Geographically, Wyoming is the tenth largest state in the United States (U.S.) spanning 97,813 square miles. There are 23 counties ranging from the Great Plains to the Rocky Mountains. The Wind River Indian Reservation (WRIR), located toward the center of the state, is home to two federally recognized tribes, the Eastern Shoshone and Northern Arapaho.

 

Wyoming is the least populous state in the U.S. with an estimated population of 577,737 (2018 estimate, American FactFinder, U.S. Census) representing a slight decline from the 2017 estimate of 578,934. The population is predominantly White alone (92.8%). The remaining population is Black or African American alone (1.3%), American Indian and Alaska Native alone (2.7%), Asian alone (1.0%), Native Hawaiian and Other Pacific Islander alone (0.1%), Two or More Races (2.1%), and Hispanic or Latino (10.0%) (2018, U.S. Census QuickFacts). In 2017, of the population aged 5 years and older, 92.7% speak only English at home and 7.3% speak a language other than English. 

 

Almost one quarter of the population is under 18 years of age. Nearly 93% of persons over 24 years of age have a high school education or higher. Over one quarter of this group (26.7%) have at least a Bachelor’s degree. The median household income is $60,938. Persons in poverty are estimated to be 11.3% of the population (U.S. Census Quick Facts, Wyoming; 2013-2017).

 

Wyoming is a rural/frontier state. Two counties, Laramie and Natrona, each have a town with over 60,000 people and are considered urban.  Seventeen of the remaining 21 counties are considered frontier with less than six persons per square mile. These 17 counties are home to 46% of the population (Wyoming Economic Analysis Division, Estimates of Wyoming and County Population: April 1, 2010 to July 1, 2018).

 

In the recent past, the economy in the state suffered from the weak demand for oil, warmer weather, and increases in domestic supply for natural gas. However, the most recent unemployment rate (2018, Q4) is 4.1 percent; just slightly higher than the U.S. level of 3.8 percent. Wyoming experienced an overall growth in employment by 1 percent (representing about 2,800 jobs) between the fourth quarter of 2017 and 2018.  (Economic Analysis Division, Wyoming).

 

According to America’s Health Rankings (2018), Wyoming’s strengths include low levels of air pollution and a low proportion of children in poverty. Challenges include a high percentage of uninsured and low rates of primary care physicians.

 

The top two leading causes of death for children between ages 1-24 years in Wyoming are unintentional injury (n=33) and suicide (n=27). Homicide is the third leading cause of death with totals suppressed due to small numbers (Web-based Injury Statistics Query and Reporting System (WISQARS), Centers for Disease Control and Prevention (CDC)).

 

The American Fact Finder (2017, U.S. Census) reports that the percent of Wyoming residents with no health insurance coverage was 12.3%; higher than the U.S. (8.7%) in the same year and ranked as 7th highest in the nation. In Wyoming, among children and youth aged 18 or younger, 9.5% had no health insurance as compared to 5.0% nationally. Wyoming has not expanded Medicaid.

 

According to the Health Resources and Services Administration’s Designated Health Provider Shortage Areas (HPSA) Quarterly Summary Report, Wyoming had a total of 44 Primary Care Health Provider Shortage Area (HPSA) Designations, with 187,903 residents residing in primary care shortage areas. There were 28 Dental HPSA designations in the state with a total of about 49,650 Wyoming residents residing in these areas. Finally, the entire state (comprised of five regions) is considered a HPSA for mental health. Per HRSA's Designated HPSA Quarterly Summary (12/31/18); only 31% of the mental health needs are being met and 25 full-time psychiatrists are needed to meet the need of the population.  

 

There are currently 63 physicians practicing Obstetrics and Gynecology (OB/GYN) in Wyoming and 54 practicing Pediatricians. Ten counties have no OB/GYN and 12 counties have no Pediatrician.

 

Over 14,500 Wyoming women of childbearing age (15-44 years) live in a county with no practicing OB/GYN and approximately 30,000 Wyoming children and youth (<18 years of age) live in a county with no practicing Pediatrician.

 

There are 179 family practice physicians in the state. Twenty-nine individuals practice in Natrona County, 28 in Laramie County, 15 in Park County, and 12 in Fremont County. Nine counties have fewer than 5 family practice physicians.

 

Results from the CDC-developed Levels of Care Assessment Tool (LOCATe) reported that Wyoming lacks Level III facilities for both neonatal and maternal levels of care.  This requires families to travel long distances for health care, miss work, and coordinate care for children left at home. In many cases, families must cross state boundaries to receive care.

 

Health Equity in Wyoming

 

The definition used for health equity by Healthy People 2020 is the “attainment of the highest level of health for all people”. Health equity removes barriers such as poverty and discrimination. It equalizes opportunities for good jobs, a quality education, safe neighborhoods, and access to health care.

 

Due to the unique nature of the state, a number of barriers to measuring health equity exist. Small population numbers (particularly for minorities) at the state and county level make stratification by geographic region, race, and ethnicity challenging. Wyoming continually monitors maternal and child health (MCH) outcomes for minority populations (primarily for American Indian/Alaskan Native and Hispanic/Latino) through the calculation of rolling rates and data aggregation. Too often, even with multiple years, numbers are too small to report. In 2019, the MCH Unit will work to operationalize all of its core values with specific emphasis on health equity. 

 

As stated in the 2019 Robert Wood Johnson County Health Rankings & Roadmaps, Wyoming fares well compared to the nation for children in poverty (13% versus 18%) but the proportion of children in poverty varies widely by county, with rates ranging from 7% (Teton) to 22% (Fremont). When race and ethnicity are examined, child poverty rates range from 13% to 32%.

 

Wyoming’s overall high school graduation rates have risen steadily over the past five years. Since the 2013-2014 school year, high school graduation rates have increased from 78.6% (2013-2014) to 81.7% (2017-2018). However, gaps continue to exist by racial and ethnic categories. While 83.7% of White youth graduated from high school in the 2017-2018 school year, only 75.4% of Hispanic youth and 58.8% of American Indian youth graduated during the school year (Wyoming State 4-Year Graduation Rates, 2017-2018). Educators report that the four-year graduation rate for Native American youth increased substantially from the previous period but recognized that more work needs to be done.   

 

Agency Organizational Structure and Role

 

The Maternal and Child Health (MCH) Services Title V Block Grant is managed by the MCH Unit within the Community Health Section (CHS) and Public Health Division (PHD) of the WDH. The mission of the WDH is to promote, protect, and enhance the health of all Wyoming residents. The 2014-2018 WDH priorities include:

●     Implement Medicaid reform, including improving health outcomes while

containing cost and redesigning waivers to increase access;

●     Redesign the mental health and substance abuse systems to improve outcomes;

●     Focus on Wyoming’s significant public health problems (e.g. suicide and tobacco and alcohol use) to improve overall health outcomes;

●     Maintain Wyoming’s emergency response capability;

●     Strengthen Wyoming’s rural health care infrastructure to ensure access to appropriate, cost-effective, quality care;

●     Enhance the continuum of long-term care options for the elderly to support healthy aging in the most appropriate setting; and

●     Support the health of Wyoming children.

 

The PHD is working toward public health accreditation and has set several strategic priorities to address the division’s mission to promote, protect and improve health and prevent disease and injury in Wyoming:

 

●     Promote understanding of the relevance and value of public health;

●     Foster programmatic excellence;

●     Support the integration of public health and health care;

●     Foster a competent, flexible workforce; and

●     Build a sustainable, cohesive organization.

 

A summary of the PHD organizational structure is included below.

 

 

Several work groups continue to address each of these PHD strategic priorities. For example, the workgroup working to foster a competent, flexible workforce facilitates completion of an assessment of the Core Competencies for Public Health Professionals by all staff. This valuable tool helps staff identify opportunities for professional development related to public health practice.

 

As part of the accreditation process, WDH completed the required state health assessment (SHA) and is working on the state health improvement plan (SHIP).   A member of the MCH Epidemiology staff is on the leadership team for the assessment.  To view the results from the recently completed SHA, visit:  https://health.wyo.gov/publichealth/sha/.

 

The MCH Unit provides leadership for state and local level efforts that improve the health of the maternal and child health population. Structurally, the Unit’s programs are divided according to the population groups they serve: women (ages 15-44) and infants (ages 0-1), children (ages 2-11), youth and young adults (ages 12-24), and children and youth with special health care needs (CYSHCN). This structure aligns well with the Title V population domain framework and assures dedicated resources within each domain. 

 

In 2016, the MCH Unit updated its vision and mission and developed core values. The core values were last updated in 2018 ahead of the current needs assessment planning process. 

 

MCH Vision: Wyoming MCH envisions a Wyoming where all families and communities are healthy and thriving.

 

MCH Mission: The mission of Wyoming MCH is to improve the health and well-being of Wyoming families and communities by supporting and collaborating on public health activities that benefit the health of mothers, infants, children, youth, and young adults, including those with special health care needs.

 

MCH Core Values (updated December 2018):

• Data-driven:  Utilize data, evidence, and continuous quality improvement
• Engagement:  Cultivate authentic collaboration and trust with families and community partners
• Health Equity and Life Course Perspective: Integrate an understanding of how differences in social, economic, cultural, and environmental factors across generations and throughout the lifespan impact health
• Systems-Level Approach:  Prioritize work that addresses community structures, social norms, environment, and policies to maximize impact

 

The 2015 MCH Needs Assessment resulted in the selection of seven priorities for 2016-2020:

●     Prevent infant mortality

●     Improve breastfeeding duration

●     Improve access to and promote the use of effective family planning

●     Reduce and prevent childhood obesity

●     Promote preventive and quality care for children and adolescents

●     Promote healthy and safe relationships in adolescents

●     Prevent injury in children

 

Medicaid expansion in Wyoming was not approved by the state legislature. Wyoming has only one insurer, Blue Cross Blue Shield (BCBS), participating in the Federal Health Insurance Marketplace.

The MCH Unit’s Children’s Special Health (CSH) program offers care coordination and limited gap-filling financial assistance as the payer of last resort for enrolled clients (children and youth with special health care needs, high risk pregnant women, and high risk infants) who meet medical and financial eligibility criteria.  In order to be eligible for assistance, families must first apply for Medicaid, Kid Care CHIP (Children’s Health Insurance Program) and the Federal Marketplace. The program provides reimbursement to eligible providers for covered services provided to eligible clients.

 

In 2016, the Wyoming State Legislature faced difficult decisions to address decreasing state revenues. As a result, the Public Health Oral Health Program was eliminated as part of the Department’s budget reduction. The decision closed the following programs: Dental Sealants, Public Health Severe Malocclusion Program, Marginal Dental Program, Community Oral Health Coordinator Program (Public Health Dental Hygienists), Healthy Mouth Healthy Me, and the Cleft Palate Speciality Clinic. Despite a lack of state-level leadership on oral health, MCH Unit continues to participate in a Wyoming Oral Health Coalition led by the Wyoming Primary Care Association.

State statutes relating to MCH

Three state statutes impact the work of MCH. The Newborn Screening (NBS) statute, Wyoming Statute (Wyo. Stat). § 35-4-801 and 802, mandates newborn screening be available to all newborns and that WDH provide necessary education on newborn screening to hospitals, providers, and families.  WDH bills the hospitals/providers per initial screen. These funds are then used to contract with the Colorado Department of Public Health and Environment (CDPHE) Laboratory Services Division for analysis and communication of results to the provider and Wyoming NBS Program.  Additionally, funds are used for contracts with a courier to transport the blood spots to CDPHE.  In 2019, current contracts with specialists to provide follow-up for abnormal screens will expire and follow-up services will be added to a contract with CDPHE. The Wyoming Newborn Screening and Genetics Coordinator is funded by both Title V and state Trust and Agency funding, demonstrating the partnership between Title V and the WDH to assure access to newborn screening statewide. 

The second statute, Wyo. Stat. § 35-27-101, 102, 103, 104, Public Health Nurses (PHN) Infant Home Visitation Services, was passed in 2000.  The statute directs PHN to contact eligible women to offer home visitation services as part of the Healthy Baby Home Visitation (HBHV) Program, a program consisting of two models.  The initial intent of the legislation was to implement Nurse Family Partnership (NFP), an evidence-based home visiting model, in all 23 counties using Temporary Assistance to Needy Families (TANF) funds.  Due to fidelity requirements and a small birth cohort in some communities, NFP was provided in thirteen counties until State Fiscal Year (SFY) 2017 during which 11 counties implemented NFP.  During 2016, PHN, MCH and MCH Epidemiology completed a process evaluation of NFP to determine which counties have the birth cohort and capacity to deliver the model with fidelity.  As of July 1, 2019, four counties (Albany, Carbon, Natrona, and Sweetwater) deliver NFP.  All 23 counties deliver the program’s second model, Best Beginnings (BB), a home-grown home visiting model based on the research-informed Partners for a Healthy Baby curriculum developed at Florida State University.

The third statute, Wyo. Stat. § 42-5-101, Family Planning and Birth Control, grants WDH with the ability to provide gap-filling contraceptives.  The geography of the state, combined with the small population, poses challenges for assuring reproductive health services are available in all counties.  During the 2017 Wyoming legislative session, restrictions for spending state general funds on contraceptives were added to the budget through a footnote.  MCH supported gap-filling contraceptive purchases for counties with little to no Title X services in State Fiscal Year (SFY) 2016 and through SFY 2017 but discontinued support in SFY 2018 in order to reevaluate the best strategies for increasing access to the wide range of contraceptive options.  MCH will continue to partner closely with Wyoming’s Title X grantee, Wyoming Health Council (WHC), to improve access to family planning services.  See Women/Maternal Health Domain Annual Report for more information about current family planning activities.