal investments to support initiatives, programs, and models specifically targeted at improving early relational health. It highlights opportunities within the Medicaid program to redouble efforts to serve children and their families, as well as additional financing opportunities to support caregiver well-being. Of note, in the past decade, a number of private foundations and their partners have invested in efforts to advance early relational health policy and practice at the federal and state levels.² Investments like these have advanced a vision of early relational health for young children and their families. Continued investment from private and philanthropic organizations can help to spur growth and learning.

Opportunities in Medicaid to Advance Early Relational Health

Medicaid, together with its smaller companion, the Children’s Health Insurance Program (CHIP), covers more than 40% of all children under age

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² For example, Blue Meridian (2024) supports HealthySteps in New York. And the Early Childhood Funders Collaborative (n.d.) supports early relational health knowledge-building in the philanthropic community through its Early Relational Health Work Group, helping foundations align investment strategies in support of early relational health.

6 years and three-fourths of children from low-income backgrounds under age 6 years (Brooks-LaSure & Tsai, 2021). Medicaid is a key player in early relational health, particularly in its payments to the health and mental health systems, especially primary care. Medicaid offers an opportunity to reach low-income families before children reach kindergarten, as children have frequent well-child visits in the months and years following birth. Medicaid also finances a substantial share of health services delivered in most child-serving systems: health care, education,³ disability, child welfare, and mental health. Medicaid thus offers a unique opportunity to support and serve early relational health, and it is important to ensure that its payment policies meet this opportunity effectively.

Medicaid’s pediatric benefit, called Early and Periodic Screening, Diagnostic, and Treatment (EPSDT), entitles to every child covered by Medicaid a comprehensive benefit package that provides all recommended screenings, any medically necessary interventions (e.g., diagnostic testing, treatment), and support for families to access services (e.g., transportation, case management). This benefit targets the prevention or lessening of the delays or conditions identified by screens (Rosenbaum & Johnson, 2023). EPSDT sets the legal authority for financing of nearly all child health services covered by Medicaid. However, its potential has yet to be fully realized in practice, with state variation in implementation; policymakers could take a closer look at whether states are fulfilling the full EPSDT mandate for each child. While access to timely care is a challenge across the health system, Medicaid’s entitlement to its enrollees—especially developmental checks and prevention or early intervention services for children—offers significant opportunity to prioritize young children and their families during a time of rapid development before time-sensitive windows close and make delays or conditions more complex and costly to treat.

As the largest single insurance payer in the nation’s health care system, Medicaid has potential to reshape how services and systems are organized around children and their families with a dedicated prevention focus under EPSDT. Yet sustained and sufficient attention to the health and developmental needs of young children is limited in national and state health policy discussions (NASEM, 2024a). Payment reform efforts typically focus on older populations, in part to identify near-term savings. Payment reform for children, however, must recognize children’s unique developmental needs and the long-term consequences of failing to meet those needs during sensitive periods of rapid growth. Moreover, lowering short-term financial costs within the health sector may result in higher expenditures over time, as unaddressed problems can grow and potentially become catastrophic. Sustained and dedicated leadership, financial commitment, and monitoring

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³ Medicaid’s financing of health services via education includes fulfilling the requirements of the Individuals with Disabilities Education Act.

can help elevate the full range of health services that support early relational health for young children and their families—from promotion to prevention, screening, and treatment.

Medicaid’s financing structure could boost early relational health within the health care system and with the services and supports connected to it. The federal government pays a set percentage of the cost for any eligible services provided to Medicaid enrollees on an open-ended basis (i.e., a financial entitlement) to states. For that reason, Medicaid’s financing structure and state flexibility in administration offer a significant opportunity to scale promising, developmentally appropriate, research-backed services that advance optimal early childhood development and relational health.

Relatedly, increasing the federal share of Medicaid financing could reduce state budget pressures and promote more uniform implementation of benefits across states (American Academy of Pediatrics [AAP], 2023). Another opportunity in this space is incorporating social risk stratification into pediatric Medicaid payment arrangements, recognizing that children’s health outcomes are shaped not only by clinical care but also by the socioeconomic environments in which families live (Carlson et al., 2022). States are also beginning to test alternative payment models for pediatric care, which can help support comprehensive team-based approaches in primary care (DePasquale & Gunnar, 2020).

A note of caution is warranted here. In 2025, Congress passed nearly $1 trillion of reductions in Medicaid and nutrition assistance to be carried out over a decade (see Public Law 119-21). The new law adds mandatory work-reporting requirements and other administrative burdens for adults—many of whom are parents (Park & Corlette, 2025). In Arkansas and Georgia, which have implemented Medicaid work-reporting requirements, working adults have struggled to report hours or exemptions and have been disenrolled in coverage despite remaining eligible (Gangopadhyaya & Karpman, 2025; Sommers et al., 2020). In contrast, Medicaid expansion to parents has been associated with a “welcome mat” effect—when parents gain health coverage, their children who are already eligible for Medicaid or CHIP will also gain coverage (Hudson & Moriya, 2017). However, estimates suggest the reverse is also true: as work-reporting requirements and other administrative barriers cause parents to lose coverage, their children are at risk of losing coverage as well (Mann et al., 2025).

In addition to Medicaid changes, the new law makes other cuts that will likely put financial strain on state and local budgets in the years ahead (Euhus et al., 2025; Kinsley & Rusyniak, 2025). States have wide flexibility in the program’s administration, financing, and eligibility levels. State budget strains resulting from overall federal cuts may directly impact states’

capacity to maintain coverage, services, and provider payments at current levels. Cuts could further limit states’ ability to improve EPSDT implementation through managed care organizations or other providers, or cause them to scale back oversight, provider reimbursements, or income eligibility levels (Euhus et al., 2025; Kinsley & Rusyniak, 2025).

Importantly, Medicaid and the health system at large are not sufficient to fully realize early relational health. But significant opportunity lies in Medicaid’s connective tissue, broadly reaching families with low incomes in pediatric primary care before children enter kindergarten. Additionally, Medicaid’s potential to strengthen connections and linkages to the range of supports for families across systems can also advance early relational health across communities. Policy changes to remove prohibitions on same-day billing for primary care and mental health services could further strengthen this integration, enabling families to access multiple forms of support in a single visit (California Children’s Trust, 2023; Office of Congressman Neil Dunn, 2024). To allow Medicaid to grow such linkages, however, continuous child enrollment and access to strong, team-based pediatric primary care is necessary.

Opportunities to Refocus Medicaid Policies on Young Children and Their Families

Based on policy and program recommendations in recent years, several overarching Medicaid policy recommendations have emerged for federal and state leaders to create a more sustained focus on young children and their families and thus support progress to advance early relational health (Burak, 2018; Burak & Rolfes-Haase, 2018). As summarized in Box 5-2, NASEM (2024a) outlined foundational financing strategies needed to rebalance payment policies to prioritize prevention, elevate children’s earliest developmental needs, and support families.

Health insurance coverage itself is a necessary, if insufficient, step to help more children and their families access the care they need at the right time. Forty states and Washington, DC, have adopted the Affordable Care Act Medicaid expansion (Public Law No 111-148) to all adults up to 138% of the federal poverty line. In addition to supporting economic security for families, the adult expansion has been associated with improved maternal and child birth outcomes and access to mental health and other needed care (Eliason, 2020; Guth & Ammula, 2021; Guth et al., 2020; Steenland & Wherry, 2023; Saygili & Bayindir, 2024). Since 2022, all but two states have adopted a new state option to extend postpartum coverage from the federal minimum of 60 days to 12 full months following the end of pregnancy, which can help nurture mother–infant relationships during a period

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⁴ See https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker.

way to better understand its role in helping to minimize gaps in health coverage and improve access to care.

Beyond coverage itself, some isolated efforts demonstrate how states can do more to ensure that developmentally appropriate health interventions are adequately reimbursed, including those that support parents and caregivers as key partners in children’s earliest development (Damian et al., 2025; Johnson & Bruner, 2018). In recent years, for example, states have more proactively sought to ensure that Medicaid finances infant and early childhood mental health screenings and services, as well as developmentally appropriate diagnostic tools (Smith et al., 2023). However, barriers remain, as referral resources often are unavailable or waiting lists for them are onerously long.

System-level strategies can also strengthen Medicaid’s role in supporting children and families. Increased alignment between Part C and Medicaid programs offers an opportunity to address the mental and relational health needs of young children and their caregivers through coordinated screening, standardized follow-up, and support for parenting groups (DePasquale & Gunnar, 2020). An additional opportunity is to sufficiently reimburse AAP-recommended universal screenings in primary care, including developmental, autism, behavioral, maternal depression, and social drivers of health. These reimbursements can enable and incentivize providers to identify and address concerns early in life (ZERO TO THREE, 2016). Early identification and intervention could also be improved by ensuring Medicaid reimbursement for age-appropriate diagnostic codes, including nonspecific codes for mental health treatment, to better support early identification and intervention (AAP, 2023). Another opportunity to support early caregiver–child relationships through Medicaid payment policies is allowing billing for prevention-oriented dyadic services delivered in primary care settings without requiring a formal mental health diagnosis (Garner et al., 2021). Sustained change will also require long-term financing strategies. Mechanisms such as Title XXI Health Services Initiatives, Certified Community Behavioral Health Clinics, managed care quality levers, and community reinvestment requirements present some promising ways to ensure early relational health is consistently supported in Medicaid (AAP, 2023).

This committee presents additional policy strategies that recognize and go a step beyond those suggested in the National Academies report Launching Lifelong Health by Improving Health Care for Children, Youth, and Families (NASEM, 2024a). These additional strategies, outlined in Box 5-3, can encourage practice and system changes to promote early relational health across the many child-serving systems that Medicaid helps finance.

Van Niel et al., 2020) and with improved parental mental health and wellbeing (Bullinger, 2019; Cardenas et al., 2021; Irish et al., 2021; Jou et al., 2018). Several studies have evaluated the impact of California’s enactment of paid family leave in 2004, which provides eligible workers with 55% of their normal earnings (up to a maximum benefit) for up to 12 weeks postpartum; California recently extended this to 14 weeks. The studies found that the law had large positive impacts on mothers’ leave-taking (e.g., Bailey et al., 2025; Bartel et al., 2018; Baum & Ruhm, 2016; Rossin-Slater et al., 2013). Rossin-Slater et al. (2013) found that California’s policy doubled maternity leave usage among new mothers. Bailey et al. (2025), Baum and Ruhm (2016), and Bartel et al. (2018) also found that California’s policy increased leave-taking among fathers.

Policy opportunities include extending comprehensive paid family and medical leave programs to all states. As of January 2025, such policies have been enacted in 13 states and the District of Columbia.

Economic Security

Family financial security helps to minimize stress and provide optimal basic conditions for family nurturing and engagement (NASEM, 2024b). Poverty-reducing tax credits, such as the Earned Income Tax Credit (EITC) and CTC, not only influence families’ economic outcomes (Hoynes, 2019; Hoynes & Patel, 2018; Meyer & Rosenbaum, 2001) but also can reduce risk factors associated with child maltreatment (Fortson et al., 2016; Schneider & Schenck-Fontaine, 2022).

Other recent National Academies reports (NASEM, 2019b, 2023, 2024b) identified ways to reduce child poverty in the United States and decrease intergenerational poverty. Specifically, Reducing Intergenerational Poverty highlighted the importance of the EITC, the Child and Dependent Care Tax Credit, the Supplemental Nutrition Assistance Program (SNAP), and policies to support minimum wage increases (NASEM, 2024b). The committee acknowledges the critical importance of tackling childhood poverty to enhance the health and well-being of children and families; it endorses the recommendations put forward in these earlier reports. Several states have advanced policies for boosting family economic security beyond access to health coverage and nutrition services. Recent and popular examples include minimum wage of at least $10/hour (29 states), refundable state EITC (28 states), and state CTC (8 states).

Cash transfers may hold some promise. Several studies of cash transfers indicate improvement in health and family relationships (NASEM, 2019b, 2024b). However, a recent experiment by Duncan et al. (2025) analyzed the effects of cash transfers on maternal and child health and found that monthly unconditional cash transfers of $333 over 4 years did not appear

to improve maternal mental health, maternal or child body mass index, or maternal reports of children’s health. The authors suggest that this failure to impact physical and mental health could have many causes; for example, the cash gifts did not improve maternal reports of economic or material hardship or perceived stress or lead to better housing quality or moves to better-resourced neighborhoods (Duncan et al., 2025). The COVID-19 pandemic also began 1 year into this study, which could have produced challenges for families that a monthly cash gift was simply not enough to handle. Ultimately, the authors concluded that because the effects that these income supports had on health outcomes may not emerge until the children are much older, follow-ups and further research are necessary to better understand the impact that cash transfers can have on families (Duncan et al., 2025).

Expanded childcare support (e.g., childcare subsidies, expanded Early Head Start and Head Start, universal pre-K) can also support families and early relational health. The federal Child Care and Development Fund (CCDF) provides funding to states and tribal governments to help families with low incomes pay for childcare. Specifically, for Native American children and families, some tribes would like to extend the CCDF-related services they offer on reservations to members who live off-reservation but face service-area restrictions (Fabre et al., 2023). Fabre et al. (2023) suggested that federal policies could be revised to give tribes flexibility to serve members living off-reservation, or Urban Indian Organizations could be made eligible to receive CCDF funding and provide related services.

Food Security

Hunger, due to food insecurity, can directly interfere with cognitive bandwidth and emotional self-regulation (Royer et al., 2021; see Chapter 3). Ensuring that all families have access to healthy, nutritious food is essential for supporting early relational health, enhancing food security, and improving outcomes for children (Odoms-Young et al., 2024). Local communities implement a range of strategies for addressing food insecurity among families (see, for example, Seligman & Berkowitz, 2019). For many families, navigating formal food resources, whether at the community level or within the broader food system, can be challenging. Barriers such as complex eligibility criteria, limited transportation options, and restricted hours of operation often hinder access. To help families navigate and access the complex network of food-related supports, assistance from social workers, community health workers, health care providers, or case managers who are familiar with local resources is essential for promoting food security and supporting early relational health.

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⁵ See https://actcincy.org and https://act-ca.org.

⁶ Developmental Understanding and Legal Collaboration for Everyone (see Chapter 4).

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⁷ See https://www.pcpcc.org/about/medical-home.

⁸ HRSA’s National Survey of Children’s Health (NSCH) composite measure for a medical home includes having (a) a personal doctor or nurse, (b) a usual source for sick care, (c) family-centered care, (d) few problems getting connected to needed referral resources, and (e) effective care coordination when needed. The 2022 NSCH data show that less than half (47%) of U.S. families with young children ages 0–5 years reported that their children received care in a medical home. Rates of access vary by race and ethnicity: among those under age 18 years, only 55% of non-Hispanic White, 35% of non-Hispanic Black, 37% of non-Hispanic Asian, and 34% of Hispanic children had care that met the basic criteria for a medical home in 2022 (Child and Adolescent Health Measurement Initiative [CAHMI], n.d.).

of unmet basic needs on low-income children’s health” (Webb et al., 2020, p. 4). Further, the AAP policy statement Preventing Childhood Toxic Stress: Partnering with Families and Communities to Promote Relational Health proposed that family-centered pediatric medical homes need to universally promote relational health and encouraged a paradigm shift in clinical practices for greater partnership with families and improved outcomes (Garner & Yogman, 2021).

While all children need access to a medical home, many families with young children need additional support through a high-performing medical home; this model exceeds current standards of practice and medical home definitions (Johnson & Bruner, 2018). For children birth to age 5 years, high-performing medical homes focus on promoting optimal development and engaging parents of young children to achieve better outcomes. Team-based care, an element that has seen recent policy progress with Medicaid reform, is also important for high-performing medical homes (Barrett, 2017a).

Improvement is needed to ensure access to high-quality, unbiased, and effective primary care for all young children. An advanced, team-based, high-performing medical home for young children (a) provides comprehensive, relational, and strengths-based well-childcare based on the Bright Futures standards; (b) coordinates relational care with care team members to connect families with community resources; and (c) embeds or links to other services and supports. This aligns with the AAP’s statement calling for a paradigm shift to support relational health, which emphasizes that children’s primary care providers need sufficient time with patients and families; continuity of care with families; and skills for forming respectful, trusted, and collaborative relationships with families (Garner & Yogman, 2021). Team-based care using strengths-based approaches has been shown to help in building trust and making care more acceptable and effective (Wesson et al., 2019).

As a key component, a high-performing medical home requires enhanced relational care coordination; however, most medical practices are not currently equipped to provide this coordination (Johnson & Bruner, 2018; Willis et al., 2022). Enhanced relational care coordination can be prompted by medical or social complexity; these situations disproportionately affect children covered by Medicaid or residing in medically underserved and low-income communities. Enhanced care coordination offers structured and effective efforts to engage with families to identify needs and help secure services and supports to respond to their needs. An increasing body of evidence supports the use of this type of care coordination to address concrete needs and social risks (Arbour et al., 2022; Chung et al., 2016; German et al., 2023; Gottlieb et al., 2016; Pantell et al., 2020; Webb et al., 2020).

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⁹ See https://pn3policy.org/pn-3-state-policy-roadmap-2024/us/comprehensive-screenings.

states explicitly reimburse for dyadic treatment, or parent–child therapy, for young children along with their parents; 13 states allow such treatment without a formal child diagnosis, using other risk factors to establish medical necessity (Smith et al., 2023). California broadened its medical necessity criteria to remove diagnosis as a sole requirement to access family therapy; it also boosted preventive dyadic pediatric primary care models (Johnson & Burak, 2023). Forty-four states finance group parenting and parenting care in Medicaid (Johnson et al., 2024). More than half of states use Medicaid to support home visiting, which also offers a mechanism for supporting parent and child mental health (Burak & Wachino, 2023; Thompson & Hasan, 2023).

Additional promising models of family engagement and coordination within the medical home include the EnAct! (Engagement in Action) Framework developed by CAHMI.¹⁰ Complementing this is Bethell’s Whole Child Risk Index, which provides a composite population-level measure (Bethell, Blackwell, et al., 2022). When embedded into health and social data systems, this index enables public health departments to monitor community-level early relational health trends, target investments to communities with the highest burden of relational risk, and gauge improvement over time (Bethell, Blackwell, et al., 2022).

POLICIES TO SUPPORT WORKFORCE DEVELOPMENT AND WELL-BEING

The existence of a diverse, well-trained, relationship-focused workforce across all early childhood systems is critical for advancing early relational health (Burak & Wachino, 2023; Johnson et al., 2024).

There are also important opportunities for Medicaid policy to support expansion of the workforce and services that support families. One example of this is expanding Medicaid coverage for services delivered by community health workers and doulas, who are positioned to assist families during pregnancy, birth, and the early years of a child’s life (National Academy for State Health Policy, 2025; Oregon Health Authority, 2024). In particular, prenatal and postpartum doula services have been shown to decrease preterm birth and complications and improve maternal and infant outcomes (Cross, 2023). States are recognizing and reimbursing a broader range of community-based care providers that can extend the early relational health workforce, including doulas (24 states) and community health workers

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¹⁰ The EnAct! Framework offers an actionable, evidence-based road map for promoting early relational health through whole-child and family assessment. The Framework aligns with Bright Futures guidelines and integrates relational metrics into preventive care across systems (see https://www.cahmi.org).

(29 states; Chen, 2025; Halar & Hinton, 2023); these policy changes have involved state plan amendments, Section 1115 demonstration authority, or managed care contract arrangements. Washington state lawmakers funded a pilot Medicaid program to support community health workers in pediatric practices to help support early relational health for children under age 3 years and their families (Hasan, 2024; Johnson & Burak, 2023). As part of other child and mental health initiatives, California created new Medicaid provider types for doulas, community health workers, and behavioral health coaches (Johnson & Burak, 2023). Similarly, New York State reimburses nonlicensed providers such as community health workers, doulas, and several of the provider types within Children and Family Treatment and Support Services. Payment rates need to be aligned to ensure that this workforce has the capacity to utilize early relational health models as tools for their service delivery (Mendelsohn et al., 2025). Coverage policies could also support parenting education groups, provider professional development around early relational health, and parity for telehealth-delivered services, all of which expand access to relational health supports (Cross, 2023).

Accrediting and certifying bodies for the training and certification of health care professionals (e.g., physicians, nurses, nurse practitioners, physician assistants, mental and dental health providers) can also implement policies requiring training, competencies, and professional development to ensure that the health care workforce is able to promote early relational health (NASEM, 2024a).

In addition to opportunities available in medical primary care, early care and education settings and caregivers also offer broad reach to young children and their families, with early care providers fostering their own nurturing relationships with children while parents work as well as supporting children and families’ relationships. The early care and education system and its workforce offer another concrete area of action in which to advance early relational health in ways that help seed culture and systems change. This will require stabilizing the childcare system amid the crisis in care affordability, access, and care needs. The National Academies report Transforming the Financing of Early Care and Education advances a policy vision for boosting compensation and benefits for early care and education providers (NASEM, 2018). Some states are taking steps in this direction; for example, New Mexico created a trust fund to support compensation for the early care and education workforce and to provide financial support for families. The state is poised to do more to advance early relational health with a more stabilized and stable early care and education system in place.

Leveraging early care and education to advance early relational health also requires caring for the childcare workforce itself (NASEM, 2024c). This essential workforce faces challenging working conditions, including

low wages, long hours, and high physical and emotional demands (Kwon et al., 2021), leading to staff turnover, absenteeism, poor physical health conditions, high rates of burnout, emotional exhaustion, stress, and mental health problems (Haberman, 2005). A growing body of evidence demonstrates that educators’ ability to offer stable, stimulating, and inclusive education settings for young children is affected by their own wellbeing (see Buettner et al., 2016; Hindman & Bustamante, 2019; Chapter 11 in Institute of Medicine & National Research Council, 2015).

IMPLEMENTATION CONSIDERATIONS

Policy change is only as effective as its implementation and oversight. Much of the opportunity to advance early relational health lies in state policies, but most rely in whole or in part on federal funding through grants or payments from education, health care, human services, and child welfare. Variation in policies and their implementation between states can create disparities that may need attention through targeted investments and evaluation. As in Medicaid, state family leave, childcare, and home visiting policies, to name only a few, have helped to serve as the laboratories for testing policy changes and pushing upward to federal policy change and reinforcement. Effective implementation requires education and outreach about the policy change itself, consistent leadership and oversight to ensure the changes work as intended, systems that reflect policy changes, and ongoing monitoring of the policy’s impact to allow for tweaks or changes as unintended consequences emerge. Most important, co-creating and co-designing policy change and creating opportunities for feedback and input from families served is essential to gauge areas for improvement and a sense—beyond formal research—of whether a policy change is having its intended impact.

CONCLUSION

Numerous policy and practice opportunities are available at the individual, family, community, and society levels. Local, state, and federal policies and investments, as well as philanthropic and private-sector supports, can advance early relational health at the population level. While the committee was not charged with conducting cost calculations for implementation of new or expanded policies to support early relational health, it notes a large literature on the benefits and returns on investments of policies focused on supporting young children and their families. Taken together, the evidence presented in this chapter and in Chapter 4 helped the committee to identify a number of federal and state-level policy and practice opportunities to advance early relational health and promote child, family, and community flourishing.

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