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Universal Pre-K Could Affect Access to Preventive and Diagnostic Care

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While proponents of universal pre-K (UPK) and other early care and education (ECE) programs have long cited its value for promoting children’s cognitive and social emotional development, preliminary evidence shows that these programs have similar direct health benefits.

Participation in center-based ECE programs is also associated with increased rates of screening and early identification; preliminary evidence shows that UPK is associated with similar direct health benefits. UPK has the potential to expand access to healthcare services and prevent disease for participating children and to advance health equity for low- and middle-income children by improving access to preventive and diagnostic care that facilitate early intervention, when necessary.


Early childhood development is an important determinant of long-term well-being and health over a person’s lifetime. While evidence on their short-term outcomes has been mixed, there is well-established evidence that ECE programs have a positive impact on students’ long-term socioeconomic outcomes and lifelong health behaviors, particularly for low-income children.

Health and Human Services’ (HHS) Healthy People 2030 initiative highlights that timely provision of regular health and developmental screenings along with other recommended early childhood healthcare services (e.g., routine dental and vision care) is critical for reinforcing healthy behaviors and preventing disease as well as early diagnosis of health conditions and early intervention to improve outcomes.

Overall rates of developmental screening remain low, however, with well-documented disparities in screening and early diagnosis rates among low-income and minority children. Further, many markers of children’s health continue to worsen. For example, rates of type 1 and type 2 diabetes in youth continue to rise. The prevalence of obesity has also increased by 86 percent among children ages 2 through 5, and new data have shown that obesity rates have increased during the pandemic. Early screening and prevention can help to address these and related comorbidities.

ECE as a Site of Care

In 2012, 58 percent of children 4- or 5-years old regularly attended some form of center-based ECE program before kindergarten entry. Center-based ECE arrangements can be non-profit or for-profit programs that are offered in various settings, including schools, community-based organizations, and faith-based organizations. Center-based programs are distinct from home-based care programs where children are cared for in relatives’ or nonrelatives’ homes or normally cared for by their parents.

Researchers have established a link between participation in center-based ECE programs and increased use of preventive and diagnostic care. In some cases, the direct provision of healthcare services is built into ECE program design. Since 2007, Congress has required Head Start (HS) and Early HS programs to provide health and developmental screenings and referral services for participating low-income children with documented behavioral problems, unlike most large-scale ECE programs.

The Administration for Children and Families’ most recent HS impact study found that HS children were more likely to receive referral services for hearing and vision screening than their non-HS counterparts. Children participating in other forms of center-based ECE programs also have higher screening and identification rates for attention deficit disorder and hearing problems when compared to children not in an ECE program. In addition to providing important education and support for social and cognitive development, they can also support areas of physical health.

Table 1. Public Pre-Kindergarten Program Types
Publicly Funded Pre-K Program Type Ages Served Eligibility Requirements Healthcare Services Offered
Non-Universal Pre-K 3- to 4-years old May have eligibility or income requirements Varies by program
UPK 3- to 4-years old No eligibility or income requirements Varies by program
HS 3- to 5-years old Family income below the federal poverty line Medical, dental, vision, and hearing screening and referrals; nutrition services; health education; mental health screening and referrals; immunizations; assistance in establishing a medical or dental home
Early HS Up to 3-years old Family income below the FPL Health and mental health services or referrals; nutrition services; immunizations

Sources: Brookings Institution. “The Current State of Scientific Knowledge on Pre-Kindergarten Effects” (2017); National Academies of Sciences, Engineering, and Medicine. “Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity“(2019).

Public Pre-Kindergarten Policy Landscape

UPK programs are voluntary, typically state-funded ECE programs that are open to all age-eligible children regardless of family income. Of note, unrestricted eligibility does not necessarily translate to universal access to UPK, as access can be limited by funding amounts, enrollment caps, and enrollment deadlines. Most state-funded UPK programs primarily serve 4-year-olds, and only 2 states serve more than a quarter of their 3-year-olds, although the federal HS and Early HS programs do serve low-income 3-year-olds. The National Institute for Early Education Research (NIEER) estimates that at least 5 million more pre-K seats will be needed to scale up UPK nationwide, which would require an annual investment of $91 billion to ensure universal access to high-quality, full-day preschool for all 3- and 4-year-olds.

Policymakers at both the state and federal level have exhibited interested in expanding access to UPK. President Biden’s education policy platform includes a proposal to expand UPK eligibility to all 3- and 4-year-olds in the US and direct increased federal spending to low-income schools and districts. On November 3, House Democrats passed a key procedural vote that sets up the eventual passage of the Build Back Better Act, President Biden’s signature social safety net and climate change bill. The bill contains a major provision that would provide $18 billion to phase in high-quality, free UPK programs during the first 3 years of implementation. The provision would also require states to prioritize high-need communities for implementation of UPK programs before state-wide expansion. Independently, local and state policymakers have been advancing their own UPK initiatives, although many of these efforts have stagnated due to the COVID-19 pandemic. Currently, 6 states and Washington, DC, offer UPK for all 4-year-olds, but only Washington, DC, and Vermont offer UPK for all 3-year-olds.

Figure 1. Snapshot of UPK in States and Select Cities as of October 2021
Figure 1. Snapshot of UPK in States and Select Cities as of October 2021

Sources: NIEER. “The State of Preschool 2020” (2021); NIEER. “Pre-K in American Cities” (2019).

Note: Using criteria defined by Early Edge California, an early childhood education advocacy group, state-funded UPK programs were considered universal if 1) ≥95% of school districts offer the program, and 2) they had no income eligibility requirements.

*The cities listed on this map are examples of cities that have implemented UPK and is not meant to be an exhaustive depiction.

Although President Biden’s proposal notes most direct and indirect economic and developmental benefits of UPK, it doesn’t acknowledge UPK’s direct and indirect health benefits—particularly for middle- and low-income children. A high-quality UPK program has the potential to address the large disparity in access to center-based preschool that remains for both low- and middle-income families, thus increasing the opportunity for low- and middle-income children to receive preventive and diagnostic care that is offered in preschool settings.

Critics of UPK emphasize that large-scale pre-K programs have not always been scaled while maintaining their quality. Insufficient levels of funding could limit access, disproportionately impacting disadvantaged children who could otherwise benefit most from attending pre-K. Moreover, critics indicate that policymakers must consider the equity implications of expanding free, school-based, public UPK programs on private pre-K providers located in community-based or faith-based settings. Community-based providers have historically been under-resourced due to regular underinvestment and typically serve more children of color and children from families with lower incomes. Policymakers must address these issues to ensure that the potential benefits of pre-K are equitably spread across all populations. While few studies specifically assess the impact of state-funded UPK programs on healthcare utilization, preliminary evidence—along with the existing body of evidence from other ECE programs—suggests that UPK may be a lever to advance health equity.

Summary of the Evidence and Future Areas

Promising preliminary evidence comes from studies examining the impact of city-level UPK programs on early childhood healthcare outcomes and utilization patterns. A 2017 study of New York City’s UPK program using Medicaid data to assess changes in key health markers and utilization among low-income children found that eligibility for UPK increased the probability that a child received screening or was diagnosed with asthma or vision problems. The authors therefore concluded that children eligible for UPK received both “earlier and more treatment for their health problems upon diagnosis.”

As stakeholders at both the federal and state levels continue to look to improve access to preventive healthcare and quality education, there are opportunities to generate more evidence and assess the impact of city-level UPK programs on early childhood health outcomes and utilization of preventive and diagnostic services. Manufacturers of pediatric diagnostic or preventive products could look for opportunities to partner with local education or health departments in localities with strong pre-K programs to conduct research on the effectiveness of universal screening for developmental or behavioral health disorders in ECE settings.

Early childhood advocacy groups could look for opportunities to partner with health systems, state health and education agencies, and state Medicaid agencies in states/cities offering UPK to develop cross-sector models of care that leverage UPK to improve early disease screening and detection (via the Early and Periodic Screening, Diagnosis, and Treatment services benefit) among children eligible for the Children’s Health Insurance Program. Generating further evidence will be important to help standardize early childhood screening clinical guidelines.

For example, while the United States Preventive Services Task Force does not currently recommend universal screening for autism spectrum disorder (ASD) for children ages 3 and younger due to insufficient evidence, the American Academy of Pediatrics does recommend universal screening for ASD. Any of these groups may be interested in coordinating or participating in a roundtable discussion that brings together expert stakeholders to discuss the most important barriers and future opportunities for expanding upon past successes involving ECE programs.

Generating further evidence and testing new models of care can help to ensure future policies and funding for ECE are directed to effectively and efficiently optimize outcomes in education and health for even the most vulnerable children.

Avalere has worked with various cities to organize multi-stakeholder convenings and evaluate their public health initiatives; for example, Avalere is currently reviewing Nashville’s COVID-19 response in partnership with a cross-sector steering committee and non-profit organization NashvilleHealth, with a final report expected later this year. We look forward to working with more partners to improve health for all American children. To find out more about the benefits of ECE programs, connect with us.

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