Decades of research show that high-quality early learning programs can positively impact children’s learning, development, and health. Therefore, we strongly believe that access to a high-quality early learning program is one of the best investments a city can make. With funding from the de Beaumont Foundation and Kaiser Permanente, CityHealth provides cities with evidence-based policy solutions and practical tools to improve the health and well-being of their residents. CityHealth provides a framework for advancing policies using a medal rating system to assess their progress and encourage improvement in public health outcomes. Since 2017, CityHealth has partnered with the National Institute for Early Education Research (NIEER), a nonpartisan research center, to conduct research on prekindergarten (pre-K) efforts operated at the city level, to promote its High-Quality, Accessible Pre-K policy solution.
Excerpts of the study are below.
Produced in partnership with the National Institute for Early Education Research (NIEER).
While the evidence is clear that pre-K makes a meaningful difference for children in the short and long term, children need access to high-quality programs to experience these benefits. Access, however, remains unequal, particularly to programs that provide high-quality experiences.
Research findings include:
- Participation in high-quality pre-K has been found to have a positive, direct impact on children’s health through avenues such as access to nutritious meals and health screenings and a positive, indirect impact through reducing parental stress and supporting mental health. For example, a study of New York City’s pre-K program found pre-K enrollment increased the probability a child was diagnosed with asthma or vision problems, received treatment for hearing or vision issues, and had a screening or immunization during the pre-K year. In addition, a recent Tulsa, Oklahoma, study found that children who enroll in pre-K earlier than their peers (i.e., at age 3 instead of 4) are more likely to experience earlier identification of health problems such as eczema or vision concerns, which can lead to earlier treatment.
- Enrollment in pre-K can help close long-standing opportunity gaps in education and academic achievement for historically marginalized groups. For example, research suggests that low-income children may be up to 12 months behind their more advantaged peers when they start kindergarten; however, a high-quality, universal pre-K program could reduce achievement gaps by 27% in math and 41% in reading.
- Dual language learners (DLLs) may uniquely benefit from pre-K attendance, particularly if they start early. For instance, one study of DLL children who enrolled in full-day pre-K before age 4 showed at least 90% of these children scored at least one level higher on an English proficiency test than their peers who did not enroll early.
- There are long-term benefits to pre-K participation, even if benefits may vary for different groups of children. Evidence from long-term studies of Head Start and intensive, small-scale interventions shows long-term benefits such as higher high school graduation rates and years of education completed, and lower rates of teenage pregnancy and crime.
- Pre-K attendance has been shown to have a positive impact on children’s executive functioning skills, such that children who attend pre-K begin kindergarten with better executive functioning skills than children who did not attend kindergarten.
- Children who attend pre-K are less likely to be chronically absent in later school years and more likely to take more challenging coursework in high school. Not only were pre-K attenders less likely to be chronically absent, but they also had better attendance overall compared to non-attenders.
San Antonio
Sarah Baray has served as the CEO of Pre-K 4 SA since 2016. Dr. Baray, a former professor, has described that her work at Pre-K 4 SA allows her to see research come to life. Her background provides her with an understanding of the impact high-quality pre-K policies can make in supporting kindergarten readiness. In her role as CEO, she develops and creates conditions, such as access to job-embedded training and ongoing professional development, that enable educators to implement research-based policies that support children’s learning and development.
Cities Leading the Way
Pre-K programs that support positive and long-lasting academic and social-emotional outcomes in children are thoughtfully designed. We have identified cities that are leading the way through their effective leaders, establishment of sustainable funding streams, improved access for a substantial portion of their preschool-aged children, and/or have designed high-quality pre-K programs.
Local Leadership
Local leadership is necessary to create an early education vision and strategy for the city through building momentum, designing a program or enhancing the quality of existing ones, and developing a funding mechanism that not only supports quality but also addresses access. Cities are at different stages in their pre-K implementation, but some leaders that are worth noting include Boston, San Antonio, and San Francisco.
Access to Pre-K
Across the country, access to high-quality pre-K programs has been growing slowly but steadily. In 2023-2024, just 37% of 4-year-olds were enrolled in state-funded pre-K. However, these averages mask disparities and, in some cases, declining enrollment. For example, when examining state enrollment in 22 states, fewer children were served in fall 2023 than in fall 2019 (the last school year prior to COVID); in 14 states, a lower percentage of children were enrolled in fall 2023 as compared to fall 2019. The need for access to high-quality pre-K is not being met at the state level. This is an opportunity where cities can address the unmet pre-K needs of their residents. Some of the nation’s largest 75 cities have developed strategies to increase access to their pre-K programs.
- In Albuquerque, there are multiple programs that have unique funding streams (e.g., city dollars, federal Head Start funds, and/or state pre-K dollars), but all have the same high-quality programming and are housed in public schools, community-based sites, Head Start classrooms, family child care homes, etc. In addition to settings, having hours that either mirror the elementary classroom school day and/or offer extended-day programming may increase the likelihood of a child enrolling in that pre-K program.
- PHLpreK was created by the city of Philadelphia with funding from the city’s sweetened beverage tax in 2017. Since its inception, enrollment has scaled up and as of 2024-2025 serves more than 5,000 3- and 4-year-olds annually.
- Having multiple settings available to families increases the odds that they will find settings that will accommodate both their needs and their children’s. In Portland, children are served through several pre-K programs that operate in multiple settings, which helps boost access. Oregon’s Preschool Promise and Prenatal to Kindergarten (OPK) program offers high-quality options to families meeting financial need criteria, while Multnomah County’s new Preschool for All (PFA), approved in 2020, aims to provide universal pre-K by 2030.
- Washington, D.C. and New York City have been able to increase access by using their existing mixed delivery
systems. In 2014, New York City began designing its universal Pre-K for All program. Within two years, the program served almost 70,000 4-year-olds. Washington, D.C. is a standout in not only creating a universal pre-K program for 4-year-olds, but also for 3-year-olds. The city has been operating pre-K since the 1960s, but with the increased city investment in the Pre-K Enhancement and Expansion Amendment Act of 2008, the city was able to offer universal access to pre-K through the D.C. Public Schools, Public Charter Schools, and publicly funded community-based organizations.
San Francisco
As Director of the Department of Early Childhood, Ingrid Mezquita has been able to integrate her varied experiences as a leader in both the nonprofit and public settings that serve young children and their families in San Francisco. Having an understanding of different types of organizations (e.g., governance structures, funding, staffing), coupled with knowledge of the San Francisco community, has allowed Director Mezquita to develop polices and a strategy for the city that address racial disparities in early childhood programming.
"Over the past few years, our Department has focused on expanding access, fair pay for early educators, building more spaces, and improving quality. So that when the time comes, every child starts kindergarten ready to learn, thrive, and succeed.”
The 2025 CityHealth analysis of the 75 largest cities found that three-fourths of cities (58 cities) offered pre-K programming that served at least 30% of the city’s 4-year-old population. In 2019, only 60% (24) of the largest 40 cities offered a pre-K program that served more than 30% of the city’s 4-year-olds. However, it is difficult to make a true
comparison between these two time periods for the following reasons:
- Between 2019 and 2025, 35 new cities were added to the analysis for CityHealth’s annual report, many of which had already been meeting this enrollment threshold standard at the time of their addition. Additionally, a disproportionate number of the new cities added to the CityHealth portfolio are in California and Texas, where access to pre-K is more widely available.
- Different programs were evaluated in 2019 as compared to 2025. Out of the 40 programs assessed in 2019, 27 of them (68%) were the same ones reviewed in 2024. This means that in 2024, 48 programs (64%) were not assessed in 2019.
- For most of the California cities, the pre-K program assessment switched from evaluating the pre-K program that operated in a mixed delivery system (California State Preschool Program {CSPP}) to only in public schools (Transitional Kindergarten {TK}). The policies for these 13 programs (not counting San Francisco) are quite different.
Due to these reasons, it is challenging to compare the two time periods; however, we have identified some general trends throughout the report.
Adequate & Sustainable Funding Streams
Adequate and sustainable funding streams are necessary to help ensure the longevity and quality of a pre-K program. Ideally, all children should be eligible for a pre-K program. This universal system would ensure that all children within a city, including those who may have limited access to pre-K or are disproportionately represented in the program, would have access to the same experiences. Some cities’ pre-K systems are fully funded by their state’s pre-K initiatives (e.g., Atlanta), but often this funding is insufficient to implement all of the components that lead to high-quality programming. Many localities rely on local dollars to expand and/or improve the state program by:
- Enhancing program quality through offering additional professional development opportunities (e.g., Lincoln, Louisville, Pittsburgh, St. Louis, Wichita);
- Supporting curriculum implementation (e.g., all of the Texas cities offer pre-K curriculum support) and use of the state’s early learning standards (e.g., Milwaukee);
- Requiring smaller group sizes and/or lower student to teacher ratios (e.g., California’s TK and Colorado’s state pre-K program do not have policies in place that meet the recommended class size of 20 or lower or student to teacher ratios of 10:1; however, some cities in both of these states have implemented policies to cap class sizes/ratios); and/or
- Supporting a system of ongoing quality improvement using structured classroom observation tools and using the information for decision making (e.g., Anaheim).
Other cities have used local dollars to create a new pre-K program that operates alongside the state pre-K program (e.g., Denver, San Antonio, Seattle). Across the country, 2025 out of 70 of the nation’s largest cities (or counties that include the cities) have used local dollars to fund and implement local pre-K programs, separate from the state pre-K program in 2023-2024.
Funding strategies that increase the likelihood of a program’s financial stability and have more political feasibility include the use of taxes (e.g., property, sales, income, parcel, expiration of pay in lieu of taxes (PILOT) incentives, specialty), blending funding sources, city general funds/budget set-asides, embedding in the school funding formula, private donations, and tuition.
Well-Designed Programs
Research has identified several characteristics associated with high-quality pre-K programs. Building upon this research base, NIEER has created 10 pre-K quality policy benchmarks. Four out of the 10 address the workforce (lead and assistant teacher qualifications and education, ongoing professional development) and the remaining six address both
structural policy decisions (required health screenings, class size, and student to teacher ratios) and process policies (supports for curriculum implementation, the use of early learning child standards, systems of continuous improvement and support). In 2023-2024, 26 city pre-K programs met nine or 10 NIEER benchmarks; 10 met eight NIEER benchmarks; and 35 met four to seven NIEER benchmarks. One city did not have a program, and three cities met fewer than three NIEER benchmarks.
Health Screenings & Referrals
Screening for health issues provides both preventative health benefits and increased access to care for children. To meet NIEER’s Health Screenings & Referrals benchmark, pre-K systems must have policies in place that require programs that ensure children receive vision and hearing screenings and at least one additional health screening, as well as referrals when needed. This benchmark recognizes that children’s overall well-being and educational success involve not only their cognitive development but also physical health and well-being. For the 2025 CityHealth medals, 65 of the 75 CityHealth cities met this benchmark.
In the case of California, each local educational agency (LEA) (e.g., unified school district, county office of education, charter schools) is responsible for implementing the state’s largest pre-K program, transitional kindergarten (TK). The state offers guidance and some regulations, but additional decisions are made at the local level.
Class Size & Student to Teacher Ratios
Smaller class sizes and student-to-teacher ratios allow teachers more opportunity to provide individualized attention to children, and to gain a better understanding of each child’s needs and abilities, which can provide long-term positive impacts on educational success when combined with additional quality benchmarks. In the 2023-2024 school year, 44 out of the 75 largest U.S. cities (59%) met this benchmark. Since 2019, there has been little movement in cities
meeting the class size (20 or fewer children per class) and student-to-teacher ratio (1:10 or lower) quality benchmarks. One reason may be due to the additional number of classrooms that would need to be created to maintain the same number of funded slots.
Learning Standards & Curriculum Support
Almost all of CityHealth’s 75 cities met the quality benchmarks for Early Learning and Development Standards (ELDS) (97% of cities) and Curriculum Supports (95% of cities). The ELDS are child development standards that identify clear and appropriate expectations for learning and development across multiple domains (e.g., physical well-being and motor development, social/emotional development, approaches toward learning, language development, cognition and general knowledge). The ELDS should be aligned with standards for younger and older children so that a child’s experiences build on prior knowledge. To meet these two benchmarks, a city’s pre-K system must support the implementation of the ELDS and curriculum. Cities can do this by:
- Providing professional development on the ELDS so teachers can understand them and use them appropriately;
- Requiring the alignment of the ELDS to child assessments and curriculum;
- Allocating resources and/or providing other supports to assist programs in selecting a curriculum; and
- Offering training, technical assistance, and job-embedded opportunities to learn how to implement the curriculum with fidelity.
Workforce Qualifications & Supports
Research suggests that teachers with higher educational levels generally provide higher-quality educational environments for young children. In addition to degree requirements, research – including the Institute of Medicine (IOM) and National Research Council (NRC) of the National Academy reports – has also emphasized that pre-K lead teachers should have specialized preparation that includes knowledge of learning, development, and pedagogy specific to preschool-age children.
Qualifications
In 2023-2024, almost 80% (59 of 75) of city programs required pre-K teachers to have a bachelor’s degree, and 71% required teachers to have specialized training in teaching young children. Additionally, fewer than 20% of cities require teaching assistants to have specialized training in teaching young children. One of the challenges for pre-K programs in meeting these three benchmarks is that often the policies for the pre-K programs differ by the setting in which the teacher works. Pre-K programs housed in public schools tend to require lead teachers to have a BA degree and licensure (which may or may not cover early childhood years/pre-K) and assistant teachers to have an AA degree, but not specialization in working with pre-K aged students. Nonpublic school settings, on the other hand, are typically regulated by child care licensing and do not require a BA degree for lead teachers but do require early childhood knowledge for both lead and assistant teachers.
Pay Equity
Very few pre-K systems have addressed pay equity, the same salary and benefits as elementary school teachers based on qualifications. However, there are some local efforts underway to address some of this inequity:
- Washington, D.C. established the Early Childhood Educator Pay Equity Fund in 2021 through the Fiscal Year 2022 (FY22) Budget Support Emergency Amendment Act of 2021. The Act also established the Early Childhood Educator Equitable Compensation Task Force that developed a proposed salary scale for early childhood educators differentiated by role (teacher and assistant teacher) and by credential level (not setting).
- Multnomah County’s Preschool for All (PFA) has established a required salary scale based on qualifications
for both lead and assistant teachers. In addition, PFA programs are required to offer paid time off
and cover at least 50% of employee health insurance premiums.
Professional Development (PD)
Research has identified the components of an effective PD system:
- Participation in a required number of professional development hours for both lead and assistant teachers, often specified on an annual basis;
- Required coaching or job- embedded training that occurs within the classroom during the pre-K day; and
- A tracking system that is inclusive of both lead and assistant teachers, often referred to as an individual
PD plan.
Less than half of the 75 largest U.S. cities (45%) require that both lead and assistant teachers receive ongoing PD. In part, the low percentage of cities meeting this benchmark may be the result of many pre-K programs not requiring teaching assistants to participate in the same level of ongoing professional development as teachers. In addition, there are some cities in which one setting (e.g., Head Start) requires coaching or participation in PD hours, but not all settings in which the program operates.
Continuous Quality Improvement System
Data-informed program improvements help educators provide high-quality early learning opportunities, and programs must have a system to assess program quality which then guides improvement to meet this benchmark. Nearly 80% of cities report using a system of continuous quality improvement, which monitors program implementation and uses the data to guide program improvement. Research has shown that the use of planning, observation, and feedback is characteristic of highly effective programs. To meet this benchmark, a city’s policy must require (1) the systematic collection of data on classroom quality, and (2) that the program use this data to improve program quality through policy or practice. Some pre-K programs, such as the Denver Preschool Program and the Cleveland Metropolitan School District Preschool Program, require program providers to participate in the state’s formal Quality Improvement System. Some cities, such as Boston, Philadelphia, and Seattle, have funded formal program evaluations to ensure that funds are used in providing high-quality pre-K for city residents.
Equity Data
Collecting data on the demographics of students, families, and teachers allows local officials and residents to see not only who in their community has access to pre-K but also who is delivering the programming. This criterion is met if the city’s pre-K program collects race and/or ethnicity data on children, families, and/or teachers at the city level. Additionally, these data must be able to be reported publicly. In 2024-2025, 74 cities collected ethnicity/race data about their pre-K programs and were able to report that information.
Next Steps
This paper outlines the ways in which high-quality pre-K programming can positively impact children in the short- and long-term. Although equitable access for children across the U.S. remains a concern, many cities have stepped up to fill in gaps in access, with 70 of the 75 largest cities providing additional funding and many
cities adding additional quality components. Based on the research outlined in this report about the benefits of pre-K, it is clear why so many cities choose to invest in these programs: A high-quality early learning program is a proven way to see a return on investments in child development.
Some cities have enhanced the state’s pre-K program. For example, in California, there are policies that the city’s largest school district has developed that will allow the TK program to meet more of the NIEER benchmarks, such as most of the city school districts requiring child vision, hearing, and other screenings as well as referrals for follow-up as needed, even though the state policy does not require this to occur. In Texas, the state recently relaxed teacher qualifications for the state pre-K program, but only for teachers in non-public schools. However, school districts can step up and require additional policies, such as Houston ISD, which requires a BA degree for pre-K lead teachers in an all settings.
However, early learning programs are not the only way to support young children. Cities may consider other evidence-based practices that support children’s development outcomes. These could include:
- Children’s Cabinets. These local-level systems typically include a group of agencies or organizations (e.g., parks and recreation departments, mayors’ offices, local school districts) who come together to support the needs of local children through collaboration, data sharing, and vision setting. See the Local Children’s Cabinet for examples.
- Supporting Infant and Maternal Health. The U.S. ranks 34th out of 38 countries who participate in the Organization for Economic Cooperation and Development (OECD) in infant mortality rates, at four deaths per 1,000
live births (compared to 1.7 deaths per 1,000 live births in the two highest-ranked countries). Cities can support
the health of women and babies through local initiatives, such as the CelebrateOne initiative in Columbus, which
includes a safe sleep promotion campaign and collaborations with health care providers. - Baby bonds. These “start-up capital” funds are intended to provide families with a publicly-funded nest egg to
address the inequitable distribution of wealth in the U.S. Funds could be accessed between ages 18-30 for costs
such as college education, starting a business, or purchasing a home. Simulation research of the impacts of baby
bonds shows they could be a useful tool for reducing income inequality.
Cities have powerful tools to support the healthy development of young children from investing in early learning
to advancing policies that center families’ needs. When these investments are absent or fragmented, disparities
in health, development, and long-term economic stability persist. By adopting thoughtful, inclusive policies that
prioritize children and families, cities can interrupt these inequities and create the conditions for every child to
thrive.
