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Public Health and Early Childhood Education: Support for Universal Preschool in the United States

  • Date: Nov 07 2017
  • Policy Number: 20173

Key Words: Education, Child Health And Development


More than 60% of 4-year-olds in the United States do not have access to publicly funded preschool programs. Among preschool-aged children eligible for federally subsidized preschool programs, only 30% receive such services. High-quality early childhood preschool education is pivotal for a child’s physical, social, emotional, and intellectual development. In the absence of a universal preschool program, students enter kindergarten with varying levels of social and academic development, creating an educational achievement gap. Closing this gap becomes more difficult and costly as children advance through elementary, middle, and high school. Limited access, high costs, and low-quality standards form barriers to high-quality preschool education. The disparities in access to high-quality preschool are most evident among racial and ethnic minority children. When children from low-income families do attend preschools, they are more likely to attend low-quality primary and secondary programs. A national voluntary, universal, affordable, high-quality preschool program will bring short- and long-term benefits to all children, their families, and society.

Relationship to Existing APHA Policy Statements

APHA has issued several policy statements related to education and health. Policy Statement 20101 (Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities) notes that access to education improves public health. Also, APHA has advocated for wraparound services such as school health programs (as outlined in Policy Statement 20049, Promoting Public Health and Education Goals through Coordinated School Health Programs). In Policy Statement 20131 (Endorsing Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Early Care and Education Programs, Third Edition), APHA advocated for high-quality early education for families that can afford and/or find placement in preschool through its support of the Caring for Our Children standards. In addition, Policy Statement 201013 (American Public Health Association Child Health Policy for the United States) calls on federal and state governments to ensure adequate funding for early childhood education interventions to improve child and adult health outcomes. However, APHA has yet to advocate for ensuring that all children have access to voluntary, publicly funded, high-quality universal preschool across the United States.

Problem Statement

Advancing public education opportunities is critical for the academic and social success of each child.[1] In 2012, the United States ranked 35th among developed economies in preprimary and primary school enrollments among 3- to 5-year-olds.[2] Access to high-quality preschool varies by race, income, and geography,[3] and with no standardized universal preschool system for all children in the United States, many children enter primary school with differing levels of social and academic development.[1] Children of color and those from low-income families are less likely to be prepared to start kindergarten than their peers with access to quality preschools. A longitudinal study showed that upon  entry to kindergarten, African and African American, Latino, Native Hawaiian/Pacific Islander, and American Indian/Alaska Native children had lower reading and math scores than White students. Moreover, scores were lowest among students from households with incomes below the federal poverty level.[4] While the cost of preschool soars, the availability of federal and state subsidized options stagnates or shrinks. There are not currently enough spots in subsidized preschools for the more than 3.4 million preschool-aged children living in poverty. Closing the educational achievement gap becomes more difficult and costly as children advance through elementary, middle, and high school.[1]

One in four of the 13.5 million U.S. children of preschool age live below the federal poverty level, which was $22,350 for a family of four in 2011.[3] Despite increased state investments in subsidized early childhood education for low-income families, the U.S. Department of Education reports an extreme ongoing unmet need for subsidized preschools, with hundreds of thousands of preschool-aged children lacking access to such schools.[5] Federal and state subsidized preschool programs have varying eligibility requirements, with some states offering programs with more inclusive requirements and others incorporating more limiting eligibility criteria.[6]  

Disparities in access to high-quality preschool are most evident among racial and ethnic minority children.[5] Although federal, state, and locally subsidized programs are highly popular, program eligibility and capacity restrictions greatly limit participation. Despite many subsidized programs targeting children of color and children from low-income families, these families still experience the most barriers to high-quality preschool. This is especially relevant in the case of African American, Latino, and low-income families, as children from these families are more likely to attend low-quality than high-quality preschool programs.[7] In addition, citizenship requirements for many public early childhood education programs (a federal funding restriction) leave thousands of children without access to high-quality preschool services. Expanding government subsidized preschool programs to low-income and immigrant families would mitigate this disparity.

Low wages and difficult working conditions for child-care teachers and administrators undermine the quality of preschool programs. Low-quality preschool programs are associated with poorer cognitive, social, and emotional outcomes for children.[8] Preschool teachers are tasked with shaping our nation’s future, yet most are poorly paid, especially in comparison with elementary and secondary school teachers who have similar qualifications.[8] The median salary for preschool teachers in the United States is $23,320 per year, half the median pay of a kindergarten teacher and less than 145% of the federal poverty level for a family of two.[9] Early childhood education centers experience very high turnover rates, often attributed to low teacher compensation.[8] High turnover is expensive, as it requires more frequent staff onboarding and certification training.[8] A well-compensated workforce is considered a fundamental component of high-quality early childhood education.[10] Many low-quality preschools have high student-to-teacher ratios, have few resources, and lack support for teachers.[11] Higher teacher stress and lack of support for teachers are associated with disproportionate student discipline rates,[11] including suspensions and expulsions.

Providing high-quality, voluntary universal preschool for all children is an upstream and straightforward approach to closing the achievement gap and ensures that all children have experiences that encourage success in life.[1] Although early childhood education is pivotal for a child’s physical, social, emotional, and intellectual development in the early years,[1] obtaining it is not only difficult for low-income parents but also challenging for some middle-income families.

Evidence suggests that all children will benefit from access to high-quality preschool. Studies from Tulsa, Boston, and Georgia, which have universal preschool policies, show that middle-class children experience substantial gains from participation in high-quality preschool programs.[12,13]

Furthermore, schools with racial and economic integration benefit students of all backgrounds. A diverse learning environment representing the nation’s increasing demographic diversity encourages students to think critically and eliminate prejudice, providing them civic, social, and cognitive benefits.[14]

Although there are many benefits of high-quality universal preschool programs, they are costlier to implement in the short run than targeted programs. Universal preschool is simpler to implement than a targeted program, however, as it eliminates administrative costs and time spent on distinguishing between eligible and ineligible students. Still, it requires a larger workforce of well-trained, well-educated teachers,[15] a long-term economic cost. Even with their added costs, universal preschool programs have shown to be an investment that would strengthen the nation’s economy and lessen various economic, social, and health problems.[16]

Evidence-Based Strategies to Address the Problem

Internationally and within the United States, governments are expanding access to affordable, high-quality preschool education. Evidence from current U.S. federal, state, and local preschool programs, along with those in other countries, supports the need to expand access to high-quality, affordable preschool. Multiple U.S. states have universal preschool policies in varying capacities, including Florida, Vermont, Georgia, Oklahoma, New Jersey, Illinois, Iowa, New York, and West Virginia.[17]

Oklahoma was one of the first states to offer universal preschool for 4-year-olds.[18] The Oklahoma preschool program initially enrolled 9,000 children in 1998 and has since expanded access to 40,000 children.[18,19] The program follows best practices surrounding provision of high-quality standards, including maintaining student-teacher ratios of 10:1, capping class sizes at 20 children or fewer with two teachers, requiring lead teachers to have early childhood education certificates and bachelor’s degrees, and ensuring that salaries for early childhood educators are on the same scale as those of K–12 teachers.[18] Evaluations show that students enrolled in Oklahoma’s pre-kindergarten program consistently outperform those not enrolled in the program, and this effect is observed across racial groups and in low-income and middle-class families.[18] The Oklahoma outcomes are in alignment with the findings of the report of the Community Preventive Services Task Force, which indicated that instructors with a bachelor’s degree or higher have a greater impact on their students’ standardized achievements.

Selected international universal preschool models: Many European countries provide all children with a minimum of 2 years of free early childhood education before they begin primary school.[20] Examples of these programs can be found in France, Sweden, and Denmark.[4]

The French universal preschool program, école maternelle, is a foundational piece of the French education system.[21] Under the French model, all 3- to 5-year-olds are guaranteed a place in école maternelle regardless of income or social status.[21] Parents are responsible solely for optional expenses such as school-provided lunches and extended care in the summer, which are provided on a sliding scale fee.[21]

Denmark ensures universal access to preschool through public subsidies covering two thirds of the cost, with the remaining third covered by parents of enrolled children. In the case of low-income families and single parents, this cost is waived.[22] Denmark’s funding structure allows greater accessibility to early childhood education, which is evident in the fact that more than 85% of Danish children younger than 6 years are enrolled in publicly funded universal preschool.[22]

Sweden’s model for universal preschool has resulted in the enrollment of more than 77% of the country’s children between the ages of 1 and 5 years.[23] In Sweden, municipalities are responsible for collecting tax revenue to fund public services. Higher-income municipalities subsidize services in lower-income municipalities. Each municipality covers 90% of the cost of preschool, and parents are responsible for the remaining 10%.[24]

U.S. early childhood education best practices: Most child-care and preschool programs in the United States are rated as poor to mediocre in quality, and almost half are below minimal standards.[25] According to research conducted by the National Institute for Early Education Research and the National Association for the Education of Young Children (NAEYC), best practices with respect to high-quality early childhood education include the following[26]:

  • Developing children’s knowledge and skills in the areas of language, literacy, math, science, social studies, and art
  • Facilitating children’s social, moral, emotional, and physical development to shape their attitudes, beliefs, dispositions, and habits
  • Ensuring that preschool teachers and staff are adequately prepared to work with children, whether through early childhood expertise, specialized training, or relevant work experiences
  • Offering small class sizes
  • Providing support to teachers through expert supervision and professional development focused on their classroom performance
  • Accommodating children with unique needs, including English language learners
  • Preparing and maintaining a safe, healthy, and nurturing environment

Another important best practice is supporting preschool students with disabilities. Educators can use three elements to create a more inclusive preschool environment: assistive technology, instructional technology, and universal designs for learning.[27]

Improved child health: Enrollment of children in preschool helps improve child health, and the health benefits extend well into adulthood.[7] Children in preschools are required to be up to date on immunizations, aiding in increasing immunization rates among young children. Preschools also help reduce childhood obesity, as they engage children in physical activity and provide healthy food and nutrition education to children and families.[7] Moreover, many preschool programs provide wraparound health care services such as screenings, preventive care, and referrals for specialized care.[28] These wraparound services lead to increased overall well-being.[28]

Enhanced language skills: Research shows that preschool is an opportune time for language acquisition. Children’s attendance at preschool can help improve their vocabulary, color identification, literacy, and math skills.[7,28,29]

Social and cognitive benefits: Preschool can offer short- and long-term social and cognitive benefits for children. Collaborative play earlier in life can create team-building skills that are valuable for a lifetime.[29] Children enrolled in preschool perform better on content-knowledge tests, develop social skills, and strengthen their ability to work well in structured environments.[19] High-quality preschool attendance results in healthier kindergartners, fewer children repeating grades, and fewer children in special education. Not only does preschool foster short-term skills, but studies show that those who attend preschool reap long-term benefits and are more likely to graduate from high school and go to college.[30]

Addressing racial and social inequities at an early age to improve health outcomes: Free and reduced-fee preschools have directly improved enrollments among students of color and low-income families facing systematic exclusion from preschool options due to high costs and limited access.[31] Researchers have highlighted the importance of addressing systems of racism to eliminate health inequities.[32] Access to high-quality universal preschool has the potential to create an education system that is more supportive of and responsive to communities of color and that can improve overall health outcomes in these communities.[33]

Implementing trauma-informed care could help improve academic outcomes among students of color, especially those in preschool, given that expulsion and other discipline rates are higher for students of color than their White peers according to the Yale University Child Study Center.[34]

Economic benefits: A cost-benefit analysis based on the HighScope Perry Preschool Project (PPP) and the Abecedarian Early Childhood Intervention Project revealed that a high-quality preschool has a 12% return on investment after inflation, a better return to overall society than the stock market.[35] Unemployment rates are lower among those who have attended a high-quality preschool than those who have not attended preschool or have attended a low-quality preschool,[28] and they make approximately $143,000 more in their lifetime.[36] Another analysis showed that if the United States implemented a universal preschool program, by 2050 the government would reap $82 billion in budget benefits, workers would be compensated an additional $108 billion, and better health and less crime would lead to a savings of $115 billion.[16] In addition, according to the report of the Community Preventive Services Task Force, center-based preschools increase maternal employment and income and reduce welfare dependency.

Societal benefits: A government commitment to universal preschool programming should emphasize access to and use of high-quality early education programs, with the greatest benefits accruing to low-income children and those of racial and ethnic minority backgrounds. High preschool attendance rates are associated with societal benefits such as job growth, crime prevention, and reduced reliance on safety net programs.[29]  

For example, the PPP experiment of 1962 offered high-quality preschool education to 3- and 4-year-old African American children in Ypsilanti, Michigan, who were living in poverty and were at high risk of school failure. Forty-year follow-up data show that high school graduation rates were higher among program attendees than among controls (66% versus 45%), arrest rates for violent crime were lower (32% versus 48%), and the benefit-to-cost ratio was 8.7:1 (i.e., the ratio of the aggregate monetary program benefits over the life of a child to the input costs of the preschool program showed a high return on investment).[37]

In addition, preschool attendees were less likely to become pregnant as teenagers, to be involved in crime, or to use safety net programs and more likely to be employed and to earn more as an adult than children who did not attend a high-quality early education program.[38] Finally, recent evidence shows that life expectancy in the United States would be approximately 3.75 years longer if our nation had the average social policy generosity of the other 17 Organisation for Economic Co-operation and Development nations.[39] The country’s lack of generous social welfare policies, including universal preschool, contributes to shorter life expectancies.[39]

Opposing Arguments

Opposition to high-quality, affordable universal preschool programming is largely based on the argument that there is insufficient evidence for the benefits of preschool, and any benefits that do exist dissipate early in elementary school.[40] Some argue that, with the Oklahoma preschool program for instance, there is not substantial evidence showing long-term positive effects.[18] However, high-quality longitudinal studies of preschool programs for low-income children have shown the opposite: the socioeconomic, emotional, academic, and health benefits of preschool extend well into adulthood.[28,29,35] Other opponents of expanding preschool accessibility argue against offering universal programs, believing that subsidies should target only the neediest students to maximize existing resources.[41] While children below the federal poverty level have been shown to benefit the most from preschool, a lack of subsidized programs and available preschool spots denies millions of children regular early education.[42]

Some argue that universal preschool would be too expensive.[43] According to one study, preschool programming would cost between $11,000 and $15,000 per year per student.[44] In a state with 4 million preschool-aged students, this could cost about $50 billion per year. Despite this substantial upfront cost, studies show that investing in preschool actually saves money through, for example, lower crime and unemployment rates.[16]

Others argue that given the political climate and competing fiscal interests, universal preschool will not be prioritized. If advocacy organizations and policymakers are able to raise awareness about its widespread societal and economic benefits, universal preschool will become a priority and be funded. The Oklahoma model offers ample evidence of the benefits of universal preschool.

Conservative policy institutes argue that publicly funded preschool is emblematic of government overreach.[45] Research shows that market-driven preschool models, limited enrollments in federal and state subsidized preschools, and poverty-based eligibility requirements consistently leave low- and middle-income families unable to afford or access high-quality preschool.[2,42]  Federal child-care programs serve only 30% of federally eligible children 3 to 4 years of age, with some state programs boosting this percentage to approximately 50%.[2] Market forces have yet to adequately respond to the demand and need for preschool programming throughout the United States.[2]

Action Steps

High-quality, affordable preschool will benefit our nation’s children. APHA:

  1. Calls for federal, state, and local governments to implement voluntary, universal, publicly funded preschool programming based on a sliding fee scale (such that tuition does not exceed 10% of families’ monthly household incomes) for all preschool-aged children, regardless of their citizenship status. Also, APHA urges federal, state, and local governments to appropriate sufficient funding for this programming.
  2. Urges federal, state, and local governments and preschools to ensure high-quality preschool standards, including developmentally appropriate curricula and play-based learning. The nationally respected NAEYC is an accrediting body that could ensure high preschool standards.[26]
  3. Calls on federal, state, and local governments to ensure that preschool teachers and staff are adequately prepared to work with children, whether through early childhood expertise, specialized training, or relevant work experiences. Furthermore, preschool staff should be ensured continuing education relevant to the needs of the children served, as well as livable wages and benefits matched to those of kindergarten teachers.
  4. Encourages state and local school districts to develop and implement anti-racist, culturally relevant, and trauma-informed approaches in preschools through thoughtful hiring, educational training, leadership development, and evaluation of disciplinary procedures to minimize suspensions and expulsions.  
  5. Calls on federal and state governments to seek opportunities to expand preschools into K–12 public school systems for the year before kindergarten.
  6. Encourages collaboration among health professionals, community health care centers, and preschool programs to support wraparound services, increased child immunizations and health screenings, early detection of physical and behavioral needs, and access to other health resources. Also, APHA encourages preschool programs to participate in the Child and Adult Care Food Program (a federally funded food program) to ensure that healthful meals and snacks are provided.
  7. Encourages collaboration between early education and child-care programs in providing wraparound education and before- and after-school care to support families’ work schedules and mitigate daytime disruptions.
  8. Encourages research to expand knowledge about the early childhood approaches that best encourage creativity, intelligence, social skills, and well-being.


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