Geography, Demographics, and Economy

Michigan encompasses 56,804 square miles of land and is the only state made up of two peninsulas. Composed of 83 counties, Michigan is the10th most populous state and 11th largest state by total square mileage. Nearly 10 million people lived in the state in 2019. According to the U.S. Census Bureau, while Michigan saw its eighth consecutive year of population growth, it has slowed to less than 3,000 new residents over the past year. Michigan has seen a steady decrease in birth rates over the past 20 years, including a decline in teen births. Most of Michigan’s population resides in the southern half of the Lower Peninsula, with approximately half of the population residing in Southeast Michigan. The state’s largest cities are Detroit, Grand Rapids and Warren. Over 1.7 million people live in rural areas. The median age of the population is 39.5 years of age. Out of the total population, approximately 22% are age 0-17 and 78% are age 18 and over. Michigan’s population is 79.3% Caucasian, 14.1% Black or African American, 3.4% Asian and Pacific Islander, 2.5% two or more races, 1.1% other races, and 0.7% Native American. Out of the total population, 5.2% identify as Hispanic or Latino.

Michigan’s economy saw improvements over the past nine years, with the seasonally adjusted unemployment rate decreasing from 14.9% in June 2009 to 4.0% in January 2019. However, the COVID-19 pandemic is having severe economic impacts on the state. Since March 15, over 1.7 million workers applied for unemployment in Michigan. The immediate and long-term effects of COVID-19 are expected to have a significant impact on recent economic gains as well as future economic viability. In addition to COVID-19, the state faces significant challenges that affect the maternal and child health (MCH) population. For instance, even before the pandemic certain areas of the state experienced higher unemployment. According to the 2019 ALICE (Asset Limited, Income Constrained, Employed) report, 61% of jobs in Michigan were low wage jobs, paying less than $20 per hour; out of those jobs, two-thirds paid less than $15 per hour.

Poverty remains a significant issue, especially for Michigan’s children. Michigan ranks 32nd in the nation for overall child well-being. According to Kids Count in Michigan (2019), one in five children (416,305) ages 0-17 live in poverty. Statewide, the percentage of students eligible for free or reduced-price lunches increased 30% over a nine-year span. In 2017, 50.3% of students were eligible for free or reduced-price lunches.

Of additional concern are findings from the 2019 ALICE report indicating that even in households with earnings above the federal poverty level (FPL), 43% of households struggle with basic needs such as housing, childcare, food, health care and transportation. In addition to households below the FPL in Michigan, this equates to more than 1.66 million households struggling to meet basic needs. Given this environment plus the impacts of COVID-19, family support programs—such as WIC, food and cash assistance, health care and childcare—will continue to be critical resources for Michigan families.

Agency Roles and Priorities

The Title V program is administered by the Division of Maternal and Infant Health (DMIH) which is housed in the Bureau of Health and Wellness (BHW) within the Public Health Administration. The DMIH program areas include Family Planning and reproductive health, the Maternal Infant Health Program, infant safe sleep, and Early Hearing Detection and Intervention. In addition to the DMIH, the BHW includes the Division of Child and Adolescent Health; Women, Infants and Children (WIC) Division; Division of Chronic Disease and Injury Control; and Local Health Services. To coordinate the Title V grant, the DMIH works in partnership with the Children’s Special Health Care Services (CSHCS) Division and the Division of Child and Adolescent Health (DCAH). CSHCS includes the Family Center for CYSHCN, CSHCS customer support, policy and program development, and quality and program services. The DCAH oversees Title V contracts to Michigan’s 45 local health departments which implement local MCH work. These Title V areas work collaboratively with an array of programs within the Michigan Department of Health and Human Services (MDHHS) which oversees program areas including but not limited to public health; environmental health; emergency preparedness and response; communicable and chronic disease; Medicaid; food and cash assistance; migrant and refugee services; child support; juvenile justice; child and adult protective services; and foster care and adoption.

In 2020, MDHHS released a new vision and new strategic priorities. The MDHHS vision to “Deliver health and opportunity to all Michiganders, reducing intergenerational poverty and health inequity” is supported by four strategic priorities:

• Give all kids a healthy start. Improve maternal-infant health and reduce outcome disparities; become a national leader in reducing childhood lead exposure; and create a child welfare system that reduces maltreatment and is a model for prevention.
• Provide families with stability to escape poverty. Expand and simplify safety net access and protect the gains of the Healthy Michigan Plan.
• Serve the whole person. Address food and nutrition, housing, and other social determinants of health; integrate services, including physical and behavioral health, and medical care with long-term support; and reduce opioid and drug-related deaths.
• Use data to drive outcomes. Manage to outcomes; invest in evidence-based solutions; and drive value in Medicaid.

Michigan’s Title V program aligns with and supports several of these priorities. In September 2019, Michigan released the 2020-2023 Mother Infant Health & Equity Improvement Plan (MIHEIP) which focuses on the mother-infant dyad and builds on previous work and existing partnerships, while expanding partnerships and strategies that can enhance the ability to address the root causes of adverse outcomes—social determinants of health and drivers of health inequity. Efforts to achieve the collective vision of “Zero preventable deaths. Zero health disparities” are focused on working with local communities and Michigan’s families to 1) align public and private sector interventions, 2) integrate evidence-based and promising practice interventions, and 3) explicitly address disparities.

The MIHEIP was developed collaboratively by MDHHS and stakeholders. Through town hall listening sessions, input was garnered from MCH stakeholders, families and community members across the state. Feedback from the Maternal Infant Health and Equity Collaborative (MIHEC), health care providers, hospitals, local health departments, health plans, universities, professional associations, business, community leaders and the voices of Michigan families have been infused into the MIHEIP as well as the work of Regional Perinatal Quality Collaboratives (RPQCs). Implementation of the MIHEIP is multi-faceted to increase its reach and impact. It includes alignment of programs within MDHHS to increase the awareness, reach, and availability of public health resources; implementation of quality improvement projects within each RPQC; and external implementation through community partners and maternal infant health providers.

To support the MDHHS priority to give all kids a healthy start, early childhood system building is also critical. The Office of Great Start (OGS) within the Michigan Department of Education (MDE) leads the integration of the state’s health, development and early learning investments for prenatal to age 8. MDHHS collaborates with OGS and other partners to support the development of early childhood systems that are designed around the needs of children and families. One example of Michigan’s cross-systems work is the launch of a new Home Visiting Advisory (co-led by MDHHS and MDE) in 2019 that is charged with building an integrated home visiting system that provides Michigan’s families with the right model, at the right time, in the right place. Several MDHHS program areas, including Title V, serve on the Advisory and on the Great Start Operations Team (GSOT). The GSOT convenes state agencies and partners to provide strategic direction and to address early childhood services integration and coordination for programs that serve Michigan's families and young children.

Strengths and Challenges that Impact the MCH Population

Through the 2020 Title V needs assessment and ongoing program work, Michigan’s Title V program identified strengths and challenges that impact the MCH population. In summary, strengths include:

• Strong, longstanding relationships with Michigan’s local health departments.
• Home visitation programs with the ability to positively impact maternal and infant health and early childhood development.
• Commitment to addressing health disparities and pursuing equity within the MCH system.
• Educational campaigns that leverage technology, social media, and community voice to disseminate health information.
• Recognition of the impact of social determinants on health.
• Existing resources and services intended to meet basic needs.
• A strong system to elevate family voices and serve children and youth with special health care needs.

A core strength is Michigan’s public health system which is comprised of 45 LHDs serving 83 counties and the City of Detroit. MDHHS works closely with LHDs to provide comprehensive public health services to Michiganders. This decentralized public health infrastructure allows for local efforts within the community to remain connected to the state for support, funding and other resources.

Michigan has a robust home visiting system that provides preventive services to pregnant women and families with infants and young children. Evidence-based home visiting models in Michigan include the Maternal Infant Health Program (MIHP), Nurse-Family Partnership, Healthy Families America, Early Head Start-Home Based, Parents as Teachers, and Family Spirit. These models offer families the opportunity to connect with a home visitor who can partner with them to meet their needs. The potential of home visiting has been recognized by Governor Whitmer, who discussed healthcare concerns for women and new moms (including health disparities among women of color) and called attention to home visiting programs in her January 2020 State of the State address. Details are included in the Healthy Moms, Healthy Babies factsheet.

MDHHS and its MCH partners are working to intentionally change MCH policies and programs to address discrimination and disparities in health outcomes. MDHHS has instituted a Diversity, Equity and Inclusion Plan that details the Department’s “commitment to eliminating systematic inequities and promoting diversity, equity and inclusion.” The MDHHS Office of Equity and Minority Health (OEMH) delivers an annual report to the state legislature on the Department's progress and health disparities among key populations within the state. The OEMH also provides training to the MDHHS workforce on unconscious bias, systemic racism, and community engagement.

Another strength is the recognition of social determinants of health and the understanding that good health requires a robust infrastructure to meet basic needs. MI Bridges is an online site managed by MDHHS that enables users to apply for benefits (including healthcare coverage, food assistance, cash assistance, childcare, and state emergency relief) and to find resources such as transportation, food, and utilities assistance. MI Bridges users can review and access their benefits information; renew benefits; and share beneficiary information with their specialist. Women, Infants and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP) both provide resources and support for families experiencing food insecurity. These and many other programs connect Michigan’s MCH population to resources to help meet basic needs.

In 2020, MDHHS identified social determinants as a strategy integral to serve the whole person.  The goal of this strategy is to improve the health and social outcomes of all Michiganders while working to achieve health equity by eliminating disparities and barriers to social and economic opportunity. Sub-strategies include: realign programs, policies and resources to improve equity and address community directed SDOH needs; reduce barriers to economic mobility; and support robust community continuums of care.

Michigan has created innovative educational campaigns that leverage technology and social media to reach their intended audiences, such as safe sleep. Additionally, initiatives like the Mother Infant Health and Equity Improvement Plan leverage community voice to influence decision making and provide cohesive messaging.

Finally, Michigan’s CSHCS program has a long-standing history of providing services and resources to children and youth and elevating parent leadership within its organizational structure. Michigan’s CSHCS program provides medical care and treatment, care coordination services, insurance payment, transportation support, and access to social support groups.

The Title V needs assessment also highlighted challenges facing Michigan’s MCH system and the families it serves, including:

• The impact of poverty coupled with limitations in the MCH system for addressing poverty as a driver of health outcomes and health disparities.
• Gaps in capacity to support access to services that meet basic needs like reliable transportation, quality childcare, and quality healthcare.
• Communities face inadequate investment in their cities and neighborhoods.
• Culturally and linguistically appropriate health information is not consistently produced across programs and services.
• Gaps in respite care for caregivers of CSHCN.
• Systemic barriers impede access to mental and behavioral health services.
• Racism and other drivers of health inequity.

The MCH system recognizes a substantial need for strategies and resources to address basic needs created by poverty. Availability, accessibility, program capacity, eligibility requirements and programmatic silos are challenges that impede families’ ability to meet their basic needs. Access to public or reliable transportation, quality childcare services, and access to healthcare services were frequently identified in the needs assessment as gaps driven by poverty.

A lack of investment in communities and low resident engagement also negatively contributes to the health of communities. Therefore, funding and support for community resources, in conjunction with community member engagement, is needed to improve the environment where people learn, live, work and grow.

The needs assessment also identified the importance of tailoring health information materials to be more culturally and linguistically appropriate. While dissemination of health information via technology and social media was noted as a strength, the materials and messages themselves were not always adapted to reflect the state’s cultural and linguistic diversity.

Respite care for families with a child with special health care needs was identified as a gap. Families and caregivers expressed difficulties finding quality and reliable respite care. Michigan currently has few options for reimbursing families for respite care and has identified this as an area for increased attention in the future.

Access to quality, integrated physical and mental health care was identified as a challenge for the MCH population. Barriers to accessing care were exacerbated by provider shortages, rural disparities in access, a lack of specialty care providers, the rising cost of health care services and prescription drugs, and the stigma associated with receiving mental health care.

Lastly, the MCH system faces a challenge in tackling racism, discrimination, and health inequities across programs and services. There continues to be a need to identify and address racism and discrimination in policies, procedures, and practices. This requires the allocation of time, resources, and continued prioritization by leadership, as well as elevating the voices of those most impacted.

Changes in Health Status and Needs

MDHHS continues to closely monitor infant and maternal mortality and has seen the following trends and emerging concerns. The infant mortality rate in Michigan for 2018 was 6.6 deaths per 1,000 live births, which has remained stable over the past five years (range 6.6 to 6.8 per 1,000 live births since 2014). Racial and ethnic disparities remain a major contributor to the persistence of these rates. The Black infant mortality rate has continued to be approximately three times that of the White infant mortality rate (most recently, 14.5 versus 4.6 per 1,000 live births in 2018). The pregnancy-related mortality ratio in Michigan for 2016 was 11.5 maternal deaths per 100,000 live births[1]. As with infant mortality, disparities between Black and White mothers are striking, with the Black pregnancy-related mortality ratio more than two times that of the White rate (20.4 versus 8.6 per 100,000 live births based on 2012-2016 data). In addition to maternal deaths caused by pregnancy-related issues, addressing pregnancy-associated mortality[2] remains an important component of Title V work: 47.4% of all pregnancy-associated injury deaths from 2012-2016 were caused by accidental poisoning/drug overdose. Michigan’s maternal mortality committees have focused their efforts on developing recommendations to help prevent current and expecting mothers from developing opioid use disorders.

Emerging Public Health Issues that Impact the MCH Population

Infant and maternal mortality remain two critical public health issues in Michigan. Other public health issues include COVID-19, substance use challenges, lead exposure, per and polyfluoroalkyl substances (PFAS), and vaccine hesitancy which are discussed below.

COVID-19

The Coronavirus (COVID-19) pandemic has had a significant impact on public health in Michigan, including the MCH population. As of July 15, 2020, Michigan had 71,197 confirmed cases and 6,085 deaths. Michigan’s first presumptive positive COVID-19 case was reported on March 10 and Governor Whitmer declared a state of emergency on the same day. On March 16, the Governor ordered restrictions on restaurants, bars, and entertainment venues. On March 24, the Governor issued a statewide “Stay Home, Stay Safe” executive order 2020-21 to fight the spread of COVID-19. All of Michigan’s 83 counties have at least one confirmed case with the majority in Southeast Michigan (Macomb County, Oakland County, and Wayne County including the City of Detroit). Michigan made progress in containing the spread of COVID-19, but given an increase in cases and emerging hotspots in July, the Governor signed executive order 2020-147 on July 10 requiring individuals to wear a face covering in indoor public spaces to help reduce the chance of spreading of COVID-19.

While deaths in Michigan have ranged from ages 5 to 107, the direct health impact of COVID-19 has disproportionately affected African Americans and individuals with pre-existing health conditions and/or over the age of 60. According to a press release from the Governor’s office, “As of July 5, Black Michiganders represented 14% of the state population, but 40% of confirmed COVID-19 deaths in which the race of the patient was known. COVID-19 is over four times more prevalent among Black Michiganders than among white Michiganders.” Governor Whitmer created the Michigan Coronavirus Task Force on Racial Disparities to assess disparities and make recommendations to address systemic inequities. In July, the Governor signed executive directive 2020-7 which will require implicit bias training for licensure and registration of health care professionals. The MDHHS OEMH also created resources on COVID-19 and minority health.

The economic impact of COVID-19 in Michigan has been extreme. As of late May, claims for unemployment benefits passed 1.7 million. On March 25, the Governor signed executive order 2020-24 to temporarily expand unemployment benefits. The expansion included individuals who cannot work due to caring for family members (including children who are home due to school and daycare closures) and individuals who are sick or quarantined but do not have paid sick leave, both of which will assist Michigan’s MCH population. The Governor also signed an agreement with the U.S. Department of Labor as part of the federal CARES Act to extend unemployment benefits to workers in the gig economy and those who are self-employed or independent contractors.

Throughout the pandemic, Michigan’s MCH programs have worked hard to continue to support women, mothers, children, and CSHCN. For example, Michigan’s home visiting programs have continued to deliver services through remote appointments and referrals. MCH programs have provided regular updates to community members, partners, and providers on COVID-19 resources. MCH staff has supported the state’s COVID-19 hotline and contact tracing. Additional information on COVID-19 in Michigan and the state’s response is available on the State of Michigan website.

Substance Use

Michigan continues to experience an increase in opioid use during pregnancy and, as a result, an increase in the number of infants diagnosed with Neonatal Abstinence Syndrome (NAS). Figure 1 details the incidence of NAS by region. As illustrated by the map, rural areas of Michigan have been hardest hit by this epidemic.

Figure 1. Map of 2018 NAS Rates by Prosperity Region

Data source: Michigan Resident Inpatient Files created by the Division for Vital Records and Health Statistics, Bureau of Epidemiology and Population Health, MDHHS, using data from the Michigan Inpatient Database obtained with permission from the Michigan Health and Hospital Association Service Corporation (MHASC). All data analyses were conducted by the MDHHS, Maternal and Child Health Epidemiology Section.

The number of drug exposed infants increased by 49% from FY 2010 to FY 2013, from 2,589 to 3,866 infants[3]. Additionally, infants hospitalized and treated for drug withdrawal symptoms has increased[4]. In 2010, 478 infants in Michigan had a diagnosis code of 779.5 (ICD-9-CM) and needed treatment for withdrawal from a drug, not specifically identified as opioids. In 2018, the number of infants with a diagnosis code of P96.1 (ICD-10-CM) increased to 794 infants. This represents a jump from 41.7 per 10,000 live births in 2010 to 72.1 in 2018. The opioid epidemic has also impacted maternal deaths. In 2011, 9% of maternal deaths were opioid related compared to 19% of maternal deaths in 2016[5].

MDHHS remains committed to supporting opioid use disorder prevention for pregnant and parenting women and women of childbearing age; increasing screening and identification; maintaining data collection and reporting; optimizing resource allocation to target resources to those in greatest need; developing a quality improvement system; and improving workforce development and training programs. In December 2019, MDHHS also released the End the Sigma campaign to decrease stigmas related to opioid use and treatment.

On November 6, 2018, Michigan voters approved Proposal 1, creating the Michigan Regulation and Taxation of Marihuana Act (MRTMA). This Act delegates responsibility for marijuana licensing, regulation and enforcement to the Michigan Department of Regulatory Affairs (LARA). LARA’s Bureau of Marijuana Regulation (BMR) is responsible for the oversight of medical and adult-use (recreational) marijuana in Michigan. The MRTMA permits the personal possession and use of marijuana by persons 21 years of age or older. MDHHS is closely monitoring ongoing research on marihuana use in pregnancy and during breastfeeding. Studies have demonstrated that use during pregnancy increases the chance of low birthweight, lower IQ, and risk for admission to NICU. Studies also show that use during breastfeeding may lead to slower development of infant motor skills. Moving forward, MDHHS will assess and assure public health education and messaging for the MCH population.

Michigan has a strong foundation of family support services within community and clinical settings to address substance use. Home visiting services are critical in addressing perinatal substance use disorders among pregnant and parenting women. Home visitor education and training has been inclusive of motivational interviewing and other evidence-based interventions. Healthcare professionals remain abreast of Perinatal Substance Use Disorder (PSUD) and NAS and the importance of linking families to ongoing support services after hospital discharge. However, substance use prevention and response efforts pose staffing challenges to an already taxed public health, nursing, and behavioral health workforce—especially given the current COVID-19 pandemic.

Lastly, the use of e-cigarettes in Michigan has increased, especially among youth and young adults. From 2015-2016 to 2017-2018, counties in Michigan saw between a 30% and 118% increase in high school students who used an e-cigarette during the past month.[6]  The use of e-cigarettes among Michiganders aged 18-24 is 12.8% (2017 BRFSS), higher than cigarette use in this group. E-cigarette use among women three months before pregnancy is 3% and 1% in the last three months of pregnancy (PRAMS 2015-17). E-cigarette rates are highest in socioeconomic status groups with low income and low educational attainment (Vital Statistics, 2017). To address the dangers of e-cigarettes and to adopt 24/7 comprehensive tobacco free policies, the MDHHS Tobacco Control Program works closely with Regional School Health Coordinators and MDE to educate parents, coaches, teachers and administrators. The Michigan Tobacco Quitline also offers a specialized quit tobacco program for pregnant and postpartum women, which includes nine counseling phone calls with a health coach who is trained in motivational interviewing.

Lead and PFAS

Lead has continued to be a priority public health issue in Michigan. MDHHS staff coordinate initiatives to prevent lead poisoning through case management services available through local health departments; surveillance systems for blood lead testing data; lead abatement services in homes; and lead educational materials for health care providers, child care providers, schools, and families of young children. As illustrated in the figure below, the percent of tested children under age six with an elevated blood lead level has decreased since reporting began in 1998.

Michigan is also addressing PFAS, an emerging class of contaminants. Although the health impacts of PFAS are still being investigated, the better-studied PFAS chemicals appear to have greater health impacts during early life with higher exposure through breastfeeding because the substances bioaccumulate. The state’s activities to address PFAS include:

• Identify sources of these contaminants.
• Sample private drinking water wells near known sources and resample previously sampled private drinking water wells to determine if levels have changed.
• Provide alternate water (e.g., certified water filter) when private wells are impacted.
• Sample post-filter water at residences over time (throughout the certified life of the filter) to evaluate the potential for breakthrough above screening levels but below the concentration considered for the certification and for additional PFAS not included in the certification. If breakthrough is seen, additional filter in series will be added and tested for efficacy.
• Sample public water supplies and schools/daycare centers with drinking water wells.
• Investigate other potential PFAS sources (e.g., fire-fighting foam, biosolids, surface water discharges) and exposures (e.g., recreating in surface water, eating fish and deer).
• Develop public health screening levels for some PFAS and future development of regulatory levels including enforceable drinking water standards for PFAS.
• Research the blood levels, exposure history, water levels, and health outcomes over three time points in three communities with higher levels of PFAS in drinking water.

Vaccine Hesitancy

Vaccine hesitancy was identified by the WHO as a threat to global health in 2019. Pockets of low vaccination coverage have allowed serious and highly contagious diseases like measles to make a resurgence in countries where it had previously been eliminated. The U.S. recently experienced multiple measles outbreaks, including one in Michigan. Michigan also has an active anti-vaccine community that has branded itself as "pro vaccine choice." The anti-vaccine community has fought Michigan administrative rules on immunization education required to obtain a non-medical immunization waiver for school entry and introduced new legislation to eliminate public health's right to exclude unvaccinated children from school and daycare during vaccine-preventable disease outbreaks.

The MDHHS Division of Immunization works diligently to correct anti-vaccine messages. One strategy is through the I Vaccinate media campaign in partnership with the Franny Strong Foundation. The I Vaccinate campaign is a parent-to-parent network to provide accurate vaccine information. MDHHS also works through the Parent Information Network, the Alliance for Immunizations in Michigan, the Michigan Advisory Committee on Immunizations, and other stakeholder groups to diminish vaccine hesitancy. The division also provides immunization education to healthcare providers via education modules, conferences, and webinars.

Components of the State’s Systems of Care

Michigan’s health care system currently includes 206 hospitals of which 155 are acute care, teaching or critical access hospitals. These include 80 birthing hospitals and 21 Neonatal Intensive Care Units. The remaining hospitals are for psychiatric or long-term care. The health care system also includes 45 Federally Qualified Health Centers with over 250 delivery sites; over 120 school-based/school-linked health centers; 33 Family Planning agencies providing services at 77 clinic sites; and 186 rural health clinics.

Health Care Reform

Since its passage in 2010, the Affordable Care Act (ACA) has impacted how health care is accessed and delivered across the country. In Michigan, the impact has been particularly significant since the implementation of Medicaid expansion in 2014. ACA coverage expansions provided Michigan consumers with two new options: Healthy Michigan Plan (HMP) and Health Insurance Marketplace (Marketplace). In January 2014, eligible individuals above 133% of the FPL could enroll in private health insurance coverage through the Marketplace. In April 2014, Michigan expanded its Medicaid program to cover residents aged 19 to 64 who were at or below 133% of the FPL, and who were not previously eligible for traditional Medicaid. Between the HMP and Marketplace, Michigan insured over 700,000 people in less than a year, exceeding initial enrollment expectations.

The ACA also provided significant funds through HRSA to expand access to primary care by increasing the number of Community Health Centers in Michigan. The number of Federally Qualified Health Centers (FQHCs) grew as additional centers were funded and look-alike sites were approved. According to the Michigan Primary Care Association, Michigan has 45 Health Centers that provide care at over 250 delivery sites and are health care homes to more than 680,000 individuals.

As of March 23, 2020, 674,853 beneficiaries are enrolled in HMP (HMP County Enrollment Report). The benefit design of the Healthy Michigan Plan ensures beneficiary access to quality health care, encourages utilization of high-value services, and promotes adoption of healthy behaviors. HMP benefits include preventive/wellness services, chronic disease management, prenatal care, oral health and family planning services. Most HMP beneficiaries are required to pay some level of cost-sharing via monthly contributions and co-pays based on income. Some populations are excluded from cost sharing, such as individuals enrolled in CSHCS, under 21 years of age, pregnant women, and those with no income. To promote the health and well-being of HMP beneficiaries, MDHHS developed a Health Risk Assessment which provides health plan beneficiaries the opportunity to earn incentives for actively engaging with the health care system. HMP enrollees who complete a health risk assessment and agree to maintain or address healthy behaviors, as attested by their primary care provider, may be eligible for select cost-sharing reductions.

For CSHCN, ACA consumer protections have improved access to private insurance by eliminating preexisting condition exclusions and discrimination based on health status, the two most frequently encountered enrollment barriers for families. The ACA also expanded access to parent employer coverage for adults 19-26. As of December 2019, the HMP covers approximately 1,649 individuals who are dually enrolled in CSHCS. LHDs, Family Resource Centers and designated state staff work with families and community partners to help families understand and access private and publicly funded resources to meet individual needs.

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

MDHHS currently supports five community-based collaborative bodies called Community Health Innovation Regions (CHIRs). The CHIRs were first funded through Michigan’s State Innovation Model to create a mechanism for addressing social determinants of health. CHIRs bring together partners from across sectors to change community conditions, improve service delivery networks between clinical and community providers, and link individuals to services. A CHIR evaluation plan is currently being created which will focus on CHIRs’ clinical community linkages infrastructure and the work of CHIR hubs. Each CHIR has established a hub that receives referrals, identifies needs, and makes referrals to clinical and community services. While the specific population served by each hub differs, as do the mechanisms for screening and referral, their purpose is to improve access to clinical and community services.

Integration of Services

Michigan’s Title V and Title XIX programs share the common goal to improve the overall health and well-being of the MCH population through implementation of affordable health care delivery systems, expanded coverage, and implementing strategies to address social determinants of health and reduce health disparities. Areas of collaboration include maternal and infant care, adolescent health, perinatal care, developmental screening and referral, home visitation, oral health, and CSHCS. Like programs located within the Public Health Administration, Michigan Medicaid employs a population health management framework to build a Medicaid managed care delivery system that maximizes the health status of beneficiaries, improves beneficiary experience, and lowers cost. Medicaid contracts with 10 Medicaid Health Plans (MHPs) to achieve these goals through evidence-based and value-based care delivery models, supported by health information technology, and robust quality strategies to prevent chronic disease and coordinate care.

The BHW and Michigan Medicaid jointly manage several programs for the Medicaid-eligible MCH population. One of the largest collaborations is the Maternal Infant Health Program (MIHP), Michigan’s largest population-based home visiting program available to all Medicaid-eligible pregnant women and infants up to age one. Effective January 1, 2017, MIHP services provided to beneficiaries enrolled in an MHP are administered by the MHPs.

Another area of coordination is for CSHCN, as 78.5% of individuals with both CSHCS and Medicaid coverage are enrolled in an MHP. MHPs are responsible for the medical care and treatment of CSHCS members while community-based services beyond medical care and treatment are provided through the LHD’s CSHCS office. MHPs are responsible for coordinating and collaborating with LHDs and the Children’s Multidisciplinary Specialty Clinics to make a range of essential health care and support services available to enrollees. MHPs are also responsible for the coordination and continuity of care for enrollees who require integration of medical, behavioral health and/or substance abuse services.

In October 2016, the Healthy Kids Dental program was expanded statewide to cover all children with Medicaid under the age of 21. It provides dental services to approximately 1 million youth. As of October 2018, eligible beneficiaries are offered a choice of two statewide HKD dental health plans. In July 2018, MDHHS also expanded managed care dental coverage for non-Healthy Michigan Plan Medicaid eligible pregnant women through a Comprehensive Health Care Program 1915(b) waiver amendment. This managed care dental benefit is intended to provide greater access to dental services and comprehensive prenatal care. BHW and MSA are coordinating outreach and engagement efforts for these oral health programs via multiple avenues including MIHP and other home visiting networks.

Additionally, due to collaborative efforts between DMIH, MSA and other state partners, MDHHS updated its hospital reimbursement policy for Long Acting Reversible Contraceptives (LARCs) including intrauterine and implant devices. To improve access, beginning in October 2018 Michigan Medicaid now reimburses for immediate postpartum LARC devices, paid in addition to the standard DRG-based payment for childbirth services.

Overall, MDHHS recognizes the importance of integrating both physical health and behavioral health services to effectively address enrollee needs and improve health status. In December 2019, MDHHS Director Robert Gordon announced a new approach to improving the state’s behavioral health system. As outlined in this MDHHS press release, the approach will “lead to greater choice of providers, better coordination of services, and increased investment in behavioral health.” To achieve these goals, three key components are: preserve a strong safety net; integrate physical and behavioral health in care and financing; and establish Specialty Integrated Plans. In January 2020, MDHHS announced five public forums throughout the state to receive input from Michigan residents and families about the proposed plan and ways to improve the behavioral health system. Additional information is available on the MDHHS Future of Behavioral Health webpage although implementation plans are currently being impacted by the COVID-19 pandemic.

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

Health Services Infrastructure

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

MDHHS also developed and implemented CareConnect360 (CC360), a statewide web-based care management system that allows for the bi-directional exchange of health care information. CC360 allows for the identification and coordination of services to Medicaid beneficiaries—particularly in relation to physical and behavioral health information—by sharing of cross-system information between state health plans and the Community Mental Health/Prepaid Inpatient Health Plans. CC360 makes it possible to analyze healthcare program data, manage and measure programs, and improve enrollee health outcomes. Within the Division of Maternal and Infant Health, CC360 addresses the need for improved communication within MIHP, including sharing care elements that can aid in successful case management by assuring that MIHP home visitors are part of the care team. CC360 enables access to comprehensive Medicaid claims and encounter data for patients of record to support care coordination services. It will also allow for comparison of population health data across counties or regions. As previously discussed, MI Bridges is another important component of the MDHHS service platform to better interface with customers through technology and to make the service delivery system more focused on customer needs.

State Statutes Relevant to Title V

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

In FY 2020, state funding for MCH and CSHCS programs was appropriated through Public Act 67 Enrolled Senate Bill 139 Health and Human Services of 2019. CSHCS is mandated by the Michigan Public Health Code, Public Act 368 of 1978, in cooperation with the federal government under Title V of the Social Security Act and the annual MDHHS Appropriations Act. State general fund dollars for MCH programs are itemized in Sec. 117 of Public Act 67 of 2019, whereas CSHCS is addressed in Sec. 119. Additional MCH details are provided in Sec. 1301- 1305; 1308 – 1317; 1320. These sections identify how funding shall be used; MDHHS and contractor requirements; and requirements that some appropriated funding be used to implement evidence-based programs to reduce infant mortality, continue development of an outreach program on fetal alcohol syndrome services, enhance education and outreach efforts to seek early prenatal care, allocate funds to the Michigan Dental Association to administer a volunteer dental program that provides dental services to the uninsured, and the provision of high-quality dental homes for seniors, children, and adults enrolled in Medicaid and low-income uninsured. Statutory requirements in the FY 2019 Health and Human Services budget for CSHCS included criteria in Sec. 1360 for MDHHS to provide services; and in Sec. 1361, the authorization that some of the appropriated funding be used to develop and expand telemedicine capabilities and to support chronic complex care management.

[1] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management. Data source: Maternal Deaths in Michigan, 2012-2016 Data Update. MDHHS. Michigan Maternal Mortality Surveillance Program.

[2] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy due to a cause unrelated to pregnancy.

[3] Data from Michigan’s Services Worker Support System (SWSS).

[4] Data from Michigan Inpatient Hospitalization Files.

[5] Division for Vital Records and Health Statistics, MDHHS.

[6] Michigan Profile for Healthy Youth Survey by MDE and MDHHS, 39 County Data from 2015-16 and 2017-18.