Geography and Population

New Mexico (NM) is the fifth largest U.S. state, comprising 121,298 square miles, yet its population is only 2.1 million.  These wide-open plains provide breathtaking scenery; however, this vastness makes it a challenge to provide access to services such as health care.  NM has only four cities with populations of 50,000 or more, and only 17.2 persons per square mile, making it one of the most rural U.S. states.

Fifty percent of New Mexico’s population is concentrated in three counties (Bernalillo, Doña Ana, and Santa Fe) which together comprise only 6% of the state’s land area. In more sparsely populated areas of the state, providing health care and public health services pose challenges, such as the ability to hire and maintain full-time clinicians and specialists, and the great distances that many people must travel to get care. (See Figure 1)

While 62% of the population lives in the seven more urban counties -- including Bernalillo County, which is home to a third of the state’s population-- over 7% of the population resides in frontier or sub-frontier areas. Most counties, 25 out of 33, have population densities of less than 15 persons per square mile. The mean travel time for employment is 22 miles, and nearly 20% of the population lives in poverty (US Census, 2014-2018). From 2010 to 2018, nearly two-thirds of the state’s counties experienced a

decline in population. In 2018, 5.9% of persons were under the age of 5, 23% were under the age of 18, and 50.5% were female

New Mexico is home to resilient and culturally rooted populations. Thirty-five percent of the population speaks a language other than English at home, and almost 10% are foreign-born persons. Minority populations, mostly indigenous or having over five generations of family history make NM one of very few “majority minority” states.  In 2018, NM's total population was 49.1% Hispanic, 37.9% non-Hispanic White, 9.1% American Indian, 2.2% African American, and 1.8% Asian and Pacific Islander. (NM-IBIS: University of New Mexico, Geospatial and Population Studies (GPS) Program, 2018).

NMDOH Priorities

The Title V grant in NM has its home in the Family Health Bureau (FHB) in the Public Health Division (PHD) of the Department of Health (DOH).  With a new Governor and agency administration in January 2019, the NM Department of Health created an Interim Strategic Plan for FY2020.  This plan is in place while work on a new FY21-23 Strategic Plan moves forward.  The Interim plan includes the following goals:

1. Improve organizational communication and collaboration;
2. Provide benchmarks for practice improvements and monitor state health status;
3. Develop policies and plans that support agency-wide health efforts;
4. Assure a competent public health workforce; and
5. Improve health status of all New Mexicans.

The PHD and FHB activities align closely with these DOH goals, as is evident throughout the Block Grant.  The Public Health Division provides a coordinated system of community-based public health services focusing on disease prevention and health promotion to improve health status, reduce disparities, and ensure timely access to quality, culturally sensitive health care.  The Public Health Division works closely with the Epidemiology and Response Division, which tracks disease outbreaks and investigations, monitors community health status, and mobilizes emergency response.

NM Strengths

Culture and Bilingualism

NM has a rich cultural heritage with a blend of many peoples and cultures.  Most NM residents (over 60%) identify as a person of color or American Indian/Alaska Native.  The Hispanic populations of NM include deeply rooted families and more recent immigrants.  Many families are of mixed status, documented and undocumented, and several NM cities have passed policies supportive of immigrant safety.  The Black population is small (2.2%) in NM but has a significant voice in improving health through organizations such as the Office of African American Affairs, the NM Birth Equity Collaborative, Black Health New Mexico, and the newly formed Governor’s Task Force on Racism and Equity.

Native languages are spoken in all of New Mexico’s tribes and pueblos. A high proportion of Native American children ages 5 to 17 living in their communities speak their native language, and a higher proportion of Native American children (34 percent) speak English and another language than do New Mexico children as a whole (26 percent). Tribes with more than half of their children speaking two languages include Acoma, Cochiti, Jemez, San Felipe, Santo Domingo, Zia, and Zuni (American Community Survey 2014-2018).

Increasing evidence has shown that bilingualism, especially among young children, improves the brain’s executive functions and cognitive ability. Preschool children who speak more than one language demonstrate a greater ability to solve mental puzzles than monolingual children. Efforts to promote bilingualism in schools hold great value and contributes to protective factors or buffering against risks for social and health-related outcomes across the life course.

Strong Support for Early Childhood

With Governor Michelle Lujan Grisham leading the state as of January 2019, there is a renewed focus on children and a dedication to improving outcomes, which is critical in a state where we are 50th in many areas according to the annual Annie E. Casey Kids Count report.  The newly revived Children’s Cabinet, comprised of state agency Secretaries and led by the Governor’s Office Children’s Cabinet Director, is working with NM Voices for Children (who puts out the Kids Count report for NM) to assess what policies or programs would best help NM move the needle on these educational outcomes.

In the past three years NM has been the recipient of a Preschool Development Grant as well as a Pritzker Prenatal to Three Policy Grant, and Title V staff have participated in the steering committees and needs assessment.  A new state agency, the Early Childhood Education and Care Department (ECECD), started in July 2020, making NM one of only four states to have an entire agency devoted to improving health and learning outcomes in the prenatal to five age group.  A new funding stream was created in the 2020 Legislative Session to provide a dedicated fund for the ECECD.  Additionally, the NM Title V Director was appointed to the UT Austin Prenatal to Three Policy Advisory Board, providing national guidance for a prenatal to three evidence-based road map.

Commitment to Health Equity

NMDOH, and FHB in particular, has identified health equity as a guiding principle for all our programming, but especially in regard to our Title V work.  From the beginning of the process, we centered equity in our discussions related to the needs assessment and our new five-year plan. Currently, with the national interest in equity and justice and anti-racism, it is an opportune time to increase our equity work even more, working with others in DOH and external stakeholders who are more focused on equity now than ever before.

We strive to establish partnerships with communities, other agencies, and organizations to reduce health disparities and we implement evidenced-based models and best practices that consider the roots of inequity and the diversity of the populations we serve. FHB is working with the Office of African American Affairs, the NM Birth Equity Collaborative, and multiple other stakeholders to reduce disparities in birth outcomes, maternal mortality and infant mortality through data analysis, provider education, and increasing public awareness. We have also committed to making health equity the overarching framework for our 2020 Title V Needs Assessment.  Equity is embedded in each domain with regards to assessing needs using an equity lens and ensuring that equity, justice and anti-racism are part of the five-year plan, throughout all domains and performance measures.

Access to Medicaid and Insurance Coverage

New Mexico was one of the states that expanded Medicaid to include low-income adults under the Affordable Care Act (ACA).  This has helped improve access to some extent, although having insurance does not guarantee access to a healthcare provider. Immediately after ACA implementation, the state’s uninsured rate was down to 12.8% in 2015, compared to 20.2% in 2013, and current estimates are approximately 10%. At the end of 2018, 840,486 New Mexico children and adults were enrolled in Medicaid. Currently, 42.3% of Medicaid enrollees are children under age 21 years, 9.5% are non-expansion parents and caretakers, 32% are adults under Medicaid expansion, and .7% are pregnant women. (HSD, 2020). Sixty-three percent of NM children under the age of 21 were enrolled in Medicaid in 2018.  Medicaid finances over 65% of prenatal care for resident births in NM (NM PRAMS, 2018 births). During pregnancy, women are covered if their household income is at or below 250% of the federal poverty level (FPL). This provides women and mothers a good start, but at 60 days after delivery, the eligibility threshold declines to 133% FPL, leaving many families without adequate or even any health insurance.

NM also has had a High-Risk Pool (NM Medical Insurance Pool) since the 1980s.  While many states have closed their insurance pools, NM has maintained this safety net for those who cannot access other insurance coverage due to not qualifying, losing employer-related insurance, or being outside of the enrollment period for applying for coverage.

NM Challenges

Poverty

New Mexico is one of the five poorest states in the nation, with a median household income of $48,059 compared to of US median of $60,293, 2014-2018. In 2018, 19.7% of New Mexicans are now living in poverty, compared to 12.3%, nationwide.  (https://www.census.gov/quickfacts/fact/table/nm,US/PST045218?).   

Almost one-third of NM children, aged 0-17, living in poverty (26.3% between 2014-2018, according to the U.S. Census, American Community Survey).  The New Mexico annual unemployment rate decreased from 7% in 2015 to 5.0% in 2017, approaching pre-recession (2009) rates of 4%; however, 36% of NM children live in a household where no parent holds regular, full-time employment (Annie E. Casey Foundation, Kids Count Data Center). Compared to the U.S. rate (27%), this puts NM kids at considerable disadvantage. Additionally, 37% of NM children are part of families receiving public assistance, putting our rank for that indicator at 50th in the U.S.

Education

In recent years, early learning (including the first 3-5 years of brain development, early literacy, and school readiness) has received focused attention from legislators, and in 2019, legislation passed to create a new Early Childhood Education and Care Department (ECECD) in state government. This new Department became a reality on July 1, 2020 and the NM Title V Director has been appointed to the ECECD Advisory Council.  Although early care and education have received quite a bit of attention and funding in the past five years, NM still has a long way to go to ensure all families have access to these services.  For example, less than 10% of children receive home visiting services, and only 40% of 3 and 4-year-olds are enrolled in pre-kindergarten (Pre-K) education programs.  The proportion of high school students in New Mexico not graduating on time has declined from 32% in 2013-2014 to 26% in 2017-2018, but this proportion is still nearly double the U.S. average (15%).; seven percent of NM teens 16-19 years were not enrolled in school or high school graduates, and 12% were not enrolled in school or working (national average is 7%), ranking NM as worst in the nation for this indicator (2018, Annie E. Casey Foundation, Kids Count).  

Access to Healthcare

There are many barriers to accessing health care in NM, including provider shortages, lack of affordable insurance, and having to travel long distances for care. This is especially true for pediatric subspecialty care, since most of the subspecialists and the state’s only Children’s Hospital, are located in Albuquerque. Due to a shortage of medical providers, many families are referred out of state to receive specialty care. Thirty-two of NM’s thirty-three counties are designated full or partial “health professional shortage areas”. Additional barriers to care include appropriate language, lack of trust in health providers and systems, and inadequate or low-quality carem, which can affect healthcare utilization for many communities.

FHB is working to transition more patients into a medical home that provides comprehensive primary care services. One example is to co-locate Women, Infants and Children (WIC) and public health clinics with rural and primary health care centers. This co‐location facilitates warm handoffs to a medical home for more comprehensive care. PHD’s social workers actively work to connect children with special health care needs to a medical home and to facilitate the communication between the pediatric subspecialists and the medical home for patients seen in the Children’s Medical Services specialty outreach clinics.

Substance Use

In 2017, NM had the 17th highest drug overdose death rate in the nation. Drug overdose death rankings have been improving for NM since 2014 when NM was the second highest in the nation. However, these changes are not due to significant improvement in the NM death rate, but rather the worsening of rates in other states. Between 1999 and 2015, the overdose death rated in NM increased by 62.0%, tapering moderately. Between 2014-2018, the average rate of drug overdose death was 24.3 per 100,000 in the population (NM DOH BVRHS, 2018). Among women, drug overdose death from prescription drugs was more common than from illicit drugs, across all age ranges (NM Substance Use Epi Profile, 2018).

While drug overdose and prenatal substance use receive a lot of attention nationally and locally, alcohol-related deaths are three times as prevalent in New Mexico (66.1 per 100,000 population), and alcohol abuse is still the leading preventable cause of death in the United States (NM-IBIS, 2015-2017). Since 1997, NM has had the nation’s highest alcohol-related death rate and is nearly twice as high as the US average rate.

The Family Health Bureau works on substance misuse and its effects in many ways.  The PRAMS survey added supplemental questions to 2017 birth data collection that have helped inform programs on prescription, over-the-counter and illicit drug use in pregnancy and postpartum.  FHB leadership has been on the Board of the NM Perinatal Collaborative (NMPC) for several years, and FHB has helped provide funding for one of the NMPC projects to improve diagnosis and treatment of babies born with NAS/NOWS (Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome).

The Children, Youth and Family Department engaged with us to help them respond to federal requirements to report all babies born exposed to substances and develop safe care plans for each of these infants. Together, we were able to pass legislation in 2019 that will promote a less punitive approach to mothers whose babies are born exposed to substances, which we hope will encourage more pregnant women to self-report and enter treatment earlier in pregnancy. New Mexico, like many parts of the country experienced a skyrocketing (about 9 times) increase in neonatal abstinence syndrome (NAS) diagnosis in infants born between 2000 and 2018. Between 2011 and 2018, the statewide rate increased more than two-fold from 6.1 to 12.6 per 1,000 live births. It is important to note that it is hard to discern the exact cause of the rising NAS rates. Contributing factors include more infants diagnosed with infant withdrawal symptoms due to better training and case recognition by medical providers and overall more attention paid to the current opioid crisis in the US. (See Figure 1)

Legalization of marijuana was again considered in the 2020 legislative session, and the bill received more support than in previous sessions but still did not pass.  The Medical Marijuana program continues to expand in the number of eligible conditions and in the number of certified growers and users. Opioid misuse in 2019 became the newest condition to be added to the list of qualifying conditions for a medical marijuana card.  One of our upcoming challenges will be to make sure any changes in marijuana laws consider the safety of children; we have already started to see incidents of children finding or accidentally ingesting marijuana and other substances.

Summary

Many of the same challenges noted in previous block grant report continue, including the constant challenges of high poverty rates; health care provider shortages; inadequate funding for schools, Medicaid, and social programs; and the challenges of addressing health inequities in a multi-cultural state.  The state budget in 2019 had improved due to oil and gas revenues increasing; however, in 2020 that changed drastically, and a special session of the Legislature had to be held to deal with budget shortfalls.  Hiring in state government remains a challenge due to a current hiring freeze, budget shortfalls, and loss of staff.  The challenges inherent in a multi-layered bureaucracy include lengthy and complicated contracting and hiring processes that can make the programmatic work more difficult.

Insurance coverage for all New Mexicans remains a significant challenge.  NM has a large population of immigrants, many of whom are undocumented or reside in mixed-status families.  Insurance coverage for the undocumented is a major challenge, as the undocumented are not eligible for subsidies to buy insurance on the Health Insurance Exchange, and anecdotal reports seem to show that the undocumented have trouble purchasing private insurance on the open market.  Currently the only affordable insurance coverage for the undocumented is through the Low-Income Premium Plan, which is part of the NM Medical Insurance Pool (High Risk Pool). Title V, Children’s Medical Services' funds are used to procure insurance for children with chronic or high cost conditions who are not eligible for any other coverage.  A Title V high-risk prenatal fund helps cover care for women with medical conditions or barriers to health insurance which put them or their pregnancy at risk.

Health Equity is both an opportunity and a challenge, one that has been highlighted by the pandemic we are currently experiencing.  The rural nature of NM, the high poverty rate, and the disparities in the social determinants of health (housing, access to healthy food, etc.) are continual challenges that exacerbate health inequities. Climate change is another continual and increasing challenge that is exacerbating inequities.  We know the health of all New Mexicans is at risk from climate change, but we also know some people are more at risk than others.  According to the Yale climate map, 68% of New Mexicans believe climate change is happening, which is approximately the same as the U.S rate of 67%, which is hopeful, but needs to be higher.

New Mexico, especially in the Native American communities, has been hit hard by COVID.  Food distribution has been a key part of the COVID response.  Climate change has the potential to inflict the same sort of damage as COVID in terms of loss life and economic insult. But it will be difficult for NM to make policy changes that improve effects of climate change, because our economy is very dependent on fossil fuels and our tax base is small.  In our health equity work, we must consider these issues and find ways to address the challenges.

Table 1:

Data Source: NMDOH - Hospital Inpatient Discharge Database (HIDD), 2011-2018.

NAS cases were identified by presence of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 779.5 (through 2015 third quarter) and the ICD-10-CM code P96.1 (starting in 2015 fourth quarter) on any of the diagnosis fields on the infant's record. Cases have been deduplicated and are presented by birth-year.