1. The state’s demographics, geography, economy and urbanization

 

Demographics

In 2019, Oklahoma, the 28th most populous state, accounted for 1.2% of the United States population. The state’s population of approximately 3.9 million individuals had grown by 5.5% since the decennial 2010 Census. A rural state, Oklahoma has three large cities. Oklahoma City, the state’s centrally located capital, is the largest of these and home to 16% (649,000 residents) of the state’s population. About 100 miles to the northeast is Tulsa, a city accounting for 10% (401,000 residents) of the state’s population. Nearly 90 miles southwest of the capital, sits Lawton, a city consisting of 93,000 residents, or 2.4% of Oklahoma’s population.

 

Nearly a quarter (24.5%, 956,000) of the Oklahoma population is less than 18 years of age. Individuals aged 65 years and older make up 15.7% of the population, and roughly 60% of the population is between 18 and 64 years of age. The male-female ratio is about 1:1, with slightly more females (1.99 million) than males (1.95 million). Females of childbearing age (15-44 years) number 774,000, about 20% of the total population. The number of females aged 15-19 years has increased by 1.4% since 2010, up from 128,600 to 130,400 in 2018. The number of women aged 30-34 has increased by 10% over the same timeframe, rising from 118,800 to 131,200.

 

Where residents choose to live varies by race and ethnicity. Largest in number the white population tends to be geographically diffuse, while African Americans generally reside in the Oklahoma City and Tulsa metropolitan areas. The American Indian population has a larger presence in the northeast quadrant of the state, a legacy of the U.S. government’s removal programs of the 19th century. In 2018, 72% of the population was classified as white, down marginally from 74% in the 2010 Census. American Indians and African Americans each account for about 7% of the state’s population. Approximately 2% of Oklahoma’s population is categorized as Asian or Pacific Islander. The Hispanic population has grown from 8% (302,000) of the total population in 2010 to 10% (429,000) in 2018, a growth of 42% over the time period. Oklahoma is home to the largest number of federally recognized American Indian tribal governments (38), and according to the American Indian Cultural Center and Museum, more languages are spoken in Oklahoma than in all of Europe.

 

Data from the U.S. Bureau of Economic Analysis indicate that Oklahoma’s per capita personal income was $47,951 in 2019, ranking 40th among all states, and representing about 85% of the national average of $56,663. U.S. Census Bureau data show that 15.6% (597,000 people) of Oklahoma residents were living in poverty in 2018, a decrease from 16.2% the previous year. Females (16.8%) were more likely to be living in poverty than were males (14.4%). Among children less than 18 years of age, 21.7% lived in poverty in 2018. Poverty status was more likely in minority populations when compared to the white population, with African Americans (27.6%) having the highest percentage of residents in poverty.

 

Oklahoma’s birth rate was 12.6 births per 1,000 total population in 2018, ranking 43rd among other states, and about 9% higher than the comparable U.S. birth rate (11.6). Since 2010, the birth rate has decreased by 10.6%, with the state averaging about 52,300 births per year. Similarly, the fertility rate has decreased from 71.9 births per 1,000 females aged 15-44 years to 64.5 over the same time period. Oklahoma has experienced a strong decrease in the rate of births to teens but still ranks poorly when compared nationally. In 2018, Oklahoma’s teen birth rate for ages 15-19 was 27.2 births per 1,000 population, ranking 5th for the highest (worst) teen birth rate.

 

Geography

Positioned in the South Central region of the United States, Oklahoma has a diverse geography, with a quarter of its land mass covered by forests. The state is home to four mountain regions – the Arbuckle Mountains, in south-central Oklahoma; the Ouachita Mountains, in the southeast; the Ozark Plateau, in the northeast; and the Wichita Mountains, in the southwest part of the state. Oklahoma is one of only four states with more than 10 distinct ecological regions. To the west, the state has semi-arid plains, while in the state’s center, transitional prairies and woodlands give way to the elevated terrain of the Ozark and Ouachita Mountains, which stretch out to Oklahoma’s eastern border. Oklahoma is landlocked in the center of the 48 contiguous states, bordered by Arkansas, Colorado, Kansas, Missouri, New Mexico, and Texas.

 

Economy

Oklahoma is a major producer of natural gas, oil, and agricultural products. The state’s economic base relies on aviation, energy, telecommunications, and biotechnology. The two largest metropolitan centers, Oklahoma City and Tulsa, serve as the primary economic anchors for the state. The top employers by workforce size for Oklahoma include the Department of Defense (69,000 employees, military and civilian) and Walmart Associates, Inc. (32,000). In the health sector, INTEGRIS Health has 8,800 employees, followed by the University of Oklahoma Health Sciences Center (6,700), Mercy Health (6,200), Saint Francis Hospital (6,100), and St. John Medical Center (3,900).

 

Oklahoma’s real gross domestic product (GDP), the output of all goods and services produced by the economy in current dollars, totaled $201.3 billion in 2019, according to data from the U.S. Bureau of Economic Analysis, increasing by 6% from 2015 ($190.2 billion). The private sector comprises 85% of Oklahoma’s real GDP, with government making up the remainder (15%). As a percentage of GDP, the industry share in the economy was led by the FIRE sector (i.e., finance, insurance, real estate; 14%), trade (12%), natural resources and mining (12%), manufacturing (10%), and transportation and utilities (8%). Education and health care services comprised 8% of the state’s GDP.

 

Gaming (lotteries and casinos) continue to be a major contributor to the state’s economy. The state of Oklahoma collected nearly $139 million in tribal gaming exclusivity fees in fiscal year 2018, a 3.5% increase over the previous year. Those fees were based on $2.3 billion in tribal gaming revenue. Exclusivity fees were distributed to the Education Reform Revolving Fund ($121.7 million), the General Revenue Fund ($16.6 million), and the Department of Mental Health and Substance Abuse Services ($250,000).  This distribution of fees is determined by Oklahoma statute.

 

Data from the U.S. Bureau of Labor Statistics for calendar year 2019 showed that annual average unemployment rate for Oklahoma was 3.3%, ranking the state 18th nationally and approximately 11% lower than the US unemployment rate at that time. Of the state’s 77 counties, 48 counties had an unemployment rate less than the state average, 26 counties had a rate in excess of the state average, and 3 counties had the same unemployment rate for 2018.  County unemployment rates ranged from 1.7% (Cimarron County, located in the state’s panhandle) to 6.3% (Latimer County, southeast region of state). Oklahoma’s employment-population ratio, the number of working age persons who are employed divided by the total population of working age persons, was 58.8 in 2019, compared to the national rate of 60.8.

 

Urbanization

Approximately 64% of the Oklahoma population resides in the metropolitan statistical areas (MSAs) of Oklahoma City (1,396,000; 35%) and Tulsa (994,000; 25%), while a much smaller proportion of the state’s citizens lives in the Lawton MSA (126, 000; 3%). The remainder of the Oklahoma population resides in rural cities and towns. The Oklahoma City MSA is made up of seven counties (Canadian, Cleveland, Grady, Lincoln, Logan, McClain, and Oklahoma) surrounding the principal city, Oklahoma City. Population growth in the Oklahoma City MSA has been strong, increasing by 11% between 2010 and 2018. Likewise, the Tulsa MSA is comprised of the seven counties (Creek, Okmulgee, Osage, Pawnee, Rogers, Tulsa, and Wagoner) encircling the principal city, Tulsa. Population growth in the Tulsa MSA reached at 6% between 2010 and 2018. The Lawton MSA, made up of Comanche and Cotton counties, has experienced a marginal increase in population size, up 0.5% since 2010.

 

2. The state’s unique strengths and challenges that impact the health status of its MCH population (e.g., availability and access to health care services)

 

Oklahoma’s MCH Service has developed close partnerships, both internal and external to OSDH, including other state agencies and community organizations. Since 2009, with the inception of the Preparing for a Lifetime, It’s Everyone’s Responsibility, the statewide infant mortality reduction initiative, MCH has collaborated with OSDH service areas to staff the initiative, perform analyses, formulate and implement strategies, and develop MCH-related programming. Internal partners include the Center for Chronic Disease Prevention and Health Promotion; Health Policy Planning and Partnerships; the Center for Health Statistics; Immunization Service, Injury Prevention Service; Screening and Special Services, Family Support and Prevention Services; WIC Service; SoonerStart; and the county health departments (CHD). These service areas and CHDs have participated in other state and national efforts as well, including the CoIIN to Reduce Infant Mortality, the Oklahoma Perinatal Quality Improvement Collaborative, the Oklahoma Health Improvement Plan Child Health Group, the Period of Purple Crying Program, the MCH Safe Sleep Project, as well as other activities not mentioned here.

 

Joining the internal partners mentioned above were entities external to OSDH, but who contribute in large and meaningful ways. Sister agencies like the Oklahoma Health Care Authority (OHCA), the state’s Medicaid agency, the Oklahoma Department of Human Services (OKDHS), the Oklahoma Commission on Children and Youth, and  the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) are frequent and routine collaborators on the many efforts to improve and promote health in the maternal, infant, and child populations. Other colleagues in MCH-related work include those from the Oklahoma Hospital Association, the Office of Perinatal Quality Improvement (OPQI), Tulsa Health Department, the Oklahoma City-County Health Department, the Oklahoma Family Network, and the Southern Plains Tribal Health Board (SPTHB). These relationships continued to be drawn on, as well as new ones were developed to inform the 2021-2025 Title V MCH Five-Year Needs Assessment. The many partnerships and collaborations developed and maintained by Oklahoma Title V programs were essential for achieving MCH goals.

 

Oklahoma has experienced a number of successes related to health outcomes and behaviors. The Every Week Counts, a partnership among MCH, OPQI, and state birthing facilities active between 2011 and 2014, brought about a 96% reduction in the number of early elective deliveries. In January 2017, the March of Dimes recognized MCH’s achievement of lowering the preterm birth rate by 8% since 2010 by awarding the state with the Virginia Apgar Prematurity Campaign Leadership Award. However, for the last three reporting years (2016 through 2018) for which Oklahoma birth data are final, the state has observed an increase in preterm birth rate, rising from a low of 10.3% in 2015 to 11.4% in 2018. Despite still having the 5th highest birth rate among teens aged 15-19, Oklahoma has experienced significant declines in the last two decades. In 2018, the teen birth rate for this population group was 27.2 births per 1,000 female population. While this rate was still much higher than the comparable national rate (17.4), it was a remarkable improvement since the year 2000, when the state rate was recorded at 59.1 (decrease of greater than 50%). Another improvement includes the uptake in the use of long acting reversible contraceptives (LARCs), the result of program emphasis on providing LARCs when indicated for women not seeking to become pregnant. With the efforts of the Preparing for a Lifetime initiative, along with other state activities, Oklahoma’s infant mortality rate has decreased from 8.6 per 1,000 live births in 2007 to 7.1 in 2018, a relative decrease of 17.4% over the study period. Still, IMR varies sharply among race/ethnic groups in Oklahoma with African American infants dying at more than twice the rate of white infants. Moreover, the trend among other minority groups (American Indian, Asian/Pacific Islander, and Hispanic) shows rising rates of infant mortality.

 

3. The defined roles, responsibilities and targeted interests of the state health agency and how they influence the delivery of Title V services

 

With governor, Kevin Stitt, assuming office in January 2019, state health and human services were re-organized under the Cabinet Secretary of Health and Mental Health and the Cabinet Secretary of Human Services and Early Childhood Initiatives. Respectively, these positions are held by Kevin Corbett and Justin Brown. Health and Human Services agencies in Oklahoma include the OSDH, Oklahoma Department of Human Services (DHS), ODMHSAS, Department of Rehabilitation Services, Office of Juvenile Affairs, OHCA, and the Oklahoma Commission on Children and Youth (OCCY).

 

The Oklahoma State Department of Health, created under Oklahoma Statute Title 63 § 1-105, is responsible for protecting and improving the public’s health status through strategies that focus on preventing disease. There are two major health service branches making up OSDH: Community Health Services (CHS) and Regulation, Prevention, and Preparedness. This latest configuration of services remains in effect as of June 2020. Directly under CHS is the Family Health Services Division. It is home to the MCH Service, Dental Health Service, Family Support and Prevention Service, Screening and Special Services, Sooner Start, and WIC. Community Health Services is comprised of Oklahoma’s county health departments, Community Evaluation and Records Support, the Nursing Service, and Community Development.

 

Oklahoma administers the MCH Title V Block Grant through two state agencies, the OSDH and the DHS. OSDH, as the state health agency, is authorized to receive and disburse the MCH Title V Block Grant funds as provided in Title 63 of the Oklahoma Statutes, Public Health Code, Sections 1-105 through 1-108. These sections created the OSDH, and originally charged the Commissioner of Health to serve under the Board of Health, and outlined the Commissioner of Health's duties as "general supervision of the health of citizens of the state." In 2018, new legislation was enacted making the Board of Health an advisory body to the Commissioner of Health, who is now appointed by the state’s governor. Title 10 of the Oklahoma Statutes, Section 175.1 et.seq., grants the authority to administer the CSHCN Program to the DHS.

 

The MCH Title V Program is located in the OSDH within Family Health Services (FHS). The FHS is organizationally placed under the Community Health Services. Joyce Marshall, Director of the MCH Service, is directly responsible to the Assistant Deputy Commissioner of the FHS, Tina Johnson, who is directly responsible to the Deputy Commissioner of Community Health Services, Keith Reed. Mr. Reed reports directly to the Interim Commissioner of Health, Lance Frye, MD. Tamela Hamilton, MD, is the Chief Medical Officer for the OSDH.

 

Programs administered in some part with Title V funds include: Preparing for a Lifetime, It’s Everyone’s Responsibility infant mortality reduction initiative; Maternal Mortality Review; Pregnancy Risk Assessment Monitoring System (PRAMS), The Oklahoma Toddler Survey (TOTS), and the Youth Risk Behavior Survey (YRBS) surveillance programs; adolescent pregnancy projects throughout the state; State Systems Development Initiative (SSDI); Fetal and Infant Mortality Review; School Health; Oklahoma Birth Defects Registry; Becoming Baby Friendly Oklahoma; and, other-related programs and initiatives.

 

The Title V CSHCN Program is located in the OKDHS within the Health Related and Medical Services (HRMS) unit. HRMS is organizationally placed under the Adult and Family Services Division. Carla McCarrell-Williams, the CSHCN Director, is directly responsible to Deputy of Programs Linda Cavitt, AFS Director Patrick Klein, and Director of Adult Services, Kristi Blackburn. Title V CSHCN provides funding for respite, equipment, and formula not covered by Title XIX. Likewise, funding and supports are provided to several groups at the University of Oklahoma Health Sciences Center and OU Children’s Medical Center to enhance services for CSHCN families. These groups include Oklahoma Family Network (family-to-family support), Family Support 360 Center (family health system navigation) and Family Partners (developmental and behavioral screening services), Sooner SUCCESS (comprehensive system of health and educational services), the Sickle Cell Clinic (healthcare transition services) and the Oklahoma Infant Transition Program (family support for NICU newborns).   Title V CSHCN also collaborates with Child Welfare Services at DHS to provide funding for psychological evaluation assessments not covered by Medicaid.

 

4. Components of the state’s systems of care for meeting the needs of underserved and vulnerable populations, including CSHCN. This discussion may include, but is not limited to, the following descriptors:

 

1. Population served;

Overall, in FFY 2018, 2,853 Oklahoma children with special health care needs received direct services from a Title V partner in FFY2018. Per the National Survey of Children’s Health, there were an estimated 217,565 children in Oklahoma with a special health care need in 2016-2018.

 

Note: The number of children served is a conservative estimate intended to reduce the risk of duplication. Additionally, Title V representatives continue to encourage collaboration across partners and to reach out to families in under-served populations by speaking at family support groups and attending local health conferences that address children with special health care needs.

 

2. Health services infrastructure (e.g., number of children’s hospitals, pediatric specialists, accountable care organizational structure, etc.);

The state now has three Children's Hospitals – the Children’s Hospital at Saint Francis in Tulsa, Oklahoma, the Children’s Hospital at OU Medical Center in Oklahoma City, and the INTEGRIS Children’s Hospital at Baptist Medical Center, also in Oklahoma City. The Children’s Hospital at Saint Francis provides comprehensive medical care through inpatient and outpatient services and a network of more than 100 pediatricians and 65 pediatric subspecialists covering eastern Oklahoma. The Children’s Hospital at OU Medical Center has 314 inpatient beds and is the only freestanding pediatric hospital in Oklahoma solely dedicated to the treatment of children. Its NICU contains 93 beds providing the highest level of neonatal care in the state. INTEGRIS Children’s includes a 40-bed level III NICU, a 26-bed pediatrics unit, and a 10-bed pediatric intensive care unit.

 

According to the Oklahoma Board of Medical Licensure and Supervision, there were 644 active pediatricians in the state in May 2019.

 

OHCA administers two health programs for the state. The first is SoonerCare, Oklahoma's Medicaid program. SoonerCare works to improve the health of qualified Oklahomans by ensuring that medically necessary benefits and services are available. Qualifying Oklahomans include certain low-income children, seniors, the disabled, those being treated for breast or cervical cancer and those seeking family planning services. The second program OHCA operates is Insure Oklahoma, which assists qualifying adults and small business employees in obtaining health care coverage. Under certain circumstances, Insure Oklahoma extends coverage to dependents within the household, which may include children with special health care needs.

 

3. Integration of services, such as physical, social and behavioral services;

Oklahoma has 77 counties with 68 county health departments where families of children and youth with special health care needs can access reproductive health care, vaccines, and, in some cases, mental health and dental services. This allows families affordable access to care, some services at no charge while others have sliding scale fees. Additionally, each county in Oklahoma has at least one health home which integrates medical, behavioral and social supports needed, coordinated in a way that recognizes all of their needs as an individual, not just patients. To be eligible for a Health Home, children and youth must have Medicaid, have either a serious mental illness or a serious emotional disturbance, and one or more chronic health conditions. A Care Manager from the Health Home organization assists patients with coordination and access to necessary medical, mental health, and social services.

 

Children and youth with special health care needs may also receive services while they are in school. There are 250 nurses across the state in schools providing a limited scope of services. Many school districts contract with mental health providers to provide services during and after the school day. All of these services add to the services available in the child's community.

 

4. Financing of services (e.g., managed care arrangements and Medicaid eligibility).

Medicaid is managed by the Oklahoma Health Care Authority, Oklahoma's Medicaid agency. CHIP funding is blended with other Medicaid dollars to ensure better access for more children. Some examples include funding long-acting reversible contraceptives for adolescents and providing cribs to Medicaid-eligible families. At the close of FFY2018, Oklahoma had 643 children 18 years and under accessing SoonerCare via TEFRA. Additionally, 17,826 children received SoonerCare based on their Aged/Blind/Disability (ABD) status. Both groups, TEFRA and ABD, have high medical needs and/or significant disabilities and are better able to access needed medical/mental health services because of their access to SoonerCare. The Oklahoma Health Care Authority also manages Insure Oklahoma, which is a premium assistance program for families of low income status. In addition, several community, state and national programs provide access to grants and other funds to assist youth in receiving needed durable medical equipment, respite, co-pay assistance, etc. These vital funds fill gaps where families cannot afford to meet their child's needs.

 

5. Specific state statutes and other regulations that have relevance to the MCH Block Grant authority and impact the state’s MCH and CSHCN programs.

 

MCH serves as a resource and provides education to state legislators and their staff prior to and during the legislative session each year to assist in the setting of state policy and procedure. Analyses of bills are accomplished each year during session to identify issues that may present obstacles to improving the health of Oklahoma's maternal and child health population. These written analyses are shared with legislators and their legislative staff by the Commissioner of Health and the OSDH Legislative Liaison. MCH also participates in state boards, task forces, work groups, and committees during and between sessions per request of members of the state Legislature or as appointed by the governor. MCH is able to provide to the legislative process the latest in national health care policy and practice; information on national, regional, and state health care issues and practices; and the most recent available national, regional, and state data for the maternal and child health population.

 

The following is a list of some of the legislative bills that were monitored by OSDH and MCH during the 2020 legislative session. SB indicates a Senate bill, HB, a House bill.

 

Community Health Services

SB 1823 created Shepherd’s law, which provides for oversight and licensing of midwifery for the Oklahoma State Department of Health. It also requires midwives to disclose certain information to prospective clients at the beginning of a professional relationship. Governor Stitt signed into law on May 18, 2020 and the law will become effective on November 1, 2020.

 

Data/Policy

SB 1423 adjusts the age required to purchase tobacco products from 18 years of age or older to 21 years of age or older, and updates any relevant labeling and selling requirements. Governor Stitt signed into law on May 19, 2020 and the law taking immediate effect.

 

Operations

SB 285 requires employers to provide reasonable paid break time to an employee who needs to breastfeed or express breast milk for her child to maintain milk supply and comfort in a designated lactation room. Governor Stitt signed into law on May 19, 2020 and the law will become effective on November 1, 2020.

 

SB 1349 replaces the State Board of Health with the State Commissioner of Health with regards to receiving recommendations from Health Advisory Councils. SB 1349 updates statutory language within the Oklahoma Public Health Advisory Council Modernization Act to reflect recent legislative changes. The State Board of Health is changed to the State Commissioner of Health as the oversight authority. Governor Stitt signed into law on May 20, 2020 and the law will become effective on November 1, 2020.

 

SB 1877 requires appropriate authority of covered public buildings to ensure the availability of a lactation room and provide certain break time. SB 1877 requires a building owned or leased by the state, and where state employees work, to contain a lactation room for state employee use. Governor Stitt signed into law on May 19, 2020 and the law will become effective on November 1, 2020.

 

SB 1058 sets budget limits for the Oklahoma State Department of Health. This bill directs funding authorized under SB 1922 to cover an increase in sickle cell outreach ($50,000), operations for the Oklahoma Athletic Commission ($100,000), the implementation of Choosing Childbirth Act ($2 million), operations of the Dental Loan Repayment Program ($463,670), and to increase access to primary care in medically underserved areas and populations through health centers. Further, the bill allows for appropriations to be budgeted for FY 2021 or FY 2022. Governor Stitt signed into law on May 20, 2020 and the law will become effective on July 1, 2020.

 

On June 30, 2020, Oklahoma became the latest state to expand Medicaid coverage to adults between the ages of 18 and 65 whose income is 133% of the federal poverty level or below, via a statewide vote on State Question 802. OHCA now has 90 days to submit all documents necessary to obtain federal approval for implementing Medicaid expansion by July 1, 2021.