Early Childhood Health Systems Transformation

Adverse childhood experiences (ACEs)—potentially traumatic events in childhood, including abuse, neglect, and household dysfunction—and toxic stress are among the most significant and least addressed drivers of lifelong health. An estimated 63 percent of American adults have experienced at least one ACE, and the associated burden in direct medical spending and lost healthy life years costs trillions of dollars annually. Yet our current health care system only treats the downstream consequences of childhood adversities, rather than proactively preventing them.

What We’re Doing

In June 2026, in partnership with Dr. Nadine Burke Harris and the ACE Resource Network, the Clinton Policy Institute (CPI) launched the ACEs National Leadership Council, co-chaired by Secretary Clinton and former Surgeon General Dr. Jerome Adams. The inaugural leadership council meeting brought together national experts in the science of ACEs and toxic stress, healthcare and clinical leaders, early childhood advocates, and philanthropic partners to examine how to shift health care systems toward early identification and intervention. While individual programs and state efforts are making progress, the greatest opportunity lies in aligning them within a coordinated public health framework that addresses the identified risk of toxic stress proactively, rather than waiting for developmental harm to appear.

Trauma Is Treatable, and Early Intervention Changes Trajectories

Children’s environments and experiences shape their biology in ways that influence health across the lifespan. The primary biological pathway is the toxic stress response: prolonged activation and dysregulation of the body’s stress system can disrupt healthy development, harm mental, physical, and behavioral health, and reduce the effectiveness of standard clinical care when underlying stress goes unaddressed. And yet, the same science affords powerful opportunities. Integrating interventions alongside standard medical care can meaningfully improve outcomes, including dyadic parent-child care models, mental health services, and nutrition and physical activity support. This evidence base supports an ambitious but achievable goal: cutting ACEs and the risk of toxic stress in half within a generation.

A Proven Model: Screening Tied to Reimbursement, Training, and Risk-Based Access

Launched in 2019, California’s statewide ACEs initiative offers a tested blueprint. It established three pieces of public health infrastructure: (1) reimbursement for ACE screening; (2) required provider training to unlock that reimbursement; and (3) patient eligibility for wraparound care based on risk identified through ACE screening. Over five years, the model produced durable uptake with more than 50,000 individuals trained in trauma-informed screening, over 5 million screens conducted, and more than 3 million unique Medicaid members screened, including over 40 percent of California’s children on Medicaid. Emerging research from clinics implementing screening indicates statistically significant reductions in both inpatient admissions and emergency department use, suggesting better outcomes and more efficient use of health care resources. With implementation support from the ACE Resource Network, this approach is now extending to additional states, including New York, Georgia, Tennessee, Hawai’i, and Utah.

Medicaid Policy Is Essential But Not Sufficient

State Medicaid agencies are the most powerful lever for scaling this work, particularly where benefit design can extend behavioral health services, enhanced care management, and dyadic care based on identified risk without requiring an additional diagnosis. But experience across states shows that meaningful change requires a coordinated, system-wide approach that aligns financing, provider training, clinical practice, referral infrastructure, and community-based supports. Where reimbursement exists but provider training and referral networks remain underdeveloped, adoption stalls. Where interest is strong but systems are fragmented, states need coordinated infrastructure and implementation support more than they need new policy. When any component of the ecosystem is missing, the model’s effectiveness erodes.

Priorities for Scaling Prevention and Early Intervention

Sustainable state Medicaid reimbursement pathways remain the most effective driver of provider adoption in the absence of comprehensive federal action. Provider training must be expanded and standardized, grounded in trauma-informed care and toxic stress science, and built into the education of future clinicians across medical, nursing, social work, and public health programs. Established pediatric clinical guidance offers a ready platform for integrating screening into routine care. Additionally, screening efforts must be aligned with community-based networks of care and proven interventions, including evidence-based parenting programs and home-visiting models, so that families identified through screening can be connected to effective services. As federal funding grows more uncertain, state leadership, philanthropic investment, and cross-sector collaboration become more important to sustaining this capacity.

Clinical implementation alone will not produce systems change. Sustained progress depends on a shared public understanding of childhood adversity as a significant and addressable public health issue. This means elevating awareness among policymakers of both the human and societal costs that include reduced workforce participation, lower productivity, and greater demands on public systems. Framing childhood adversity as a cross-sector issue with implications for economic development, education, public safety, and housing stability can increase awareness. It also means shaping public understanding that the effects of adversity are neither inevitable nor irreversible when timely, evidence-based intervention and supportive relationships can promote healing. A coordinated advocacy infrastructure that pairs credible evidence with compelling narrative is needed to translate the science into policy and financing reform.

Ongoing Work

CPI and its partners are developing an action plan identifying strategic priorities and concrete opportunities to advance a coordinated public health response to childhood adversity that aligns primary, secondary, and tertiary prevention so that systems treat the risk of toxic stress before serious harm emerges.