Demographics, Geography & Economy

Arizona’s population was estimated to be 7,431,344 in 2023 by the U.S. Census Bureau.1 Arizona is one of the fastest growing and most diverse states in the nation—5th in the nation for overall population growth from 2020 to 2023 (3.8% growth, which equates to 273,442 additional residents).2 Arizona is expected to experience an additional growth of at least 25% by 2060.3 Geographically, Arizona is the 6th largest state in the nation with 113,653 square miles total area1, sharing a 389-mile international border with the states of Sonora and Baja California in Mexico.

Approximately 47% of Arizona’s population belongs to a racial or ethnic minority group. The racial and ethnic makeup of the state is different from the nation. Arizona has a higher proportion of Hispanics and American Indians and a lower proportion of African Americans compared to the nation. In 2023, Arizona’s population was 32.5% Hispanic (compared to 19.1% nationally), 5.5% African American (compared to 13.6% nationally), and 5.2% American Indians (compared to 1.3% nationally).4

The racial makeup of Arizona varies by age group. Among older age groups, the population is predominantly white, while younger populations are more racially and ethnically diverse. Over 46% of those younger than five are Hispanic compared to 11% of people 75 and older.5

Poverty is a social determinant of health and continues to be a critical concern in Arizona. According to 2022 Kaiser Family Foundation estimates, Arizona has the country’s 23rd highest poverty rate (15.7%) among children. Arizona’s childhood poverty rate has decreased over ten percentage points in the past decade (26.4% in 2012) and is now slightly lower than the national rate of 16.1%.6 In a five-year estimate for 2018-2022, 13.1% of Arizonans lived in poverty—down from 14.1% in 2020, but higher than the current national poverty rate of 12.5%— and 23.6% of those without a high school diploma lived below the poverty line.7 Poverty varies dramatically by county within Arizona. The highest rates of poverty are in Apache (32.5%) and Navajo (25.5%) counties; the lowest rates are in Greenlee (12.8%), Yavapai (12.3%), Maricopa (11.5%), and Pinal (11.3%) counties.7 U.S. Department of Agriculture, Economic Research Service 2022 estimates show that poverty in rural Arizona (22.5%) far exceeded the rate in urban areas of the state (12.4%).8

In addition to rural communities, poverty disproportionately impacts women and children. In Arizona in 2022, 17.9% of children under age 18 lived below the poverty line.7 The poverty rate among nonelderly adult females was 13.4% in 2022, while that rate among men was 10.6%.6 Nearly half a million women (494,334) live in poverty in Arizona.9 The Arizona Foundation for Women notes that gender wage gaps are detrimental to women’s and families’ well-being, leading to more children and families in poverty. They cite a national analysis completed by the Institute for Women’s Policy Research that demonstrated equal pay across genders would cut poverty among working women and their families in half.10

Median household income in Arizona has historically tended to be lower than national averages. According to the U.S. Census, Arizona’s median household income in 2022 was $72,581 compared to the national median income of $75,149. Median household income also varies widely by county and type of household. At $80,675, Maricopa County had the highest median household income; Apache County had the lowest at $37,483. Median household income also varies by type of household, with married couple families earning $102,016, families with children under 18 earning $82,948, and female-headed, single-parent families earning $38,757.11

Arizona’s unemployment rate ranged from 4.7-5.0% from mid-2017 until March 2020, when it quickly spiked due to the emerging global pandemic; reaching a high of 13.8% in April 2020 with 468,096 unemployed. It has since decreased to a rate of 3.6% during the first quarter of 2024. Unemployment varies across the state of Arizona. As of April 2024, Greenlee County had the lowest unemployment rate (2.5%), while Yuma County had the highest (9.7%).12

In addition to individuals, poverty is calculated for families with children under the age of 18. In a five-year estimate for 2018-2022, 14.4% of families in Arizona with children were below the poverty line; 0.8 percentage points higher than the national average (13.6%).13 Rates of poverty for families with children vary widely by ethnic background. The Annie E. Casey Foundation Kids Count Data Center reports that in Arizona in 2022, 10% and 9% of Asian and white children, respectively, lived in poverty compared to 39% of American Indian children, 20% of black children, and 20% of Hispanic children.14

Household food insecurity is often a consequence of poverty. Food insecurity, to paraphrase the USDA definition, is “limited or uncertain access to adequate food.” Low food security results in a reduced quality, variety, or desirability of diet. Very low food security is classified as multiple indications of disrupted eating patterns and reduced food intake.15 Food insecurity is lower in Arizona than in the United States as a whole (10.2 vs. 11.2%) and has decreased significantly—nearly 5 percentage points—over the past ten years. In 2020-2022, 4.0% of Arizona households had very low food security.16

There is also wide variation in the proportion of households receiving assistance such as Supplemental Security Income, Cash Assistance, or Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program) in Arizona. The most recent American Community Survey data shows that in 2022, 10.1% of households in Arizona received SNAP assistance (or food stamps). The lowest is 7.7% in Greenlee County and 7.8% in Yavapai County, compared to a high of 28.3% and 23.3% in Apache and Santa Cruz Counties, respectively.17

As children, Arizonans face other challenges as well. A 2023 America’s Health Rankings report placed Arizona with the 20th highest rate of adverse childhood experiences (ACEs) - 16.3% of Arizona’s children experienced two or more ACEs last year (compared to 14.0% nationally). This is a significant improvement over 2019 when 27% of children in Arizona reported experiencing two or more ACEs (third worst in the country).18 ACEs include parental divorce or separation; living with someone who had an alcohol or drug problem; neighborhood violence victim or witness; living with someone who was mentally ill, suicidal, or severely depressed; domestic violence witness; parent served jail time; being treated or judged unfairly due to race/ethnicity; or death of a parent. ACEs are associated with negative impacts on adult life, such as poor health, heavy drinking, smoking, and depression.

The rate of children (ages 0-17) living in foster care in Arizona increased from 5.9 in 2009 to 8.5 in 2021. Four percent of children in the state are being raised by their grandparents. Of the 14,890 children in foster care in Arizona in 2021, 70% were of a racial or ethnic minority group.19

Arizona consistently ranks among the lowest in the nation in per-pupil spending on education. The National Center for Education Statistics reported that Arizona spent $10,401 per student compared to the national average of $15,591 per student in fiscal year 2022.20 The U.S. Census ranked Arizona 48th of the 50 states and the District of Columbia in public per pupil spending in fiscal year 2022.21 The National Assessment of Educational Progress (NAEP) is an assessment of what America’s students know. In 2022, 24% of Arizona eighth-graders tested at or above proficient in mathematics, down from 35% in 2015, and 28% tested at or above proficient in reading (down from 31% in 2015).22

Unique Strengths & Challenges

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

Provider Shortages

Arizona has a shortage of medical providers. Large sparsely populated areas make the distribution of providers difficult. Recruiting providers to rural areas is often challenging due to the appeal of higher salaries and better school districts and community amenities that urban areas can offer. Even in urban areas, Arizona’s healthcare workforce has not kept pace with the state’s rapid population growth. These challenges are quantified by the total of 685 federally designated Health Professional Shortage Areas (HPSAs), which include 248 primary care, 249 dental, and 236 mental health HPSA designations. There are also 37 Medically Underserved Areas and 12 Medically Underserved Population designations in the state. Arizona needs an additional 667 full-time primary care physicians, 485 dentists, and 227 psychiatrists statewide to eliminate the existing HPSAs.23

Arizona's Primary Care Areas (PCAs) serve as the state's rational service area boundaries for shortage designation purposes and are used by ADHS and other state agencies for health data analysis. Of Arizona's 126 PCAs, 29 have a population-to-primary care physician ratio of greater than 5,000:1 or no primary care physicians in their community at all. Of these, 9 are rural areas, 5 are tribal, and 15 are urban. Travel distance to the nearest primary care physician ranged from 2 to 73 miles. Of the six PCAs with the longest travel distance, half are tribal areas and all are rural or frontier.24

Lack of Health Insurance

As of June 2024, there are 2,204,281 enrollees in the Arizona Medicaid Program (AHCCCS)—a decrease of 153,173 in the past year.25 While the number of people without insurance fell in Arizona over the past several years (from 19% in 2013 to 10.8% in 2022), it remains higher than the national average (8.7%). There are about 759,133 people in Arizona without health insurance, of which 147,689 are children and youth under the age of 19. This is an 8.7% uninsured rate for this age group; substantially higher than the national average of 5.3%.26 While Arizona’s percentage of uninsured children has decreased from a high of 15% 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 62.9, compared to 93.8 nationally.4 Rural residents often endure long drives, sometimes over dirt roads, to access health care.  Concerns about traveling 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. People with higher levels of education are more likely to be healthier and live longer. With Arizona ranking in the bottom two nationally for high school graduation rates, this is a significant contributor to women’s and children’s overall health status. Only 77.3% of high school students in Arizona graduate with a regular high school diploma within four years of starting ninth grade - compared to 86.5% nationally.18

Language and Culture

More than a quarter (26.4%) of Arizonans reported speaking a language other than English at home, compared to 21.7% nationally, and this rate is 78.7% in one Arizona/Mexico border county.4 Culturally and linguistically appropriate healthcare 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 22 federally recognized tribes and has the largest total American Indian population of any state—over 386,000 individuals.4 The majority of the Navajo Nation, the largest reservation in the U.S., lies in Arizona, and five of the top ten largest reservations in the United States 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. The infant mortality rate among American Indians was 5.6 (per 1,000 live births) in 2021, as compared to 4.3 among White non-Hispanics. While the racial disparity persists, this is a significant improvement from the 9.5 infant mortality rate for American Indians in 2017.27 Between 2018 and 2019, 15.1% of pregnancy-associated deaths in Arizona were among American Indian women—despite only 5.8% of births during that period being to American Indian women.28

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 5.5 (per 1,000 live births)—close to the national average of 5.4—but this rate jumps to 12.9 for African Americans within Arizona.27 Similarly, while the percent of births that are low birthweight across all races in Arizona (7.9%) is lower than the national average, a much higher percentage (12.9%) of African American babies are born low birthweight.6

The Healthy Smiles Healthy Bodies Survey indicated that more than half (52%) of Arizona's kindergartens have a history of tooth decay, higher than the national average for 5-year-olds (36%), and almost two in three third-grade children (64%) have a history of tooth decay compared to 52% of third-grade children in the general U.S. population.29

Arizona’s vaccine coverage rates continue to decrease. Non-medical exemption rates—the percentage of students exempt from one or more vaccines—for kindergarteners increased in the past five years from 5.9% to 8.7%. A range of 95%-100% vaccine coverage is the target for childhood vaccines to fully protect a community and curtail the spread of disease. Arizona's percentage of children who received the recommended doses of childhood immunizations by kindergarten remains below that target at rates that range from 88-93% for each recommended immunization.30 

Women of color (Hispanic, black, and Native American) are disproportionately affected by maternal mortality in Arizona. Like much of the country, Arizona’s maternal mortality rate continues to increase. The latest data in Arizona shows 91.1 pregnancy-associated mortalities and 26.3 pregnancy-related mortalities per 100,000 live births. As we see with other MCH indicators, American Indian and African American women are disproportionately impacted by pregnancy-associated mortality, with rates of 233.9 and 166.8, respectively.18

Impact of COVID-19

As in most places, public health—and life in general—was impacted substantially by the COVID-19 pandemic. As of June 8, 2024, there have been 2,615,926 cases of COVID-19 in Arizona.31 Arizona’s total COVID-19 death rate (per 100,000) is 335.1 - currently the sixteenth highest rate among all states.32

In Arizona, as we have seen across the nation, the COVID-19 pandemic has laid bare long-standing inequities in health outcomes and provision and shown us the true cost of our indifference to these disparities. In particular, there has been a disparate impact of COVID-19 deaths on the Navajo Nation and other tribal lands. The main contributing factors to this disproportionate impact are healthcare quality, accessibility, and cultural relevance; infrastructure challenges (e.g., homes with no running water, multi-generational housing, etc.); and underlying health conditions (e.g., disparate burden). We have also seen a disparate burden of COVID-19 incidence and deaths among essential workers (e.g., healthcare workers, meat packers, prison guards, etc.) and the communities in which they live.

The COVID-19 pandemic created some emerging and unique public health issues for Arizona’s MCH populations, apart from the immediate impact of the disease.  For some women and children, the stay-at-home orders meant that they were isolated with an abusive partner or caregiver. The City of Phoenix Police reported that domestic violence calls and deaths increased during the pandemic.

In addition, stay-at-home orders and social distancing measures implemented to mitigate the spread of COVID-19 did result in increased feelings of isolation for many people. The impact of this isolation could be mediated or exacerbated, depending on factors like living situation (e.g., alone or with others), alternative means of access to family and friends (e.g., comfort or access to virtual technology), and underlying mental health issues. While we still don’t fully understand the impact the pandemic may have had on diseases of despair, Arizona continues to monitor suicide and injury data to assess this impact. A CDC analysis reported that 37% of high school students reported experiencing poor mental health during the pandemic, and 44% reported feeling persistently sad or hopeless in the past year.33 A newly released CDC brief highlighted a particular concern for mental health among teen girls in the country - 57% of whom felt persistently sad or hopeless in 2021 (double that of boys), and 30% seriously considered suicide.34

There is also a concern that people have been deferring preventative and essential care during the pandemic. Specific to our MCH populations, we have observed a decrease in attendance of well-child visits. The childhood immunization rate decreased during the pandemic, an issue that goes hand-in-hand with the decrease in well-child visits. 72% of Arizona’s children ages 0-17 received one or more preventive visits in the past 12 months - ranking the state 45th nationally.18

Some other changes that Arizona’s Title V Program has observed with respect to our MCH populations are:

• Fewer referrals and more refusals by clients for referrals for behavioral health services and tobacco cessation services
• Fewer developmental screenings completed for children
• Potential for youth to engage in more risky behaviors due to lack of peer support, isolation, and increased exposure to unhealthy coping behaviors and environments

These secondary impacts of the pandemic are likely to last for a while, and it will be important to identify and address them with targeted actions and resources in the years to come.

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 (BWCH) is part of the ADHS Public Health Prevention Services Division.  Laura Luna Bellucci, Chief of the Bureau of Women’s and Children’s Health, serves as the Title V Administrator and the state’s Maternal and Child Health Director. Jessica Stewart-Gonzalez is the Children with Special Health Care Needs (CSHCN) Director. In Arizona, the Office of Children’s Health oversees programming within ADHS for children and youth with special health care needs (CYSHCN). Please refer to State Title V Program Purpose and Design and Organizational Chart for more detail.

ADHS adopts a strategic plan each year. The Strategic Priorities for the Fiscal Year 2024 Strategic Plan include:

• improve health outcomes;
• promote and support public health and safety;
• transform and modernize public health infrastructure;
• foster team member inclusion and excellence; and
• implement the Arizona Health Improvement Plan.

 

ADHS conducted the first State Health Assessment (SHA) in 2014. The second, and current, SHA was published in 2019 and places an increased focus on health equity and the social determinants of health. The SHA is updated each year as new data sources become available, the most recent version published in 2022. ADHS used a variety of primary and secondary data sources to produce the analysis for this assessment. Input on the SHA was collected from many stakeholders, including local health officers and tribal partners.

ADHS used this assessment to set priorities and performance objectives for the Arizona Health Improvement Plan (AzHIP), published in 2021 and updated in December 2023. Development of the 2021-2025 Arizona Health Improvement Plan (AzHIP) reflects the commitment to improving the public health of public health professionals, advocates and community stakeholders at the state, county and community levels. The 2021-2025 plan consists of 5 priorities: Health Equity, Health in All Policies/Social Determinants of Health, Mental Well-being, Rural & Urban Underserved Health, and Pandemic Recovery & Resiliency. Each priority has defined strategies, tactics, and action plans led by a variety of community partners. A BWCH staff member co-chairs the Rural & Urban Underserved Health Core Team.

In addition, as a condition of the block grant, HRSA requires each state’s Title V Program to complete a needs assessment every five years, and to track emerging issues and identify how they affect the MCH population in Arizona on an ongoing basis. For the 2020 Title V Needs Assessment, ADHS partnered with the University of Arizona, Diné College of the Navajo Nation, and the Inter-Tribal Council of Arizona (ITCA) to conduct the assessment. In addition to collecting and analyzing quantitative MCH data from national and state data sources, the assessment was designed to engage families and the public through a public survey, focus groups, and community forums to capture qualitative and quantitative data that draws on the experience and knowledge of the communities we serve.

The ADHS Prevention Services established a Racial Equity Core Team in August 2020 and released a Racial Equity Action Plan in February 2022 to better understand and address the persistent health disparities among systematically oppressed populations. The Core Team had a vision of advancing racial equity to further the vision of healthcare and wellness for all Arizonans. To accomplish this, four Action Teams were established including data and evaluation; program planning and contracts; communications; personnel development; and community engagement. Each Action Team developed recommendations, strategies, and key milestones. Key Performance Measures were identified to support the momentum of the work and to track progress. Current activities include the development of education and training for staff; assessing data collection using a health equity lens; improving data sharing and access; development of tools and resources that enhance division program planning and contracts; implementation of best practices to enhance the HR process of recruiting and retaining a culturally diverse workforce; enhance training opportunities to increase knowledge and awareness of racial inequities and how to advance equality; host listening sessions to gain understanding of the workforce perspective.

Arizona’s Title V Program developed our current maternal child health (MCH) priorities by collecting and analyzing data from the 2020 Needs Assessment, sharing that data with community members and other MCH stakeholders on our Needs Assessment Steering Committee, and soliciting their input to identify priority areas in line with the intent of the Title V Maternal Child Health Block Grant.  A key component of this analysis was disaggregating the data to expose disparities that might not be obvious in the aggregated data. For instance, although Arizona’s infant mortality is below the national average at 5.5 (per 1,000), there is a disparity between white non-Hispanic and black infant mortality—and each of these rates needs improvement to meet the Healthy People 2030 goal of 5.0 (per 1,000).

Prescription drug abuse and subsequent neonatal abstinence syndrome (NAS) are an ongoing challenge. The opioid crisis was declared a public health emergency by Arizona’s Governor in 2017, and in the seven years since that declaration, there have been 11,460 opioid deaths and 26,196 non-fatal opioid overdoses in Arizona.35 As part of the State Agency Performance Measures, ADHS provides the development and implementation of the Suicide Action Plan, Sexually Transmitted Diseases Control Action Plan, Increasing Immunization Coverage Rates in the Arizona Action Plan, and the Maternal Mortality Action Plan. BWCH will continue to be the lead on Maternal Mortality and participate in the Governor’s State priorities and performance measures.

Components of State’s System of Care

Medicaid aims to ensure access to health care for low-income individuals, and 20.4% of Arizona’s population is covered by the Arizona Health Care Cost Containment System (AHCCCS), the state Medicaid program. 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 (51.3%), Medicare (16.1%), and other public coverage such as VA or military (2.1%).  However, this leaves 10% of Arizona’s population uninsured and vulnerable.36

In Arizona, the Primary Care Office is housed within the Bureau of Women’s and Children’s Health and Arizona’s Title V Program supports programming to meet the needs of uninsured and underinsured Arizonans. For example, 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. Over 400 sites are utilizing a sliding fee scale in Arizona that offers some combination of primary care, dental, and/or behavioral health services. In addition, Arizona has several community health centers, rural health clinics, Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals that offer essential lower-cost care to vulnerable Arizonans. In 2023, Arizona’s Title V Program partnered with the Arizona Alliance for Community Health Centers (AACHC), Arizona’s Primary Care Association (PCA), to educate communities about programs and resources that can help recruit healthcare professionals in areas with significant challenges with recruitment and to improve the coordination of rural recruitment efforts between the ADHS’ Primary Care Office, PCA, and the State Office of Rural Health (University of Arizona’s Center for Rural Health). In addition, Title V partnered with AACHC to help support and expand clinical rotation and internship opportunities for healthcare providers at community health centers focused on maternal and child health.

The Medical Services Project, funded through Title V and implemented by the Arizona Chapter of the American Academy of Pediatrics, works to increase the statewide network of pediatric providers and pediatric subspecialists willing to take a limited number of patients without insurance or AHCCCS to ensure that Arizona’s children have necessary acute health care. Title V-funded Family Planning Clinics, administered by 9 local county health departments and one public health system in Arizona, make family planning and reproductive health services available to uninsured and/or low-income families in Arizona.

Arizona’s system of care also includes a Level III Neonatal Care Center and a wide variety of pediatric specialists through the Phoenix Children’s Hospital, one Level IV Perinatal Care Center, seven Level IIIA Perinatal Care Centers, eight Level IIIB Perinatal Care Centers, thirteen Level II Perinatal Care Centers, and seven Level I Perinatal Care Centers. These hospitals offer critical health care for children and families but also an opportunity for education. In FY 2023, 55,132 families of newborns left the hospital with tools to help them support their child’s health and learning.37

Arizona’s Children’s Health Insurance Program (CHIP), or KidsCare, serves children in households earning too much to qualify for AHCCCS but earning under 225% of the federal poverty level (FPL). Over the past decade, several changes in federal and state policy affected Arizona’s CHIP program, including enrollment freezes and reinstatements. In a major public health win for Arizona, KidsCare eligibility was expanded to families earning up to 225% (from the previous 200%) of the federal poverty limit in the FY2024 state budget signed by Governor Hobbs. This expansion began on March 1, 2024, and provided 10,000 more children with critical access to care.38, 39 

Since the start of the COVID-19 pandemic in 2020, AHCCCS had not disenrolled most AHCCCS members, regardless of eligibility. The Consolidated Appropriations Act (CAA) enacted in December 2022 required AHCCCS to reinstate the regular renewal process for all Medicaid and KidsCare members. On April 1, 2023, this process of disenrolling members who no longer met eligibility criteria began. As a result, the total number of individuals enrolled in AHCCCS has decreased by over 153,000 (6%) in the past year.25

Over the past decade, there was a 66% increase in SOBRA enrollments for eligible pregnant women. Amended under Title VI of the Sixth Omnibus Budget Reconciliation Act (SOBRA) 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 pregnant women decreased by 1,700 (9%) in the past year. SOBRA services for children under the age of 18 also increased by over 400% in the past decade but decreased by 5% over the past year.25

At the close of the 2024 open enrollment period, 348,055 Arizonans selected marketplace plans through the federally facilitated exchange – an increase of over 100,000 from 2023.40 Figure 4 illustrates the characteristics of the individuals selecting marketplace plans in Arizona.

Figure 4. Marketplace Plan Selection Characteristics – Arizona, Close of 2024 Open Enrollment Period40

Characteristics	Number of Individuals	Percentage of Total
Total individuals with plan selections	348,055
New consumers	102,716	30%
Younger than 18 years of age	46,518	13%
Aged 18-64 years	297,673	86%

 

The efficiencies and benefits of integration of physical and behavioral health care have been an issue often discussed in Arizona over recent years, prompting AHCCCS to create a new integrated system of care called “AHCCCS Complete Care” (ACC).  ACC began on October 1, 2018, combining physical and behavioral healthcare services to treat all aspects of members’ healthcare needs under one chosen health plan.  Improved coordination between providers within the same network is expected to result in better health outcomes for AHCCCS members.

In SFY 2024, over two-thirds of the $17.8 billion Arizona budget was for K-12 education, AHCCCS, and the Department of Corrections. Forty-four percent (44%) of the general fund went to elementary and secondary education (approximately $7.8B), about 14% for AHCCCS (approximately $2.5B), and about 8% for corrections (approximately $1.5B). ADHS received less than 1% of the general fund expenditures ($167M).41 The FY 2025 budget has not been finalized as of June 15, 2024.

The 2024 Arizona Legislative Session has not yet concluded. Arizona’s elected officials are trying to balance budgets - both a $729 million deficit for the current year and an estimated $690 million gap for the coming fiscal year. To this point, a few bills have been signed that will improve public health, particularly improvements in public health licensing and court-ordered behavioral health procedures that will protect some of the state’s most vulnerable residents. The Governor vetoed several bills that would have been harmful to women’s and children’s health, including one making employment and training programs mandatory for SNAP benefits, and another that would allow parents access to all of their minor children’s medical records, including treatment for STIs.

There have been some other recent policy-related developments that impact women’s and children’s health. Arizona’s Medicaid agency, AHCCCS, has filed a State Plan Amendment that adds coverage and payment for doula services effective October 1, 2024. On May 17, Governor Hobbs issued an Executive Order Protecting Reproductive Freedom Through Increased Access to Contraception. This year AHCCCS implemented continuous coverage for children enrolled in Medicaid/KidsCare - ensuring 12 months of health care coverage even if they no longer qualify for Medicaid during the 12 months before the child’s annual renewal date.

Relevant Statutes

Several Arizona statutes impact and support MCH and CYSHCN programs.  Arizona Revised Statute (A.R.S. 36-691) formally accepts Title V and designates ADHS as the Title V agency accepting the conditions of Title V of the Social Security Act, entitled "grants to states for maternal and child welfare," enacted August 14, 1935, and as amended.

Additional state statutes authorize several MCH programs or functions not specific to Title V. The statutory list of functions (A.R.S. 36-132) of ADHS includes: encouraging and aiding in coordinating local programs concerning maternal and child health, including midwifery, antepartum, and postpartum care; infant and preschool health and the health of school children, including special fields such as the prevention of blindness and conservation of sight and hearing; and encourage, administer, and provide dental health care services and aid in coordinating local programs concerning dental public health, in cooperation with the Arizona Dental Association. Subject to the availability of monies, develop and administer programs in perinatal health care. Some of these programs are managed outside of the Bureau of Women’s and Children’s Health (BWCH); in those instances, BWCH staff remain involved by coordinating closely with agency colleagues.

Amended rules (R9-101-117), effective July 1, 2014, were adopted for the licensing of lay midwives in Arizona. The new rules include a change to the scope of practice to include the delivery of frank breech and vaginal delivery after cesarean section under certain prescribed circumstances. The rule changes also add clear requirements for reporting, transfer of care, and emergency action plans. Title V leadership was involved in the rulemaking process.

During the 2015 legislative session, the Governor signed into law HB 2643, which prohibits the state and its political subdivisions from using any personnel or financial resources to enforce, administer, or cooperate with the Affordable Care Act in many ways except for public health prevention programs.

State statute (A.R.S. 36-697) authorized the Health Start program, administered by BWCH. The program, serving pregnant women, children, and their families, is required to be statewide, based in identified neighborhoods, and delivered by lay health workers through pre-scheduled home visits or group classes that begin before the child's birth or during the postnatal period and may continue until the child is two years of age.

Lay health workers, or Community Health Workers (CHWs), will be able to apply for voluntary certification through ADHS.  Bill H2324 was passed in the 2018 Arizona Legislative Session requiring ADHS to adopt rules prescribing the scope of practice, minimum qualification, education and training standards, and criteria for certification of community health workers.  A nine-member Community Health Workers Advisory Council was established and is currently working through this rule-making process. Approximately $50,000 in Title V funds were utilized in 2021 to support the development of the new CHW Licensing Database.

BWCH also manages the Oral Health Fund established by ARS 36-138. Funds received as reimbursement from the state’s Medicaid program contractors for dental services provided by BWCH are put into the Oral Health Fund, which is then used to fund additional dental health services. Additionally, Bill H2235 was passed in the 2018 Legislative Session requiring ADHS, in consultation with the Board of Dental Examiners, to conduct a study by December 31, 2023, on the impact of licensing Dental Therapists on patient safety, cost-effectiveness, and access to dental services in Arizona.

State statute (A.R.S. 36-899.01) also requires ADHS, through BWCH, to administer a program of hearing evaluation services to all school-aged children.

Vision screening legislation (SB1456) was passed on August 17, 2019. This bill requires vision screening of children in Arizona upon initial entry to school as well as not more than two additional grade levels in a district or charter school that provides preschool and/or K-12 instruction. The vision screening law is now officially in the Arizona Revised Statutes and can be found at ARS §36-899.10. During 2023, the Sensory Screening Program finalized the draft of the administrative rules that will guide these screenings and require the submission of annual reports. The Governor's Regulatory Review Council in Arizona passed updated hearing and vision screening rules on May 7, 2024. The Sensory Screening program updated hearing and vision screening materials and guidelines that reflect the updated rules effective for the 2024-2025 school year.

The Child Fatality Review Program, authorized by A.R.S. 36-3501, requires the State Child Fatality Review Team to conduct an annual statistical report on the incidence and causes of child fatalities and submit a copy of this report, including its recommendations for action, to the Governor and legislative leadership on or before November 15 of each year. This report also includes recommendations from the committee for the public. The Program is housed in the BWCH and the Bureau Chief is a legislatively required member of the State Team.

The Arizona Revised Statute (A.R.S. § 36-3501) was amended in April 2011 to establish the Arizona Maternal Mortality Review Committee (MMRC) as a subcommittee of the Child Fatality Review (CFR) Program. Though unfunded, Arizona Maternal Mortality Review Program (MMRP) has convened an MMRC since June 2012 to review all identified maternal deaths in the state. In 2019, ADHS was awarded $450,000 per year for five years from the CDC's Preventing Maternal Deaths: Supporting Maternal Mortality Reviews grant. ADHS is using this funding to strengthen the current structure and data collection processes of the Arizona MMRC and to build a just, strong, sustainable, and focused effort to systematically increase access, quality of care, and overall health for all women in Arizona.

Senate Bill 1040 was passed into law during the 2019 legislative session and was repealed on July 1, 2021. The bill established an advisory committee on maternal fatalities and morbidity and dictates the advisory committee composition. The bill delegated authority to ADHS to designate a chair and appoint committee members. The primary role of the advisory committee was to recommend improvements to data collection regarding the incidence and causes of maternal fatalities and severe maternal morbidity.  The statute also directed the advisory committee to submit two reports to the House of Representatives, Senate, and the Governor’s Office. The first report was due and submitted in December 2019 with recommendations regarding improvements in data collection.  The second and final report was submitted in December 2020, providing an account of the incidence and causes of maternal fatalities and morbidity for 2016–2018. The Arizona MCH Director served as the Committee Chair and the MCH program staff provided data analysis for the committee.

Senate Bill 1011, passed in 2021, establishes a Maternal Mental Health Advisory Committee, which will be conducted through the state Medicaid program, AHCCCS. The committee will recommend improvements for screening and treating maternal mental health disorders. Initially, ADHS was not given a seat on the Committee; however, through an amendment to the bill, a “representative from the Department of health services maternal health program” is now required on the advisory committee.

Senate Bill 1181, passed in 2021, allows for the voluntary certification of doulas. The bill requires ADHS to establish an advisory committee of at least nine Director-appointed doulas that represent diverse and underrepresented communities along with other experts. The committee will be tasked with creating a scope of practice and core competencies that are essential to expand health and wellness, reduce health disparities, and promote culturally relevant practices within diverse communities.

Senate Bill 1680, passed in 2021, requires the Newborn Screening (NBS) Program to include all congenital disorders on the Recommended Uniform Screening Panel (RUSP). The bill allows automatic updates to the state’s required newborn screening list when the federal government adds more conditions to its recommended list. The passing of this bill will expand Arizona's screening list from 31 conditions to all 35 conditions, as federally recommended.

Senate Bill 1020, passed on February 13, 2024, requires the Arizona Department of Health Services to add Duchenne muscular dystrophy to the state’s newborn screening panel by October 1, 2026. The newborn screening program must include all congenital disorders on the RUSP for both core and secondary conditions. More information about the Office of Newborn Screening and the newborn screening program can be found in the Perinatal/Infant Health 2023 Annual Report and the 2025 Application.

House Bill 2126, passed on March 23, 2021, added the following language to the Arizona State Loan Repayment Program Rules: “An applicant who works at an Indian Health Service or tribal facility is not required to provide a sliding fee scale to be eligible for the program.” Many tribal and IHS facilities do not implement Sliding Fee Schedules because they do not charge IHS-eligible clients for healthcare services rendered. This exemption allows these entities to increase participation in the Arizona State Loan Repayment Program without implementing a Sliding Fee Schedule.

The 2022 Legislative Session resulted in expanded healthcare workforce recruitment and retention programs. House Bill 2863 established the Arizona Behavioral Health Loan Repayment Program, administered by BWCH, to pay off portions of educational loans taken out by behavioral health care providers and nurses, including behavioral health technicians, behavioral health nurse practitioners, psychiatric nurse practitioners and licensed practical nurses, physicians, psychiatrists, and psychologists. House Bill 2691 established a Student Nurse Clinical Rotation and Licensed or Certified Nurse Training Pilot Program, administered by the Arizona Board of Nursing, to expand the capacity of preceptor training programs at healthcare institutions, including assisted living facilities, centers or nursing care institutions for nursing students and newly licensed or certified nurses.

House Bill 2863, passed in 2022, expanded postpartum coverage for Medicaid members from 60 days to 365 days.

House Bill 2442, passed February 6, 2024, states that immunizations for which a U.S. Food and Drug Administration emergency use authorization has been issued are not required for school attendance. This currently impacts the human papillomavirus, COVID-19 or any variant of COVID-19 are not required for school attendance.

House Bill 2451, passed on February 13, 2024, establishes advertising restrictions for marijuana establishments and nonprofit medical marijuana dispensaries. This includes any public communication in any medium that offers or solicits a commercial transaction involving the sale, purchase or deliver of marijuana or marijuana products who are under 21 years of age.

House Bill 2116 amended A.R.S. 36-3503 on February 20, 2024. The bill requires a law enforcement agency to provide unredacted reports to the state or local child fatality review (CFR) team or maternal mortality review program (MMRP) unless the records might interfere with a pending criminal investigation or prosecution. Allows a member of the state or local CFR team or MMR Program to contact, interview, or obtain information from a close contact or family member of a deceased child or mother with approval from the CFR team or MMR Program.

Senate Bill 1048, passed on February 6, 2024, modifies the membership and duties of the State Child Fatality Review Team and local child fatality review teams. The bill provides the Chairperson of the State CFR Team or a local review team access to all information and records regarding a child fatality or near fatality under review. Provisions include an annual statistical report which must include a variety of child fatality data and recommendations.