Geography, Demographics, and Economy

Michigan encompasses 56,804 square miles of land and is the only state made up of two peninsulas. Composed of 83 counties, Michigan is the 11th largest state by total square mileage and the eighth largest state by population. According to the U.S. Census Bureau, Michigan saw its seventh straight year of population growth. Nearly 10 million people live in the state in 2019, up 0.2 percent from the previous year. Michigan has seen a steady decrease in birth rates over the past 20 years, including a decline in teen births. The majority of Michigan’s population resides in the southern half of the Lower Peninsula, with approximately half of the population residing in Southeast Michigan. The state’s largest cities are Detroit, Grand Rapids and Warren. Over 1.7 million people live in rural areas. The median age of the population is 39.5 years of age. Out of the total population, approximately 22% are age 0-17 and 78% are age 18 and over. Michigan’s population is 78.9% Caucasian, 13.9% Black or African American, 2.8% Asian and Pacific Islander, 2.7% two or more races, 1.1% other races, and 0.5% Native American. Out of the total population, 4.95% identify as Hispanic or Latino.

Michigan’s economy has seen improvements over the past nine years, with the seasonally adjusted unemployment rate decreasing from 14.9% in June 2009 to 4.5% in June 2018. The median household income in Michigan in 2017 was $69,664 (U.S. Census Bureau). However, the state still faces significant challenges that impact the maternal and child health (MCH) population. For instance, certain areas of the state continue to experience higher unemployment. Additionally, according to the 2017 ALICE (Asset Limited, Income Constrained, Employed) report, 62% of jobs in Michigan were low wage jobs, paying less than $20 per hour; out of those jobs, two-thirds paid less than $15 per hour.

Poverty has also remained a significant issue, especially for Michigan’s children. According to Kids Count in Michigan (2018), 23.3% of children (444,100) ages 0-17 live in poverty. Statewide, the percentage of students eligible for free or reduced price lunches has steadily increased in recent years. With a 30% increase over a nine-year span, 50.3% of students in 2017 were eligible for free or reduced-price lunches.

Of additional concern are findings from the 2017 ALICE report which found that even in households with earnings above the federal poverty level (FPL), 40% of households struggle with basic necessities such as housing, child care, food, health care and transportation. In addition to households below the FPL in Michigan, this equates to more than 1.54 million households struggling to meet basic needs.

Given this environment, family support programs continue to be an important source of assistance. For example, 29.7% of pregnant mothers enrolled in Michigan’s Women, Infants, and Children (WIC) program during their first trimester in 2018. In 2017, out of mothers enrolled in WIC, 83.2% lived at or below 150% of the FPL.

Agency Roles and Priorities

The Title V program is administered by the Division of Maternal and Infant Health (DMIH) in coordination with the Children’s Special Health Care Services (CSHCS) Division which are both housed in the Michigan Department of Health and Human Services (MDHHS). MDHHS was created in 2015 through the merger of the Michigan Department of Community Health and the Michigan Department of Human Services. As such, MDHHS oversees a wide range of health and human service programs, including but not limited to public health; environmental health; communicable and chronic disease; Medicaid; food and cash assistance; migrant and refugee services; child support; juvenile justice; children and adult protective services; and foster care and adoption.

With a new MDHHS administration in 2019, Title V will continue to identify opportunities for alignment and synergy with emerging departmental priorities and initiatives. A departmental reorganization in July 2019 moved the Title V program from the Bureau of Family Health Services (which was dissolved) into the DMIH, which was previously in the Bureau of Family Health Services. The DMIH—which has a long-standing history of leadership and involvement in Title V—is now housed in the Bureau of Health and Wellness (BHW) within the Public Health Administration. This reorganization was intended to more closely align prevention-focused public health programs with maternal and child health. As such, the BHW now includes the Division of Maternal and Infant Health; Division of Child and Adolescent Health; Women, Infants and Children (WIC) Division; Division of Chronic Disease and Injury Control; and Local Health Services.

In 2018, Michigan began developing the 2019 Mother Infant Health & Equity Improvement Plan (known as the Improvement Plan) which serves as the next iteration of the infant mortality reduction plan. The Improvement Plan for 2020-2023 was released in September 2019 and builds upon previous work and existing partnerships and expands to partners and strategies that can enhance our ability to address the root causes of maternal and infant outcomes—social determinants of health and drivers of health inequity. The collective vision of “Zero preventable deaths and Zero health disparities” will be achieved by working with local communities and Michigan’s families to 1) align public and private sector interventions, 2) integrate interventions across the mother infant dyad, and 3) explicitly address disparities by employing Population Health Model techniques that ensure the most marginalized populations receive high-impact interventions.

The Improvement Plan was developed collaboratively by the Maternal Infant Strategy Group and MDHHS. In 2018, stakeholder input and engagement were garnered around the state at Town Halls in Grand Rapids, Kalamazoo, Detroit, Ann Arbor, Grayling, Marquette, Saginaw, Bad Axe, and Caro. The Maternal Infant Health and Equity Collaborative, health care providers, hospitals, local health departments, health plans, universities, professional organizations and associations, business, community leaders and—most importantly—the voices of Michigan families have been infused into the Improvement Plan. Efforts to collect and integrate community and family feedback continued after the Town Halls with the development of the Ambassador Program. Ambassadors play an important role in providing feedback that is used to ensure the Improvement Plan is adapted for their community and to identify barriers to implementation. Ambassadors include mother, fathers, grandparents, aunts, uncles, and other caregivers who share their lived experience and act as advocates in their communities.

Implementation of the Improvement Plan is multi-faceted to increase its reach and impact. It includes alignment of internal programs within MDHHS to increase the awareness, reach, and availability of public health resources; implementation of quality improvement projects within each of Michigan’s Regional Perinatal Quality Collaboratives (RPQCs); and external implementation through community partners and maternal infant health providers. Within each RPQC, the Improvement Plan outlines a Population Health Model strategy to address disparities and implement evidence-based interventions tailored to populations with the highest likelihood of adverse health outcomes.

Early childhood system building is also an MDHHS priority. The Office of Great Start (OGS) within the Michigan Department of Education leads the integration of the state’s health, development and early learning investments for prenatal to age 8. MDHHS collaborates with OGS and other partners to support the development of early childhood systems that are designed around the needs of children and families. One example of Michigan’s cross-systems work is the launch of a new Statewide Home Visiting Advisory in 2019 that is charged with building an integrated home visiting system that provides Michigan’s families with the right model, at the right time, in the right place.

Strengths and Challenges that Impact the MCH Population

Many strengths and opportunities are being leveraged to support and expand Michigan’s MCH infrastructure and delivery system. Strengths include collaboration and coordination across state and local public health systems; a commitment to eliminating preventable infant, maternal, and child deaths; recognition and expansion of the significant impact of early life experiences on health and wellness across the life course; integration of the patient-centered medical home model; and strong leadership and expertise within public health systems. MDHHS also has a long-standing relationship with Michigan’s local health departments (LHDs). Michigan’s 45 LHDs serve 83 counties and the City of Detroit. LHDs act on behalf of the state health department to deliver public health prevention and control programs throughout Michigan. This local oversight and delivery of public health services provides strong, locally-based leadership of public health programs while maintaining state-level oversight.

Michigan’s Home Visiting Initiative (MHVI) highlights the state’s commitment to prevention, early childhood, and collaboration between public health, healthcare, and other sectors that impact health outcomes. Michigan’s system of evidence-based Home Visiting models includes the Maternal Infant Health Program (MIHP), a model available to every pregnant woman and infant receiving Medicaid, as well as Nurse-Family Partnership, Healthy Families America, Early Head Start-Home Based, Parents as Teachers, and Family Spirit. Infant Mental Health and Healthy Start are promising home visiting models in Michigan. By leveraging federal and state funding, Michigan is creating a system of home visiting services to meet the diverse and complex needs of families with young children, particularly in communities facing elevated risks. In 2017, MHVI served over 34,000 families to improve maternal and child health, development, and family safety, and to create pathways for families to access the resources they need. The reauthorization of MIECHV made it possible to continue creating a robust system of supports for families and children. Furthermore, collaboration with the Behavioral Health and Developmental Disabilities Administration has increased awareness and assessment of strategies to support families enrolled in MHVI.

Another strength is the launch of MI Bridges as part of MDHHS’s Integrated Service Delivery (ISD). The ISD is intended to reform how MDHHS interfaces with customers through technology and by making the service delivery system more focused on customer needs. MI Bridges enables each user to have an individual account to find resources such as transportation, food, and utilities assistance. Individuals with existing cases can review and access their benefits information, including renewal date and benefit amount. Individuals can also apply for or renew benefits, upload documents and verifications, and share household and benefit information with relevant community partners. In 2019, MDHHS plans to strengthen integration with 2-1-1 and community-based partners.

Along with these strengths and the state’s health care infrastructure, significant challenges still exist. Both nationally and in Michigan, health care costs are driven by competing factors such as payment systems, malpractice regulations, chronic disease incidence, nursing care costs, emergency room “super utilizers,” population demographics, prevalence of adverse health behaviors and the absence of access to hospitals and physicians in rural areas. According to U.S. Census Bureau data, many geographic regions in Michigan face provider shortages with the greatest provider shortage occurring among nurse practitioners. According to HRSA data from the Kaiser Family Foundation, Michigan has 366 primary care Health Professional Shortage Areas (HPSA) that would require 647 practitioners to remove the HPSA designation.

Access to all forms of health care is a problem for many Michigan residents, particularly those living in rural areas. The ratio of population to primary care providers in Michigan overall is 1240:1. However, in some rural counties the ratio was greater than 6500:1. According to Kids Count 2017, 3.0% of children aged 0-17 in Michigan did not have health insurance. While 3.0% are uninsured, 35% are publicly insured only and another 5% are covered by both public and private payers. The greatest number of uninsured children resides in large urban counties, while the greatest proportion of uninsured children resides in low-income rural counties with relatively high unemployment rates. Lack of providers, health care facilities and lack of transportation all underscore the need for safety net services such as those provided to the MCH population by LHDs and programs supported by MDHHS.

Particularly in rural areas and the Upper Peninsula, transportation continues to be a challenge. This includes not only the method of transportation, but also the time and distance that needs to be covered to reach services. Securing transportation providers and appropriate levels of reimbursement is also challenging for the CSHCS population. Families who need to take a child to specialized care often travel long distances with overnight stays. This requires extended time away from work as well as additional child care and other expenses.

Another factor is the complexity of embracing an upstream approach to health and wellness to impact the systemic conditions that contribute to poor health outcomes. The knowledge that health begins during preconception—and optimal health and development must occur during the earliest stages of life to improve adult health—is still being established in the broader population. Additionally, redirecting resources to early life stages is difficult given the acute needs of individuals who require costly and often long-term care. Among key stakeholders who work with Michigan’s most at-risk families, there is a growing understanding of and commitment to reducing early life adverse experiences and strengthening protective factors. However, the challenge is to translate these concepts into actionable strategies that compel resource and policy support.

Addressing social determinants of health holds the same challenge. It is increasingly understood that access to quality education, housing, adequate and sustainable income, transportation, and social and cultural supports are critical to achieving and maintaining health. However, impacting these factors in communities—and having the resources to do so—is complex. Furthermore, the layered funding that communities receive from federal, state, local and private sources can be difficult to align or sustain.

Finally, economic disadvantage is dispersed inequitably among racial and ethnic groups in our state, particularly for African American children, who are roughly five times more likely to live in poverty than an Asian child and three times more likely than a White child. Half of the state’s African American children and one-third of Hispanic children live in poverty. Poverty is linked with conditions such as substandard housing, homelessness, inadequate nutrition and food insecurity, inadequate childcare, lack of access to health care, unsafe neighborhoods and under-resourced schools. Poorer children and teens are also at greater risk for poor academic achievement, school dropout, behavioral and social-emotional problems and physical health problems (such as higher rates of asthma, higher exposure to environmental contaminants such as lead, exposure to violence and developmental delays). These effects are compounded by the barriers children and families encounter when trying to access health care.

Components of the State’s Systems of Care

Michigan’s health care system includes 147 hospitals (including 21 hospitals with Neonatal Intensive Care Units); 45 Federally-Qualified Health Centers with over 260 delivery sites; over 100 school-based/school-linked health centers; 30 Family Planning agencies providing services at 93 clinic sites; and 195 rural health clinics.

Health Care Reform

Since its passage in 2010, the Affordable Care Act (ACA) has impacted how health care is accessed and delivered across the country. In Michigan, the impact has been particularly significant since the implementation of the Medicaid expansion in 2014. Given the current uncertainty surrounding health care legislation, Michigan continues to monitor activities related to ACA and other possible changes to health care access and delivery. MDHHS remains committed to assuring that access to health care continues to stabilize and improve even as payment systems and providers may change.

Health care reform via ACA has impacted Michigan’s MCH population. ACA coverage expansions provided Michigan consumers with two new options: the Healthy Michigan Plan (HMP) and the Health Insurance Marketplace (Marketplace). In January 2014, eligible individuals above 133% of the FPL could enroll in private health insurance coverage through the Marketplace. In April 2014, Michigan expanded its Medicaid program to cover residents aged 19 to 64 who were at or below 133% of the FPL, and who were not previously eligible for traditional Medicaid. Between the HMP and the Marketplace, Michigan insured over 700,000 people in less than a year, exceeding initial enrollment expectations.

As of February 2019, 535,310 beneficiaries had HMP coverage. HMP benefits include preventive/wellness services, chronic disease management, prenatal care, oral health and family planning services. Most HMP beneficiaries are required to pay some level of cost-sharing in the form of monthly contributions and co-pays based on income. Some populations are excluded from cost sharing, such as individuals enrolled in CSHCS, under 21 years of age, pregnant women, and those with no income. Enrollees who complete a health risk assessment and agree to maintain or address healthy behaviors, as attested by their primary care provider, are eligible for cost-sharing reductions.

For CYSHCN, ACA consumer protections have improved access to private insurance by eliminating preexisting condition exclusions and discrimination based on health status, the two most frequently encountered enrollment barriers for families. The ACA also expanded access to parent employer coverage for adults 19-26. The HMP covers approximately 969 individuals who are dually enrolled in CSHCS. LHDs, Family Resource Centers and designated state staff work with families and community partners to help families understand and access all available private and publicly-funded resources to meet individual needs.

CYSHCN often require and use more health care services than other children. Specialty care and extensive, on-going or long-term treatments and services may be required to maintain or improve health status. Financing these costs can pose significant challenges and burdens for families even with access to private insurance. Family health care costs can include deductibles, cost sharing and premium payments. In addition, private insurance may not include any covered benefit for a specific, medically necessary service. In other cases, only a limited benefit may be available through insurance. Although ACA eliminated annual and lifetime dollar limits, other annual limits exist and benefits may be exhausted for the current contract year even though needs continue. As such, CSHCS helps to limit costs to families and continues to be a significant resource for achieving adequate, appropriate health and specialist care. Steady CSHCS enrollment following ACA’s implementation reflects the value of CSHCS to families even when private insurance is available.

Finally, ACA provided significant funds through HRSA to expand access to primary care by increasing the number of Community Health Centers in Michigan. The number of Federally Qualified Health Centers (FQHCs) grew as additional centers were funded and look-alike sites were approved. According to the Michigan Primary Care Association, Michigan has 45 Health Centers that provide care at over 260 delivery sites and are health care homes to more than 680,000 individuals.

In addition to ACA, Michigan entered into a four-year cooperative agreement with the Center for Medicare and Medicaid Innovations to test its State Innovation Model (SIM) for health care payment and delivery system transformation. The final product of the SIM grant planning process, the Blueprint for Health Innovation, is guiding the state as it strives for better care coordination, lower costs and improved health outcomes. The Blueprint focuses on transforming service delivery and payment models by concentrating on patient-centered medical homes and integration among health care and community resources. Its goals are better health, better care, and lower costs. An updated summary of Michigan’s SIM work was released in October 2018, and the Award Year 4 Update was submitted in December 2018.

Integration of Services

Michigan’s Title V and Title XIX programs share the common goal to improve the overall health and well-being of the MCH population through implementation of affordable health care delivery systems, expanded coverage, and implementing strategies to address social determinants of health and reduce health disparities. Areas of collaboration include maternal and infant care, adolescent health, perinatal care, developmental screening and referral, home visitation, oral health, and CSHCS. Like programs located within the Public Health Administration, Michigan Medicaid employs a population health management framework to build a Medicaid managed care delivery system that maximizes the health status of beneficiaries, improves beneficiary experience, and lowers cost. Medicaid supports 11 contracted Medicaid Health Plans (MHPs) in achieving these goals through evidence-based and value-based care delivery models, supported by health information technology, and robust quality strategies to prevent chronic disease and coordinate care.

The BHW and Michigan Medicaid jointly manage several programs for the Medicaid-eligible MCH population. One of the largest collaborations is the Maternal Infant Health Program (MIHP), Michigan’s largest population-based home visiting program available to all Medicaid-eligible pregnant women and infants up to age one. Effective January 1, 2017, MIHP services provided to beneficiaries enrolled in an MHP are administered by the MHPs.

Another area of coordination is for CSHCN, as more than 80% of individuals with both CSHCS and Medicaid coverage are enrolled in an MHP. MHPs are responsible for the medical care and treatment of CSHCS members while assistance with community-based services beyond medical care and treatment is provided through the LHD’s CSHCS office. MHPs are responsible for coordinating and collaborating with LHDs and the Children’s Multidisciplinary Specialty Clinics to make a wide range of essential health care and support services available to enrollees. MHPs are also responsible for the coordination and continuity of care for enrollees who require integration of medical, behavioral health and/or substance abuse services.

MDHHS recognizes the importance of integrating both physical health and behavioral health services to effectively address enrollee needs and improve health status. To meet this goal, MHPs are required to work with MDHHS to develop initiatives to better align services with Community Mental Health Services Programs/Prepaid Inpatient Health Plans to support behavioral health integration. The MHPs must also provide or arrange for the provision of community health worker (CHW) or peer-support specialist services to enrollees who have significant behavioral health issues and complex physical co-morbidities. CHWs serve as a key resource for services and information needed for enrollees to have healthier, more stable lives. Examples of CHW services include conducting home visits; participating in office visits; arranging for social services; and helping enrollees with self-management skills.

As part of Public Act 107 of 2017, the Michigan legislature directed MDHHS to "implement up to 3 pilot projects to achieve fully financially integrated Medicaid behavioral health and physical health benefit and financial integration demonstration models. These demonstration models shall use single contracts between the state and each licensed Medicaid health plan that is currently contracted to provide Medicaid services in the geographic area of the pilot project." In March 2018, MDHHS announced three pilot sites: Muskegon County Community Mental Health and West Michigan Community Mental Health; Genesee Health System; and Saginaw County Community Mental Health Authority. Known as the Section 298 Initiative, this work continued under Section 298 of the FY 2019 Appropriations Act. In November 2018, a Section 298 Progress Report was released. Implementation of the Section 298 Initiative is anticipated October 1, 2020.

In October 2016, the Healthy Kids Dental program was expanded statewide to cover all children with Medicaid under the age of 21. It currently provides dental services to approximately 1 million youth. As of October 2018, eligible beneficiaries are offered a choice of two statewide HKD dental health plans (DHPs). In July of 2018, MDHHS also expanded managed care dental coverage for non-Healthy Michigan Plan Medicaid eligible pregnant women through a Comprehensive Health Care Program (CHCP) 1915(b) waiver amendment. This managed care dental benefit is intended to provide greater access to dental services and comprehensive prenatal care. BHW and MSA are coordinating outreach and engagement efforts for these oral health programs via multiple avenues including MIHP and other home visiting networks.

Additionally, as a result of collaborative efforts between DMIH, MSA and other state partners, MDHHS updated its hospital reimbursement policy for Long Acting Reversible Contraceptives (LARCs) including intrauterine and implant devices. Beginning in October 2018, Michigan Medicaid provides specific reimbursement for immediate postpartum LARC services, in addition to the standard DRG-based payment for childbirth services.

Health Services Infrastructure

MDHHS has developed multiple health information systems to support the care and services provided to Michigan residents. The Michigan Care Improvement Registry (MCIR) allows for the identification of children who are not up-to-date on Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) well child visits according to the American Academy of Pediatrics Bright Futures Recommendations for Preventive Pediatric Health Care periodicity schedule. All MHPs have access to MCIR, and it is an approved data source for Medicaid Healthcare Effectiveness Data and Information Set (HEDIS) immunization and lead testing data. MIHP providers also have access to MCIR to facilitate referral and access to appropriate preventive services.

MDHHS also developed and implemented CareConnect360 (CC360), a statewide web-based care management system that allows for the bi-directional exchange of health care information. CC360 allows for the identification and coordination of services to Medicaid enrollees with significant behavioral health issues and complex physical co-morbidities to facilitate sharing of cross-system information between plans and the Community Mental Health/Prepaid Inpatient Health Plans. CC360 makes it possible to assess and analyze healthcare program data, manage and measure programs, and improve enrollee health outcomes.

State Statutes Relevant to Title V

The Michigan Public Health Code, Public Act 368 of 1978, governs public health in Michigan. The law indicates that the state health department shall “continually and diligently endeavor to prevent disease, prolong life, and promote the public health through organized programs” (MCL 333.2221). Furthermore, it shall “promote an adequate and appropriate system of local health services throughout the state and shall endeavor to develop and establish arrangements and procedures for the effective coordination and integration of all public health services including effective cooperation between public and nonpublic entities to provide a unified system of statewide health care” (MCL 333.2224).

In FY 2018, state funding for MCH and CSHCS programs was appropriated through Public Act 107 of 2017 (House Bill 4323). CSHCS is mandated by the Michigan Public Health Code, Public Act 368 of 1978, in cooperation with the federal government under Title V of the Social Security Act and the annual MDHHS Appropriations Act. State general fund dollars for MCH programs are itemized in Sec. 117 of Public Act 107 of 2017, whereas CSHCS is addressed in Sec. 119. Additional MCH details are provided in Sec. 1301-1309. These sections identify how funding shall be used; MDHHS and contractor requirements; and requirements that some appropriated funding be used to implement evidence-based programs to reduce infant mortality. Statutory requirements in the FY 2018 omnibus budget for CSHCS included criteria in Sec. 1360 for MDHHS to provide services; and in Sec. 1361, the authorization that some of the appropriated funding be used to develop and expand telemedicine capabilities.