Ongoing and emerging issues that impact the MCH population are discussed in this section, including infant and maternal mortality, COVID-19 and pregnancy, COVID-19 vaccination, routine childhood vaccination trends, the impact of the COVID-10 pandemic on local public health, the unwinding of the Public Health Emergency and Medicaid continuous enrollment, fluoridation, and health concerns specific to children and youth with special health care needs (CYSHCN). Additionally, Title V needs assessment activities in FY 2023 focused on assessing the public health workforce and broadband access for service delivery, which are also discussed in this section.

Ongoing and Emerging Issues that Impact MCH

Infant and Maternal Mortality

MDHHS closely monitors infant and maternal mortality and has seen the following trends and emerging concerns. The infant mortality rate (IMR) in Michigan for 2021 was 6.2 deaths per 1,000 live births, which is another lowest on record IMR. The last lowest on record IMR occurred in 2019. Racial and ethnic disparities remain a major contributor to Michigan’s infant mortality rates. The gap between the Black and white infant mortality rate widened in 2021. The Black infant mortality rate was more than three times that of the White infant mortality rate (13.6 versus 4.4 per 1,000 live births in 2021). The pregnancy-related mortality ratio in Michigan for 2019 was 23.2 maternal deaths per 100,000 live births[[1]]. As with infant mortality, disparities between Black and white mothers exist, with the Black pregnancy-related mortality ratio nearly three times that of the white rate (29.8 versus 10.7 per 100,000 live births based on 2015-2019 data). In addition to maternal deaths caused by pregnancy-related issues, addressing pregnancy-associated, not related mortality[[2]] remains important: 37.9% of all pregnancy-associated, not related deaths from 2015-2019 were caused by accidental poisoning/drug overdose. Michigan’s maternal mortality committees have focused on developing recommendations to help prevent current and expecting mothers from developing substance use disorders.

COVID-19 and Pregnancy

Michigan continues to participate in the CDC COVID-19 Pregnancy and Neonate Surveillance Project. For the project, women who have received a confirmed diagnosis of COVID-19 during pregnancy are identified through the Michigan Disease Surveillance System (MDSS) which is then linked with birth and death certificates to track pregnancy outcomes. After each pregnancy outcome has taken place, medical records for both mother and infant are requested to obtain details regarding the impacts of COVID-19 on the health of mother and infant.

For the 2020 cohort, 1,378 Michigan women were identified with a confirmed COVID-19 diagnosis during pregnancy. A pregnancy outcome was confirmed for 1,288 (93.5%) with the remaining 90 women (6.5%) lost to follow-up. The 1,288 documented pregnancy outcomes resulted in 1,316 live births and less than five fetal deaths. Black pregnant persons were 3.4 times more likely to have a COVID-19 complication than white pregnant persons. Infants of Black parenting persons that were diagnosed with COVID-19 during pregnancy were 2.5 times more likely to be low birthweight compared to infants of white parenting persons that were diagnosed with COVID-19 during pregnancy. Furthermore, birthing parent races other than white were 1.2 times more likely to be in the COVID-19 cohort than those without a COVID-19 diagnosis during pregnancy. Michigan is currently completing data collection for the 2021 project cohort.

In addition to this surveillance project, the Michigan Pregnancy Risk Assessment Monitoring System (MI PRAMS) added COVID-19 questions to the survey. Results from the 2020 MI PRAMS COVID-19 questions indicate that an estimated 2.6% of new Michigan mothers reported that a health care worker told them they had COVID-19 during their most recent pregnancy, and it was confirmed through testing. When including mothers who were told by a health care worker that they had COVID-19 during their most recent pregnancy but they weren’t tested, this number increases to an estimated 3.7% (which represents 3,589 new mothers in 2020). Black, non-Hispanic mothers were nearly twice as likely to report COVID-19 during their most recent pregnancy when compared to white, non-Hispanic mothers. Michigan is awaiting the final 2021 Michigan PRAMS data file from the CDC. Similar analyses will be conducted on the COVID-19 questions.

COVID-19 Vaccination

Table 1 provides Michigan COVID-19 vaccine coverage percentages by age group as of January 14, 2023. Initiation is defined as the percentage of Michigan residents who have received 1 or more doses of any vaccine; completion is defined as the percentage receiving 2 doses of Pfizer or Moderna or 1 dose of Johnson & Johnson, and up to date is defined as the percentage who have received the Pfizer or Moderna Bivalent Booster. Just over one quarter of Michigan residents aged 5-11 years have either initiated or completed their initial COVID-19 vaccinations, but less than 5% of this group are up to date on their COVID-19 vaccinations (i.e., received Pfizer or Moderna Bivalent Booster). Initiation and completion rates increase to around 50% for those aged 12-29 years and increase to 60% or above for Michigan residents aged 30 years and above. Most of the Michigan population is not up to date with COVID-19 vaccinations.

Table 1. COVID-19 Vaccine Coverage Percentages by Age Group

Priority Childhood Vaccinations

Table 2 provides Michigan child vaccination percentages for January through September 2022. When compared to the US average, Michigan reports lower immunization percentages for each of the main childhood vaccinations. Table 3 provides information on child vaccination percentages in Michigan over time. Since the first quarter of 2020 (January-March 2020), Michigan has experienced consistent decreases in each of the priority childhood vaccinations.

Table 2. Michigan Childhood Vaccination Rates in Comparison to US

Table 3. Michigan Childhood Vaccination Rates Over Time

*4313314(2): 4 DTaP, 3 Polio, 1 Measles/Mumps/Rubella (MMR), 3 Hib, 3 Hepatitis B, 1 Varicella, 4 PCV, (2 Hepatitis A)

Impact of COVID-19 on Local Public Health

In 2022, the MDHHS Division of Local Public Health held site visits with 40 of 45 Local Health Departments (LHDs) to obtain feedback about the impacts of COVID-19. Conversations with LHD staff revealed that both the immediate and longer-term impacts of the pandemic have been significant and far-reaching for staff, families, and communities. LHD staff described trauma in the form of battle fatigue, lost leave, threats to staff and leadership, heartbreak at the community response, and mental and behavioral health challenges. State and local staff turnover was another challenge that resulted in loss of institutional knowledge. LHD staff also noted the need to promote workplace flexibility and to rebuild relationships with the community. They suggested that flexibility in background and experience in hiring may also help to mitigate staff turnover.

Staff also described how LHDs have had to contend with misinformation. Additionally, the ending of the public health emergency impacted Medicaid, WIC, and MIHP eligibility. Essential worker funds have been exempted from LHDs all but one time, significantly impacting morale and retention. Reengagement with LPH services, including clinical services, especially WIC and Immunizations, has become necessary. After Action Reporting has been proposed to capture the response in a useful form for the future. Despite the many challenges, there have been positives, such as the Michigan National Guard (MING) partnership, establishment/strengthening of regional lab systems, volunteers in the community, and CDC Foundation surge staffing.

Unwinding of the Public Health Emergency and Medicaid Continuous Enrollment

During the COVID-19 Public Health Emergency (PHE), state Medicaid agencies were required to continue health care coverage for all medical assistance programs, even if a person’s eligibility changed. The end of the PHE on May 11, 2023, triggered the unwinding of the Medicaid continuous enrollment provision which ends on March 31, 2023. Starting in June, Michigan Medicaid beneficiaries will have to renew their coverage as the state resumes eligibility redeterminations. MDHHS has taken many steps to make beneficiaries aware of the redetermination requirements and to help individuals retain Medicaid coverage if eligible. MDHHS communications provide consistent messages about three key steps for Medicaid beneficiaries related to the redetermination process and avoiding gaps in coverage: make sure contact information is up to date; report any changes to a household or income; and complete a renewal packet by the due date, if eligible. A Medicaid Benefit Changes website provides information on the PHE, eligibility renewal timeline, an FAQ document, and resources for Medicaid providers and community partners. A stakeholder toolkit includes a “Get Ready” flyer in English, Spanish, and Arabic; a platform to request redetermination materials in English, Spanish, and Arabic (e.g., wallet cards, posters, and animated files); Medicaid renewal information; and a Beneficiary Renewal Alert Letter example. MDHHS will also launch a multi-media campaign with radio ads, mobile and social media ads, audio streaming, and outdoor ads.

MDHHS issued a press release about the unwinding on February 15, 2023, which included information related to individuals who are no longer eligible for Medicaid:

Michiganders who no longer qualify for Medicaid will receive additional information about other affordable health coverage options available, including on HealthCare.gov. Affected Michiganders will be able to shop for and enroll in comprehensive health insurance as they transition away from Medicaid, and many Michiganders can purchase a plan for less than $10 per month. Renewals for traditional Medicaid and the Healthy Michigan Plan will take place monthly starting in June 2023 and run through May 2024. Monthly renewal notices will be sent three months prior to a beneficiaries’ renewal date starting with June renewal dates.

To help ensure that the MCH population continues to receive Medicaid services and, if no longer eligible, avoids gaps in coverage, MCH programs have shared information about the unwinding with partners and program recipients. For example, the Child and Adolescent Health Center (CAHC) Program provided detailed information on the unwinding to school based/linked health centers and School Wellness Program sites. Information included MDHHS information and resources, a link to the MDHHS stakeholder toolkit, and tips for how CAHCs—since they provide Medicaid outreach and enrollment assistance onsite—can help families navigate the redetermination process.

The CSHCS program reached out to Medicaid partners to provide an overview of the unwinding and redetermination process for the CSHCS Advisory Committee. The Advisory Committee is comprised of organizations (providers, disease specific organizations, etc.) and parent/family members with a focus on children with special needs. A discussion about the redetermination process will focus on how CSHCS stakeholders can support clients with redetermination eligibility. Additionally, potential loss of Medicaid coverage due to the end of the PHE could have cost implications for the CSHCS program. CSHCS dual enrollment with Medicaid increased during the PHE. If dual enrollment numbers return to pre-Covid levels, it will lead to an increase in non-Medicaid costs for the CSHCS Title V medical care and treatment program.

Michigan’s MCH programs will continue to monitor the unwinding and redetermination processes and identify ways to assist partners and clients, so that everyone who is eligible for Medicaid benefits continues to receive them.

Fluoridation

In 1945, Community Water Fluoridation (CWF) began in Grand Rapids, Michigan. Over the last 78 years, it has been a safe and effective strategy in the prevention of cavities. The US Surgeon General states that CWF is one of the most cost-effective, equitable, and safe measures communities can take to prevent tooth decay and improve oral health. Over the past few years, anti-fluoridation groups have grown more visible. Nationally, municipal water systems that have had an interruption in their supply line for fluoride have come under pressure to stop fluoridating. In a northern Michigan community, the city council recently voted to discontinue community water fluoridation due to the lack of supply and increased costs despite community support of fluoridation. The once robust School Mouth Rinse Program has ended with the last manufacturer discontinuing production. The removal of this fluoride delivery system leaves many children at risk of tooth decay and poorer oral health outcomes.

Children with Special Health Care Needs

There is an emerging focus on Children with Medical Complexity (CMC) who suffer from one or more chronic conditions that affects three or more organ systems or one-life limiting illness or rare pediatric disease. Nationwide, CMC make up less than 4% of the total children’s population but are estimated to account for 40% of Medicaid’s pediatric spending. To address the complex needs of this population, CSHCS is collaborating with Michigan Medicaid, Michigan Medicine, Michigan-based Children’s Hospitals, and stakeholders to explore the establishment of a CMC benefit in Michigan. The goals of the CMC benefit are to improve patient outcomes, increase patient and family satisfaction, and reduce health care costs by enhancing the systems of care for CMC and, more broadly, CYSHCN.

Application of a health equity lens has contributed to greater awareness of disparities in access to health care experienced by individuals with sickle cell disease (SCD) which disproportionately affects African Americans. An estimated 3,500 to 4,000 Michiganders are living with SCD. Individuals with SCD are prone to higher rates of hospitalization, emergency room utilization, and premature death. In FY 2021, CSHCS partnered with the Lifecourse Epidemiology and Genomics Division (LEGD) to submit a proposal to the Governor’s Office to expand CSHCS eligibility to adults with SCD, expand clinical services, and enhance the system of care serving clients with SCD. The proposal was embraced by the Governor and enacted in the FY 2022 budget appropriation. In FY 2022, 421 adults were enrolled with CSHCS. The program continues to implement outreach strategies to reach adults who can benefit from the CSHCS eligibility expansion, while also partnering with colleagues in LEGD to enhance clinical capacity to serve individuals with SCD. In addition, CSHCS is implementing strategies to expand the CMDS clinic model to include adult clinics caring for patients with SCD and developing toolkits for transition programs to improve transition to adulthood.

Improved access to respite care for families with CSHCN was identified as a need in the 2020 Needs Assessment. According to the 2019-2020 National Survey of Children’s Health, parents/caregivers of children with special health care needs in Michigan are five times more likely to have left a job, requested a leave of absence, or reduced their work hours due to the stress of their child’s health or health conditions. In response, CSHCS engaged with Partners for Children which completed a survey of 15 states to identify respite gaps and reached out to the Catalyst Center for additional evidence to support a policy change for CSHCS respite. CSHCS convened an internal workgroup with representation from Program Review Division, CSHCS, Office of Medical Affairs, and other partners to review and revise existing CSHCS respite policy. The committee has identified eligibility criteria and is in the process of estimating the population that would benefit from this policy change.

Literature Review

In 2023, a literature review was completed to understand more about the public health workforce and broadband access in Michigan. The full literature review, including citations, is included as a Supporting Document to this application. Highlights are included below.

Public Health Workforce

The public health workforce is essential to protecting and promoting the health and wellbeing of Michigan’s population of over 10 million people. The workforce is responsible for a range of essential services, including disease prevention and control, environmental health, emergency preparedness and response, health education, and health policy development. The COVID-19 pandemic exerted significant pressure on the public health system, including the maternal and child health system, and highlighted gaps that were compounded by the lack of investment into the state’s public health infrastructure, which has been understaffed and underfunded for many years (Bridge Michigan, 2023).

The strain on Michigan’s public health infrastructure is further exacerbated by several other challenges facing the public health workforce. One of the biggest challenges is the shortage of public health professionals in the state. According to a report by the National Public Health Information Coalition (NPHIC), there is a significant nationwide shortage of public health professionals, especially among nurses (NPHIC, 2021). Michigan ranked 5th in the highest number of mental health HPSAs, after California, Texas, Arkansas, and Missouri. The state ranked 6th in the highest number of primary care HPSAs and 7th in the highest number of dental health HPAs (HRSA, 2022).

Figure 1. Primary Care Health Professional Shortage Areas (HPSAs)

Source: Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, 2022

According to 2022 data from the Health Resources and Services Administration (HRSA), 55 of 83 counties in Michigan (66%) were considered whole area dental care shortage areas. A higher percentage of counties (71%) were considered whole area primary care shortage areas, while 86% of counties in Michigan were considered whole area mental health shortage areas.

Figure 2. Dental Care, Primary Care, and Mental Health HPAs, by County, 2022 – Michigan

Source: Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, 2022

Although these shortages were observed before the pandemic, they were exacerbated by stressors placed on the workforce during the pandemic. Several factors contribute to the shortage of public health workers in Michigan, including:

• Burnout, Stress, and Trauma
• Aging Workforce
• Lack of Funding and Low Pay

The need for additional specialized skills and training is another obstacle facing the public health profession in Michigan. Finally, there is a need for a more diverse public health workforce in Michigan. According to the PH WINS, the public health workforce is not representative of the communities it serves, particularly in terms of race and ethnicity. This lack of diversity can limit the effectiveness of public health programs and services in reaching and engaging communities of color.

To address workforce issues in the state, Michigan has implemented several initiatives to support the maternal and child health workforce and increase access to care for these populations. For example, the state has established loan repayment programs and other financial incentives to encourage mental health providers to provide direct service and physicians to practice in underserved areas. Additionally, Michigan has implemented telehealth programs to expand access to care in rural areas. Another potential solution includes increasing the number of healthcare professionals trained to provide maternal and child healthcare services in rural areas.

Broadband Access

Michigan is a state with diverse geography and population, ranging from urban areas like Detroit and Grand Rapids to rural and remote communities in the Upper Peninsula and Northern Lower Peninsula. Although more communities have access to broadband in recent years than in the past, significant disparities in broadband access remain. According to a report by the Michigan Department of Labor and Economic Opportunity (LEO), which houses the newly established Michigan High-Speed Internet Office (MIHI), an estimated 1.24 million Michigan households (31.5%) do not have a permanent, fixed internet connection at home and an additional 865,000 households face barriers related to cost, adoption, or digital literacy. The lack of access is more severe in rural areas and among low-income families, communities of color, and individuals with disabilities. According to LEO, “Black and Latino Michiganders are nearly half as likely to have a home broadband connection than non-Black or Latino residents” and “nearly 35% of households earning less than $20,000 annually do not have a broadband connection.” These disparities in access have implications for public health, as they can limit access to health information, public health services, telemedicine, and eHealth technologies, particularly for under-resourced communities and populations. The map below shows the availability of broadband service with speeds of at least 25 Mbps download in Michigan.

Figure 3. Broadband Service with Speeds of at Least 25 Mbps Download/3 Mbps Upload – Michigan

Source: Connected Nation Michigan, 2021

The lack of broadband access can have significant public health implications for residents of Michigan. Limited access to telemedicine can limit the ability of residents to receive timely and appropriate medical care. Initial data suggest that employing virtual care to replace some traditional in-person sessions, such as home visiting, may be a positive long-term alternative for some families and some types of services. Telemedicine can be particularly important for individuals living in rural areas or those with mobility challenges.

Strategies to Improve Broadband and Telehealth Access

Strategies have been proposed to address the digital divide and improve public health outcomes in Michigan. These strategies include:

1. Increasing broadband infrastructure in rural areas
2. Providing affordable internet and technology
3. Improving digital literacy and accessibility
4. Partnering with community organizations
5. Leveraging telehealth technology

Michigan has taken several steps to address the digital divide and promote public health broadband access, including the creation of the Michigan Broadband Roadmap, which was developed by the Michigan Department of Labor and Economic Opportunity (LEO) in collaboration with stakeholders from government, industry, and community organizations. The roadmap aims to identify gaps in broadband infrastructure and services, prioritize investment and deployment strategies, and promote public-private partnerships to expand access.

Broadband Funding Opportunities and Initiatives

Another important strategy for promoting public health broadband access in Michigan is the use of federal funding programs, such as the Connect America Fund (CAF) and the Rural Digital Opportunity Fund (RDOF). These programs provide subsidies and grants to broadband providers to expand their networks to unserved and underserved areas, including rural and low-income communities.

Other state-level programs include Connecting Michigan Communities (CMIC). The Michigan Department of Technology, Management, and Budget (DTMB) is offering a grant to extend broadband service to unserved Michigan areas. The grant funds are available for projects that demonstrate collaboration to achieve the area's community investment and economic development objectives. Statewide funding of $20 million was allocated to this grant program for the 2019 application year. The initial round of awards has been announced, and next year, approximately $15 million is anticipated to be allocated to this program.

Conclusion

The public health infrastructure in Michigan plays a critical role in promoting and protecting the health of communities. However, the public health workforce is facing a range of challenges, including an aging workforce, shortages of certain types of professionals, low compensation, stress and trauma, and a need for workforce development and training. By addressing these challenges and seizing these opportunities, Michigan can support a robust and effective public health workforce that is well-equipped to meet the needs of its diverse communities.

Technology and access to broadband can be leveraged to further strengthen public health infrastructure and access to services. Improving broadband access for people of childbearing age, pregnant people, infants, children, adolescents, and children and youth with special health care needs in Michigan is critical to improving public health outcomes and reducing health disparities for these populations.

By implementing innovative strategies, Michigan can improve public health outcomes for all residents, including those who are currently unserved and marginalized. By continuing to prioritize the public health workforce and broadband access as essential elements of an effective public health system, Michigan can make progress towards improving health outcomes and reducing health disparities for the MCH and CSHCN populations.

[[1]] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management. Data source: Maternal Deaths in Michigan, 2014-2018 Data Update. MDHHS. Michigan Maternal Mortality Surveillance Program.

[[2]] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy due to a cause unrelated to pregnancy.