Geography, Demographics, and Economy

Michigan is the only state made up of two peninsulas and has the longest freshwater shoreline in the world. Comprised of 83 counties, Michigan is the 10th most populous state and 11th largest state by total square mileage. Approximately 10 million people live in the state (2020 Census). Compared to other states, Michigan had the 32nd lowest rate of population change from 2021 to 2022, and estimated 36th lowest birth rate in 2022. Most of Michigan’s population resides in the southern half of the Lower Peninsula, with approximately half of the population residing in Southeast Michigan. The state’s largest cities are Detroit, Grand Rapids and Warren. Over 1.8 million people live in rural areas. The median age of the population is 40.2 years. Out of the total population, approximately 22.1% are ages 0-17 and 77.9% are ages 18 and over. Michigan’s population is 79.0% White, 14.1% Black or African American, 3.4% Asian, 2.7%, two or more races, and 0.7% American Indian and Alaska Native[1]. Out of the total population, 5.6% identify as Hispanic or Latino.

Michigan’s economy saw improvements over the nine years leading up to 2020. While the seasonally adjusted unemployment rate decreased from 14.9% in June 2009 to 4.0% in January 2019, the unemployment rate spiked to 22.7% in April 2020 at the start of the COVID-19 pandemic. The economic impact of COVID-19 was significant, but Michigan’s 2022 labor market continued to show improvement with an annual jobless rate only 0.2 percentage points above the 2019 pre-pandemic rate. Michigan’s seasonally adjusted unemployment rate was 4.3% in December 2022, compared to 5.1% in December 2021.

However, the economic recovery has been uneven across the state. According to the 2021 ALICE (Asset Limited, Income Constrained, Employed) report, 38% of households in Michigan struggled to afford the basic needs of housing, childcare, food, technology, health care and transportation. The 2020 poverty rate in rural Michigan was 12.1%, compared with 12.8% in urban areas (USDA Economic Research Service). According to the 2022 Kids Count, Michigan ranks 27th in health, 29th in both economic and family wellbeing, and 40th in education for children. The percent of children ages 0-17 who live in poverty is 16.8% and certain areas of the state experience higher levels of poverty. Statewide, 51.1% of students receive free and reduced-price lunch.

Roles and Priorities of the State Health Agency

The Title V program is located in the Division of Maternal and Infant Health (DMIH), which is housed in the Bureau of Health and Wellness (BHW) in the Public Health Administration. DMIH includes Family Planning, the Maternal Infant Health Program, the Michigan Perinatal Quality Collaborative (PQC), Early Hearing Detection and Intervention, infant safe sleep, breastfeeding, maternal and fetal morbidity and mortality reduction, Fetal Infant Mortality Review, the Doula Initiative, Safe Delivery of Newborns, and Fetal Alcohol Spectrum Disorder efforts. DMIH works in partnership with the Children’s Special Health Care Services (CSHCS) Division and the Division of Child and Adolescent Health (DCAH) to administer Title V. CSHCS includes CSHCS Customer Support, Policy and Program Development, Quality and Program Services, and the Family Center for Children and Youth with Special Health Care Needs (Family Center). DCAH oversees school-based health centers, oral health for children and pregnant women, teen pregnancy prevention, the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, and Title V funding to Michigan’s 45 local health departments. Title V works collaboratively with other programs in the Michigan Department of Health and Human Services (MDHHS) which include Medicaid; environmental health; emergency preparedness and response; communicable and chronic disease; food and cash assistance; migrant and refugee services; child protective services; and juvenile justice.

The MDHHS vision to “Deliver health and opportunity to all Michiganders, reducing intergenerational poverty and promoting health equity” is supported by 11 goals:

• Public health investment
• Racial equity
• Address food and nutrition, housing, and other social determinants of health
• Improve the behavioral health service system for children and families
• Improve maternal-infant health and reduce outcome disparities
• Reduce lead exposure for children
• Reduce child maltreatment and improve rate of permanency
• Implement the Families First Preservation Services Act state plan
• Expand and simplify safety net access
• Reduce opioid and drug-related deaths
• Manage to outcomes and invest in evidence-based solutions

Michigan’s MCH programs align with several of these goals. The 2020-2023 Mother Infant Health & Equity Improvement Plan (MIHEIP) focuses on the mother-infant dyad to achieve the vision of “Zero preventable deaths, Zero health disparities.” The MIHEIP provides a framework for expanding partnerships and strategies to enhance local and state efforts in addressing the root causes of adverse outcomes—social determinants of health and systemic racism. A Year Three Update was released in September 2022 to highlight stakeholder achievements and updated indicator data.

The current MIHEIP sunsets in 2023, with a new iteration, Advancing Birth Equity, to be released in September 2023. Much like the current plan, the contents and structure will be developed collaboratively by MDHHS and stakeholders and informed by input garnered from regional town hall meetings, the Mother Infant Health and Equity Collaborative (MIHEC), Regional Perinatal Quality Collaboratives (RPQCs), Michigan families, MCH stakeholders, health care providers, and community leaders. Implementation of the MIHEIP relies on internal alignment of programs within MDHHS; quality improvement efforts of RPQCs; and external implementation through community partners and health care providers.

Improving maternal and infant health outcomes continues to be a priority for Gov. Whitmer. In 2020, Gov. Whitmer released the Healthy Moms, Healthy Babies initiative to address health disparities and provide all women with access to high-quality health care. Expansion of Healthy Moms, Healthy Babies continues through allocations in the state budget. The FY 2021 and FY 2022 budgets allocated funds to increase access to evidence-based home visiting and continuous postpartum Medicaid coverage for 12 months postpartum. The FY 2023 budget allocated funds to support doula infrastructure and increase investment in Early On. The Governor’s FY 2024 budget recommendations include increased funding for Healthy Moms, Healthy Babies and expanded access to family planning services, the Michigan Perinatal Quality Collaborative, Centering Pregnancy, Levels of Maternal Care and the Michigan Alliance for Innovation on Maternal Health.

Additionally, a Home Visiting Advisory is charged with building an integrated home visiting system for families. Michigan’s evidence-based home visiting (EBHV) system includes the Maternal Infant Health Program, Nurse-Family Partnership, Healthy Families America, Early Head Start-Home Based, Parents as Teachers, Infant Mental Health, Play and Learning Strategies, and Family Spirit. The Advisory is intended to have an active role in system development through discussions about centralized access, professional development, and equity. Title V leadership participates in the Advisory.

Michigan is expanding EBHV to better support families who have been impacted by child welfare involvement and family separation. The first expansion is to implement EBHV in seven high-risk counties under the Families First Prevention Services Act. The Children’s Services and Public Health Administrations are partnering on this initiative. The second expansion is to support families with infants who have been exposed prenatally to substances in 10 communities with high rates of maternal substance misuse. The project is piloting Peer Navigators within the healthcare system to break down barriers of shame and stigma. Peer navigators will connect families to resources, including EBHV, and will provide support 12 weeks postpartum.

Early childhood partnerships and systems building are also critical to supporting children and their families. The Office of Great Start (OGS) within the Michigan Department of Education (MDE) leads the integration of the state’s healthy development and early learning investments for prenatal to age 8. MDHHS collaborates with OGS to support the development of early childhood systems that meet the needs of children and families. The Great Start Operations Team (GSOT) convenes state agencies and partners to provide strategic direction for early childhood integration and coordination. Several MDHHS program areas, including Title V and home visiting, serve on the GSOT. GSOT work is grounded in Michigan’s early childhood outcomes which include “children born healthy” and “children healthy, thriving, and developmentally on track from birth to third grade.”

In 2021, Michigan was awarded an Early Childhood Comprehensive Systems (ECCS) Grant which is housed in DCAH. The five-year project is intended to foster the development and integration of maternal and early childhood systems of care that are equitable, sustainable, comprehensive, and inclusive of the health system. The ECCS Advisory Committee is developing a strategic plan for infrastructure and fiscal supports to support alignment between early childhood partners, including Title V and MIHEIP staff, and to achieve integration rather than duplication.

Advancing equity is a priority within the State of Michigan and MDHHS. At the state level, Gov. Whitmer implemented several initiatives to address implicit bias, racism, and racial disparities. Executive Directive 2019-09 established Equity and Inclusion Officers within each state department. Executive Directive 2020-07 required implicit bias training for licensed health care professionals. Racism was recognized as a public health crisis in August 2020 through Executive Directive 2020-09. As part of that directive, all state employees must complete an implicit bias training. Related goals have included building Diversity, Equity, and Inclusion (DEI) infrastructure and leadership and measuring DEI efforts across state departments.

In response to COVID-19, Gov. Whitmer created the Michigan Coronavirus Task Force on Racial Disparities in April 2020. The Task Force investigated causes of COVID-19 racial disparities and recommended actions to address disparities including transparency in data reporting; reducing medical bias in testing and treatment; and developing systems to support economic recovery and access to physical/mental health care. MDHHS collaborated with the Task Force to establish 22 Neighborhood Testing Sites in 15 communities. A data-driven approach used the CDC’s Social Vulnerability Index and mortality data for six comorbid conditions associated with increased risk of adverse COVID-19 outcomes. MDHHS partnered with churches, colleges, community-based organizations, and cultural brokers to establish neighborhood testing sites. Between August 2020 and November 2022, neighborhood testing sites hosted 7,365 testing events, administering at least 364,104 COVID-19 tests (PCR, Antigen). The Taskforce released a final report in February 2023.

At the departmental level, MDHHS is working to assess and change policies and programs to support DEI. The MDHHS DEI Plan, rolled out in 2018, details the Department’s “commitment to eliminating systematic inequities and promoting diversity, equity and inclusion.” A DEI Council was created to promote and foster a culture that values DEI throughout MDHHS and the diverse communities it serves. In October 2020, the Race, Equity, Diversity, and Inclusion (REDI) Office was created to address racial, health, social and wealth disparities. MDHHS’ Equity and Inclusion Officer is the director of the REDI Office. The MDHHS Office of Equity and Minority Health (OEMH) is part of REDI and delivers an annual Health Equity Report to the state legislature. The OEMH also provides training and technical assistance to the MDHHS workforce on implicit bias, systemic racism, cultural and linguistic competency, health equity, and equitable community engagement.

Starting in 2021, all MDHHS job postings require a Valuing Diversity and Inclusion competency in the posting questions as well as DEI questions in the interview. A Countering Bias in the Interview training is required for all MDHHS interview panelists. Within annual performance plans, a DEI objective is required. “Introduction to Health Equity” and “Systemic Racism” trainings are required for all MDHHS staff. These trainings address factors that contribute to inequities; the impact of health inequities; how state or national systems may perpetuate inequitable outcomes; and how MDHHS can help to achieve health equity. In 2022, MDHHS issued a training on working with Michigan’s Tribal Governments, which is mandatory for MDHHS employees to support tribal relations, address disparities, and improve outcomes.

In response to Executive Directive 2020-09, the OEMH was selected to pilot the Equity Impact Assessment (EIA) in coordination with the Governor’s Office and completed the EIA in 2022. The EIA also responds to the Biden-Harris administration’s Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities. The EIA is intended to “inform decisions and create more equitable solutions by identifying potential unintended impacts of a policy, program or initiative on marginalized populations” (Health Equity Report). MDHHS is currently streamlining and making efficiencies based on the pilot process. An EIA Expansion phase will be rolled out between October 2023 and September 2026 with 8-15 new work areas at MDHHS and other state government agencies.

Lastly, the MDHHS Office of Policy and Planning led development of a collaborative, statewide Social Determinants of Health (SDOH) Strategy. The goal of the SDOH Strategy is to “Improve the health and social outcomes of all Michigan residents while working to achieve health equity by eliminating disparities and barriers to social and economic opportunity.” Phase 1 of the SDOH Strategy included the release of “Michigan’s Roadmap to Healthy Communities.” The initial focus areas are health equity, housing stability, and food security. Phase 2 of the SDOH Strategy launched with a virtual summit in January 2023. Phase 2 explores community health worker expansion, community information exchanges, and bridging food security and housing stability efforts. REDI-OEMH is partnering on this effort.

Equity is also being addressed within MCH programs. In addition to strategies to achieve equity discussed in state action plans, MCH activities include:

• The Medicaid doula reimbursement policy went into effect January 1, 2023. The policy allows for Medicaid recipients to receive doula care under their Medicaid health plan. A Doula Council with statewide representation, including tribal doulas, was created to inform the advancement of doula services in Michigan.
• The Infant Safe Sleep program allocates funds and provides technical assistance in an equitable, data-driven manner. Funding is allocated to five local health departments and the Inter-Tribal Council of Michigan whose geographical areas account for over 50% of sleep-related infant deaths.
• MIHP engaged the Michigan Public Health Institute (MPHI) to promote health equity and inclusion among staff to better understand the needs of diverse MIHP agencies and apply best practices. MPHI also provides DEI training for agencies.
• MIHP holds bi-weekly Health Equity Meetings so that program documents and services are created using an equity lens. At the local level, MIHP agency staff are required to take a Health Equity and Systemic Racism course so that staff are equipped to provide equity-based services tailored to family needs. Licensed social workers and registered nurses who provide MIHP case management services are required to pursue education on implicit bias and its effect on service delivery. They also assist in referring families to community supports like healthy food, transportation, and housing.
• The Early Hearing Detection and Intervention DEI plan was designed to decrease the number of children “lost to follow up” after a failed hearing screen by addressing medically underserved geographies/populations. The plan includes efforts to investigate local data sources, establish local improvement teams, explore barriers to follow up, and develop targeted outreach and education strategies.
• To improve perinatal and birth outcomes, Regional Perinatal Quality Collaboratives (RPQCs) address disparate outcomes in their quality improvement efforts and actively address health inequities and social determinants of health.
• The DMIH DEI Council was formed in September 2022. The council meets monthly to move health equity in the division forward. Short term goals include creating an internal DEI mission statement and creating an equity in hiring framework.
• DCAH participated in the MIECHV Health Equity CoIIN and supported local agencies to test and implement equitable practices. Core knowledge expectations for home visitors were updated to include equity. Technical assistance was provided for local staff regarding equitable recruitment, hiring, and pay. Focus groups were held with home visiting parents regarding SDOH.
• DCAH facilitated discussions with advisory bodies about language that promotes equity and is updating an environmental scan of the division’s DEI activities.
• The Bay Area Regional Health Inequities Initiative framework was incorporated into ECCS grant activities.
• Families were engaged to update the cultural competence and diversity training module in the Parents Partnering for Change training.
• DCAH provided DEI training to grantees and expanded use of the Rapid Adolescent Prevention Screening tool + additional SDOH questions within CAHCs to assess need and connect to local resources.
• CSHSC began a project with MPHI in FY 2022 to move equity forward and expand equity in managed care. The goal is to eliminate racial and ethnic disparities in health care and health outcomes by focusing on vulnerable populations in CSHCS. The project team is creating a valid and reliable system to quantify and monitor racial and ethnic disparities to identify gaps in care; reviewing data; and identifying performance standards to address barriers to care. Policy and contracting levers will be established to sustainably address disparities. Throughout the process, transparency and accountability will be promoted to drive improvements in disparities. The project mirrors work underway in the MDHHS Managed Care Plan Division.

Within Title V, the 2020 five-year needs assessment identified three key “pillars” that are important to all MCH populations: achieving equitable health outcomes, engaging families and communities, and delivering culturally and linguistically appropriate health education. Strategies related to these pillars are included in the state action plans.

Strengths and Challenges that Impact the MCH Population

The Title V five-year needs assessment was completed in 2020 prior to the COVID-19 pandemic. It identified strengths and challenges that impact the MCH population which are discussed in detail in the FY 2021 application. Strengths include longstanding relationships with local public health, commitment to addressing health disparities and pursuing equity, elevation of family voices to serve CSHCN, a robust home visiting network, health campaigns that leverage technology and community voice, recognition of the impact of social determinants on health, and resources and services to meet basic needs.

Challenges facing Michigan’s MCH system and families include the impact of poverty coupled with system limitations to address poverty as a driver of health disparities; gaps in capacity and access to services for basic needs like transportation, childcare, and healthcare; inconsistent distribution of culturally or linguistically relevant health information; gaps in respite care for caregivers of CSHCN; barriers to accessing behavioral health services; and racism and other drivers of health inequity.

Since March 2020, the most significant public health challenge has been the COVID-19 pandemic. In 2021 and 2022, Title V conducted assessments to gauge the pandemic’s ongoing impact on the MCH population. Findings are included in prior years’ Needs Assessment Updates. In 2023, assessment activities have focused on the public health workforce and broadband in Michigan which are discussed in the Needs Assessment Update. The NPM/SPM annual reports and state action plans also include information about the impact of the pandemic on programs and service delivery.

Comprehensive information on the state’s COVID-19 response is available on the Coronavirus website. As of March 10, 2023, Michigan reported 3,064,125 confirmed and probable cases and 42,205 confirmed and probable deaths. Cumulative data including trends, demographics, and testing information is available on the COVID-19 Data Dashboard. The pandemic disproportionately affected certain populations in Michigan. Total cases per million are 212,024 for Black/African American in comparison to 185,343 for White. Deaths per million by race are also highest for Black/African American (4,725 per million) and American Indian/Alaska Native (4,455 per million) in comparison to White (3,543 per million). However, the disparity between Black and White death rates was nearly eliminated in 2022. The death rate for Black/African American was 8.6 per 10,000 in 2022 compared to 8.7 deaths per 10,000 for White. According to the Michigan Coronavirus Racial Disparities Task Force Final Progress Report issued in February 2023, “the stark racial disparities in death rates detected during the early COVID-19 waves, and specifically targeted by the Task Force, were virtually eliminated during the omicron and subsequent smaller waves, an outcome that compares favorably with the national experience.” Death rates for American Indian/Alaska Native also decreased from 25.4 per 10,000 in 2021 to 10.0 per 10,000 in 2022.

To mitigate and contain the spread of COVID-19 and to prevent overwhelming healthcare systems, especially early in the pandemic, the State of Michigan utilized Executive Orders and MDHHS Orders (e.g., related to mask wearing and social distancing). The Protect Michigan Commission was created by executive order in December 2020 to serve in an advisory capacity to the Governor and MDHHS and to elevate the COVID-19 vaccine. The COVID-19 Vaccination Dashboard indicates that 69.5% of residents have initiated vaccination (i.e., one or more doses of any vaccine) as of March 3, 2023; 59.5% have completed vaccination. In February 2022, MDHHS adopted a new Readiness (pre-surge) – Response (surge) – Recovery (post-surge) cycle to allow the state to respond to surges in COVID-19 and adapt public health recommendations accordingly.

Efforts to address COVID-19 and to support vaccination among the MCH population include the following:

• Michigan’s public schools, teachers, and students continued to feel the burden of the pandemic in 2022. Efforts to bring resources to schools included establishing onsite COVID-19 testing and reporting; launching the School Backpack Program to send home tests for families in communities at high-risk; and embedding Health Resource Advocates and School Liaisons to support testing, contact tracing, and other mitigation strategies.
• Child and Adolescent Health Centers (CAHCs) provide school-based or school-linked comprehensive primary and preventive health and mental health services for children and adolescents ages 5-21. CAHCs help students keep vaccination status up to date by providing any needed vaccines. CAHCs directly supported influenza and COVID-19 vaccination efforts during the pandemic. In FY 2022, these sites delivered 11,645 COVID-19 vaccines to youth and are continuing to deliver COVID-19 vaccines as part of routine care.
• The DMIH hired a Nurse Consultant in 2021 within the Maternal Infant Health Program (MIHP) to focus on immunization efforts. The consultant worked with a marketing firm to develop and launch a campaign in 2022 to increase awareness of immunizations. A vaccine education toolkit is under development for MIHP agencies with resources to communicate with families about vaccines during pregnancy and vaccines for infants. A required training module for MIHP agencies is being developed to focus on vaccine communication using motivational interviewing, with anticipated completion in 2023. The consultant also held trainings to increase knowledge about immunizations and led efforts to develop web-based vaccine resources for families and MIHP agencies. In 2023, the consultant will begin site visits at MIHP agencies to consult on vaccine promotion.
• The CSHCS Vaccine Initiative addresses vaccination gaps in CYSHCN and their families. Funding is provided to LHDs to improve access to COVID-19 vaccines; expand vaccination education, messaging, and partnerships; and improve understanding of barriers to vaccination.

Components of the State’s Systems of Care

Health Services Infrastructure and Financing

Michigan’s health care infrastructure includes 176 hospitals, including 37 critical access hospitals that serve rural areas (Michigan Health & Hospital Association). The state has 78 birthing hospitals and 21 Neonatal Intensive Care Units. Michigan also has six children’s hospitals (Children’s Hospital Association). The health care system includes 39 Federally Qualified Health Centers with over 250 delivery sites (Michigan Primary Care Association); 122 school-based/school-linked health centers (MDHHS); 34 Family Planning agencies providing services at 94 clinic sites (MDHHS); and 230 rural health clinics (Michigan Center for Rural Health). According to HRSA data on Health Professional Shortage Areas (HPSAs), as of March 2023, Michigan had 285 primary care HPSAs; 248 dental health HPSAs; and 257 mental health HPSAs. These include facility, geographic area, and population group HPSAs.

The public health infrastructure to protect and promote community health is supported by MDHHS and 45 local health departments (LHDs) that serve all 83 counties and the City of Detroit. MDHHS works closely with LHDs to provide comprehensive public health services. This decentralized structure allows for local efforts to address local needs while staying connected to the state for support, funding, and other resources.

Coverage expansions under the Affordable Care Act (ACA) provided Michigan consumers with two new options: Healthy Michigan Plan (HMP) and Health Insurance Marketplace (Marketplace). Eligible individuals above 133% of the federal poverty level (FPL) could enroll in private health insurance coverage through the Marketplace. In April 2014, Michigan expanded HMP to cover residents who were at or below 133% of the FPL and who were not previously eligible for traditional Medicaid. According to the HMP website, the plan provides health care coverage to Michigan residents who:

• Are age 19-64 years.
• Have income at or below 133% of the FPL.
• Do not qualify for or are not enrolled in Medicare.
• Do not qualify for or are not enrolled in other Medicaid programs.
• Are not pregnant at the time of application.

As of January 23, 2023, 1,062,063 beneficiaries are enrolled in HMP (HMP County Enrollment Report) which is an increase from March 23, 2020 (674,853 beneficiaries). The Medicaid program has kept Medicaid eligibility cases open until the end of the COVID-19 Public Health Emergency, which is discussed in the Needs Assessment Update.

The Healthy Michigan Plan (HMP) provides beneficiary access to quality health care, encourages utilization of high-value services, and promotes adoption of healthy behaviors. HMP benefits include preventive/wellness services, chronic disease management, prenatal care, oral health, and family planning services. Most HMP beneficiaries are required to pay cost-sharing based on income. Some populations are excluded from cost sharing, such as individuals enrolled in CSHCS, under 21 years of age, pregnant people, and those with no income. A Health Risk Assessment gives beneficiaries the opportunity to earn incentives for engaging with the health care system. Enrollees who complete a health risk assessment and agree to maintain or address healthy behaviors, as attested by their primary care provider, may be eligible for cost-sharing reductions.

ACA consumer protections improved access to private insurance for CSHCN by eliminating preexisting condition exclusions and discrimination based on health status, the two most frequent enrollment barriers. The ACA also expanded access to parent employer coverage for adults 19-26 years of age. The CSHCS/Healthy Michigan Plan enrollment for November 2022 was 1,418 (MDHHS Health Services Data Warehouse, 2/1/2023). LHDs, Family Resource Centers, and designated state staff work with families and community partners to help families understand and access private and publicly funded resources to meet needs.

CSHCN often require and use more health care services than other children. Specialty care and extensive, on-going, or long-term treatments and services may be required to maintain or improve health status. Financing these costs can pose significant challenges and burdens for families even with access to private insurance. Health care costs can include deductibles, cost sharing and premium payments. Private insurance may not include any covered benefit for a specific, medically necessary service. In other cases, only a limited benefit may be available. Although ACA eliminated annual and lifetime dollar limits, other annual limits exist, and benefits may be exhausted for the current contract year even though needs continue. CSHCS helps to limit costs to families and continues to be a resource for achieving appropriate and equitable health and specialist care. Steady CSHCS enrollment following ACA’s implementation reflects the value of CSHCS to families even when private insurance is available.

Integration of Services

MDHHS and Michigan’s MCH programs recognize the importance of integrating physical and behavioral health services to improve health and address individual or family needs. In March 2022, MDHHS announced a behavioral health restructuring (described in the Cross-Cutting/Systems Building plan) to support services across community-based, residential, and school locations. MDHHS initiatives to address behavioral and mental health needs include:

• The Michigan Peer Warmline is a statewide, anonymous line for any Michigander experiencing a mental health or substance use condition. The warmline is staffed by certified peer support specialists and recovery coaches. Additionally, the Michigan Crisis and Access Line (MiCAL) is now available statewide after being piloted in the Upper Peninsula and Oakland County in 2021. MiCAL is staffed 24/7 and provides crisis and warmline services, information, and coordination with local systems of care such as Community Mental Health Services Programs.
• The Expanding, Enhancing Emotional Health (E3) model helps to address the need for mental health services for children and youth. E3 is a designated model through the Child & Adolescent Health Center (CAHC) Program. E3 programs provide on-site comprehensive mental health services from mild to moderate severity of need by a licensed Mental Health Professional. Services include assessments, brief intervention, ongoing therapy, referrals, and follow-up. E3 sites are open year-round and provide telehealth when school is not in session. Services are designed for children and adolescents 5-21 years of age when access to behavioral health resources are limited or inaccessible in a community. Currently, 104 E3 sites operate in 43 counties.
• The CAHC program budget increased by $25 million in FY 2023 and will allow MDHHS to fund approximately 75 new school-based or school-linked health centers. Each of these new sites, in addition to primary health care, will have a full-time master’s level mental health worker to provide one-on-one and small group mental health therapy for the K-12 population.
• The CAHC program is also using $4.25 million in MI Kids Now funding to expand mental health services for youth throughout the state via existing CAHCs. These funds will allow for expansion of mental health staffing from 0.5 FTE to 1 FTE per site.
• In 2021, Michigan continued to roll out expanded coverage for nursing and mental health services for general education students through a CMS approved Medicaid waiver. The Caring 4 Students (C4S) expansion allows schools that provide mental health and nursing services to general education students to receive Medicaid reimbursement. All 56 Intermediate School Districts participate in C4S.
• In August 2020, MDHHS was approved for a two-year CMS Certified Community Behavioral Health Clinic (CCBHC) Demonstration. In 2021, the demonstration was extended an additional four years. CCBHC demonstration sites provide nine core behavioral health services, including care coordination with primary care providers, and must meet standards for service provision, staffing, governance, and quality and financial reporting. Currently 13 CCBHCs participate in Michigan’s demonstration made up of 10 Community Mental Health Services Programs and three nonprofit Behavioral Health Providers. MDHHS is conducting an evaluation to identify how the model impacts behavioral health service delivery for Michiganders.
• MDHHS was awarded the Promoting Integration of Primary and Behavioral Health Care (PIPBHC) Grant in FY 2019. PIPBHC is a five-year grant to promote integration and collaboration in clinical practice between primary and behavioral health care, and to support improvement of integrated care models for primary and behavioral health care to improve the overall wellness of adults with serious mental illness or children with serious emotional disturbance. Grantees promote integrated care for screening, diagnosis, prevention, and treatment of mental and substance use disorders and co-occurring physical health conditions and chronic diseases.
• The Michigan Child Collaborative Care (MC3) increased access to mental health treatment for underserved children, adolescents, and high-risk perinatal women in all 83 counties. The expansion was significant given the shortage of specialty providers, especially in rural areas. MC3 provides psychiatry support to primary care providers who have patients with behavioral health concerns. Behavioral Health Consultants are linked with or embedded in pediatric primary care practices to assess and link children to mental health services. Patients are linked to evidence-based interventions if specialty services are not available. MC3 also provides behavioral health education for primary care providers, including cultural sensitivity. MC3 is administered collaboratively by MDHHS, the University of Michigan, and Michigan State University.
• MC3 for MOMs was launched in FY 2021 to engage Michigan’s perinatal providers and their patients in targeted areas. The initiative is intended to improve perinatal providers’ knowledge of and comfort with perinatal behavioral health screening and treatment (e.g., mood and anxiety disorders, substance/opioid use disorders). Universal psychiatric screening is important since up to 25% of perinatal women experience depression and anxiety. Behavioral Health Consultants are being trained in interventions to address behavioral health issues that impact the perinatal period.
• CSHCS continues to work with Behavioral Health partners to identify challenges accessing services experienced by populations served by the mental/behavioral health, intellectual/developmental disabilities, and physical health systems. Work includes cross-sector education, tools to assist families, and addressing systemic access issues.

Title V and Medicaid

Michigan’s Title V and Title XIX programs are both housed within MDHHS and share the common goal to improve the health and well-being of the MCH population through implementation of affordable health care delivery systems, expanded coverage, and strategies to address social determinants of health and reduce health disparities. Areas of collaboration include maternal and infant care, perinatal care, child and adolescent health, developmental screening and referral, home visitation, oral health, and CSHCS. Key partnerships are discussed in the Title V–Title XIX section of this application.

In January 2023, 2,281,448 Medicaid beneficiaries were enrolled in Medicaid Health Plans (and 1,374,016 beneficiaries were enrolled in fee for service). Medicaid uses a managed care delivery system to maximize the health status of beneficiaries, improve beneficiary experience, and lower cost. Medicaid contracts with nine Medicaid Health Plans (MHPs) to achieve these goals through evidence- and value-based care delivery models; health information technology; strategies to prevent chronic disease; and coordination of care that includes assessing social determinants of health such as transportation, housing, and food access. MDHHS requires MHPs to annually report the Healthcare Effectiveness Data and Information Set (HEDIS) and uses a Pay for Performance Incentive Program with access, process, and outcome metrics for all managed care populations, including women and children. Each MHP governing body must either have a minimum of 1/3 representation of Medicaid enrollees or the plan must establish a consumer advisory council that reports to the governing body. The council must include at least one Medicaid enrollee, one family member or legal guardian of an enrollee, and one consumer advocate. MHPs must recruit CSHCS beneficiary parents/guardians to participate in non-compensated governing bodies or consumer advisory councils.

To help achieve integrated care, MHPs are required to work with MDHHS to develop initiatives to better align services with Community Mental Health Services Programs/Prepaid Inpatient Health Plans (PIHPs) to support behavioral health. Medicaid incentivizes performance by MHPs and PIHPs on shared populations and metrics. MHPs must also provide or arrange for the provision of community health worker (CHW) or peer-support specialist services to enrollees who have behavioral health needs and complex physical co-morbidities. CHWs serve as a key resource for services and information needed for enrollees to have healthier, more stable lives. CHW services include home visits; participating in office visits; arranging for social services; and helping enrollees with self-management skills.

The DMIH and Michigan Medicaid jointly manage several programs for the Medicaid-eligible MCH population. One of the largest collaborations is the Maternal Infant Health Program (MIHP), Michigan’s largest population-based home visiting program available to all pregnant people and infants up to age one eligible for Medicaid insurance. MIHP services provided to beneficiaries enrolled in an MHP are administered by the MHPs. In FY 2022, MIHP provided services to 12,127 adults and 15,069 infants.

Another area of coordination is for CSHCN. In January 2023, CSHCS program data indicate that 31,137 CSHCS beneficiaries were dually enrolled in an MHP. MHPs are responsible for the medical care and treatment of CSHCS members while community-based services beyond medical care and treatment are provided through an LHD’s CSHCS office. MHPs are responsible for coordinating and collaborating with LHDs and Children’s Multidisciplinary Specialty Clinics to provide a range of essential health care and support services to enrollees. MHPs are also responsible for coordination and continuity of care for enrollees who require integration of medical, behavioral health and/or substance abuse services.

Information Systems

MDHHS uses CareConnect360 (CC360), a statewide web-based care management system that allows for the bi-directional exchange of health care information. CC360 allows for the identification and coordination of services to Medicaid beneficiaries by sharing information between state health plans and Prepaid Inpatient Health Plans. CC360 makes it possible to analyze healthcare program data, manage and measure programs, and improve enrollee health outcomes. CC360 will help to improve communication among MIHP agencies by sharing care elements to support successful case management, so MIHP home visitors are engaged as part of the care team. It will also allow for comparison of population health data across counties or regions.

MI Bridges is also a key component of the MDHHS service platform to meet consumer needs. MI Bridges is an online site managed by MDHHS that enables users to apply for benefits (including healthcare, food and cash assistance, childcare, and state emergency relief) and to find resources such as transportation, food, and utility assistance. MI Bridges users can review and access their benefits information; renew benefits; and share beneficiary information. In 2020, functionality was built into MI Bridges to include home visiting. In 2022, the self-referral function was updated so that families now receive a custom list of home visiting models in their community for which they are eligible. Information on each model, including program descriptions and parent testimonials, are provided to help identify a model to best fit their needs. Continuous quality improvement activities are being used to enhance family and program useability.

MDHHS also uses health information systems to support the care and services provided to the MCH population. The Michigan Care Improvement Registry (MCIR) allows for the identification of children who are not up to date on Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) well child visits according to the American Academy of Pediatrics Bright Futures Recommendations for Preventive Pediatric Health Care periodicity schedule. All MHPs have access to MCIR, and it is an approved data source for Medicaid HEDIS immunization and lead testing data. MIHP providers also have access to MCIR to facilitate referrals and access to preventive services.

State Statutes Relevant to Title V (Effective July 20, 2022)

The Michigan Public Health Code, Public Act 368 of 1978, governs public health in Michigan. The law indicates the state health department shall “continually and diligently endeavor to prevent disease, prolong life, and promote the public health through organized programs” (MCL 333.2221). Furthermore, it shall “promote an adequate and appropriate system of local health services throughout the state and shall endeavor to develop and establish arrangements and procedures for the effective coordination and integration of all public health services including effective cooperation between public and nonpublic entities to provide a unified system of statewide health care” (MCL 333.2224).

In FY 2023, state funding for MCH and CSHCS programs was appropriated through Public Act 166 Enrolled House Bill 5783, Article 6, Health and Human Services of 2022. CSHCS is mandated by the Michigan Public Health Code, Public Act 368 of 1978, in cooperation with the federal government under Title V of the Social Security Act and the annual MDHHS Appropriations Act. State general funds for MCH programs are itemized in Sec. 116, Family Health Services, of Public Act 166 of 2022, and CSHCS is addressed in Sec. 117.

Additional MCH funding requirements and legislative reporting relate to evidence-based programs to reduce infant mortality (Sec. 1308), family planning/pregnancy prevention (Sec. 1301-1305, 1309, 1314, 1320, 1347), healthy moms healthy babies (Sec. 1348), prenatal care outreach and rural home visiting (Sec. 1311), Healthy Start (Sec. 1312), fetal alcohol syndrome services (Sec. 1313), oral health initiatives (Sec. 1315-1317, 1343), Michigan Model for Health™ (Sec. 1321), drinking water declaration of emergency fund support services (Sec. 1306), healthy exercise programs for school-age children (Sec. 1342); and immunization policy, practices and statewide media campaign (Sec. 1322, 1349).

Requirements in the FY 2023 Health and Human Services budget for CSHCS included criteria in Sec. 1360 for MDHHS to provide services; Sec. 1361 authorizes that some funding be used to develop and expand telemedicine capabilities and to support chronic complex care management.

[1] American Indian race is known to be underreported in Michigan due to several reasons, including a hesitancy to identify as American Indian given a history of inequitable treatment by state and local governments.