Demographics

Known as the Land of 10,000 Lakes, Minnesota is a medium-sized state, encompassing slightly more than 84,000 square miles. In 2017, 5,577,487 people lived in the state, with more than half of its residents living in the 7-county Minneapolis-St. Paul metropolitan area. 

For most of the twentieth century, Minnesota had a relatively homogeneous population. While non-Hispanic whites made up 97.8% of the state’s population in 1960, they currently make up 80% of the population. Between 2010 and 2017, the state added five times as many people of color (Asian, black, multiracial, and/or Hispanic) and American Indians as non-Hispanic white residents. Populations of color and American Indians are distributed unevenly across the state, and are more likely to live in metro areas than rural areas. Between 2010 and 2017, the fastest growing racial group in Minnesota was the black population, which grew by 29%, adding more than 80,000 people. Second fastest was the Asian population, which also grew by 29%, adding 64,000 people, followed by the Hispanic population, which grew by 20%, adding 50,000 people (black and Asian race groups are that race "alone" and non-Hispanic). While still less diverse than the U.S. as a whole, in 2017 30% of Minnesota births were to women of color and 32.4% of children under age 5 and 30.4% of children under 18 are of color or American Indian. In some parts of the state, the percentage of preschool-age children of color is approaching 50% or more (Mahnomen County (71%); Nobles County (60%); Ramsey County (54%) and Hennepin County (48%)).

There are eleven federally recognized Tribal Nations in Minnesota. The Minnesota Chippewa Tribe is a federally recognized tribe that provides unified leadership to six member tribes: Bois Forte, Fond du Lac, Grand Portage, Leech Lake, Mille Lacs and White Earth. Red Lake is another Anishinaabe (Chippewa/Ojibwe) Band, and is the only closed reservation in Minnesota. The other main group of Minnesota American Indians are the Dakota (Sioux) with four Dakota Communities: Lower Sioux, Prairie Island, Shakopee-Mdewakanton, and Upper Sioux. There are approximately a hundred thousand individuals in Minnesota who identify as American Indian and/or Alaska Native (alone or in combination with another race), representing approximately 2% of the state’s population. Approximately 20% of American Indians in Minnesota live on a reservation.

In 1920, about 1 in 5 Minnesotans were foreign-born. In 2017, approximately 1 in 11 were foreign-born (486,243 residents). Fifty-two percent of Minnesota’s foreign-born population are naturalized U.S. citizens. Minnesota’s largest groups of foreign-born were born in Mexico, Somalia, India, Laos, Vietnam, China, Myanmar and Ethiopia. Minnesota is home to more refugees than any other state per capita. Minnesota has the largest Somali and urban Hmong populations in the United States, most living in Minneapolis and St. Paul. Over half of the Asian population in Minnesota identifies as Southeast Asian (compared to 21% nationally). More than 80 languages are spoken in the Twin Cities. Many immigrants, who came to the state as children or young adults, are now having children, and as such are influencing the racial and ethnic changes that are occurring in the state.

Even though Minnesota's birth rates are at historic lows, Minnesota had a growth rate of 5.2% between 2010 and 2017, adding 273,562 residents (net). The fastest growing counties by population between 2010 and 2017 were Carver (13.0% increase), Scott (11.4%), Hennepin (8.4%), Clay (8.1%), and Olmsted (8.0%). The counties that added the most residents between 2010 and 2017 on net were Hennepin (+97,087), Ramsey (+37,677), Dakota (+24,028), Anoka (+21,830), Washington (+18,769), and Scott (+14,789). Forty-six counties have lost population since 2010.

In 2017, there were 68,603 live births in the state, down from the peak of 73,675 babies born in 2007. In 2017, Minnesota was home to 1,298,657 children under age 18, representing 23% of the population. Overall, Minnesota's age distribution is similar to the national average. In 2017, children under the age of five represent 6.3% of Minnesota's population, 18 years and older comprising 76.7% of the population, and individuals 65 and over comprising 15.4%. By 2035, the number of Minnesotans over age 65 will make up more than one-fifth of the state’s population. Minnesota’s diverse cultural groups have very different age distributions. Our state’s large Baby Boomer generation, born between 1946 and 1964, is overwhelmingly white, one of the reasons the median age among white Minnesotans is higher than any other group. Younger generations have more origins that are global. Most populations of color are much younger than white Minnesotans. Notably, among Somali and Hmong Minnesotans, half or more of the population is under age 21. Minnesotans ages 18 to 64 are the lion’s share of our present-day workforce, while children under 18 represent the workforce of the not-too-distant-future, whose preparation is critical to the continued economic success of Minnesota. Demographic changes (aging of the population, decreasing birth numbers, growth in communities of color, concentration of growth in dense urban communities, and rising dependency ratios of elderly and children as a ratio to the working-age population) will impact not only the need for and the type of healthcare necessary, but will also affect housing, education, business, commerce, and social services.

Economics

Minnesota’s unemployment rate of 3.1% (June 2018) compares favorably to the national unemployment rate of 4.0%. Minnesota's median household income in 2016 was $65,600, $1,300 higher than 2015 (inflation-adjusted, shown in 2016 dollars). However, there are significant disparities in median household income between different race/ethnicities, and within race/ethnicities.

Despite the slow but steady economic improvement of recent years, the number of Minnesota children and families living in poverty is concerning. Minnesota’s overall poverty rate was 10.8% in 2016, slightly up from 10.2% in 2015. An estimated 577,196 Minnesotans, including 175,079 children under age 18 had family incomes below the official poverty threshold. More alarming are the persistent disparities in poverty seen among American Indian children and children of color. Poverty rates were highest for those who are black (34%), American Indian (31.4%), and Hispanic (22.2%), three to four times higher than the rates of non-Hispanic Whites (8.2%).

More Minnesota seniors than ever before graduated in 2018 - 83.2% or 55,869 students graduating. Additionally, 3,641 students from earlier classes also earned their diplomas in 2018, graduating five, six, or seven years after beginning high school. High school graduation rates continue to rise in Minnesota, though gaps remain between white students and students of color - even as progress is made. Graduation rates increased statewide for all racial/ethnic student groups this year, as well as for English language learners, students receiving special education services, and students qualifying for free or reduced-price meals.

Over the past five years, graduation rates for the following:

• Black students increased 7.2 percentage points.
• American Indian/Alaska Native students increased by 2.8 percentage points.
• Asian students increased by 4.2 percentage points.
• Hispanic students increased by 3.6 percentage points.
• Students identifying as two or more races increased by 3 percentage points.
• Students receiving special education services increased by 4 percentage points.
• English learners increased by 2.5 percentage points.
• Students eligible for free or reduced-price meals increased by 3.5 percentage points.
• White students increased by 1.9 percentage points.

When looking at students of color and American Indian students together, we find they have increased by 4.9 percentage points during that same time. This change represents an almost 15% reduction in the gap between white and nonwhite students. Putting the growth into actual numbers, 977 more students of color and American Indian students, including 515 more black students, graduated with the Class of 2018 than if graduation rates had stayed at 2014 levels.

Health Care Access

Despite the stronger economy, Minnesota’s uninsured rate saw one of its largest, one-time increases in the rate of people without health insurance since 2001.The uninsured rate rose from 4.3% in 2015 to 6.3% in 2017, leaving approximately 349,000 Minnesotans without coverage. The rate increase corresponded with two private market trends including a decline in Minnesotans with coverage offered by employers (group coverage) and shrinking enrollment in the individual market. Public coverage increased by 3 percentage points to 36.5%over the same two-year period. The 2017 Minnesota Health Access Survey found that the top reasons people cited for losing insurance coverage included losing a job that offered coverage, losing eligibility for coverage or finding the cost of coverage too high. Unlike in 2015 when the improvement in uninsurance rates was felt across the board – for virtually all demographic groups – in 2017 some groups maintained their coverage gains, while others lost ground. The uninsured were more likely to be young adults (age 18 to 34), in a lower income bracket, and people of color or American Indians.

Public health care coverage is available through three primary programs in Minnesota: Minnesota Health Care Programs, which includes Medical Assistance and MinnesotaCare, and Advanced Premium Tax Credit program. 

Medical Assistance (MA) is a state and federal program that fully covers a broad array of health care services for people living in poverty, including seniors and people with disabilities. Income eligibility requirements vary by age: for infants up to age 2 (283% FPL), for pregnant women and children ages 2-18 (275% FPL), and for parents, children ages 19-20 and adults under age 65 (133% FPL). Children ages 0 to 18 are the single largest group making up 45%of total enrollment. Minnesota is one of 19 states that allows the Tax Equity and Fiscal Responsibility Act, known as TEFRA, which parents to receive in-home supports and medical services for their children with disabilities through Medical Assistance as a supplement to private insurance. Parents may have to pay a parental fee. Nearly 3,000 Minnesota children with disabilities are enrolled in the program.

MinnesotaCare is a state and federal program that provides a low-cost health insurance option to people who earn too much to qualify for Medicaid yet struggle to afford health insurance. Minnesota is only one of two states with this type of coverage. MinnesotaCare provides comprehensive health care coverage for more than 89,000 Minnesotans who pay no more than $80 a month in premiums. Income eligibility is for adults with incomes over 133% FPG up to 200% of FPG.

Advanced Premium Tax Credit is a federal program that reduces the cost of premiums for individual health insurance based on income and is available through federal or state marketplaces, such as MNsure. A record number of Minnesotans in the individual market signed up for 2018 health coverage through MNsure. According to the state's insurance exchange, 116,358 Minnesotans enrolled for 2018, which exceeded the previous year's record of 114,810, despite this year's open enrollment period being shorter by three weeks.

Of the births in Minnesota in 2017, Minnesota Health Care Programs paid for 44.8%. The majority of individuals enrolled in Minnesota Health Care Programs are on Medical Assistance and receive services through the state’s contracted managed care organizations. In 2018, about 945,070 people monthly were receiving health care through a managed care organization, of which 801,655 were on Medical Assistance. Approximately 280,000 enrollees received care though a fee-for-service model. They are individuals with disabilities, individuals who are eligible with a spenddown, children receiving adoption assistance and American Indians who live on a federally recognized reservation.  Spending on health care services for Minnesota Health Care Programs was approximately $13 billion.

Other important public programs are the Minnesota Family Planning Program (MFPP), administered by the Minnesota Department of Human Services, and the Family Planning Special Projects (FPSP) program, administered by Minnesota Department of Health.

• MFPP provides covers family planning services (contraception services, including STI screening and treatment) and transportation services to and from providers of family planning service for individuals 15 years of age or older and under age 50, who are not eligible for other public programs and who have an income at or below 200%of the federal poverty level. Applicants may apply directly at a provider's office.
• The FPSP program provides low-income, high-risk individuals pre-pregnancy family planning services. MDH receives state and federal TANF funds to provide statewide family planning services and infrastructure support to family planning clinics. Using these funds, the Family Planning Special Projects program awards more than $6.3 million annually in grants to local family planning providers including counties, Tribal governments, or nonprofit organizations. Funding is targeted to individuals who would have difficulty accessing services because of barriers such as poverty, lack of insurance, or transportation. During state fiscal year 2018, FPSP reached 96,000 individuals through outreach activities (e.g., classes and health fair fairs) and provided 29,641 men and women with a range of family planning method services, with 25.6% of women choosing a Tier 1 or most effective contraceptives.

These funding sources along with the federal Title X investment maintain a statewide system of family planning clinics as resources in local communities.

A cornerstone of Minnesota’s 2008 bipartisan health reform efforts is Health Care Homes, a voluntary medical home program that supports primary care providers, families, and patients to work in partnership to improve health outcomes and quality of life for patients, including those with chronic conditions or disabilities. In 2017, 58%of all primary care clinics, serving an estimated 3.6 million patients, were certified as a Health Care Home. Minnesota’s Health Care Home efforts have reduced Medicaid costs by 9%and are less expensive in four categories of healthcare spending:  inpatient hospital admissions, hospital outpatient visits, skilled nursing facilities and pharmacy costs.  Even more impressive, racial disparities are significantly smaller for Medicaid, Medicare, and dual eligible beneficiaries served by certified health care homes versus non-health care homes for most outcome measures. The Title V, Children and Youth with Special Health Needs program partners with the Health Care Homes program to assure the Health Care Home system benefits children and youth with special health care needs. 

Minnesota Department of Health

The mission of MDH is to protect, maintain and improve the health of all Minnesotans. The department has broad responsibilities in the areas of health protection, health improvement, and reforming the health care system around a public health framework. Minnesota often ranks high for overall quality of life: community-minded and caring people, beautiful parks and recreation areas, internationally known arts community, and world-renowned universities, hospitals, and businesses. Minnesota consistently is among the top 10 states for overall health, best run state, and best state to raise a family. However, these overall statistics mask the significant inequities and the persistent health disparities within Minnesota. Over the past several years, significant attention has been placed on addressing health inequity, the need for safe and stable environments for our children, and a statewide response to the opioid epidemic. 

The 2017 Statewide Health Assessment, built upon the 2014 Advancing Health Equity in Minnesota report to the Legislature, increased statewide attention to the persistent inequities for populations of color and American Indians, for the LGBTQ community, for women and children and for people with disabilities.  The statewide health improvement framework, released in early 2018, placed a renewed emphasis on the social determinants of health in order to advance health equity.  While dismantling structural racism is acknowledged as essential for shifting policies and programs that can have the greatest impact on health for all, true systems change is much harder. Current state agency leaders acknowledge that health is much more than good medical care and that optimal health for Minnesotans requires excellent schools, economic opportunities, environmental quality, secure housing, good transportation, safe neighborhoods, social justice and much more and therefore, the Children’s Cabinet embraced this as an emphasis during 2018.

Public Health Opioid Epidemic

As in the nation, Minnesota is struggling to respond to the opioid crisis.  This public health epidemic requires coordinated efforts between multiple state and local agencies. The Minnesota Department of Health has been aggressive in assuring internal coordination between all programs that have a role including the Maternal and Child Health program. These efforts resulted in a broad based legislative initiative that made its way through the 2018 legislative session, but its inclusion in the Omnibus bill led to its veto by the Governor. On the state level, state agencies continue to coordinate between various efforts. The Maternal and Child Health Section is engaged in those discussions.     

Early Childhood

Title V staff are engaged in a variety of early childhood/maternal child health building activities. Staff serve on the Expanded Help Me Grow leadership group; and are engaged in the on-going World’s Best Workforce interagency conversation working to develop shared data, narrative, and indicators around five key outcomes: Kindergarten readiness; 3rd grade reading, high school graduation; closing the opportunity gap; and college and career readiness.  During 2018, the Children’s Cabinet supported the efforts of four primary initiatives: Early Childhood Systems Reform Initiative; Two Generation Policy Network; the Early Learning Council (legislatively directed to provide the Governor on recommendations related to early childhood); and the Birth to 8 Early Childhood Workforce Initiative.  Additionally, Division Directors from the Department of Health, the Department of Human Services, and the Department of Education formed the Interagency Leadership Team to provide leadership for and assure that these Children’s Cabinet initiatives would carry forward during the transition to a new administration.  The Division Director, along with Title V staff participate fully in these initiatives bringing content expertise; coordination of data; programs and services; and a developing health and racial equity perspective.  This work has culminated in grant proposals, including the Preschool Development Grant, legislative proposals related to systems coordination and a unique identifier, and collaborative processes with sister agencies around race equity training for early childhood leadership. CFH staff serve on the Early Childhood Learning Data System (ECLDS) governing body and the Research and Evaluation group in order to advance better understanding of longer term education and economic outcomes related to MCH, CYSHN, and Family Home Visiting programs.

Minnesota Statutes 145.88 – 145.883 lays out requirements for the distribution of Minnesota’s federal Title V Maternal and Child Health Block grant award. Statutory language allows the Commissioner of Health to retain up to a third of the block grant to:

1. Meet federal requirements of a statewide needs assessment and the preparation of the annual federal block grant application and report
2. Collect and disseminate statewide data on the health status of mothers and children
3. Provide technical assistance to local public health agencies in meeting statewide outcomes,
4. Evaluate the impact of maternal and child health activities on the health status of mothers and children
5. Provide services to children under age 16 receiving benefits under Title XVI of the Social Security Act
6. Perform other maternal and child health activities as listed in federal code for the MCH block grant and as deemed necessary by the Commissioner of Health.

The remaining two-thirds of the approximately $9.1 million awarded annually to Minnesota is distributed, by formula, to Community Health Boards (CHBs) that provide local public health services across the state. In addition, it requires that CHBs provide at least a 50% match for the Title V funds they receive. Title V funds allocated to local public health agencies and must be used for programs that:

1. Address the highest risk populations, particularly low-income and minority groups with a high rate of infant mortality and children with low birth weight
2. Specifically target pregnant women whose age, medical condition, maternal history or chemical abuse substantially increases the likelihood of complications associated with pregnancy
3. Address the health needs of young children who have or are likely to have a chronic disease or disability
4. Provide family planning and preventive medical care for specifically identified target populations
5. Address child and adolescent health issues
6. Address child abuse and neglect prevention, reducing juvenile delinquency, promoting positive parenting and resiliency in children through public health home visits.

Minnesota statutes articulate maternal and child health program requirements and state supported efforts for a variety of services, including: family planning, abstinence education, fetal alcohol syndrome, maternal depression screening, education and information; breastfeeding, and safe-sleep for newborns. Statutes also pronounce requirements and state supported efforts for Minnesota programs: Women’s Right to Know; Positive Alternatives Program; Maternal Mortality Review; Family Home Visiting Program; Birth Defects Information System; the Early Hearing Detection and Intervention Program; and tests of infants for heritable and congenital disorders. During the 2018 Legislative session, the Minnesota state budget had an estimated $329 million surplus allowing the state to consider expanding services to fight the Opioid epidemic and bolster oversight of nursing homes. The session ended with very little expansion of any services, due to the lack of agreement between the Governor and the legislature, resulting in the veto of the omnibus budget bill. Of significance for MCH is a bill which passed adding birth defects resulting in a stillbirth to the Birth Defects Information System (BDIS). Near the end of the session, the Office of Legislative Auditor (OLA) released an evaluation report on Early Childhood Programs, which included Family Home Visiting and Early Childhood Health and Developmental Screening. The report provided a list of six recommendations specific to the Legislature; however, it was too late in the session for the Legislature to respond.  The report resulted in work during the legislative recess to move bills forward during the 2019 session.