Alaska is a large, sparsely populated state. The land mass of the state encompasses 570,641 square miles, averaging a population density of just 1.3 persons per square mile. This is the lowest population density of any state. The July 2019 Alaska resident population was estimated at 731,007 by the Alaska Department of Labor and Workforce Development. This represented a decrease of 5,232 people compared to 2018 and was the third year of annual population decrease in Alaska since the oil crisis in the mid-1980s. The decrease was primarily driven by negative migration, however the state also had 265 fewer resident births compared to 2018 and fell below 10,000 annual births for the first time since 2002. There were 9,830 resident births in 2019. Alaska had 154,964 children less than 15 years of age (21.1% of the total population) and 144,515 women of childbearing age (15-44 years) in 2019 (19.8% of the total population).

In 2019, 20% of Alaskans lived in cities or places with populations of fewer than 2,500 people. Cities with more than 20,000 people included the Municipality of Anchorage (291,845), the City and Borough of Juneau (31,986), and the City of Fairbanks (30,995). These three areas were home to 49% of Alaska’s population. Alaska has a trend of migration from rural to urban areas that has remained relatively stable over the past 20 years. Of those who dwell in rural areas, the majority are Alaska Native people.

The industries with the greatest number of employees in Alaska include government, health care, retail trade, leisure, and hospitality. According to the Department of Defense, as of March 31, 2020, 19,760 active duty military personnel were stationed in Alaska. Additionally, Alaska was home to 4,709 service members in the national guard/reserves and 5,089 permanently assigned civilian military personnel. Anchorage, Fairbanks, and Kodiak Island all have large active duty military and dependent populations. Compared with other states, Alaska has the highest per capita number of veterans, with 73,226 veterans as of 2018, including 22,630 veterans under age 45, 19% of whom were women. Currently, 17% of Alaska’s active duty service members are female. As of 2018, veterans and current active duty military personnel made up approximately 13% of the population.

According to the Department of Labor statewide projections, Alaska’s statewide population is projected to increase from 731,007 in 2019 to 813,822 in 2045. As Alaska’s population ages in the coming years, annual growth is expected to slow. Alaska’s population aged 65+ is expected to grow at the fastest rate over the projection period, followed by the population aged 20-64. Recent declines in birth rates are projected to slow growth among the population aged 0-19.

In 2018, 67% of Alaska’s population was reported to be White, 19% Alaska Native/American Indian, 8% Asian, 5% African American, and 2% Native Hawaiian or Other Pacific Islander (all percentages are for the race alone or in combination). Alaskans of Hispanic origin made up 7%. Cultural diversity among the non-Native population is increasing. The 2013-2017 American Community Survey (ACS) indicates 8% of Alaskans were foreign-born. Pacific Islanders are the fastest-growing racial group in Alaska, largely due to immigration, and the largest immigrant group in Alaska are Filipinos (documented and undocumented) (Anchorage Daily News, 2019).

More than half of the students in the Anchorage School District are ethnic minorities, speaking 110 different languages. In the 2018-2019 school year, 16 of the top 30 highest diversity public schools in the United States were in Anchorage. The Asian and Pacific Islander population has been increasing overall, as well as among the birth population, growing from 6% of births in 2000 to 11% in 2019. In Alaska, Filipinos comprise half of the Asian American community, and the Pacific Islander population (2%) is five times higher than the national average (ADN 2019).

Strengths and challenges that impact health status

Health disparities and health equity have large implications for the health status of Alaska’s MCH population. The most well documented and commonly studied differences in health status are between the Alaska Native and non-Native populations and between rural/frontier and urban populations. Alaska Native people experience disproportionate health outcomes in several domains. The causes of these disparities are multifactorial and include a long history of colonization, discrimination, and the loss of traditional lifestyles. As the Alaska Native population becomes increasingly urban or adopts western lifestyles and diet, whether by choice or not, chronic diseases such as diabetes and heart disease are of increasing concern. Living in remote communities with high unemployment rates, low income and significantly higher costs for food, fuel, and supplies, as well as barriers to accessing health care services are also contributing factors.

Significant improvements in the health of Alaska Native people have been made since the 1970s. Large investments in infrastructure including housing, safe water and sanitation facilities, community health aide-staffed tribal village clinics, and regional hospitals contributed to significant improvements in life expectancy, infant mortality and infectious disease. However, continuing and significant disparities remain, including in key MCH outcomes such as post-neonatal mortality; child, adolescent, teen (especially teen suicide), and maternal mortality; and oral health.

Uninsured populations are less likely to access routine, preventive care and more likely to seek care when health problems are severe and require treatment. In 2018, 61% of Alaskan adults aged 19-64 years were covered by employer or other private health insurance and 17% were covered by Medicaid (Kaiser Foundation). Among children with special health care needs, 48% were covered by Medicaid. According to the 2019 Scorecard on State Health System Performance by the Commonwealth Fund, Alaska ranks 46th in the nation for uninsured adults and 47th for uninsured children. In 2017, 10% of Alaska children under age 19 were not covered by any health insurance, compared to 5% for the U.S. (ACS data published by Kids Count). In the same year, 13% of Alaska parents (defined as adults who live with at least one of their own children under age 18) were not covered by any health insurance. A limitation of many of these data sources on health insurance is that they do not count tribal coverage or Indian Health Service as insurance, which may inflate Alaska’s percentage who are uninsured.

Poverty affects health both through decreased access to material resources, like health care and nutritious food, and through increased exposure to negative social and environmental factors, like violence, lead, and air pollution. It is associated with poor maternal health and birth outcomes such as infant mortality, low birth weight, and child maltreatment. According to the Kids Count Alaska Economic Well-Being report, there are significant disparities in family income by race/ethnicity in Alaska. While median family income was $75,500 in 2015, only White families earned more, on average, than the median ($91,300) while all other race/ethnicities earned less (non-White median family income was $48,700).

Survivors of violent crimes are at risk for posttraumatic stress disorder, major depressive episodes, and drug abuse/dependence. Youth exposed to community violence have increased rates of anxiety, aggression, and future violent behavior. In 2018, Alaska’s homicide rate per 100,000 individuals was 7.5, compared to 6.0 for the US.  The 2015 Alaska Victimization Survey results show a decline in intimate partner violence and sexual assault since 2010, although data support that fully 50% of adult women in the state have experienced violence in their lifetime, compared to 37.3% nationwide. In 2017-2018, 59% of Alaskan children lived in a safe neighborhood (based on parental opinion, NSCH). Adverse Childhood Experiences (ACEs) are major risk factors for leading causes of illness and death as well as poor quality of life. The higher the number of ACEs a person has, the more likely they are to experience poor health. The 2013-2015 Alaska BRFSS found that 65.7% of Alaskans had one or more ACEs, while 19.5% reported four or more.

Health care delivery in Alaska consists of four distinct systems; tribal, military, public and private. The Alaska Native Tribal Health Consortium (ANTHC) is a consortium of tribal entities that provides several levels of medical care: primary care at village clinics, primary and secondary care at regional hospitals, and tertiary care at the Alaska Native Medical Center hospital in Anchorage. ANMC receives some funding from the Indian Health Service but is supported to a greater extent by the various regional corporations. Publicly-funded health care agencies serve the largest portion of low income, uninsured individuals and families in Alaska. To date, there are a total of 27 organizations (including tribal corporations) that provide primary care and preventive health services at over 150 community health centers (CHCs) statewide. In addition to CHCs, the state government operates 16 Public Health Centers that provide population-based health services, disease screening and referral, and extensive collaboration with other community providers to assure coordinated care and access to services for vulnerable populations. On the private side, there are private non-profit and for-profit secondary and tertiary care hospitals, as well as self-employed and private practice health care providers. The military system is expansive, with clinics and hospitals in some of the larger population areas of the state, as well as a relationship with the Veteran's Administration supporting the active duty and retired armed forces.

Geographic isolation means significant challenges in assuring all MCH populations have access to routine preventive care, and acute medical and specialty care. Approximately 75% of Alaskan communities, including the capital city of Juneau, are not connected to a road system. Accessing "nearby health services" or specialized health care means travel by commercial jet, small plane, the marine ferry system, all-terrain vehicles, small boats or snow machines. Some residents may travel distances equivalent to Washington, D.C. to New Orleans for even routine medical care. Severe weather can render travel impossible, creating especially critical situations in medical emergencies.

Specialty care, even in urban areas of the state, is limited. Many communities have no facilities equipped for childbirth, so pregnant women must leave their homes four weeks before their due date and travel to a larger community with a hospital that performs births. Even well-child check-ups, prenatal exams and regular dental exams are difficult to provide. Recruiting and retaining physicians and primary health care providers for non-urban practices is an ongoing barrier to providing health care services.

Innovative systems have been created to overcome barriers to health care delivery related to high transportation costs and lack of skilled resources in the small communities. The Community Health Aide Program is a network of about 550 Community Health Aides/Practitioners (CHAPs) who work in over 170 rural Alaska villages to provide basic health care services and referrals. The CHAP program is a vital link in the Alaska Tribal Health System. The Alaska Dental Health Aide Therapist Initiative, another ANTHC program, is conducted in collaboration with the University of Alaska-Barrow and various established sites in Bethel and Anchorage to train Alaska Native dental health aides for community-level dental disease prevention in underserved Alaska Native populations. The Behavioral Health Aide Project aims to develop village-based behavioral health service capacity, focusing on prevention, early intervention, and case management.

Title V in the Context of the State Health Agency

The Alaska Department of Health and Social Services (DHSS) was originally established in 1919 as the Alaska Territorial Health Department. With the proclamation of statehood on January 3, 1959, the department’s responsibilities were expanded to include the protection and promotion of public health and welfare. These core duties are reflected in the mission of the department – to promote and protect the health and well-being of Alaskans – and are outlined in Article 7, Sections 4 and 5 of the Constitution of the State of Alaska.

Programs for the MCH and CYSCHN populations in Alaska are primarily managed within Sections of the Division of Public Health (DPH) located in DHSS. The Section of Women's, Children's and Family Health (WCFH) is the designated Title V and CYSCHN agency. WCFH programs are described in the WCFH Program Descriptions (attached as a supporting document, in addition to the WCFH organizational chart). The Section of Chronic Disease Prevention and Health Promotion (CDPHP) manages the following programs that serve the MCH population: Physical Activity and Nutrition; School Health; Youth Risk Behavior Survey (YRBS); Tobacco Prevention and Control; and Injury Prevention. The Section of Epidemiology (SOE) manages the Alaska Immunization Program.

Other MCH programs are managed in other Divisions of DHSS: EPSDT Outreach – Division of Health Care Services (Medicaid agency); Early Intervention/Infant Learning Program – Division of Senior and Disability Services; Strengthening Families – Office of Children’s Services (OCS); WIC/Nutrition Programs – Division of Public Assistance.

Over the past several years, DHSS has faced significant budget cuts in its share of state general fund dollars and has eliminated or reduced programs while trying to live within a budget that depends entirely on the price of oil and federal funding. DPH is frequently the target of across-the-board cuts. Cuts to administrative services largely funded by state funds, such as information technology, human resources, and financial/procurement, have also had a significant impact on public health program operations. It is anticipated that given the continued decrease in the price of oil, and the COVID-19 pandemic and subsequent worsening of the economy, DHSS may continue to be cut.

Three local governments, the Municipality of Anchorage, North Slope Borough, and Maniilaq Association, operate local health departments as grantees of the State Public Health Nursing section. As noted above, Alaska DHSS offers a wide range of health assessment and disease prevention services through Public Health Centers (PHC) and itinerant nursing services that reach approximately 280 communities statewide. However, since 2015, many public health nursing positions have been cut in addition to the closure of six community PHC’s across the state. Specific services that are no longer provided due to budget cuts include well child exams for children over 7 years of age, and immunizations, reproductive health services, and sexually transmitted infection screening and treatment for adults 30 and over. The impact of these ongoing cuts to Public Health Nursing has been clear as the Department responds to the 2020 COVID-19 pandemic, and some nursing positions have been reinstated recently using federal funding specific to COVID.  Public Health Nursing has had to bring on many new long-term, non-permanent positions to support COVID-19 contact tracing efforts statewide.

State Priorities

The mission of the Alaska DHSS is to promote and protect the health and well-being of Alaskans. The Department's priorities – Health and wellness across the life span; Health care access, delivery and value; and Safe and responsible individuals, families and communities – span the breadth of the department and encompass the unique service-areas represented within.

In 2019, DHSS, in partnership with ANTHC, conducted the Healthy Alaskans 2030 State Health Assessment and developed new leading health indicators for Healthy Alaskans 2030 (HA2030). The 30 health priorities identified for HA2030 include reducing the rates of cancer, suicide and poor mental health, child maltreatment and interpersonal violence and sexual assault. Alaskans also wanted to see alcohol, tobacco and drug use curtailed, and an increase in disease prevention through vaccines, improved community access to in-home water and sewer services and optimally fluoridated water, and increasing the percent of children at a healthy weight. As well, there are goals for improved healthcare access, protective factors for adolescents and social determinants of health. WCFH staff members participate in several HA2030 workgroups.

The Alaska DPH mission is to protect and promote the health of Alaskans; with a vision of healthy Alaskans today and tomorrow. In 2019, DPH conducted a strategic planning process to update the Division’s Strategic Plan, and the summary 2020-2023 Strategic Plan was released in June 2020. The COVID-19 pandemic response has currently put further development of the new Strategic Plan temporarily on hold.

In 2017, the WCFH established a strategic plan (attached as a supporting document) reflective of the priorities outlined in the MCH Title V needs assessment as well as state priorities. The Section plans to update this plan during the second half of 2020, now that the DPH Strategic Plan goals have been finalized and the Title V 2020-2024 Five Year Needs Assessment is completed.

DPH is actively pursuing accreditation status with the national Public Health Accreditation Board (PHAB). The process of obtaining initial accreditation status will give DPH the opportunity to assess its performance against a set of nationally recognized standards and measures based on the 10 Essential Public Health Services.  WCFH staff are represented on the core team leading this effort as well as domain-specific teams such as workforce development.

Components of Alaska’s System of care for meeting the needs of underserved and vulnerable populations

Alaska ranked 30th in the nation on the Commonwealth Fund’s 2019 Scorecard on State Health System Performance, which was based on more than 40 measures of health care access, quality, efficiency, health outcomes and disparities. Alaska was below the national average in three of the main categories (access and affordability, prevention and treatment, and healthy lives) and above average on avoidable hospital use and cost and health care disparities.

The only children’s hospital in Alaska is the Children’s Hospital at Providence (TCHAP), located in Anchorage. The state’s only Level III NICU is at TCHAP, while Alaska Native Medical Center and Alaska Regional Hospital in Anchorage and Fairbanks Memorial Hospital have Level II NICUs. Increasing NICU services has been discussed at some hospitals. WCFH is monitoring this in terms of any effects to regionalization of care. To reduce costs, in May 2018 the military hospital at Joint Base Elmendorf-Richardson (JBER) began transferring infants born between 32-36 weeks and/or patients in labor to ANMC instead of Providence, as was previously done. Since both JBER and ANMC are federal entities, this agreement allows JBER to save funds in comparison to transferring the patients to a private facility. It also serves to increase the census at ANMC.

There is a chronic shortage of pediatric subspecialists in the state. While TCHAP and ANTHC have been successful in recruiting subspecialists to the state, many are represented by only one clinician in that specialty. While we have had success is recruiting two pediatric neurodevelopmental specialists, with one additional specialist anticipated later in 2020, the past year has seen a decline of pediatric providers from other areas such as endocrinology, rheumatology, among others.

While tribal health has been increasing their number of pediatric specialties, TCHAP is noting a reduction as the health system has seen positions cut across multiple disciplines in Anchorage. This includes sub-specialty providers, the Medical Director of TCHAP, among other positions. In November of 2019, the All Alaska Pediatric Partnership (AAPP) convened a community meeting to begin work on addressing this issue as a state. The Title V Director helped in the planning and facilitation of this event. This has become a priority for AAPP in their multi-year strategic plan. Work group focuses include telehealth, provider training and workforce development, coordination of services, partnerships with additional universities and provider recruitment. The Title V MCH, CYSHCN Director and CYSHCN Program Manager will be active in this process.

As of 6/30/19, there has not been a Genetics Clinic in the state of Alaska. The contractors providing these services previously (Oregon Health & Science University) no longer had the staffing capacity to travel to Alaska. Genetics Clinics in Seattle and Portland have even experienced long waiting times for an appointment. ANTHC is about to enter into an agreement with the University of Utah to provide diagnostic genetics services to begin hopefully in fall 2020. While this does provide services to the Alaska Native population, there will remain a gap for children who are not beneficiaries. One of the main concerns regarding sponsorship of genetics in Alaska is the cost. There are concerns regarding Medicaid reimbursement for genetic testing due to denials. There is a workgroup looking at this with Medicaid that includes the Title V MCH Director.

Many of the existing resources for specialty care continue to be concentrated in the large population centers. The majority of the state’s pediatricians and neonatal and maternal specialists are primarily based in Anchorage, Fairbanks, and Juneau. Access to these resources from other areas often entails high transportation costs, many times borne by the Medicaid program. While telemedicine is being used increasingly in rural and frontier Alaska, it is limited to tribal health care centers where the mix of patients is predominantly tribal health beneficiaries. Infrastructure availability and use in the private sector is limited and tends to be within the corporation and service area. One exception to this is the E-ICU, Providence provides coverage from their tertiary medical center to secondary hospitals outside of Anchorage. Billing on a fee for service model with no managed care, lengthy waits for licensure, and siloed telecommunication systems and practice models are three significant impediments to expansion of this technology. Since the COVID-19 pandemic began, access to telehealth has increased and this public health emergency could pave the way for increased access to telemedicine in the future.

Medicaid and Denali KidCare (CHIP) serve a large share of Alaska’s at-risk and vulnerable child population, including approximately 79% of children living in or near poverty, 48% of children with disabilities or other special health care needs, and 100% of children in foster care (Georgetown University Health Policy Institute Alaska Snapshot 2019). Medicaid coverage for pregnant women and children was broadened in the 1980s with an expansion of eligibility based on higher income standards and the addition of EPSDT, which broadened specific services that the state was required to provide children. Alaska implemented Medicaid expansion under the Affordable Care Act in September 2015, extending coverage to childless adults up to 138% FPL.

Alaska is one of two remaining states whose Medicaid payments are based on fee for service. Because of this, CYSHCN and their families are only able to access care coordination at two points within our system of care. The first is if they are eligible for Part C Early Intervention services, where the child must be under 36 months of age and have a documented 50% developmental delay. The second is if they are eligible for either a Children with Complex Medical Needs or Intellectual or Developmental Disability waiver. To contain costs, Senior and Disability Services is only selecting 50 new waivers a year limiting families’ access to care coordination.

Specific state statutes and other regulations that have relevance to title v

Alaska state law directs DHSS to promulgate regulations for the control of conditions or diseases of public health importance. Alaska statutes authorize the Department to (among other activities) collect, analyze, and maintain databases of confidential information related to conditions of public health importance and any data needed to provide essential public health services and functions. Alaska regulations mandate reporting of certain conditions of public health importance to the Division of Public Health, including birth defects, which are reported to WCFH.  Additionally, the Department may identify, assess, prevent, and ameliorate conditions of public health importance through:

1. Surveillance—WCFH surveillance programs include the Pregnancy Risk Assessment Monitoring System (PRAMS), Childhood Understanding Behaviors Survey (CUBS), Alaska Birth Defects Registry (ABDR), and Maternal Child Death Review (MCDR);
2. Epidemiological tracking, program evaluation, and monitoring—in WCFH this includes the Title V Maternal-Child Health Indicators Program;
3. Testing and screening programs—in WCFH these programs include Breast and Cervical Cancer Screening; Pediatric subspecialty clinics; and newborn bloodspot and hearing screening;
4. Treatment;
5. Administrative inspections; or other techniques.

During 2018, regulations that affect the newborn bloodspot screening and Alaska Birth Defects Registry programs were revised. On July 1, 2018, Alaska became a one-screen state for bloodspot screening and also funds and coordinates a courier system for transport. The updated birth defects registry regulations expand the list of organizations required to report and includes private or public health insurance organizations and diagnostic laboratories operating in Alaska, and requires infant/child and maternal identifiers to be reported.

The following is a full list of Alaska state statutes (AS) and Alaska administrative code (AAC) regulations of relevance to Title V. Items that are bolded have direct relevance to programs in WCFH.

AS 08.65 Direct-Entry Midwives

AS 08.68 Board of Nursing

AS 11.41.434-440 Sexual Abuse of a Minor

AS 14.07.020 Duties of the Department of Education and Early Development

AS 14.12.115 Indemnity to School Staff

AS 14.20.680  Required Alcohol and Drug Related Disabilities Training

AS 14.30.045 Tuberculosis screening

AS 14.30.065-127 Physical Examinations and Screening Examinations

AS 14.30.141 Self-administered Medication in School

AS 14.30.231 Assure appropriate programs & services for children with disabilities

AS 14.30.355-356 Sexual Abuse and Sexual Assault Awareness and Prevention

AS 14.30.362 Suicide Awareness and Prevention Training

AS 14.33.100  School Crisis Response Plan

AS 14.33.200 Harassment, Intimidation, or Bullying Prohibition Policy

AS 18.05 Administration of Public Health and Related Laws

AS 18.15.010-900 Disease Control & Threats to Public Health

AS 18.15.200 Screening for Metabolic Disorders

AS 18.16.010 Regulation of Abortions

AS 18.50.010-040 Vital Statistics Act

AS 18.66.310 Continuing Education for Public Employees

AS 25.20.010 Age of majority

AS 25.20.025 Examination and Treatment of Minors

AS 40.25.125 Public Record Disclosures

AS 44.29.020 Duties of the Department of Health & Social Services

AS 47.07.030 Medical Services to be Provided for Pregnant Women

AS 47.07.067 Payment for adult dental services

AS 47.17.010-290 Child Protection

AS 47.20 Services for Developmentally Delayed or Disabled Children

AS 47.20.300-390 Newborn and Infant Hearing Screening, Tracking and Intervention Program

04 AAC 06.055 Immunizations required for school entry

04 AAC 52.250  Special Education Aides

07 AAC 12.401-.449 Free Standing Birth Centers

07 AAC 23.010-.900 Programs for Children with Disabilities

07 AAC 27.007 Reporting by laboratories

07 AAC 27.012 Birth Defects Registry

07 AAC 27.110-.111 Prophylactic treatment of newborn's eyes

07 AAC 27.510-590 Screening of newborn children for metabolic disorders

07 AAC 27.600-650 Newborn Hearing Screening

07 AAC 27.890-.900 Confidentiality, authorized users, and security standards; definitions

07 AAC 78 Grant Programs

07 AAC 80 Fees for Department Services

12 AAC 02.280-282 Board of Nursing - licensing fees

12 AAC 44 Board of Nursing, including Advanced Nurse Practitioner

14 AAC 12-14 Renewal & Continuing Competency Requirements for Certified Direct-Entry Midwives

CH. 56 SLA 13 Critical Congenital Cardiac Screening