To understand maternal and child health (MCH) population needs in Pennsylvania (PA), it is necessary to learn the geographical, social, economic, and political traits of the Keystone State and its residents. PA is a vast, increasingly diverse state comprised of large rural areas and concentrated urban centers which are both evolving economically and socially. Located in the northeast, PA is the fifth most populous state, home to over 12.8 million people. In addition to its rural and urban divide, the state is physically divided in half by a large swath of rural forest created by the Appalachian Mountains.

PA is anchored by two urban counties, Allegheny in the west and Philadelphia in the east. Urban counties are those with a population density higher than the state population density, while rural counties have a lower density. Harrisburg, the capital and headquarters for the Department of Health (DOH), is situated in the southcentral part of the state. As of March 2020, PA’s 19 large counties (counties where 75,000 or more are employed) accounted for 77% of total employment within the commonwealth. All but two of those counties are considered urban. In 2019, nearly 80% of the state gross domestic product was produced by urban counties. PA has the sixth largest economy in the nation but, as of February 2021, had a seasonally adjusted unemployment rate that was higher than the national average. In 2019, 27% of PA’s population was low income (under 200% federal poverty level or FPL), and, in 2020, more than half of PA’s Medicaid expansion population worked a job that did not offer health benefits.

The educational services, health care and social assistance, manufacturing, and retail trade sectors are major contributors to the economy. The industry with the greatest number of employees in PA in 2019 was educational services, health care, and social assistance, growing eight percent since 2010. Employment in agriculture, forestry, and fishing (which includes farming) increased from 2010-2019. Of PA ‘s 67 counties, 52 have at least 500 individuals employed in agriculture, forestry, and fishing.

The delivery of health care services is significantly impacted by the distinctive rural and urban characteristics across the state. While 48 of PA’s 67 counties are considered rural, nearly three-quarters of PA’s residents live in urban counties. The concentration has become even more pronounced since 2010, as most of the population growth in PA has occurred in urban counties. In 2018, there was one primary care provider in direct practice for every 1,075 residents in urban counties, as compared to one rural primary care physician for every 1,561 residents. Of the 16 counties without Federally Qualified Health Centers (FQHC), all but one are rural. As of 2020, of the estimated 510,983 residents living in a designated Primary Care Health Provider Shortage Area (HPSA), the majority lived in a rural county. The only non-rural areas designated as HPSA were in Allegheny, Beaver, York and Franklin counties. Small areas of several urban counties are considered medically underserved. As of 2017, approximately 17.6 percent of PA’s population lived in an area designated as medically underserved. In 2019, there were 65 general acute care hospitals, with a total of 7,753 beds, in rural PA. Seven rural counties had no hospitals. On average, there were 2.28 hospital beds for every 1,000 rural residents compared to 2.74 hospital beds for every 1,000 urban residents.

In addition to a general lack of healthcare resources, rural areas have other challenges including an aging population, a growing young minority population with higher rates of poverty and unemployment, and a lack of resources or training to meet the language and cultural needs of the growing immigrant populations. On average, rural PA residents are older than urban PA residents. In 2019, nearly 20% of the rural population was 65 years old and older compared to 17% of the urban population. From 2010 to 2040, the number of senior citizens in rural PA is projected to increase by 54%.

Across the state in 2019, the 147 general acute care hospitals (including 15 Critical Access Hospitals [CAH]) with over 33,500 licensed beds handled over 1.41 million admissions. An additional 85 federal and specialty hospitals handled over 160,000 admissions. There are nine children’s hospitals in PA, six of which are in either Philadelphia or Pittsburgh. The other three are in Danville, Erie, and Hershey. Children who live in rural areas or in areas not near these hospitals may not have ready access.

Supplementing the hospitals are over 200 FQHC or rural health centers providing primary care services in 44 counties. FQHCs are an important resource for PA’s vulnerable populations. In 2019, 87% of FQHC patients were at or below 200% FPL, 48% were on Medicaid, and 54% were members of a racial or ethnic minority.

CAH are rural hospitals that provide 24-hour emergency services with an average daily census of 25 patients or less. These hospitals serve as key providers in areas with sparse populations, geographic barriers to care, and significant health professional shortages to address populations who are generally older, sicker, and poorer. Besides anchoring a broad range of health and human services in their communities, many of these hospitals continue to be the top employers in their county and major contributors to local economies. Of concern is that in Fiscal Year (FY) 2019, five of the CAH (33%) reported negative operating margins. CAHs also operate on thinner margins in general. Four of the CAHs had positive operating margins of 2.3% or less. As of 2017, the average operating margin for CAHs in PA was 2.3%, compared with 5.2% at hospitals across the state.

Other important partners in the delivery of services within the MCH system of care are the County/Municipal Health Departments (CMHDs) and state health centers. The ten CMHDs are in urban areas and tailor services to the needs of their local communities. Primary and secondary preventive health services are emphasized and geared to improve the community’s health through direct health services, education, and leadership. CMHDs are funded by Act 315, PA’s Local Health Administration Law, with additional funding by state, federal, and local government going towards local office priorities. At a local level, CMHDs currently cover more than 41% of PA’s population. In addition, several CMHDs have either applied for or achieved public health accreditation through the Public Health Accreditation Board (PHAB). As a result, those communities have access to higher-quality programming and services.

Counties without CMHDs have state health centers who provide and support public health programs throughout PA. To organize the state health centers, PA is split into six community health districts, each covering a geographic region of the state. Each health district in turn has a district office that helps coordinate activity throughout the district. Through the utilization of community health assessments and outreach, the centers focus on five core functions: communicable disease investigation and prevention, immunizations, public health education, human immunodeficiency syndrome/sexually transmitted disease services, and tuberculosis investigation and treatment.

Health insurance is a key factor for health care access. In 2019, 5.8% of the approximately 12.6 million civilian noninstitutionalized population in PA were uninsured. By gender, 6.5% of men were uninsured compared to five percent of women. Only 5.2% of whites were uninsured compared to 6.9% of blacks and 12.5% of Hispanics. More than 10% of 26 to 34-year-olds were uninsured, the largest proportion of any age group. As educational attainment increased, the percentage insured increased.

The Affordable Care Act (ACA) has brought some insurance relief with the introduction of the federal Marketplace. While the uninsured rate ranges from 2.9 to 11.3% across counties, the uninsured are primarily working families with an income below 400% of the FPL, unemployed or employed less than full-time, less than a high-school graduate and non-white. In 2020, over 331,000 residents selected a Marketplace plan, of which 84% received financial assistance. While the uninsured rate has fallen for all racial and ethnic groups because of the ACA, as of 2019, whites are still more likely to be insured than blacks.

A key component in the MCH system of care is Medicaid, administered in PA by the Department of Human Services (DHS). Medicaid eligibility is determined by having a special condition or belonging to a particular group such as pregnant women, children, low-income adults, elderly adults, or disabled adults and meeting financial and citizenship requirements. Medicaid eligibility levels are highest in PA for children and pregnant women and both are higher than the median United States (U.S.) rate.

Medicaid also has special programs for specific medical conditions and waiver programs available for those who require assistance with activities of daily living or who meet functional requirements (such as those with AIDS, on home ventilators, or with autism). Although these waivers provide a wide array of services (such as home health aides, transportation, and case management), they are not an entitlement and there is no guaranteed entrance.

In addition to covering basic Medicaid services, states can choose to cover up to 30 optional benefits. PA covers 24, including prescription drugs, vision, dental, physical therapy, home health, and hospice care. PA’s Medicaid expansion coverage includes the ACA’s ten essential health benefits and expanded mental health and substance use treatment services. Children with special health care needs (CSHCN) are served by Special Needs Units (SNU) within Medicaid. SNU are housed within physical health Managed Care Organizations (MCO) and ensure CSHCN receive services and supports in a timely manner. SNU also assist CSHCN with access to services and information, coordinate between physical health and behavioral health and other systems, and staff a dedicated special needs hotline. Each physical health MCO has a full-time SNU coordinator. SNU staff also work in close collaboration with the SNU housed within DHS.

Individuals not eligible for Medicaid may qualify for Children’s Health Insurance Program (CHIP), also a part of DHS. CHIP provides free or low-cost health insurance to uninsured children and teens up to age 19 in families with incomes over the Medicaid limit (133% FPL). As of April 2021, there were 161,645 children enrolled in CHIP. As of January 2021, CHIP and Medicaid combined provided health and long-term care coverage to more than 3.3 million in PA. Medicaid is also a major source of funding for safety-net hospitals and nursing homes, and most Medicaid spending in PA is for the elderly and people with disabilities. In State Fiscal Year (SFY) 2019, Medicaid accounted for 61% of all federal funds received by PA and 36% of the state general fund spending.

Following a national trend, PA is becoming more racially and ethnically diverse. From 2010 to 2019, the minority population increased from 36 to 40% nationally, and from 21 to 24% in PA. Minority residents make up more of the population in urban areas (29%) than in rural areas (9 percent). From 2010 to 2019, the population identifying as Hispanic increased in PA by 39%, and the population identifying as black increased by 11.8%. From 2000 to 2019, the rural population became more racially diverse, as the non-white or Hispanic rural population increased from 5 percent of the total population, to 9 percent. As of 2017, approximately one in three PA children are children of color. With the total minority population projected to double between 1990 and 2025, the responsibility and challenge of the Title V program is to understand their diverse backgrounds and how services and Title V programming can adapt to their needs.

With an increasingly diversifying population, it is important to consider how people of color experience PA’s system of care, signified by key MCH indicators. In 2018, the infant mortality rate for whites was 4.8 per 1,000 live births. The rate for blacks was more than twice that, and for Hispanics, it was 52% higher. For blacks, the disparity has persisted since at least 1999, and for Hispanics, since 2012. Preterm births are a leading cause of infant death. In 2019, the percentage of preterm births for whites was 9.1 percent. Blacks had a percentage that was one and a half times that of whites (roughly 50% higher), and for Hispanics, the percentage was 15% higher than that of whites. The disparity for preterm births for Blacks has been roughly the same since 2003. From 2013 to 2017, the maternal mortality rate for whites was 9.1 per 100,000 births. The rate for black mothers was more than 2.5 times the rate for whites. In 2019, one percent of white mothers had no prenatal care; for black mothers, it was more than four times that, a disparity that has not changed since 2011. For Asian mothers, the percentage was approximately twice that of whites, and more than three times that of whites for Hispanic mothers. Since 2003, the rate for Hispanic mothers has been at least twice that of whites for every year except one. A lack of prenatal care has been linked to poor birth outcomes, including low birth weight and infant mortality. In 2019, the teen pregnancy rate for whites was 3.2 per 1,000 females aged 15-17. Despite teen pregnancy rates for blacks having dropped over 67 percent from 2010-2019, rates are still more than three times that of whites. Like blacks, despite a decline in teen pregnancy rates from 2010 to 2019, the teen pregnancy rate for Hispanics was more than five times that of whites. That disparity has been roughly the same since 2010. With the projected increase in populations of color, if health disparities in these populations are not addressed, they have the potential to create a greater burden over time.

Overlapping the disparities are familial, educational and economic characteristics of the population that further define their interaction with the MCH system of care. In general, PA is growing older. In 2019, about one-quarter of Pennsylvanians were under the age of 20 and one-third were 55 and older. The percentage of population aged 65 and older was greater in PA (18.7%) than the US overall (16.5%). From 2010-2019, PA’s population grew less than 1 percent, the number of young residents (under 18) decreased more than 5 percent, but the number of residents 65 and older increased more than 21%. In 2040, an estimated 25% of the total rural population will be 65 and older. At that time, there will be more senior citizens than children and youth in rural PA. Counties with large elderly populations could face the possibility of diverting resources from MCH populations towards their elderly residents.

Of the approximately 5 million households in the state in 2019, over 3.2 million of these households are defined as families, with an average size of 3.02 members. The U.S. Census Bureau categorizes families as: married-couple families, male householder (no wife present) and female householder (no husband present). While married families are most common, nearly 71% of non-married families are female-led. These households have slightly larger family sizes, are more likely to have members less than 18 years of age and are more likely to live in multi-unit structures. Over eight percent of all households in PA are single parent households with children under 18 and no spouse present. PA had a lower percentage of households with children (24%) than the national figure (26%). The population of children under age 18 is evenly distributed across age groups for each family type. Of the 2.62 million children in the state, approximately 1.7 million live in a married family. Over 221,000 children live in male-led families; and over 675,000 children live in female-led families, which are less likely to have an unmarried partner present.

The racial distribution greatly varies between types of households with children. While 81% of children in married families are identified as white, nearly 70% of children in male-led families and nearly 52% of children in female-led families identify as white. Over 59% of black adolescents and over 42% of Hispanics live in female-led families compared to only 18.4% of whites. Female-led families are more likely to have grandchildren in their households, and more likely to have a child with a disability in their household when compared to other households.

According to the 2018-19 National Survey of Children’s Health, 20.8% of children in PA have special health care needs. Children and their families may encounter multiple barriers to perform daily life functions and often need services from multiple systems of care which can be challenging for families to navigate.

Median income varies by county from $39,700 to $100,214; for families with children, it is $80,661. However, there are stark differences in median income when considering family type. The median income for married families is $108,305, $47,220 for male-led families and $30,665 for female-led families. In addition, female-led families are slightly larger in size than male-led or two-parent families, but their median income is much lower. Women’s income is also affected by the wage gap. In 2018, women in PA are earning 79 cents for every dollar a man makes, less than the national average of 82 cents. The wage gap is even greater if the woman is a minority.

In 2019, a smaller percentage of PA residents (12.4%) lived in poverty compared to the national rate (13.4%). However, there are still large swaths of the population living in poverty, as 26% of PA’s black residents and 28.1% of PA’s Hispanic residents lived in poverty and families with black or Hispanic householders were more than three times as likely to be living in poverty than whites. Of the 1.37 million families with related children under 18, 14.3% were living below the poverty level during the previous year. Female-led families were more likely than any other to be living below the poverty level. For families with children under 18, female-led families were twice as likely to be living below the poverty level. The highest rates of poverty were for those families with a householder having less than a high school education. However, at all levels of educational attainment, the percentage of female-led families living below the poverty line was higher than other families, more than double in most cases.

Adolescents (15 to 19 years) are an important sub-population within the MCH population, numbering approximately 803,000 with more than 89% enrolled in school in 2019. School enrollment among adolescents is consistent by race and ethnicity, with black adolescents having the lowest enrollment at 87.3%.

Future earnings are related to a person’s level of educational attainment. For the more than 9 million people aged 25 years and over in PA in 2019, 91% have a high school degree or higher, varying a bit by county, and more than 32% have a bachelor’s degree or higher. For this same population, for whom poverty status is determined, the rate of poverty for those with less than a high school diploma is 25.1% and decreases with educational attainment. The median annual income for those aged 25 years and older is approximately $42,225 and ranges from $26,350 for those with less than a high school diploma or equivalency to $73,800 for graduate or professional degree holders. Of the approximately 1.16 million 18 to 24-year old’s, 35.5% have graduated high school; 44.2% are enrolled in college or graduate school and 13.5% have a bachelor’s degree or higher. Females in this age group are enrolled in college or graduate school at a higher rate than males.

According to a 2016 Williams Institute analysis of Census Bureau data, there are 22,340 same-sex couples in PA (sixth nationally) compared to 646,500 in the U.S. with almost 16% of these couples in PA raising children. Most same-sex couples in PA are women (56%) and 81% are white. The mean income for same-sex couples is higher than that of different-sex couples, $52,000 versus $46,000, and over half have a college education as compared to only 33% of different-sex couples. Ninety percent of same-sex couples have health insurance. In PA, three percent of people identify as Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) with 27% raising children; the U.S. numbers are four and 29%, respectively. As with same-sex couples, most of the LGBT population is white (72%). PA ranks 38th in percentage of LGBT individuals. Over a quarter (28%) of LGBT individuals have an income less than $24,000 as compared to non-LGBT individuals (21%). More non-LGBT (90%) individuals have health insurance than LGBT individuals (86%). The percentage of non-LGBT and LGBT individuals having a college education is nearly equal. As of 2018, 4.1% of PA is LGBT, compared to 4.5% nationally, and five percent of the PA workforce is LGBTQ. As of 2019, PA has 36,711 same sex households (980,276 nationally), 52.3% of whom are married.

LGBTQ residents face ongoing health inequities in terms of their absence in statewide surveillance systems, discrimination by healthcare providers, in the workplace, and in social situations. Over half of LGBTQ individuals have reported discrimination at some point based solely on sexual orientation, which remains legal in PA. There are few laws protecting LGBTQ families regarding insurance coverage, hospital visitation rights, and powers of attorney. Members of LGBTQ groups have health needs both regular and specific to their sexual and gender orientation that often go unmet. In response to a range of discriminatory laws being passed in other states, Governor Wolf signed executive orders in April 2016 stating, “no agency under the governor’s jurisdiction shall discriminate on the basis of sexual orientation, gender expression, and identity, among other areas.” These orders pertain to commonwealth employees, and the commonwealth grants and procurement process. Over 40 municipalities have passed separate ordinances to prohibit discrimination based on sexual orientation and gender identity.

The Secretary of Health’s priorities combined with the State Health Improvement Plan (SHIP) and the DOH’s Strategic Plan guide the agency and illuminate areas for Title V to implement work to improve the health of populations in PA. The 2015-2020 SHIP was developed in partnership with a broad representation of public health system stakeholders. The SHIP priorities are: 1) obesity, physical inactivity, and nutrition; 2) primary care and preventive services; and 3) mental health and substance abuse. Through the process of defining the SHIP priorities, five cross-cutting themes were also identified: health literacy, public health systems, health equity, social determinants of health, and integration of primary care and mental health. In 2018, the DOH prioritized the protection of access to health care in rural communities using a Rural Health Model, developed in coordination with the Centers for Medicaid and Medicare Services.  As of January 2021, there were 18 hospitals participating in the model. The 2020-2021 annual SHIP work plan includes the current evidence-based strategies for each SHIP priority, the activities planned to implement the strategies, the target populations, collaborators, targets, and data sources.

The State Health Assessment (SHA), which reports on the health status of PA's population, factors that contribute to health issues, and resources that can be mobilized to address population health improvement, was recently updated. The Department released the 2020 SHA in January 2021.

The DOH 2020-23 Strategic Plan consists of the following five key strategies: 1) Maintain and enhance emergency services and public health preparedness; 2) Continually develop our talents to significantly advance public health in PA; 3) Promote public health with awareness, prevention and improvement of outcomes where the need is greatest; 4) Use data, measures, and technology to enable public health performance; and 5) Improve staff, customer, and partner experience with consistent, efficient, and effective services and work processes. These department strategies closely align with the work of Title V in PA and the Bureau of Family Health (BFH), as the Title V administrator, will continue to emphasize evidence-based and data driven decision-making within its programming while increasing the integration of quality improvement techniques throughout its work.

In March 2019, the DOH achieved national public health accreditation per notification from the Public Health Accreditation Board. Accreditation ensures that the DOH is meeting national evidence-based standards and providing PA residents with the best programs and services available. Accreditation can help the BFH improve collaborations between staff and stakeholders and further the Title V mission and programming through increased accountability, quality service delivery, and institutionalized processes, such as the use of evidence-based practices and integration of quality improvement techniques.

PA’s MCH system of care is further augmented by state statutes mandating programs serving the MCH populations and requiring the resources of Title V in both staff and funding. The Newborn Child Testing Act (35 P.S. § 621, et. seq. and amended by Act 36 of 2008 and Act 133 of 2020) establishes a program providing for the screening tests of newborn children and follow-up services related to case management, referrals, confirmatory testing, assessment and diagnosis of newborn children with abnormal, inconclusive or unacceptable screening tests results.  Act 133 of 2020 mandates submitters order testing for conditions which have been recommended for screening by the United States Department of Health and Human Services. These conditions include the disorders on the Mandatory Screening Panel and the Mandatory Follow-up Panel except for three disorders which were removed because of not being federally recommended for screening. Act 87 of 2008 mandates the Child Death Review (CDR) Program, which provides for statewide and county-based multidisciplinary CDR teams to conduct reviews of all deaths of children aged 21 and under. The Act also requires an annual report on the information, distribution and causes of child deaths in PA and reflects information collected during the CDR process from collaborative processes between the DOH and local CDR teams. The Pennsylvania Code (028 Pa. Code § 27.22 and 028 Pa. Code § 27.34) requires laboratories and providers to report blood lead test results to the DOH. Act 24 of 2018 establishes a Maternal Mortality Review Committee to conduct multidisciplinary reviews of maternal deaths and develop recommendations for the prevention of future maternal deaths.

Impacting PA residents, the health care system and the broader landscape of the MCH system of care are several important, emerging issues. The 2019 novel coronavirus (COVID-19) pandemic has presented an unprecedented challenge to the world, to the U.S., and to PA and its public health system. COVID-19 prompted the federal declaration of a nationwide emergency and, in PA, the activation of a command center at the Pennsylvania Emergency Management Agency and a disaster declaration. PA continues to monitor COVID-19 cases and fatalities across the state and is actively engaged in supporting the public health and medical systems with the response. While COVID-19 cases continue to rise daily, as of June 2021, PA has over 1.14 million positive cases, more than 26,000 Pennsylvanians have died, and over five million Pennsylvanians are fully vaccinated. Effective May 31, COVID mitigation orders were lifted. Effective June 28, the order requiring universal face coverings was lifted statewide. However, DOH continues to urge Pennsylvanians to follow CDC guidance for wearing a mask where required by law, rule, and regulations, including healthcare, local business and workplace guidance and get vaccinated if eligible. While adults aged 65 and older as well as those who are immunocompromised or with underlying conditions are at highest risk of contracting the virus, the CDC also advises pregnant persons to take extra precautions. Many Pennsylvanians have reported delays and interruptions in their and their children’s routine health care visits as a result of COVID-19. Title V-supported programs offer important safety-net services during times of crisis when the health care system may be overwhelmed by caring for emergent cases.

Like other states, the simultaneous epidemic of opioid use remains a priority of both the Governor’s administration and the DOH. In 2019, PA’s mortality rate from opioid deaths was higher than the national rate (25.1 versus 15.5 per 100,000), and more than double that of 2015 (11.2). According to the CDC, there were 4,377 drug-related overdose deaths in 2019, a 2.5 percent decrease from 2018. While there is a broad range of ages for these deaths, the typical decedent is male and between 25 and 34 years old. The distribution of overdose deaths by race in PA roughly corresponds to the state’s racial makeup, and 70 percent of all overdose deaths in PA were male. An additional impact of opioid use that affects the MCH population is that of Neonatal Abstinence Syndrome (NAS). According to data from the PA Health Care Cost Containment Council, in 2019, there were 1,610 reported newborn hospital stays with NAS, a rate of 12.9 per 1,000 newborn hospital stays. This puts an additional burden on the health care system, as the mean length of hospital stay for newborns with NAS during that time was 15.9 days, nearly five times the average stay of 3.4 days for all other newborns. NAS-related stays added an estimated $15.2 million in hospital payments in FFY 2017-2018. Another impact of NAS is premature births - 16 percent of NAS births in PA in 2018 were premature, compared to 9 percent statewide.

Attempts to combat the drug problem are multi-faceted and range from improving prescribing practices to providing better and more widely available addiction treatment services. In January 2018, Governor Wolf declared the heroin and opioid epidemic a statewide disaster emergency, a first for a public health emergency. The declaration allowed for the creation of a command center that will track progress and enhance the coordination of health and public safety agencies, helping commonwealth agencies address the opioid epidemic. In May 2021, the Governor signed a fourteenth consecutive 90-day renewal of the declaration extending the designation of the opioid epidemic as a disaster emergency.

In addition to the aforementioned emerging issues, the DOH is assessing how to leverage growing support at the state level to name racism as a public health crisis and evaluate policies and practices to identify and eradicate systemic racism. The DOH Antiracism and Health Equity Task Force, established in 2021, has been tasked by the Secretary’s office with developing a series of action steps and initiatives to further this work over the next 18 months. Title V-funded staff sit on the Antiracism and Health Equity Task Force and will look for opportunities to align the work of the Title V State Action Plan and BFH Health Equity Committee with Task Force initiatives. Additionally, PA’s Title V program will be participating in the Healthy Beginnings with Title V: Advancing Anti-Racism in Preterm Birth Prevention learning and practice cohort and intends to apply lessons learned to other Title V priority areas and share experiences with the DOH Antiracism and Health Equity Task Force. PA is also following the Black Maternal Health Momnibus Act of 2021 progress and, if passed, will seek opportunities to utilize the legislation to further antiracism and health equity work.

Finally, in May 2021, the Wolf administration released the Pennsylvania Climate Impacts Assessment 2021. In the corresponding press release, Governor Wolf stated, “On our current path, the Pennsylvania our children and grandchildren inherit will be very different from the one we grew up in and continue to enjoy today…We simply cannot afford to ignore the warning signs, and this report underscores the critical need to take action to reduce emissions and do our part to address climate change.” Pennsylvania Climate Impacts Assessment 2021 uses federal, state, and local data to show the trend of rising temperatures and increasing rainfall and project how it will continue into midcentury (2041-2070) and beyond, if greenhouse gas emissions are not reduced. The extent of impacts, from limited to catastrophic, is projected for numerous aspects of life in PA. Pennsylvanians living in communities that have been disinvested and are ripe for resource development, including maternal and child health populations, often face significant challenges that are exacerbated by climate change impacts. These challenges include living near industrial sites, living in older housing stock, often without air conditioning, and facing limited transportation options. Heat and extreme weather events caused by climate change can aggravate health conditions stemming from poor air quality and heat exposure. The Department of Environmental Protection’s Environmental Justice Office is calling on state and local leaders to work proactively and intentionally with communities and other partners to reduce the significant risks of climate change and cultivate resources, health supports, and other development in communities that disproportionately confront these critical climate issues.

PA is a state of contrasts presenting unique challenges to the delivery of services and resources across the MCH system of care. An aging but diverse population will gradually force a system adjustment to meet geographic, programmatic, and cultural needs. Swaths of poverty are inseparable from gender, education, race and ethnicity, with women led families bearing an unequal burden. Systems of care are equipped to meet urban needs but not rural needs. This, however, is not as dire as it seems. There is strength in the access to care provided by Medicaid and CHIP, the local work of the CMHD, and DOH development of strategic plans, initiatives, and programs to meet current and emerging challenges such as COVID-19, opioid addiction, racism, maternal mortality, and climate change. The PA Title V program will have to be nimble and adaptable to meet the changing landscape of MCH service needs in PA.