Geography and Population

New Mexico (NM) is the fifth largest U.S. state in area, yet its population is only 2.09 million.  These wide-open plains provide breathtaking scenery; however, this vastness makes it a challenge to provide access to services such as health care.  Fifty percent of New Mexico’s population live in three counties (Bernalillo, Doña Ana, and Santa Fe) which together comprise only 6% of the state’s land area. In more sparsely-populated rural 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)

Figure 1: Estimated Population County by County- Population Density, 2017

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 (US Census). 

From 2010 to 2018, nearly two-thirds of the state’s counties experienced a

decline in population. Population growth by age group was confined entirely to the

population aged 65 and over. While retirees are moving into the state, young people

are leaving rural communities in favor of metropolitan areas in New Mexico and

elsewhere to take advantage of education, employment, and entertainment

opportunities. And, the proportion of New Mexicans aged 65 and over is outpacing that

of other states.

Minority groups make up a majority of the population.  According to the NM Indicator-Based Information System (NM-IBIS), in 2017, NM's total population consisted of 48.8% Hispanic, 38.2% non-Hispanic White, 9.08% American Indian, 2.2% African American, and 1.7% Asian and Pacific Islander. In 2018, 6.1% of persons were under the age of 5, 23.4% were under the age of 18 and 50.5% were female. (US Census, American Community Survey, 2018). The Hispanic population of NM is a mix of deeply rooted families that have been in NM for generations and more recent immigrants.  Many families are of mixed status, documented and undocumented, and several NM cities have passed policies supportive of immigrants.

Poverty

Poverty is a root cause of many other health issues and inequities, such as inability to access medical care, inadequate school readiness, food insecurity, and obesity. New Mexico continues to be one of the five poorest states in the nation, with a median household income of $46,718 compared to of US median of $57,652 for the time period of 2013-2017.  According to the most current American Community Survey estimates, 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?).   

Children perhaps suffer the most from the high poverty rate, with almost a third of NM children, aged 0-17, living in poverty (27.2% in 2017, according to the Annie E. Casey Foundation).  The elevated percentage of those living in poverty in New Mexico is especially true for those children living with grandparents (23%) as well as single-mother households (24%) for the year 2016. New Mexico has seen a slow decrease in the unemployment rate annually since the year 2013, and unemployment was at the lowest in a 5-year period in 2017 at 6.2% (Annie E. Casey Foundation). But the decrease in unemployment rates does not seem to have affected the poverty level, probably due to low wages.

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. United Way of Santa Fe County has made early learning their sole focus for the past several years and several other private foundations have also been funding efforts to improve the early learning and support system. In 2019, legislation passed to create a new Early Childhood Education and Care Department in state government.

In New Mexico, we have seen that at least since 2007, more than 50% of 3 and 4-year-olds have not been enrolled in prekindergarten programs. Increased access to Pre-K programs may be most beneficial to the highest-risk children, as the greatest gains have been seen in this demographic (Annie E. Casey Foundation). Between 2015-2017, this equates to an estimated 29,000 children that are missed.

New Mexico's 2016-2017 high school completion rate (71.1%) remains fairly consistent since 2010 (KidsCount data center). NM needs an educated workforce to meet the needs of businesses and attract technology and other new companies to the state.  In the same year, 7% of teens ages 16-19 were not in school and not high school graduates (national average is 4%), ranking NM as one of the worst in the nation in this indicator (2017, 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 specialty care. Travel is even more of an issue for pediatric subspecialty care, since most of the subspecialists, and the state’s only Children’s Hospital, are 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 “health professional shortage areas”.

Cultural barriers to care include language barriers and lack of trust in health providers and systems, which can affect healthcare utilization, most notably among women and children residing on tribal reservations. 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. Over 40% of Medicaid enrollees were children under age 21 years. (NM IBIS May 2019).  The majority of new enrollees were in the Adult Expansion category. For children in NM, Medicaid, Children’s Health Insurance Program (CHIP), and the managed care organizations that contract with the Human Services Department are vital to healthcare access. Medicaid covers over 70% of births in NM (NM PRAMS data 2018).

To help support retention and recruitment of primary care and behavioral health providers, the Human Services Division (HSD), in collaboration with the Governor’s office, has proposed nearly $60 million in payment rate increases. The impact to the state general fund for these proposed changes is $13.1 million. HSD proposes to increase payment for Evaluation and Management (E&M) office visits from 70% to 90% of the 2019 Medicare fee schedule, effective July 1, 2019. E&M patient visits represent the core of most family practice, primary care, and specialty provider practices, and close to half of all Medicaid patient encounters. By raising these payment rates, HSD hopes to bolster its network of primary care and family practice providers, many of whom also provide behavioral health services through regular office visits in rural NM.

NMDOH Priorities

The 2017 – 2019 DOH Strategic Plan outlines the vision, mission, values, and priorities for the Department. It is part of the NMDOH Strategic Planning Roadmap, which also includes the State Health Assessment (SHA), a systematic review of New Mexico’s health status, and the State Health Improvement Plan (SHIP), a collaborative effort to identify, analyze, and address health issues in the state.

In the FY19 Strategic Plan, NMDOH identified a set of guiding principles to inform program strategies and actions and the development of cross-agency partnerships. These guiding principles establish a framework for the Department and its partners to act collectively to implement comprehensive programs that are efficient, effective, and sustainable. NMDOH has been using these guiding principles to inform programmatic activities. Below are some examples of how Title V staff are contributing to this work.

Create accountable programs and engage communities in aligned, collective

impact partnerships to achieve optimal population health status.

The Family Health Bureau (FHB) is working with the Children, Youth and Families Department (CYFD) to develop a multi-disciplined, multi-sectorial program to provide a safe plan of care for all infants exposed to harmful substances. FHB/PHD collaborates with multiple partners as members of the statewide Long Acting Reversible Contraception (LARC) working group to align activities and leverage different funding streams to achieve the goals of reducing unintended pregnancies and increasing knowledge of and access to LARC.

Achieve health equity by addressing the social determinants of health;

partnering with communities and American Indian tribes, pueblos, and

nations to reduce health disparities; and applying a health in all policies

philosophy.

NMDOH, and FHB in particular, has identified health equity as a guiding principle. 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 and multiple other stakeholders to reduce disparities in birth outcomes 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.

Promote access to person- and community-centered health and wellness by

aligning and integrating public health, behavioral health, oral health, and

primary care.

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.

Gather and analyze data for meaningful use.

FHB gathers data from every birthing hospital in NM to ensure that every baby receives the mandatory newborn screenings, including screening for metabolic and hematologic conditions, screening for congenital heart disease, and screening for hearing loss. Feedback is provided to hospitals and audiologists for quality assurance purposes such as improving blood spot collection and transit times and improving appointment times for infants needing audiologic diagnoses.

Empower and educate individuals in self-responsibility for their health.

The Family Planning Program’s comprehensive sex education programs promote self-responsibility by helping youth to make responsible choices and to develop effective life skills and healthy relationships. Service learning programs provide positive alternatives and leadership opportunities and engage youth to build on their strengths and interests in constructive ways. Adult-teen communication programs give adults information and skills to communicate effectively with young people about reducing risky sexual behavior.

In addition, the DOH retained the four priority areas from the prior strategic plan:  obesity, substance misuse, diabetes and teen pregnancy.  FHB/Title V staff work on these priority areas in the following ways:

Obesity: Obese children are more likely to become obese adults and to suffer from chronic diseases such as heart disease, cancer, and diabetes. WIC staff continue to educate families who receive WIC services about the importance of healthy diet and healthy weight in childhood.  The Title V Director and the WIC Director, along with staff from the Chronic Disease Bureau, have been working on a collaboration with NM State University (NMSU) to teach healthy eating and cooking habits to WIC and other PHO clients in public health offices.  NMSU staff provide cooking classes for clients who can get their WIC benefits at the same time.

Drug and Alcohol Misuse: The Family Health Bureau works on substance misuse and its effects in many ways.  The PRAMS survey added supplemental questions in 2014 that have helped inform programs on drug use in pregnancy.  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 NMPC is also working with hospitals to implement the Maternal Opioid AIM bundle.

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.  This has been a wonderful opportunity for interagency collaboration. 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 sky-rocketing (about 9 times) increase in neonatal abstinence syndrome (NAS) diagnosis in infants born between 2000 and 2015. Just between 2011 and 2017, the statewide rate increased more than two-fold from 6.1 to 14 per 1,000 live births. It is important to note that it is hard to discern the exact cause of the rising NAS rates. Several contributing factors include: more women being surveyed for NAS and overall more attention being paid to the current opioid crisis in the US. (See Figure 2)

Figure 2:

Data Source: NMDOH - Hospital Inpatient Discharge Database (HIDD), 2008-2017. Catron, De Baca, Harding, and Union counties have been removed due to lack of cases throughout the period here reported.

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.

In 2017, NM had the 17th highest drug overdose death rate in the nation. Drug overdose death rankings have seemingly been improving for NM since 2014 when NM was the second highest in the nation. However, these changes are not due to an improvement in the death rate, but rather the worsening of the rates in other states. Between 1999 and 2015, the overdose death rated in NM increased by 62.0% and since 2014, rates have remained fairly stable. Between 2013-2017, the average rate of drug overdose death was 24.6 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).

Legalization of marijuana was again considered in the 2019 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.

Along with smoking, alcohol abuse also has its place in the top preventable causes of death in the United States. 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 negative health consequences of excessive alcohol use include domestic violence, crime, poverty, unemployment, injury, mental illness among other problems (NM Substance Use Epidemiology Profile, 2018).

Youth in New Mexico are slightly above the average rate in the US for binge drinking. Alcohol is the most commonly used drug among youth in New Mexico, though most high school students do not drink with 26.2% of students saying that they were current drinkers in 2017. Students who identify as Hispanic are more likely to currently drink while American Indians are the least likely to drink.  Since 2003, self-reporting data shows that the rate of youth who are current drinkers has been declining (NM Substance Use Epi Profile, 2018).

Diabetes: Generally, both New Mexico and the U.S. prevalence of diabetes have remained similar since the mid-1990s. However, rates among different populations vary drastically. Diabetes rates are highest in the American Indian/Alaska Native population, whose rate is three times that of white adults. For women, the Hispanic rate was twice the rate of that for Whites. Both of these disparities are important in the context of NM where the respective populations are higher in percentage than other states. (https://ibis.health.state.nm.us/indicator/complete_profile/DiabPrevl.html).

A partnership between the University of New Mexico and the Maternal Health program at DOH is currently working to address the issues faced by mothers diagnosed with gestational diabetes to help ensure follow-up care to prevent the development of Type II diabetes later in life. An important part of this project is that the clinics that we are working in serve a majority of low-income and Hispanic ethnicity women. More about this project is in the Maternal Health Domain Annual Report section of this submission.

Teen Births: The Title V Director and the Family Planning Program staff have been working diligently on the issue of reducing unintended births in NM and increasing access to long-acting reversible contraception (LARC). They work with UNM, Young Women United, Planned Parenthood, the ACLU and others as part of the LARC Statewide Working Group to train providers and promote access to LARC.  In 2017, there were 23,708 births to NM resident mothers. According to data from NM IBIS, NM’s birth rate for teens has declined 57.9% between 2000-2017 but remains higher than the national rate. The 2017 NM rate for 15-19-year-old females was 27.6 per 1,000 live births down even from last year (29.4) (2018, NM-IBIS).

Disparities persist for Hispanic and American Indian teens. While most rates decreased since 2016, the 2017 data shows that American Indian teens had the highest birth rates in NM (34/1000) followed by Hispanic teens (31.7/1000).  Hispanics constitute more than half of NM’s 15-19-year-old female population, and their share of teen births is higher, representing about 60% of the births in this age group.  African-American females ages 15 to 19 gave birth at a rate of 25.1 per 1,000; White females ages 15 to 19 gave birth at 16.4 per 1,000. Using the majority population (White) as the reference group, both Hispanic and American Indian teens have about two more births to every White birth. Births to Black teen mothers did increase in NM in 2017 from the previous year (NM-Indicator Based Information System [IBIS], 2017 births). 

In 2017, teen mothers were the most likely to report an unintended pregnancy (54.7% of 15-17 year olds and 39.4% of 18-19 year olds).  Broken down by race/ethnicity, unintended pregnancy rates do not vary so vastly. Between 2015-2017, Hispanics had the highest unintended pregnancy rate at 26%, followed by Native Americans, 24% and Whites, 21% (NM Pregnancy Risk Assessment Monitoring System [PRAMS], 2017 births).

The Family Planning Program (FPP) applied for and were given a two-year grant from the Brindle Foundation to fund a social media campaign; this campaign, which wrapped up in spring, 2019, aims to educate NM teens about contraceptive options and how to access these options.  Response rates were excellent and FPP is considering how to replicate and expand on this effort. In addition, FHB received $250,000 from the Legislature in 2018 and $1.1 million in 2019 for LARC training and stocking. Through an RFP process, Envision NM was awarded the contract for training.  FHB is requiring comprehensive training for the whole office, including clerical staff, that includes life planning and a reproductive justice framework.

The NMPC has also worked for three years on a project to increase Immediate Post-Partum LARC insertion in hospitals.  This project, originally started by ASTHO, has moved slowly due to several roadblocks having to do with data collection and billing problems, as well as resistance from hospital administrators.  However, the work continues.  NMPC was awarded $100,000 for general administration by the 2019 NM Legislature and will receive another $100,000 from the LARC legislative funding to continue the IPP work with hospitals and birth centers.

Current and Emerging Issues

Oral Health:  Access to oral health care in NM continues to be largely inaccessible to individuals who are uninsured and are low-income. In 2016, 37.7% of New Mexican residents reported not having a dental visit in the past year and 85.1% of residents over age 65 have had all of their natural teeth extracted (2018, NM-IBIS). Tooth decay and other oral diseases are attributable to lack of understanding of the importance of oral health, poor oral hygiene, poor nutritional habits, and lack of access to care. American Indians and Hispanics have the highest rate of tooth decay among all populations. Hispanic and American Indians are less likely to have a dental visit.

Less than half of the adults with an annual income of less than $15,000 have had a dental visit within the past year. The Legislative Finance Committee has estimated that the state needs an additional 153 dentists, the great majority of whom are needed in rural, underserved parts of the state. Additionally, many dentists are not trained in how to provide services to children and youth with intellectual and cognitive disabilities, resulting in an even greater gap in services for this population. 

Climate Change:  Climate change is an ongoing threat with potential to impact human health in numerous ways: by making existing diseases and conditions worse, by helping to introduce new pests and pathogens, through extreme weather events (e.g., floods, droughts, heat waves, storms, hurricanes, wildfires), by influencing illnesses transmitted by food and water, by decreasing air quality, and by affecting the transmission of numerous infectious diseases whose agents are sensitive to weather conditions.  The new Governor and the legislator are taking steps to address our dependence on oil and gas production and increase alternative energy sources such as wind and solar. 

Leadership Changes:  The Public Health Division will have a new Director starting in July of 2019.  The previous Director retired in December and the two Deputy Directors have been filling in since then. In addition, three of the four PHD Regional Director Positions have turned over in the past year and two of the three are still in the process of being hired, with interim directors filling in. We also have a new Governor, Secretary and Deputy Secretary for DOH, all of whom started their positions in January 2019. DOH staff are hopeful about the new leadership and the opportunity for improvement in some of the inefficient processes that have plagued the Department in recent years.

Public Health Transformation:  The Public Health Division (PHD) continues its discussions around the “transformation of public health”. The PHD Leadership team has struggled somewhat with regard to maintaining or decreasing clinical services in the health offices. There has been a slight trend towards decreasing clinical services, and there is interest in making the public health offices hubs of community activities, but more discussion is needed to reach agreement and alignment in all regions.  Family Planning services, in particular, have continued to decrease every year, possibly due to the Medicaid expansion giving low-income residents more options for medical care or possibly due to staffing issues.

Legislative Updates:  The establishment of a new Early Childhood Education and Care Department will bring an even higher profile to the early childhood programs. The Governor’s Children’s Cabinet has been reconvened and had its first meeting in May 2019. This will be an opportunity for collaboration at the highest agency level and will hopefully result in better use of resources and alignment of the different Departments’ work.  Title V leadership is meeting with the Director of the Children’s Cabinet (and will meet with the head of the new Early Learning and Care Department once a Secretary and Deputy Secretary are named) to discuss our programs and how our work in Title V supports the early learning system. Two programs from DOH, including Families FIRST from FHB, will be moved into the new Department, which will also house federally funded home visiting, Pre-K, childcare, and the Part C Early Intervention Program.

Data Improvements:  Over the last four years, several programs in the FHB have been undergoing major changes in their IT and client data collection systems. Children’s Medical Services (CMS) and Families FIRST share a new case management system named CACTUS, which was originally scheduled to be fully rolled out in 2015-2016 but had several delays. It has been implemented statewide and program staff are using it for their work, but the system is still not fully developed.  Both programs continue to work with DOH IT and with the IT vendor (ACRO) to improve these systems. NM WIC partnered with Texas and Louisiana in a three-state IT solution called MOSAIC; this system was rolled out statewide in September 2018 and is almost complete, although reports are still in the validation phase. 

The Human Services Department (Medicaid agency) is developing a new Management Information System that they anticipate rolling out in the next 2-3 years.  The plan is for this system to serve as a “hub” for data from all state agencies, both receiving this data and acting as a source for data review and analysis.  CMS and Families FIRST received some state funding to ensure the connection of CACTUS with the new MMIS system. WIC is also working with the Human Services Department (HSD, the NM Medicaid agency) to develop a shared application portal so that clients can apply simultaneously to both Medicaid and WIC. 

Challenges

Many of the same challenges continue as in previous years, including the constant challenges of high poverty rates, health care provider shortages, inadequate funding, and the challenges of addressing health inequities in a multi-cultural state.  The state budget has improved due to oil and gas revenues increasing; however, hiring in state government remains a challenge due to changes in the hiring process 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. 

NM is bordered by Arizona, Utah, Colorado, Oklahoma, Texas, and Mexico, which presents unique challenges as there has been a recent increase in migrant families coming to the border seeking asylum. Our status as a border state with Mexico influences many aspects of life in New Mexico, and national and local debate over immigration issues are more than just theoretical for those residing here. The recent increase in migrants coming into the US through the Southern border has impacted life in many NM communities including Las Cruces, Deming, Albuquerque and more as volunteers try to meet the needs of the continued influx of migrant families, including children, who are passing through, many of whom have been affected by trauma, violence, and mental and physical exhaustion. NM DOH is trying to assure that all migrants receive medical screening and that those who seem ill receive treatment, either on site or by referring them to a local hospital or urgent care. NM DOH was able to obtain a mobile van from Santa Fe County and it is being used in Las Cruces as a place where migrants can receive private medical exams from volunteer medical providers.