Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

 

The Arkansas Department of Health (ADH) is the state public health agency with primary responsibility for protecting, promoting, and improving the health of all citizens and visitors within the state. To understand the health problems facing Arkansas it is important to look at the people and how they live.  The following pages will provide an overview of Arkansas’s population, including how poverty and limited access to health care and preventive health services impact the state.  A review of some of the social determinants of health and health disparities that challenge the state is also given, followed by a description of ADH’s priorities and current efforts to improve the health of all Arkansans.

 

Health Status Rankings

 

Arkansas ranks 48th out of 50 states in terms of overall health and 49th in health of women and children.  An extremely broad range of health measures in the state rank unfavorably when compared to other states. With 50 being the worst and one being the best, Arkansas ranks:

 

• 50th – adult obesity in women and teen births
• 49th – physical inactivity, diabetes, and smoking in adult women
• 47th – adverse childhood experiences, and infant mortality
• 46th – maternal mortality
• 44th  – child mortality
• 42nd – low birthweight live births

 

Arkansas ranks 40th of 50 in child-well-being, which has four domains: health, education, economic well-being, and community and family.  Within these domains, Arkansas ranks 45th in community and family, 40th in health, 46th in economic well-being, and 31st in education. 

 

Although the state has seen improvement in all areas of economic well-being, three areas (eighth graders not proficient in math, children and teens who are overweight or obese, children in single-parent families) remain the same and three have gotten worse:

 

• Young children (ages 3 and 4) not in school (from 51% in 2009-2011 to 52% in 2016-2018; U.S. data =52%)
• Low birth-weight babies (from 8.8% in 2010 to 9.4% in 2018; U.S. data = 8.3%)

• Children and teen deaths per 100,000 (from 34 in 2010 to 37 in 2018; U.S. data= 25)

 

Population

 

There are close to three million people living in Arkansas. Children under the age of 18 make up 23.2% of the population and 6.24% are children under age five. This means that 23 out of every 100 people are children. There are slightly more females than males in Arkansas. That is, for every 100 females there are 96 males. There are more than 2,385,000 whites (includes Hispanics) in Arkansas, which makes whites the largest racial group. This group makes up 79% of the population. There are more than 473,000 African- Americans in Arkansas, which makes African-Americans the second largest group.  African-Americans are 15.7 % of the population. The main minority ethnic group in Arkansas is the Latino group. This group is also called Hispanic. There are nearly 237,000 Latinos in Arkansas, which is about 8% of the population.  There are several smaller groups included in the Latino group. The largest groups are Mexican, Puerto Rican, and Cuban.  The next largest group is Asians, which is made up of several smaller groups. Overall, there are nearly 50,000 Asians, which is about 1.7% of Arkansas’s population.  Included in the Asian group are Indian, Vietnamese, Chinese, Filipino, Korean, and Japanese. There are more than 30,000 Arkansans who are American Indians or Alaska natives. This group makes up 1% of the population. Also, Arkansas is home to more than 12,000 people in the Native Hawaiian and other Pacific Islander group.  Most of the people in this group are Pacific Islanders from the Marshall Islands. They make up less than a ½% of the population. Arkansas and Hawaii are home to the largest groups of Marshall Islanders living outside of the Marshall Islands. 

 

The racial, ethnic, and cultural diversity of Arkansas’s population creates unique challenges as well as increased opportunities. This diversity makes Arkansas a more interesting place to live, work, and play. As the racial and ethnic make-up of the country, our state, our workplaces, and schools become increasingly varied, it is important that we recognize and value these differences. People from diverse cultures contribute language skills, new ways of thinking, new knowledge, and different experiences. Cultural diversity helps us recognize and respect the customs, behaviors, and traditions of others, allowing for bridges of trust, respect, and understanding to be built across cultures.

 

Demographics

 

The state is located in the southern region of the United States (U.S) and covers an area of 53,178 square miles.  Compared with other U.S. states, Arkansas would fit into Texas about five times, but it is six times larger than New Jersey. Arkansas borders six other states. Missouri to the north, Tennessee to the northeast, Louisiana to the south, Mississippi to the southeast, Texas to the southwest, and Oklahoma in the west.  The Mississippi River forms the state borders to Tennessee and Mississippi in the east. The capital and largest city is Little Rock. Population centers are in Little Rock-North Little Rock, Conway, Fort Smith, Pine Bluff, and Jonesboro.

 

Arkansas is a very rural state and when talking about rural health, we mean the health of people living in the parts of the state that are away from cities – out in the country.  According to U.S. Census Data, only 19% of people in the U.S. live in rural areas, compared to 44% of people in Arkansas.  But, defining exactly where a city ends and a rural area starts can be hard. So, we have used the definition for rural that the U.S. Office of Budget and Management has used.  It defines a rural county as any county that is not part of a Metropolitan Statistical Area (MSA).  A MSA is a city that has a population of 50,000 people or more.  By this definition, 54 of the 75 counties in Arkansas are considered rural.   We realize, however, that there are rural areas even in counties that are not defined as rural counties. 

 

The county with the most people is Pulaski County, where Little Rock is located. The number of people in each county has changed over the years. Some counties in central Arkansas, northwest Arkansas and northeast Arkansas had an increase in the number of people living there during the past several years.  Benton County had the greatest increase. The population there grew from 221,000 to 279,000 between the years of 2010 and 2019.  This is a 20% increase. Many counties in southern and eastern Arkansas had a decrease in the overall number of people who live there. The population there decreased from 77,000 to 67,000 between the years of 2010-2017.  The number of people living in Phillips County decreased from 22,000 to 18,000 between the years 2010 and 2019. This is a 18.3% decrease which was the largest decrease in the state. Overall, 49 counties in Arkansas had a decrease in their population. The decline is largely a result of out of state migration.

 

Income

 

The average family income in Arkansas is $58,000 per year. This is lower than the average family income in the U.S., which is $76,000. Almost 40% of Arkansas households have incomes less than $25,000 per year and 39% receive some form of supplemental income.  Family income takes into account every person in the family who works, so it may include more than one worker.  Median household income declined from 2012 to 2016 and was 23% lower than the national median income in 2016. The disparity in earnings per job between rural and urban areas remains great, with urban residents earning on average 19% more than rural residents.

 

Poverty

 

Arkansas’s poverty rate continues to be high.  At 17%, it is the 4th highest in the U.S.  This means there are 505,000 people in Arkansas who are living in poverty.  The counties in southeast Arkansas have the highest poverty rates.  The counties with the lowest poverty rates are in central and northwest Arkansas.  In 2018, 24.7% of Arkansas’s children under the age of 18 lived in poverty compared to 18% in the U.S.  The situation was worse for children under the age of five: 29.5% live in poverty compared to 19.5% in the U.S. Across the U.S. and in Arkansas, approximately 20% of children ages five through 17 live in poverty.  In the Coastal Plains and Delta Region of the state, 36% of children live in poverty. The percent of children living in extreme poverty (50% of FPL) has been declining since 2013. However, 10% of Arkansas’s children still live in extreme poverty, compared to 8% nationwide.  These children live in census tracts with poverty rates of 30% or more and many live in a single-parent family. 

 

The effects of poverty are statistically linked to negative outcomes for children, from low birth weight, poor nutrition in infancy to increased chances of academic failure, emotional distress, and teen parenthood. Access to basics such as food, adequate shelter, and transportation is limited for many Arkansans. More than 23% of Arkansas children experience food insecurity, the 3rd worst in the country (Feeding America). There are 6,200 homes without plumbing and 10,000 without kitchens.  There are 24,000 homes in Arkansas with no phone service available.  There are also 76,000 homes with no cars, vans, or trucks that are kept at the home for household use of members.  When basic needs are not met, children and families are left to suffer the debilitating effects of poverty.

 

Social and Behavioral Determinants of Health in Arkansas

 

Many of the needs that were identified in the three NA were used to inform the new five-year NA were health determinants. These can be divided into two categories: upstream and direct. The upstream determinants are further divided into education, occupation, income, social position, access to care, physical environment, and social cohesion. The direct determinants include genetics, individual medical care, behavior, environmental exposures, and stress. Almost 45% of Arkansans live in rural areas.  The rural regions have higher rates of infant mortality, obesity, food insecurity, and child poverty than urban areas. Infant mortality rates range from 2.1 deaths per 1,000 live births in Lee County to 16.2 per 1,000 in Bradley County.  People in rural areas may experience barriers to good health that people who live in cities may not. They must travel greater distances to see a doctor or go to the hospital and are more likely to be involved in serious accidents.

 

Health Literacy

 

The adults who live in rural counties are also more likely to struggle with low health literacy.  Health literacy is often defined as how well people can get and use information to make good choices about their health.  There is often a mismatch between the skills of the patient and the demands placed on them by the clinics, hospitals, and insurance companies.  It is estimated that there are 820,000 adults in Arkansas with low health literacy.  This is more than one out of three (37%) of the adult population (Rand, 2012).

 

Unintentional Injuries

 

In Arkansas, unintentional injuries are the fourth leading cause of death overall, which is the same as in the U.S. Unintentional injuries include motor vehicle crashes, falls, poisonings, fires and burns, and drowning. In 2018, almost 1,500 people in Arkansas died from unintentional injuries.

 

Figure 1: Arkansas and U.S. unintentional injury mortality rates, 2009-2018

Data Source: Centers for Disease Control and Prevention (CDC) WONDER

 

Below is another chart that shows the death rate for different age groups in Arkansas. It shows that adults age 75 and over have the highest death rates from unintentional injuries, while children and teens under the age of 20 have the lowest death rates.  However, unintentional injuries are the number one killer of Arkansans between the ages of one and 44.

 

Figure 2: Arkansas unintentional injury death rates by age group, 2014-2018 combined

Data Source: Centers for Disease Control and Prevention (CDC) WONDER

 

Infant Mortality

 

Infant mortality is a way of looking at the number of babies who die each year before they reach their first birthday. It is usually defined as the number of babies who die out of every 1,000 babies who are born alive.  In 2018, 279 babies died in Arkansas before their first birthdays. Arkansas’s neonatal mortality rate was 4.7 per 1,000 live births. This was higher than the U.S. neonatal mortality rate, which was 3.8. Arkansas’s post-neonatal mortality rate was 2.8 per 1,000 live births. This was much higher than the U.S. post-neonatal mortality rate, which was 1.9.

 

The chart below compares the Arkansas infant mortality rate with the U.S. rate for the past several years. It shows that Arkansas has had a higher infant mortality rate than the U.S. for a long time. However, Arkansas’s infant mortality rate has remained high while the national rate has declined, increasing the difference. 

 

Figure 3: Arkansas and U.S. infant mortality rates, 2009-2018

Data Source: Centers for Disease Control and Prevention (CDC) WONDER

 

The leading causes of neonatal death in Arkansas are birth defects, prematurity and low birth weight, and problems with the pregnancy. The leading causes of post-neonatal death are Sudden Infant Death Syndrome (SIDS) and birth defects. The infant mortality rate for 2018 was 7.5 deaths per 1,000 live births, a slight decrease from the previous year.  In Arkansas, African Americans have higher rates of infant mortality compared to whites or Latinos. The infant mortality rate for African Americans in 2017 was 12.6 compared to 6.9 for whites and 6.2 for Latinos.

 

Health Care and Preventive Health Services

 

Availability of and accessibility to health care and preventive health services varies widely in Arkansas. The Central Region around Little Rock is relatively urban and well supplied with available health services for women and children. However, even in these counties low-income families experience barriers in access to care. All other regions are rural and poor and many are medically underserved as defined by the Health Resources and Services Administration (HRSA).  

 

Counties in the Mississippi Delta along eastern border of Arkansas are especially rural and poor. These counties have high concentrations of minority populations, especially African American. Some counties along the western border are mountainous and rural. They have fewer minorities, but are high in immigrant Hispanic families from Central and South America. A group of Marshallese families live in the far northwestern counties and experience outbreaks of infectious diseases including sexually transmitted infections, tuberculosis, and Hansen's disease. Counties along the southern border of the state are also rural and poor, depending on farming and timber as their predominant source of income.

 

People in rural Arkansas have greater difficulty getting the health care they need compared to those who live in the non-rural counties.  One reason they have difficulty getting health care is because of the cost. In general, 15.3% of Arkansans report that they were not able to see a doctor in the past 12 months due to the cost, compared to 13% in the U.S. However, in many rural counties, more than 20% of residents were not able to see a doctor due to cost. Lack of health insurance makes the cost of seeing a doctor hard, if not impossible to afford. In Arkansas, 25% of working-age adults have no health insurance. That is one out of every four working-age adults. In many rural counties it is even higher. A second reason that people who live in rural Arkansas find it hard to get health care is that there is a shortage of health care on hand in their communities.

 

Arkansas’s healthcare delivery environment improved as a result of the Affordable Care Act. As of

May 2020, more than 260,000 people enrolled in health care coverage. No other state experienced a more rapid decline in its uninsured rate. The overall uninsured rate fell from 16% in 2013 to 8% in 2018. Almost 100% of children have health insurance, 69.8% of which is considered adequate for their needs. Arkansas’s Medicaid expansion is in the form of the "Private Option," which allows Medicaid to fund private insurance companies to provide insurance to those whose income does not exceed 138% of the FPL. The state legislature changed the name of the Medicaid expansion to Arkansas Works. Participation exceeded predictions. While expanding Medicaid, the 1115 Medicaid Waiver that funded family planning services for women up to 200% of the FPL was ended on December 31, 2013.

 

Additionally, Medicaid has transitioned from a fee-for-service system to an organized care delivery model for the highest need behavioral health and developmental disability populations. The model, the Provider-Led Arkansas Shared Savings Entity (PASSE), was implemented in February 2017 and provides care coordination services. The program began providing comprehensive services to members in January 2019. PASSEs are responsible for integrating physical and behavioral health as well as developmental disability services for assigned members. Members are assigned a care coordinator who is responsible for creating a person-centered service plan for them.

 

State Healthcare System Infrastructure

 

The capitol city, Little Rock, is the state’s largest and most populous, with 6.54% of the state’s total population. The city is situated in the middle of the state, and is the site for the ADH, five large hospitals including the University of Arkansas for Medical Sciences (UAMS), the state’s only medical school, the Arkansas Department of Human Services (ADHS), and other state agencies focused on improving the health of women and children. Cities of moderate size are located in the corners of the state. These cities provide the population base for sizable medical communities and are the locations of UAMS’s Regional Programs.

 

In addition to the hospitals in Little Rock, there are 97 others, 28 of which are identified as Critical Access, having no more than 25 acute care beds. The state has 12 Federally Qualified Health Centers (FQHCs) that provide services at 99 sites and there are also 76 rural health clinics. Forty-three community hospitals have fewer than 100 beds and 39 counties are served by a single hospital. Eighteen counties are served by a single Critical Access Hospital. Twenty-three counties do not have a local community hospital.

 

So far, 64 hospitals have been named as trauma centers at these levels: six (6) at Level I, four (4) at Level II, 19 at Level III, and 35 at Level IV. Level I is the highest level and Level IV is the lowest level. The higher the trauma level, the more severe the injury a hospital can handle. Some of the hospitals in Arkansas’s trauma system are out of state because they treat many people from Arkansas. These include hospitals in Memphis, Tennessee; Springfield, Missouri; and Texarkana, Texas.

 

The number of physician practices in the state is inadequate to provide necessary medical services to the population. Physician and other healthcare provider shortages are common. The average caseload for a Primary Care Physician (PCP) is 1,522 patients. Arkansas ranks 43rd in the nations for number of PCPs (122.3 per 100,000 population). There are only 639 pediatricians and 340 obstetricians/gynecologists in the state. Arkansas ranks 49th in the number of dentists (42.1 per 100,000) to population.

 

The UAMS is a centralized point of referral for all medically complicated patients and provides medical and health education for the entire state. Except for the communities of West Memphis and Helena on the eastern border that depend on the city of Memphis, Tennessee, all state communities relate to UAMS and Little Rock hospitals as major sources of highly specialized medical care. UAMS's Regional Programs provide Family Medicine residency training in communities around the state, which has improved the distribution of PCPs. Family physicians provide most of the state's medical care and are by far the most numerous specialty practitioners in Arkansas. Specialists in obstetrics, pediatrics, internal medicine, surgery, and others have practices in the more urban communities. While Arkansas is geographically of modest size compared to some other states, the distances from cities such as Fayetteville and Texarkana to Little Rock require 2-1/2 to four hours of travel time. For families with few resources, these distances represent significant barriers to access specialized care.

 

In March of 2018, a third satellite clinic of Arkansas Children’s Hospital (ACH) opened in Springdale. The clinic is in a rapidly growing area of the state and will allow more CSHCN access to pediatric specialty care.

 

State Plans and Priorities

 

Healthy Active Arkansas

 

In 2015, Governor Asa Hutchinson launched Healthy Active Arkansas (https://healthyactive.org/).

It is a state-wide, public-private supported partnership, framework, and plan for improving the health of Arkansans. The collaboration brings together a total of 12 state agencies, non-profit organizations, businesses, and entire communities to help children and adults make consistent, informed choices about healthy eating and active living.  The initiative works closely with partners to leverage existing resources to maximize reach and impact.  Encouraging physical activity and healthier food choices has a positive impact on birth outcomes and child health.  Women who are healthier before and during pregnancy lessen the risk of maternal and infant morbidity and mortality. The ADH was involved in the development of the ten-year plan along with the Arkansas Center for Health Improvement (ACHI); Arkansas Coalition for Obesity Prevention; Arkansas Minority Health Commission; Baptist Health; UAMS; and the Winthrop Rockefeller Institute.  The final plan includes nine priority areas: 1. Physical and Built Environment 2. Nutritional Standards in Government, Institutions, and Private Sector 3. Nutritional Standards in Schools: Early Child Care through College 4. Physical Education and Activity in Schools: Early Child Care through College 5. Healthy Worksites 6. Access to Healthy Foods 7. Sugar-sweetened Beverage Reduction 8. Breastfeeding and 9. Marketing Program.

 

ADH Strategic Plan

 

All state agencies were asked by Governor Asa Hutchinson to prepare a two-year strategic plan to cover the period encompassing FY2018-2019. The plan presented by the ADH, and approved by the Governor, is an adaptation of a four-year plan ADH began in January 2016. The goal areas in the two-year plan includes seven areas: 1. Childhood Obesity 2. Hypertension 3. Immunizations 4. Mental and Community Wellness 5. Teen Pregnancy 6. Tobacco Use and 7. Efficiency and Responsiveness.  The ADH publishes and regularly updates the plan that highlights a number of major concerns and issues, including many that are directly related to the MCH population.  The draft FY 2020-2023 plan is in the process of being updated and will continue to include goals and supporting strategies to address MCH population needs.

 

ADH Health Services

 

ADH’s health services are prioritized according to the agency’s strategic plan. The highest priority services are: Immunizations, Family Planning, Women, Infants, and Children (WIC), Sexually Transmitted Infections (STI) testing and treatment, Infectious Disease Outbreak Management, Breast and Cervical Cancer Control, and Environmental Health. All highest priority services are provided in all 75 counties.

 

High-priority services that are not provided in the LHUs are organized through ADH’s central office:  newborn metabolic and hearing screening, school health, safe sleep CoIIN, and home visiting. Secondary priority services include basic preventive services needed in all counties that local healthcare systems may not have sufficient capacity to provide, especially maternity care.

 

Reducing disparities continues to be a major focus of the ADH. The Office of Health Equity and HIV Elimination (OHEHE) provides leadership in improving health outcomes by advocating for health equity for at-risk populations as defined by race or ethnicity, age, education, disability, gender, geographical location, income, and sexual orientation for all MCH programing. OHEHE also serves as ADH’s coordinating office for consultative services and training in the areas of cultural and linguistic competency, coordination, partnership building, program development and implementation, and other related comprehensive efforts to address the health needs of Arkansas’s minority and underrepresented populations. This office promotes the integration of Culturally and Linguistically Appropriate Services (CLAS) within health-related programs across the state to ensure that the needs of the state’s racial and ethnic minority communities are addressed.

 

Title V Priorities and Initiatives

 

There are a number of current priorities and initiatives that provide direction and impact upon the state’s Title V directives. The Title V MCH and CSHCN administrators, along with MCH partners and ADH staff, utilize various methods to determine the importance, magnitude, value, and priority of competing factors that impact health services delivery in the state. The five-year NA and continual assessment during interim years provides valuable direction. The Title V program receives input and advice from statewide partnerships, stakeholders, and other agencies and organizations. Many of our policies and services originate through legislative bills, statutory regulations, administrative rules, and directives from the State Surgeon General and Secretary of Health. Priorities are discussed in the state priorities section, and initiatives are discussed throughout the application.

 

The overall goal of Arkansas's MCH program is to improve health and reduce disparities. Supporting that goal are five Priority Areas:

 

1) Strengthen core services: Family Planning, Prenatal Care, WIC Program, Immunizations, and Home Visiting.

2) Develop more effective population-based approaches: prevent injuries, reduce infant mortality, increase physical activity, and improve oral health.

3) Communicate public health value and societal contribution: economic development, public awareness, and benefits of prevention.

4) Secure adequate human and financial resources: workforce needs and training and funding acquisition.

5) Increase departmental effectiveness and accountability: strengthen leadership, management systems, Information Technology (IT) infrastructure, data use, and accountability.

 

Cross-cutting these areas is an emphasis on community engagement, partnerships, and policy development. The overall theme is to strengthen and improve traditional public health clinical services while focusing on specific program developments, engaging more in public awareness and policy developments, and retooling administrative processes to work more effectively and efficiently. The public is engaged through ADH’s Hometown Health Initiative (HHI), a community-driven process that empowers local communities to take ownership of health problems by working to identify and implement solutions that improve the health of the citizens.

 

MCH Core Partnership Linkages

 

The ADHS houses programs that are important to improving MCH in the state. The ADHS’s Division of Medical Services (DMS) administers the Medicaid Program, which serves approximately two-thirds of children in the state at any given time. Most children are covered on the basis of income eligibility, known as ARKids First (ARKids A or B, depending on income level). Almost 30,000 women in Arkansas receive pregnancy-related Medicaid coverage annually. In 2018, Medicaid paid for 68% of all births.

 

Successful transitioning from pediatric to adult care is a priority of ADH for all youth and young adults in Arkansas, including those with disabilities, chronic health conditions, or other special health care needs. The ADHS is also home to the state’s Title V CSHCN program, which is in the Division of Developmental Disabilities Services (DDS). ADH’s Title V Director is working to improve collaboration with this division, which includes maintaining an important partnership with the Division’s Medical Director. Services for CSHCN are closely associated with specialty services of the UAMS Department of Pediatrics. The Division also supports the state's early intervention program (Part C), also known as First Connections.

 

As the only medical school in the state, UAMS’s role in Arkansas's healthcare system is difficult to overestimate. Development of the UAMS College of Public Health in 2001 led to stronger links between state health-engaged agencies and the university. UAMS's Regional Programs are located around the state and provide direct patient care as well as training of family medicine residents. The University's pediatrics and obstetrics/gynecology departments partner with ADH to provide direct care to women and children and to carry out ongoing public health programs and initiatives to improve systems of care.

 

Arkansas Children’s Hospital (ACH) also plays an important role in the healthcare system. It is one of the largest children's hospitals in the U.S., attracting patients from around the region and other countries. The hospital provides most of the pediatric critical care in the state. The hospital’s administration is also committed to involvement in community and state-level public health concerns such as infant mortality, injury prevention, home visiting, and school health initiatives.