Demographics

Oklahoma, the 28th most populous state, accounts for 1.2% of the U.S. population. Its population of 3.9 million people has grown by 5% since the 2010 Census. A rural state, Oklahoma has three large cities. Oklahoma City, the state’s centrally located capital, is the largest of these and home to 16% (629,000 residents) of the state’s population. About 100 miles to the northeast is Tulsa, a city accounting for 10.3% (401,000 residents) of the state’s population. Nearly 90 miles southwest of the capital, sits Lawton, a city consisting of 95,000 residents, or 2.4% of Oklahoma’s population.

 

Nearly a quarter (24.5%, 956,000) of the Oklahoma population is less than 18 years of age. Individuals aged 65 years and older make up about 15% of the population, and roughly 61% of the population is between 18 and 64 years of age. The male-female ratio is about 1:1, with slightly more females (1.97 million) than males (1.93 million). Females of childbearing age (15-44 years) number 765,000, about 20% of the total population. The number of females aged 15-19 years has decreased by 2% since 2010, down from 128,600 to 125,800 in 2017. The number of women aged 30-34 has increased by 11% over the same timeframe, rising from 118,800 to 131,600.

 

Where residents choose to live varies by race and ethnicity. Largest in number, the white population tends to be geographically diffuse, while African Americans generally reside in the Oklahoma City and Tulsa metropolitan areas. The American Indian population has a larger presence in the northeast quadrant of the state, a legacy of the U.S. government’s removal programs of the 19th century. In 2017, nearly 73% of the population was classified as white, down marginally from 74% in the 2010 Census. American Indians and African Americans each account for about 7% of the state’s population. Approximately 2% of Oklahoma’s population is categorized as Asian or Pacific Islander. The Hispanic population has grown from 8% (302,000) of the total population in 2010 to 10% (395,000) in 2017, a growth of 31% over the time period. Oklahoma is home to the largest number of federally recognized American Indian tribal governments (38), and according to the American Indian Cultural Center and Museum, more languages are spoken in Oklahoma than in all of Europe.

 

Data from the U.S. Bureau of Economic Analysis indicate that Oklahoma’s per capita personal income was $46,128 in 2018, ranking 37th among all states, and representing about 86% of the national average of $53,712. U.S. Census Bureau data show that 16.2% (613,000 people) of Oklahoma residents were living in poverty in 2017, a decrease from 16.5% the previous year. Females (17.8%) were more likely to be living in poverty than were males (14.6%). Among children less than 18 years of age, 22.4% lived in poverty in 2017. Poverty status was more likely in minority populations when compared to the white population, with African Americans (28.8%) having the highest percentage of residents in poverty.

 

Oklahoma’s birth rate was 12.8 births per 1,000 total population in 2017, ranking 42nd among other states, and about 8% higher than the comparable U.S. birth rate (11.8). Since 2010, the birth rate has decreased by 9.2%, with the state averaging about 52,600 births per year. Similarly, the fertility rate has decreased from 71.9 births per 1,000 females aged 15-44 years to 65.2 over the same time period. Oklahoma has experienced a strong decrease in the rate of births to teens but still ranks poorly when compared nationally. In 2017, Oklahoma’s teen birth rate for ages 15-19 was 29.7 births per 1,000 population, ranking 3rd for the highest (worst) teen birth rate.

 

Geography

Positioned in the South Central region of the United States, Oklahoma has a diverse geography, with a quarter of its land mass covered by forests. The state is home to four mountain regions – the Arbuckle Mountains, in south-central Oklahoma; the Ouachita Mountains, in the southeast; the Ozark Plateau, in the northeast; and the Wichita Mountains, in the southwest part of the state. Oklahoma is one of only four states with more than 10 distinct ecological regions. To the west, the state has semi-arid plains, while in the state’s center, transitional prairies and woodlands give way to the elevated terrain of the Ozark and Ouachita Mountains, which stretch out to Oklahoma’s eastern border. Oklahoma is landlocked in the center of the 48 contiguous states, bordered by Arkansas, Colorado, Kansas, Missouri, New Mexico, and Texas.

 

Economy

Oklahoma is a major producer of natural gas, oil, and agricultural products. The state’s economic base relies on aviation, energy, telecommunications, and biotechnology. The two major metropolitan centers, Oklahoma City and Tulsa, serve as the primary economic anchors for the state. The top employers by workforce size for Oklahoma include the Department of Defense (69,000 employees, military and civilian) and Walmart Associates, Inc. (32,000). In the health sector, INTEGRIS Health has 8,900 employees, followed by the University of Oklahoma Health Sciences Center (6,800), Mercy Health (6,300), Saint Francis Hospital (6,200), and St. John Medical Center (4,000).

 

Oklahoma’s real gross domestic product (GDP), the output of all goods and services produced by the economy in current dollars, totaled $199.9 billion in 2018, according to data from the U.S. Bureau of Economic Analysis, increasing by 5% from 2015 ($190.2 billion). The private sector comprises 85% of Oklahoma’s real GDP, with government making up the remainder (15%). As a percentage of GDP, the industry share in the economy was led by the FIRE sector (i.e., finance, insurance, real estate; 14%), trade (12%), natural resources and mining (12%), manufacturing (10%), and transportation and utilities (8%). Education and health care services comprised 8% of the state’s GDP.

 

Gaming (lotteries and casinos) continue to be a major contributor to the state’s economy. The state of Oklahoma collected nearly $134 million in tribal gaming exclusivity fees in fiscal year 2017, a 1.4% increase over the previous year. Those fees were based on $2.2 billion in tribal gaming revenue. Exclusivity fees were distributed to the Education Reform Revolving Fund ($117.6 million), the General Revenue Fund ($16 million), and the Department of Mental Health and Substance Abuse Services ($250,000). This distribution of fees is determined by Oklahoma statute.

 

Data from the U.S. Bureau of Labor Statistics for calendar year 2018 showed that annual average unemployment rate for Oklahoma was 3.4%, ranking the state 16th nationally and approximately 13% lower than the U.S. unemployment rate at that time. Of the state’s 77 counties, 38 counties had an unemployment rate less than the state average, 37 had a rate in excess of the state average, and 2 counties had the unemployment rate for 2018. County unemployment rates ranged from 1.9% (Cimarron and Dewey Counties, panhandle and northwest counties, respectively) to 6.0% (Latimer County, southeast region of state). Oklahoma’s employment-population ratio, the number of working age persons who are employed divided by the total population of working age persons, was 61.3 in 2018, compared to the national rate of 62.9.

 

Urbanization

Approximately 59% of the Oklahoma population resides in the metropolitan statistical areas (MSAs) of Oklahoma City (1,349,000; 34%) and Tulsa (994,000; 25%), while a much smaller proportion of the state’s citizens lives in the Lawton MSA (126,000; 3%). The remainder of the Oklahoma population resides in rural cities and towns. The Oklahoma City MSA is made up of seven counties (Canadian, Cleveland, Grady, Lincoln, Logan, McClain, and Oklahoma) surrounding the principal city located in Oklahoma County. Population growth in the Oklahoma City MSA has been strong, increasing by 11% between 2010 and 2017, with growth in the individual counties comprising the MSA ranging from a low of 2% (Lincoln County) to a high of 25% (Canadian County). Likewise, the Tulsa MSA is comprised of the seven counties (Creek, Okmulgee, Osage, Pawnee, Rogers, Tulsa, and Wagoner) encircling the principal city, Tulsa. Population growth in the Tulsa MSA reached at 6% between 2010 and 2017. Some counties have experienced positive growth ranging from 2% (Creek County) to 10% (Wagoner County). Other counties have observed decreases in population numbers (Okmulgee, 4%; Osage and Pawnee, 1%) The Lawton MSA, made up of Comanche and Cotton counties, has experienced a reduction in size, down 3% since 2010.

 

Unique Strengths and Challenges Impacting the MCH Population

Oklahoma’s MCH Service has forged close partnerships, both internally to the Oklahoma State Department of Health (OSDH) and externally with other state agencies and community partners. Since 2009 when the Preparing for a Lifetime, It’s Everyone’s Responsibility, the statewide infant mortality reduction initiative, was launched MCH has collaborated with OSDH service areas to staff the initiative, perform analyses, develop public service announcements, formulate strategy, and implement programs. Internal partners include the Center for Chronic Disease Prevention and Health Promotion; Health Policy, Planning and Partnerships; the Center for Health Statistics; Immunization Service; Injury Prevention Service; Screening and Special Services; Family Support and Prevention Services; WIC Service; Sooner Start; and the county health departments (CHDs). These service areas and CHDs have taken part in other state and national efforts as well, including the CoIIN to Reduce Infant Mortality, the Oklahoma Perinatal Quality Collaborative, the Oklahoma Health Improvement Plan Child Health Group, the Period of Purple Crying Program, the MCH Safe Sleep Project, and many others unnamed here.

 

Joining the internal partners mentioned above are entities external to OSDH, but who contribute in large and meaningful ways. Sister agencies like the Oklahoma Health Care Authority (OHCA), the state’s Medicaid agency, the Oklahoma Department of Human Services, the Oklahoma Commission on Children and Youth, and ODMHSAS are frequent and routine collaborators on the many efforts to improve and promote health in the maternal, infant, and child populations. Other colleagues in MCH-related work include those from the Oklahoma Hospital Association, the Office of Perinatal Quality Improvement (OPQI), Tulsa Health Department, the Oklahoma City-County Health Department, the Oklahoma Family Network, and the Southern Plains Tribal Health Board (SPTHB). With the Title V Needs Assessment for 2016-2020, the relationship with the SPTHB enabled MCH to connect with individual tribes for the purpose of conducting Tribal Listening Sessions. These relationships continue and will be drawn on again and new ones created to inform the 2021-2025 Title V MCH Five-Year Needs Assessment. As always, the many partnerships and collaborations developed and maintained by Oklahoma Title V programs continue to be the vehicles for achieving MCH goals.

 

Oklahoma has experienced a number of successes related to health outcomes and behaviors. The Every Week Counts, a partnership among MCH, OPQI, and state birthing facilities active between 2011 and 2014, brought about a 96% reduction in the number of early elective deliveries. In January 2017, the March of Dimes recognized MCH’s achievement of lowering the preterm birth rate by 8% since 2010 by awarding the state with the Virginia Apgar Prematurity Campaign Leadership Award. However, for the last two reporting years (2016 and 2017) for Oklahoma birth data, the state has observed an increase in preterm birth rate, rising from a low of 10.3% in 2015 to 11.1% in 2017. Despite still having the 2nd highest birth rate among teens aged 15-19, Oklahoma has experienced significant declines in the last two decades. In 2017, the teen birth rate for this population group was 29.7 births per 1,000 female population. While this rate was still much higher than the comparable national rate (18.8), it was a remarkable improvement since the year 2000, when the state rate was recorded at 59.1 (decrease of 50%). Another improvement includes the uptake in the use of long-acting reversible contraceptives (LARCs), the result of program emphasis on providing LARCs when indicated for women not seeking to become pregnant.

 

The United Health Foundation (UHF) creates an annual report which ranks each state within the U.S., as well as the U.S. in comparison to other nations. The rankings are based on core measures in the following areas: behaviors, community and environment, policy, clinical care, and outcomes. The UHF’s report, American’s Health Rankings 2018, has ranked the state of Oklahoma 47th among all U.S. states, down four spots from 43rd just the previous year, the largest rank decline among all states. The UHF report cited three specific challenges that must be addressed if Oklahoma hopes to improve its national standing and the overall health of its population:  high percentage of population who are uninsured (ranked 48th), high cardiovascular death rate (ranked 48th), and high prevalence of physical inactivity (ranked 47th). The 2017 report did highlight areas of strength: low prevalence of excessive drinking, low prevalence of low birthweight, and higher number of mental health providers. The AHR 2018 report gave Oklahoma a ranking of 47th for the health of women and children, citing state strengths as low prevalence of excessive drinking among women, high percentage of publicly funded women’s health services needs met, and low prevalence of substance dependence or abuse among adolescents. Noted challenges included high percentage of uninsured women, low prevalence of neighborhood amenities, and high infant mortality rate.

 

As a rural state, Oklahoma continues to be challenged on the availability and accessibility of health care services. Interrelated contributors to these challenges include lack of transportation (public and/or personal), limited number of providers in remote areas, and lack of or inadequate health insurance.

 

Roles, Responsibilities and Interests of Title V Services

In Oklahoma, state health and mental health services are organized under the Cabinet Secretary of Health and Mental Health, a position appointed by the governor, and held by Jerome Loughridge, MPP. Health and Mental Health agencies in Oklahoma include the OSDH, Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), and OHCA. Human services agencies are organized under the Secretary of Human Services and Early Childhood Development, Steven Buck, Executive Director of Office of Juvenile Affairs, and include the Department of Human Services (DHS), Department of Rehabilitative Services, and the Oklahoma Commission on Children and Youth (OCCY).

 

The Oklahoma State Department of Health, created under Oklahoma Statute Title 63 § 1-105, is responsible for protecting and improving the public’s health status through strategies that focus on preventing disease. There are four major health service branches making up OSDH: Community Health Services, Prevention and Preparedness Services, Protective Health Services and Family Health Services. This configuration of services was created in 2018 with the breakup of Community and Family Health Services into two separate service areas. Family Health Services is home to the MCH Service, Dental Health Service, Family Support and Prevention Service, Nursing Services, Screening and Special Services, Sooner Start, and WIC. Community Health Services now consists of Oklahoma’s county health departments, Community Evaluation and Records Support, and the Immunization Service.

 

Oklahoma administers the MCH Title V Block Grant through two state agencies, the OSDH and DHS. OSDH, as the state health agency, is authorized to receive and disburse the MCH Title V Block Grant funds as provided in Title 63 of the Oklahoma Statutes, Public Health Code, Sections 1-105 through 1-108. These sections create the OSDH, charge the Commissioner of Health to serve under the Board of Health (which will change this year as new legislation has made the Board advisory to the Commissioner), and outline the Commissioner of Health's duties as "general supervision of the health of citizens of the state." Title 10 of the Oklahoma Statutes, Section 175.1 et.seq., grants the authority to administer the CSHCN Program to the DHS.

 

The MCH Title V Program is located in the OSDH within Family Health Services (FHS). The FHS is organizationally placed under the Commissioner of Health. Joyce Marshall, Director of MCH, is directly responsible to the Deputy Commissioner of the FHS, Tina Johnson, who is directly responsible to the Interim Commissioner of Health, Tom Bates. Dr. Edd Rhoades is Medical Director for the FHS and the Chief Medical Officer for the OSDH.

 

Programs administered in some part with Title V funds include: Preparing for a Lifetime, It’s Everyone’s Responsibility; the Maternal Mortality Review Committee; Pregnancy Risk Assessment Monitoring System (PRAMS), The Oklahoma Toddler Survey (TOTS), and the Youth Risk Behavior Survey (YRBS) surveillance programs; Teen Pregnancy Projects throughout the state; State Systems Development Initiative (SSDI); Fetal and Infant Mortality Review; School Health; Oklahoma Birth Defects Registry; Becoming Baby Friendly Oklahoma; and, other-related programs and initiatives.

 

The Title V CSHCN Program is located in the DHS within the Health Related and Medical Services (HRMS) unit. HRMS is organizationally placed under the Adult and Family Services Division. Carla McCarrell-Williams is the CSHCN Director. Title V CSHCN provides funding for respite (through both DHS and the JD McCarty Center), adaptive equipment, professional services, and formula not covered by Title XIX. Likewise, funding and supports are provided to several groups at the University of Oklahoma Health Sciences Center and OU Children’s Medical Center to enhance services for CSHCN families. These groups include, Oklahoma Family Network (family-to-family support), Family Support 360 Center (family health system navigation) and Family Partners (developmental and behavioral screening services), Sooner SUCCESS (comprehensive system of health and educational services), the Sickle Cell Clinic (health care transition services) and the Oklahoma Infant Transition Program (family support for NICU newborns). Title V CSHCN also collaborates with Child Welfare Services at DHS to provide funding for psychological evaluation assessments not covered by Medicaid.

 

Systems of Care for Underserved and Vulnerable Populations

1.  Population Served

Overall, in FFY 2018, 2,853 Oklahoma children with special health care needs received direct services from a Title V partner in FFY2018. Per the National Survey of Children’s Health, there were an estimated 222,256 children in Oklahoma with a special health care need in 2017.

 

Note: The number of children served is a conservative estimate intended to reduce the risk of duplication. Additionally, Title V representatives continue to encourage collaboration across partners and to reach out to families in under-served populations by speaking at family support groups and attending local health conferences that address children with special health care needs.

 

2. Health Services Infrastructure

The state now has three Children's Hospitals – the Children’s Hospital at Saint Francis in Tulsa, Oklahoma, the Children’s Hospital at OU Medical Center in Oklahoma City, and the INTEGRIS Children’s Hospital at Baptist Medical Center, also in Oklahoma City. The Children’s Hospital at Saint Francis provides comprehensive medical care through inpatient and outpatient services and a network of more than 100 pediatricians and 65 pediatric subspecialists covering eastern Oklahoma. The Children’s Hospital at OU Medical Center has 314 inpatient beds and is the only freestanding pediatric hospital in Oklahoma solely dedicated to the treatment of children. Its NICU contains 93 beds providing the highest level of neonatal care in the state. INTEGRIS Children’s includes a 40-bed level III NICU, a 26-bed pediatrics unit, and a 10-bed pediatric intensive care unit.

 

According to the Oklahoma Board of Medical Licensure and Supervision, there are 644 active pediatricians in the state as of May 2019.

 

OHCA administers two health programs for the state. The first is SoonerCare, Oklahoma's Medicaid program. SoonerCare works to improve the health of qualified Oklahomans by ensuring that medically necessary benefits and services are available. Qualifying Oklahomans include certain low-income children, seniors, the disabled, those being treated for breast or cervical cancer and those seeking family planning services. The second program OHCA operates is Insure Oklahoma, which assists qualifying adults and small business employees in obtaining health care coverage. Under certain circumstances, Insure Oklahoma extends coverage to dependents within the household, which may include children with special health care needs.

 

In 2017, OHCA took action to cancel the Request for Proposal (RFP) for SoonerHealth+, the fully capitated, statewide model of care coordination that has been in development for Oklahoma Medicaid's aged, blind, and disabled population. A new statute (SB 773) requires OHCA to initiate an RFP for care coordination models for children in DHS custody.

 

Currently, Oklahoma neither has nor is pursuing a state Medicaid Accountable Care Organization Program.

 

3. Integration of Services

Oklahoma has 77 counties with 68 county health departments where families of children and youth with special health care needs can access reproductive health care, vaccines, and, in some cases, mental health and dental services. This allows families affordable access to care, some services at no charge while others have sliding scale fees. Additionally, each county in Oklahoma has at least one health home which integrates medical, behavioral and social supports needed, coordinated in a way that recognizes all of their needs as an individual, not just patients. To be eligible for a Health Home, children and youth must have Medicaid, have either a serious mental illness or a serious emotional disturbance, and one or more chronic health conditions. A Care Manager from the Health Home organization assists patients with coordination and access to necessary medical, mental health, and social services.

 

Children and youth with special health care needs may also receive services while they are in school. There are 250 nurses across the state in schools providing a limited scope of services. Many school districts contract with mental health providers to provide services during and after the school day. All of these services add to the services available in the child's community.

 

Financing of Services

Medicaid is managed by the Oklahoma Health Care Authority, Oklahoma's Medicaid agency. CHIP funding is blended with other Medicaid dollars to ensure better access for more children. Some examples include funding long-acting reversible contraceptives for adolescents and providing cribs to Medicaid-eligible families. At the close of FFY2018, Oklahoma had 643 children 18 years and under accessing SoonerCare via TEFRA. Additionally, 17,826 children received SoonerCare based on their Aged/Blind/Disability (ABD) status. Both groups, TEFRA and ABD, have high medical needs and/or significant disabilities and are better able to access needed medical/mental health services because of their access to SoonerCare. The Oklahoma Health Care Authority also manages Insure Oklahoma, which is a premium assistance program for families of low income status. In addition, several community, state and national programs provide access to grants and other funds to assist youth in receiving needed durable medical equipment, respite, co-pay assistance, etc. These vital funds fill gaps where families cannot afford to meet their child's needs.

 

Legislative Update

A number of legislative bills were tracked by OSDH and MCH during the 2019 first regular session of the 57th Legislature. This included 114 active bills, many were considered high priority for the agency. A broad set of topics were monitored including abortion, medical marijuana, e-cigarette vapor products, trauma-informed care, mental health, maternal mortality, agency funding, and vital records.

 

SB 33 defines vapor products in the Tobacco-free Schools Act as a noncombustible product that may or may not contain nicotine that employs a mechanical heating element, battery, electronic circuit or other mechanism, regardless of shape or size that can be used to produce a vapor in a solution or other form. The measure prohibits use of vapor products at early childhood centers and educational facilities in which children K-12 are educated. Governor Stitt signed into law on April 15, 2019.

 

SB 318 defines “qualified residential treatment program” in the Oklahoma Children’s Code to mean a trauma-informed treatment model to address the needs of children with serious emotional or behavioral disorders and has registered or licensed nursing staff. The program, as defined by the measure, must also facilitate a variety of family-based programs. Governor Stitt signed on April 25.

 

SB 419, signed by the governor on April 26, 2019, allows certain state boards to work with health care services to develop policies and procedures related to perinatal mental health disorders. The State Board of Medical Licensure and Supervision, the State Board of Osteopathic Examiners, and the State Board of Nursing are permitted to work with hospitals and licensed health care professionals to develop information, policies and education materials specific to perinatal mental disorders.

 

SB 614 requires abortion facilities in the state to conspicuously post a sign warning patients about certain risks associated with mifepristone if certain actions are not taken. The sign must be posted in the clinic’s waiting room or the patient abortion admission area if in a hospital. Physicians must also inform patients of the possibility to reverse the process 24 hours before the procedure is performed and issue discharge information. In medical emergencies, the physician must inform the patient that, in their judgement, an abortion is necessary and must be implemented immediately. OSDH will be required to maintain the content of the required signage and content highlighting the reversibility of the procedure on the Department’s website. There are financial penalties for violating the provisions of the measure. Governor Stitt approved on April 25.

 

SB 773 creates the Oklahoma Mental Health Loan Repayment Act. The program, administered by the ODMHSAS based on available funding, shall provide educational loan repayment assistance for mental health or substance abuse treatment providers in Health Professional Shortage Areas for mental health. The award shall be available after one year of service and after review of provider’s activities by ODMHSAS. Awards may not exceed a total of five years. Providers participating in the program must ensure that at least 25% of their patients are Medicaid recipients and/or uninsured patients. Governor Stitt signed into law on May 1.

 

SB926 requires sex education curriculum and materials to include information on consent, as defined in Section 113 of Title 21. The bill was signed into law on April 23.

 

HB 2091 adds two members to the Domestic Violence Fatality Review Board. The two new members are to be appointed by the Attorney General. One of the new members must be an American Indian survivor of domestic violence selected from a list of three names submitted by the Native Alliance Against Violence.

 

HB 2334 establishes the Maternal Mortality Review Committee for the purpose of developing and coordinating a system of health services to decrease maternal mortality. Duties of the committee include reviewing cases of pregnancy-related maternal deaths of women in Oklahoma. The measure directs the OSDH to provide staff support for the committee and empowers the Commissioner of Health to subpoena, if necessary, the production of any records that contain evidence that the committee believes to be relevant. The bill was signed by the Governor on May 28th.

 

HB 2517 authorizes the Commissioner of Health to require general acute care hospitals, and others as necessary, to make electronic medical records of patients who have been diagnosed with birth defects or had poor reproductive outcomes available to OSDH. Bill was approved by Governor Stitt on April 25.

 

HB 2610 requires the OCCY to adopt rules regarding the training and responsibilities of child abuse medical examiners. The measure also requires, subject to the availability of funding, the Director of the Bureau of Vital Statistics to forward information regarding a child death within 72 hours to OCCY. The Commission will submit the information for a child maltreatment medical review. The governor approved on April 29.

 

HB 2612 creates the Oklahoma Medical Marijuana and Patient Protection Act to provide oversight and regulation of the medical marijuana industry, overseen by a Medical Marijuana Authority within OSDH. Governor Stitt approved on March 14.

 

HB 2735 reduces the funding appropriation to the OSDH for FY2019 and directs funds from the agency’s previous year appropriations and funds to the Special Cash Fund of the Treasury. The bill returns $30 million appropriated to the health department in FY 2018, funds requested to staunch what was perceived and presented as an agency funding crisis. Upon thorough audit, the funds were not needed and so returned. Bill approved by the Governor on March 13.

 

HB 2736 repeals the requirement that the OSDH submit to the legislature a corrective action report leading to greater financial controls at the agency. The bill repeals a 15% FY19 savings mandate previously enacted for the state agency.