To understand maternal and child health (MCH) population needs in Pennsylvania (PA), it is necessary to learn the geographical, social, economic, and political traits of the Keystone State and its residents. PA is a vast, increasingly diverse state comprised of large rural areas and concentrated urban centers which are both evolving economically and socially. Located in the northeast, PA is the fifth most populous state, home to over 12.8 million people. In addition to its rural and urban divide, the state is physically divided in half by a large swath of rural forest created by the Appalachian Mountains.

PA is anchored by two urban counties, Allegheny in the west and Philadelphia in the east. Urban counties are those with a population density higher than the state population density, while rural counties have a lower density. Harrisburg, the capital and headquarters for the Department of Health (DOH), is situated in the southcentral part of the state. As of March 2018, PA’s 19 large counties (counties where 75,000 or more are employed) accounted for 77 percent of total employment within the commonwealth. All but two of those counties are considered urban. In 2018, nearly 80 percent of the state gross domestic product was produced by urban counties. PA has the sixth largest economy in the nation but, as of February 2020, had a seasonally adjusted unemployment rate that was higher than the national average. In 2018, 28 percent of PA’s population was low income (under 200 percent federal poverty level or FPL), and 43 percent of the state’s Medicaid expansion population worked full or part time but made less than the eligibility threshold of 138 percent FPL.

The health care and social assistance, manufacturing and retail trade sectors are major contributors to the economy. The industry with the greatest number of employees in PA was health care and social assistance in 2018, growing 18 percent since 2008. Employment in agriculture, forestry and fishing (which includes farming) increased from 2012-2018. Of PA ‘s 67 counties, 63 have at least 500 individuals employed in agriculture, forestry and fishing.

The delivery of health care services is significantly impacted by the distinctive rural and urban characteristics across the state. While 48 of PA’s 67 counties are considered rural, nearly three-quarters of PA’s residents live in urban counties. The concentration has become even more pronounced since 2010, as most of the population growth in PA has occurred in urban counties. In 2017, there was one physician for every 775 residents in urban counties, as compared to one rural primary care physician for every 1,387 residents. Of the 16 counties without Federally Qualified Health Centers (FQHC), all but one are rural. As of 2017, of the estimated 512,978 residents living in a designated Primary Care Health Provider Shortage Area (HPSA), the majority lived in a rural county. The only urban areas designated as HPSA were in Allegheny, Beaver, Erie, Luzerne, and Westmoreland counties. Small areas of several urban counties are considered medically underserved. As of 2017, approximately 17.6 percent of PA’s population lived in an area designated as medically underserved. In 2018, there were 68 general acute care hospitals, with a total of 7,827 beds, in rural PA. Seven rural counties had no hospitals. On average, there were 2.14 hospital beds for every 1,000 rural residents compared to 2.54 hospital beds for every 1,000 urban residents.

In addition to a general lack of healthcare resources, rural areas have other challenges including an aging population, a growing young minority population with higher rates of poverty and unemployment and a lack of resources or training to meet the language and cultural needs of the growing immigrant populations. On average, rural PA residents are older than urban PA residents. In 2018, 19 percent of the rural population was 65 years old and older compared to 17 percent of the urban population. From 2010 to 2040, the number of senior citizens in rural PA is projected to increase by 54 percent.

Across the state in 2018, the 154 general acute care hospitals (including 15 Critical Access Hospitals [CAH]) with over 34,400 licensed beds handled nearly 1.45 million admissions. An additional 93 federal and specialty hospitals handled over 160,000 admissions. There are nine children’s hospitals in PA, six of which are in either Philadelphia or Pittsburgh. The other three are in Danville, Erie, and Hershey. Children who live in rural areas or in areas not near these hospitals may not have ready access.

Supplementing the hospitals are over 260 FQHC or rural health centers providing primary care services in 50 counties. FQHCs are an important resource for PA’s vulnerable populations. In 2018, 88 percent of FQHC patients were at or below 200 percent FPL, 49 percent were on Medicaid, and 54 percent were members of a racial or ethnic minority.

CAH are rural hospitals that provide 24-hour emergency services with an average daily census of 25 patients or less. These hospitals serve as key providers in areas with sparse populations, geographic barriers to care, and significant health professional shortages to address populations who are generally older, sicker, and poorer. Besides anchoring a broad range of health and human services in their communities, many of these hospitals continue to be the top employers in their county and major contributors to local economies. Of concern is that in Fiscal Year (FY) 2017, nine of the CAH (60 percent) reported negative operating margins. CAHs also operate on thinner margins in general. As of 2017, the average operating margin for CAHs in PA was 2.3 percent, compared with 5.2 percent at hospitals across the state.

Other important partners in the delivery of services within the MCH system of care are the county/municipal health departments (CMHD) and state health centers. The ten CMHD are in urban areas and tailor services to the needs of their local communities. Primary and secondary preventive health services are emphasized and geared to improve the community’s health through direct health services, education, and leadership. CMHD are funded by Act 315, PA’s Local Health Administration Law, with additional funding by state, federal, and local government going towards local office priorities. At a local level, CMHD currently cover more than 41 percent of PA’s population. In addition, several CMHD have either applied for or achieved public health accreditation through the Public Health Accreditation Board (PHAB). As a result, those communities have access to higher-quality programming and services.

Counties without CMHD have state health centers who provide and support public health programs throughout PA. To organize the state health centers, PA is split into six community health districts, each covering a geographic region of the state. Each health district in turn has a district office that helps coordinate activity throughout the district. Through the utilization of community health assessments and outreach, the centers focus on five core functions: communicable disease investigation and prevention, immunizations, public health education, HIV/STD services, and tuberculosis investigation and treatment.

Health insurance is a key factor for health care access. In 2017, 5.5 percent of the approximately 12.6 million civilian noninstitutionalized population in PA were uninsured. By gender, 6.4 percent of men were uninsured compared to 4.8 percent of women. Only 5 percent of whites were uninsured compared to 7 percent of blacks and 12.3 percent of Hispanics. More than 10 percent of 26 to 34-year-olds were uninsured, the largest proportion of any age group. As educational attainment increased, the percentage insured increased.

The Affordable Care Act (ACA) has brought some insurance relief with the introduction of the federal Marketplace. While the uninsured rate ranges from 3.1 to 12.5 percent across counties, the uninsured are primarily working families with an income below 400 percent of the FPL, unemployed or employed less than full-time, less than a high-school graduate and non-white. As of January 2020, over 331,000 residents had selected a Marketplace plan, of which 88 percent received financial assistance. While the uninsured rate has fallen for all racial and ethnic groups because of the ACA, as of 2018, whites are still more likely to be insured than blacks.

A key component in the MCH system of care is Medicaid, administered in PA by the Department of Human Services (DHS). Medicaid eligibility is determined by having a special condition or belonging to a particular group such as pregnant women, children, low-income adults, elderly adults, or disabled adults and meeting financial and citizenship requirements. Medicaid eligibility levels are highest in PA for children and pregnant women and both are higher than the median United States (U.S.) rate.

Medicaid also has special programs for specific medical conditions and waiver programs available for those who require assistance with activities of daily living or who meet functional requirements (such as those with AIDS, on home ventilators, or with autism). Although these waivers provide a wide array of services (such as home health aides, transportation, and case management), they are not an entitlement and there is no guaranteed entrance.

In addition to covering basic Medicaid services, states can choose to cover up to 30 optional benefits. PA covers 24, including prescription drugs, vision, dental, physical therapy, home health, and hospice care. PA’s Medicaid expansion coverage includes the ACA’s ten essential health benefits and expanded mental health and substance use treatment services. Children with special health care needs (CSHCN) are served by Special Needs Units (SNU) within Medicaid. SNU are housed within physical health Managed Care Organizations (MCO) and ensure CSHCN receive services and supports in a timely manner. SNU also assist CSHCN with access to services and information, coordinate between physical health and behavioral health and other systems, and staff a dedicated special needs hotline. Each physical health MCO has a full-time SNU coordinator. SNU staff also work in close collaboration with the SNU housed within DHS.

Individuals not eligible for Medicaid may qualify for Children’s Health Insurance Program (CHIP), also a part of DHS. CHIP provides free or low-cost health insurance to uninsured children and teens up to age 19 in families with incomes over the Medicaid limit (133 percent FPL). As of April 2020, there were 196,427 children enrolled in CHIP. CHIP and Medicaid combined provided health and long-term care coverage to more than 3 million in PA. Medicaid is also a major source of funding for safety-net hospitals and nursing homes, and most Medicaid spending in PA is for the elderly and people with disabilities. In State Fiscal Year (SFY) 2018, Medicaid accounted for 62 percent of all federal funds received by PA and 27 percent of the state general fund spending.

Following a national trend, PA is becoming more racially and ethnically diverse. From 2010 to 2018, the minority population increased from 36 percent to 40 percent nationally, and from 21 to 24 percent in PA. Minority residents make up more of the population in urban areas (30 percent) than in rural areas (9 percent). The population identifying as Hispanic increased in PA by 35 percent from 2010 to 2018, increasing by at least 7 percent in every county but two. From 2000 to 2018, the rural population became more racially diverse, as the non-white or Hispanic rural population increased from 5 percent of the total population, to 9 percent. As of 2017, approximately one in three PA children are children of color. With the total minority population projected to double between 1990 and 2025, the responsibility and challenge of the Title V program is to understand their diverse backgrounds and how services and Title V programming can adapt to their needs.

With an increasingly diversifying population, it is important to consider how people of color experience PA’s system of care, signified by key MCH indicators. In 2017, the infant mortality rate for whites was 4.8 per 1,000 live births. The rate for blacks was more than three times that, and for Hispanics, it was 31 percent higher. For blacks, the disparity has persisted since at least 1999, and for Hispanics, since 2012. Preterm births are a leading cause of infant death. In 2018, the percentage of preterm births for whites was 8.7 percent. Blacks had a percentage that was one and a half times that of whites (roughly 50 percent higher), and for Hispanics, the percentage was 15 percent higher than that of whites. The disparity for preterm births for Blacks has been roughly the same since 2003. From 2011 to 2015, the maternal mortality rate for whites was 13.3 per 100,000 births. The rate for black mothers was three times the rate for whites. In 2018, one percent of white mothers had no prenatal care; for black mothers, it was nearly four times that, a disparity that has not changed since 2011. For Asian and Hispanic mothers, the percentage was approximately twice that of whites. That disparity has existed for Hispanic mothers since 2003. A lack of prenatal care has been linked to poor birth outcomes, including low birth weight and infant mortality. In 2018 the teen pregnancy rate for whites was 4.2 per 1,000 females aged 15-17. Despite teen pregnancy rates for blacks having dropped over 60 percent from 2010-2018, rates are still three times that of whites. Like blacks, despite a decline in teen pregnancy rates from 2010 to 2018, the teen pregnancy rate for Hispanics was nearly four times that of whites. That disparity has been roughly the same since 2010. With the projected increase in populations of color, if health disparities in these populations are not addressed, they have the potential to create a greater burden over time.

Overlapping the disparities are familial, educational and economic characteristics of the population that further define their interaction with the MCH system of care. In general, PA is growing older. The median age of PA residents is 40.8 years old, nearly three years older than the U.S. median age. From 2010-2018, PA’s population grew less than 1 percent, the number of young residents (under 18) decreased nearly 5 percent, but the number of residents 65 and older increased 19 percent. In 2040, an estimated 25 percent of the total rural population will be 65 and older. At that time, there will be more senior citizens than children and youth in rural PA. Counties with large elderly populations could face the possibility of diverting resources from MCH populations towards their elderly residents.

Of the approximately 5 million households in the state in 2018, over 3.2 million of these households are defined as families, with an average size of 3.04 members. The U.S. Census Bureau categorizes families as: married-couple families, male householder (no wife present) and female householder (no husband present). While married families are most common, over 71 percent of non-married families are female-led. These households have slightly larger family sizes, are more likely to have members less than 18 years of age and are more likely to live in multi-unit structures. Over eight percent of all households in PA are single parent households with children under 18 and no spouse present. PA had a lower percentage of households with children (25 percent) than the national figure (27 percent). The population of children under age 18 is evenly distributed across age groups for each family type. Of the 2.63 million children in the state, approximately 1.73 million live in a married family. Almost 213,000 children live in male-led families; and roughly 672,000 children live in female-led families, which are less likely to have an unmarried partner present.

The racial distribution greatly varies between types of households with children. While 82 percent of children in married families are identified as white, nearly 74 percent of children in male-led families and nearly 50 percent of children in female-led families identify as white. Over 58 percent of black adolescents and nearly 41 percent of Hispanics live in female-led families compared to only 17.4 percent of whites. Female-led families are more likely to have grandchildren in their households, and more likely to have a child with a disability in their household when compared to other households.

According to the 2017-18 National Survey of Children’s Health, 19.6 percent of children in PA have special health care needs. Children and their families may encounter multiple barriers to perform daily life functions and often need services from multiple systems of care which can be challenging for families to navigate.

Median income varies by county from $38,400 to $96,700; for families with children, it is $75,601. However, there are stark differences in median income when considering family type. The median income for married families is $101,515, $44,158 for male-led families and $27,500 for female-led families. In addition, female-led families are slightly larger in size than male-led or two-parent families, but their median income is much lower. Women’s income is also affected by the wage gap. In 2018, women in PA are earning the national average of 82 cents for every dollar a man makes. The wage gap is even greater if the woman is a minority.

In 2018, a smaller percentage of PA residents (12.2 percent) lived in poverty compared to the national rate (13.1 percent). However, there are still large swaths of the population living in poverty, as 26.1 percent of PA’s black residents and 26.3 percent of PA’s Hispanic residents lived in poverty and families with black or Hispanic householders were more than three times as likely to be living in poverty than whites. Of the 1.37 million families with related children under 18, 13.8 percent were living below the poverty level during the previous year. Female-led families were more likely than any other to be living below the poverty level. For families with children under 18, female-led families were twice as likely to be living below the poverty level. The highest rates of poverty were for those families with a householder having less than a high school education. However, at all levels of educational attainment, the percentage of female-led families living below the poverty line was higher than other families, more than double in most cases.

Adolescents (15 to 19 years) are an important sub-population within the MCH population, numbering approximately 823,000 with almost 88 percent enrolled in school in 2017. School enrollment among adolescents is consistent by race and ethnicity, with Hispanics having the lowest enrollment at 84.1 percent.

Future earnings are related to a person’s level of educational attainment. For the nearly 9 million people aged 25 years and over in PA, 91 percent have a high school degree or higher, varying a bit by county, and nearly 32 percent have a bachelor’s degree or higher. For this same population, for whom poverty status is determined, the rate of poverty for those with less than a high school diploma is 23.5 percent and decreases with educational attainment. The median annual income for those aged 25 years and older is approximately $41,250 and ranges from $26,100 for those with less than a high school diploma or equivalency to $71,200 for graduate or professional degree holders. Of the approximately 1.16 million 18 to 24-year old’s, 35.5 percent have graduated high school; 44 percent are enrolled in college or graduate school and 13 percent have a bachelor’s degree or higher. Females in this age group are enrolled in college or graduate school at a higher rate than males.

According to a 2016 Williams Institute analysis of Census Bureau data, there are 22,340 same-sex couples in PA (sixth nationally) compared to 646,500 in the U.S. with almost 16 percent of these couples in PA raising children. Most same-sex couples in PA are women (56 percent) and 81 percent are white. The mean income for same-sex couples is higher than that of different-sex couples, $52,000 versus $46,000, and over half have a college education as compared to only 33 percent of different-sex couples. Ninety percent of same-sex couples have health insurance. In PA, three percent of people identify as Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) with 27 percent raising children; the U.S. numbers are four and 29 percent, respectively. As with same-sex couples, most of the LGBT population is white (72 percent). PA ranks 38th in percentage of LGBT individuals. Over a quarter (28 percent) of LGBT individuals have an income less than $24,000 as compared to non-LGBT individuals (21 percent). More non-LGBT (90 percent) individuals have health insurance than LGBT individuals (86 percent). The percentage of non-LGBT and LGBT individuals having a college education is nearly equal. As of 2018, 4.1 percent of PA is LGBT, compared to 4.5 percent nationally, and PA has 32,719 same sex households (935,229 nationally), 58.6 percent of whom are married.

LGBTQ residents face ongoing health inequities in terms of their absence in statewide surveillance systems, discrimination by healthcare providers, in the workplace and in social situations. Over half of LGBTQ individuals have reported discrimination at some point based solely on sexual orientation, which remains legal in PA. There are few laws protecting LGBTQ families regarding insurance coverage, hospital visitation rights and powers of attorney. Members of LGBTQ groups have health needs both regular and specific to their sexual and gender orientation that often go unmet. In response to a range of discriminatory laws being passed in other states, Governor Wolf signed executive orders in April 2016 stating, “no agency under the governor’s jurisdiction shall discriminate on the basis of sexual orientation, gender expression, and identity, among other areas.” These orders pertain to commonwealth employees, and the commonwealth grants and procurement process. Over 40 municipalities have passed separate ordinances to prohibit discrimination based on sexual orientation and gender identity.

The Secretary’s priorities combined with the State Health Improvement Plan (SHIP) and the DOH’s Strategic Plan guide the agency and illuminate areas for Title V to implement work to improve the health of populations in PA. The DOH is currently near the end of its SHIP for 2015-2020, developed in partnership with a broad representation of public health system stakeholders. The SHIP priorities are: 1) obesity, physical inactivity, and nutrition; 2) primary care and preventive services; and 3) mental health and substance abuse. Through the process of defining the SHIP priorities, five cross-cutting themes were also identified: health literacy, public health systems, health equity, social determinants of health and integration of primary care and mental health. In 2018, the DOH prioritized the protection of access to health care in rural communities using a Rural Health Model, developed in coordination with the Centers for Medicaid and Medicare Services. Five hospitals and five payers participated in year one of the model in 2019.

The State Health Assessment (SHA), which reports on the health status of PA's population, factors that contribute to health issues and resources that can be mobilized to address population health improvement, was last updated in 2019. The Department is currently conducting work for the 2020 SHA.

The DOH 2020-23 Strategic Plan consists of the following five key strategies: 1) Maintain and enhance emergency services and public health preparedness; 2) Continually develop our talents to significantly advance public health in PA; 3) Promote public health with awareness, prevention and improvement of outcomes where the need is greatest; 4) Use data, measures, and technology to enable public health performance; and 5) Improve staff, customer, and partner experience with consistent, efficient, and effective services and work processes. These department strategies closely align with the work of Title V in PA and the Bureau of Family Health (BFH), as the Title V administrator, will continue to emphasize evidence-based and data driven decision-making within its programming while increasing the integration of quality improvement techniques throughout its work.

The planning process for the 2020-2023 Strategic Plan resulted in 20 annual planning projects to be conducted during the first year of the plan. The BFH will be leading one of these projects - improving maternal and child health outcomes through data-driven, collaborative, and evidence-based approaches. The project is aimed at benefitting populations experiencing disparate outcomes and those most at risk for adverse outcomes.

In March 2019, the DOH achieved national public health accreditation per notification from the Public Health Accreditation Board. Accreditation ensures that the DOH is meeting national evidence-based standards and providing PA residents with the best programs and services available. Accreditation can help the BFH improve collaborations between staff and stakeholders and further the Title V mission and programming through increased accountability, quality service delivery and institutionalized processes, such as the use of evidence-based practices and integration of quality improvement techniques.

PA’s MCH system of care is further augmented by state statutes mandating programs serving the MCH populations and requiring the resources of Title V in both staff and funding. The Newborn Child Testing Act (35 P.S. § 621, et. seq. and amended by Act 36 of 2008) establishes a program providing for the screening tests of newborn children and follow-up services related to case management, referrals, confirmatory testing, assessment and diagnosis of newborn children with abnormal, inconclusive or unacceptable screening tests results. Act 87 of 2008 mandates the Child Death Review (CDR) Program, which provides for statewide and county-based multidisciplinary CDR teams to conduct reviews of all deaths of children aged 21 and under. The Act also requires an annual report on the information, distribution and causes of child deaths in PA and reflects information collected during the CDR process from collaborative processes between the DOH and local CDR teams. The Pennsylvania Code (028 Pa. Code § 27.22 and 028 Pa. Code § 27.34) requires laboratories and providers to report blood lead test results to the DOH. Act 24 of 2018 establishes a Maternal Mortality Review Committee to conduct multidisciplinary reviews of maternal deaths and develop recommendations for the prevention of future maternal deaths.

Impacting PA residents, the health care system and the broader landscape of the MCH system of care are several important, emerging issues. Like other states, the epidemic of opioid use is now a priority of both the Governor’s administration and the DOH. In 2018, PA’s mortality rate from opioid deaths was higher than the national rate (23.8 versus 14.6 per 100,000), and more than double that of 2015 (11.2). According to the Drug Enforcement Administration’s PA Opioid Report, there were 4,491 drug-related overdose deaths in 2018, an 18 percent decrease from 2017. While there is a broad range of ages for these deaths, the typical decedent is male and between 25 and 34 years old. The distribution of overdose deaths by race in PA roughly corresponds to the state’s racial makeup, and 70 percent of all overdose deaths in PA were male. An additional impact of opioid use that affects the MCH population is that of Neonatal Abstinence Syndrome (NAS). According to data from the PA Health Care Cost Containment Council, in Federal Fiscal Year (FFY) 2017-18, there were 1,833 reported newborn hospital stays with NAS, a rate of 15.2 per 1,000 newborn hospital stays. This puts an additional burden on the health care system, as the mean length of hospital stay for newborns with NAS during that time was 15.9 days, nearly five times the average stay of 3.4 days for all other newborns. NAS-related stays added an estimated $15.2 million in hospital payments in FFY 2018.

Attempts to combat the drug problem are multi-faceted and range from improving prescribing practices to providing better and more widely available addiction treatment services. In January 2018, Governor Wolf declared the heroin and opioid epidemic a statewide disaster emergency, a first for a public health emergency. The declaration allowed for the creation of a command center that will track progress and enhance the coordination of health and public safety agencies, helping commonwealth agencies address the opioid epidemic. In December 2019, the Governor signed an eighth consecutive 90-day renewal of the declaration extending the designation of the opioid epidemic as a disaster emergency. The Secretary of Health, Dr. Rachel Levine, is working to have the epidemic declared a public health disaster, which is an unprecedented step.

Another challenge in PA is the rate of suicide and the stigma around mental health. Suicide rates in PA have increased by 34 percent since 1999. In May of 2019, Governor Wolf announced the establishment of a statewide Suicide Prevention Task Force which will be responsible for developing a statewide strategy to prevent suicide and promoting resources and training. The task force’s initial report indicated that mental health and wellness services as well as suicide prevention strategies are needed among school-aged youth and adolescents. PA applied and was accepted into the 2020-2021 School Health Services National Quality Initiative Collaborative Improvement and Innovation Network (CoIIN) Comprehensive School Mental Health Track, with the first meeting expected in October of 2020. PA’s focus in the CoIIN will be to inform interagency efforts around trauma-informed practices and best practices for development of community schools and implementation of mental health services in the school system.

Children in PA are also increasingly experiencing trauma and adverse childhood experiences (ACES) early in life. As of 2016-17, 24% of children in PA had experienced at least one ACE and ACES were most commonly reported among racial and ethnic minority children and among CSHCN. In 2019, Governor Wolf established the Office of Advocacy and Reform (OAR), which was tasked with the protection of vulnerable populations in PA, including children. Since then, the OAR launched a think tank to develop a plan to make PA a trauma-informed state. PA was also recently selected as one of four states that will participate in the National Governor Association’s Robert Wood Johnson Foundation “Improving Well-being and Success of Children and Families - Adverse Childhood Experiences Learning Collaborative” initiative. Through these efforts, PA aims to develop best practices for addressing ACES and a plan that will aid state and local agencies as they work to use trauma-informed principles to guide decisions.

In addition to the aforementioned health issues, the 2019 novel coronavirus (COVID-19) pandemic has presented an unprecedented challenge to the world, to the U.S., and to PA and its public health system. COVID-19 prompted the federal declaration of a nationwide emergency and, in PA, the activation of a command center at the Pennsylvania Emergency Management Agency and a disaster declaration. PA continues to monitor COVID-19 cases and fatalities across the state and is actively engaged in supporting the public health and medical systems with the response. While COVID-19 cases continue to rise daily, as of June 2020, PA has over 78,000 positive cases and over 6,000 Pennsylvanians have died. While adults aged 65 and older as well as those who are immunocompromised or with underlying conditions are at highest risk of contracting the virus, the CDC also advises pregnant persons to take extra precautions.

Many women in PA have reported delays and interruptions in their routine health care visits as a result of COVID-19. Title V-supported programs offer important safety-net services during times of crisis when the health care system may be overwhelmed by caring for emergent cases. For example, in March 2019 a mother brought her four-month-old infant to a routine well-child visit at an IMPLICIT Interconception Care (ICC) provider. The physician utilized the IMPLICIT ICC screening tool and found that the woman was at risk for depression. The mother reported a history of depression and indicated that the stress of the global COVID-19 crisis – as well as the stay-at-home orders in place for much of PA – was making it difficult for her to maintain her mental wellness. The child’s physician provided counseling to the mother regarding her mental health and shared information regarding how to stay safe and healthy during this time. During the screening process, the mother also shared that she was not utilizing any form of contraception and that she was concerned about becoming pregnant so soon after delivery. She reported that her contraception appointment with her provider had been cancelled due to the pandemic. As a result of this information, the child’s physician discussed options regarding contraception with the mother and was able to start the mother on oral contraceptive pills that day.

Additionally, both national and state data demonstrate that a disproportionate burden of illness and death due to COVID-19 is apparent among racial and ethnic minority groups and among other disparate populations. In response, the Department of Health’s, Office of Health Equity established the COVID-19 Health Equity Response Team (CHERT) to ensure that the needs of disparate communities were included in the plans to address COVID-19, that communities survive the pandemic, and that the communities have an equitable recovery. The CHERT is charged with mitigating the effects of COVID-19 in the present and in the future by leading a group of stakeholders, including the Department of Health’s Culturally and Linguistically Appropriate Services (CLAS) Task Force and the Pennsylvania Interagency Health Equity Team, as they apply a health equity lens to the state’s response and work to address challenges relevant to twelve subpopulations: pregnant women/young children, Pennsylvanians 65 years and older, racial and ethnic minorities, rural Pennsylvanians, Pennsylvanians with disabilities/individuals who live in short-term or persistent housing insecurity/live in congregate housing, survivors of intimate partner violence, individuals living with mental health or substance use disorders, economically challenged individuals/low wage essential employees/un- or underinsured and LGBTQ persons. The BFH has deployed staff to participate on nine of the twelve subcommittees as they work on clinical care considerations for vulnerable populations at risk for COVID-19, predictive modeling, strategic communications, coordination of strategic partnership, mass fatality management, and economic stability and revitalization.

Governor Tom Wolf and Lieutenant Governor John Fetterman also created the COVID-19 Response Task Force for Health Disparity in order to help communicate how the pandemic is affecting the state’s minority and vulnerable populations. This task force elevates recommendations from diverse groups and allocates resources and support to drive action to address the disparities. Facilitated by the Lt. Governor, the Task Force is comprised of members of the Wolf Administration, the Governor’s five commissions representing minority populations, stakeholders and legislators, the Department of Community and Economic Development and CHERT leadership from the Department of Health. An initial effort to better account for the burden of COVID-19 on vulnerable LGBTQ populations came in early May 2020 when the Governor announced that new data collection on COVID-19 will include sexual orientation and gender identity. Recommendations from the CHERT and its subcommittees will be shared with Department of Health leadership, the COVID-19 Response Task Force for Health Disparity and the Governor for the benefit of Pennsylvanians.

While the COVID-19 response in PA has been swift and robust, the pandemic and associated measures to prevent the spread of infection have had an economic impact. Due to reduced revenues over the past two months, PA currently faces a deficit. While the impact of the deficit on the 2020-2021 state budget remains to be seen, it is possible that the funds typically available for the Title V state match may be affected.

PA is a state of contrasts presenting unique challenges to the delivery of services and resources across the MCH system of care. An aging but diverse population will gradually force a system adjustment to meet geographic, programmatic, and cultural needs. Swaths of poverty are inseparable from gender, education, race and ethnicity with women led families bearing an unequal burden. Systems of care are equipped to meet urban needs but not rural needs. This, however, is not as dire as it seems. There is strength in the access to care provided by Medicaid and CHIP, the local work of the CMHD, and DOH development of strategic plans, initiatives and programs to meet current and emerging challenges such as maternal mortality, opioid addiction, mental health/suicide, ACES and COVID-19. The PA Title V program will have to be nimble and adaptable to meet the changing landscape of MCH service needs in PA.