Overview of Idaho
Demographics
Idaho is a large western state with impressive mountain ranges, large areas of high desert and massive expanses of forested terrain. Idaho contains the second largest wilderness area in the lower 48 states, the Frank Church – River of No Return Wilderness, which covers almost 2.4 million acres. Geography and distance impact both the demographic characteristics and social determinants of health within Idaho.
Idaho is ranked 39th of the fifty United States for total population and 14th for geographic size. The 2018 estimated population for Idaho was 1,754,208, and because of its large size and relatively small population, Idaho remains one of the most rural states in the nation. The Idaho Department of Commerce defines rural as any county that does not have a population center with 20,000 persons or greater. With approximately 19.0 people per square mile, Idaho ranks 44th of the 50 states in population density. Thirty-five of Idaho’s 44 counties are rural with 18 of these counties considered frontier or having fewer than six people per square mile. Idaho has seven population centers throughout the state with approximately 66% of the population residing in one of these populated areas. Delivering adequate health services to the entire state remains a challenge in this very rural environment.
Idaho is an important agricultural state, producing nearly one-third of the potatoes grown in the United States. Wheat, sugar beets, and alfalfa hay are also major crops. Other industries contributing to Idaho’s economy include information technology, mining, lumber, tourism, and manufacturing.
According to the U.S. Census 2017 Population Survey, 12.8% of Idahoans were living below the poverty level. It is estimated that more than half of children under the age of five live in a low-income household. Regarding Idaho’s economy, there is good indication it has stabilized with an unemployment rate of 3% in 2018. The median household income in Idaho was $50,985, compared to the U.S. median household income of $61,372. Idaho’s per capita income in 2017 was $25,471.
In 2017, there were 22,911 infants under the age of one and 420,881 children aged one through 17 residing in Idaho. Of those, about 18% or 79,175 of Idaho’s children have a special health care need. There were 328,941 women of reproductive age (15 to 44 years old) residing in Idaho, which is just over 19% of the total state population. Idaho’s birth rate was 12.9 per 1,000 population.
For 2017, the percentage of Idahoans over the age of 25 who have graduated from high school is higher than the national average (90.2% and 84.6%, respectively). Four-year college retention rates for new students has increased for Idaho at 75% and for two-year institutions it was 59%. A quarter (26.8%) of Idahoans over the age of 25 hold a bachelor’s degree or higher, compared with the national average of 32%.
The racial groups that comprised Idaho’s population estimates for 2018 are: (a) white, 93.2%; (b) black, 0.9%; (c) American Indian/Alaska Native, 1.7%; and (d) Asian or Pacific Islander, 1.7%. It is estimated that 2.4% of Idahoans identify as being of two or more races.
Hispanic/Latino Idahoans are the largest minority population that make up roughly 12.5% of Idaho’s total population with nearly 215,392 Hispanics/Latinos residing in Idaho. Most Hispanic Idahoans are U.S. born (73%), and U.S. citizens (79%), 43% born in Idaho. Most of Idaho's Hispanic population (77%) resides in Southern Idaho. Hispanics/Latinos are the only population whose numbers are rising in rural Idaho along the Snake River Plain (University of Idaho, 2019) and moving upward to the Panhandle for employment opportunities in the agricultural industry.
Idaho has a small but growing immigrant population. While only 6 percent of the state’s residents are immigrants, they represent a greater share of the workforce. Idaho’s farming and fishing industry—one of the state’s top economic drivers—benefits from immigrants who make up over 40 percent of its labor force. In 2015, Idaho was home to approximately 44,500 women and 6,400 children who were immigrants, with more than half being from Mexico.
Idaho has two refugee centers, one located in Ada County in southwest Idaho and one located in Twin Falls County in south central Idaho. Idaho received an estimated 400 refugees in 2018, a 67% decrease since 2016. Most of the refugees seeking resettlement in Idaho are women and children with the majority being from Iraq, Congo, Burma, Bhutan, Afghanistan, and Somalia. Priorities established for FY 2020 will include assessing gaps in services for the resettlement communities with efforts underway to engage our refugees in the five-year needs assessment surveys and to establish new partnerships.
Idaho is home to four federally recognized tribes: Coeur d’Alene Tribe, Kootenai Tribe of Idaho, Nez Perce Tribe of Idaho, and the Shoshone-Bannock Tribes of the Fort Hall Reservation. Collectively, the tribes are spread across 12 communities with almost two million acres of trust. In addition to federally-funded Indian Health Service services, each tribe has individually-operated health centers located on its reservation (Indian Health Services, 2016). Efforts to engage with tribal communities to collaborate and identify gaps in services within these communities will be a focus for SFY2020 with plans to encourage participation in the next five-year needs assessment and build on new collaborative partnerships.
The Idaho 2-1-1 Careline is a statewide, bilingual, toll-free information and resource referral service linking Idaho citizens to health and human services. In SFY 2018, the Careline facilitated 98,362 customer contacts which resulted in 122,361 referrals. The Careline referral database has an estimated 11,382 active services that are linked to 3,558 Idaho programs to increase the health, stability and safety of Idahoans. The Careline serves as Idaho’s mechanism to meet the required OBRA legislation.
Local public health infrastructure is established around the state’s population centers and arranged in seven autonomous public health districts (PHDs) containing contiguous counties across the state. These seven areas are further defined by geographic barriers and transportation routes. Each district responds to local needs to provide services that may vary from district to district, ranging from community health nursing and home health nursing to environmental health, clinical services, dental hygiene, and nutrition. Many services are provided through subgrants with the Division of Public Health.
Idaho's citizenry and leadership tend to emphasize the importance of individual and local control over matters involving economy, health, education, and welfare. The independent nature and philosophy of Idahoans manifests itself through development of local programs and services through grassroots efforts rather than a centralized approach. This philosophy is present within the political leadership, which influences allocations to programs within state government, including Idaho's health programs. As reflected in the MCH priorities, access to health care and other services has been identified as a barrier to improving health outcomes for Idaho residents.
Idaho Division of Public Health
The Idaho Department of Health and Welfare (IDHW) is the state’s health and human services agency. With the overarching mission of promoting and protecting the health and safety of Idahoans, IDHW is dedicated to protecting the social, economic, mental and physical health and safety of Idahoans, while promoting healthy behaviors and positive lifestyles. IDHW provides critical and valued services to more than a third of all Idahoans and strives to be a vital partner to other agencies and communities in our state, both in leadership and supportive roles. The IDHW Director, David Jeppesen, oversees all department operations and is advised by a seven-member State Board of Health and Welfare appointed by the Governor. IDHW is made up of eight divisions, as well as the Office of Healthcare Policy Initiatives and Indirect Support Services. Across these organizations, essential programs and services are delivered to Idahoans, including Medicaid, SNAP, child protective services, foster care, early intervention, child support, and mental health services. The IDHW is the largest state agency with approximately 2,800 full-time employees, 23 state offices, two psychiatric hospitals, and one care facility for intellectual disabilities.
Within the IDHW, the Idaho Division of Public Health (DPH) is the state’s public health agency. The Idaho DPH is nationally accredited by the Public Health Accreditation Board (PHAB) staffed with 247 employees. Idaho’s DPH provides a statewide infrastructure that serves and protects the health and safety of Idahoans through a range of public health services, population health initiatives, and acts as the first responder during times of public health need. The DPH is comprised of eight bureaus, as well as the Center for Drug Overdose and Suicide Prevention. The range of programs and services include immunizations, nutrition services, chronic and communicable disease surveillance, public health intervention, food safety regulation, emergency medical personnel licensing, vital records administration, health surveillance and epidemiology, rural healthcare provider recruitment, laboratory services, and bioterrorism preparedness.
Within DPH, the Bureau of Clinical and Preventive Services (BOCAPSs) fulfills the primary roles of administering grant programs, developing policies, assuring health care access, and overseeing statewide public health programs across the life course focused on providing gap-filling clinical services, nutrition and medical benefits, health education and prevention, population-based screening, and testing and treatment of STDs. BOCAPs is organized into three sections, including the Women, Infants, and Children supplemental food program (WIC) Section, the HIV, STD, and Hepatitis Section, and the Maternal and Child Health (MCH) Section. The MCH Section serves as the state’s Title V Program and is managed by the Title V Director. The Title V Program leverages the existing public health infrastructure with local public health districts, health systems, and community partners to meet the unique needs of Idaho’s MCH populations. Please see the “Title V Program Design and Purpose” for more information about Idaho’s Title V Program.
Health Care Systems
Idaho’s health care infrastructure is comprised of 24 not-for-profit hospitals, a veteran’s affairs hospital, nine district hospitals, 10 county hospitals, two state hospitals, and six investor-owned hospitals. Twenty-seven of these hospitals are critical access hospitals, owning 30 clinics. These clinics include primary care and specialty services and may be co-located with the hospital as well as remote clinics.
There are 29 birthing hospitals statewide, and 44 free-standing birthing clinics and midwifery practices. In 2017, 96% of births occurred in a hospital, 1.4% occurred in freestanding birthing centers, and 2.3% occurred in a home-setting.
There are 16 community health centers (CHCs) that provide patient-centered primary healthcare services for medical, dental, and behavioral health services on a sliding scale serving 50 communities with 72 clinic sites. These community clinics help bring affordable access for care in rural communities with the majority on Medicaid or Medicare with pockets of uninsured individuals. CHCs provide essential health services and are often the only source of primary and preventive care in rural Idaho.
The largest health care system is St. Luke’s Health System with 200 clinics across Idaho, 1,000 beds, 30 medical centers, specialty clinics, and the state’s only Children’s Hospital. In 2018, St. Luke’s opened its first virtual hospital with a 35,000 sq. ft. center that offers a telehealth program filling the gap for patients experiencing challenges to accessing medical care, especially those living in remote rural areas. In 2019, St. Luke’s opened Idaho’s first pediatric trauma program at its children’s hospital.
The second largest health care system is Saint Alphonsus, which is a member of the national Trinity Health System. Saint Alphonsus has hospitals in Boise and Nampa in the southwestern portion of the state as well as two hospitals in Oregon near the Idaho border. Saint Alphonsus Regional Medical Center in Boise is a 381-bed medical, surgical, and acute care hospital with primary care and specialty medical centers and a Level II trauma center. The system has over 350 providers across 38 clinic locations.
Idaho has 19 designated trauma centers, but only three are Level II, and the remainder are Levels III and IV. Idaho does not have a Level I Trauma Center, so Idahoans needing Level I medical care are transported via LifeFlight to Utah, Oregon, or Washington state.
Approximately 40% of Idaho births are covered by Medicaid, and it is estimated that 38% of Idaho children had public health insurance, such as Medicaid, in 2016-2017. In FY 2018, Medicaid enrollment decreased about 3% from the previous year, and it is projected to continue to decline in FY 2019. In FY 2018, Idaho experienced a significant decrease (6.7%) in children enrolled in Medicaid and CHIP. While the cause is unknown, a major factor believed to contribute to the drop is the state’s strong economy and families accessing employer-based insurance. In 2018, legislation was passed to restore dental benefits to all Medicaid eligible adults, including pregnant women. At the time, it was estimated that 29,000 Medicaid eligible adults would gain access to basic dental care.
In 2017, all Idaho counties were federally-designated as having mental health professional shortages. In 2018, four behavioral health community crisis centers were in operation serving Idahoans across three regions with plans to expand by adding crisis centers at hospitals and in other rural regions. The crisis centers have shown to reduce unnecessary hospitalizations and incarceration and have become an integral part of the continuum of care in these underserved communities with special needs. However, the sustainability of these centers has been a challenge with the requirement for centers to submit a plan to become 50% self-sustainable by the end of the second year in operation.
In 2017, 96.4% of Idaho counties were federally-designated as a shortage area for primary care. The Idaho legislature reserves 40 seats in the University of Washington School of Medicine in partnership with the University of Idaho (WWAMI Program) which allows medical students to train in their own state for four years to increase their familiarity with rural Idaho and the rural health care needs across regions. The goal of this partnership is to increase the likelihood that graduating medical students will seek opportunities in Idaho that could fill the shortage of physicians.
To further address the shortage of physicians in Idaho and with the impending retirement of approximately 30% of practicing physicians over the age of 60, Idaho’s new medical school, Idaho College of Osteopathic Medicine (ICOM) opened with an emphasis on the medical needs of rural, underserved areas. ICOM officially opened August 2018 and enrolled its first cohort of 97 students from across the US. A third of the new medical students are from Idaho and the remaining states in the targeted region (Montana, North Dakota, South Dakota, and Wyoming).
The demand for genetic services in Idaho has increased with an estimated 1,000 individuals seeking access annually, which has resulted in an eight-month waitlist for an appointment. Title V partially supports a Genetics and Metabolic Clinic at St. Luke’s Children’s Hospital, which has the state’s only geneticist. Expanding access to genetic counseling has been a challenge due to licensed genetic counselors not recognized as billable providers of care, lack of accessibility for the uninsured or underinsured (as most are on Medicaid), and the lack of provider education on the limited genetic services. To help remedy the need for genetic counseling services, Boise State University will be adding a genetic counseling graduate program in the Fall 2019.
To address the need for improving and implementing a new care delivery model for children’s mental health services, the Youth Empowerment Services (YES) project was conceived in 2018 after a class-action suit settlement (Jeff D. v Otter) in 2016. The settlement agreement targeted the provision of community-based services rather than housing mentally ill children within the correctional system without treatment. The YES system of care relies on a model of service delivery in which all child-serving systems coordinate care collaboratively to support youth and parents as the main drivers of care and treatment with the goal of producing positive outcomes.
Disparities, Challenges, and Strengths
Through on-going needs assessment efforts, the following populations have been identified by the Title V Program as Idaho’s disparate MCH populations. Identification of these groups was based on a systematic review of secondary data (vital records and health survey data) stratified across multiple demographic and geographic variables, and these groups were found to be the most vulnerable and at the highest risk for poor health outcomes, including birth outcomes.
- Hispanic and Latino residents
- Rural and frontier residents
- American Indians and Alaska Natives
- Low-income residents
- Refugees
In Idaho, Hispanic and Latino women had higher rates of smoking during pregnancy, preterm births, and teen pregnancy rates than non-Hispanic or Latino women. When compared with their urban counterparts, Idaho women living in frontier and rural areas accessed first trimester prenatal care at a lower rate, had higher rates of unintended pregnancy, lower breastfeeding initiation and duration, higher rates of unsafe sleep practices, higher prevalence of overweight and obesity, higher rates of smoking during pregnancy, and higher rates of low birth weight and preterm births (rural only). Low-income women were less likely to access first trimester prenatal care, had higher rates of unintended pregnancy, lower breastfeeding initiation and duration, higher rates of unsafe sleep practices, and higher rates of smoking during pregnancy when compared with women in higher income categories.
Due to small numbers, there is limited Idaho-specific vital record or health survey data for refugees and American Indians/Alaskan Natives. The poverty rate for each tribe in Idaho is above the national average with about 26.7% of Native Americans living in poverty in the state (compared with 14.4% of white residents). Higher poverty rates are associated with greater challenges accessing health care services. Recently, there has been media attention on the high suicide rate among Native Americans, especially women. Since 1999, the suicide rate has increased 71% for Native American men and 139% for Native American women (compared with the 33% increase nationwide). American Indian women also experience higher levels of violence than other US women, with nearly 84% experiencing violence in their lifetime. American Indian and Alaska Native people experience lower life expectancy due in part to higher chronic disease burden, inadequate eductation, poverty, discrimination, and cultural differences.
For refugees, time spent in war zones and refugee camps result in a higher likelihood to suffer from unmet health care needs (University of Idaho, 2016). These may include untreated chronic illnesses such as diabetes and hypertension, mental health issues and post-traumatic stress disorder, sexual trauma, as well as hearing, dental, and vision issues. Refugees in Idaho face difficulties navigating the complex health care system and are likely to forgo health care due to inability to pay and/or afford health insurance. Refugees are less likely to work for businesses that provide health insurance and more likely to face unemployment and low wages compared to U.S. natives (U.S. Bureau of Labor Statistics, 2014).
Idaho’s Bureau of Rural Health and Primary Care is dedicated to strengthening healthcare access in rural and underserved communities across Idaho. The Bureau programs have been fundamentally vital in identifying and addressing health profession shortages and promoting partnerships to improve healthcare in rural areas. In 2017, all of Idaho’s counties were designated as a Health Provider Shortage Area (HPSA). Idaho had 73 primary care physicians per 100,000 population in 2017, ranking 49th in the U.S. for the number of physicians and 50th for primary care per capita in the nation. Qualifying physicians serving federally designated HPSA’s can apply for the Rural Physician Incentive Program, a medical education loan repayment program receiving up to $100,000 over four years.
There are 137 practicing pediatricians with a ratio of one pediatrician for approximately every 3,000 children under the age of 18. Sixty-eight percent of counties in the state do not have a pediatrician. Again, there are general practitioners, family practice doctors, and advanced practice providers, but it’s unknown how many serve children. For pediatric sub-specialties, only 17 specialites are practiced in Idaho and most are located in Ada county (home to the state’s only children’s hospital in Boise). Lack of access to pediatric sub-specialists is a critical barrier to receiving quality care and treatment, especially for children with special health care needs (CSHCN).
Idaho’s Title IV-E waiver for foster care provides federal funds to implement practices to assure child safety, help children in foster care move to safe, permanent homes more quickly, and to improve on the well-being of any child entering the foster care system. Priority is placed on reunification with a parent or placement with a family member. The need to recruit and retain licensed families for placement of foster children in Idaho is critical, with a focus on recruiting Hispanic, African-American, and Native American families and families who can provide care for CSHCN. During SFY 2018, 2,936 children were served through the foster care program, and 42% of these children left foster care with 66% being reunified with their parents. Compared to other states, Idaho has approximately half the rate of children placed in non-family settings, such as group home settings.
In December 2014, Idaho was awarded $39.6 million dollars to implement the Statewide Healthcare Innovation Plan (SHIP) strategies over a four-year model test period. The primary goals of SHIP were to transform primary care practices across the state into patient-centered medical homes, improve care coordination through the use of electronic health records and health data exchange, establish seven regional collaboratives to support the integration of each medical home within the broader community, improve rural patient access to care, build a statewide analytics system, align payment mechanisms across payers to transform payment methodology from volume to value, and reduce healthcare costs overall. By 2018, there were 166 clinics enrolled in SHIP across 24 counties. Additionally, four of the largest commercial insurance companies in Idaho (Blue Cross of Idaho, Regence Blue Shield, PacificSource, Select Health) along with Medicaid and Medicare participated in the model test by paying for improving health outcomes as opposed to the traditional model of paying for volume of services. This resulted in reducing overall healthcare system costs by $213 million over the life of the grant. To address Idaho’s clinical workforce shortage, innovative strategies were implemented that included training of community health workers, establishing new community health EMS programs, and the establishment of 13 new telehealth grants to expand medical access to rural and underserved communities.
The Idaho Child Fatality Review Team (CFRT) was formed by the Governor’s Task Force for Children At Risk, under Executive Order 2012-2013, to review deaths to children under the age of 18 using a comprehensive and multidisciplinary process. In 2016, the Title V MCH Director became a member of this team to inform the MCH program of findings for program activity prioritization and general awareness of review determinations. The team utilizes information gathered by coroners, law enforcement, medical personnel and state government agencies in their reviews. With the recent reorganization to the Title V MCH Program structure, the Chief of the Bureau of Clinical and Preventive Services continues to serve on the CFRT and provides information and recommendations from the MCH Program to the team.
Idaho Legislation
Idaho voters passed Medicaid expansion in November 2018. After a contentious 2019 legislative session with multiple expansion bills introduced, the Idaho Governor signed the Medicaid expansion bill into law which included 10 sideboards, including work requirements, family planning restrictions, and substance abuse assessment. The Title X Family Planning Program, which is part of the Idaho MCH Section, is currently working with Medicaid to understand the impact of the family planning waiver to Title X service delivery. Other proposed provisions include allowing for Idahoans earning 100%-138% of the federal poverty level to have the option to purchase subsidized health insurance through Your Healthy Idaho exchange; directing Medicaid expansion patients be placed in a medical home managed care program to help coordinate their medical care; giving the state the option to repeal Medicaid expansion if the federal government reduces its 90% funding rate; a requirement that the House and Senate Health and Welfare Committees review all fiscal, health, and other impacts of Medicaid expansion by 2023 and recommend whether expansion should remain in effect; and nullification of Medicaid expansion if the U.S. Supreme Court rules that the Affordable Care Act is unconstitutional. It is estimated that Medicaid expansion could serve up to 91,000 Idahoans.
Idaho enacted House Bill 109 during the 2019 Legislative Session which authorizes the implementation of a Maternal Mortality Review Committee (MMRC) in Idaho beginning July 1, 2019. This review committee will conduct comprehensive, multidisciplinary review of maternal deaths in Idaho for the purposes of identifying causative and associated factors and to make policy recommendations to improve health care services for women, reducing the incidence of maternal mortality in Idaho leading to improved Maternal and Child Health (MCH) outcomes. The Idaho Title V Program has been tasked with the implementation and operation of the MMRC. The bill passed without any appropriated funding, therefore, Title V will fund and staff the committee and program activities.
During the 2019 Idaho legislative session, House Bill 120 was introduced to amend the existing Idaho statute on sex education. Although the bill did not pass, it would have reversed the procedures for how sex education is taught in Idaho from an “opt-out” approach to a mandatory “opt-in” approach, requiring parents to approve participation in sex education. The premise of the bill was focused on increasing parental rights in the oversight of their child’s education and included language on the role and limitations of guest presenters in the classroom. Most states and school districts, including Idaho, currently rely on opt-out policies. The Sexuality Information and Education Council of the U.S. recommends opt-out policies for sex education, as parents retain control over their child’s education by granting them the option for their child to be excused from any sex education components of a curriculum, while maintaining access to essential education that youth need. The Adolescent Pregnancy Prevention (APP) Program within the MCH Section was actively engaged in responding to public records requests and monitoring progress on the bill. This included attending several House and Senate Education Committee meetings to respond to questions and keeping community partners informed of the bill’s potential impact on their work at the local level. The APP Program anticipates that this issue will be brought forward again during the 2020 legislative session and will continue to work on a coordinated communication plan with Division of Public Health leadership in preparation for the next session.
During the 2019 session, the legislature appropriated a second one-time general fund allocation in the amount of $1,600,000 to support the home visiting programs at the PHDs. The funds are meant to expand home visiting services to additional counties beyond the MIECHV service areas. It is anticipated that the Division of Public Health will include an on-going budget request for home visiting state general funds in future fiscal years. This would allow the MIECHV Program to administer the funds and ensure seamless home visiting implementation and build the current home visiting infrastructure.
Idaho Maps
http://healthandwelfare.idaho.gov/LinkClick.aspx?fileticket=b294jKv2R6Q%3d&tabid=415&portalid=0&mid=9711
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