Geographic Considerations

Mississippi is a heavily forested and largely rural state located in the southeastern portion of the United States (U.S.), named for the river that flows along its western border. The state is bordered on the north by Tennessee, on the east by Alabama, on the south by Louisiana and a narrow coast on the Gulf of Mexico; and on the west, across the Mississippi River, by Louisiana and Arkansas. In terms of land area, Mississippi ranks 31st among the nation, covering nearly 47,000 square miles. Mississippi's physical features are lowland with the hilliest portion located in the northeast section of the state, where the foothills of the Appalachians cross the border. Woodall Mountain rises to 806 feet. However, the mean elevation for the entire state is only 300 feet. From east central Mississippi heading south, the land contains large concentrations of piney woods which give way to coastal plain features further towards the Gulf Coast. Southwest Mississippi tends to be quite rural with significant timber stands. The Mississippi Delta, the northwest section of the state, is technically an alluvial plain, created over thousands of years by the deposition of silt over the area during repeated flooding of the Mississippi River. The Delta is exceedingly flat and contains some of the world's richest soil. Mississippi leads the nation in catfish production and the Mississippi Delta is the birthplace of the Blues, which preceded the birth of Jazz, the only other original American art form.

The residents of Mississippi are dispersed throughout 82 counties and 298 incorporated municipalities. While three‐fourths of the state’s citizens reside in one of these incorporated places, the vast majority of these cities and towns are small. As of July 2018, Jackson, the state’s capital and largest city, has a population of 164,422, and the next largest city is Gulfport, with a population of 71,870. The state is predominantly rural, where 65 (79.3%) of the 82 counties are considered rural areas. Mississippi has three standard metropolitan statistical areas (MSA): the Jackson Metropolitan Area (Hinds, Madison, and Rankin Counties) ; the Hattiesburg area (Forrest and Lamar Counties) ; and the Gulf Coast Region (Hancock, Harrison, and Jackson Counties). Desoto County, located in North Mississippi, is included in the Memphis, Tennessee MSA. All 82 counties in Mississippi are designated whole or in part as medically underserved areas, according to the Health Resources and Services Administration (HRSA).

Population and Demographics

Mississippi is the 32nd most populous state, accounting for just less than 1% of the U.S. population. As of 2017, Mississippi has an estimated population of 2.986 million. “White, non-Hispanic” is the predominant racial/ethnic group comprising approximately 59.2% of the population; with “Black/African American, non-Hispanic” as the second largest group accounting for over 37.8% of the population; and Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander accounting for less than 2% of the population. Mississippi has the highest percentage of residents identifying as “Black/African American” in any U.S. state. The immigrant populations, including non-citizens, continues to grow, as Latinos seek work in the poultry, forestry, and construction industries in the state. Those identifying as Hispanic or Latino account for 3.2% of the population. A relatively large Latino population is found in Scott County between Jackson and Meridian. The Mississippi Gulf Coast has a Vietnamese population that has grown since the 1980s when they began to settle along the coastlines of Louisiana, Mississippi, Alabama and Florida after leaving their native country. There has been a greater increase in the number of Latino patients being seen by the health department. The influx of Latino patients produced a need for Spanish interpreters, which have been obtained to assist in helping the Latino population, especially in Harrison and Jackson counties. Some patients are not able to read their own language, and the addition of interpreter assistance has been instrumental in helping meet their needs. Because of a lack of health insurance or knowledge of the health system, Latino women often present late in their pregnancy which increases risks related to prenatal care. Once the newborn is delivered, mothers and their newborns continue to be served through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), immunizations, and Family Planning clinics.

Regarding the Maternal and Child Health (MCH) population, there are an estimated 591,744 women of reproductive age (15 to 44 years), 713,567children and youth (age 18 and younger), and 169,815 children and youth with special health care needs (0 to 17 years). According to the U.S. Census Bureau, approximately 51.5% of Mississippi residents are female, and 23.9% of residents are under 18 years old. In 2017 the fertility rate was 63.1 live births per 1,000 females aged 15‐44 years of age.

Note: Rate per 1,000 females aged 15-44

Source: MSDH, Vital Records and Public Health Statistics

Socioeconomics

Mississippi faces enormous health challenges, with long‐term social, educational, and economic problems linked to profound inequities in access to medical and dental care. Data from the U.S. Census Bureau shows that less than one‐fourth (21.3%) of all Mississippians age 25 and older have a bachelor’s degree or higher. Regarding educational attainment among different racial and ethnic groups in the state, 24.7% of White, non‐Hispanic earn a bachelor’s degree or more, 14.6% of Black/African Americans, and 12.9% of those identifying as Hispanic or Latino. Nearly 14% of those 25 or older with a bachelor’s degree and 8.6% with a graduate or professional degree in the state are women. According to the M.S. Department of Education, the 2017 high school graduation rate in Mississippi was 82.3%, compared to the national rate of 83.2%. The graduation rate for students with disabilities also increased, to 34.7% in 2017 from 33.6 % the previous school year. The drop‐out rate dipped to 10.8% in 2017 from 11.8% the previous school year.

Mississippi is among states with higher unemployment rates, as of September 2017, the state had an unemployment rate of 5.2% compared to the national rate of 4.2%. There is 21.0% of the population in the state at or below the poverty level, compared to the nation at 13%. The state’s per capita income was $21,651 (2012‐2016). The median household income for the state was $40,528. Approximately 30% of Mississippi children live in poverty compared to 19% in the U.S. When looking at children below the federal poverty level by race, Black/African American children account for 46% compared to White, non‐Hispanic children at 15%. Those who live in poverty have increased risk for poor health outcomes, as demonstrated by CDC data that reveal that Mississippi leads the nation in obesity, cancer, heart disease, and infant mortality rates. Poverty, lack of education, geographical isolation and entrenched cultural norms contribute to a lack of access to health care and health disparities.

State Health Agency’s Roles and Delivery of Title V

Working alongside other state agencies such as the Department of Human Services and the Department of Environmental Quality, the Mississippi State Department of Health (MSDH) is the lead state entity in Mississippi providing core public health functions  and essential services. As the leading public health agency in the state, the central offices are housed in Jackson, the state’s capital. The public health system includes policy guidance from the State Board of Health, the State Health Officer, and programmatic/administrative personnel distributed across seven main programmatic divisions: Health Administration, Health Services, Health Protection, Public Health Field Services, Public Health Regions, Communicable Disease, and Public Health Laboratory. In 2017, the state underwent public health transitions. The state decreased from nine public health districts to three public health regions (north, central and south) with regional offices, and county health departments (See MSDH Regional Map).

As the leading public health agency in the state, the central offices are housed in Jackson, the state’s capital. The public health system includes policy guidance from the State Board of Health, the State Health Officer, and programmatic/administrative personnel distributed across seven main programmatic divisions: Health Administration, Health Services, Health Protection, Public Health Field Services, Public Health Regions, Communicable Disease, and Public Health Laboratory.

The major operations of the MSDH include the following:

• Disease Surveillance
• Environmental Protection
• Disease and Injury Prevention
• Standards of Care
• Immunizations
• Emergency Preparedness
• Community and Emergency Health Communications
• Comprehensive Reproductive Health
• Women, Infants and Children
• Licenses and Records

• Social Services

The Health Services division of the MSDH is the lead entity that administers the Title V MCH Block Grant. Health Services oversees provision of the Women, Infants and Children's Nutrition Program (WIC); Child and Adolescent Health, including the genetic disease screening program; Women’s Health; Oral Health; the Office of Tobacco Control. The division also includes the Office of Health Data and Research, providing scientific integrity and quality assurance in management, surveillance, data analysis, reporting, and program evaluation related to MCH, chronic disease, and tobacco control. Title V aligns with the MSDH mission to provide services and programs that promote and improve the health and well-being of the Mississippi’s mothers, children, including children with special needs, and their families.

In order to protect the future of the state and give each of its residents the best possible start to life, the MSDH focuses on improving infant health as a top priority. To address this priority need, MSDH’s various offices including the Office of Health Services, are collaborating with agencies with similar goals and objectives to reduce infant mortality, promote equity in birth outcomes, and properly provide services to community members in need. The Mississippi Perinatal Quality Collaborative (MSPQC) is one of these collaborations. MSPQC leads initiatives to promote quality improvement and evidence‐based activities at the hospital and community level to improve birth outcomes across Mississippi. Furthermore, MSDH and Department of Medicaid are working to address preterm birth and infant mortality through policy changes in areas such as partial reimbursement for high risk obstetrical care to stabilize and transfer pregnant women to maternal‐fetal medicine specialists, non‐payment of charges for non‐medically indicated induction prior to 39 weeks gestation, and payment for 17P administration for high risk pregnancies.

In addition to reducing infant mortality, improving women/maternal health is another priority of the state health agency. MSDH is involved in several initiatives focused on increasing contraceptive access. These include: Office of Population Affair’s Contraceptive Access Learning Community regarding unintended pregnancies and contraceptive access; ASTHO Contraceptive Learning Community to develop and leverage partnerships and collaborative efforts to expand contraceptive access along with facilitating training in birthing hospitals and clinical settings; and the Infant Mortality COIIN addressing birth spacing and preconception and inter-conception care. MSDH and Department of Medicaid are working to address preterm birth and infant mortality through policy changes in areas such as partial reimbursement for high risk obstetrical care to stabilize and transfer pregnant women to maternal-fetal medicine specialists, non-payment of charges for non-medically indicated induction prior to 39 weeks gestation, and payment for 17P administration for high risk pregnancies. In addition, MSDH is working with Medicaid and other partners to expand access to Long-Acting-Reversible Contraception (LARC) to help women improve their health before pregnancy and space births adequately.

Health Indicators and Outcomes

The social determinants of health, such as geographical, economic, and social factors, contribute to the overall health and health equity of Mississippi’s MCH population. But, the socioeconomic disadvantages facing many Mississippi residents are consistently linked to poor health outcomes in communities, contributing to some of the nation’s highest rates of poor health outcomes across many health    indicators. However, there has been some improvement in such areas as the decreasing infant mortality and teen birth and pregnancy rates. The following provides a snapshot of key factors that relate to the MCH population, providing state-specific context for consideration of the challenges facing the state’s MCH population.

Please See Chart in Appendix for additional details related to health indicators and outcomes.

Health Insurance:

Based on the U.S. Census Bureau data, 85.5% of Mississippians under 65 years have health insurance of some kind, and 14.5% were uninsured. Among the uninsured population, 5.0% are under 19 years. Others that are uninsured include 12.5% of the White non-Hispanic population compared to 15.8% of Black/African-Americans.

State’s Strengths and Challenges

Access to comprehensive, quality health care services is important for the achievement of health equity and for increasing the quality of a healthy life for everyone. Health care access impacts overall physical, social, and mental health status; prevention of disease and disability; detection and treatment of health conditions; quality of life; preventable death; and life expectancy.

Mississippians receive health care from a variety of sources that provide a continuum of care. The health care delivery system in Mississippi includes services for long-term care, including care for the aged and those with intellectual disabilities; mental health care, including psychiatric, chemical dependency, and long-term residential treatment facilities; perinatal care; acute care, including various types of diagnostic and therapeutic services; ambulatory care, including outpatient services and freestanding ambulatory surgical centers; comprehensive medical rehabilitation; home health services; and end stage renal disease facilities. Mississippi has 32 critical access hospitals, 19 rural hospitals with 49 beds or less, 21 Federally Qualified Community Health Centers, and 160 Rural Health Clinics.

Efforts are being made to support and expand Mississippi’s MCH infrastructure and health care delivery system. Strengths include strong partnerships and collaboration with private sectors, other state agency and local departments; Increasing access to quality health care for mothers and children, especially for people with low incomes and/or limited availability of care; Health promotion efforts that seek to reduce maternal mortality, infant mortality, and teen pregnancy; and Family-centered, community-based systems of coordinated care for children with special healthcare needs.

One of the MSDH’s major strength is being nationally accredited. In 2017, MSDH became a nationally accredited public health department, joining a select group of state health departments that meet rigorous standards of policy, practice and quality improvement. National accreditation involves measuring and monitoring all of MSDH’s programs and discovering ways to be more effective in its mission. Accreditation will help MSDH provide primary and expert leadership in promoting and protecting the health of communities throughout the state, and that the agency meets or exceeds national standards of public health practices and performance.

Another strength of MSDH is establishing the Maternal Mortality Review Committee to review maternal deaths and design and implement strategies to prevent maternal deaths. This committee consists of approximately 8-10 members who commit to serve a 2-year term. The committee performs a multidisciplinary review of cases to: 1) gain a holistic understanding of the issues, 2) determine the annual number of maternal deaths related to pregnancy, 3) identify trends and risk factors among pregnancy-related deaths in Mississippi, 4) prioritize the findings and recommendations to guide the development of effective actions, 5) promote the translation of findings and recommendations into quality improvement actions at all levels. All of these activities will lead to developing actionable strategies for prevention and intervention.

The Perinatal High Risk Management/Infant Services System (PHRM/ISS) is another unique program within the MSDH which promote health care access among MCH population. PHRM/ISS provides case management services to high risk maternity patients until 60 days postpartum and high risk infants during the first year of life. This case management program provides support to families through a variety of areas, such as health education literature surrounding medical needs, wellness visits, child development, and others; referrals for social services, medical services, nutritional services, mental health services, transportation and others; knowledge of resources within the communities, such as parenting classes; and appointment assistance along with monitoring for compliance. Additionally, in order to increase the utilization of specific health service, the PHRM/ISS program is also collaborating with the Office of Oral Health to provide dental brushes, dental hygiene packages and referral and educational information to the mothers who participate in the PHRM/ISS program. Pregnant mothers participating in PHRM/ISS are given dental screenings and oral health education provided by Regional Oral Health Consultants, who also coordinate follow up care with a local dentist.

In addition to partnership with the PHRM/ISS, the Office of Oral Health collaborates with WIC to offer oral health education to   WIC participants by Regional Oral Health Consultants (ROHC’s). Through these educational sessions, mothers learn and become equipped with the tools needed to ensure their babies teeth and gums are healthy. Additionally, it allows the oral health team members to share with the parents the need to have good oral hygiene themselves, as maternal dental health is an indicator of a child’s risk for dental caries. In order to promote oral health among underserved children, the Office of Oral Health implemented “Cavity Free in MS”. This program is a collaborative effort that began in June of 2017 between the Office of Oral Health and medical providers (physicians, nurse practitioners’, and physician’s assistants) to focus on providing limited dental services to children who have little or no access to a dental provider.

In order to promote access to quality health and health care services among adolescents, MSDH joined the School-Based Health Alliance’s National Quality Initiative Collaborative Improvement and Innovation Network (NQI CoIIN) for School-Based Health Centers). As part of the NQI CoIIN, the program collaborates with a school‐based health center to make measurable improvements in health and mental health of students during the 2019-2020 school year. This effort has three areas of focus:

• Improving the quality and sustainability of health and mental health services delivered to students in schools;
• Expanding access to school-based health and mental health services to a greater number of children and adolescents; and
• Working with state leadership to increase policies and programs that promote quality, sustainability, and growth of school-based health

The CoIIN Team in Mississippi includes: University of Mississippi Medical Center and Aaron E. Henry Community Health Services Center, Inc., Mississippi Division of Medicaid, Community Health Center Association, and clinical providers at the school‐based health center.

Despite these strengths and efforts, significant challenges still exist. Mississippi is still ranked last among all states for overall health system according to the Commonwealth Fund. Mississippi ranks 50th for access and prevention and treatment, 51st for avoidable hospital use and costs, 43rd for disparity, and 50th for healthy lives. Mississippians, including our children, are routinely ranked as the fattest in the country and we lead the nation in high blood pressure, diabetes, and adult inactivity. The Delta region which is well known for its poverty and rural characteristics in the country, is at even greater risk for health problems because of lack of accessibility and availability of medical care. An estimated 60% of residents live below the poverty level here. In 2013, as part of the Behavioral Risk Factor Surveillance System (BRFSS), 21.8% of Mississippians surveyed said they were unable to see a doctor at some point in the prior twelve months because of cost.

Beside the poverty, another the major problems in Mississippi healthcare system which is one of the risk factors of poor overall health in the state is mal-distribution of providers. High quality health care services depend not only on an adequate supply of fully qualified health care professionals, but also require appropriate distribution of these providers for adequate access. The HRSA Data Warehouse current listing of Health Professional Shortage Areas (HPSAs) for Mississippi includes 109 primary care (75 of which are single county designations), 110 dental (77 of which are single county designations), and 42 mental health (29 facility and 13 catchment areas).

 As mentioned earlier, Mississippi is one of the most rural states in the nation with 79% of the counties classified as rural as defined by the federal Office of Management and Budget. Rural areas face more challenges with recruitment and retention of health care professionals. Eighty-four percent of the single county primary care HPSA designations are for these rural counties. Approximately 2,304 (41%) of the state's active medical doctors are primary care physicians, and near 60% of primary care physicians are serving the 17 counties in the state’s federal Metropolitan Statistical Areas (MSAs). According to the Mississippi State Board of Dental Examiners there are 1,049 licensed (1,022 “active” and 27 “inactive”) dentists in the state, and 65% of the state’s dentists are serving the 17 counties in the state’s federal MSAs.  Four counties (Claiborne, Franklin, Jefferson, and Quitman) have only one active dentist. Two counties (Benton and Issaquena) have no active dentists.

These challenges particularly impact the state’s most vulnerable residents, including CYSHCN’s and their families, Medicaid recipients, the working poor, undocumented immigrants, and rural residents. Mississippi has a high percentage of CYSHCN, a high percentage of CYSHCN living in poverty, and more severe health care provider shortages than most states. In addition to those challenges are Medicaid changes to MCOs, closure of the Title V Children’s Special Health Services clinic, and the decision not to expand Medicaid within the state of Mississippi. However, Mississippi still faces challenges as a result of health care reform, in particular the rising cost of health care. In the absence of any intervention, the burden of high health care costs will worsen, as health care spending per capita in Mississippi is projected to nearly double between 2010 and 2020.

Components of the state’s systems of care

The Mississippi State Department of Health's mission is to promote and protect the health of the citizens of Mississippi, and fulfills its mission through partnerships with various public and private sectors including community health centers. A primary care cooperative agreement with the MSDH Bureau of Primary Health Care has been administered by the MSDH since 1985. The cooperative agreement provides a mechanism for joint perinatal planning and provider education between the state MCH program and Community Health Centers. Perinatal providers are placed in communities of greatest need through a joint decision making process of the Mississippi Primary Health Care Association and the MSDH Primary Care Development Program. Community Health Centers also participate in MS SEALS to increase utilization of sealants among eight-year-old children. MSDH partners with Community Health Centers on the Empowering Communities for a Healthy MS Conference each May. MSDH and its partners at the community levels are committed to promote health care access, strengthen leadership for addressing health disparities, and improve cultural and linguistic competency in delivering health services, particularly in underserved area. 

Health Care Reform

With the passage of the ACA, MS has had the opportunity to make substantial changes in the availability of health insurance coverage to its citizens. MS present uninsured rate is forecast to be near 21% with some counties rates as high as 27 %. Under the ACA, in MS 50% of currently uninsured non-elderly people are eligible for financial assistance in gaining coverage (Kaiser Family Foundation, 2014). A small number of uninsured adult parents are eligible for Medicaid in MS under the eligibility pathways in place before the ACA.

The passage of the Affordable Care Act has also created pathways to coverage for Mississippi’s MCH and CYSHCN populations. But, the state did not choose to participate in Medicaid expansion, which may leave gaps in coverage among that population. According to the Robert Wood Johnson Foundation, variation and change in the uninsured rate by state could be related to whether the state expanded Medicaid. Data show that in 2014, the uninsured rate in states that expanded Medicaid eligibility (9.8%) was lower than in states that did not expand eligibility (13.5%).

In order to increase access to care, CYSHCN monitors and works closely with patients identified as not having medical health coverage. The program maintains a partnership with the states' Navigator office. Parents referred are expected to keep their appointments and to submit their letter of eligibility to the program in the processing of their application for services as verification of efforts to obtain affordable healthcare insurance.

Integration of Services

Children and youth with special health care needs (CYSHCN) are probably one the most vulnerable populations as health care delivery evolves. Timely access to comprehensive, coordinated patient/family-centered care in a medical home is critical for CYSHCN.  It may potentially minimize the prevalence of chronic physical, developmental, behavioral, and emotional conditions, maximize their independence as they transition to adulthood and more importantly, improve their quality of life. The National Survey of Children with Special Health Care Needs estimates that MS has about 169,815 CYSHCN, and nearly 27.5%  of MS CSHCN live below 200% of the Federal Poverty Level.

The CYSHCN Program provides quality care coordination services to meet clients' needs and preferences.  Regional care coordinators and care coordinators recently secured by participating healthcare systems (federally qualified health centers (FQHC), rural health clinics, and UMMC hospital clinics) work within many settings to assist families and connect them to a medical home.

To broaden our reach, CYSHCN parents and caregivers are involved at every level of decision making, from the central office to clinical and hospital based services. The CYSHCN Program increased its efforts in strengthening parent engagement since a CYSHCN Parent Consultant (PC) was hired (part‐ time) and housed within MSDH Central Office. The PC provides feedback on programmatic policies, strategic planning, educational material and designing and conducting parent surveys with other CYSHCN families.  Approximately 40% CYSHCN parents serve as members/subject matter experts on the CYSHCN Leadership Team.  Lastly, a CYSHCN PC was placed in each of the five participating CYSHCN Cares 2 healthcare systems. All PCs were trained as Community Health Workers and other parent leadership trainings will follow.

State Statutes Relevant to Title V

The Mississippi Legislature passed House Bill 494 in March 2017 authorizing the Mississippi State Department of Heath to establish the Maternal Mortality Review Committee to review maternal deaths and establish strategies to prevent maternal deaths. The Mississippi Maternal Mortality Review Panel is a multidisciplinary committee whose geographically diverse members represent various specialties, facilities and systems that interact with and impact maternal health. The panel consists of approximately 8-10 members who commit to serve a 2-year term. Maternal Mortality Review Panel will review and make decisions about each case based upon the case narrative and abstracted data. The purpose of the review is to determine the causes of maternal mortality in Mississippi and identify public health and clinical interventions to improve health systems of care. Maternal mortality includes deaths occurring during pregnancy and up to one year after pregnancy. Information is gathered from death certificates, birth certificates, medical records, autopsy reports, and other pertinent resources. Records are abstracted by a trained abstractor and de- identified case narratives are reviewed by the committee of experts from diverse disciplines.