Rhode Island - 2020 - III.B. Overview of the State

Overview of the State

Geography and Demographics

The state of Rhode Island (RI) is a small, coastal area with just over one million residents (1,057,315)[1]. The state measures just 48 miles from north to south, and 37 miles from east to west, with a total area of 1,214 square miles and over 400 miles of coastline. Rhode Island is divided into 39 cities and towns that each govern primary and secondary education, subdivision of land and zoning, and housing code enforcement in their local community [2]. The city of Providence is Rhode Island’s capital and largest community, with an estimated 179,335 residents. Most of RI’s population (636,084) lives in Providence county.

Children under 5 years of age represent 5.1% of RI’s population, and 19.4% of the population is under the age of 18. Rhode Islanders age 65 and older make up 17.2% of the population. Based on the most recent Census estimates, RI’s population is 83.9% White, 15.9% Hispanic or Latino, 8.4% Black or African American, 3.6% Asian, 2.8% Multiracial, and 1.3% Native American, Alaskan Native, Native Hawaiian, or Pacific Islander. Currently, 29.2% of all Rhode Islander residents are foreign-born (U.S. Census 2013-2017). The largest share of the foreign-born population in RI is from Latin America (44.7%), followed by Europe (22.6%), Asia (17.8%), and Africa (12.2%). Among RI residents over 5 years of age, 21.7% speak a language other than English at home, and Spanish is the most common of those languages (52%)1.

Communities of color are growing rapidly throughout many areas of Rhode Island, and most of Rhode Island’s population growth over the last few decades is attributable to people of color. Between 2000 and 2010, the Latino population experienced the most growth (44%), followed by Asian population (29%), and the Black, non-Latino population (28%)3. This trend is expected to continue well into the future, as people of color are projected to represent 41% of the population by 2040 [3]. The largest communities of color are found in Providence, Pawtucket, Central Falls, Cranston, Woonsocket, and East Providence. It is also estimated that about 32,000 undocumented individuals live in RI and approximately 8,000 of these individuals are parents of U.S. born children1.

The median household income in RI between 2013 and 2017 was $61,043, and the statewide poverty rate was 11.6%. In the city of Providence, however, the poverty rate is 26.9%4. Providence is considered one of Rhode Island four “core” cities, which are urban communities in the state where over 25 percent of children live in poverty [4]. RI’s “core” cities are Providence, Pawtucket, Central Falls, and Woonsocket. Within the four “core” cities, the poverty rate is over two times higher than the state average. Nearly one third of children in RI live with these “core” cities and 46% of children in the four core cities live in single-parent households4.

Strengths and Challenges that Impact Maternal and Child Health

RI’s small size is an advantage for the state to be at the forefront of developing and testing innovative statewide health care policies that work to improve the health and well-being of the state's maternal and child health (MCH) populations. In RI, all public health services are managed by the RIDOH, there are no local health departments. The centralization of RI’s public health services to a single agency helps simplify the management and implementation of statewide strategic plans, programs, and initiatives, including those that address maternal and child health. The RIDOH upholds strong partnerships with many community organizations, hospitals, healthcare providers, and academic institutions. Through these partnerships, various initiatives, programs, and population health priorities can be integrated at all levels of public health service and health care delivery throughout the state.

Community, healthcare, and academic partners also help assess the health needs of all Rhode Islanders. From place-based community health evaluations to hospitals, they provide data that may highlight emerging issues, diseases, or inequities.

In 2017, only 2.1% of RI's children under age 19 were uninsured. RI ranks third best in the U.S., with 97.9% of children having health insurance. Rhode Island does offer health coverage through HealthSource RI, RI’s health insurance market place under the federal Affordable Care Act. As of October 2018, 1,749 children were enrolled in private health coverage through HealthSource RI, 52% of whom received financial assistance through a premium tax credit or a cost sharing reduction4. The rate of children in RI ages 19 to 35 months that were fully immunized (76%) was above the national average of 71% and 14th best in the U.S. in 2016. Rhode Island also ranked first in the U.S. for rotavirus vaccines, second for the 3-Polio vaccine, and fifth for the DTaP vaccine series in 2017. In 2014, 94% of RI’s children had dental insurance that paid for routine dental care, up from 73% in 2001. Newborn screening is mandated for all babies born in Rhode Island. Rhode Island screens newborns for 31 conditions, including hearing loss.

RI also faces several challenges that impact maternal and child health. RIDOH is a close partner and data contributor to Rhode Island Kids Count - the state's children's policy organization. Every year RI Kids Count publishes one of the most comprehensive collection of data about the health and well-being of the state's children. Through the analyses in the annual RI Kids Count Factbook, many important issues are highlighted that impact RI's Maternal and Child Health populations.

RI’s child poverty rate was 19% between 2013 and 2017, during which time there were 39,229 children living in families with incomes below the federal poverty threshold. In 2017, nearly one in six (17%) children in RI (a total of 33,858 children) lived in poverty, 48% of whom were children were Hispanic. Many families with incomes above the poverty level also have a difficult time meeting the high costs of housing, utilities, food, child care, and health care. Between 2013 and 2017, nearly two thirds (64%) of Rhode Island's children living in poverty lived in the four “core” cities of Providence, Central Falls, Pawtucket, and Woonsocket. In 2018, the four core cities also have substantial numbers of children living in extreme poverty, defined as families with incomes below 50% of the federal poverty threshold, or $10,116 for a family of three with two children and $12,733 for a family of four with two children. 4 Almost two-thirds (66%) of children living in poverty lived with single female caregiver. During the 2016-2017 school year, RI public school personnel identified 1,245 children as homeless. 4 Of these children, 65% lived with other families ("doubled up"), 27% lived in shelters, 7% lived in hotels or motels, and 2% were unsheltered. 4

Although progress has been made on many health indicators across racial and ethnic populations, disparities still exist for several maternal and infant health outcomes in Rhode Island. Minority women are more likely than White women to receive delayed or no prenatal care and to have preterm births. Black children are more likely to die in infancy than White, Hispanic, or Asian children. Hispanic and Black youth are more likely than White and Asian youth to give birth as teenagers. Black and Hispanic children in RI are more likely to be hospitalized as a result of asthma than White children5.

Roles, Priorities, and Interests of the RI Department of Health

RIDOH is the lead RI agency responsible for addressing the maternal and child health needs throughout the state. Section 23-13 of the RI General Laws gives RIDOH broad authority for administering and overseeing Title V MCH services. RIDOH is located within the state's Executive Office of Health and Human Services (EOHHS), a cabinet agency that reports directly to the Governor. (See Appendix for organizational charts).

Further, the RI MCH (Title V) Program is a part of the newly created Health Equity Institute (HEI). HEI was created by Director Nicole Alexander-Scott, MD, MPH in 2016 as a strategy to promote RIDOH’s three leading priorities. The priorities include: 1) addressing the social and environmental determinants of health; 2) eliminating the disparities of health and promote health equity; and 3) ensuring access to quality health services for Rhode Islanders, including our vulnerable populations. The mission of the HEI is to address systemic inequities so that all Rhode Islanders achieve their ideal life outcome regardless of their race, geography, disability status, education, gender identity, sexual orientation, religion, language, age, or economic status. HEI recognizes that achieving health equity requires action, leadership, inclusion, cross-sectoral collaboration and shared responsibility throughout RIDOH, and communities across the state. HEI has substantial expertise in providing communities and policy-makers with data, technical assistance, and evidence-based programs to address health disparities in vulnerable populations. Several large programs are housed within the HEI, including: Disability & Health, Minority Health, Refugee Health, Maternal and Child Health and the Health Equity Zones (HEZ). HEI also provides collaborative support to all of RIDOH’s equity initiatives including: the Social Justice Roundtable, Sexual Orientation and Gender Identity Workgroup, Vulnerable Populations Data Collection Workgroup, Disparities in Population Health Goals, Social Determinants of Health Workgroup, Community Health Assessment Group, Commission for Health Advocacy & Equity, Community Health Resiliency Project, and the Kresge Initiative. HEI systematically addresses health disparities across the Department by providing guidance on data analysis, the development of joint work plans, and technical assistance. Health equity is an important priority if the Title V program, especially for women and children, people with disabilities, and racial and ethnic minorities. The HEI is strategically located in the Office of the Director, who provides leadership, vision, communication, and direction across all RIDOH divisions and programs.

It is the responsibility of the RI Title V Program to assure that that MCH initiatives, within RIDOH and throughout the state, work together to ensure a continuous system of care for mothers, children, CSHCN, and families that is coordinated, comprehensive, and community-based.

Various RIDOH programs take the lead on different MCH strategies. All RIDOH’s programs work together to ensure a statewide system of services. This complex work is pursued utilizing a variety of strategies that engages other state agencies, policy makers, community-based agencies, clinical and social service providers, and target populations. RIDOH also highly values and works with the community as a core partner in MCH and works with the state's 39 cities and towns to assure that equity in maternal and child health becomes a reality. This is most exemplified in the Health Equity Zone (HEZ) Initiative, a place-based initiative developed by RIDOH in 2015 with braided federal, state, and restricted funding including Title V. RIDOH has funded 9 RI non-profit organizations and local governments to support innovative approaches to preventing chronic diseases, improve MCH outcomes, and address the social and environmental determinants of health. HEZs are designed to affect change at the lowest level of the population health pyramid by increasing strategic planning and the integration of non-traditional partners to promote health and well-being within smaller geographic areas and target populations.

Rhode Island’s System of Care

Infrastructure and Maternal and Child Health Services Providers

Rhode Island has several hospitals that specialize in caring for maternal and child populations. Hasbro Children’s Hospital, the pediatric division of Rhode Island Hospital, is RI’s primary dedicated children’s hospital. Hasbro has RI’s only pediatric emergency department, Level 1 Trauma Center, and pediatric critical care teams. Hasbro is part of the Lifespan health system and is affiliated with the Warren Alpert Medical School of Brown University. Women and Infants Hospital, part of the Care New England system, specializes in care of women and newborns, and is the 9th largest stand-alone obstetrical service in the US. Over 80% of newborns in RI are delivered at Women and Infants Hospital. There are four additional birthing hospitals located throughout the state that split the remaining birth. Bradley Hospital and Butler Hospital both specialize in providing psychiatric care to children and youth. There are approximately 30 prenatal care and 60 pediatric practices throughout the state that serve pregnant women and children.

Healthcare Access, Delivery, and Financing

For decades, RIDOH has been focused on strengthening and improving the health of RI’s community and health care system. From the ground-breaking RIte Track (which ensured prenatal, childbirth, and postpartum care for women), and its successor RIte Care (the state's Medicaid managed care program for children and adults) to capitated, limited network health plans, to a national focus on patient-centered medical homes, RI has pressed forward on health care innovation.

RI is a Medicaid expansion state and HealthSource RI is the state's health insurance marketplace. HealthSource RI enrolls customers for both commercial health insurance and the state's Medicaid program. HealthSource RI held its fifth open enrollment period between November 1, 2017, and December 31, 2017. During that time, 30,637 total customers were enrolled in private plans through the state marketplace (and paid their first month's premium). Of those, 22,603 were renewing customers and 8,034 were new customers. [5] Recently released data from the 2019 open enrollment period show that 32,486 customers enrolled, which is an increase of 1,849 customers from the previous year. [6] During state fiscal year 2017, Rhode Island’s Medicaid Program served an average of 305,000 enrollees with full Medicaid benefits and another 17,6000 average enrollees received partial benefits. Children and families represent 51% of the enrollment (165,894) and children with special health care need represented 4% of all enrolled (12,060). Another 74,773 low-income adults without dependent children, 32,296 adults with disabilities, and 19,970 older adults were enrolled in Medicaid coverage during this time.[7]

RI has made primary care practice transformation a center-piece of its health care reform efforts. State agencies and commercial and Medicaid insurers have embraced the Patient-Centered Medical Home model as a mechanism to improve care, improve health, and lower costs. RI is advancing medical homes as evidenced by multi-payer payments to medical homes underway, approved ACA section 2703 health home state plan amendment, and medical home payments aligned with national and state developed qualification standards. In a state with about 1,190 active primary care physicians, 443 (37%) are practicing in medical homes recognized by the National Committee for Quality Assurance (NCQA). The medical home projects underway in RI include the Pediatric Care Coordination, Community Health Teams, Chronic Care Sustainability Initiative (CCSI), Connect Care Choice, and the ACA Section 2703 Health Homes-Cedar Family Centers project.

Office of the Health Insurance Commissioner (OHIC) provides the state oversight on healthcare insurance providers within the state. OHIC is responsible for: Guarding the solvency of health insurers; Protecting the interests of consumers; Encouraging policies and developments that improve the quality and efficiency of health care service delivery and outcomes; and Viewing the health care system as a comprehensive entity and encourage and direct insurers towards policies that advance the welfare of the public through overall efficiency, improved health care quality, and appropriate access. Consumer protection is at the core of the work of the Office of the Health Insurance Commissioner. OHIC helps consumers understand the healthcare system, and protects Rhode Island consumers by making sure federal and state laws are followed.

RIDOH participates in the standards development and implementation of Accountable Entities (AE) which is Medicaid’s version of an Accountable Care Organization (ACO) where a provider organization is accountable for quality health care, outcomes and the total cost of care of its population. Rhode Island launched its first pilot AE in the spring of 2016. Six (6) organizations participated in the AE pilot and five (5) became certified AEs when standards were released in 2018. Guiding Principles of Rhode Island’s AEs reflect several MCH priorities and include:

Promoting and supporting multi-disciplinary capacity, a strong foundation in primary care, effective behavioral health integration
Having the ability to manage the full continuum of care, including “social determinants”
Having analytic capacity to support data driven decision-making and real time interventions.
Focusing on high utilizers- Medicaid beneficiaries with complex needs or high costs

Rhode Island was one of 24 states to receive a State Innovation Model (SIM) Test Grant from the federal Centers for Medicare and Medicaid Services (CMS). The state received $20 million with the expectation that the funds would be used to transform the way healthcare is delivered and paid for – and to improve Rhode Island’s population health. RI’s SIM grant ended in June 2019 and sustainability efforts are underway to support the three categories of activities: improving the primary care and behavioral health infrastructure, engaging patients in positive health behaviors and self-advocacy, and expanding the ability of providers and policy makers to use and share data.

Services for Underserved and Vulnerable Populations

RI offers many programs and services to underserved and vulnerable populations. The Supplemental Nutrition Assistance Program (SNAP) is available to households with a gross monthly income below 185% of the federal poverty level ($38,443 for a family of three in 2018). In 2018, 160,272 Rhode Islanders were enrolled in SNAP, 34% of whom were children. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves pregnant, postpartum, and breastfeeding women, infants, and children under five years of age living in households with incomes below 185% of the federal poverty level. Any individual who participates in SNAP, RIte Care, Medicaid, or RI Works is automatically income-eligible for WIC. Participants must also have a specified nutritional risk, such as anemia, abnormal growth, or high-risk pregnancy. In September 2018, 21,209 women, infants, and children were enrolled in WIC in Rhode Island, and infants and children under 4 years of age comprised 78% of the population being served by WIC.5 The percent of eligible enrolled of women, infants and children was 46% in 2018. There we 4,430 families who received cash assistance during 2018 with a max benefit of $554 per month for a family of three.

As of June 2018, there were 21,488 students ages six to 21 (15% of all kindergarten through grade 12 students) receiving special education services through RI public schools. Thirty-six percent of these students had a learning disability, 18% had a health impairment, 12% had a speech/language disorder, 11% had an autism spectrum disorder, 8% had an emotional disturbance, 7% had a developmental delay, 4% had an intellectual disability, and 3% had other disabilities.5

In 2017, an estimated 21% of children in RI had at least one special health care need. As of June 2018, there were 2,619 children ages 3 to 21 with autism spectrum disorder receiving special education services. Likewise, as of June 30, 2018, 2,219 children were provided appropriate Early Intervention services through nine certified EI provider agencies, as required by the Individuals with Disabilities Education Act (IDEA) Part C for all infants and toddlers under age three who have developmental delays, or a diagnosed physical or mental condition associated with a developmental delay. Also, as of June 30, 2018, there were 3,121 children between ages three and five who received preschool special education services. Almost 5,000 children and youth in RI under age 19 receive Medical Assistance benefits through enrollment in the federal Supplemental Security Income program. As of October 2018, there were 1,278 RI families enrolled in family home visiting programs, which are designed to reach young children and families at home to foster healthy, safe, and stimulating environments for young children in at-risk families.5

RI Statutes and Regulations that have an impact on MCH and CSHCN Programs

RI General Law Section 23-13-1 provides RIDOH with broad authority for administering Title V MCH services. Specifically, the statute “designates RIDOH as the state agency for administering in RI, the provisions of Title V of the Social Security Act relative to maternal and child health services”.

2019 Legislative Updates – While a number of bills effecting MCH populations were introduced this legislative session, the follow bills were passed by the general assembly.

S409, H6086 Requirement for all public and private schools to have Narcan onsite, including elementary schools was codified in RIGL 16-21-35.
S572,H5431- Allows a “licensed public health dental hygienist” to conduct dental screening for children in kindergarten, third, and ninth grade.
S754,H5543– Adds the multi-disciplinary maternal mortality review committee to the review of the office of the state medical examiner and extends certain immunities and confidentiality agreements to multidisciplinary teams.
S676,H5541– Expands the provisions requiring the reporting of immunization status and any other relevant information to adults, not just children, and requires the department of health to include routine adult immunization in the department’s immunization program. This legislation will expand KIDSNET to include adults.

2015 – 2018 Legislative and Regulatory Updates

H-7644, S-2669 – Requires any RI public school that has elementary grades K – 6 to offer students daily supervised, safe and unstructured free play recess for 20 consecutive minutes each day and was codified in RIGL 16-22-4.2 statue in 2016.
H-6307, S-0493; Requires RI health care professionals to discuss the risks of developing a physical or psychological dependence prior to issuing prescriptions for a schedule II controlled dangerous substances and was codified in RIGL 21-28-3.18 in 2017. This legislation aligns with the SBIRT program and other enacted pieces of legislation that seek to reducing substance use disorders in Rhode Island.
Mental Health
- H-6306, S-322 – Requires medical treatment facilities to provide discharge plans for patients with nonsubstance abuse related mental health disorders and was codified in RIGL 23-17.26-3 in 2017.
- H-7806, S-2540 - Requires that insurers treat behavioral health counseling and medication maintenance visits the same as primary health care visits when determining patient cost-sharing. This law also directs the Office of the Health Insurance Commissioner to work with insurers to enhance mental health parity and to report to the General Assembly on the impacts of the legislation. This legislation was codified in RIGL 27-38.2-1 and RIGL 42-14.5-3 statute in 2018.
- S-328 – The RI Senate passed a resolution in 2017 requesting that the Executive Office of Health and Human Services examine policies and make recommendations on improving the quality of mental health services, including those relating to maternal depression and early childhood mental health.
H-5953 ,S-683 – This legislation establishes a new license that allows dental hygienists to perform dental hygiene procedures in a public health setting subject to conditions adopted by the RI board of examiners in dentistry without the immediate supervision or direction of a dentist and was codified in RIGL 5-31-1-39 statute in 2015.
H-7220 , S-2096 – This legislation established the RI Family Home Visiting Act within state law. The RIDOH is charged with developing and coordinating a system of early childhood visiting services to meet the needs of vulnerable families with young children. This was codified in RIGL 23-13.7 in 2016.
H-5819, S-672 – This legislation instructs any physician, duly certified registered nurse practitioner or other health care provider is involved in the delivery or care of infants born with or identified as being affected by substance abuse or withdrawal symptoms resulting from prenatal drug exposure, or a Fetal Alcohol Spectrum disorder” to make a referral to the Department of Children, Youth, and Families for follow-up to ensure that both the mother and child have a plan of care developed for discharge. This was codified in RIGL 40-11-6 statute in 2017.
H-5456, S-0275 – This legislation requires infants and toddlers under two or under 30 pounds to be in car seats that face the rear of the vehicle, in a seat other than the front seat, as long as the vehicle has one. This was codified in RIGL -31-22-22 statute in 2017.
H-5177, S-0306 – This legislation encourages the RI Department of Elementary and Secondary Education to consult with the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals for the incorporation of substance abuse prevention and suicide prevention into the health education curriculum. Substance abuse prevention is defined as the implementation of evidence-based, age appropriate programs, practices, or curricula related to the use and abuse of alcohol, tobacco, and other drugs. Suicide prevention is defined as the implementation of evidence-based appropriate programs, practices, or curricula related to mental health awareness and suicide prevention. This was codified in RIGL 16-22-4 statute in 2017.
H-7419, S-2350 – This legislation prohibits the advertising of unhealthy food and beverage products in schools that do not meet minimum federal and state governmental nutrition standards. This was codified in RIGL 16-21-7.1 statute in 2018.
S-646 – This joint House and Senate Resolution established a Special Legislative Commission to Study an Early Intervention System for Deaf and Hard of Hearing Children in Rhode Island” whose purpose would be to make a comprehensive study of an early intervention system for deaf or hard of hearing children in Rhode Island, and who would report back to the General Assembly.
H5182, S175 – This legislation outlaws the use of any non-hands-free personal wireless communication device while operating a motor vehicle, except for public safety personnel or in emergency situations. This was codified into RIGL 31-22-31 statute in 2017 and went into effect on June 1, 2018.
216-RICR-30-05-3 The RI Department of Health issued a regulation mandating that all preschool-aged children attending a preschool or daycare licensed by Department of Children, Youth and Families were required to have documentation of an annual influenza vaccine beginning August 1, 2015.
216-RICR-30-05-3 The RI Department of Health issued a regulation mandating that all childcare workers working in a preschool aged setting licensed by Department of Children, Youth and Families are required to have documentation of Tdap, Varicella, MMR vaccine, and flu vaccine beginning August 1, 2015.
216-RICR-30-05-3 The RI Department of Health issued a regulation mandating that all students entering ninth (9th) grade shall be required to have completed the HPV vaccine series (3 doses) beginning August 1, 2017.
216-RICR-20-05-1 – The RI Department of Health issued a regulation to update newborn screening rules and regulation to include three new conditions pompe, adrenoleukodystrophy, mucopolysaccharidoses beginning on October 1, 2018.
H-5277, S 0267 - Prohibits licensed health care professionals from practicing conversion therapy on patients under the age of 18 years old and was codified in RIGL 23-94-3 statute in 2017.