Healthy Start: Overview and Policy Considerations

The Healthy Start program (42 U.S.C. §254c-8), currently authorized through FY2025, aims to improve health outcomes before, during, and after pregnancy. The program funds projects in geographic areas with high infant mortality rates (IMRs) and other adverse perinatal outcomes. Healthy Start emphasizes flexibility in meeting family- and community-specific needs and funds local organizations to provide tailored health and social services to women, their partners, infants, and children (up to 18 months). The program also funds the Healthy Start Technical Assistance and Support Center, which provides training, resources, and support to grantees.

Healthy Start has historically been administered by the Maternal and Child Health Bureau within the Health Resources and Services Administration (HRSA) at the Department of Health and Human Services (HHS); the extent to which the announced HHS restructuring plan might affect the program is unclear.

Overview

Healthy Start was established in 1991 as part of a presidential initiative to decrease IMRs. The pilot program funded 15 community-based sites where IMRs were 1.5 to 2.0 times higher than the national average. Grantees were tasked with identifying and developing community-based approaches to reduce IMRs and improve the health and well-being of women, infants, children, and families; such services included case management, outreach, and health education, among others. The Children's Health Act of 2000 (P.L. 106-310) codified and authorized appropriations for the program through FY2005. The Healthy Start Reauthorization Act of 2007 (P.L. 110-339) reauthorized appropriations through FY2013 and added additional grant requirements. Most recently, the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136) reauthorized appropriations through FY2025 and added evaluation requirements (including a U.S. Government Accountability Office [GAO] report discussed below), among other amendments. Recent funding is presented in Table 1.

In FY2024, the program funded a cohort of 113 grantees across 37 states, the District of Columbia, and Puerto Rico; funding is awarded to organizations with high IMRs or other adverse maternal and infant health outcomes (see Figure 1 for recent trends in the national IMR compared with Healthy Start sites). In addition to the services discussed above, grantees may provide prenatal and postnatal care, screening, and referral services, as well as peer support, provider training, and other social services. New to the FY2024 cohort, all grantees are also required to offer group prenatal health and parenting education services. Each Healthy Start project has a Community Action Network composed of community members (e.g., residents, faith/organization leaders, social and medical service providers) and is required to coordinate services with agencies administering the Title V State Maternal and Child Health Block Grant program.

Healthy Start has also provided supplemental grants aimed at training doulas, addressing infant health disparities through other determinants of health, and developing innovative care models. In addition to regular annual discretionary appropriations, Congress has at times directed supplemental funding to Healthy Start to respond to emerging issues, such as childhood lead exposure during the Flint water crisis (P.L. 114-322; P.L. 114-254).

Figure is interactive in HTML report version.

Source: Compiled by CRS using HRSA CJs, available at https://www.hrsa.gov/about/budget.

Notes: HRSA notes that higher IMRs for Healthy Start participants likely reflects the high-risk populations targeted by the program.

Program Evaluations and Policy Debates

Healthy Start has undergone multiple program evaluations since its inception. The most recent national evaluation in 2017 used a multimethod and multiyear approach to examine outcomes among Healthy Start participants compared with nonparticipants. Using program data, vital records, and other surveillance data, the evaluation indicated Healthy Start participants were more likely than nonparticipants to receive early and more frequent prenatal care, have lower rates of low birthweight infants, and implement safe sleep practices. It also noted that many participants did not reach program targets related to breastfeeding and screenings for intimate partner violence. In 2020, the CARES Act (P.L. 116-136) directed GAO to examine Healthy Start's progress and assess how its performance measures align with other HHS programs, among other tasks. GAO recommended that HRSA implement documented processes for reviewing program evaluation data and coordinating with other programs. According to GAO, HHS has partially addressed both recommendations. HRSA also initiated a national Healthy Start evaluation in 2021; the evaluation is expected to conclude in FY2025.

In recent years, some appropriations proposals have sought to eliminate funding for Healthy Start (e.g., H.Rept. 118-585), while others have sought to continue, or in some cases, expand the program (e.g., S.Rept. 118-207). Whereas some observers assert that Healthy Start is duplicative with the Maternal, Infant, and Early Childhood Home Visiting program, others contend that it is distinct, noting shared goals but differences in grantees, services provided, statutory authorities, and other requirements. The aforementioned 2024 GAO report also discussed similarities and differences in strategies, target populations, and services offered by related programs.

Policy Considerations

Legislation has not been introduced in the 119^th Congress to reauthorize Healthy Start. Aside from the proposed appropriations actions discussed above, Congress could reauthorize the program at the same, increased, or decreased funding levels; alter program requirements; or direct supplemental inquiries into specific health or program outcomes. Congress may also consider examining forthcoming evaluation data or recent IMR trends to understand program impact, take no action to continue the program, or pursue other considerations.