Principle Characteristics of Minnesota

Demographics

Known as the Land of 10,000 Lakes, Minnesota is a medium-sized state, covering slightly over 84,000 square miles. In 2019, 5,680,337 people lived in the state, with more than half (55%) of its residents living in the 7-county Minneapolis-St. Paul metropolitan area.

Figure 1. Map of Minnesota State Community Health Services Advisory Committee Regions

For most of the twentieth century, Minnesota had a relatively homogeneous population. While non-Hispanic Whites made up 97.8% of the state’s population in 1960, they made up 80% in 2019. Between 2010 and 2019, the state has added over five times as many people of color (Asian/Pacific Islander, Black, multiracial, and/or Hispanic) and American Indians than non-Hispanic White residents.[1] Black people, Indigenous people, and people of color (BIPOC) are distributed unevenly across the state, being more likely to live in urban than rural areas. Between 2010 and 2019, the fastest growing racial group in Minnesota was the Black population, which grew by 35.6%, adding around 99,500 people. Second fastest was the Asian population, which grew by 32.6%, adding over 70,000 people, followed by multiracial, which grew by 28%, adding 28,000 people. While less diverse than the United States as a whole, in 2019, 30% of Minnesota births were to BIPOC pregnant people. Furthermore, 32% of children under age 5, and 31.4% of children under 20, belong to the BIPOC community.[2]

Minnesota is home to eleven federally recognized Tribal Nations. The Minnesota Chippewa Tribe is the centralized governmental authority for six of these and its governmental powers are divided between the tribe and the individual bands. Each band directly operates their reservations. The Minnesota Chippewa Tribe is comprised of Bois Forte, Fond du Lac, Grand Portage, Leech Lake, Mille Lacs, and White Earth. Red Lake is the other Chippewa Band and one of only two entirely closed reservations in the U.S. The Chippewa self-identify as Anishinaabe and are also known as Ojibwe. The other four American Indian tribes are Dakota (Sioux), with four Communities: Lower Sioux, Prairie Island, Shakopee-Mdewakanton, and Upper Sioux. Approximately 167,400 people in Minnesota identify as American Indian and/or Alaska Native, representing 2.9% of the state’s population.[3] About 23% of American Indians in Minnesota live on a reservation, 27% in a county adjacent to a reservation, 22% in Hennepin and Ramsey counties, and 28% in other counties. [4],[5] Many in the American Indian community move from the reservation to urban communities and back again.

Figure 2. Minnesota Tribal Nations Map

Fifty-three percent of Minnesota’s foreign-born population are naturalized United States citizens.[6] In 2019, Minnesota’s largest foreign-born groups were born in Mexico, Somalia, India, Laos (including Hmong), Ethiopia, Vietnam, China, and Thailand (including Hmong).[7] Minnesota is home to more refugees per capita than any other state, and the state has the largest Somali and urban Hmong populations in the nation. Over half of Minnesota’s Asian population identifies as Southeast Asian (compared to 20.7% nationally). More than 80 languages are spoken in the Twin Cities, and 11.7% of Minnesotans ages 5+ speak a language other than English at home.[8] Many immigrants, who came to the state in their teens or early 20s, are now having children, and influencing the racial and ethnic make-up of the state.

Although birth rates are at historic lows, Minnesota had a population growth rate of 7.1% between 2010 and 2019, adding 376,412 residents (net). Most of Minnesota’s growth has been in the seven-county Twin Cities metropolitan area. The fastest growing counties by population between 2010 and 2019 (net growth) were Carver (17.7% increase), Scott (14.3%), Olmsted (11.2%), Wright (11.1%), and Hennepin (11.1%). The counties that added the most residents between 2010 and 2019 on net were Hennepin (+127,556), Ramsey (+49,608), Dakota (+34,750), Anoka (+31,804), Washington (+24,612), and Scott (+18,530). Forty-three counties have lost population since 2010.[9]

In 2019, Minnesota was home to 1,303,157 children under age 18, representing 22.9% of the population. There were 66,033 live births in the state in 2019, down from the peak of 73,675 in 2007. Minnesota’s age distribution is similar to the United States overall. In 2019, children under the age of five accounted for 6.2% of the state’s population, 18 years and older comprised 76.3%, and people 65+ comprised 16.2%. By 2035, the number of those ages 65+ is expected to surpass the number of those under 18 for the first time in history. Minnesota’s diverse cultural groups have very different age distributions. Our state’s large Baby Boomer generation, born between 1946 and 1964, is overwhelmingly White. In contrast, most BIPOC are much younger, particularly among Somali and Hmong Minnesotans, with half or more of the population under the age of 22. While Minnesotans ages 18-64 are the majority of the present-day workforce, children under 18 represent the workforce of the near future and their preparation is critical to the continued economic success of the state. Key demographic changes in Minnesota include an aging population, a decrease in birth numbers, an increase in BIPOC communities, growth concentrated in urban areas, and a rising ratio of dependent elderly people and children to the working-age population. These changes will have many implications, impacting the need for and type of healthcare services, housing, education, business, commerce, and social services.

Economics

Minnesota’s seasonally adjusted unemployment rate of 4.1% (April 2021) is lower than the national unemployment rate of 6.1%.[10] In 2018, the median household income for Minnesotans was $70,300. From 2010 to 2018, the number of part-time workers in Minnesota decreased by 88,900 whereas the number of full-time workers increased by 296,900 (59% to 64%). In June 2020, Minnesota’s unemployment rate rose to 9.9% due to the impact of lay-offs related to the COVID-19 pandemic. Approximately 26% of Minnesota’s workforce was eligible for unemployment benefits between March 2020 and March 2021. Over half of those workers were able to return to their former employer. However, racial and economic disparities are evident in Minnesotans returning to work. Black and American Indians and workers making less than $15 an hour were less likely to be rehired.[11] About 181,000 fewer jobs were reported in April 2021 compared to pre-pandemic levels. Additionally, more than 19,000 workers continue to be unemployed compared to pre-pandemic levels.[12]

Since the beginning of the decade, Minnesota has seen clear and steady progress toward greater economic stability for BIPOC communities. However, there remain significant disparities in the median household income, employment, and poverty between and within racial and ethnic groups. The number of Minnesotan children and families living in poverty remains a concern. In 2019, an estimated 495,000 Minnesotans, including 143,000 children under 18 had family incomes below the official poverty threshold, and the overall poverty rate is around 9%.[13] More alarming is the persistent disparity in poverty BIPOC communities. Among children ages 0-17, poverty rates in 2019 were highest among those identifying as American Indian (40%), Black (40%), and Hispanic (17%), which was 3.4- to 8.0-times greater than seen among non-Hispanic White children (5%)[14]. It is too early to fully understand long-term economic impact of the pandemic on Minnesota families. Conversations have started related to the COVID cliff, in anticipation of families no longer receiving the additional unemployment compensation and other benefits extended to families during this time. Potential workers have cited worries of COVID-19 infection, difficulty securing childcare, and a lack of skills required for open jobs as barriers to reemployment.[15]

Education

Minnesota’s high school graduation rate has been improving. In 2019, the state had a record number of high school graduates: 57,171 (83.7%) students graduating. Additionally, 1,767 students from earlier classes earned high school diplomas in 2019, graduating five to seven years after starting high school.[16] Despite rising high school graduation rates, gaps remain between White students and BIPOC students. In 2019, graduation rates increased statewide for all racial/ethnic groups, as well as for English learners, students receiving special education services, and students qualifying for free or reduced-price meals.

Figure 3. High School Graduation Rates by Race/Ethnicity – 2015, 2017, & 2019

Figure 3 shows the improvement in graduation rates across race/ethnicity. From 2015-2019, graduation rates increased by:

• 7.7 percentage points (PP) for Black students
• 4.1 PP for Asian students
• 4.0 PP for Hispanic students
• 1.2 PP for students identifying as two or more races
• 1.7 PP for American Indian/Alaska Native students
• 1.5 PP for White students

Minnesota also saw an increase in graduation rates for students receiving special education services, students eligible for free or reduced-price meals, and English learners (2.3 PP, 3.0 PP, and 3.2 PP, respectively).

Despite previous reduction of the gap between BIPOC and White graduation rates, the full impact of COVID-19 on educational disparities has yet to be seen. Students are experiencing higher levels of trauma and anxiety from the pandemic and unrest surrounding the murder of George Floyd, feelings of isolation, challenges to technology access, and increased financial instability, all of which may increase the disparities already present.[17] There was approximately a 2% decrease in public school enrollment. In particular, more families opted for non-public or home school kindergarten options. The decrease in enrollment will impact funding to schools.[18]

Governor Walz has allocated $75 million of the state’s flexible American Rescue Plan funds to help fund enhanced summer learning programs. The programs will provide academic enrichment, mental health support, and will help students recover from the disrupted learning caused by the COVID-19 pandemic. The programs will benefit not only Minnesota’s students, but families, educators, communities, and schools.

Health Care Insurance Environment

Comprehensive, quality health care services are important for promoting and maintaining health throughout the lifespan. Minnesota’s health care system consistently ranks near the top in overall performance according to the Commonwealth Fund.[19] Minnesota coordinates a comprehensive set of health insurance options intended to help meet the health and well-being needs of Minnesotans. However, not everyone in the state has equal access to health insurance coverage – based on their race, economic situation, geographic location, and other factors.

Impact of COVID-19 Pandemic on Insurance

New research, based on an analysis using enrollment data supplied by insurance carriers, shows Minnesota’s uninsured rate weathered the economic shock of the pandemic in the first half of 2020, staying at a historically low rate of about 5% through July 2020.[20] Economic downturns often result in higher rates of uninsurance in the U.S. due to the link between health insurance coverage and employment. The state took a proactive approach to prevent as many Minnesotans as possible from losing health care coverage during the pandemic. While there were losses of about 40,000 in employer-based group coverage, they were offset by enrollment gains of 13,000 in the individual market, and a gain of about 46,000 in Minnesota Health Care Programs (MHCP) including Medicaid and MinnesotaCare. The efforts undertaken by the state of Minnesota included:

• Temporary changes to Medicaid and MinnesotaCare by the Minnesota Department of Human Services (DHS) and at the federal level that allowed individuals to maintain continuous coverage in public health programs during the pandemic which impacted these numbers.
• Opening its individual market (MNsure) for a special enrollment period for a short period of time (March 23, 2020 – April 21, 2020) for those who were uninsured – those who found themselves unemployed or without insurance after that period would theoretically be eligible for an individual special enrollment period due to their change in circumstances.

As a result of these efforts, Minnesota saw only a modest impact on the uninsured rate during the pandemic.

Insurance Coverage and Cost

According to the most recent Minnesota Health Access Survey around 264,000 Minnesotans (4.7%) lacked health insurance coverage in 2019. The maintained high rate of coverage in 2019 was consistent with levels experienced after the full implementation of the Affordable Care Act in Minnesota in 2014 – 95.3 percent of Minnesotans had health insurance coverage that year. Compared to 2017, coverage in the state was significantly higher, likely because of Minnesota’s strong economy and job market, as well as by provisions enacted by the Minnesota Legislature to help stabilize the individual health insurance market. The Premium Security Plan, created by the Minnesota Legislature in 2017, aimed to lower premiums for Minnesotans who purchase coverage in the individual insurance market. To do this, Minnesota reduces the financial obligation of insurers by covering part of their expenses for high-cost health care claims (reinsurance).

Despite relativity high levels of insurance coverage, historical disparities in coverage experienced by certain groups persisted in 2019 and health care is still unaffordable for many families in Minnesota. While household incomes grew 80% between 1997 and 2016, family budgets devoted to health care spending rose more than twice as fast (figure 4). BIPOC are around 2 times more likely to be underinsured than White people living in Minnesota. Systemic racism creates barriers to accessing health insurance. As a result of an unfair and unjust health insurance system, the uninsured were more likely to be BIPOC, a young adult (age 18 to 34), in a lower income bracket, or have a high school education or less. The highest proportion of Minnesotans without insurance also live-in rural areas in the northern regions of the state.

Figure 4. Cumulative Growth in Household Spending, Select Categories (1997-2016)

Minnesota Health Care Programs

Minnesota Health Care Programs (MHCP) provide health care coverage to eligible families with children, adults, people with disabilities, and seniors. MHCP include Medical Assistance (MA), MinnesotaCare (MNCare), and the Minnesota Family Planning Program (FPSP). These programs are administered by the Minnesota DHS.

MHCP financed 43.3% of all births (28,550 infants) in 2019, down slightly from 43.9% in 2018. Total spending on health care services for MCHP was approximately $13.4 billion in FY 2020 an 8.9% increase from FY 2019.

Medical Assistance

MA, Minnesota’s Medicaid Program, is a state and federal program that provides health insurance that covers a broad array of health services for people, including families and children with low-incomes, older adults, and people with disabilities. MA covers one out of every five Minnesotans, a monthly average of 1.1 million. As the third largest insurer in the state after self-insured employer-based coverage and Medicare, it makes up nearly 16% of the state’s health insurance market. The composition of enrollees is 65% families with children, 17% seniors and people with disabilities, and 18% adults without children.[21] Children ages 0 to 18 are the single largest group making up 45% of total enrollment.

Figure 5. Percentage of the Medical Assistance Enrollees Verses Expenditures by Population

Income eligibility requirements for MA vary by age (see Table 1). If someone makes more than the income limit, they may still be eligible for coverage using a spenddown (a cost-sharing approach that allows people with incomes greater than the applicable limit to “spend down” their excess income to the appropriate income limit by deducting certain health care expenses).

Table 1. Minnesota’s Income Eligibility Levels for Medicaid

Most Minnesotans enrolled in MA receive services through managed care organizations (approximately 79% of enrollees). The remaining enrollees (around 234,000 people or 21% of enrollees) receive services through the traditional fee-for-service system, where providers receive a payment from the DHS directly for each service provided to an enrollee. Those who remain on fee-for-service primarily consist of those who are not required to enroll in managed care or who have chosen to opt out of managed care. In general, this includes those with disabilities, people who are eligible with a spenddown, children receiving adoption assistance, and American Indians who live on a federally recognized reservation.

MNCare

MNCare is a state and federal program that provides a low-cost health insurance option to people who do not have access to affordable employer-sponsored health insurance and have higher income levels than those eligible for MA. Minnesota is one of two states with this type of insurance coverage program, which is known as a Basic Health Program. MNCare provides comprehensive health care coverage for more than 94,000 Minnesotans, who pay no more than $80 a month in premiums. Income eligibility is for adults with incomes over 133% federal poverty line (FPL) up to 200% of FPL.

Additional Assistance for Families of Children with Disabilities

Minnesota is one of 19 states that allows parents who have a child with a disability the option to obtain MA through the Katie Beckett provision under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) if they are unable to meet the Medicaid income limit. Prior to this, families with children with disabilities who needed MA coverage but wanted care at home faced significant eligibility barriers due to the consideration of the income and assets of the parents. Oftentimes, those parents with a household income above eligibility requirements would have to place their child with a disability in an institutional setting to be able to obtain MA. Under Minnesota’s TEFRA program, higher income families raising a child with a disability can access MA by paying a fee. The payment amount is determined using a sliding scale based on the family’s annual adjusted gross income. Fees do not exceed the cost of services delivered. Legislation was passed in 2017 in Minnesota to provide parental fee relief, and bills continue to be introduced to eliminate the parental fee. Nearly 3,000 Minnesota children with disabilities are enrolled in TEFRA.

Children’s Health Insurance Program

Children’s Health Insurance Program (CHIP) supplements existing federal Medicaid funds that provide health care coverage for low-income families. When the program was created in 1997, Minnesota already covered most of the children Congress intended to cover through CHIP. Therefore, the Minnesota Legislature chose to use CHIP funds to extend benefits to a small group of children who did not have coverage at the time (children under age 2 with family incomes between 275% and 283% of the FPL). Over time, Minnesota obtained a federal Section 1115 waiver to allow the state to use CHIP funds to add coverage for parents of some children on MA and Congress revised the Title XXI of the Social Security Act to allow states to extend CHIP coverage to pregnant women who were ineligible for MA.

Table 2. Populations Covered by Federal CHIP Funding in Minnesota (2017)

Advanced Premium Tax Credit

Another public program that assists Minnesotan’s with health care coverage is the Advanced Premium Tax Credit, a federal program that reduces the cost of premiums for individual health insurance based on income, available through federal or state marketplaces, such as MNsure (Minnesota’s health insurance marketplace). Over 122,000 people enrolled in private health plans through MNsure in 2020 for coverage in 2021 – a 4% increase in signups during 2020’s open enrollment period.[22] This is an increase from the number of enrollees who signed up for private health coverage through MNsure during open enrollment in 2019 (117,520), 2018 (113,000) and 2017 (108,540).

Meeting the Needs of Minnesota’s Most At-Risk Populations

Minnesota has worked to build a comprehensive and holistic system of supports aimed at meeting the needs of our most at-risk populations, including persons of color and American Indians, those from rural areas of the state, and persons with disabilities.

Hospitals

Minnesota is home to many phenomenal hospitals, including the number one ranked hospital in the United States, according to U.S. News and World Report – the Mayo Clinic in Rochester. As of March 2020, there were 129 state licensed hospitals with 16,157 beds, of which 77 are designated Critical Access Hospitals (CAHs). CAHs are smaller hospitals (fewer than 25 beds), mostly in rural areas, which receive higher reimbursement from Medicare, as long as they maintain certain services. However, Minnesota hospitals are finding it harder and harder to sustain themselves. Between 2000 and 2015, the number of community hospitals in the state decreased by 5.8%.

Pregnant persons living in rural areas have particularly experienced the issue of declining hospital services, as the number of community hospitals offering birth services in rural counties fell 37%. This is especially concerning because giving birth in a hospital without obstetric services can lead to higher rates of hemorrhage, emergency surgery, and maternal death. More rural hospitals plan to stop offering birth services in 2020, further deepening disparities seen in access to prenatal and birth care.

Minnesota’s hospitals voluntarily participate in a statewide trauma system by attaining designation as a Level 1, 2, 3, or 4 trauma hospital. These designation levels reflect the resource capabilities of the hospital (with a Level 1 facility having the most capabilities). Around 98% of Minnesotans live within 60 minutes of a trauma hospital, which is an important predictor of survival after sustaining a traumatic injury or needing life-saving care. However, though Minnesotans overall fair well when it comes to living near a trauma hospital, designated pediatric facilities are lacking in rural Minnesota. All four Level 1 pediatric facilities are located in the Twin Cities or Rochester. There are three Level 2 pediatric facilities serving Minnesota residents in Duluth and two in bordering states (Fargo, ND and Sioux Falls, SD).

Health Care Homes and Behavioral Health Homes

Health Care Homes (HCHs) was a cornerstone of Minnesota’s bipartisan health reform efforts in 2008. The voluntary program continues to support primary care providers, families, and patients to work in partnership to improve health outcomes and quality of life for patients, including those with chronic conditions or disabilities. As of December 2019, a total of 378 clinics in Minnesota were certified as HCHs (55% of the 683 primary care clinics in the state), serving 64 counties (74%). Minnesota’s HCH efforts reduced MA costs by 9% and helped to reduce inpatient hospital admissions, hospital outpatient visits, skilled nursing facilities and pharmacy costs. Even more impressive was that racial disparities were significantly smaller for Medicaid, Medicare, and Dual Eligible beneficiaries served by HCHs versus those served in non-certified clinics.

Behavioral Health Homes (BHHs) were implemented in 2016 for eligible people with serious and persistent mental illness, emotional disturbance, or severe emotional disturbance - a subpopulation of persons known to be at higher risk for poorer health outcomes and fragmented care. BHH services build upon the successes of HCH and create a comprehensive care coordination service that integrates physical health, mental health, the health concerns of substance use, long-term services and supports, and social services for people. There are currently 37 provider locations certified to provide BHH services.

Family Planning

The Minnesota Family Planning Program (MFPP) and the Family Planning Special Projects (FPSP) provide vital family planning services to low-income/underserved people.

The MFPP, administered by DHS, is an insurance program that pays for family planning services and transportation services to and from providers of family planning service for people between 15 and 50 years old, who are not eligible for other public programs, and who have an income at or below 200% of the FPL.

The FPSP program is administered by MDH and provides pre-pregnancy family planning services for people who are low-income and at high-risk for unintended pregnancy. MDH receives state and federal TANF funds to provide statewide family planning services and infrastructure support to clinics that provide family planning services. Using these funds, the FPSP program awards more than $6.3 million annually to local family planning providers including counties, Tribal governments, and nonprofit organizations. Funding is targeted to people who would have difficulty accessing services because of barriers such as poverty, lack of insurance, or transportation. During state fiscal year 2020, FPSP reached around 72,888 people through outreach activities, and provided 20,494 clients a range of contraceptive method – with 19.6% of clients choosing Tier 1 (most effective), long-acting reversible contraceptives.

Together, these funding sources support a statewide system of family planning clinics. With changes in federal Title X Family Planning Grant eligibility requirements, Planned Parenthood in Minnesota chose not to accept funding. Because of this funding reduction, multiple sites within Greater Minnesota were unable to continue to support their clinics and thus reduced access to reproductive and sexual health services across the state.

Family Home Visiting

Family home visiting (FHV) is a voluntary, home-based service ideally delivered prenatally through the early years of a child's life. FHV provides social, emotional, health-related and parenting support and information to more than 14,000 of Minnesota’s most at-risk families, and links them to appropriate resources. By participating in home visiting, some examples of services a family may receive are:

• Connections/referrals for pregnant persons to prenatal care
• Early support to parents in their role as a child’s first teacher
• Help in creating a safe and healthy environment for a young child to thrive in
• Parenting skills and support that decrease the risk of child abuse

FHV services in Minnesota are supported by a number of funding streams, including state, federal, and local resources. At the state level, MDH oversees and distributes funding for home visiting services provided under Temporary Assistance to Needy Families (TANF) funding, the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program, Minnesota evidence-based home visiting funding, and Minnesota's Nurse-Family Partnership legislation. Funding administered by MDH is granted to Community Health Boards, Tribal Governments, and non-profit organizations. Local tax levies and Medical Assistance reimbursement also fund FHV in Minnesota.

Women, Infants, and Children (WIC) Special Supplemental Nutrition Program

WIC is a special supplemental nutrition program for pregnant and post-partum women, infants and children up to age 5 who are at nutritional risk and meet specific income guidelines or who are enrolled in TANF, SNAP or Medicaid. The program is funded by USDA and provides the following services to influence lifetime nutrition and health behaviors in high-risk populations:

Nutrition Services & Breastfeeding Support

• Participants receive an individualized nutrition assessment along with education and referrals to community resources.
• WIC promotes and supports breastfeeding, including exclusive breastfeeding for the first six months of an infant’s life.
• WIC supports healthy diets and infant feeding practices. These practices can help prevent obesity and anemia among other benefits.
• Many local WIC programs provide peer breastfeeding support to mothers and infants.

Healthy Foods

• WIC provides healthy foods including fruits, vegetables, whole grains and low-fat dairy. The WIC food package contributes to healthy diets, which aid in preventing obesity and chronic disease.

In 2020, MN WIC provided healthy food and nutrition services to almost 157,000 pregnant women, infants and young children.

Minnesota’s Government

In 2019, Tim Walz was elected Minnesota’s 41st Governor and Peggy Flanagan is Minnesota’s 50th Lieutenant Governor, our first American Indian Lieutenant Governor.

Children’s Cabinet

Minnesota’s Children’s Cabinet is an interagency partnership the Governor tasked with making Minnesota the best place for children to grow up. The Children’s Cabinet was established in 1993 (Minnesota Statute § 4.045) and is a broad interagency partnership of 22 state agencies that utilizes a whole-family systems approach to support the healthy development of children and families. The cabinet includes Commissioners from the Minnesota Departments of Administration, Agriculture, Commerce, Corrections, Education, Employment and Economic Development, Health, Housing Finance Agency, Human Rights, Human Services, Labor and Industry, Management and Budget, Military Affairs, Natural Resources, Public Safety, Revenue, and Transportation. Representatives from the state’s Office of Higher Education, Met Council, Minnesota IT Services, the Iron Range Resources and Rehabilitation Board, and Pollution Control Agency also participate.

The Children’s Cabinet engages with two external advisory bodies: Children’s Cabinet Advisory Council and the State Advisory Council for Early Education and Care. These groups, made up of individuals with the perspective of youth and families, diverse and underrepresented communities, and tribal and county leadership, provide guidance to inform the priorities and activities of the Children’s Cabinet.

The Cabinet utilizes a results-based accountability lens in these priority areas:

• Healthy Beginnings (addressing infant and maternal mortality)
• Child Care and Early Education
• Mental Health and Well-Being
• Housing Stability

The Children’s Cabinet established work groups of Assistant Commissioners, Division Directors, and subject matter experts from each agency, to address the priorities. The CFH Division Director, along with Title V staff, participate fully in these initiatives, bringing subject matter expertise; coordination of data; programs and services; and a developing health and racial equity perspective to the work. This work has culminated in grant proposals, including: The Preschool Development Implementation Grant, legislative proposals related to systems coordination and expanded funding for maternal and infant health equity programs, and collaborative processes with sister agencies around race equity training for early childhood leadership through the BUILD initiative.

Maternal and Child Health Advisory Task Force

The MCH Advisory Task Force was created by the Minnesota Legislature in 1982 (Minnesota Statute § 145.8811) to advise the Commissioner of Health on:

1. The health care needs of mothers and children throughout Minnesota
2. The type, frequency and impact of maternal and child health services in the state
3. Program guidelines and criteria considered essential to providing an effective maternal and child health care program to low-income populations and high-risk persons and fulfilling the purposes of the state and federal maternal and child health statutes
4. The use of federal and state funds available to meet maternal and child health needs
5. Priorities for funding the following maternal and child health services:
   1. Prenatal, delivery and postpartum care
   2. Comprehensive health care for children, especially from birth through five years of age
   3. Adolescent health services
   4. Family planning services
   5. Preventive dental care
   6. Special services for children with chronic illness or disabilities
   7. Any other services that promote the health of mothers and children
6. Establish statewide outcomes that will improve the health of mothers and children

The Task Force consists of 15 legislatively authorized members appointed by the Commissioner of Health to four-year terms with equal representation in three categories:

• Professional representatives with expertise in maternal and child services
• Community health boards representatives
• Consumer representatives interested in the health of mothers and children

For a complete list of members on the MCH Advisory Task Force, please refer to the MCH Advisory Task Force webpage.

Minnesota Department of Health

The mission of MDH is to protect, maintain and improve the health of all Minnesotans. MDH has broad responsibilities in the areas of health protection, health improvement, and reforming the health care system around a public health framework. Historically, Minnesota is cited consistently among the top 10 states for overall health, best run state, and best state to raise a family. However, these overall ratings mask the significant inequities and the persistent health disparities based on race, geography and/or economic status within Minnesota. While significant attention has been given to health equity and the need for safe, stable environments for our children, the disparities persist.

Healthy Minnesota Partnership

MDH facilitates the Healthy Minnesota Partnership, which brings together community partners to improve the health and quality of life for people, families, and communities. The partnership is responsible for developing a statewide health improvement plan based upon a statewide health assessment. The 2017 Statewide Health Assessment gave us a picture of the health and well-being of people across the state and resulted in increased emphasis on the persistent inequities for the BIPOC community, the LGBTQ community, women and children, and for people with disabilities. The statewide health assessment set the stage for Healthy Minnesota 2022, which identified three priorities: the opportunity to be healthy is available everywhere and for everyone; places and systems are designed for health and well-being; and all can participate in decisions that share health and well-being.

Figure 6. Healthy Minnesota 2022 Framework

Health Equity at MDH

Research shows that the conditions needed for health are peace, shelter, education, food, income, and social justice. In short, health is created where people live, work, and play. Minnesota needs to address health disparities as part of a broad spectrum of public investments in housing, transportation, education, economic opportunity and criminal justice. The MDH Center for Health Equity (CHE) was created in 2013 to advance health equity within MDH and across the state. The mission of the CHE is to connect, strengthen, and amplify health equity efforts within MDH and across the state of Minnesota.

Figure 7. MDH Center for Health Equity Mission, Values, and Approaches

Some highlights of the CHE over the past four years:

• Publishing the Eliminating Health Disparities Initiative (EHDI) impact report, Cultivating a Health Equity Ecosystem: Lessons Learned from the Eliminating Health Disparities Initiative. This groundbreaking report emphasizes the impact of consistent funding and support of community-driven solutions, as well as the need for institutions of power to (re)assess their role in uplifting or polluting the health equity ecosystem.
• Quadrupling the size of the Center for Health Equity from three to 12 staff in four years.
• Leading the training of all 1,600+ MDH staff statewide in a half-day racial and health equity training to create common language and understanding of our collective role in addressing inequities.
• Hosting the 2019 Health Equity Summit, which spurred the creation of the Health Equity Leadership Network.
• Numerous initiatives which centered communities most impacted to address long-standing health disparities, such as infant health and early childhood development.
• Catalyzing the transformation of how MDH does business by embedding equity into all we do.
• Creating MDH’s Health Equity Advisory and Leadership (HEAL) Council to hold ourselves accountable to communities most impacted.

The COVID-19 pandemic laid bare the inequities that remain alive and thriving within our systems and institutions. This made it ever more critical that MDH embed equity across our COVID response from day one. Equity continues to be central to our community testing and vaccine work.

Legislative Priorities

In the 2021 Legislative Session, the Minnesota House and Senate had the critical task of developing, debating and passing a biennial budget for the state (2022-2023). During regular and special sessions, legislators introduced a wide variety of health, education, labor, and social safety net bills positively impacting children and youth, families, and community, especially those who are most at risk for poor health and educational outcomes. Governor Walz and Lieutenant Governor Flanagan included many family-centered priorities in their proposals to the Legislature, and their support and advocacy resulted in many positive legislative outcomes in support their goal of making Minnesota the best place for every child to grow up.

The following legislation will be implemented by CFH and will benefit the MCH population throughout the state:

• The Dignity in Pregnancy and Childbirth Act requires hospitals and birth centers to provide continuing education on anti-racism and implicit bias for all staff and requests CFH to do community-based work to increase the diversity of and access to midwife and doula care for in groups with the most significant disparities including BIPOC communities; rural communities; and people with low incomes.
• The Maternal Mortality Review Committee was established in statute, which will ensure the group’s sustainability, and funds were appropriated for the first time to review maternal deaths.
• MDH will provide a grant to the African American Babies Coalition to support its work engaging African American and other parents, caregivers, faith communities and others as key champions in maternal and infant health.
• The Family Home Visiting program was established in statute with additional funding, and the types of home visiting models were expanded to include evidence-informed and promising practice models.
• The Vivian Act establishes outreach and education for women and health care providers about congenital cytomegalovirus (CMV). In addition, it directs Minnesota’s Newborn Screening Advisory Committee to review CMV for inclusion on Minnesota’s Newborn Screening Panel. If the Committee approves the recommendation to add CMV to the panel, an increase in fees is provided effective upon publication in the State Register. 
• The Newborn Screening Fee was increased to address a financial and structural deficit.  In addition, the increase will help with the acquisition of equipment and staff (including CYSHN program staff) for new condition additions.

Additional “wins” this Session in other state agencies that will impact children and families include:

• Passage of the Healthy Start Act which allows pregnant and parenting women (up to 12 months postpartum) who are incarcerated in state prisons to be moved to alternative community settings to promote parent-child bonding during the crucial time of infancy. Minnesota is the first state in the nation to pass a law of this kind.
• Medical Assistance postpartum coverage was extended from 60 days to 12 months.
• Expansion of the Integrated Care for High-Risk Pregnancies (ICHRP)---work that DHS does with communities to create Medical Assistance funded strategies that address maternal and infant health inequities.
• Mandated reporting no longer required for pregnant people using controlled substances as long as they continue to be engaged in prenatal and well child care.
• Establishment of worker protections for pregnant and lactating individuals, allowing for paid time to pump breast milk.
• Expanded telehealth services.
• New funding for DHS to provide parent-to-parent support grant funding to an alliance member of Parent-to-Parent USA.

Although included as part of the Governor’s priorities, the bill to re-establish MDH’s authority to conduct fetal and infant mortalities reviews was not included in the final budget. During this session, the bill made it further than it has in the past 20 years, and MDH will work towards its passage in a future year.

Title V MCH Block Grant Specific Statues

Minnesota Statutes § 145.88 – 145.883 lay out requirements for the distribution of Minnesota’s federal Title V Maternal and Child Health Block Grant award. Statutory language allows the Commissioner of Health to retain up to one-third of the block grant to:

• Meet federal requirements of a statewide needs assessment and prepare the annual federal block grant application and report,
• Collect and disseminate statewide data on the health status of mothers and children,
• Provide technical assistance to LPH agencies in meeting statewide outcomes,
• Evaluate the impact of maternal and child health activities on the health status of mothers and children,
• Provide services to children under age 16 receiving benefits under Title XVI of the Social Security Act, and
• Perform other maternal and child health activities as listed in federal code for the MCH block grant and as deemed necessary by the Commissioner of Health.

The remaining two-thirds of the approximately $9.1 million awarded annually to Minnesota is distributed by formula to Community Health Boards (CHBs) that provide local public health services across the state. In addition, the statute requires that CHBs provide at least a 50% match for the Title V funds they receive. Title V funds allocated to LPH agencies must be used for programs that:

• Address the highest risk populations, particularly low-income and minority groups with a high rate of infant mortality and children with low birth weight
• Specifically target pregnant people whose age, medical condition, maternal history or chemical use substantially increases the likelihood of complications associated with pregnancy
• Address the health needs of young children who have or are likely to have a chronic disease or disability
• Provide family planning and preventive medical care for specifically identified target populations
• Address child and adolescent health issues
• Address child abuse and neglect prevention, reducing juvenile delinquency, promoting positive parenting and resiliency in children through public health nurse home visits

[1] https://mn.gov/admin/demography/data-by-topic/age-race-ethnicity/

[2] https://www.mncompass.org/topics/demographics/race-ethnicity?population-by-age-and-race#1-14884-g

[3] https://www.mncompass.org/topics/demographics/cultural-communities/native-american

[4] https://www.census.gov/tribal/?st=27&aianihh=1940

[5] https://www.census.gov/data/tables/time-series/demo/popest/2010s-state-detail.html

[6] https://www.americanimmigrationcouncil.org/research/immigrants-in-minnesota

[7] https://www.mncompass.org/topics/demographics/immigration

[8] https://mn.gov/admin/demography/data-by-topic/immigration-language/

[9] https://mn.gov/admin/demography/data-by-topic/population-data/our-estimates/

[10] https://mn.gov/deed/data/current-econ-highlights/state-national-employment.jsp

[11] https://mn.gov/deed/newscenter/publications/trends/june-2021/reemployment.jsp

[12] https://mn.gov/deed/data/current-econ-highlights/state-national-employment.jsp

[13] https://data.census.gov/cedsci/table?q=poverty%20in%20minnesota&tid=ACSST1Y2019.S1701

[14] ACS 1-Year Estimates-Public Use Microdata Sample 2019

[15] https://mn.gov/deed/newscenter/publications/trends/june-2021/simple.jsp

[16] https://rc.education.mn.gov/#graduation/orgId--999999000000__groupType--state__year--2019__graduationYearRate--4__p--5/orgId--999999000000__groupType--state__year--2019__graduationYearRate--5__p--5/orgId--999999000000__groupType--state__year--2019__graduationYearRate--6__p--5/orgId--999999000000__groupType--state__year--2019__graduationYearRate--7__p--5

[17] https://www.educationminnesota.org/EDMN/media/edmn-files/advocacy/EPIC/EPIC-Disrupted-Learning-Report.pdf

[18] https://minnesota.cbslocal.com/2021/02/19/mn-education-officials-public-school-enrollment-decreased-due-to-pandemic-will-impact-funding/

[19] https://2020scorecard.commonwealthfund.org/state/minnesota/

[20] Pandemic’s Impact on Health Insurance Coverage in Minnesota Was Modest by Summer 2020. https://www.health.state.mn.us/data/economics/docs/inscoverage2020.pdf

[21] https://mn.gov/dhs/assets/forecast_202011_tcm1053-457232.pdf

[22] https://www.mnsure.org/news-room/news/index.jsp?id=34-414321#/detail/appId/1/id/461086