Overview of the State

Nebraska is a state that covers a large geographic area, but has a smaller population base, much of which is located in the eastern half of the state. Measuring 387 miles across with a total area of approximately 77,000 square miles, almost 20% larger than all of New England, much of the land is utilized in the state’s large agricultural sector.   58.9% of the state’s population reside in the population centers of Grand Island, Lincoln, and Omaha, which represent Metropolitan Statistical Areas (MSA) with populations larger than 50,000. In contrast, 55.5% of all square miles in Nebraska are considered to be frontier and remote (level three), which includes ZIP code areas with majority populations living 60 minutes or more from urban areas of 50,000 or more

people; and 45 minutes or more from urban areas of 25,000-49,999 people; and 30 minutes or more from urban areas of 10,000-24,999 people. Many residents of frontier and remote areas find it hard to access "high order" goods and services, such as advanced medical procedures, stores selling major household appliances, regional airport hubs, or professional sports franchises and "low order" goods and services, such as grocery stores, gas stations, and basic health-care services.

Nebraska has experienced shifts in its demographic composition of the state between 2010 to 2020, according to the U.S. Census, which includes an overall aging of the population as well as an increasing diversity. Statewide, as of 2020, 15.7% of the population was 65 and over, a 17% increase from 2010. While the population is aging statewide, the percentage of the population over age 65 was over 20% in 60 counties and over 25% in 26 of those counties. In terms of increased diversity, Nebraska has seen its minority population grow 82% from 2010 to 2020 – which represents 19.5% of the total population. These demographic shifts can have significant implications for healthcare delivery, creating a need to focus on services that are relevant to an older population as well as those that are culturally and linguistically appropriate.

In addition to providing services that are culturally and linguistically appropriate overall, health care providers should be aware of the specific minority populations that exist in their areas in order to provide quality care and to address existing health disparities. While this is a standard of care that all providers should adhere to, there is an increased stress on providers in metropolitan areas the state as the density of the population of color and the number of spoken languages is much higher in urban parts of the state.

Within its minority populations, Nebraska saw the largest percent increase in the Asian population, which increased 64% from 31,919 in 2010 to 52,359 in 2020 according to the U.S. Census estimates. Though this population had the largest percent of growth, it is still a relatively small population within Nebraska, comprising 2.7% of the state’s overall population in 2020. The second largest percent increase during this same time-period was seen in the Hispanic population. Hispanic Americans now comprise 12% of the state's population, with a gain of 40.2% between 2010 and 2020 (an increase of 67,310 people). The African American population saw a 16.6% increase and the White population decreased by 1% in the 10-year period between 2010 and 2020. 

The Native American population in Nebraska increased by 1.7% between 2010 and 2020. Four federally recognized Native American Tribes are headquartered in Nebraska - the Omaha, Ponca, Santee Sioux, and Winnebago. Though many Native Americans live on reservations, the majority do not. Omaha, Thurston, and Lancaster have the largest Native American populations in Nebraska. In northeastern Nebraska, Thurston County is home to the Winnebago Tribe and Omaha Tribe. A sizable number of Native Americans also reside in the northwestern part of Nebraska adjoining the Pine Ridge Reservation in South Dakota. The Santee Sioux Nation resides in Knox County. The Ponca Tribe operates within a designated service area covering 15 counties in Nebraska, South Dakota, and Iowa. Tribal offices exist in four Nebraska locations, with a fifth in Iowa. The Iowa and the Sac and Fox Indian Reservation is on the Nebraska-Kansas border, but this reservation accounts for a small percentage of Nebraska's total Native American population.

Health disparities exist in Nebraska and impact many issues relevant to maternal and child health. The DHHS Office of Health Disparities and Health Equity’s 2021 Nebraska Minorities Disparity Facts Chart Book included a “Socioeconomic and Health Disparities Report Card” that identified disparity ratios of 2.0 or greater to require intervention. The report also identified disparity ratios over 2.5 as “Unacceptable disparity. Immediate intervention needed.” A number of issues relevant to maternal and child health had disparities over 2.0. American Indian women in Nebraska had 2.7 times higher rate of inadequate prenatal care, Hispanic women had 2.1 times higher rates of inadequate prenatal care, and African American women had 2.0 times higher rates of inadequate prenatal care than White women. Teen birth rates were disparate as well, with American Indian (3.1 times the White teen birth rate), Hispanic (2.6 times the White teen birth rate), and African American (2.3 times the White teen birth rate) teens having higher teen birth rates than White teens. Disparities in sexually transmitted diseases by race/ethnicity are large. African Americans have 12 times high rates of sexually transmitted disease than Whites. American Indian rates of sexually transmitted disease were 5.3 times higher than White rates.

Mental health disparities exist as well. From 2016-2020, the age-adjusted suicide rate per 100,000 people was 16.4for American Indians and 14.9for Whites. These populations have higher rates than African American (9.4), Asian (7.2), and Hispanic (7.3) populations.

Finally, according to CDC Wonder, the 2017-2019 infant mortality rate (expressed as per 1,000 live births) among African Americans was 10.8, compared to that among the White population at 4.8.

The ability to physically access care remains a challenge for this primarily rural, low-population state. Rural areas have difficulty recruiting and retaining providers and health care professionals, and in supporting facilities such as hospitals or other comprehensive care centers, despite multiple student loan repayment programs geared towards these professions. These challenges have resulted in a proliferation of shortage areas throughout the state. The NDHHS Office of Rural Health tracks state-designated shortage areas by discipline. In May 2022, 58 counties out of 93 had this designation for the Family Practice discipline. For the OB/GYN discipline, the entirety of 76 counties had this designation along with portions of counties surrounding Lancaster and Douglas counties. A similar situation exists for the Psychiatry and Mental Health disciplines, with the majority of Nebraska’s 93 counties designated as shortage areas - only 3 counties (and a portion of the counties surrounding Lancaster and Douglas counties) were not considered a shortage area as of May 2022.

Facilities located in federal shortage areas provide affordable and accessible primary and public health care services, including 138 Medicare-certified Rural Health Clinics (RHC), eight Federally Qualified Health Centers (FQHC), nine Indian Health Service (IHS) funded clinics and local public health departments. These facilities not only address access issues, but also make up the safety net healthcare system in Nebraska; serving the 8.1% of Nebraskans who do not have health insurance as well as other vulnerable groups. Expectations are that more Nebraskans will have coverage moving forward since  Medicaid expansion, called Heritage Health Adult (HHA), was implemented October 1, 2020.

The Nebraska Medicaid program has also been a driving force towards integration of services in Nebraska. Beginning in 2017, Medicaid offered enrollees a single plan combining physical health, behavioral health, and pharmacy benefits in an integrated health care program – a practice that has continued throughout recent changes to the overall program. Since Community Health Centers and many private providers are connected to larger health systems serving both private pay and Medicaid patients, integration of health services is not unique to Medicaid enrollees.

The population of children and youth with special health care needs (CYSHCN) in Nebraska is especially vulnerable, as they often face confounding challenges and barriers. By creating a partnership between the DHHS Medically Handicapped Children’s Program and the Munroe-Meyer Institute (MMI) within the University of Nebraska Medical Center (UNMC), a network of clinics exists across the state to provide a range of services for individuals with disabilities. In addition, the partnership has created a strong referral network, ensuring that services are covered by insurance as much as possible, and by training and supporting parent resource coordinators as family support. However, it should be noted that not every child with complex medical needs is eligible for services and supports through the Medically Handicapped Children’s Program.

An additional component of the CYSHCN health care system is how newborns and infants are screened for metabolic diseases and hearing issues. 100% of Nebraska’s birthing facilities collect a bloodspot sample from every baby born in Nebraska and send to the screening laboratory for analysis; those facilities also conduct hearing screenings consistent with state statutes governing standard of care for newborns. These timely screenings ensure that debilitating and sometimes deadly conditions are identified and, if possible, treated to prevent negative health effects or developmental delays. Staff at these facilities also undertake parent education regarding the screening and, if necessary, follow up care. Staff with the Newborn Screening programs also conduct follow up on screened infants to ensure that any additional screening, testing, or connection to care occurs – a process that can often involve healthcare staff, data, and communication with families.

As tele-health continues to advance throughout Nebraska – with the COVID pandemic a large driver of uptake – it is important to call out the tele-audiology framework that was initiated by the NE Early Hearing Detection and Intervention (EHDI) program. For those families in western NE with a newborn who did not pass the hearing screen, a follow up re-screen or diagnostic hearing test can be conducted via tele-audiology with the University of Nebraska-Lincoln’s Barkley Speech Language and Hearing Clinic. Appointments are conducted using end-to-end encryption via Zoom HIPAA-compliant conferencing. The testing is completed by a Doctor of Audiology in Lincoln, with a Teacher of the Deaf and Hard of Hearing as a trained facilitator at the test site. 

NDHHS Title V has many strengths to facilitate the ongoing engagement needed to address the daunting challenges faced by CYSHCN and their families – particularly with experienced staff and a strong administrative foundation. This expertise asserts itself across all MCH populations as Title V facilitates statewide, systems-level work such as engaging partners, ensuring quality improvement, and/or developing system supports. The success in these activities is a testament to the leadership that Title V staff have consistently demonstrated for years. 

Administratively, Nebraska Title V takes advantage of having co-leads who are housed in separate Divisions.  Nebraska Title V is jointly administered by the Title V MCH Director and the Children and Youth with Special Health Care Needs (CYSHCN) Director. The Unit Administrator for the Lifespan Health Services Unit within the Division of Public Health is designated as the Title V MCH Director. The CYSHCN Director role lies with the Economic Assistance Policy Administrator II within the Division of Children and Family Services (CFS), Programs and Services Unit. Having state co-leads in two Divisions of NDHHS extends the reach of Title V activities, expands the amount of available state support, and extends the staff expertise on the Title V Team. This framework helps to ensure that Title V priorities are fully aligned with those of the larger state agency and of other statewide efforts.

The MCH Director oversees multiple programs, many of which align directly with the mission of Title V, including Newborn Screening, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Immunizations, Maternal, Infant, and Early Childhood Home Visiting (MIECHV), Adolescent/Reproductive Health, Office of Women’s and Men’s Health, Women’s Health Initiatives, and more. Likewise, the CYSHCN Director is responsible for numerous program areas, including the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance to Needy Families (TANF), Child Care and Development Fund (CCDF), the Medically Handicapped Children’s Program (MHCP), and more.  Additional key staff in both Public Health and CFS lead the Title V MCH Block Grant and partner with stakeholders statewide. These are the Maternal Child Health (MCH) team, the MCH Epidemiology team, a Federal Grants Administrator, the Disabled Persons Program Administrator, and the MHCP Program Coordinator.

Solidifying this operational approach is an Intra-Agency Protocol between the Divisions of CFS, PH, and Medicaid and Long-Term Care. While the agreement is statutorily required, it also provides a means to formalize the long-standing relationships between the Divisions by describing shared and individual responsibilities of each Division.

Another part of the administrative framework for Nebraska Title V work are the statutes pertaining to the broad authority to carry out maternal and child health services in the state, found in Nebraska Revised Statutes (Neb. Rev. Stat.) §§71-2201 to 71-2208. Additional related authorities include the statute requiring a Birth Defects Registry (found in §§71-645 through 71-648), Child Maternal Death Review (found in §§71-3404 through 71-3411), the Childhood Vaccine Act (found in §§71-526 through 71-530), metabolic screening and associated responsibilities (found in §§71-519 through 71-524), newborn hearing screening (found in §§71-4734 through §§71-4744), WIC (found in §71-2227), and the Women’s Health Initiative program (found in §§71-701 through 71-707). The statutes pertaining to the Medically Handicapped Children’s Program are found in Neb. Rev. Stat. §43-522, §68-309, and §68-717 with the associated NDHHS regulations found in Title 467 Chapters 1 through 7.

NDHHS Title V additionally relies on established relationships with key stakeholders to ensure that the public health and direct care infrastructures have CLAS and health equity standards in place to inform how staff interact with clients, and that services are offered in a family-centered, comprehensive way. These relationships are enhanced by the technical expertise that Title V offers to others. The programmatic staff within Title V offer a significant output of high-quality continuing education and professional development activities every year for professionals statewide. While training participants are frequently licensed health professionals, particularly nurses, training opportunities also are delivered to youth-serving professionals and home visitors. Additionally, Title V participates in developing new roles for MCH workers, such as home visitors, parent resource coordinators, and the TOP ® educators working in positive youth development.

In the area of data collection and analysis, Nebraska has an experienced MCH Epidemiology team who work with MCH data regularly and maintain a deep understanding of health indicators. Examples of the collaborative contributions of these staff include building linkages between separate datasets, providing learning opportunities and technical assistance to colleagues, and participating on Division- and Department-wide workgroups on data governance, collection, and release policies and procedures. The addition of a CDC assignee with the Office of MCH Epidemiology has deepened the expertise and capacity available to the state.

With issues around health disparities, medical shortage areas, a shifting demographic, and health care access, Nebraska certainly has challenges to improving the health of Nebraska’s maternal and child population. However, as discussed above, there is a solid framework in place to address these issues. The blend of experienced staff, technical expertise, long-term relationships with stakeholders, as well as statute and general fund availability make up an infrastructure that is in place to support Nebraska’s priorities and vulnerable populations. This existing infrastructure provides fertile ground for Title V funds to enhance efforts and bring additional resources to this important work. Through a framework of assessment, inclusive planning, and regular evaluation Nebraska Title V seeks to promote systems change that will directly benefit families, and ultimately improve the health of the maternal and child population in Nebraska.