III.B. Overview of the State - New Hampshire - 2024
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Demographics, Geography, Economy and Government: New Hampshire (NH) is one of the ten oldest states in the country; it was originally a land grant in 1623 and became a state in 1775. NH’s population of 1.38 million live in 9,351 mostly forested (85%[1]) square miles bordered by Canada on the north and by Massachusetts on the south. On the east is the Atlantic Ocean and Maine and on the west is Vermont. With its 1,300 lakes and ponds, 40,000 miles of river and 18 miles of seashore, NH is the 45th largest state at 190 miles long and 70 miles wide. The state’s landscape lends itself to many different types of outdoor recreation. However, that same topography lends itself to difficult driving and long distances between places, particularly in the winter months, as well as disparities in broadband access with 10% of households not having an internet service subscription[2].
With its ten counties, approximately 37% of the population and 84% of the landmass in NH is considered rural[3]; most of the land area lies north and west of the capital Concord. The three most urban or metro areas are Manchester, Nashua and Concord, all located in the state’s southern tier where the majority of the population lives.
NH’s Title V Program consists of the Maternal and Child Health Section (MCH) located in the Bureau of Family Health and Nutrition (new name change as of 07/01/23) in the Division of Public Health Services (DPHS) and the Bureau for Family Centered Services (BFCS), located in the Division of Long Term Supports and Services (DLTSS). Many factors guide its efforts.
Both DPHS and DLTSS reside within the NH Department of Health and Human Services (DHHS), the State’s largest agency made up of approximately 10,000 employees and the bulk of the State’s budget (with Medicaid being the most costly line item). A Commissioner oversees the NH DHHS, appointed by the Governor for what typically is a four-year term. Both MCH and BFCS are physically located in the capital city of Concord. However, much of the Title V work takes place in funded agencies across the State in the form of community health centers (CHCs), specialty health clinics, health care quality improvement partnerships and human services agencies that provide home visiting and the like.
NH has the largest bicameral legislature in the English-speaking world, with 24 Senators and 400 Representatives, and operates under a unique Governor and Council (G&C) system. Five Executive Councilors, each representing 1/5 of the population are elected separately from the Governor, though for the same two-year term. All state departments and agencies must seek approval for both receipt and expenditure of state and federal funds, budgetary transfers within the department and all contracts with a value of $10,000 or more. There is also a Joint Legislative Fiscal Committee. This group of both Senators and Representatives has to accept and give the approval to expend any new or additional funding in between the preparation and approval of the two-year biennium budget.
Christopher T. Sununu, Republican, is the 82nd Governor of the State and is currently serving his fourth term which is up the end of calendar year 2024. The current Legislature and the Executive Council also have terms ending 12/31/24 with neither changing makeup significantly in the November 2022 election. Title V policy and funding is heavily influenced by both the Legislature (particularly the Joint Legislative Fiscal Committee) and G&C.
Last year’s legislative session and G&C meetings were busy for Title V staff who between MCH and BFCS have a substantial number of contracts. This is in addition to the House and Senate bills that spanned a wide range of issues affecting the MCH population from child passenger restraints to the birth certificate worksheet. Title V staff are asked to provide input through a bill’s fiscal detail sheet and through written and in-person testimony. A good deal of time this past year was also spent on the State 24-25 biennium (0701/23-06/30/25). The work began the summer of 2022 with Title V staff developing budgets for each separate accounting unit and preparing justification for any state, general funds. This was the first year in decades that the biennium budget passed both chambers without having to a Committee of Conference before sending it over to the Governor to be signed. Title V came out intact with no reduction of state, general funds.
NH continues to see an increase in population, approximately 11,107 people from 2021 to 2022 according to the U.S. Census Bureau[5]. This has been consistent over the past decade and is from migration into the state, not births. Deaths have outnumbered births since 2017. It is interesting to note that international migration (as opposed to domestic) to the state has increased during 2020 to 2022.[6]
As stated previously, NH is one of the oldest states in the country with approximately 20% of its population 65 and older, compared to the United States as a whole at 16.8%.[7] NH is routinely among the top five for the highest percentage of its population enrolled in Medicare at 23%.[8] As a result, its older population will more than double over the next 20 years. NH’s older populations are not represented evenly within the state: the percentage of the population of older adults is greatest in the North Country, while the biggest number of older adults live in the Southern part, which is the most populated.
Specifically looking at the Title V populations, the percentage of reproductive age females 15-44 in NH is 18.1 (as compared to the U.S. at 19.6%) as shown separated by age groups below: [9]
Approximately 18% of the state’s population is younger than 18 and 4.5% is younger than five, which is significantly less than the 22% of those the same age bracket in the entire U.S.[10] In the last decade, the number of children in NH under 18 declined close to 11%. This same decline was seen in the U.S. but at a much smaller percent. NH in fact, continues to have the lowest number of children per household in the country at 1.73 children.[11]
The actual population of the State of New Hampshire is primarily non-Hispanic white (89%), but its residents of color (Asian, 3.2%; Black, 2%; Hispanic, 4.6%; Two or more races, 2% and Other at less than 1%) are increasing.[12] Diversity continues to be geographically uneven in NH. Many square miles of the State are uniformly white, while the urban part in southern NH is more diverse as is the Hanover/Lebanon area (where Dartmouth College is) in the Upper Valley and a few areas of the Seacoast.
NH’s children, however, are more racially and ethnically diverse than its adults. An estimated 13.87% of children under five (5) in New Hampshire were non-white in 2021; 13.72% of children five (5) to nine (9) were non-white, 14% of children 10 to 14 were non-white, and 12.05% of children 15 to 17 were non-white.[13] Racial and ethnic diversity amongst children also is geographically uneven mirroring that of the total population. In NH’s two largest cities, Manchester and Nashua, approximately 20% of the children are non-white. [14]
Eight percent of NH’s population 5 and older speaks another language other than English at home, with Spanish, French, Chinese, Portuguese and Nepali in the top five.[15] Looking at the state in more detail, 21% of those 5 and older in Manchester and 23% in Nashua speak a language other than English at home. Almost 2% of the population in the state have limited English proficiency (LEP).[16]
NH is often ranked in the top ten states for overall well-being, child well-being and places to deliver a baby as well as many of the social determinants of health.[17],[18],[19], [20] Scores are based on a composite index of metrics that give a snapshot of the health of a population or its health care, such as Title V measures such as a low adolescent birth rate and preterm births (4.4% and 8.1% respectively in 2022 in NH compared to 13.5% and 10% respectively in the US)[21]. The state also scores high because some of its key social determinants of health such as economic stability, quality of education and public safety in general are good.
[22]New Hampshire
Juxtaposing that, NH is a low-revenue, low-expenditure state. Its revenue structure is distinctive in that the state lacks a broad-based personal income or sales tax, and its second largest source of tax revenue behind business profit taxes are local property taxes. Because it is such, funding of NH’s school districts is largely at the local level through those property taxes, which has led to disparities across the state in property poor districts. State funding for elementary and secondary local public education is the lowest in the country.
Other large tax revenues for the state level are those on business, tobacco, rooms and meals, real estate transactions and from the state enterprises selling liquor and lottery tickets.
NH has a diverse mix of industries, which usually makes its economy more resilient than that of states that are dependent on fewer. The state’s jobs are most heavily concentrated in retail, health care, government, and manufacturing with the lowest minimum wage in New England at $7.25 an hour connected with the current federal minimum wage. NH’s unemployment rate, pre-pandemic, was usually well below that of the U.S. as a whole (hovering around 2.0 to 2.5 % for over a decade). Part of that is due to consistently having a more educated workforce. However, with the advent of the COVID‑19 pandemic, NH, like the rest the country, experienced a significant increase in its incidence of new and sustained unemployment claims. Yet, also like the rest of the country, NH’s current unemployment rate has bounced back to even lower than before the pandemic at 1.9% as of May 2023. [24]
Typically, in any one year NH has one of the lowest poverty rates in the country with the latest estimate of 7.2% for the overall population (99,360) and 9% of children (23,000).[26], [27], [28] State and federal assistance programs and policies helped families during the pandemic, but most have expired such as continuous Medicaid coverage. There are clearly disparities in poverty level such as geography. From 2016-2020, the poverty rate in Rockingham County, south and by the Seacoast was 4.6% compared to the 11.7% in Coos County, the farthest north and most rural. In NH, households headed by a single woman have higher rates of poverty.[29] Poverty is also more prevalent to those who are foreign born (who make up a large part of the in-migration to the state).
The level of income families and individuals need to meet basic expenses also range across geographical areas of NH. It is estimated that the average cost of living in NH is $56,727, which is relatively low amongst other states in the U.S. However, the percent of daily living expenses as part of total income has been skyrocketing. particularly for the Title V populations living with low incomes (less than $35,000 a year) in the state. NH, like much of the rest of New England, has a housing shortage with rent and sale prices going up significantly as well as child-care costs. This forces low income parents into a conundrum between working or paying these costs.
In 2022, the NH Preschool Development Grant’s (PDG) Family Needs Survey (with the University of NH as the lead) explored how New Hampshire families with children under age nine fare in accessing early childhood care and education, measured their knowledge and use of supportive programs, and identified new and enduring needs. Using survey responses from a non-random sample of parents statewide, many respondents noted a lack of affordable childcare options as well as a limited availability.
Using another survey, this time using participatory action research, the NH Charitable Foundation first asked NH individuals if there was any difficulty in accessing daily living needs and following up, what did those interviewed think was the reason for the barriers. It is interesting to note that cost of housing is up there as well as transportation and lack of knowledge of community and assistance programs. NH Title V staff have been responding to the latter two (as well as transportation) in all of their programs.
According to the latest Household Pulse Survey from the U.S. Census Bureau, 34% of respondents said that paying for usual household expenses was somewhat or very difficult in the previous seven days beginning the end of June 2023.[33] This is up from previous years, probably because of the end of various kinds of assistance that took place during the COVID pandemic and the high rate of inflation.
Components of the state’s systems of care and Title V populations: According to the National Survey of Children’s Health (NSCH) from 2016 to 2021, the percentage of children whose parent identifies them as having special health care needs based on the CYSHCN Screener has increased, overall, from 20.5% in 2016-2017 to 24.2% in 2020-2021. However, the data from 2019 – 2020 and 2020-2021 are identical indicating a possible drop in 2021.[34] This will be reviewed further once the individual year data for 2020 and 2021 become available.
The number of Autism Spectrum Disorder (ASD) diagnoses reported to the NH ASD Registry[35] varies from year to year. As stated in other sections, this data reflects only those providers who report making a diagnosis in NH. It is known that a number of children are diagnosed in neighboring states that are not required to report to NH are not included in this data making it difficult to use as a predictor of services as intended.
Although the number of child development clinics available to assess, evaluation, and diagnose children with suspected developmental delay continues to decrease, the number of referrals to the Title V-funded Child Development Clinic Network increased more than 88%, from 328 in 2016 to 618 in 2022. The decrease in FY 20 and 21 is likely the result of the COVID-19 PHE and related issues of children missing well-child checks, dropping out of Early Supports & Services, and clinic closures. [36]
Annual reporting from community programs indicate that Developmental Pediatrician availability in NH remains very limited. Highly qualified psychologists, particularly those familiar with developmental differences in very young children have limited availability.
Wait lists are long for Applied Behavioral Analysis (ABA) and availability varies greatly by region. Few service providers offer ABA in the home setting, making it difficult for children to learn daily living skills and for parents to learn strategies to interact and teach their children. There is evidence that training parents to support developmental skill building is essential to good outcomes, and is mandated by NH Medicaid Managed Care. Few providers offer interpreters for families who speak little English, making it nearly impossible for them to have equal access to services for their young children with autism. The majority of insurance carriers in NH will not provide coverage for ABA until a full report with a recommendation for medically necessary ABA services is submitted. A letter of diagnosis, generated on the day of diagnosis, is not sufficient and therefore children wait longer to commence intensive services and are at risk of returning to provider waitlists.
Child Psychiatry, particularly for children having Medicaid, is also limited in NH and finding experienced behavioral health providers for children and parent counseling for challenging behavior is difficult for families and complicated by waitlists at the community mental health centers. Increased number of referrals for children presenting with “behavioral concerns” were seen during and since the COVID-19 Public Health Emergency (PHE). Limited availability of mental health and behavioral coaching for parents, across the state has made triaging more challenging, as it is difficult to refer for immediate help and support.
Special Education preschools are tasked with providing free and appropriate education to children diagnosed with autism or other significant disabilities, but are confined by offering less than five days a week and for only a few hours per day based on district policy. Families struggle to coordinate a preschool schedule, transportation to additional outpatient therapy sessions, and work obligations. This results in inequity in services for working parents who need fulltime childcare, whose first language is not English, have limited income and/or lack dependable transportation.
While the workforce shortage has affected most, if not all, professions, the lack of nurses and Direct Service Providers continues to be of great concern for families with CSHCN. According to supply and demand projections for 2030, NH will have a significant shortage, 37.3%, of Licensed Practical Nurses (LPNs).[37] These professionals often work for home health care organizations providing basic medical care to children with medical complexities in their homes, allowing families to care for their child in their community. Shortages of this nature often force families to leave work to provide care on a 24/7 basis.
NH’s Title V population is served by its 26 acute care hospitals. Thirteen of the 26 are designated as critical access hospitals, which have 25 beds or less and are the smaller, rural systems. Six specialty hospitals provide psychiatric and rehabilitative care with 480 beds. NH DHHS administers NH Hospital and Hampstead Hospital for the provision of psychiatric care for adults and children respectively. Hampstead is a recent purchase of DHHS. Dartmouth Health (DH) is the largest medical system in the State with its flagship hospital in Lebanon having the only Level 1 designated trauma classification. It also offers the State’s only comprehensive, full-service children’s hospital, a Level II designated pediatric trauma center, the Children’s Hospital at DH. Three hospitals in Boston are the closest Level I designated pediatric trauma centers to almost all locations in the State. A few pediatric subspecialties are also sometimes only found in Boston, which is particularly critical for Title V programs such as newborn screening and follow up. However, that is changing as more hospitals merge, and subspecialties practice part of the time in new ambulatory centers, particularly in southern NH.
NH has a highly concentrated health care delivery system. Acute care hospital systems are more than just inpatient and emergency room services. Many of NH’s hospitals have evolved to include the majority of the medical and primary care practices in the state as well as ownership of ambulatory surgery centers, health centers including rural health clinics, assisted or skilled nursing care facilities and home care and hospice. In the past three years, most of the hospitals in the State have also merged and affiliated with one another and across stateliness, joining hospital and health care systems nationally and with the border states of Massachusetts, Maine and Vermont (e.g. Massachusetts General Brigham and HCA Healthcare-which is for profit). Only two (Cottage and Speare Memorial, both critical access) of the 26 acute care hospitals have not been the subject of recent merger activity; thus, narrowing the healthcare delivery system to a handful of players.
There are 10 Federally Qualified Health Centers (FQHCs), one FQHC look-alike and 12 Rural Health Clinics (RHCs), all but two them critical access hospital-affiliated. They provide services at 63 sites. Through MCH, Title V helps to support the efforts of the majority of the FQHCs, the FQHC look-alike and one RHC.
NH DHHS also supports mental health services regionally through a network of ten designated Community Mental Health Centers. DHHS also implements Rapid Response (833-710-6477) and nh988.com, both of which provide mental health crisis services via phone, text and chat for children, youth and adults in NH who may be experiencing a mental health or substance misuse crisis. It is available 24/7 and can deploy mobile crisis teams around the state.
NH also has a network of 13 regional Public Health Networks (established in 2013 through emergency planning and drug and alcohol prevention funds) which seek to integrate multiple public health initiatives and services into a common network of community stakeholders for communities with comparable public health issues and priorities in order to improve health outcomes specific to these regions. The Public Health Networks are currently under an assessment, which will provide information on outcomes and plans for the future. These Public Health Networks took the lead along with DPHS in the State’s response to the COVID‑19 pandemic.
A State Health Assessment (SHA) and State Health Improvement Plan (SHIP) Advisory Council was established in July 2020 with RSA 126-A: 87-88. A SHA describes the status of a broad array of issues related to the health of the people in NH. The SHIP will guide decision makers in choosing where to put resources that will address NH residents’ greatest needs. Those priority issues are identified from the SHA data review, which included community engagement activities, such as surveys and listening sessions. A draft SHA is complete and the final is expected to be released the fall of 2023. Of particular note to Title V is the inclusion in the SHA draft a priority to expand access to quality prenatal, labor and delivery and postpartum care
The shortage of health care professionals in NH, exacerbated by the pandemic and a rapidly increasing aging of the population, is of particular concern to the state’s Title V population. Title V staff continue to work with colleagues at DPHS’s Office of Rural Health and Primary Care with participation in activities such as the Legislative Commission on Primary Care Workforce Issues and the NH Health Professions Data Center. With COVID 19 and American Rescue Plan funding, several health care workforce initiatives have opened in the state, including:
- Coos County Teaching Health Center Family Medical Residency Program (Coos County Family Health Center)-taking residents in 2024
- NH Needs Caregivers Initiative (LNA training) currently taking students
- Cheshire Medical Center/Dartmouth Health Family Medicine Residency Program taking residents in 2024
- Portsmouth Regional Hospital Psychiatry Residency currently taking residents (rotate through Lamprey Health Care)
- University of NH Psychiatric Nurse Practitioner Master’s Program currently taking nurses
- Bi-State Primary Care Association/Harvard School of Dental Medicine Dental Health Rural Residency currently taking dentists
Financing of services for the MCH population: It is estimated that 5.0 percent of NH residents were uninsured in 2021, the lowest percentage ever recorded in the state.[39] Of children zero through 18, 3% were uninsured. [40]
NH Medicaid utilizes a managed care model for medical services with three insurance plans, NH Healthy Families, Well Sense and AmeriHealth Caritas.
New Hampshire Medicaid Point in Time Enrollment at End of Month, 6/30/2023
At the end of June 2023, approximately 14% of NH’s population was enrolled in Medicaid (including expansion). Forty-three percent of those enrolled are children. However, with the disenrollment of potentially individuals and families who do indeed qualify for Medicaid, it is estimated that these numbers will go up slightly.
Title V staff joined their Medicaid colleagues this past year in reaching out to individuals and families to maintain their coverage or find alternative health insurance options during the wind down of the public health emergency and a return to routine annual redeterminations. Many of both MCH and BFCH’s Title V funded contractors worked closely with families to make sure their Medicaid did not lapse, either directly, through the MCOs, patient navigators, etc. NH Medicaid’s unwind approach was extremely comprehensive with a community as well as individual component. Letters were sent, calls were made and in-person discussions were held.
NH also operates a partnership health insurance exchange with the federal government (New Hampshire health insurance marketplace guide 2023 | healthinsurance.org), with the Department of Insurance having control over plan management and consumer assistance functions on the federal Marketplace.
Challenges that impact the health status of Title V populations:
Closure of Labor and Delivery Hospitals: Of particular concern to the MCH population is the closure of 11 labor and delivery (L&D) hospital units over the past two decades which leaves only 15 birth hospitals and four free standing birthing centers. The most recent closure was Frisbie Memorial Hospital in 2022. In rural NH, nine birthing hospitals have closed their L&D units since 2000, largely because of financial pressures and quality concerns associated with declining birth rates. In birthing hospitals which have closed their L&D units, many had small volume births in a year and typically had a higher percentage of patients that give birth paid for by Medicaid (up to 61% as shown in the figure below), which typically pays for a quarter of NH’s births in a year. Obstetrical services typically have high fixed costs and low reimbursement rates. Weekly for the past several years. Title V staff confer with their Alliance on Innovation in Maternal Health (AIM) partners, the Northern New England Perinatal Quality Improvement Network (NNEPQIN) on these and other similar issues.
Legislative responses include the 2022 passing of an omnibus House Bill (HB) 1661, which increased the Medicaid reimbursement rate for facility-based birth services provided at hospitals by 25%, in the aggregate, based on the rate in effect as of June 30, 2022. The DHHS Commissioner has the discretion to implement the reimbursement increase to adjust for access risk geographically; provided that no critical or non-critical access hospital receives less than a 20% increase. In addition, 2022 Senate Bill (SB) 408 increased the Medicaid facility fee reimbursement schedule for freestanding birthing centers. In 2023, a host of legislative initiatives were successfully included in HB 2, which accompanies the State 24/25 biennium budget signed into law the end of June 2023.[44],[45] This included the following significant legislative wins in 2023:
- extension of postpartum Medicaid through one year and Medicaid coverage for lawfully residing pregnant people and children (who haven’t been in the U.S. for a total of five years),
- a continuation of overall Medicaid expansion through 2030,
- coverage of doulas beginning in 2025 and
- donor breastmilk in 2024.
Title V staff provided testimony as well as informed their very large group of stakeholders.
In rural NH, the rate of unplanned location births for 2020-2022 was 4.8 per 1,000 live births compared to 2.9 per 1,000 live births in urban NH. 
Those covered by private insurance had a smaller rate (2.3 per 1,000 live births) of unplanned birth location as compared to those who paid for their deliveries using Medicaid (5.1 per 1,00 live births) or other payment methods (9.8 per 1,000 live births).[46] Additionally, most births which occurred in unplanned locations happened at home (unplanned) or in-route to the nearest open L&D. A 2021 study reported the median driving time to the nearest labor and delivery (L&D) unit increased from 18 to 39 minutes after closures across eight hospitals[47]. The share of pregnant women who lived more than 30 minutes from an open L&D unit increased from 20.2 percent in 2000 to 27.3 percent in 2018. Reduced proximity to an open unit was associated with an increased probability of attending fewer prenatal care visits than is recommended and giving birth in-route to the hospital or having an unplanned home birth.
A project focusing on increasing education to both emergency medical services and non-labor and delivery hospitals on unplanned births is taking place with NNEPQIN and the State’s Department of Safety, Bureau of Emergency Medical Services. This group is also looking to correlate these unplanned location births with weather patterns, outcomes, characteristics of the mom (parity, gestational age, etc.), and driving distance to a birth hospital from residence.
NH is also noticing slow increases in the number of Nulliparous, Term, Singleton, Vertex (NTSV) cesareans.
Pediatric Obesity: Childhood and adolescent obesity has been on the rise across the US. Recent data (2017-2020) indicate a prevalence of 12.7% among 2- to 5-year-olds, 20.7% among 6- to 11-year-olds, and 22.2% among 12- to 19-year-olds with an overall prevalence of 19.7% which is about 14.7 million children and adolescents. The figure below shows the prevalence of childhood obesity in US and New Hampshire among children ages 2-4 years participating in WIC. The prevalence of obesity among children aged 2-4years was 17.2% in 2018 and 16.1% in 2020[49]. In 2018, NH ranked second among 51 States and eight of 51 states in 2020. In that same year, the obesity rate among children 10-17 years and high school children was 15.2% and 12.7% respectively.[50] One strategy to reduce this prevalence is by promoting exclusive breastfeeding, which is a proven preventive measure.
Maternal Depression: Maternal mental health, a subset of behavioral health, impacts approximately one in five childbearing people each year in the US[51]. The cost of untreated maternal mental health conditions is estimated to reach about $14 million during the time from conception to 5-years postpartum, which includes lost wages due to mental health conditions and poor health outcomes of mothers and children[52]. The proportion of birthing people affected by maternal depression in New Hampshire has increased overtime, from about 17% in 2013 to 24% in 2020, during the COVID pandemic[53]. Behavioral health disorders, including substance use disorder (SUD), are identified and analyzed in the PRAMS and state Maternal Mortality Review Committee reports. Health related behaviors including WIC participation during postpartum, marijuana use, and discrimination in health services were more common among birthing people with depression based on 2016-2020 PRAMS data, while breastfeeding for longer than eight weeks was more common among birthing people who did not report depression. The figure below indicates that postpartum depression was more common among birthing people in NH who were under age 20 yrs., who had less than 12 years of education, were below 185% Federal Poverty Level (FPL), and who were ensured by Medicaid.
Monitoring the access and quality of improvement measures such as availability of the crisis hotline, screening for prenatal and postpartum depression and implementation of Alliance Innovation for Maternal Health (AIM) patient safety bundles are an important component of New Hampshire’s behavioral health services to reduce maternal depression during the perinatal period.
Adolescent Mental Health: With the release of the 2021 Youth Risk Behavior Survey results in 2023, NH saw an alarming rise in the percentage of high school students who felt sat or hopeless, seriously considered suicide and attempted suicide.
In addition to NH’s resources for addressing mental health described previously, Title V staff in the state routinely work with the DHHS Division of Behavioral Health Services, Bureau of Children’s Behavioral Health. In addition, MCH leveraged Title V funds to support a full time Pediatric Mental Health Program Manager, who works on SPM #2 as well as HRSA’s Pediatric Mental Health Care Access Program.
Substance Use Disorder: NH’s opioid overdoses and deaths have been plaguing the state for more than a decade and severely strains the health care system as a whole. This epidemic is particularly tragic for the MCH population.
One of the leading causes of maternal mortality in the State is accidental drug overdose.[55] Poisoning, mostly due to opioids, has overtaken car crashes, as the leading cause of death due to unintentional injuries particularly in the adolescent and young adult population (unintentional injuries, primarily poisoning due to opioids, continue to be the leading cause of death for all NH residents ages one through 44).[56]
MCH is the lead on the CDC’s Overdose to Action grant, which funds several opioid overdose surveillance and prevention strategies including the:
- Collection of real-time emergency department overdoses;
- Collection and dissemination of data related to overdose deaths;
- Enhancement of the state’s Prescription Drug Monitoring Program and
- Education of health care providers and support health care systems related to best practices around prescribing opioid medications.
MCH also facilitates both NH’s Maternal Mortality Review Committee and its Child Fatality Review Committee. Many case reviews in both committees (the majority in maternal mortality, which reviews all deaths, unlike child fatality, which picks representative cases) result in recommendations specifically related to overdose prevention such as the provision of naloxone if warranted. For the last six years, MCH has been collecting drug exposure data on its birth worksheet. Aggregated and de-identified data on drug-affected infants is submitted to DHHS’s Division of Children, Youth and Families (DCYF; the State’s Child Protection Agency) for its federal CARA/CAPTA notification requirements. The fact that an infant has been prenatally exposed to or born affected by drugs and/or alcohol does not itself require a mandatory DCYF report.
Title V staff also work in coordination with statewide colleagues on the Perinatal Substance Exposure Collaborative as well as NNEPQIN on encouraging the completion of the Plan of Safe Care, developed by a pregnant person and health care and social service providers when substance misuse is present. This has been a recommendation of both maternal mortality and child fatality review committees. MCH and NNEPQIN, in their co-sponsorship of NH as an AIM State, have been spearheading efforts within perinatal care of both SUD screening and treatment if necessary, and the dispensation of naloxone as part of implementing the AIM patient safety bundle, “Care for Pregnant and Postpartum People with Substance Use Disorder.” [57]
Disparities: NH just like any other state has various disparities in maternal, infant and child health outcomes when disaggregated by race, age, payer, rural or urban and other socio-demographic factors such as education and income levels. Medicaid payer have significantly more poor maternal and birth outcomes as compared to private payers. Those living in Rural NH have inadequate prenatal care visits due to proximity to an open labor and delivery unit and recent closures of rural birthing hospitals. The graphs below highlight some of the observed disparities from previous analysis of Severe Maternal Morbidity (SMM) and birth outcomes. SMM is a discrete set of life threatening complications defined by CDC as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health deliveries for NH births. Disseminated intravascular coagulation, hysterectomy, and acute renal failure were the leading indicators of SMM.
Between 2016-2020, the five-year aggregate SMM excluding transfusions was 67.2 per 10,000 live births. When disaggregating by mother’s race, rates of SMM were highest among those who identified as Black/African American and those who declined to respond. However, the rates calculated with numbers less than 20 in the numerator are considered unstable. Disaggregation by race often produces unstable values because birthing people who do not identify as White Non-Hispanic are not very populous in NH hence requires aggregation of multiple years. Additionally, SMM rates were highest among birthing people aged >35 years between the years of 2016-2020. The higher SMM rate is expected for birthing people aged >35 years, which qualifies the pregnancy as advanced maternal age and can put pregnancies into the high-risk category.[58]
The rates of Severe Maternal Morbidity (SMM) increased significantly from 2020-2021 by over 30% for SMM with blood product transfusions and over 40% for SMM without blood transfusions. Highest rates in 2021 were observed among Black or African American population, among mothers aged beyond 35years followed by 20-24years and those covered by Medicaid.[59]
Even though New Hampshire has a majority white population, poor health outcomes are observed among Black or African American followed by Asian in regards to percentage of low birth weight and preterm births.
There are also ethnic, gender and sexual orientation disparities shown within the latest YRBS mental health adolescent (high school) data. Hispanic, Native American and LGBTQA+ students were more likely to report attempting suicide than others. Title V staff are part of the state’s Suicide Prevention Council who are addressing these issues as is the Child Fatality Review which MCH facilitates.
Statutes and other regulations that have passed or are in process within the last year and have relevance to the Title V program: In addition to the legislative changes in Medicaid funding previously described, MCH’s Newborn Screening Program revised Administrative Rule He-P 3008, He-P 3000 (state.nh.us) to accurately reflect its current operations and procedures as well as ensure that definitive diagnostic results on infants who screen positive are reported in a timely manner.
[1] New Hampshire Forests | Wildlife Journal Junior (nhpbs.org) retrieved on 07/12/23.
[2] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/12/23.
[3] State Data (usda.gov) retrieved on 07/12/23.
[4] NHFPI The Legislature's State Budget_Investments in Health 6.15.23 retrieved on 07/12/23.
[5] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[6] https://www.nhes.nh.gov/elmi/products/vs.htm retrieved on 07/13/23
[7] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[8]Medicare Beneficiaries as a Percent of Total Population | KFF retrieved on 07/16/23,
[9] https://www.marchofdimes.org/peristats/data?top=14&lev=1&stop=128&ftop=125®=99&obj=3&slev=1 retrieved on 07/15/23.
[10] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[11] https://www.testhut.com/average-size-of-an-american-family-statistics/ retrieved on 07/13/23.
[12] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[13] https://datacenter.aecf.org/data/tables/10247-child-population-by-race-and-ethnicity#detailed/2/any/false/2048,574,1729,37,871,870/185,437,172,9,12,826,3378,2579,107/19835
[14] Ibid.
[15] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[16] State Demographics Data | migrationpolicy.org retrieved on 07/13/23.
[17] ahr_2022annualreport.pdf (americashealthrankings.org) retrieved on 07/18/23.
[18] https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance retrieved on 07/17/23.
[19] https://wallethub.com/edu/best-and-worst-states-to-have-a-baby/6513 retrieved on 07/17/23.
[20] aecf-2023kidscountdatabook-2023.pdf retrieved on 07/17/23.
[21] https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance retrieved on 07/17/23.
[22] aecf-2023kidscountdatabook-2023.pdf retrieved on 07/10/23.
[23] https://nhfpi.org/ retrieved on 07/17/23.
[24] nr-current (nh.gov) retrieved on 07/17/23.
[25] chart01.pdf (nh.gov) retrieved on 07/17/23.
[26] aecf-2023kidscountdatabook-2023.pdf retrieved on 07/10/23.
[27] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[28] https://nhfpi.org/ retrieved on 07/17/23.
[29] Ibid.
[30] Ibid.
[31] https://carsey.unh.edu/publication/new-hampshire-parents-use-child-care-but-seek-more-options accessed on 07/19/23.
[32] CLT-Report.pdf (nhcf.org) accessed on 07/19/23.
[33] Making-Ends-Meet-SHED-HPS-Urban-Data-Blog-7.25.23_1.pdf (nhfpi.org) retrieved on 07/23/23.
[34] Child and Adolescent Health Measurement Initiative. 2020-2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 07/26/23 from www.childhealthdata.org.
[35] Downie, E. (2022). NH Registry for Autism Spectrum Disorders Annual Report (July 1, 2021 - June 30, 2022). Autism Spectrum Registry. Retrieved 07/26/23 from https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents2/asdr-datasheetfy22.pdf
[36] Smith, J, LaFleur, L, Clark, J, & McLean, P. (2022), Title V Special Medical Services Programs –Child Development Clinic - Annual Report.
[37] U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2017. National and Regional Supply and Demand Projections of the Nursing Workforce: 2014-2030. Rockville, Maryland.
[38] 2022-NHHA_Hospital_Fact_Sheet_FINAL.pdf retrieved on 07/19/23.
[39] State Category | Health Coverage & Uninsured | KFF retrieved on 07/17/2023
[40] Ibid.
[41] Ibid
[42] bpq-da-medicaid-enrollment.pdf (nh.gov) retrieved on 07/14/23.
[43] NH Medicaid. “DHHS Continuous Enrollment Unwinding” (2023). Presentation to the Medicaid Clinical Medical Care Advisory Committee. July 17, 2023.
[44] HB 2 Chapter Law.pdf (state.nh.us) retrieved on 07/20/23.
[45] HB 1 Chapter Law Combined.pdf (state.nh.us) retrieved on 07/20/23.
[46] MCH Epidemiologist.
[47] Timothy Fisher and Sarah Benatar (October 2021). Following Labor and Delivery Unit Closures in Rural New Hampshire, Drive Time to the Nearest Unit Doubled, Urban Institute.
[48] MCH Epidemiologist.
[49] Ages 2-4 - State of Childhood Obesity retrieved on 07/14/2023.
[50] Ibid.
[51] Griffen A, McIntyre L, Belsito JZ, et al. Perinatal Mental Health Care In The United States: An Overview Of Policies And Programs. Health Aff (Millwood). Oct 2021;40(10):1543-1550. doi:10.1377/hlthaff.2021.00796
[52] Luca DL, Margiotta C, Staatz C, Garlow E, Christensen A, Zivin K. Financial Toll of Untreated Perinatal Mood and Anxiety Disorders Among 2017 Births in the United States. Am J Public Health. Jun 2020;110(6):888-896. doi:10.2105/ajph.2020.305619
[53] HPRAMS. Data Brief: Maternal Depression around the time of Pregnancy, 2016-2020. MCH; 2022. October 2022. Accessed June 2nd, 2023.
[54] Ibid.
[55] DPHS (2023). Annual Report on Maternal Mortality to the NH Health and Human Services Oversight Committee, Annual Report 2022.
[56] DHHS, MCH (2022); Child Fatality Review Committee 2022. Retrieved on 07/24/2023 from https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/inline-documents/sonh/child-fatality-review-report-2022.pdf.
[57] Alliance for Innovation on Maternal Health (2023). Care for Pregnant and Postpartum People with SUD. Retrieved on 07/24/2023 from Care for Pregnant and Postpartum People with Substance Use Disorder | AIM Program (Previously Council on Patient Safety) (safehealthcareforeverywoman.org).
[58] MCH Epidemiologist.
[59] Ibid.
[60] MCH Epidemiologist.
Demographics, Geography, Economy and Government: New Hampshire (NH) is one of the ten oldest states in the country; it was originally a land grant in 1623 and became a state in 1775. NH’s population of 1.38 million live in 9,351 mostly forested (85%[1]) square miles bordered by Canada on the north and by Massachusetts on the south. On the east is the Atlantic Ocean and Maine and on the west is Vermont. With its 1,300 lakes and ponds, 40,000 miles of river and 18 miles of seashore, NH is the 45th largest state at 190 miles long and 70 miles wide. The state’s landscape lends itself to many different types of outdoor recreation. However, that same topography lends itself to difficult driving and long distances between places, particularly in the winter months, as well as disparities in broadband access with 10% of households not having an internet service subscription[2].
With its ten counties, approximately 37% of the population and 84% of the landmass in NH is considered rural[3]; most of the land area lies north and west of the capital Concord. The three most urban or metro areas are Manchester, Nashua and Concord, all located in the state’s southern tier where the majority of the population lives.
NH’s Title V Program consists of the Maternal and Child Health Section (MCH) located in the Bureau of Family Health and Nutrition (new name change as of 07/01/23) in the Division of Public Health Services (DPHS) and the Bureau for Family Centered Services (BFCS), located in the Division of Long Term Supports and Services (DLTSS). Many factors guide its efforts.
Both DPHS and DLTSS reside within the NH Department of Health and Human Services (DHHS), the State’s largest agency made up of approximately 10,000 employees and the bulk of the State’s budget (with Medicaid being the most costly line item). A Commissioner oversees the NH DHHS, appointed by the Governor for what typically is a four-year term. Both MCH and BFCS are physically located in the capital city of Concord. However, much of the Title V work takes place in funded agencies across the State in the form of community health centers (CHCs), specialty health clinics, health care quality improvement partnerships and human services agencies that provide home visiting and the like.
NH has the largest bicameral legislature in the English-speaking world, with 24 Senators and 400 Representatives, and operates under a unique Governor and Council (G&C) system. Five Executive Councilors, each representing 1/5 of the population are elected separately from the Governor, though for the same two-year term. All state departments and agencies must seek approval for both receipt and expenditure of state and federal funds, budgetary transfers within the department and all contracts with a value of $10,000 or more. There is also a Joint Legislative Fiscal Committee. This group of both Senators and Representatives has to accept and give the approval to expend any new or additional funding in between the preparation and approval of the two-year biennium budget.
Christopher T. Sununu, Republican, is the 82nd Governor of the State and is currently serving his fourth term which is up the end of calendar year 2024. The current Legislature and the Executive Council also have terms ending 12/31/24 with neither changing makeup significantly in the November 2022 election. Title V policy and funding is heavily influenced by both the Legislature (particularly the Joint Legislative Fiscal Committee) and G&C.
Last year’s legislative session and G&C meetings were busy for Title V staff who between MCH and BFCS have a substantial number of contracts. This is in addition to the House and Senate bills that spanned a wide range of issues affecting the MCH population from child passenger restraints to the birth certificate worksheet. Title V staff are asked to provide input through a bill’s fiscal detail sheet and through written and in-person testimony. A good deal of time this past year was also spent on the State 24-25 biennium (0701/23-06/30/25). The work began the summer of 2022 with Title V staff developing budgets for each separate accounting unit and preparing justification for any state, general funds. This was the first year in decades that the biennium budget passed both chambers without having to a Committee of Conference before sending it over to the Governor to be signed. Title V came out intact with no reduction of state, general funds.
NH continues to see an increase in population, approximately 11,107 people from 2021 to 2022 according to the U.S. Census Bureau[5]. This has been consistent over the past decade and is from migration into the state, not births. Deaths have outnumbered births since 2017. It is interesting to note that international migration (as opposed to domestic) to the state has increased during 2020 to 2022.[6]
As stated previously, NH is one of the oldest states in the country with approximately 20% of its population 65 and older, compared to the United States as a whole at 16.8%.[7] NH is routinely among the top five for the highest percentage of its population enrolled in Medicare at 23%.[8] As a result, its older population will more than double over the next 20 years. NH’s older populations are not represented evenly within the state: the percentage of the population of older adults is greatest in the North Country, while the biggest number of older adults live in the Southern part, which is the most populated.
Specifically looking at the Title V populations, the percentage of reproductive age females 15-44 in NH is 18.1 (as compared to the U.S. at 19.6%) as shown separated by age groups below: [9]
Approximately 18% of the state’s population is younger than 18 and 4.5% is younger than five, which is significantly less than the 22% of those the same age bracket in the entire U.S.[10] In the last decade, the number of children in NH under 18 declined close to 11%. This same decline was seen in the U.S. but at a much smaller percent. NH in fact, continues to have the lowest number of children per household in the country at 1.73 children.[11]
The actual population of the State of New Hampshire is primarily non-Hispanic white (89%), but its residents of color (Asian, 3.2%; Black, 2%; Hispanic, 4.6%; Two or more races, 2% and Other at less than 1%) are increasing.[12] Diversity continues to be geographically uneven in NH. Many square miles of the State are uniformly white, while the urban part in southern NH is more diverse as is the Hanover/Lebanon area (where Dartmouth College is) in the Upper Valley and a few areas of the Seacoast.
NH’s children, however, are more racially and ethnically diverse than its adults. An estimated 13.87% of children under five (5) in New Hampshire were non-white in 2021; 13.72% of children five (5) to nine (9) were non-white, 14% of children 10 to 14 were non-white, and 12.05% of children 15 to 17 were non-white.[13] Racial and ethnic diversity amongst children also is geographically uneven mirroring that of the total population. In NH’s two largest cities, Manchester and Nashua, approximately 20% of the children are non-white. [14]
Eight percent of NH’s population 5 and older speaks another language other than English at home, with Spanish, French, Chinese, Portuguese and Nepali in the top five.[15] Looking at the state in more detail, 21% of those 5 and older in Manchester and 23% in Nashua speak a language other than English at home. Almost 2% of the population in the state have limited English proficiency (LEP).[16]
NH is often ranked in the top ten states for overall well-being, child well-being and places to deliver a baby as well as many of the social determinants of health.[17],[18],[19], [20] Scores are based on a composite index of metrics that give a snapshot of the health of a population or its health care, such as Title V measures such as a low adolescent birth rate and preterm births (4.4% and 8.1% respectively in 2022 in NH compared to 13.5% and 10% respectively in the US)[21]. The state also scores high because some of its key social determinants of health such as economic stability, quality of education and public safety in general are good.
[22]New Hampshire
Juxtaposing that, NH is a low-revenue, low-expenditure state. Its revenue structure is distinctive in that the state lacks a broad-based personal income or sales tax, and its second largest source of tax revenue behind business profit taxes are local property taxes. Because it is such, funding of NH’s school districts is largely at the local level through those property taxes, which has led to disparities across the state in property poor districts. State funding for elementary and secondary local public education is the lowest in the country.
Other large tax revenues for the state level are those on business, tobacco, rooms and meals, real estate transactions and from the state enterprises selling liquor and lottery tickets.
NH has a diverse mix of industries, which usually makes its economy more resilient than that of states that are dependent on fewer. The state’s jobs are most heavily concentrated in retail, health care, government, and manufacturing with the lowest minimum wage in New England at $7.25 an hour connected with the current federal minimum wage. NH’s unemployment rate, pre-pandemic, was usually well below that of the U.S. as a whole (hovering around 2.0 to 2.5 % for over a decade). Part of that is due to consistently having a more educated workforce. However, with the advent of the COVID‑19 pandemic, NH, like the rest the country, experienced a significant increase in its incidence of new and sustained unemployment claims. Yet, also like the rest of the country, NH’s current unemployment rate has bounced back to even lower than before the pandemic at 1.9% as of May 2023. [24]
Typically, in any one year NH has one of the lowest poverty rates in the country with the latest estimate of 7.2% for the overall population (99,360) and 9% of children (23,000).[26], [27], [28] State and federal assistance programs and policies helped families during the pandemic, but most have expired such as continuous Medicaid coverage. There are clearly disparities in poverty level such as geography. From 2016-2020, the poverty rate in Rockingham County, south and by the Seacoast was 4.6% compared to the 11.7% in Coos County, the farthest north and most rural. In NH, households headed by a single woman have higher rates of poverty.[29] Poverty is also more prevalent to those who are foreign born (who make up a large part of the in-migration to the state).
The level of income families and individuals need to meet basic expenses also range across geographical areas of NH. It is estimated that the average cost of living in NH is $56,727, which is relatively low amongst other states in the U.S. However, the percent of daily living expenses as part of total income has been skyrocketing. particularly for the Title V populations living with low incomes (less than $35,000 a year) in the state. NH, like much of the rest of New England, has a housing shortage with rent and sale prices going up significantly as well as child-care costs. This forces low income parents into a conundrum between working or paying these costs.
In 2022, the NH Preschool Development Grant’s (PDG) Family Needs Survey (with the University of NH as the lead) explored how New Hampshire families with children under age nine fare in accessing early childhood care and education, measured their knowledge and use of supportive programs, and identified new and enduring needs. Using survey responses from a non-random sample of parents statewide, many respondents noted a lack of affordable childcare options as well as a limited availability.
Using another survey, this time using participatory action research, the NH Charitable Foundation first asked NH individuals if there was any difficulty in accessing daily living needs and following up, what did those interviewed think was the reason for the barriers. It is interesting to note that cost of housing is up there as well as transportation and lack of knowledge of community and assistance programs. NH Title V staff have been responding to the latter two (as well as transportation) in all of their programs.
According to the latest Household Pulse Survey from the U.S. Census Bureau, 34% of respondents said that paying for usual household expenses was somewhat or very difficult in the previous seven days beginning the end of June 2023.[33] This is up from previous years, probably because of the end of various kinds of assistance that took place during the COVID pandemic and the high rate of inflation.
Components of the state’s systems of care and Title V populations: According to the National Survey of Children’s Health (NSCH) from 2016 to 2021, the percentage of children whose parent identifies them as having special health care needs based on the CYSHCN Screener has increased, overall, from 20.5% in 2016-2017 to 24.2% in 2020-2021. However, the data from 2019 – 2020 and 2020-2021 are identical indicating a possible drop in 2021.[34] This will be reviewed further once the individual year data for 2020 and 2021 become available.
The number of Autism Spectrum Disorder (ASD) diagnoses reported to the NH ASD Registry[35] varies from year to year. As stated in other sections, this data reflects only those providers who report making a diagnosis in NH. It is known that a number of children are diagnosed in neighboring states that are not required to report to NH are not included in this data making it difficult to use as a predictor of services as intended.
Although the number of child development clinics available to assess, evaluation, and diagnose children with suspected developmental delay continues to decrease, the number of referrals to the Title V-funded Child Development Clinic Network increased more than 88%, from 328 in 2016 to 618 in 2022. The decrease in FY 20 and 21 is likely the result of the COVID-19 PHE and related issues of children missing well-child checks, dropping out of Early Supports & Services, and clinic closures. [36]
Annual reporting from community programs indicate that Developmental Pediatrician availability in NH remains very limited. Highly qualified psychologists, particularly those familiar with developmental differences in very young children have limited availability.
Wait lists are long for Applied Behavioral Analysis (ABA) and availability varies greatly by region. Few service providers offer ABA in the home setting, making it difficult for children to learn daily living skills and for parents to learn strategies to interact and teach their children. There is evidence that training parents to support developmental skill building is essential to good outcomes, and is mandated by NH Medicaid Managed Care. Few providers offer interpreters for families who speak little English, making it nearly impossible for them to have equal access to services for their young children with autism. The majority of insurance carriers in NH will not provide coverage for ABA until a full report with a recommendation for medically necessary ABA services is submitted. A letter of diagnosis, generated on the day of diagnosis, is not sufficient and therefore children wait longer to commence intensive services and are at risk of returning to provider waitlists.
Child Psychiatry, particularly for children having Medicaid, is also limited in NH and finding experienced behavioral health providers for children and parent counseling for challenging behavior is difficult for families and complicated by waitlists at the community mental health centers. Increased number of referrals for children presenting with “behavioral concerns” were seen during and since the COVID-19 Public Health Emergency (PHE). Limited availability of mental health and behavioral coaching for parents, across the state has made triaging more challenging, as it is difficult to refer for immediate help and support.
Special Education preschools are tasked with providing free and appropriate education to children diagnosed with autism or other significant disabilities, but are confined by offering less than five days a week and for only a few hours per day based on district policy. Families struggle to coordinate a preschool schedule, transportation to additional outpatient therapy sessions, and work obligations. This results in inequity in services for working parents who need fulltime childcare, whose first language is not English, have limited income and/or lack dependable transportation.
While the workforce shortage has affected most, if not all, professions, the lack of nurses and Direct Service Providers continues to be of great concern for families with CSHCN. According to supply and demand projections for 2030, NH will have a significant shortage, 37.3%, of Licensed Practical Nurses (LPNs).[37] These professionals often work for home health care organizations providing basic medical care to children with medical complexities in their homes, allowing families to care for their child in their community. Shortages of this nature often force families to leave work to provide care on a 24/7 basis.
NH’s Title V population is served by its 26 acute care hospitals. Thirteen of the 26 are designated as critical access hospitals, which have 25 beds or less and are the smaller, rural systems. Six specialty hospitals provide psychiatric and rehabilitative care with 480 beds. NH DHHS administers NH Hospital and Hampstead Hospital for the provision of psychiatric care for adults and children respectively. Hampstead is a recent purchase of DHHS. Dartmouth Health (DH) is the largest medical system in the State with its flagship hospital in Lebanon having the only Level 1 designated trauma classification. It also offers the State’s only comprehensive, full-service children’s hospital, a Level II designated pediatric trauma center, the Children’s Hospital at DH. Three hospitals in Boston are the closest Level I designated pediatric trauma centers to almost all locations in the State. A few pediatric subspecialties are also sometimes only found in Boston, which is particularly critical for Title V programs such as newborn screening and follow up. However, that is changing as more hospitals merge, and subspecialties practice part of the time in new ambulatory centers, particularly in southern NH.
NH has a highly concentrated health care delivery system. Acute care hospital systems are more than just inpatient and emergency room services. Many of NH’s hospitals have evolved to include the majority of the medical and primary care practices in the state as well as ownership of ambulatory surgery centers, health centers including rural health clinics, assisted or skilled nursing care facilities and home care and hospice. In the past three years, most of the hospitals in the State have also merged and affiliated with one another and across stateliness, joining hospital and health care systems nationally and with the border states of Massachusetts, Maine and Vermont (e.g. Massachusetts General Brigham and HCA Healthcare-which is for profit). Only two (Cottage and Speare Memorial, both critical access) of the 26 acute care hospitals have not been the subject of recent merger activity; thus, narrowing the healthcare delivery system to a handful of players.
There are 10 Federally Qualified Health Centers (FQHCs), one FQHC look-alike and 12 Rural Health Clinics (RHCs), all but two them critical access hospital-affiliated. They provide services at 63 sites. Through MCH, Title V helps to support the efforts of the majority of the FQHCs, the FQHC look-alike and one RHC.
NH DHHS also supports mental health services regionally through a network of ten designated Community Mental Health Centers. DHHS also implements Rapid Response (833-710-6477) and nh988.com, both of which provide mental health crisis services via phone, text and chat for children, youth and adults in NH who may be experiencing a mental health or substance misuse crisis. It is available 24/7 and can deploy mobile crisis teams around the state.
NH also has a network of 13 regional Public Health Networks (established in 2013 through emergency planning and drug and alcohol prevention funds) which seek to integrate multiple public health initiatives and services into a common network of community stakeholders for communities with comparable public health issues and priorities in order to improve health outcomes specific to these regions. The Public Health Networks are currently under an assessment, which will provide information on outcomes and plans for the future. These Public Health Networks took the lead along with DPHS in the State’s response to the COVID‑19 pandemic.
A State Health Assessment (SHA) and State Health Improvement Plan (SHIP) Advisory Council was established in July 2020 with RSA 126-A: 87-88. A SHA describes the status of a broad array of issues related to the health of the people in NH. The SHIP will guide decision makers in choosing where to put resources that will address NH residents’ greatest needs. Those priority issues are identified from the SHA data review, which included community engagement activities, such as surveys and listening sessions. A draft SHA is complete and the final is expected to be released the fall of 2023. Of particular note to Title V is the inclusion in the SHA draft a priority to expand access to quality prenatal, labor and delivery and postpartum care
The shortage of health care professionals in NH, exacerbated by the pandemic and a rapidly increasing aging of the population, is of particular concern to the state’s Title V population. Title V staff continue to work with colleagues at DPHS’s Office of Rural Health and Primary Care with participation in activities such as the Legislative Commission on Primary Care Workforce Issues and the NH Health Professions Data Center. With COVID 19 and American Rescue Plan funding, several health care workforce initiatives have opened in the state, including:
- Coos County Teaching Health Center Family Medical Residency Program (Coos County Family Health Center)-taking residents in 2024
- NH Needs Caregivers Initiative (LNA training) currently taking students
- Cheshire Medical Center/Dartmouth Health Family Medicine Residency Program taking residents in 2024
- Portsmouth Regional Hospital Psychiatry Residency currently taking residents (rotate through Lamprey Health Care)
- University of NH Psychiatric Nurse Practitioner Master’s Program currently taking nurses
- Bi-State Primary Care Association/Harvard School of Dental Medicine Dental Health Rural Residency currently taking dentists
Financing of services for the MCH population: It is estimated that 5.0 percent of NH residents were uninsured in 2021, the lowest percentage ever recorded in the state.[39] Of children zero through 18, 3% were uninsured. [40]
NH Medicaid utilizes a managed care model for medical services with three insurance plans, NH Healthy Families, Well Sense and AmeriHealth Caritas.
New Hampshire Medicaid Point in Time Enrollment at End of Month, 6/30/2023
At the end of June 2023, approximately 14% of NH’s population was enrolled in Medicaid (including expansion). Forty-three percent of those enrolled are children. However, with the disenrollment of potentially individuals and families who do indeed qualify for Medicaid, it is estimated that these numbers will go up slightly.
Title V staff joined their Medicaid colleagues this past year in reaching out to individuals and families to maintain their coverage or find alternative health insurance options during the wind down of the public health emergency and a return to routine annual redeterminations. Many of both MCH and BFCH’s Title V funded contractors worked closely with families to make sure their Medicaid did not lapse, either directly, through the MCOs, patient navigators, etc. NH Medicaid’s unwind approach was extremely comprehensive with a community as well as individual component. Letters were sent, calls were made and in-person discussions were held.
NH also operates a partnership health insurance exchange with the federal government (New Hampshire health insurance marketplace guide 2023 | healthinsurance.org), with the Department of Insurance having control over plan management and consumer assistance functions on the federal Marketplace.
Challenges that impact the health status of Title V populations:
Closure of Labor and Delivery Hospitals: Of particular concern to the MCH population is the closure of 11 labor and delivery (L&D) hospital units over the past two decades which leaves only 15 birth hospitals and four free standing birthing centers. The most recent closure was Frisbie Memorial Hospital in 2022. In rural NH, nine birthing hospitals have closed their L&D units since 2000, largely because of financial pressures and quality concerns associated with declining birth rates. In birthing hospitals which have closed their L&D units, many had small volume births in a year and typically had a higher percentage of patients that give birth paid for by Medicaid (up to 61% as shown in the figure below), which typically pays for a quarter of NH’s births in a year. Obstetrical services typically have high fixed costs and low reimbursement rates. Weekly for the past several years. Title V staff confer with their Alliance on Innovation in Maternal Health (AIM) partners, the Northern New England Perinatal Quality Improvement Network (NNEPQIN) on these and other similar issues.
Legislative responses include the 2022 passing of an omnibus House Bill (HB) 1661, which increased the Medicaid reimbursement rate for facility-based birth services provided at hospitals by 25%, in the aggregate, based on the rate in effect as of June 30, 2022. The DHHS Commissioner has the discretion to implement the reimbursement increase to adjust for access risk geographically; provided that no critical or non-critical access hospital receives less than a 20% increase. In addition, 2022 Senate Bill (SB) 408 increased the Medicaid facility fee reimbursement schedule for freestanding birthing centers. In 2023, a host of legislative initiatives were successfully included in HB 2, which accompanies the State 24/25 biennium budget signed into law the end of June 2023.[44],[45] This included the following significant legislative wins in 2023:
- extension of postpartum Medicaid through one year and Medicaid coverage for lawfully residing pregnant people and children (who haven’t been in the U.S. for a total of five years),
- a continuation of overall Medicaid expansion through 2030,
- coverage of doulas beginning in 2025 and
- donor breastmilk in 2024.
Title V staff provided testimony as well as informed their very large group of stakeholders.
In rural NH, the rate of unplanned location births for 2020-2022 was 4.8 per 1,000 live births compared to 2.9 per 1,000 live births in urban NH. Those covered by private insurance had a smaller rate (2.3 per 1,000 live births) of unplanned birth location as compared to those who paid for their deliveries using Medicaid (5.1 per 1,00 live births) or other payment methods (9.8 per 1,000 live births).[46] Additionally, most births which occurred in unplanned locations happened at home (unplanned) or in-route to the nearest open L&D. A 2021 study reported the median driving time to the nearest labor and delivery (L&D) unit increased from 18 to 39 minutes after closures across eight hospitals[47]. The share of pregnant women who lived more than 30 minutes from an open L&D unit increased from 20.2 percent in 2000 to 27.3 percent in 2018. Reduced proximity to an open unit was associated with an increased probability of attending fewer prenatal care visits than is recommended and giving birth in-route to the hospital or having an unplanned home birth.
A project focusing on increasing education to both emergency medical services and non-labor and delivery hospitals on unplanned births is taking place with NNEPQIN and the State’s Department of Safety, Bureau of Emergency Medical Services. This group is also looking to correlate these unplanned location births with weather patterns, outcomes, characteristics of the mom (parity, gestational age, etc.), and driving distance to a birth hospital from residence.
NH is also noticing slow increases in the number of Nulliparous, Term, Singleton, Vertex (NTSV) cesareans.
Pediatric Obesity: Childhood and adolescent obesity has been on the rise across the US. Recent data (2017-2020) indicate a prevalence of 12.7% among 2- to 5-year-olds, 20.7% among 6- to 11-year-olds, and 22.2% among 12- to 19-year-olds with an overall prevalence of 19.7% which is about 14.7 million children and adolescents. The figure below shows the prevalence of childhood obesity in US and New Hampshire among children ages 2-4 years participating in WIC. The prevalence of obesity among children aged 2-4years was 17.2% in 2018 and 16.1% in 2020[49]. In 2018, NH ranked second among 51 States and eight of 51 states in 2020. In that same year, the obesity rate among children 10-17 years and high school children was 15.2% and 12.7% respectively.[50] One strategy to reduce this prevalence is by promoting exclusive breastfeeding, which is a proven preventive measure.
Maternal Depression: Maternal mental health, a subset of behavioral health, impacts approximately one in five childbearing people each year in the US[51]. The cost of untreated maternal mental health conditions is estimated to reach about $14 million during the time from conception to 5-years postpartum, which includes lost wages due to mental health conditions and poor health outcomes of mothers and children[52]. The proportion of birthing people affected by maternal depression in New Hampshire has increased overtime, from about 17% in 2013 to 24% in 2020, during the COVID pandemic[53]. Behavioral health disorders, including substance use disorder (SUD), are identified and analyzed in the PRAMS and state Maternal Mortality Review Committee reports. Health related behaviors including WIC participation during postpartum, marijuana use, and discrimination in health services were more common among birthing people with depression based on 2016-2020 PRAMS data, while breastfeeding for longer than eight weeks was more common among birthing people who did not report depression. The figure below indicates that postpartum depression was more common among birthing people in NH who were under age 20 yrs., who had less than 12 years of education, were below 185% Federal Poverty Level (FPL), and who were ensured by Medicaid.
Monitoring the access and quality of improvement measures such as availability of the crisis hotline, screening for prenatal and postpartum depression and implementation of Alliance Innovation for Maternal Health (AIM) patient safety bundles are an important component of New Hampshire’s behavioral health services to reduce maternal depression during the perinatal period.
Adolescent Mental Health: With the release of the 2021 Youth Risk Behavior Survey results in 2023, NH saw an alarming rise in the percentage of high school students who felt sat or hopeless, seriously considered suicide and attempted suicide.
In addition to NH’s resources for addressing mental health described previously, Title V staff in the state routinely work with the DHHS Division of Behavioral Health Services, Bureau of Children’s Behavioral Health. In addition, MCH leveraged Title V funds to support a full time Pediatric Mental Health Program Manager, who works on SPM #2 as well as HRSA’s Pediatric Mental Health Care Access Program.
Substance Use Disorder: NH’s opioid overdoses and deaths have been plaguing the state for more than a decade and severely strains the health care system as a whole. This epidemic is particularly tragic for the MCH population.
One of the leading causes of maternal mortality in the State is accidental drug overdose.[55] Poisoning, mostly due to opioids, has overtaken car crashes, as the leading cause of death due to unintentional injuries particularly in the adolescent and young adult population (unintentional injuries, primarily poisoning due to opioids, continue to be the leading cause of death for all NH residents ages one through 44).[56]
MCH is the lead on the CDC’s Overdose to Action grant, which funds several opioid overdose surveillance and prevention strategies including the:
- Collection of real-time emergency department overdoses;
- Collection and dissemination of data related to overdose deaths;
- Enhancement of the state’s Prescription Drug Monitoring Program and
- Education of health care providers and support health care systems related to best practices around prescribing opioid medications.
MCH also facilitates both NH’s Maternal Mortality Review Committee and its Child Fatality Review Committee. Many case reviews in both committees (the majority in maternal mortality, which reviews all deaths, unlike child fatality, which picks representative cases) result in recommendations specifically related to overdose prevention such as the provision of naloxone if warranted. For the last six years, MCH has been collecting drug exposure data on its birth worksheet. Aggregated and de-identified data on drug-affected infants is submitted to DHHS’s Division of Children, Youth and Families (DCYF; the State’s Child Protection Agency) for its federal CARA/CAPTA notification requirements. The fact that an infant has been prenatally exposed to or born affected by drugs and/or alcohol does not itself require a mandatory DCYF report.
Title V staff also work in coordination with statewide colleagues on the Perinatal Substance Exposure Collaborative as well as NNEPQIN on encouraging the completion of the Plan of Safe Care, developed by a pregnant person and health care and social service providers when substance misuse is present. This has been a recommendation of both maternal mortality and child fatality review committees. MCH and NNEPQIN, in their co-sponsorship of NH as an AIM State, have been spearheading efforts within perinatal care of both SUD screening and treatment if necessary, and the dispensation of naloxone as part of implementing the AIM patient safety bundle, “Care for Pregnant and Postpartum People with Substance Use Disorder.” [57]
Disparities: NH just like any other state has various disparities in maternal, infant and child health outcomes when disaggregated by race, age, payer, rural or urban and other socio-demographic factors such as education and income levels. Medicaid payer have significantly more poor maternal and birth outcomes as compared to private payers. Those living in Rural NH have inadequate prenatal care visits due to proximity to an open labor and delivery unit and recent closures of rural birthing hospitals. The graphs below highlight some of the observed disparities from previous analysis of Severe Maternal Morbidity (SMM) and birth outcomes. SMM is a discrete set of life threatening complications defined by CDC as unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health deliveries for NH births. Disseminated intravascular coagulation, hysterectomy, and acute renal failure were the leading indicators of SMM.
Between 2016-2020, the five-year aggregate SMM excluding transfusions was 67.2 per 10,000 live births. When disaggregating by mother’s race, rates of SMM were highest among those who identified as Black/African American and those who declined to respond. However, the rates calculated with numbers less than 20 in the numerator are considered unstable. Disaggregation by race often produces unstable values because birthing people who do not identify as White Non-Hispanic are not very populous in NH hence requires aggregation of multiple years. Additionally, SMM rates were highest among birthing people aged >35 years between the years of 2016-2020. The higher SMM rate is expected for birthing people aged >35 years, which qualifies the pregnancy as advanced maternal age and can put pregnancies into the high-risk category.[58]
The rates of Severe Maternal Morbidity (SMM) increased significantly from 2020-2021 by over 30% for SMM with blood product transfusions and over 40% for SMM without blood transfusions. Highest rates in 2021 were observed among Black or African American population, among mothers aged beyond 35years followed by 20-24years and those covered by Medicaid.[59]
Even though New Hampshire has a majority white population, poor health outcomes are observed among Black or African American followed by Asian in regards to percentage of low birth weight and preterm births.
There are also ethnic, gender and sexual orientation disparities shown within the latest YRBS mental health adolescent (high school) data. Hispanic, Native American and LGBTQA+ students were more likely to report attempting suicide than others. Title V staff are part of the state’s Suicide Prevention Council who are addressing these issues as is the Child Fatality Review which MCH facilitates.
Statutes and other regulations that have passed or are in process within the last year and have relevance to the Title V program: In addition to the legislative changes in Medicaid funding previously described, MCH’s Newborn Screening Program revised Administrative Rule He-P 3008, He-P 3000 (state.nh.us) to accurately reflect its current operations and procedures as well as ensure that definitive diagnostic results on infants who screen positive are reported in a timely manner.
[1] New Hampshire Forests | Wildlife Journal Junior (nhpbs.org) retrieved on 07/12/23.
[2] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/12/23.
[3] State Data (usda.gov) retrieved on 07/12/23.
[4] NHFPI The Legislature's State Budget_Investments in Health 6.15.23 retrieved on 07/12/23.
[5] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[6] https://www.nhes.nh.gov/elmi/products/vs.htm retrieved on 07/13/23
[7] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[8]Medicare Beneficiaries as a Percent of Total Population | KFF retrieved on 07/16/23,
[9] https://www.marchofdimes.org/peristats/data?top=14&lev=1&stop=128&ftop=125®=99&obj=3&slev=1 retrieved on 07/15/23.
[10] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[11] https://www.testhut.com/average-size-of-an-american-family-statistics/ retrieved on 07/13/23.
[12] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[13] https://datacenter.aecf.org/data/tables/10247-child-population-by-race-and-ethnicity#detailed/2/any/false/2048,574,1729,37,871,870/185,437,172,9,12,826,3378,2579,107/19835
[14] Ibid.
[15] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[16] State Demographics Data | migrationpolicy.org retrieved on 07/13/23.
[17] ahr_2022annualreport.pdf (americashealthrankings.org) retrieved on 07/18/23.
[18] https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance retrieved on 07/17/23.
[19] https://wallethub.com/edu/best-and-worst-states-to-have-a-baby/6513 retrieved on 07/17/23.
[20] aecf-2023kidscountdatabook-2023.pdf retrieved on 07/17/23.
[21] https://www.commonwealthfund.org/publications/scorecard/2023/jun/2023-scorecard-state-health-system-performance retrieved on 07/17/23.
[22] aecf-2023kidscountdatabook-2023.pdf retrieved on 07/10/23.
[23] https://nhfpi.org/ retrieved on 07/17/23.
[24] nr-current (nh.gov) retrieved on 07/17/23.
[25] chart01.pdf (nh.gov) retrieved on 07/17/23.
[26] aecf-2023kidscountdatabook-2023.pdf retrieved on 07/10/23.
[27] U.S. Census Bureau QuickFacts: New Hampshire retrieved on 07/13/23.
[28] https://nhfpi.org/ retrieved on 07/17/23.
[29] Ibid.
[30] Ibid.
[31] https://carsey.unh.edu/publication/new-hampshire-parents-use-child-care-but-seek-more-options accessed on 07/19/23.
[32] CLT-Report.pdf (nhcf.org) accessed on 07/19/23.
[33] Making-Ends-Meet-SHED-HPS-Urban-Data-Blog-7.25.23_1.pdf (nhfpi.org) retrieved on 07/23/23.
[34] Child and Adolescent Health Measurement Initiative. 2020-2021 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Retrieved 07/26/23 from www.childhealthdata.org.
[35] Downie, E. (2022). NH Registry for Autism Spectrum Disorders Annual Report (July 1, 2021 - June 30, 2022). Autism Spectrum Registry. Retrieved 07/26/23 from https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents2/asdr-datasheetfy22.pdf
[36] Smith, J, LaFleur, L, Clark, J, & McLean, P. (2022), Title V Special Medical Services Programs –Child Development Clinic - Annual Report.
[37] U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. 2017. National and Regional Supply and Demand Projections of the Nursing Workforce: 2014-2030. Rockville, Maryland.
[38] 2022-NHHA_Hospital_Fact_Sheet_FINAL.pdf retrieved on 07/19/23.
[39] State Category | Health Coverage & Uninsured | KFF retrieved on 07/17/2023
[40] Ibid.
[41] Ibid
[42] bpq-da-medicaid-enrollment.pdf (nh.gov) retrieved on 07/14/23.
[43] NH Medicaid. “DHHS Continuous Enrollment Unwinding” (2023). Presentation to the Medicaid Clinical Medical Care Advisory Committee. July 17, 2023.
[44] HB 2 Chapter Law.pdf (state.nh.us) retrieved on 07/20/23.
[45] HB 1 Chapter Law Combined.pdf (state.nh.us) retrieved on 07/20/23.
[46] MCH Epidemiologist.
[47] Timothy Fisher and Sarah Benatar (October 2021). Following Labor and Delivery Unit Closures in Rural New Hampshire, Drive Time to the Nearest Unit Doubled, Urban Institute.
[48] MCH Epidemiologist.
[49] Ages 2-4 - State of Childhood Obesity retrieved on 07/14/2023.
[50] Ibid.
[51] Griffen A, McIntyre L, Belsito JZ, et al. Perinatal Mental Health Care In The United States: An Overview Of Policies And Programs. Health Aff (Millwood). Oct 2021;40(10):1543-1550. doi:10.1377/hlthaff.2021.00796
[52] Luca DL, Margiotta C, Staatz C, Garlow E, Christensen A, Zivin K. Financial Toll of Untreated Perinatal Mood and Anxiety Disorders Among 2017 Births in the United States. Am J Public Health. Jun 2020;110(6):888-896. doi:10.2105/ajph.2020.305619
[53] HPRAMS. Data Brief: Maternal Depression around the time of Pregnancy, 2016-2020. MCH; 2022. October 2022. Accessed June 2nd, 2023.
[54] Ibid.
[55] DPHS (2023). Annual Report on Maternal Mortality to the NH Health and Human Services Oversight Committee, Annual Report 2022.
[56] DHHS, MCH (2022); Child Fatality Review Committee 2022. Retrieved on 07/24/2023 from https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/inline-documents/sonh/child-fatality-review-report-2022.pdf.
[57] Alliance for Innovation on Maternal Health (2023). Care for Pregnant and Postpartum People with SUD. Retrieved on 07/24/2023 from Care for Pregnant and Postpartum People with Substance Use Disorder | AIM Program (Previously Council on Patient Safety) (safehealthcareforeverywoman.org).
[58] MCH Epidemiologist.
[59] Ibid.
[60] MCH Epidemiologist.
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