Arkansas’s Title V Maternal and Child Health Services Block Grant

Overview of the State

2018 Report/2020 Application

 

 

 Arkansas ranks 47th out of 50 in overall health and 49th in health of women and children. A range of measures rank unfavorably when compared to other states. With 50 being the worst and one being the best, Arkansas ranks:

 

• 50th - adverse childhood experiences, physical inactivity in adult women, and teen births
• 49th - adult obesity in women
• 48th - adult women who smoke
• 47th - diabetes in adult women
• 44th - infant mortality and maternal mortality
• 43rd - child mortality
• 42nd - low birthweight live births
• 39th - immunizations of children

 

Arkansas ranks 40 of 50 in child well-being, which has four domains: health, education, economic well-being, and community and family. Within these domains, Arkansas ranks 45th in community and family, 37th in health, 36th in economic well-being, and 32nd in education. Although the state has seen improvement in all areas of economic well-being and family and community, two areas (young children (ages 3 and 4) not in school and teens who abuse alcohol or drugs) remain the same and three have gotten worse:

 

• eight graders not proficient in math (from 73% in 2009 to 75% in 2017)
  • compared to 67% in U.S.
• low birth-weight babies (from 8.8% in 2009 to 9.3% in 2017)
  • compared to 8.3% in U.S.
• children and teen deaths per 100,000 (from 34 in 2009 to 37 in 2017)
  • compared to 26 per 100,000 in U.S.

 

In 2017, 25.7% of Arkansas’s children under the age of 18 lived in poverty compared to 20.3% in the U.S. The situation was worse for children under the age of five: 29.5% live in poverty compared to 22.5% in the U.S. Across the U.S. and in Arkansas, approximately 20% of children ages 5-17 live in poverty. In the Coastal Plains and Delta Region of the state, 36% of children live in poverty.

 

The Arkansas Department of Health’s (ADH) 2013 report, Arkansas’s Big Health Problems and How We Plan to Solve Them provides an in-depth overview of health problems in the state. Areas of concern include life expectancy, infant mortality, health literacy, the cost of poor health, rural health, lack of equal opportunity for good health, and emerging public health issues.

 

Population

 

Arkansas’s population in 2018 was 3,013,825. Of that, 23.5% were children under age 18 and 6.4% were children under age five. Arkansas’s population is primarily a mix of white (79.3%) and African American (15.7%). Hispanics represent 7.6% of the population and 5% are classified as “other.” From 2000-2010, Arkansas experienced 82% growth in its foreign-born population and was ranked 4th in the nation for this indicator. Almost 5% of the state’s population is foreign-born.

 

Education levels in Arkansas are lower than the U.S. average for both high school and bachelor’s level degrees or higher. Approximately 85% of Arkansans ages 25 or older finished high school or an equivalency exam compared to 87% nationwide. The discrepancy is wider between those who have a bachelor’s degree: 22% of Arkansas possess a bachelor’s degree compared to 31% in the U.S.

 

Almost 40% of Arkansas’s households have incomes less than $25,000 per year and 39% receive some form of supplemental income. Per capita income is $24,426. Median household income declined from 2012 to 2016 and was 23% lower than the national median income in 2016.

 

Eighty-three percent (N=62 of 75) of Arkansas’s counties are classified as rural. Forty-one percent of Arkansans live in a rural county compared to 14% nationally. Between 2010 and 2017, population declined in each rural region of the state: a decline of 0.4% in the Highlands, 5.3% in the Coastal Plains, and 5.7% in the Delta. The decline is largely a result of out-migration.

 

Poverty and Economic Stress

 

One of Arkansas’s main social problems is generational poverty, in which at least two generations of the same family live at or below the federal poverty level (FPL). Parents living in poverty with their children may not have the opportunity to learn the skills necessary to manage their households and optimize their resources. In 2017, Arkansas had a poverty rate of 16.4%, the 8th highest in the nation. The percent of children living in poverty (100% of FPL) has been decreasing slowing since 2012; however, 24% of Arkansas’s children live in poverty compared to 19% nationwide. In addition, the percent of children living in extreme poverty (50% of FPL) has been declining since 2013; however, 10% of Arkansas’s children still live in extreme poverty, compared to 8% nationwide. These children live in census tracts with poverty rates of 30% or more and many live in a single-parent family. The effects of poverty are statistically linked to negative outcomes for children, including low birthweight, poor nutrition in infancy, increased chances of academic failure, emotional distress, and teen parenthood. Many people with disabilities also live in poverty. In Arkansas, 12.3% of the people under the age of 65 live with a disability.

 

In 2017, Arkansas had the highest teen birth rate in the nation: 32.1 per 1,000, 60% higher than the national average. Although these percentages are high, they represent a decrease from 2016 and a 50% decrease from 1991. The 18-19 year olds drove the statistics in 2017 with an estimated birth rate of 62.2 per 1,000, 75% higher than the national average. The estimated rate for 15-17 year olds in 2017 was 12.3 per 1,000 live births.

 

Poverty is the factor most strongly related to teen pregnancy. According to The National Campaign (2012), 48% of mothers ages 15-19 lived below the poverty line in 2009-2010 and 63% of teen mothers who did not live with their own family lived in poverty. In addition, 41% of mothers who had a child before the age of 20 lived in poverty within one year of the child’s birth and the chances of living in poverty rose to 50% by the time the child turned three years old.

 

Access to basics such as food, shelter, and transportation is limited for many Arkansans. There are 7,600 homes in the state without plumbing and 11,000 without kitchens. More than 47,000 homes are without phone service and 73,000 are without a method of transportation. As a result, families are limited in their ability to connect with others or access necessary goods and services.

 

Health Care and Preventive Health Services

 

In 2017, Arkansas’s health care (HC) delivery environment improved as a result of the Affordable Care Act: more than 250,000 people enrolled in HC coverage. No other state experienced a more rapid decline in its uninsured rate. The overall uninsured rate fell from 16% in 2013 to 8% in 2016. Almost 100% of children have health insurance, 79.6% of which is considered adequate for their needs. Arkansas’s Medicaid expansion is in the form of the "Private Option," which allows Medicaid to fund private insurance companies to provide insurance to those whose income does not exceed 138% of the FPL. Participation exceeded predictions. While expanding Medicaid, the 1115 Medicaid Waiver that funded family planning services for women up to 200% of the FPL was ended on December 31, 2013.

 

The state legislature changed the name of the Medicaid expansion to Arkansas Works and added a requirement for those on the program to actively seek employment. Among Arkansas Works beneficiaries, about 75% will be exempt. For the approximately 69,000 recipients to whom the requirement applies, the state’s Department of Human Services (DHS) mandates 80 hours of approved work activities each month, including school, job searches, and volunteering. As a result, several thousand participants have been removed from the rolls, due to not reporting work-related activity. There is currently a stay to stop the removal of more participants off the rolls.

 

Additionally, Medicaid is transitioning from a fee-for-service system to an organized care delivery model for the highest need behavioral health and developmental disability populations. The model, the Provider-Led Arkansas Shared Savings Entity (PASSE), was implemented in February 2017 and provides care coordination services. The program began providing comprehensive services to members in January 2019. PASSEs are responsible for integrating physical and behavioral health as well as developmental disability services for assigned members. Members are assigned a care coordinator who is responsible for creating a person-centered service plan for them. 

 

Availability of and accessibility to HC and preventive health services varies widely in Arkansas. The Central Region is urban and well-supplied with health services for women and children. However, even in this area low-income families experience barriers in access to care. All other regions of the state are medically underserved as defined by the Health Resources and Services Administration.

 

Counties in the Mississippi Delta are especially rural and poor. They have high concentrations of minority populations, especially African American. Counties along the western border are mountainous and rural. The population of immigrant Hispanic families from Central and South America is high in these counties. A group of Marshallese families lives in the far northwestern counties. These families experience outbreaks of infectious diseases including sexually transmitted infections, tuberculosis, and Hansen's disease. Counties along the southern border of the state are rural and poor, with farming and timber as the predominant sources of income.

 

The capitol city, Little Rock, is the state’s largest and most populous, with 6.67% of the state’s total population. The city is situated in the middle of the state, and is the site for the ADH, five large hospitals (including the University of Arkansas for Medical Sciences (UAMS), the state’s only medical school), the DHS, and other state agencies focused on improving the health of women and children. Cities of moderate size are located in the corners of the state. These cities provide the population base for sizable medical communities and are the locations of UAMS’s Regional Programs. 

 

In addition to the hospitals in Little Rock, there are 101 others, 29 of which are identified as Critical Access, having no more than 25 acute care beds. The state has 12 Federally Qualified Health Centers that provide services at 99 sites and there are also 76 rural health clinics. Forty-four community hospitals have fewer than 100 beds and forty counties are served by a single hospital. Nineteen counties are served by a single Critical Access Hospital. Twenty-two counties do not have a local community hospital.

 

The number of physician practices in the state is inadequate to provide necessary medical services to the population. Physician and other HC provider shortages are common. The average caseload for a primary care physician is 1,522 patients. There are only 120 pediatricians and 170 obstetricians/gynecologists in the state. Arkansas continues to rank 50th in the number of dentists (40.9 per 100,000) to population.

 

The UAMS is a centralized point of referral for all medically complicated patients and provides medical and health education for the entire state. Except for the communities of West Memphis and Helena on the eastern border that depend on the city of Memphis, Tennessee, all state communities relate to UAMS and Little Rock hospitals as major sources of highly specialized medical care. UAMS's Regional Programs provide Family Medicine residency training in communities around the state, which has improved the distribution of primary care physicians. Family physicians provide most of the state's medical care and are by far the most numerous specialty practitioners in Arkansas. Specialists in obstetrics, pediatrics, internal medicine, surgery, and others have practices in the more urban communities. While Arkansas is geographically of modest size compared to some other states, the distances from cities such as Fayetteville and Texarkana to Little Rock require 2-1/2 to four hours of travel time. For families with few resources, these distances represent significant barriers to access specialized care.

 

In March of 2018, a third satellite clinic of Arkansas Children’s Hospital (ACH) opened in Springdale. The clinic is in a rapidly growing area of the state and will allow more Children with Special Health Care Needs (CSHCN) access to pediatric specialty care. 

 

Social Determinants of Health in Arkansas

 

The rural regions have higher rates of infant mortality, obesity, food insecurity, and child poverty than urban areas. Infant mortality rates range from 7.2 deaths per 1,000 live births in urban areas to 8.2 per 1,000 in the Delta. More than 50% of adults in the state are classified as overweight or obese. Arkansas ranks in the top five states for food insecurity. The disparity in earnings per job between rural and urban areas remains great, with urban residents earning on average 19% more than rural residents. Arkansas has 14 rural counties with “persistent poverty” and “persistent child poverty”. Persistent child poverty is defined as having child (<18 years old) poverty rates of at least 20% in all of the following sources: 1980, 1990, and 2000 decennial censuses, and 2007-2011 American Community Survey 5-year average. Each of the risk factors noted here contribute to significant socio-economic inequality.
 

Mortality

 

In 2015, Arkansas ranked 48th in the nation for average life expectancy. In 2014, life expectancy was 76.1 years compared to 78.8 years nationally. Benton County (northwest) had the longest life expectancy: 79.6 years. Phillips County (eastern) had the shortest life expectancy: 71.5 years. This difference in life expectancy reflects the impact that the social factors and determinants noted above can have on the health of a population.

 

Arkansas ranks 45th in the nation for premature death, the leading causes of which are chronic diseases, accidents, influenza and pneumonia. Heart disease, cancer, chronic lung disease, stroke, diabetes, and kidney disease are the leading causes of death associated with chronic disease. The state’s high rates of chronic disease can be linked to lack of physical activity combined with very high rates of obesity, high blood pressure, and tobacco use.

 

Unintentional injury is the 4th leading cause of death in the state. Accidents are the number one killer of Arkansans between the ages of 1-44 and the ages of 1-14. Death from influenza and pneumonia is the 8th most common cause of death in Arkansas.  

 

The leading causes of neonatal death in Arkansas are birth defects, prematurity, problems with the pregnancy, difficulty breathing, and bleeding. The leading causes of post-neonatal death are unintentional injuries, SIDS, birth defects, problems with blood circulation, lung problems, infection, and homicide. The infant mortality rate for 2017 was 8.0 deaths per 1,000 live births, a slight decrease from the previous year. In Arkansas, African Americans have higher rates of infant mortality compared to whites or Latinos. The infant mortality rate for African Americans in 2017 was 12.2 compared to 6.9 for whites and 6.4 for Latinos. 

 

Agency Priorities & Partnerships

 

The overall goal of Arkansas's maternal and child health (MCH) program is to improve health and reduce disparities. Supporting that goal are five Priority Areas:

 

1)   Strengthen core services: Family planning; prenatal care; Women, Infants and Children (WIC) program; immunizations, and home visiting.

2)   Develop more effective population-based approaches: Prevent injuries; reduce infant mortality; increase physical activity; and improve oral health.

3)   Communicate public health value and societal contribution: Economic development; public awareness; and benefits of prevention.

4)   Secure adequate human and financial resources: Workforce needs and training; and funding acquisition.

5)   Increase departmental effectiveness and accountability: Strengthen leadership, management systems, IT infrastructure, data use, and accountability.

 

Cross-cutting these areas is an emphasis on community engagement, partnerships, and policy development. The overall theme is to strengthen and improve traditional public health clinical services while focusing on specific program developments, engaging more in public awareness and policy developments, and retooling administrative processes to work more effectively and efficiently. The public is engaged through ADH’s Hometown Health Initiative, a community-driven process that empowers local communities to take ownership of health problems by working to identify and implement solutions that improve the health of the citizens.

 

ADH’s health services are prioritized according to the agency’s strategic plan. The highest priority services (immunization; family planning; WIC; sexually transmitted infections testing and treatment; infectious disease outbreak management; breast and cervical cancer control; and environmental health) are provided in all counties. High-priority services that are not provided in the local health units are organized through ADH’s central office (newborn metabolic and hearing screening, school health, safe sleep CoIIN, and home visiting). Secondary priority services include basic preventive services needed in all counties that local HC systems may not have sufficient capacity to provide, especially maternity care.

 

The DHS houses programs that are important to improving MCH in the state. The DHS’s Division of Medical Services administers the Medicaid Program, which serves approximately two-thirds of children in the state at any given time. Most children are covered on the basis of income eligibility, known as ARKids First (ARKids A or B, depending on income level). Almost 30,000 women in Arkansas receive pregnancy-related Medicaid coverage annually. In 2016, Medicaid paid for 64% of all births.

 

The DHS is also home to the state’s Title V CSHCN program, which is in the Division of Developmental Disabilities Services. ADH’s Family Health Branch Chief is working to improve collaboration with this division, which includes maintaining an important partnership with the Division’s Medical Director. Services for CSHCN are closely associated with specialty services of the UAMS Department of Pediatrics. The Division also supports the state's early intervention program (Part C), also known as First Connections. Another DHS unit, the Division of Children and Family Services, conducts programs to protect children who are abused, neglected, orphaned, or otherwise in need of basic care.

 

As the only medical school in the state, UAMS’s role in Arkansas's HC system is difficult to overestimate. Development of the UAMS College of Public Health in 2001 led to stronger links between state health-engaged agencies and the university. UAMS's Regional Programs are located around the state and provide direct patient care as well as training of family medicine residents. The University's pediatrics and obstetrics/gynecology departments partner with ADH to provide direct care to women and children and to carry out ongoing public health programs and initiatives to improve systems of care.

 

The ACH also plays an important role in the HC system. It is one of the largest children's hospitals in the U.S., attracting patients from around the region and other countries. The hospital provides most of the pediatric critical care in the state. The hospital’s administration is also committed to involvement in community and state-level public health concerns such as infant mortality, injury prevention, home visiting, and school health initiatives.

 

The 83 general hospitals in the state provide the bulk of in-patient care. The ADH works closely with these local providers to assure that standards of care are met. Apart from this regulatory relationship, ADH also partners with the Arkansas Hospital Association on issues of common interest at the systems level, including the development of the breastfeeding toolkit for hospital use and the state’s Infant Mortality Collaborative Improvement and Innovation Network initiatives.

 

Professional boards of medicine, nursing, and other disciplines are other state agencies that provide support to the HC system. These disciplines, along with dentistry, pharmacy, chiropractic, and hospital administration are all represented on the Arkansas Board of Health. 

 

The Family Health Branch is collaborating with Project LAUNCH to pioneer new ways to promote young child wellness. A key objective of this partnership is to improve coordination and collaboration across disciplines at the local, state, and federal levels to address the developmental, behavioral, and mental needs of Arkansas’s children. The ADH has formalized a partnership with Project LAUNCH, which includes housing LAUNCH staff in the local health unit in Mississippi County.

 

ADH’s partnerships with ACH have strengthened over time. The Family Health Branch Chief co-leads the Natural Wonders Partnership Council’s Reproductive Health Workgroup and the ADH’s Child and Adolescent Health Medical Director serves in a co-leadership role within the Council’s Parenting Support Workgroup. The ADH also partners with ACH to implement the Arkansas Home Visiting Network. The Network is made up of 31 local implementing agencies and 100 full-time equivalent staff that provide services in 60 of the state’s 75 counties. The Network supports four evidence-based home visiting models and a promising program, Following Baby Back Home, which follows babies in NICUs back into their home community. The ADH also works with ACH to execute the Infant and Child Death Review, which has six review teams around the state to investigate deaths that are not conclusively determined.

 

Current Efforts to Improve the Health of Arkansans

 

To decrease injuries, the ADH worked with the Trauma Advisory Council’s Injury Prevention Subcommittee, the Injury Community Planning Group, and the National Governors Association State Leaders Prescription Abuse Planning Committee to create the Arkansas State Injury and Violence Prevention Plan for 2013-2018. Goals are to:

 

• Reduce motor vehicle crashes
• Prevent suicide
• Reduce unintended poisoning
• Reduce falls

 

The Immunization Program at the ADH works with local communities, schools, and other organizations to develop a state plan for flu prevention. The single goal of the Arkansas Flu Prevention Plan is to increase the number of Arkansans who receive a yearly flu vaccine.

 

The MCH Program at ADH is focused on decreasing infant deaths in Arkansas. To that end, ADH has partnered with several agencies and organizations to achieve this goal through:

 

• Improved understanding of the causes of infant death
• Prevention of unplanned pregnancies
• Prevention of low birthweight and birth defects
• Prevention of post-neonatal mortality
• Increased access to quality and appropriate care before and after birth

 

In addition, the MCH Program proposed and help draft legislation to create a Maternal Mortality Review Committee and a Maternal and Perinatal Outcomes Quality Review Committee.

 

Healthy Active Arkansas is a state-wide, Governor-supported partnership. The ADH was involved in the development of the plan along with the Arkansas Center for Health Improvement; Arkansas Coalition for Obesity Prevention; Arkansas Minority Health Commission; Baptist Health; UAMS; and the Winthrop Rockefeller Institute. The plan includes nine priority areas:

 

1. Physical and Built Environment
2. Nutritional Standards in Government, Institutions, and Private Sector
3. Nutritional Standards in Schools: Early Child Care - College
4. Physical Education and Activity in Schools: Early Child Care - College
5. Healthy Worksites
6. Access to Healthy Foods
7. Sugar-sweetened Beverage Reduction
8. Breastfeeding
9. Marketing Program

 

Current and Emerging MCH Issues

 

Violence and risky behavior affect the health and welfare of young Arkansans. A recent Youth Risk Behavior Survey revealed high school students in Arkansas have been forced to have sex, seriously considered attempting suicide, and been bullied at school more than in any other state. A recent study by Child Trends found that children in Arkansas have a higher percentage of adverse childhood experiences than peers in other states. The National Survey of Children’s Health revealed Arkansas has the highest rate in the nation of children having more than one adverse childhood experience. Child maltreatment and partner abuse are also significant problems. The issue of violence and risky behavior spills over into many other problems faced by Arkansans. At the same time, it is also the product of many of the other problematic issues that are noted in this section of the report.

 

Housing, Homelessness, and Poor Housing

 

The state also lacks policy and planning efforts that could help reduce child homelessness, including a statewide plan for child homelessness and increasing the number of housing units to help homeless families.

 

Childhood Obesity

 

Arkansas’s comprehensive body-mass index screening for school-age children (Arkansas Act 1220) has provided 11 years of data on childhood obesity. Although the obesity rate has not increased over time, it has not gone down either. During the 2015-2016 school year, 39% of Arkansas students screened as overweight or obese category and one-third of kindergarten students were already overweight or obese when they started school.

 

Suicide

 

In 2016, 546 Arkansans died by suicide, 67 of whom were 10-24 years old. The teen suicide rate is 11.0 per 100,000 (24th of 50) and the suicide rate for all ages is 48% higher than the U.S. rate. An increasing percentage of Arkansas youth (19%, up significantly from 14% in 2011) report having considered suicide in the past year. Alarmingly, 16.5% of youth made a plan for suicide and 10.8% attempted suicide at least one time. Arkansas’s female (23.3%) and Hispanic (24.3%) youth consider suicide at much higher rates than national rates.

 

Behavioral Health Care

 

Arkansas’s behavioral HC system is fragmented and services are not available in all parts of the state. Many providers do not offer front-line treatment for behavioral health issues. Additionally, preventive services and care coordination services are limited through public and private health coverage. Treatment is primarily limited to situations in which conditions have already escalated.

 

High Infant Mortality

 

Arkansas ranks 47th of 50 in the nation in infant mortality (8.2 per 1,000 live births) and low birthweight rates (9.3 per 1,000 live births). Almost 11.4% of babies born in Arkansas in 2017 were preterm and one-in-three mothers did not receive first trimester prenatal. Significant disparities exist by race for infant mortality: African American babies die at a 55% higher rate than white babies according to 2013 birth data.

 

Child Injury

 

Access to firearms affects child health. Arkansas is one of seven states with a disproportionately high rate of unintentional firearm-related death. Access to unlocked guns puts families at risk of injury and death, including suicide. Other risky behaviors related to motor and recreational vehicles, infant sleep practices, and medication misuse also put youth at risk of injuries and death.  

 

Oral Health

 

A Basic Screening Survey (BSS) of childhood oral health was performed in 2016. Results showed 64% of children had dental decay experience, which was similar to survey findings in 2010. Experience includes any teeth with untreated decay and/or existing dental restoration where decay previously existed. The incidence of untreated decay decreased from 10% from 2010 (29%) to 2016 (19%). Forty-three percent of children had dental sealants on their permanent molar teeth, which is 13% higher than the Healthy People 2020 goal. Arkansas has been recognized nationally because 86% of citizens receive fluoridated drinking water from public water systems, 6% above the Healthy People 2020 goal.

 

Food Insecurity

 

For the past three years, Arkansas had the 2nd highest food insecurity rate in the nation. In 2016, the overall food insecurity rate was 19.9% and more than 26% of households with children identified as food insecure. Surveys in the emergency department at ACH found that 23% of families with children under the age of four were food insecure. Many Arkansans live in food deserts with limited access to healthy and affordable food.

 

Access to Care

 

Poor access to services ranges from primary pediatric care to more specialized services, such as behavioral, mental, and psychiatric health services. Only 70.9% of women aged 18-44 have a dedicated HC provider and 88.7% of babies aged 0-2 years of age received a well-baby check-up in the past 12 months (45th of 50).

 

Mental Health and Substance Use

 

Behavioral and mental health problems are top areas of concern. Use of illicit and prescription drugs as well as problems with behavioral and mental health affect many children, increasing the need for more specialized care. In 2017, 42.1% of children, ages 3-17, received treatment or counseling for a mental or behavioral condition.

 

Parent Support

 

Child neglect and lack of parental involvement are associated with many health problems. Lack of parental involvement and child neglect is linked to teen pregnancy, substance abuse, and incarceration. In Arkansas, 28.4% of children aged 0-17 years have experienced two or more adverse childhood experiences, compared to 22.6% nationally.

 

Maternal Mortality

 

In 2018, there were 34.8 maternal deaths per 100,000 live births in Arkansas compared with 19.9 deaths per 100,000 nationally (44th of 50). ADH and its partners are in the process of starting a maternal death review committee. Legislation was passed in 2019 that provides the authority and confidentiality and also removes liability from the committee.