America’s child care workers are on their feet day in and day out and are routinely exposed to children’s germs and illnesses. But because of low wages and high rates of uninsurance, many cannot access the health care they need.
In 2019, 16 percent of child care center staff and 8 percent of licensed or regulated home providers were uninsured, compared with just 3 percent of elementary and middle school teachers. This gap may exist in part because many child care programs are small businesses, for which high health insurance costs are increasingly unaffordable. Even when their employers do offer health insurance, it may be out of reach for early educators, who are often paid low wages—an average of $13.07 per hour in 2022—and who face premiums and other health care costs that make up a larger portion of their incomes compared with higher earners.
Without health insurance coverage, early educators can find health care unaffordable, potentially leading to worsened physical and mental health that can ultimately affect the quality of their work and care.
The District of Columbia is working to solve this problem with HealthCare4ChildCare, a first-in-the-nation investment to provide free and low-cost health insurance for the child care workforce. The program offers health insurance plans that are affordable for both employers and employees who choose to participate and is available to staff whose employers opt in, as well as DC residents who work in licensed child care programs and their dependents.
Our team conducted an in-depth case study of HealthCare4ChildCare, examining its implementation, early outcomes, and viability. Here are four key steps HealthCare4ChildCare took to support the health of DC’s child care workforce that other states and cities can consider to achieve the same goal.
- Expand existing infrastructure to make health insurance affordable
DC’s innovation shows that governments don’t need to start from zero to improve health insurance affordability for the child care workforce. Leveraging existing infrastructure set up under the Affordable Care Act, such as DC’s Health Insurance Marketplace and DC Health Benefit Exchange Authority (HBX) technology and staff, helped launch HealthCare4ChildCare quickly and effectively. Drawing on federal dollars, such as those available through advance premium tax credits and Medicaid expansion, can also complement local investments to cover costs, even as state fiscal belts tighten.
Health insurance initiatives can also leverage infrastructure beyond health care. In 2021, the DC Council voted to raise a tax on individuals making more than $250,000 a year and use that revenue to, among other things, improve compensation for the early childhood workforce. HealthCare4ChildCare was one piece of that compensation reform. The council established a task force to inform implementation of the new investment, and the task force identified health insurance as the “highest priority” among comprehensive benefits.
By 2022, the Office of the State Superintendent of Education (OSSE), which administers the overall compensation initiative, partnered with HBX, which administers DC’s Affordable Care Act Marketplace, to launch HealthCare4ChildCare. These intergovernmental partnerships were critical for offering health insurance coverage to employees in OSSE-licensed child care facilities, their spouses, and children.
- Pair effective policy with comprehensive implementation
We estimate 79 percent of eligible child care facilities participated in HealthCare4ChildCare in 2025, in addition to more than 300 employees who enrolled as individuals (based on enrollment in 2024). Key informants attributed this high participation rate to an “all-in approach” to implementation. HBX staff visited child care facilities, placed individual calls to employees, and provided step-by-step enrollment support outside of working hours. One director described her customer service experience with an HBX staff member as going “like clockwork. Any questions I had, she was able to answer them… It was easy.”
The program also engaged trusted community organizations to increase awareness of HealthCare4ChildCare through its Outreach and Engagement Partnership Grant Program. Their expertise from within the child care community, such as knowledge about business ownership and multilingual outreach skills, increased program visibility and trust among the workforce. Robust outreach and enrollment assistance likely contributed to HealthCare4ChildCare enrollment growing by 39 percent (or 855 new individuals) in 2024.
- Learn as you go
Key informants and child care program leaders described how HBX was nimble and responsive in implementing HealthCare4ChildCare. They described HBX’s intentional approach to continuous improvement and highlighted one large policy change: upgrading the reference, or base, plan from Silver to Gold in 2024. This change reflected advocacy from the child care community and meant participants could receive considerably more generous coverage for health services. Participants and their employers could upgrade their plans and still have $0 or low-cost premiums, while HealthCare4ChildCare paid a larger share of the overall cost (81 percent versus 68 percent, or $821 versus $776, per month).
- Safeguard future funding
Although HealthCare4ChildCare is unique, most of the 12 key informants we interviewed emphasized how it serves as a proof of concept for other states and localities.
“These things are not out of reach. These are intentional policy and funding decisions. [HealthCare4ChildCare is] not this pie in the sky, utopian resource. It’s normalizing something that was previously seen as out of reach or impossibility.”
—Key informant
HealthCare4ChildCare has quickly become an essential benefit for DC’s child care workforce and has fostered what one key informant called a “respected professional” identity, but its long-term prospects remain uncertain.
A short waiting list for new employers seeking to enter HealthCare4ChildCare emerged in January as a control to prevent future costs from growing beyond available resources. The initiative was funded through fiscal year 2026 but not in future years. One key informant described the importance of ongoing advocacy in ensuring the future of HealthCare4ChildCare: “Having the funding [now] doesn’t mean you will always have it… We have to keep our eyes and ears open, and just be very active, not just advocating, but being activists.”
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