Section III.B. Overview of the State  

 

North Dakota is a rural state located in the geographic center of the United States (U.S.). It encompasses significant landmass (69,001 square miles) and is the 19th largest state by geographic size. According to the U.S. Census Bureau, North Dakota is the second least populated state in the nation (760,077 residents) with a population density of approximately 10 persons per square mile. Most North Dakota counties possess a population base below 5,000 residents, including 36 counties considered “frontier,” defined as having a population density of six or fewer residents per square mile. North Dakota’s health status is confronted by a variety of challenges, including the unique geography and climate, socioeconomic factors and demographics of the state.

North Dakota has traditionally been one of the leading agricultural producers in the nation. According to the U.S. Department of Agriculture (USDA), North Dakota ranked sixth in the nation for the value of crops sold (2014 Census of Agriculture). Energy development also plays a large role in North Dakota’s economy. Top industries for jobs in North Dakota include government (17.1%), education and health (14.9%); retail trade (11.5%); leisure/ hospitality (9.5%); professional/ business services (8.3%); and construction (6.5%).

 

Over the last decade, North Dakota has had one of the fastest growing economies in the nation as measured by Gross Domestic Product (GDP). The 2000-2017 compound annual growth rate for North Dakota’s real GDP of 4.7%, was almost two times greater than the national average (1.7%) for this period (North Dakota Office of the State Tax Commissioner, 2019). From 2008-2018, oil and gas extraction and production taxes have raised almost 18 billion for the state, which accounts for almost 44% of total tax revenues collected by the state during that period. Over the last five years alone, oil and gas extraction and production taxes accounted for more than 50% of all tax revenues collected by the state (North Dakota Department of Mineral Resources, 2019).  

 

For decades, North Dakota experienced out-migration of its young adult population, leaving it an older-population state with about three-fifths of its population in the eastern half of the state. North Dakota has experienced a dramatic population change over the last several years. According to the U.S. Census Bureau, the state has grown by over 12.3% between 2010 and 2017, making it the second fastest population growth of all states during that time. The rapid population changes in the state are the result of an influx of people coming to work in energy development and related industries in the western part of the state. This influx of people has changed North Dakota from being an older-than-average state to one of the youngest. The median age was 35.1 in 2017, making North Dakota the fourth youngest state. The population growth in the state, especially among young adults, has strengthened North Dakota’s workforce and revitalized the state’s natural increase through more births. Age distribution data from 2017 estimates that approximately 7.2% of the North Dakota population is less than five years of age, 23.3% is under 18 years of age and 15% of the population is elderly (65 years of age or older) (North Dakota Census Bureau, 2017).

 

Racial and ethnic diversity continued to grow in North Dakota. The increase in the non-White population from 2010 to 2017 was the greatest percentage of any state. The population of color saw a 56.9% increase from 2010 to 2017 compared to the U.S. population of color increase of 14.8% during the same time (ND Compass, 2018). Despite the increase in the population of color, North Dakota was less racially diverse than most states (44 out of 50 states). The White, non-Hispanic population comprised 88% of all residents statewide in 2016, which is down from 92% in 2000 (U.S. Census Bureau, 2017). Among the racial and ethnic groups in North Dakota, the Black/African American population had the largest increase from 1.2% in 2010 to 3.1% in 2017 (185% increase). The Hispanic population increased from 2.0% in 2010 to 3.7% in 2017 (108% increase). The American Indian (AI) population continues to make up the largest minority population in North Dakota and remained constant as a percentage of the total population at 5.5% from 2010 to 2017 (ND Compass, 2018).

 

There are five-federally recognized Tribes and one Indian community located at least partially within North Dakota. The five tribes include the Mandan, Hidatsa and Arikara Nation (Three Affiliated Tribes), the Spirit Lake Nation, the Standing Rock Sioux Tribe, the Turtle Mountain Band of Chippewa Indians, the Sisseton-Wahpeton Oyate Nation, and the Trenton Indian Service Area. As of 2017, the median age of North Dakota’s AI was 26.1, a full nine years younger than North Dakota’s overall median age of 35 years (U.S. Census Bureau, 2017). Unemployment and poverty continue to be an issue on the reservations in North Dakota. Disparities facing the AI population include higher rates of diabetes, cancer, addiction, heart disease, and other public health issues, including unintentional injuries. The average age at death for AI is 54.7 years, compared to 75.7 years for the White population (ND Compass, 2013). According to the 2014 County Health Rankings, all 10 North Dakota counties identified as “least healthy,” are either within a tribal reservation or designated as rural/frontier.

 

Differences in poverty exist by race/ethnicity. Nationally, 25% of AI’s were estimated to be in poverty both in 2007 and in 2017. In North Dakota, the rate of poverty of AI’s was 40%, reaching its highest point during this timeframe in 2011 of 46%. The 2017 estimate of 33.8% is the lowest annual estimate (U.S. Census Bureau, 2017). According to the Current Population Survey (CPS), North Dakota has the second lowest unemployment rate in the nation at 2.3%. The U.S. poverty rate was estimated to be 13.4%. North Dakota’s rate was 10.3%, putting the state among the 10 with the lowest rates of poverty for 2017. Since 2007, while the U.S. poverty rate climbed at one point to nearly 16%, North Dakota’s never exceeded 13%, reaching the highest point in 2009 and generally declining since. The state’s rate of poverty has trended down over the past 10 years. In 2007, North Dakota had an estimated poverty rate of 12.1%, just under the national estimate of 13%. North Dakota ranked 27th lowest of the 50 states in that year (U.S. Census Bureau, 2017).

 

There is a direct correlation between the rate of poverty for a given area and the percentage of house­holds receiving public assistance. According to the 2015 “Growing North Dakota by the Numbers: Public Assistance Programs Tracked by the Census” report by the North Dakota Department of Commerce, from 2009-2013, the percentage of North Dakota households receiving Supplemental Security Income (SSI), cash assistance such as Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) benefits, ranged from over 45.6% in Sioux Coun­ty (AI reservation area) to 1.3% in Bill­ings County (an oil-producing county). Counties with the highest rates of public assistance all had a high AI population. These same counties had the highest rates of poverty in the state.

 

The health care delivery system in North Dakota consists of 52 hospitals – 36 smaller Critical Access Hospitals (CAHs) with 25 or fewer acute-care beds, six larger general acute-care hospitals located in the four largest cities, three psychiatric hospitals, two long-term acute-care hospitals, two Indian Health Service hospitals, and one rehabilitation hospital – and about 300 ambulatory care clinics. There are 31 facilities or programs statewide that provide mental health services and more than 50 licensed substance abuse programs. Outpatient care is augmented by 66 federally certified rural health clinics and five federally qualified health centers. All hospitals, including all 36 CAHs, except for one IHS hospital, are designated as trauma centers. Each of the “Big Six” hospitals, located in the four largest cities in North Dakota, are home to a Level II trauma center. Most emergency medical service support in the state is ground-based and provide basic services; which is under duress because of its dependence on volunteers and funding challenges. There has been an expansion across the state in the deployment and use of electronic health records, but financial and other barriers to full implementation remain (Health Issues for the State of North Dakota, 2019, University of North Dakota).

 

Local public health units also provide valuable health care in North Dakota. The public health system is made up of 28 single- and multi-county local public health units; all are autonomous and not part of the Department of Health. Services offered by each health unit vary, but all provide services in the areas of maternal and child health (MCH) (Health Issues for the State of North Dakota, 2019, University of North Dakota).

 

Like the rest of the country, North Dakota is facing a major health care delivery challenge – how to meet a burgeoning need for health care services now and in the future with a supply of health care professionals that is not keeping pace with the growing demand, thereby impacting the health status and needs of the MCH population. If the population increases to 800,000 by 2040 as predicted, 500 additional physicians will be needed in the state. Part of the challenge in North Dakota is an inadequate number of providers; however, a larger portion of the challenge is a maldistribution of providers who are disproportionately located in the larger urbanized areas of the state. People in rural areas of the state are often older, poorer, have less or no insurance coverage than people in non-rural areas, all of which are challenges to providing adequate health care. Frontier areas of the state face greater difficulties than rural areas in maintaining their health care workforce. These thinly populated regions cannot easily compete with the wages and amenities offered to health care providers by hospitals and clinics in urbanized areas. Even communities that do have adequate staffing are often one doctor or nurse away from a shortage (Health Issues for the State of North Dakota, 2019, University of North Dakota).

Census Bureau Health Insurance statistics break the population into major age cohorts: children under age 18, workforce age (18 through 64) and those age 65 and above. In 2017, an estimated 95% of children in the state had health insurance, very similar to the national rates. North Dakota children who are White have insurance at a rate higher than the state’s average (95%), while AI children are insured at rates substantially lower that the state’s average, at 86% although this rate has increased from 80% in 2012.

 

According to the 2017 American Community Survey (ACS), most North Dakotans have some form of health insurance. About 92% were insured in North Dakota, 80.2% are privately insured, 25% are on public insurance, and approximately 8% are uninsured. As of 2017, 8% of residents under age 65 in North Dakota lacked health insurance coverage (92% had some form of health coverage). White residents under age 65 were the highest of the insured at 94%, while AI’s reported the lowest rates of insurance at only 72.4%. Adults least likely to be covered tend to be in younger age groups. North Dakota residents in the age range of 18 through 24 tended to have the lowest coverage at 72.9%. Males tended to have lower rates of coverage than females in this age range regardless of race or ethnicity. Due to Medicare coverage, nearly 100% of residents age 65 and over were estimated to have health insurance.

 

Approximately one-tenth (10.7%) of North Dakota adults under the age of 65 have a disability. North Dakotans with disabilities, compared to those without disabilities, were more likely to be of AI descent at 12.7% (ACS 2017). According to the 2016-2017 National Survey of Children’s Health (NSCH), North Dakota provided slightly more coordinated and comprehensive care services within a medical home to children with special health care needs (CSHCN) (47.1%), compared to the national average (43.2%). Also in the 2016-2017 NSCH, only 67.2% of North Dakota families with CSHCN felt they received effective care coordination if they needed it, and 20% of families with CSHCN ages zero through 17 reported to have difficulty paying medical or health care bills in the last twelve months. These results indicate the dynamic need for medical homes and adequate health insurance within the state.

 

As of March 2019, according to state health facts from the Kaiser Foundation, North Dakota has enrolled 91,995 individuals in Medicaid and CHIP (Children’s Health Insurance Program). Out of all North Dakota Medicaid/CHIP enrollment, 47% of these individuals are children. This can be compared to the U.S., where an average of 51% of Medicaid/CHIP enrollees are children.

 

According to healthinsurance.org, there are three carriers that offer plans in the North Dakota exchange. Blue Cross Blue Shield of North Dakota, Sanford Health Plan and Medica offer coverage statewide. Medica rejoined North Dakota’s exchange for 2019; bringing insurer participation back to where it was prior to 2018. Open enrollment for 2019 coverage in North Dakota ended on December 15, 2018, but residents with qualifying events can still enroll. Short-term health plans are available in North Dakota with initial plan terms up to 185 days. A new state law requires short-term plans to allow insured individuals to renew their coverage, but total duration can’t exceed 12 months. Insurers added the cost of Cost Share Reduction (CSR) to on-exchange silver plans for 2019, after not being allowed to add the cost of CSR to any premiums in 2018. North Dakota has enacted legislation to create a reinsurance program; the next step is to seek federal pass-through funding with a 1332 waiver proposal. Enrollment in North Dakota’s exchange increased every year from 2014 through 2018, going from 10,597 to 22,846 enrolled. However, the Insurance Commissioner supported Affordable Care Act repeal, and then conducted a study on potential state-based reform. This showed a 3% decrease (21,820) of enrollees in private plans through the North Dakota exchange during the open enrollment period for 2019 plans (this enrollment window ran from November 1, 2018 through December 15, 2018).

 

North Dakota is one of 36 states that make up the Federally Facilitated Marketplace (FFM) for the Affordable Care Act (ACA). There were 21,820 people enrolled in qualified health plans through the North Dakota exchange during the 2019 open enrollment period, which ended December 15, 2018, representing a 3% decrease from the 2018 open enrollment period.

 

North Dakota’s exchange has had more consistent insurer participation over the years than most states. Medica, Sanford, and Blue Cross Blue Shield of North Dakota (Noridian) all offered plans in 2014 — the first year the exchanges were operational — and continued to do so through 2017.

 

The first major change came in 2018 when Medica exited the exchange altogether. Although Sanford had offered plans statewide in previous years, they drastically reduced their coverage area in 2018. Sanford plans were only available in a total of five counties in the Fargo and Bismarck areas. Residents in the rest of the state only had Blue Cross Blue Shield of North Dakota options available.

 

For 2019, insurer participation returned to what it had been in 2017, with Sanford once again offering plans statewide, and Medica offering plans in all but a few northwestern counties. Blue Cross Blue Shield of North Dakota continues to offer plans statewide in the exchange, as they have since 2014.

 

Three organizations in North Dakota received a total of nearly $637,000 in navigator grants in 2016 that were used for outreach, education and enrollment assistance to consumers eligible for coverage through the Marketplaces and through Medicaid. In 2017, organizations in North Dakota received funding of $208,524, a reduction of 67%. However, when navigator grants were announced in September 2018, only one organization in North Dakota, Family HealthCare Center, received $85,000.

 

The Family HealthCare Center has served as a navigator since 2015 and partners with Valley Community Health Centers to reduce the number of uninsured in North Dakota.  They also provide outreach and education to seven northeastern and southeastern North Dakota counties with focus on consumers at or below 200% of the federal poverty level (FPL), new Americans and refugees, pregnant women and new mothers, AI’s, the justice-involved population, disabled consumers and Medicaid-eligible populations.

 

Knowledge and awareness of CSHCN has been an asset in supporting access to affordable care for families. Navigators who were supported in the past with ACA funding were employees of organizations that understood programs that could assist families of CSHCN. When approached by a family for health care options, they still provide navigational support and link families to resources.

 

There are still gaps that exist with the ACA, in that some children need services that are not available through current benefit plans. Service limits may also pose a challenge. Lower income families may not be able to afford a plan that covers the needs of their children or the associated co-payments for services.

 

In addition to private plan enrollments, there were approximately 21,000 people enrolled in North Dakota’s expanded Medicaid as of November 2018. North Dakota previously followed a unique public-private partnership model of Medicaid expansion, allowing private health insurance carriers to bid for the opportunity to provide health insurance coverage to the state’s newly-eligible Medicaid population using federal Medicaid funds. The decision to bring North Dakota’s Medicaid expansion in-house to North Dakota Medical Services was passed during the 2019 Legislative Session. 

 

Healthy Steps (North Dakota’s Children’s Health Insurance Program (CHIP)) and North Dakota Medicaid have been effective public programs in reducing the number of uninsured, low-income children in the state. Healthy Steps provides premium-free, comprehensive health, dental and vision coverage to uninsured children up to 19 years old who do not qualify for North Dakota Medicaid. The income eligibility limit is at 175% of the Federal Poverty Level (FPL). Modest co-payments apply for certain services, which are waived for AI children. North Dakota Medicaid covers children ages 0 to 6 (thru the month they attain age 6) at 152% of the FPL and children ages 6 through 18 (through the month they attain age 19) at 138% of the FPL. North Dakota Medicaid has some limitations or restrictions for some covered services. For State Fiscal Year (SFY) 2018, there were a total of 121,501 North Dakota Medicaid recipients compared to 123,766 in SFY 2017. For SFY 2018, there were a total of 2,870 Healthy Steps recipients. It was estimated in November 2018 that approximately 28% of CSHCN were covered by North Dakota Medicaid.

 

1-877-KIDS-NOW is a toll-free resource line that helps uninsured families learn about low-cost and free health care coverage programs in North Dakota. A seamless eligibility process for health coverage programs has helped to assure coverage for North Dakota’s children. In February 2019, the combined monthly child enrollment in Medicaid and the CHIP in North Dakota was 47%, compared to 51% in the U.S.

 

Program data from the North Dakota Department of Health (NDDoH), Division of Special Health Services (SHS), indicated that 89% of the 1,990 children served by SHS had a source of healthcare coverage. Of these, about 57% were privately insured (1,134); 31% were insured by North Dakota Medicaid; 0.4% were covered by CHIP, 1.0% had no source of coverage, and 11% were unknown. 

 

The information provided below defines the roles, responsibilities and targeted interests of the state health agency and the influence of the delivery of Title V services:

Legislative activity serves to determine priorities and to identify current and emerging issues. NDDoH leadership is very supportive of allowing staff to provide testimony on key public health issues. Title V staff monitored, tracked and/or testified on close to 100 bills during the 2019 Legislative Session. A list of the bills can be found at: http://www.ndhealth.gov/ch/Bills_HSC_Tracked_During_2019_Session.pdf. Those of interest and/or involvement for Title V staff included:

• House Bill (HB) 1285 – a bill relating to abandoned infants at certain locations, and to provide for a report to the legislative management. The state department of health, in coordination with the department of human services, shall develop and implement a public awareness campaign to provide information, public service announcements, and educational materials regarding this section to the public, including medical providers, law enforcement, and social service agencies. NDDoH State Health Officer, Mylynn Tufte, provided supportive testimony. This bill passed; MCH has been assigned to coordinate this activity.
• HB 1336 – relating to printed information by state department of health, and realting to informed consent requirements before an abortion. This passage of this bill requires the NDDoH to add language on medication abortion reversal to written materials. This activity will be the responsibility of MCH staff.
• HB 1386 – a bill relating to the imposition of tax on electronic smoking devices. The NDDoH provided supportive testimony. This bill failed to pass, although much attention and education on the critical issue of electronic nicotine delivery systems (ENDS) was raised. To continue with the momentum of increased awareness, the NDDoH’s Tobacco Prevention and Control Program hosted an ENDS Summit in May 2019. Educational presentations as well as strategic planning were achieved.
• HB 1426 – a bill relating to regulation of dental therapists. This bill did not pass but raised awareness for the critical need of access to dental care.
• Senate Bill (SB) 2012 – to provide an appropriation for defraying the expenses of the department of human services. The NDDoH’s Suicide Prevention Program was transferred to the North Dakota Department of Human Services (NDDHS), Behavioral Health Division. This transition will result in better coordination of effective suicide prevention programs and practices across the behavioral health continuum of care (the continuum of care spans primary prevention, such as positive coping skills and family support, early identification and treatment, and supporting families who have lost loved ones to suicide).  
• SB 2155 – a bill relating to an exemption from the practice of pharmacy. Passage of this bill allows registered nurses working in a Title X (Family Planning) clinic to dispense certain contraceptives; thereby, increasing access to care for thousands of North Dakota women and men. The NDDoH provided supportive testimony.
• SB 2060 – relating to the amount of statutory fees and the use of safety belts; and realting to secondary enforcement of safety belt requirements (Primary Seat Belt Law). Although the bill did not pass, there was much more support and a coordinated effort on partner testimony this session, as compared to past sessions. This is the first session the NDDoH provided supportive testimony.  
• Many behavioral bills were monitored and tracked by the NDDoH. There was a great deal of support for behavioral health issues this session; the majority of the behavioral health bills were passed and funded. A summary of behavioral health initiative strategies can be found at: https://www.behavioralhealth.nd.gov/sites/www/files/documents/BH Strategy - web.pdf.

 

Behavioral health is a critical issue for the NDDoH, and partnership with the NDDHS, Behavioral Health Division, along with other key partners (e.g., Prairie St. Johns, Family Voices of North Dakota, Children’s Advocacy Center, medical systems), is essential to address these issues. In September 2018, North Dakota was awarded the Pediatric Mental Health Care Access (PMHCA) grant. The primary goals/objectives of North Dakota’s PMHCA Program are to: 1) increase tele-behavioral health services to children and adolescents living in underserved areas of the state; 2) to extend knowledge to pediatric primary care professionals across the state for the early identification, diagnosis, treatment and referral of mental health disorders; 3) to include direct school-based delivery of tele-health services due to the shortage of healthcare providers and the lack of an infrastructure for primary care clinics, and 4) to enhance existing partnerships and develop new relationships with entities that have similar goals and expectations to this program.

   

The NDDoH engaged in a strategic planning process on December 10, 2018, led by Mylynn Tufte, NDDoH’s State Health Officer. Because of this effort, the department's mission, strategic initiatives, key objectives and indicators have been updated. The NDDoH’s Strategic Plan Map (2019-2021) can be found at: http://www.ndhealth.gov/ch/Strategic_Map_2019-2021.pdf

 

The strategic plan is reviewed and revised annually and assists the department in communicating with partners, setting direction, motivating employees, making decisions, determining priorities and budgets, and monitoring progress and impact. The Title V Director and Health Equity/MCH Partnership Coordinator are members of the Strategic Planning Committee. All department programs have been linked to the strategic plan goals and objectives. Data indicators consisting of baseline data, targets and benchmarks are being developed and will be completed by July 31, 2019.

 

Title V programs align with the following NDDoH goals and objectives:

Goal: Create Healthy and Vibrant Communities

• Reduce the risk of infectious disease
• Prevent and reduce chronic disease
• Support communities in building resiliency
• Promote community driven wellness
• Increase healthy lifestyles and behaviors

Goal: Enhance and Improve Systems of Care

• Improve access to care in underserved and rural areas
• Enhance healthcare through technology
• Ensure access to and affordable health and preventative services
• Appropriately regulate and educate workforce to enhance quality and safe care
• Drive health-in-all policy agendas
• Establish system level partnerships across continuums of care

Goal: Strengthen Population Health Actions

• Prevent and reduce tobacco and other substance misuse
• Prevent violence, intentional and unintentional injury
• Reduce the risk of vaccine preventable diseases
• Reduce adverse health outcomes through early detection of disease
• Achieve a healthy weight for children and adults

Overarching Goal: Improve Health Equity and Assess Impacts of Social Determinants of Health

Overarching Goal: Manage Infrastructure for Optimal Outcomes

Overarching Goal: Integrate a Data-Driven Best Practices Approach

 

In addition to the core mission of the agency, the NDDoH is engaged in Governor Doug Burgum’s Five Strategic Initiatives for North Dakota: Main Street Initiative, Behavioral Health and Addiction, Transforming Education, Tribal Partnerships, and Reinventing Government. A description of the partnership and leadership role of the NDDoH and Title V in these initiatives can be found in III.E.2.a State Title V Program Purpose and Design.   

 

The NDDoH recognizes the importance of public health accreditation and the alignment of accreditation efforts throughout the public health system in order to strengthen performance across the state. In April 2019, the NDDoH celebrated two years as a nationally accredited health department through the Public Health Accreditation Board (PHAB). 

 

To increase the effectiveness of strategic planning and accreditation, the NDDoH has developed and implemented a performance management system and continuous quality improvement (QI) process. These efforts assist to systematically monitor and improve the quality of programs, processes and services in order to achieve high levels of efficiency and effectiveness, as well as internal and external customer satisfaction.

 

Title V program staff have varying roles and responsibilities within the department’s priorities and initiatives. The Title V Director holds a senior management position within the NDDoH and is actively involved in strategic planning and accreditation activities. As a result, Title V issues are included in department discussions, planning and decision-making processes. In addition, the Title V and CSHCN Directors and the Health Equity/MCH Partnership Coordinator provide regular updates to staff to seek input and feedback on department issues.

 

Initiatives set at the federal level also drive work priorities such as the many Collaborative for Improvement and Innovation Networks (CoIIN) (e.g., Child Safety, Healthy Weight). North Dakota’s CoIIN strategies and activities have been incorporated into the State Action Plan Tables and accompanying narratives (see III.E.1. Five-Year State Action Plan Table and III.E.2.c. State Action Plan Narrative by Domain).

 

State Specific Statues:

Priority setting also is determined by state mandates; see Supporting Document – Title V-MCH State Mandates. A State Performance Measure has been developed to address the Title V responsibilities related to these mandates titled “Implement North Dakota State Mandates Delegated to the North Dakota Department of Health Title V/Maternal and Child Health Program.” Information regarding these mandates is discussed in III.E.1. Five-Year State Action Plan Table and III.E.2.c State Action Plan Narrative by Domain – Cross-cutting/Systems Building.

 

The NDDoH’s organizational chart can be found in VI. Organizational Chart.