Demographics, Geography and Economy

As of 2018, the U.S. Census reported Arizona’s population at an estimated 7,171,646[i]. Arizona is one of the fastest growing and diverse States in the nation – eighth in the nation for overall population growth from 2010 to 2018 (12.2% growth)[ii], with an expected additional growth of over 30% between 2018 and 2055[iii].  Geographically, Arizona is the 6th largest State in the nation with 113,594 square miles total areai, with a 389-mile international border with the states of Sonora and Baja California in Mexico.

 

Arizona was particularly hard hit by the recession in 2008, and population actually decreased about three percent from 2009 to 2010. Growth resumed in 2011 with an annual growth rate of about one percent per year.[iv] Impacts of the recession were seen in a decrease in migration to Arizona as well as a decrease in resident births. Arizona Vital Statistics also noted factors affecting population growth such as the number of undocumented residents who left the state, the decline in construction jobs, the number of foreclosures and the number of built but vacant homes. It should be noted that these factors all apply primarily to metropolitan, not rural, counties.

 

Approximately 45% of Arizona’s population belongs to a racial or ethnic minority group.  The racial and ethnic makeup of the state is different than the nation. In 2018, the proportion of the population that is Hispanic in Arizona was 31.4 percent compared to 18.1 percent nationally. In addition to having a higher proportion of Hispanics, Arizona’s population also has a smaller proportion of African Americans (5.0 percent compared to 13.4 percent nationally) and a higher proportion of Native Americans (5.3 percent compared to 1.3 percent nationally).[v]

 

The racial makeup of Arizona varies by age group. Among older age groups, the population is predominantly white, while the proportion of the population represented by Hispanics is highest among the younger groups. Over 45 percent of those younger than five are Hispanic compared to 11 percent of people 75 and older.[vi]

 

Poverty is a social determinant of health and critical concern in Arizona.  According to 2017 Kaiser Family Foundation estimates, Arizona has the country’s 5th highest poverty rate (12%) overall and 7th highest for children living in poverty (18%).  The U.S. Department of Agriculture, Economic Research Service 2017 estimates show that poverty in rural Arizona (26.4%) far exceeded the rate in urban areas of the state (14.3%).  Arizona also has the nation’s 5th highest unemployment rate (4.7%). More than half of a million women live in poverty in Arizona. The Arizona Foundation for Women notes that this rate of poverty is related to women being more likely to be singularly responsible for children. Over a quarter of Arizona’s families are single mothers with children under the age of 18 living at home, and 77 percent of these single mothers are eligible for but not receiving child support. Arizona has the fifth highest adult female poverty rate in the country.[vii]

 

As children, Arizonans also face challenges. A 2018 America’s Health Rankings report placed Arizona as the worst state in the country for adverse childhood experiences (ACES). Over 30% of Arizona’s children experienced two or more ACES last year, as compared to 21.7% of children nationally.[viii] ACES include: abuse such as sexual abuse, physical abuse or verbal abuse and household dysfunction such as drug use, violence between adults and separation/divorce. ACEs are associated with negative impacts in adult life such as poor health, heavy drinking, smoking and depression.

 

Arizona has consistently ranked lower in the nation per pupil spending compared to the U.S. The National Center for Education Statistics reported that Arizona spent $7,772 per student compared to the nation’s average of $11,841 in fiscal year 2016.[ix] The US Census ranked Arizona 48th of the 50 states and the District of Columbia in public per pupil spending in fiscal year 2017.[x] The National Assessment of Educational Progress (NAEP) is an assessment of what America’s students know. In 2017, eighth grade students in Arizona public schools performed the same as 12 other states and jurisdictions, had higher performance than 10 states and jurisdictions and were below 29 states and jurisdictions in NAEP reading scores. In 2017, 25 percent of Arizona eighth graders tested below basic skill level for their grade - matching the national rate of 25 percent. This was not a statistically significant change from 2015.[xi]

 

The economy of Arizona is growing after a hard hit during the recession. The Bureau of Economic Analysis calculates the gross domestic product (GDP) of states as well as the nation. GDP is the sum of what individuals, businesses and government spend on goods and services as well as investment and trade. Arizona contracted at a faster rate than the nation as a whole from 2005-2008, with a steep decline in 2008. Since that period, there has been slow, positive GDP growth. In 2018, Arizona outpaced the national growth rate of 2.9 with growth of 4.0.[xii]

 

Median household income in Arizona has historically tended to be lower than national averages. According to the US Census, Arizona’s median household income in 2017 was $53,510 compared to the national median income of $57,652. Median household income also varies widely by county and type of household. The highest median household income was in Maricopa County with $58,580 and the lowest was in Apache County with $32,360. Median household income also varies by type of household, with married couple families earning $76,431, families with children under 18 earning $58,497 and female-headed, single parent families earning $26,907.[xiii]
 

In Arizona overall, unemployment increased dramatically during the recession and currently shows signs of a return to pre-recession rates, however, unemployment varies across Arizona. The seasonally adjusted unemployment rate for Arizona as a whole peaked in January 2010 at a rate of 11.1 from a low of 3.4 in May 2007. April 2019 figures show an unemployment rate of 4.9 with 172,607 unemployed.  While all parts of the state saw increased unemployment in late 2009 and early 2010, the Phoenix-Mesa-Scottsdale, Sierra Vista-Douglas, and Tucson Metropolitan Statistical Areas showed the lowest rates (10.4, 9.7, 10.1 in January 2010, respectively) while the Yuma Area suffered the largest percentage of unemployment (21 in January 2010). The highest rate of unemployment in Yuma Metropolitan Statistical Area was 30.3 in August 2010, most current data (April 2019) show a rate of 12.1.[xiv]

 

Arizona has a higher percentage of residents living in poverty compared to the nation. In a five-year estimate for 2013-2017, 14.6 percent of the nation lived in poverty compared to 17.0 percent of those living in Arizona. This rate was 14 percent in Arizona in 2000. In Arizona in 2017, 24 percent of children under 18 and 30 percent of those without a high school diploma lived below the poverty line.[xv] Poverty varies dramatically by county. The highest rates of poverty are in Apache and Navajo Counties with rates of 35.9 and 29.1 percent, respectively. The lowest rates are in Greenlee (11.5 percent), Yavapai (14.7 percent) Pinal (15.5 percent) and Maricopa (15.7 percent) Counties.[xvi]

 

In addition to individuals, poverty is calculated for families with children under the age of 18. In a five-year estimate for 2013-2017, 19.4 percent of families with children were below the poverty line in Arizona. This was nearly three percentage points higher than the national average of 16.7 percent.[xvii] Rates of poverty for families with children vary widely by ethnic background. The National Center for Children in Poverty reports that in Arizona in 2016, 12 and 13 percent of Asian and White children, respectively, live in a poor family compared to 45 percent of Native American children, 35 percent of Hispanic children and 30 percent of Black children.[xviii]

 

There is also wide variation in the proportion of households receiving assistance such as Supplemental Security Income, Cash Public Assistance or SNAP (food stamps) in Arizona. The most recent American Community Survey data shows that in 2017, 12.5 percent of households in Arizona receive SNAP assistance or food stamps. The lowest is in Greenlee County at 8.3 percent to a high of 26.3 and 26.1 percent in Apache and Santa Cruz Counties, respectively.[xix] Household Food Insecurity is often a consequence of poverty. The USDA definition of food insecurity can be paraphrased as: a limited or uncertain availability of food. Low food security is food insecurity without hunger. Very low food security is food insecurity with hunger.[xx] Food insecurity is similar but slightly higher in Arizona than in the United States as a whole and has increased in the past 10 years, notably between 2007 and 2008. In 2015-2017, 13.1 percent of Arizona households had limited or uncertain food availability and 5.7 percent of those were hungry.[xxi]
 

The number of children living in foster care in Arizona hit a fifteen year high in 2016, and has been declining since then. The Children’s Action Alliance reports that in February 2019, 13,896 children were in foster care.[xxii] In an independent review of the newly established Department of Child Safety, Chapin Hall reported that the increase in children in foster care was the result of the increase in abuse and neglect reports, especially since 2009; specifically, in a six year period, there was a 44 percent increase in reports. They note that this dramatic increase in abuse and neglect reports along with a weakening of other safety net supports (such as child care subsidies) during a time of economic recession, put substantial strain on public welfare agencies. The Chapin Hall report also noted that Arizona, compared to other states, places more children in foster care following a substantiated allegation of maltreatment. All these factors place pressure on the foster care system and out-of-home placements have increased dramatically.[xxiii]

 

Unique Strengths and Challenges

Arizona’s unique geographical, cultural and political climate impact women’s and children’s health status in a variety of ways:

 

 

 

Provider Shortages

Arizona’s healthcare workforce has not kept pace with the state’s rapid population growth, as is evident by a total of 550 federally designated Health Professional Shortage Areas (HPSAs).  This includes 201 primary care, 184 dental, and 177 mental health HPSA designations. There are also 36 Medically Underserved Area and 11 Medically Underserved Population designations in the state[xxiv]. The bulk of Arizona’s population lives in urban metro areas of Phoenix and Tucson, and the majority of primary care physicians practice in these areas as well.  The ratio of population to primary care physicians in Arizona’s urban areas is 2,407:1. While even that is considered over utilized per HRSA definition, the state’s rural, frontier and Native American communities face even greater provider shortages with a population-to-provider ratio of 3,896:1. Arizona needs an additional 580 full-time primary care physicians statewide to eliminate the existing primary care HPSAs[xxv].

 

Lack of Health Insurance

As of May 2019, there are 1,876,881 enrollees in the Arizona Medicaid Program (AHCCCS) – an increase of nearly 27,000 in the past year.  While the number of people without insurance fell in Arizona over the past couple years (from 19% in 2013 to 10.1% in 2017), it remains higher than the national average (8.7%) with about 694,790 people uninsured. Included in this number, 133,144 children and youth under the age of 19 (7.7%) were uninsured; this figure is substantially higher than the national percentage of 5.0 percent.[xxvi] While Arizona’s percent of uninsured children has decreased from a high of 15 percent in 2008, decreases in uninsured children have not been as consistent as national changes.

 

Transportation

There are few major highways in Arizona, and the state’s striking geographical features – including mountain ranges, valleys, canyons, and rivers – present significant barriers to transportation.  The Phoenix-area metro transit system is very limited for an urban area of its size, and public transportation is nonexistent in rural areas of the state.  Outside of the Phoenix metro area, Arizona’s population is dispersed among remote rural and frontier communities.  Arizona’s population per square mile is just 56.3, compared to 87.4 nationally.  These residents often have to endure long drives, sometimes over dirt roads, to access health care.  Concerns over travelling through border patrol road checkpoints present additional barriers to some families.  

 

Education Level

Education level can impact an individual’s health literacy and self-efficacy in accessing health care.  In Arizona, 41.1 percent of adults aged 25 years and older with at least a high school education report their health is very good or excellent compared to only 22.8 percent with less than a high school education.  With Arizona ranking in the bottom eight nationally for high school graduation rates, this is a significant contributor to the women’s and children’s overall health status.[xxvii]

 

Language and Culture

More than a quarter (27.0%) of Arizonans reported speaking a language other than English at home, compared to 21.3% nationally.  This rate is 78.6% in one Arizona/Mexico border county.[xxviii]  Culturally and linguistically appropriate health care services are lacking in many communities in Arizona. 

 

One unique aspect of Arizona’s geographic and cultural landscape is its large American Indian population.  Arizona is home to 21 federally recognized American Indian tribes and has the largest total American Indian population of any state – over 300,000 individuals in 2017[xxix].  In addition, the majority of the Navajo Nation, the largest reservation in the U.S., and the Tohono O'odham Nation, the second largest, are in Arizona. Over a quarter of the state is designated as reservation land.  American Indians experience significant disparities compared to whites for many health indicators.  Infant mortality rate among American Indians was 7.8 (per 1,000 live births) in 2015, as compared to 5.6 Arizona average, and postneonatal mortality rate among American Indians was over double the state average (4.6 vs 2.1)[xxx].

 

MCH Health Disparities

While infant and maternal outcomes are better than average overall in Arizona, this is not true across all populations within the state.  The overall infant mortality rate is 5.6 (per 1,000 live births) – below the national average of 5.9 – but this rate jumps to 10.7 for African Americans and 9.5 for American Indians within Arizona.[xxxi]  Similarly, while the percent of births that are low birthweight across all races in Arizona (7.3%) is lower than the national average, a much higher percentage (12.0%) of African American babies are born low birthweight.viii

 

The Healthy Smiles Healthy Bodies Survey indicated that more than half (52%) of Arizona's kindergarten children have a history of tooth decay, higher than the national average for 5 year olds (36%) and almost two-of-three third grade children (64%) have a history of tooth decay compared to 52% of third grade children in the general U.S. population.

Arizona’s vaccine coverage rates continue to decrease. For the third year in a row, non-medical exemption rates–the percentage of students exempt from one or more vaccines–increased across all age categories.  In 2018, Arizona's percentage of 19-35 month olds being adequately immunized has remained below our 90% target at 71%. 

Women of color (Hispanic, Black, and Native Americans) are disproportionately affected by Severe Morbidity and Mortality in Arizona. Much like the USA, Arizona’s maternal mortality rate continues to increase. The latest maternal mortality rate for Arizona was estimated at 20.3 deaths per 100,000 live births. This ranks Arizona 25th in the nation.

Roles, Responsibilities and Targeted Interests of State Health Agency

The Arizona Department of Health Services (ADHS) is one of the executive agencies that report to the Governor. By statute it has been designated the Title V agency in Arizona. The Bureau of Women’s and Children’s Health is a component of the ADHS Public Health Prevention Services Division. The Chief of the Bureau of Women’s and Children’s Health serves as the Title V administrator. The Office of Children with Special Health Care Needs (OCSHCN) is one of the offices within BWCH and the Chief of the Office of Children with Special Health Care Needs serves as the Children with Special Health Care Needs director. An organizational chart can be found in Appendix B.
 

ADHS adopted a five-year strategic map for 2018-2023. The Strategic Priorities for this plan are: Improve Health Outcomes; Promote and Support Public Health and Safety; Improve Public Health Infrastructure; Maximize Agency Effectiveness; and Implement the Arizona Health Improvement Plan.
 

In 2014, ADHS first conducted a State Health Assessment (SHA), and an updated SHA was recently released in April 2019. ADHS used a variety of primary and secondary data sources to produce the analysis for the assessment, and input on the SHA was collected from many stakeholders including local health officers and tribal partners. The 2019 State Health Assessment is structured around the themes of Healthy People, Healthy Communities. ADHS focused on health outcomes across the lifespan, examining issues in Maternal and Infant Health, Child and Adolescent Health, Healthy Adults, and Healthy Aging. ADHS will use this Assessment to set priorities and performance objectives for the next iteration of the Arizona Health Improvement Plan (AzHIP), which will be released in 2021.
 

When developing our Maternal Child Health priorities, the Title V program looked at many factors, beginning with the intent of the Title V Maternal Child Health Block Grant. The program looked at what the community has identified as a priority and at what the data had shown was a concern. This meant looking at disparities as well. For instance, although Arizona’s infant mortality is 5.6, below the Healthy People 2020 goal, there is a disparity between White non- Hispanic and Black infant mortality.

 

The Title V program is responsible for tracking emerging issues and identifying how they affect the maternal child health population in Arizona. Prescription drug abuse and subsequent Neonatal Abstinence Syndrome have been identified as emerging issues. Abuse and addiction to opioids is a serious and challenging national public health problem, and in June 2017 Arizona Governor Doug Ducey declared the opioid crisis a public health emergency. Deaths from drug overdose have risen steadily over the past two decades and have become the leading cause of injury death in the United States. (ASPE, 2015) As described later in this Application, bullying has also been identified as an emerging issue as well as safe sleep and is participating in the Safe Sleep CoIIN. The Title V program also participated in Zika planning and preparation efforts. This upcoming year, ADHS will be responsible for the development and implementation of four Governor Goal Council Breakthrough Projects - Adverse Childhood Experience & Trauma Informed Trained Agency, Sexually Transmitted Diseases, Immunizations and Maternal Mortality.  BWCH will be the lead on Maternal Mortality and have strong participation in the other Goal Council Projects. 

 

Components of State’s System of Care

As described above, Arizona has one of the highest poverty rates in the country.  Among children of families within certain racial/ethnic groups in Arizona – including African American, Hispanic and Native American– these poverty rates climb to 30-45 percent.  Thus, low income families are one of the largest underserved populations in Arizona. 

 

Arizona Health Care Cost Containment System (AHCCCS) is the state Medicaid program that aims to ensure access to health care for low income individuals, and 22% of Arizona’s population is covered by Medicaid. AHCCCS also offers medical treatment, rehabilitation and related support services to qualifying children with special health care needs through the Arizona Children’s Rehabilitative Services (CRS) program. Other sources of health insurance for Arizona residents include private via employer or non-group (51%), Medicare (15%), and other public coverage such as VA or military (2%).  However, this leaves 10% of Arizona’s completely uninsured and vulnerable.[xxxii]

 

A strong infrastructure is in place within Arizona to improve access to preventive and primary health care for these vulnerable low income and uninsured populations through Title V subcontractors, Community Health Centers, and Rural Health Clinics.  Sliding fee schedule clinics are another critical resource in providing access to care to underserved populations.  ADHS BWCH maintains, annually updates and publishes a list of primary care, dental and behavioral health providers in Arizona that offer a sliding fee schedule to under- or uninsured individuals. There are currently nearly 400 sites utilizing a sliding fee scale in Arizona that offer some combination of primary care, dental, behavioral health services, or all.

 

Arizona’s system of care also includes a Level III Neonatal Care Center and wide variety of pediatric specialists through the Phoenix Children’s Hospital, eight Level III Perinatal Care Centers, seven Level IIE Perinatal Care Centers, fifteen Level II Perinatal Care Centers, and seven Level 1 Perinatal Care Centers.  These hospitals offer not only critical health care for children and families, but also an opportunity for education.  In fiscal year 2018 alone, 66,094 families of newborns left the hospital with tools to help them support their child’s health and learning.[xxxiii]

 

Arizona’s Children’s Health Insurance Program (CHIP) or KidsCare serves children in households earning too much to qualify for AHCCCS but earning under 200 percent of the federal poverty level (FPL). Over the last nine years, there have been a number of changes in federal and state policy affecting Arizona’s CHIP program. Table 1 illustrates policy changes occurring within the past years that have directly impacted insurance status and access to care for children living in Arizona. Arizona was at risk for an automatic freeze on KidsCare when federal funding falls below 100%, but the recently passed state budget fully funded KidsCare and eliminated that legislative language that would have frozen the program as federal match requirements change. This was a major public health win in Arizona’s legislative session this year, securing health insurance coverage for more than 30,000 children.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2. Health Care Policy Changes Affecting Children, 2010 – 2019.

Source: Contents for much of this table were drawn directly from Burak, E.W. (2015). Children’s Coverage in Arizona: A cautionary Tale for the Future of the Children’s Health Insurance Program (CHIP). Georgetown University Health Policy Institute Center for Children and Families.34 and The Arizona Health Care Cost Containment System, KidsCare website35.

 

On January 1, 2014 two policy changes impacting Medicaid eligibility for childless adults went into effect. The first policy change was the restoration of Proposition 204, extending eligibility to childless adults earning between 0 percent and 100 percent FPL. The second change was Arizona’s expansion of Medicaid eligibility to include childless adults earning between 100 percent and 133 percent FPL. Proposition 204 eligibility had been frozen since 2011. Expanding coverage to the new adult group was an opportunity provided by the ACA and supported by then Governor Janet Brewer. With these policy changes, these eligibility programs provided Medicaid coverage for nearly 400,000 individuals in May 2019. The adult expansion service increased 35 percent from June 2015 to June 2016, and now growth is steady with an increase of 2% in the past year. 36 
 

From December 2009 to May 2019 there was an overall increase in SOBRA enrollments for eligible pregnant women. Amended under Title VI of the Sixth Omnibus Budget Reconciliation Act of 1986, the Act gave states the option of extending coverage to women requiring pregnancy-related medical services beyond previously set income eligibility thresholds established by states. SOBRA enrollments for pregnancy women increased 49 percent between June 2015 and June 2016, but then decreased by 38 percent between June 2016 and May 2019. SOBRA services for children under the age of 18 also increased 77 percent from June 2015 to June 2016, and are now staying steady with no change in the past year.xxxvi

 

At the close of the 2019 open enrollment period, 160,456 Arizonans selected marketplace plans through the federally-facilitated exchange. 37 Table 2 illustrates characteristics of the individuals selecting marketplace plans in Arizona.

 

Figure 3. Marketplace Plan Selection Characteristics – Arizona, Close of 2019 Open Enrollment Periodxxxiii

 

In summary, recent federal and state health policy changes have increased the number of Arizonans covered by insurance. Counting marketplace plan selections (160,456) with the Proposition 204 restoration population (320,253) and the childless adult expansion population (77,488), over half a million individuals (558,197) have health insurance that may have not had it prior to the policy changes being implemented. This increase in covered lives

 

 

[i] US Census Bureau, Quick Facts, 2018.

[ii] US Census Bureau, State Population Totals and Components of Change, 2010-2018.

[iii] Arizona Office of Economic Opportunity, 2018-2055 State Population Projections – Low Series.

[iv] Arizona Vital Statistics - Population Denominators. (2016). Arizona Department of Health Services.

[v] State and County Quickfacts. USA People Quickfacts. (July 2018). US Census.

[vi] Arizona Vital Statistics –Population denominators for 2018 – Table 10D-1. (n.d.). Arizona Department of Health Services.

[vii] 2016 Report. (n.d.). Arizona Foundation for Women.

[viii] American’s Health Rankings, 2018.  Available at: http://www.americashealthrankings.org.

[ix] Revenues and Expenditures for Public Elementary and Secondary Education: School Year 2015-2016 (Fiscal Year 2016). (December 2018). National Center for Education Statistics (NCES).

[x] Public Education Finances: 2017. (April 2019). Educational Finance Branch, US Census.

[xi] NAEP 2017 State Snapshot (n.d.). National Center for Education Statistics (NCES).

[xii] Bureau of Economic Analysis. (n.d.). U.S. Bureau of Economic Analysis (BEA).

[xiii] S1903. Median Income in the Last 12 Months 5 year estimates, 2013-2017. (n.d) US Census.

[xiv] Bureau of Labor Statistics. Data: Local Area Unemployment Statistics. (n.d.) Bureau of Labor Statistics.

[xv] American Community Survey 5 year estimates 2013-2017. Community Facts, Popular Facts. (n.d.). US Census.

[xvi] American Community Survey 5 year estimates 2013-2017. Poverty Status in the Last 12 months of Families. (n.d.). US Census.

[xvii] American Community Survey 5 year estimates 2013-2017. Poverty Status in the Last 12 months of Families by County. (n.d.). US Census.

[xviii] National Center for Children in Poverty. Arizona Demographics of Poor Children. (n.d.). National Center for Children in Poverty.

[xix] Selected Economic Characteristics by County 2013-2017. DP03. (n.d.) US Census.

[xx] US Department of Agriculture. Definitions of Food Security. (n.d.). US Department of Agriculture.

[xxi] US Department of Agriculture. Food Security. (n.d.). US Department of Agriculture.

[xxii] Children’s Action Alliance. (2019). DCS Charts and Graphs.

[xxiii] Chapin Hall Center for Children. (June 26,2015). Arizona Department of Child Safety Independent Review.

[xxiv] HRSA Data Warehouse, as of 5/26/19.

[xxv] First Quarter of Fiscal Year 2019 Designated HPSA Quarterly Summary, Bureau of Health Workforce, Health Resources and Services Administration.

[xxvi] Table S2701. Selected Characteristics of Health Insurance Coverage in the United States: 2017. (nd). US Census.

[xxvii] America’s Health Rankings, 2018.  Available at: http://www.americashealthrankings.org.

[xxviii] US Census Bureau, Quick Facts, 2018.

[xxix] United Census Bureau, 2013-2017 American Community Survey 5-Year Estimates

[xxx] Arizona Department of Health Services, American Indian Health Status Report, 2017

[xxxi] Arizona Health Status and Vital Statistics 2017 Annual Report, Arizona Department of Health Services.

[xxxii] Kaiser Family Foundation, Health Insurance Coverage of the Total Population, 2017.

[xxxiii] Arizona First Things First, 2018 Annual Report.