Federal budget negotiations in Washington have gridlocked over seemingly irreconcilable priorities. While cutting federal spending is the highest priority for some lawmakers, other lawmakers believe that the federal government has a responsibility to act in certain areas —including health care, education, mental health, criminal/juvenile justice, poverty, and the environment. Yet there is an alternative that meets both objectives. If funds were invested upfront to prevent certain major problems before they arise, future spending would be reduced; and program cuts could occur as a natural consequence of reduced need, not just to save money. Smart spending now will pay off later, often in three to ten years.
We will focus on six key areas in which a prevention model can reduce federal spending while benefiting society, but other policy areas are applicable as well: health care, mental health, education, criminal/juvenile justice, poverty, and the environment.
The U.S. health care system focuses on treating disease rather than preventing it. The Institute of Medicine estimates that costs are $750-$765 billion more than needed to attain existing health outcomes (link; link; link). Chronic diseases in particular, many of which are linked with smoking and obesity, contribute not only to expenses in the health care system, but to a loss of productivity (translating into lost tax revenue). They disproportionately consume resources, having a total economic impact of $1.3 trillion annually (link).
Though arguments have been put forward that preventative health care does not save money (link; link), there is evidence otherwise. Some prevention strategies do save money (link; link), whereas few treatment interventions do (link). The cost of medical treatment is often not even considered in whether such health care should be provided; e.g., Medicare policy explicitly states that costs will not determine coverage of a treatment. In contrast, despite ethical advantages and apparent contribution to quality of life (link), there are great demands for prevention advocates to demonstrate cost savings. We need to consider that even when prevention does not demonstrate immediate cost-savings, it can be “cost-effective” (link; link) by the substantial health benefits for the money spent. Also, in the long run, preventive health care is projected to save substantial dollars compared with treatment. A list of cost-saving and cost-effective prevention strategies is provided by Tuft’s Medical Center (link). Furthermore, the indirect benefit of increased government income tax revenues (due to higher productivity and fewer absences) are often not figured into the financial benefit equation, even though health problems affect national productivity, spending on social programs such as Social Security/Disability and tax revenue (link). And, healthier people and/or their employers pay lower health care premiums, which translate into higher taxable wages for workers.
Nevertheless, there are means to increase the likelihood that prevention will be cost-saving, and not just cost-effective. The prevailing research has been limited in its ability to demonstrate cost-savings because the intervention did not target high-risk populations, nor was a sufficient time frame allowed to achieve savings (preventive interventions often affect health far into the future (link). Also, the scale of intervention is often too small to be efficient (link), and inaccurate generalizations are made about costs. For example, total Medicare costs of those living longer, healthier lives are not greater due to added years of life and coverage, because high medical expenses tend to occur in a limited time period prior to dying (link). Social determinants of health-focused interventions (SDOH) offer strong evidence to improve health & save health care money (link; link).
As noted, the cost-savings of prevention in healthcare depends on which strategy. Those that promote healthy behavior and environmental conditions have the greatest potential for long-term cost savings ( link; link; link; link). For example, a penny-per-ounce excise tax on sugar-sweetened beverages can help prevent many deaths over time, avoid over $17 billion in medical costs, and generate about $13 billion in annual tax revenue (link). Furthermore, cost savings are more likely when targeting high-risk individuals and providing services in certain settings. For instance, an evidence-based weight loss program targeting overweight or pre-diabetic, older adults could save over $3 billion Medicare dollars within ten years, and over $12 billion over participants’ lifetime (link). Obesity prevention remains a key area of interest for reducing health care costs in the nation (link; link; link). Some community-based programs have demonstrated greater effectiveness and are less costly than medical doctors’ services. Risk-reduction programs at worksites are also less costly than medical treatment, can improve employee health and cost-savings to the company, and increase worker productivity (link; link).
There are additional health related areas in which prevention is beneficial. Health and Human Services reports that the total cost of drug use disorders in the U.S. is about $180 billion annually, and $184.5 billion annually for alcohol abuse (link). Every dollar spent in alcohol and drug prevention saves $7-$20 in costs from crime/incarceration, emergency health care, lost productivity, and early death (link). There is other relevant work regarding substance abuse showing similar results (link; link). Similarly, the rising rate of unintended pregnancies is associated with many costly consequences (e.g., public assistance); meanwhile, prevention programs exist that reduce the incidence and its costs, returning $2 – $4.26 per dollar invested (link).
Mental health is another area where prevention helps patients as well as saves money (link; link). Since deinstitutionalization began in the 1950’s-- accelerating in the 1970’s with the advent of antipsychotic medications (link)-- the focus in mental health services shifted from expensive, long-term stays in state-run hospitals to community-based services and supports. By providing patients with appropriate supports in the community, the goal was both to reduce the high cost of hospitalization and improve outcomes. Since the 1970s, research has gone beyond effective treatment, to the possibility of mitigating or even preventing mental health conditions by building resilience or intervening at first warning signs. As research has shifted to focus on the underlying causes and early warning signs of mental health conditions, community-level programs and initiatives have become crucial in reducing the burden of mental health (link).
These evidence-based interventions demonstrate effects across a range of conditions, including mental health conditions, substance use, academic achievement, risky sexual behaviors, and juvenile justice involvement, and some even show effects on the parents' behavioral health, stress, and academic and career achievement (link). Because the interventions reduce health care utilization, crime, and disability and increase labor market earnings, economic modeling predicts large returns on investment for many recipients, and even cost-savings overall for some (link). Interventions that reduce stress and environmental exposures to toxins or improve social and economic opportunity also can prevent or mitigate mental health conditions. For example, community violence, lead exposure, and even chaotic environments during development have all been linked to behavioral health issues later in life. While genetics plays a role, we can reduce the likelihood that individuals with a predisposition actually develop a behavioral health condition by addressing community-level issues.
Certain populations are identified as having elevated risks for mental illness based on biological, social and psychological risk factors. Persons living in poverty are a prime group for mental health primary prevention to curb the high cost of public expenditures that are associated with homelessness, incarceration, and repeat inpatient hospitalizations (link; link). As prevention efforts are put into place based on scientific evidence, stakes are high in that public spending produces a return on investment that justifies scaling these initiatives nationally (link). Mass media and national attention have continued to bring attention to the role of mental health prevention in reducing national tragedies such as mass shootings and avoiding the societal costs that ensue.
Despite the evidence amassed to show what works to reduce the prevalence and severity of behavioral health conditions, many of the interventions remain underutilized or poorly implemented. It is imperative that we begin to structure our health care and social systems to foster positive development and reduce risks, allowing us to have a healthier and more productive population at a lower cost.
A multitude of evidence-based strategies spanning from childhood to early adulthood have been proposed to address educational needs, both generally and for special populations (link; link; link). It is generally acknowledged that it is more costly to remediate the unmet needs of older children than to intervene earlier in life before problems become entrenched (link). Recent research has pointed to the benefits from high-quality pre-K programs, while noting that without continued high-quality education, the effects of some pre-K programs may fade (link). For instance, critics note that limited, one-year programs have struggled to demonstrate sustained benefit to children once they enter kindergarten. These findings shouldn’t be confused with other programs that are more intensive, small scale, and not facilitated through the public education system. The most cost-saving programs target high-risk children who have the most potential for improvement (link; link; link), although some research still supports the cost-benefit of certain models of publicly-funded, universal Pre-K programs (link). Nevertheless, registries employing rigorous evaluation standards include a number of programs showing robust effects on early cognitive or language development (link; link; link; link; link; link).
Early intervention essentially provides a firm foundation on which to build successful learning experiences, but environments conducive to learning following Pre-K remain an important predictor of success later in life (link). A 2005 analysis found that early childhood programs for vulnerable populations would dramatically increase savings; by 2050 there would be an annual federal/state government budget savings of $61 billion, a GDP increase of $107 billion, and a crime related savings of about $155 billion in 2004 dollars (link).
Programs for older children at-risk of educational failure have also demonstrated cost savings (link). For example, programs to build math and reading skills and to increase attendance and reduce behavior issues have shown positive effects (link). However, higher costs for remediating older youth can work against cost-effectiveness, but focusing resources on youth who are falling behind can be efficient (link).
High school graduation is paramount for success in that dropouts typically experience lost economic opportunities, pay less in tax, and add costs in crime, public health, and welfare (link). These negative effects total more than $300,000 per dropout over a lifetime (link). Cutting high school dropout rates in half would increase government revenues annually by $45 billion (“via extra tax revenues, reduced costs of public health, crime and justice, and decreased welfare payments”), with two-thirds going to the federal government (link).
Given the estimated costs of high school dropouts compared to the cost of delivering services to them (typically in the range of $3,000 to $10,000 a year (link), program costs are likely to be lower than the benefits (link). Additionally, increasing salaries to attract higher quality teachers or reducing class size has demonstrated returns of $1.5-$2.6 per dollar invested (link). The What Works Clearinghouse provides a review of research on programs that have been shown to have demonstrated value (link).
Criminal and Juvenile Justice
The US incarceration rate has grown by more than 220 percent between 1980 and 2014 (adjusting for population rates) and is four times higher than the world average (link). This significant increase has occurred while crime has been declining to rates not seen since 1970 (link). Per capita direct criminal justice expenditures peaked in 2009 and dipped slightly but held steady from 2010-2012 (latest data available, see link). In 2012, real government corrections spending totaled $83 million -- in 2015 dollars (link). On average arrest rates have remained steady or declined depending on the crimes studied (link), actual convictions however have risen and more people have been sent to prisons in the past 35 years for longer terms necessitating the need for prison construction, beds and associated services. In the United States incarceration, law enforcement and judicial policies have more to do with incarceration policies than actual crime rates. Such “drivers” as parole and technical violation rates, recidivism rates, structured sentencing, graduated responses, the array or dearth of community supports and treatment services in addition to actual crime rates all impact incarceration trends. Justice reinvestment strategies have grown more influential in the past 10 years.
The boom in prison building juxtaposed with the significant decline in overall crime rates seems puzzling. However there are several important trends impacting both issues. For example, the Urban Institute’s 2014 study of BJA’s Justice Reinvestment Initiative (JRI) noted early stage tangible savings of $23.7 million out of $165.8 million in justice system reinvestments (ongoing, see link). JRI uses a data-driven, evidence-based approach to determine state-by-state strategies for reinvesting high cost/high end criminal justice dollars into more cost-effective, cost-beneficial solutions. Through the use of cost-modeling, better implementation of structured risk assessment tools, transfer of resources from expensive incapacitation environments to accountability-focused strategies that emphasize a better balance between rehabilitation, treatment and sentencing – JRI seeks to demonstrate that public (and private) dollars can be far more effectively used when applied using evidence-based, data-driven solutions.
Juvenile crime has also declined (link). The good news is that far fewer jail, lockup and juvenile detention events are being recorded. One driver of the need for reforms are the parallel budget impacts of juvenile incarceration on state public safety systems (link). Evidence based and other developmentally focused reforms have significantly altered juvenile justice practices over the past 15-20 years (e.g., the John D. and Catherine T. MacArthur Foundation, Pew Charitable Trusts, Annie E. Casey Foundation, Tow Foundation, Robert Wood Johnson Foundation as well as governmental investments are in large measure responsible for the changes observed). A good starting point to understand the philosophical and research driven pivot in these matters can be found in the 2013 National Academies Press Publication Reforming Juvenile Justice: A Developmental Approach.
Other trends include a more intentional focus on criminal and juvenile justice reforms at multiple levels, changes in state sentencing policies and practices, bipartisan federal attention to criminal justice issues overall and a growing awareness of the benefits created through the use of prevention-oriented, evidence and community-based strategies. Prevention-oriented strategies are proven to return benefits to society at multiple levels (link, link). Population based strategies as well as early prevention and intervention in targeted groups or individuals may provide the largest cost-benefit (e.g., Nurse Family Partnership; Positive Parenting Program, Pax Good Behavior Game, etc., see link). Every dollar spent can return $7-10 or more, much of which comes from a reduced need for prisons and their operations, more youth and young adults completing school, healthier adults along with taxpayer and additional social returns. Programs targeting youth offenders have saved taxpayers up to $32,915 per youth offender (link). Multiple treatments for youth offenders offer large savings (totaling up to $88,953 per youth (link).
Additionally, reducing the cost of the criminal and juvenile justice systems can also be accomplished with strategies that reduce recidivism. On average, 1 of 2.3 prisoners returns within three years of release (link). A review of strategies used in Washington State found that programs incorporating a cognitive-behavioral approach reduced recidivism (link). Vocational education and treatment for mental illness or substance abuse reduce recidivism and offer average savings of $20,714 and $19,118 per adult offender (link). Summaries of evidence-based programs specifically focused on juvenile justice may be viewed at the Crime Solutions web site (link).
Although there are growing lists of evidence-based programs available, policy makers have to be wary of endorsing programs without mechanisms for accountability. Much of the variability in a program’s effectiveness can be attributed to how well a program is implemented (including measurements and program design; see link), which can be affected by a provider’s training, supervision, and amount of treatment he or she can offer as well as resources available to disseminate (link).
Unfortunately, far too few youth involved in the juvenile justice system actually receive evidence-based programming. Barriers include competing local government needs, training/implementation challenges, funding constraints, technical skills among other factors. Thus, it is up to state-level entities, the federal government and/or philanthropic and other contributors to share prevention cost-savings research and information with counties or other municipalities to build local capacity. For instance, eight states have passed laws that return some state savings to county probation agencies when recidivism rates are reduced (link). These reinvestment opportunities coupled with effective prevention science implementation can return significant benefits at many levels.
Reducing child and family poverty are inextricably linked with a bipartisan understanding that poverty has repercussions for the nation in terms of both misery and cost. There is a partisan divide on how to tackle poverty, which with increased opportunity for evidence-based programs and policies to narrow this divide (link). The cost of childhood poverty is estimated to be $500 billion a year (link; link).Thus, the cost of poverty pervades many systems extending beyond the individual to the community and societal level (link; link).
Children are the most vulnerable group that experience poverty and its adverse effects; this is especially a concern for minority children who are disproportionately living in poverty (link; link). Poverty is associated with mental, emotional, and behavioral health, physical health, language and cognitive development, academic achievement and educational attainment of children (link; link). All domains noted have implications for later life success, chronic disease progression, and/or overall tax burden.
The field of prevention offers tested programs and policies that can reduce the adverse effects of poverty on children and in some instances curtail the persistence of poverty. For example, there is a solid body of evidence showing that community, family, and school-based interventions can prevent or at least lower the prevalence of youth violence, drug abuse, high-risk sexual behavior, poor academic achievement, and related problems. And furthermore, such efforts have the potential to minimize the harm of poverty and assist many children in eventually escaping from it (link).
One of the key characteristics of prevention science is the adoption of a public health perspective to benefit large segments of the population including children and families experiencing adverse conditions associated with poverty. Prevention efforts that avoid stigma and engage the whole community have a better chance of acceptance and impact. For example, the use of car seats, the elimination of second-hand smoke in public settings, and the availability of high-quality low-cost childcare serve the needs of all children including those living in poverty. With respect to evidence-based parenting and family support, community-wide prevention can reduce problems that disproportionately affect children in poverty such as child abuse (link), low school readiness (link), and school dropout (link). Furthermore, these kinds of prevention strategies are known be economically beneficial in terms of return on investment, as documented by the Washington State Institute for Public Policy.
Increasing family security is a prevention approach that involves leveraging current safety net programs/policies considered promising, including the Earned Income Tax Credit (EITC) program; Supplemental Nutrition Assistance Program (SNAP); and subsidized childcare (link; link; link; link). Housing first is also a poverty reduction approach that increases the chances that families will escape a cycle of poverty and homelessness (link; link; link). State level programs with evidence to support effectiveness continue to be implemented throughout the nation; these programs to reduce poverty span the community and school level of engagement as preventive approaches (link; link; link; link; link). Local social services budgets that address prevention continue to face shortfalls in funding with a 45% decrease in prevention funds in the last five years (link; link). Tying achieved measurable outcomes with payment for service delivery is increasingly being considered; for example, the Pay for Success (PFS) California initiative (link).
Each additional ton of carbon dioxide released into the atmosphere today will cause a variety of impacts including natural disasters and slower future rates of economic growth. Using a new methodology, a 2015 study estimated the social costs of carbon at $220 per ton (link), but the U.S. government uses a more conservative social cost of $36 per ton (link). In 2015 EPA reported on the substantial benefits the US would derive from investments in climate policies (link). In the absence of fiscally-sound climate mitigation measures, the costs of inaction will be substantial and potentially catastrophic. The release of a major store of methane in melting permafrost in the Arctic would ultimately bring up to $60 trillion in global economic damages — nearly the size of global annual GDP (link). Climate costs are no longer hypothetical but rather a current budget reality; in fiscal 2012, the U.S. government spent $96 billion in climate disruption costs following natural disasters—more than all federal spending for education programs in that year (link). The 93 natural disasters from 2005 to 2015 in the U.S. cost $586 billion in losses (link).
As the Congressional Budget Office noted in 2007, well-designed measures to reduce greenhouse gas emissions offer benefits greater than associated costs (link). In 2014, MIT researchers found that health benefits alone would far outweigh the costs of a cap and trade system in the US (link). According to one study, between now and 2050 a U.S. cap-and-trade program would incur costs between $600 billion and $1 trillion while yielding benefits (some accruing to other countries) ranging from $1.5 trillion to $1.7 trillion—a highly favorable cost-benefit ratio (link). The success of an existing regional cap-and-trade program in the northeastern U.S. offers additional evidence. The program has prevented the release of millions of tons of carbon, generated hundreds of millions of dollars in revenue for participating state governments, and brought net positive benefits to the regional economy, according to a report by a consortium of participating states (link).
The prevention model applies to other kinds of environmental pollution beyond the release of greenhouse gas emissions. Sample research suggests the potential for considerable cost savings by reducing pollution at its source (link; link).
Identification of Interventions
The Coalition for Evidence-Based Policy has found that many government programs have not been based on rigorous research; i.e., the programs were established on invalid or insufficient evidence. However there are ways to evaluate evidence (link) and it will be important to start with rigorously tested best practices, pilot test programs that appear “promising” but not yet well tested, and to conduct ongoing evaluation of program effectiveness. The Coalition suggests a low-cost format for evaluating program effectiveness (link). Fortunately, though not looking specifically at the research cited here, the Coalition has analyzed well controlled studies that demonstrate effectiveness of programs in many areas of work cited above (link). And there now exist many other databases referencing successful “evidence-based programs” in the areas covered herein (link); see links at top of page (link); see links to prevention research centers/institutes (link). A guide to selecting evidence-based programs has been developed by the Interagency Working Group on Youth Programs (link).
Due to different methodological philosophies or practices, various entities differently define what is “well-tested” and thus caveat mentioned above should be noted. But even using rigorous standards that render a high percentage of interventions as unproven, there are more than sufficient well-evaluated interventions in multiple policy areas. For example, “Blueprints for Healthy Youth Development” rigorously evaluated over a thousand interventions regarding “Behavior, Education, Emotional Well-Being, Physical Health, and Positive Relationships”. They found 10 model programs and 37 promising ones, many which exert impact in multiple problem areas (link). There are programs that can benefit millions of people—with federal savings and added revenues of billions of dollars annually—if implemented widely, in many policy areas, and using established methods.
Unfortunately, the reality is that evidence-based research has not been utilized nearly as well as it could be—perhaps a major reason for insufficient progress in some policy areas. For example, a survey of the nation’s public schools revealed that a large number of prevention programs were used during the 2004-05 school year, yet only 7.8% were supported by strong research evidence. Of those using research-supported approaches, only 44% met minimum criteria for fidelity to the program model (link). The same likely applies in other policy areas.
Additionally, targeting funds for new prevention-oriented research could reveal new cost-saving and effective measures in any number of policy areas. One health care model that can be applied to other sectors involves identifying and utilizing with larger populations what works now and might in the future, and identifying programs that should be eliminated due to ineffectiveness and cost (link).
Implementation of Interventions
Sometimes well-researched, effective interventions do not subsequently bring success because they are not effectively applied. Identifying core mechanisms of change helps to support adherence to an evidence-based program’s design while still allowing flexibility to tailor interventions to the unique needs and contexts of different settings (link). The new area of “implementation science” will help this process (“research to translate evidence-based findings into common practice”; link).
Quality implementation is supported by informational tools, training, technical assistance, and quality assurance processes (link; link). Training helps to provide a strong foundation for implementing with fidelity, but alone is not sufficient to change behavior without assistance or coaching to help practitioners learn on-site. Effective trainings provide information, demonstration, and require behavior rehearsal. Further capacity must be available with critical infrastructure, resources for operation, access to a target population, and revised policies and practices that support implementation. A 10-step model known as Getting to Outcomes can help to ensure adequate capacity for effective prevention practices (link). Sites often vary in the implementation of the same program, which results in variability of cost-effectiveness ratios (link). It is necessary to continuously monitor program fidelity and outcomes with ongoing data collection that can inform continuous quality improvement. In general, there is a need for much greater investment in program evaluation at the local level, as this can help to draw some conclusions about what works and is replicable (link).
Communities striving to implement an array of evidence-based prevention programs may consider following the model of local governance known as Partnership for Results. Community leaders can lower juvenile violence and crime by institute systematic screenings that identify at-risk youth, develop a quasi-governmental partnership with system leaders, collect data about services that can be shared across agencies, provide a continuum of services that include prevention and early intervention programs, train and technically assist practitioners to maintain fidelity, and create a credible plan for sustaining programs (link).
Figure 1. Evidence-Based Prevention Implementation
Federal vs. State/Local/Private Budgeting
Another factor in the equation is that obviously not all prevention programs and costs/benefits are tied to the federal government and budget. Many are funded by the private sector or state and local governments. Thus, neither costs nor benefits are borne by the federal government. Cost savings and positive effects may remain at the state or local level initially, although it is worth noting that often times what starts out at the local level will eventually affect federal government. There are complex relationships between these sectors regarding program/budget/economic considerations, but there are still possibilities for savings if the private/state/local government sectors also apply prevention strategies. For example, private sector savings will benefit productivity and the general economy, with ramifications for the federal budget. Plus, more solvent states and cities will have lowered need for federal assistance if the outcomes for its citizens improve substantially. Besides the Washington state example above, Oregon now requires that significant funds spent by five state agencies be spent on effective (evidence-based) and cost-saving programs (link). Other state examples include Missouri’s Division of Youth Services, which has received national and international recognition as a “model” state juvenile justice system (link), Pennsylvania’s use of evidence-based delinquency prevention programs across the state (link), and Florida’s Redirection Project, which has shown a $51.2 million cost savings to the State of Florida over several years (link).
Presumably other evidence-based prevention programs could similarly benefit the federal budget as well as state budgets. Some state officials are becoming more aware that even in rough financial times, investment in some prevention is healthier for future state budgets than continued cutting (e.g., link; link; link). Cayuga County in New York (link) and Palm Beach County in Florida have also successfully utilized evidence based programs (link). Given some state and local deficits, initial outlays (even loans) by the federal government for evidence-based prevention programs might induce their participation. Additionally, an exciting new area is the introduction of private investment into social enterprises and public-private investment partnerships. One development that started in the UK in 2010 has now brought interest from both the national and state/local governments in the U.S. Social Impact Bonds allow private sector constituencies, working with governments, to invest in prevention and other interventions and to reap some of the future savings, if they occur—with governments not at risk if the interventions do not succeed financially (link; link; link; link; link).
Barriers to Implementing Prevention Strategies
Political opposition will arise from legislators who are against initial outlays for prevention or from those who have a vested interest in fixing problems rather than preventing them. Accommodations with these interests may be required to pass legislation. And the prevention model in some sectors (like health care) may require public education campaigns and “nudges” to reinforce prevention strategies (link). A strong Congress, president, and state government structures are necessary to effectively implement a prevention model—but doing so should have appeal across the ideological spectrum. Research indicates that framing budgets in terms of prevention is appealing to citizens (link).
Taken individually or in combination, these interventions represent a departure from the way federal spending currently takes place. While many billions of federal tax dollars currently are dedicated to treating preventable problems after they arise, this paper lays out a menu of prevention strategies for a far more efficient use of the federal tax dollar and to improve health, social well-being, the environment, and national security. And on a personal level, prevention also generates higher levels of welfare and happiness: it is better to not get diabetes than to successfully treat it; to avoid an oil spill rather than clean it up; to stay out of prison rather than be rehabilitated.
 The prevention model applies to state and local government spending as well; this paper is primarily concerned with federal spending. Prevention savings stated here or elsewhere cannot be merely added to find a grand total, as it will result in some double counting (e.g., savings made by some childhood interventions will alleviate problems later in life for some). At the same time, many cost-savings analyses represent conservative estimates of savings because there are indirect savings not included because they were outside the scope of analysis.
Taylor B. Scott, Doctoral Student, UNC-Charlotte; Society for Community Research and Action Neil Wollman, Senior Fellow, Bentley Service-Learning Center, Bentley University; Co-Director, National Prevention Science Coalition to Improve Lives
Amber M. Davis, Doctoral Student, Howard University School of Social Work
*In addition to the authors, we thank Nathaniel Counts, Robin Jenkins, Ron Prinz, Ronald Goetzel, Jesse Ellis, Mark Dynarski, Scott Carlin, Kelli Komro, and Diana Fishbein all of whom made contributions to this paper.