A Framework for Valuing Investments in a Nurturing Society: Opportunities for Prevention Research

Abstract

Investing in strategies that aim to build a more nurturing society offers tremendous opportunities for the field of prevention science. Yet, scientists struggle to consistently take their research beyond effectiveness evaluations and actually value the impact of preventive strategies. Ultimately, it is clear that convincing policymakers to make meaningful investments in children and youth will require estimates of the fiscal impact of such strategies across public service systems. The framework offered here values such investments. First, we review current public spending on children and families. Then, we describe how to quantify and monetize the impact of preventive interventions. This includes a new measurement strategy for assessing multisystem service utilization and a price list for key service provision from public education, social services, criminal justice, health care and tax systems.

Appendix: Public Services and Spending for Children and Families

Education

One of the main approaches to investing in children occurs through public education systems. These include publically funded pre-K, K-12 education and higher education.

1.A. Head Start The federally funded Head Start program was launched in 1965 and designed to serve low-income children. The DHHS Administration for Children and Families’ Head Start Office provides annual information about service rates and spending on this program (Office of Head Start 2016). In 2015, Head Start served 944,581 children and their families in urban and rural areas of all 50 states, the District of Columbia, Puerto Rico and US territories. In addition to pre-K for children three to five, Head Start centers often also provide health services such as health screenings and dental checkups. In 2015, over $8.2 billion was spent on Head Start resulting in an annual investment of about $8680 per child.

1.B State Pre-K For over a decade, the Rutgers National Institute for Early Education Research (NIEER) has conducted annual reviews of state-funded pre-K (Barnett et al. 2016). In 2015, Over 40 states and the District of Columbia provided varying degrees of publically funded pre-K. These efforts served almost 1.4 million children at a cost of $6.2 billion or about $4490 per child. As with many publically funded, locally operated services, quality can vary dramatically across sites. This holds true in the case of Head Start and many pre-K programs (Ludwig and Phillips 2007; Puma et al. 2010).

1.C. Primary and Secondary Education Each year, the US Department of Education’s National Center for Education Statistics assembles information about primary and secondary school enrollment and spending from across the country (NCES 2016). K-12 public education comprises about 98,300 public schools organized into 13,500 school districts that serve about 50.4 million students. About 3.1 million teachers are employed by public schools. The cost to serve these students was about $584.4 billion for the 2016–2017 school year or about $11,600 a student for the year. An estimated 5.83 million of these students use special education services and consume a relatively larger share of education resources. Best estimates are that around 55% more is spent on students using special education services than the average student who does not need services (Chambers et al. 2004). School discipline also consumes a substantial amount of educational resources with over 5% of administrator time and substantially more teacher time being spent on dealing with students’ misbehavior (Horng et al. 2009). Of all students in public education, an estimated 6.5% of these students will not graduate from high school—with substantial variability by district. An estimated 68.4% of graduates will enroll in college the fall after finishing high school (NCES 2016).

1.D. Higher Education Each year, the National Center for Education Statistics compiles information on higher education attendance (Ma and Baum 2016). In 2013, about 18.1 million students attended colleges and universities. Public higher education served over 13.7 million students a year and private high education serves about 4.4 million. Periodically, the College Board reviews government spending on higher education. Both federal and state budgets support higher education, albeit in different ways. In 2013, the federal government provided about $48.8 billion in support (excluding loans and federal research grants). Of that total, $31.3 billion supported federal Pell Grants, $12.2 billion supported veterans’ educational benefits, and $1.6 billion was provided in other financial aid grants. Another $3.8 billion was provided in general purpose appropriations to support operations within higher education institutions. States provided about $62.6 billion in total, with $9.6 billion supporting state financial aid grants and $53.0 billion in general purpose appropriations. Local governments contributed another $9.2 billion in supporting general purpose appropriations. This $120.6 billion in total public support translates into an average of about $6660 a year per student in higher education. These resources are disproportionately oriented toward public institutions, with the majority of the federal and state general purpose appropriations going only to public institutions (The Pew Charitable Trusts 2015).

Social Services

Child welfare agencies protect and promote the welfare of youth at risk for, or who have already experienced child maltreatment. Each year, the DHHS’ Administration for Children and Families’ Children’s Bureau reviews the state of child maltreatment and child welfare services utilization for the country (Child Welfare Information Gateway 2016; Children’s Bureau 2016). In 2014, the most recent data available, there were an estimated 6.6 million referrals for suspected cases of abuse or neglect, 3.3 million who received an investigation. This resulted in an estimated 702,000 substantiated victims of child abuse and neglect and 2.5 million related non-victims (e.g., siblings, non-abusing family members). Of those, 1.3 million received in-home services and 242,919 received foster care system services. Every two years for over a decade, ChildTrends has compiled information on government spending for child welfare services (Rosinsky and Connelly 2016). In 2014, federal, state and local governments spent $29.1 billion on child welfare services. States used numerous funding sources to finance their child welfare agencies and efforts. In this context, the USA spends over $40,000 on child welfare services per child victim per year. This does not include any of the downstream health care, criminal justice, social service or welfare costs known to be related to experiencing child maltreatment (Fang et al. 2012; Gilbert et al. 2009). These child welfare system costs vary greatly across cases and also include the costs to investigate a substantial amount of child maltreatment reports that are not substantiated.

Federal funding provides about 43% of child welfare funding. Title IV-E funding provided over half of federal child welfare resources (55%).Temporary Assistance for Needy Families (TANF) accounts for another 20% and Medicaid accounts for another 10%. The Social Services Block grants provides another 8%, Title IV-B. The final 3% come from a variety of other federal funding streams. These included Child Abuse Prevention and Treatment Act (CAPTA), Community-Based Child Abuse Prevention (CBCAP), Children’s Justice Act, Adoption Opportunities Adoption Incentive Awards, Maternal, Infant, and Early Childhood Home Visiting, Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Social Security Survivor’s Benefits and/or Veterans Administration funds.

State and local funds provided the remaining 57% of total child welfare resources spent in the country. The amount any particular state and local governments spends varies widely. In 2014, it ranged from 82 cents for every federal dollar spent in Puerto Rico to 12 cents for every federal dollar spent in West Virginia (Rosinsky and Connelly 2016).

Child welfare services may be divided into five categories (Aarons and Palinkas 2007; Landsverk et al. 2011): child protective services, in-home preventive services, out-of-home placement, adoption and legal guardianship, and services for youth transitioning out of foster care. Child protective services include intake, screening family assessment, investigation, services provided during the investigation and all associated administrative support. These services account for about 15% of all child welfare spending at over $4.4 billion a year or about $1360 per child served (Putnam-Hornstein and Needell 2011; Rosinsky and Connelly 2016). In-home services to prevent child abuse or neglect or prevent permanent removal from the home include family preservation services, in-home caseworker supports, post-reunification services and all associated administrative support. These services account for about 16% of all child welfare spending at over $4.7 billion a year or about $3610 per child served (Aarons and Palinkas 2007; Rosinsky and Connelly 2016). Out-of-home placement services include foster care maintenance payments, case planning and review, services provided to children in foster care and all associated administrative support. These services account for about 47% of all child welfare spending at over $13.6 billion a year or about $32,640 per child served (Kelly 2015; Rosinsky and Connelly 2016). Adoption and legal guardianship services include ongoing and nonrecurring assistance payments or services and all administrative support. These services account for about 17% of all child welfare spending at over $5.0 billion a year or about $32,760 per child served (Annie E. Casey Foundation 2014; Rosinsky and Connelly 2016). Services for youth transitioning out of foster care include services and supports intended to help youth make a successful transition and all administrative costs. These services account for about 2% of all child welfare spending at over $580 million a year or about $1290 per child served (Rosinsky and Connelly 2016). In addition, there is public support for enforcing child support payments. In 2013, the federal government provided states about $5.7 billion to enforce payment in 14.7 million cases.

Criminal Justice

The criminal justice system aims to prevent and adjudicate criminal behavior and includes law enforcement, the judicial and the corrections systems.

3.A. Law Enforcement US law enforcement includes over 17,985 state and local law enforcement agencies as well as over 100 federal law enforcement agencies. The Federal Bureau of Investigations Unified Crime Reporting program compiles information about reported offenses, arrests and clearances from across the country (FBI 2013). In 2012, 18.2 million offenses became known to law enforcement and law enforcement made over 12.2 million arrests. As a result of these arrests, over 4.0 million offenses were closed (22% of known crimes). The US Department of Justice periodically releases a summary of its budget authority by appropriations, which provides information about past and current spending on federal law enforcement. In 2012, the federal government spent about $14.4 billion on its principal criminal federal law enforcement agencies. Each year, the Bureau of Justice Statistics releases information about state and local law enforcement spending (DOJ 2014). In 2012, state governments spent $14.2 billion and local governments spent $84.1 billion on law enforcement. Nationally, this public spending translates into about $9122 per arrest or about $27,509 to clear a crime. Local sources (county and municipalities) bore 87% of these costs. The cost to clear a crime can vary greatly by the type of the crime, geography and local capacity.

3.B. Judicial System The US judicial system includes the 108 federal courts and over 1800 state district, appeals and supreme courts. In 2012, the federal judiciary filed 1.6 million cases (DOJ 2013; US Supreme Court 2012). In 2012, the federal government spent $7.0 billion on the federal judiciary (US Supreme Court 2012). Each year, the Bureau of Justice Statistics releases information about state and local judicial and legal spending and case filings (BJS 2012). In 2012, the states filed an estimated 15.3 million cases. In 2012, state governments spent $22.7 billion and local governments spent $22.0 billion. The average cost of close a federal case was around $4360 a case. The cost to close a state case is around $2930 a case.

3.C. Corrections System The US corrections system includes 1719 state prisons, 102 federal prisons, 2259 juvenile correctional facilities, 3283 local jails and 79 Indian Country jails (BJS 2016). Each year, the Bureau of Justice Statistics releases information about state and local corrections spending. In 2012, there were 1.5 million prisoners in federal and state facilities (217,815 federal; Carson and Golinelli 2013). In 2012, the federal government spent about $5.9 billion, state governments spent about $48.4 billion and local governments spent about $26.4 billion on corrections facilities (BJS 2012). Each year, the Bureau of Prisons releases an annual determination of the average cost of incarceration through the Federal Register (Prisons Bureau 2016). The official annual determination of the average cost of incarceration for federal inmates in 2012 was $29,027 a year or $79.31 per day (Prisons Bureau 2013). For federal inmates transitioning out of federal facilities, they may stay in Community Correction Centers at an annual cost of $27,003 or $73.78 per day. In 2012, state correction costs per inmate were around $47,600 a year or $130.50 a day, but vary widely by state (Association of State Correctional Administrators 2011; Henrichson and Delaney 2012).

Health care

The health care system includes organizations of people, institutions and resources that deliver health services. Of the over $2.9 trillion in health care spending in 2013, 64.3% was publically funded by federal, state and local governments (Himmelstein and Woolhandler 2016). This spending came from: (1) direct government payments for Medicare, Medicaid, and other public programs such as the Veterans Health Administration, and other public health departments; (2) government agencies’ expenditures for public employees’ health insurance coverage; and (3) federal, state and local tax subsidies to health care. Direct government expenditures are the largest category of spending and the focus here as described above.

4.A. Medicaid Medicaid is a government insurance program for individuals and families with limited resources. As a means-tested program started in the 1960s, it requires enrollees to have an income below a set amount. It is jointly funded by the federal and state governments. Medicaid enrollment varies with individuals cycling in and out depending on their income status. Further, changes under ACA have led to increases in Medicaid enrollment since its passage in 2010 (Thompson et al. 2011). Each year, the Centers for Medicare and Medicaid Services provide enrollment and national heath expenditure data about Medicaid (CMS 2014b). In 2011, enrollment was 57.1 million for the year (CMS 2011). In 2011, the most recent year available, average expenditures on Medicaid enrollees with full or partial coverage were $5790 (KFF 2013). For aged individuals on Medicaid, the average was $13,249. For individuals with disabilities, it was $16,643. For adults, it was $3247. For children, it was $2463.

4.B. CHIP The State Children’s Health Insurance Program (CHIP) is designed to cover uninsured children in families with incomes that are low, but still too high to qualify for Medicaid. CHIP is a partnership between federal and state governments (CMS 2014a). States may operate it as a separate program independent from Medicaid, use CHIP funding to expand Medicaid or combine these approaches. Each year, the Centers for Medicare and Medicaid Services provide enrollment and national heath expenditure data about CHIP (CMS 2014b, 2016; MACPAC 2016). In 2011, 7.9 million children were enrolled in CHIP. This had grown to 8.1 million by 2014. In 2014, $13.0 billion was spent on CHIP or about $1600 an enrollee a year.

4.C. TRICARE The Military Health System provides health care to active duty and retired US military personnel and their dependents. The MHS consists of 65 hospitals, 412 clinics and 414 dental clinics worldwide. Military personnel are provided with the TRICARE program that provides civilian health benefits and functions much like Medicare. Data are not frequently released about the TRICARE system. A recent review by the CBO, which was able to obtain data from the Department of Defense, provided enrollment and spending information for the TRICARE program (CBO 2014). In 2012, TRICARE served 9.6 million beneficiaries at a cost of about $52.0 billion ($5400 a beneficiary).

4.D. Veterans Administration The Veterans Health Administration consists of about 1700 hospitals, outpatient clinics, counseling centers and long-term care facilities. These facilities are owned and operated by the federal government. Each year, the National Center for Veterans Analysis and Statistics releases compiles utilization and expenditure data by state (NCEVAS 2015). In 2015, of the about 27.6 million current veterans, the VA served over 5.9 million. That year $65.6 billion was spent on VA medical care or about $11,056 per veteran who used the VA for the year (NCEVAS 2015).

Welfare

A number of welfare programs are available to support individuals, many of which are targeted toward children and families. These include Temporary Assistance for Needy Families (TANF), Women, Infant and Children (WIC) program and Supplemental Nutrition Assistance Program (SNAP).

5.A. TANF The Temporary Assistance for Needy Families (TANF) is a federal assistance program created in 1997 that replaced the Aid to Families with Dependent Children (AFDC) program. TANF provides cash assistance to poor American families with dependent children, but also provides funds for child welfare (as described above; Falk 2016). There is a federal maximum of 50 months of the cash assistance from TANF across an entire lifetime, but some states limit this further. Recipients are required to find a job within 24 months of receiving aid. Caseload and expenditure data for TANF are released each summer by the DHHS Administration for Children and Families Office of Family Assistance (ACF 2016a, b). In 2015, TANF provided support to 1.6 million families (4.1 million recipients, 2.9 million children). In 2015, federal and state governments spent $8.4 billion on cash assistance or about $5190 a year per family or about $2196 a year per individual.

5.B. WIC The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program is a federal assistance program from the United State Department of Agriculture that supports the nutrition and health of low-income pregnant women, breastfeeding women and infants under the age of five. Family income must be below 185% of the federal poverty level. The USDA Food and Nutrition Service periodically releases reports on WIC utilization and expenditures (Johnson et al. 2013). WIC serves over 50% of all infants born in the USA. In 2012, it served 9.7 million participants at a cost of $6.8 billion or a cost of about $700 a participant. Actual WIC payments to recipients vary depending on income level and family size.

5.C. SNAP The Supplemental Nutrition Assistance Program (SNAP), previously referred to as Food Stamps, is a federal aid program that provides food purchasing assistance for low-income individuals (Food and Nutrition Service and Office of Research and Analysis 2012). It is administered by the US Department of Agriculture and distributed by state social service agencies. The USDA Food and Nutrition Service releases periodic reports of enrollment (USDA 2015). In 2015, SNAP provided assistance to about 4.8 million individuals each year at a cost of about $74.0 billion or about $1616 a year per recipient.

5.D. Housing Assistance.

Tax Credits

Two major types of tax benefits are directed at children and families: the Earned Income Tax Credit (EITC) and the Child Tax Credit (CTC). These two programs come in the form of a tax credit. If the credit is more than they owe in taxes, benefits are paid out as part of the tax return (i.e., lump sum). It is estimated that together these programs have helped raise 9.4 million people out of poverty.

6.A. EITC The EITC is one of the largest anti-poverty programs. The Internal Revenue Service releases annual statistics on tax returns claiming the EITC and the amount claimed (Internal Revenue Service 2016). In 2015, 27.5 million individuals received it at a public cost of $66.7 billion. The average amount of EITC paid to those who claimed it was $2400. About 80% of those eligible for the EITC claim it. There are over 20 different determinations for eligibility for the EITC.

6.B. Child Tax Credit The child tax credit is worth up to a $1000 a child for families with children under the age of 17 (Center on Budget and Policy Priorities 2016). A qualifying child is one that is your son, daughter, stepchild, foster child, brother, sister, stepsister of descendent of any of these individuals (grandchild, niece or nephew) or non-biologically related adopted child. The child must be a dependent on the guardians’ tax return and not provided more than half of their own support. The child must be a US citizen, US national or US resident Alien and must have lived with the guardian for more than half the year. The tax credit begins to decrease when an individual’s income is over $75,000 for the year or a couple income is over $110,000 for the year. In 2014, 19.9 million households received the child tax credit (Tables 3, 4).

Table 3 Valuing Multisystem Utilization Framework (VMUF)

Table 4 Valuing Multisystem Utilization Framework–Health care Utilization Supplement VMUF-HCUS