Public health in Massachusetts is a statewide commitment to ensure that all residents have the opportunity to experience the best health and well-being regardless of race, ethnicity, socioeconomic status, geographic location, or physical ability. This vision is supported by a strong public health infrastructure and health care delivery system, led by the Massachusetts Department of Public Health (MDPH). MDPH provides outcome-driven, evidence-based programming to prevent illness, injury, and premature death; ensure access to high quality health and health care services; respond quickly to emerging public health threats; and promote wellness and health equity for all residents of the Commonwealth.
Established in 1869 – with 2019 marking its 150th anniversary – MDPH was the first state board of health in the United States. Throughout its history, MDPH has been a pioneer in the development and implementation of public health programs and strategies, including being the first state to establish a childhood lead poisoning prevention program and universal newborn screening program. MDPH uses a variety of approaches including screening, education, research, regulation, inspection, and the provision of funding to numerous local programs and interventions to promote health for all residents in the Commonwealth.
Massachusetts is a national leader in maternal and child health (MCH) programs and policy. The state’s commitment to the MCH population is demonstrated by matching of federal Title V funds. While states are required to match every $4 of federal Title V money with at least $3 of state and/or local money, Massachusetts provides more than $16 state for every $4 federal. The philosophy of the Title V program is to address the health needs of women, parents and their children, focusing on a life course approach. Efforts in Massachusetts focus on the systems, programs and services needed to optimize the health of the entire family.
The MDPH Bureau of Family Health and Nutrition (BFHN) administers the Title V program. The Title V Director, also the BFHN Director, reports directly to the MDPH Commissioner, who reports to the Secretary of the Executive Office of Health and Human Services (EOHHS). EOHHS is the largest secretariat in state government and is comprised of 12 agencies, including Medicaid, Department of Children and Families, Department of Developmental Services, and MDPH. This structure provides Title V with capacity to promote systems of service, coordinate initiatives, and work collaboratively across a range of relationships necessary for a comprehensive approach to Title V goals. The context of Title V within MDPH and EOHHS means that priorities and initiatives are synergistic and collaborative. An MDPH organizational chart is attached.
Demographics, Geography, and Economy
Massachusetts has 6.8 million residents[1] and is the fourth most densely populated state in the U.S.[2] It is often thought of as urban because of the dense concentration of people in metro-Boston and other cities; however, 48% of Massachusetts’ landmass is classified as rural (fewer than 500 residents per square mile). Residents of these rural communities comprise 13% of the state’s total population.[3]
Massachusetts is less racially and ethnically diverse than the U.S. as a whole. An estimated 81.6% of residents identified as White, 9.0% as Black, 11.2% as Hispanic, and 7.1% as Asian.[4] Immigrants make up 16% of the state’s population, and one-fifth of the Massachusetts labor force is foreign born, with immigrants supporting the state’s healthcare, science, and service industries, among others. The top countries of origin for immigrants were China (8.8%), the Dominican Republic (7.4%), India (6%), Brazil (5.6%), and Haiti (5.1%).[5] During 2016, 30.3% of births were to foreign-born women,[6] and during the 2017-2018 school year 20.9% of public school students had a first language other than English.[7]
The Commonwealth’s population is aging. Mirroring national patterns, the proportion of residents aged birth to 18 years has decreased and the percent of the population 65 years of age or older has increased. The median age is 37.8 years.[8] In 2016 the average life expectancy of Massachusetts residents was 80 years and 8 months.[9]
Approximately 11.7% of the population has one or more types of disability, including visual, hearing, ambulatory, cognitive, self-care, and independent living disabilities. In 2016, 38.6% of adults aged 18-64 with a disability were employed, a 3.5% increase from 2015. [10] During the 2017-2018 school year, 17.7% of public school students had a disability.[11]
Massachusetts is a center of higher education and is home to leading research universities and private research laboratories. Massachusetts is also a global leader in life sciences, from pharmaceuticals and medical devices to diagnostics and nanotechnology. Massachusetts has one of the highest proportions of college graduates in the nation, with 42.1% of the population having a Bachelor’s degree or higher.[12] As of December 2019, the unemployment rate was 3.3%, compared with 3.9% nationally.[13] The median household income is $74,167, higher than the U.S. household median ($57,652).[14] Despite the high median income, Massachusetts is also the third most expensive state to live.[15] The median price of a home in Boston is more than 70% higher than the national figure15 and in 2016, 46.8% of renters in the state were cost-burdened, meaning they spent 30% or more of their income on housing.[16]
There are inequities in access to services and in economic and health outcomes across demographic characteristics, most notably by race and ethnicity, which point to historical and structural systems of oppression that continue to disadvantage people of color in the state. Approximately 11.1% of the Massachusetts population lives below 100% of federal poverty level (FPL); however, only 8.7% of White residents live below the FPL compared with 27.6% of Hispanic residents, 20.6% of Black residents, and 14.1% of Asian residents.[17] The median household income for White non-Hispanics was approximately two times that for Hispanic and American Indian/Alaskan Native residents, and 1.7 times that for Black non-Hispanic residents. Furthermore the median household income for Hispanics in Massachusetts ($39,299) was 16% lower than that for Hispanics nationally ($46,627).[18]
Massachusetts is consistently recognized for good health status in national rankings. According to America’s Health Rankings 2018 Annual Report,[19] Massachusetts is the second healthiest state in the nation, with strengths such as a low uninsurance rate and high immunization coverage among children. The Report also ranked Massachusetts first in the health of women and children in part due to a low infant mortality rates and a low teen birth rate. Trust for America’s Health recognizes Massachusetts as one of the most prepared states in the nation,[20] reflecting work on health security preparedness, flu vaccination, public health accreditation, and state public health laboratory biosafety. Continued challenges identified in America’s Health Rankings included the high cost of infant child care, high prevalence of excessive drinking among women, and high prevalence of homeless families. Furthermore, MDPH and Title V recognize that good health in Massachusetts is not equally shared and that there are persistent health inequities that must be addressed.
Health Services Access, Infrastructure, and Financing
According to the 2017 Massachusetts Health Insurance Survey (MHIS),[21] only 3.7% of residents are uninsured, a rate that has remained steady since 2015. Children aged 0-18 years had an uninsurance rate of 2.1%, which is below the national uninsurance rate for this age group (5.3%). As in prior years, a majority of respondents to the 2017 MHIS reported a usual source of care other than the emergency department (88.6%) and a visit to a general doctor in the past 12 months (82.4%). In addition, 18.6% of respondents visited a mental health professional over the past 12 months. Access to and use of care tended to be better for children, women, and Whites. For example, more female respondents (91.2%) and children (97.6%) reported having a usual source of care other than the emergency department compared to males (85.9%) and non-elderly adults (84.2%). Hispanic respondents were less likely than Whites to report a usual source of care (80.4% and 90.5%, respectively) or a visit for preventive care (70.8% and 85.6%, respectively).
According to the MDPH Healthcare Workforce Center, as of 2017, there were 28,428 physicians in Massachusetts with an active license, with 52% reporting an MCH-related specialty including 10% who reported being pediatricians. Although Massachusetts has the highest number of physicians per population in the United States, these providers are not equitably distributed across the state. Over one third (38%) of physicians with an MCH-related specialty practice in Suffolk County (including Boston), which is home to just 11% of the state population. Many areas in the state, including rural communities, lack adequate access to care.
Massachusetts is home to a world-class pediatric hospital (Boston Children’s Hospital) and nine other tertiary care hospitals that provide Level III neonatal care. There are 52 community health centers (CHCs) across the state that are integral in providing high quality medical, dental, vision, pharmacy, behavioral health, addiction services and other community-based services to 988,000 residents regardless of their insurance status or ability to pay.[22] CHCs represent a major source of care for medically underserved women and children. In 2016, 24% of the state’s health center patients were women of child-bearing age (15-44) and 23% were children under 18.[23] CHCs also work to eliminate inequities in health outcomes by hiring multilingual and multicultural staff at every level of their organizations, deploying community health workers to help patients navigate the complex health system, and assisting residents in accessing health care coverage.
As of October 2017, 86% of Massachusetts CHCs had achieved patient-centered medical home (PCMH) recognition through an accredited organization, including the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations.[24] This is an important asset to the MCH system of care, particularly for children and youth with special health needs. The Massachusetts Health Policy Commission, in collaboration with the NCQA, developed the PCMH PRIME Certification program which certifies Massachusetts-based federally qualified health centers for their integration of behavioral health – through formal agreements, co-location, or provider integration – and emphasizes the importance of integrating behavioral health into primary care.
A substantial restructuring of the Medicaid (MassHealth) program also aims to achieve more integrated and outcomes-based services for its 1.8 million members.[25] Over the past year, MassHealth has transitioned from a fee-for-service model to an Accountable Care Organization (ACO) model, in which MassHealth partners with provider organizations directly to deliver coordinated, quality care to members. As of March 1, 2018, MassHealth had established 17 ACOs, which serve 45% of MassHealth members. These ACOs are held financially accountable for cost, quality, and member experience. A key goal of this new model is to improve integration of physical health, behavioral health and long-term services and support (LTSS). MassHealth is increasing investment in and support of community services for members with complex behavioral health needs or in need of LTSS, such as home health care, skilled nursing, and personal care attendants. ACOs are required to partner with certified community-based behavioral health and LTSS providers. To become a state-certified behavioral health or LTSS Community Partner, organizations must have expertise in care coordination and assessments as well as appropriate infrastructure and capacity. Furthermore, LTSS community partners must demonstrate expertise across multiple populations with disabilities. For more information about the ACO transition, see section III.E.2. Health Care Delivery System.
State Health Agency Roles and Responsibilities
The vision, mission, and priorities of MDPH, as identified by the Commissioner, Dr. Monica Bharel, are depicted in the graphic below. MDPH endeavors to provide timely access to data to reduce disparities and improve outcomes, address the social determinants of health, and eliminate health inequities. The principles underlying this work are everyday excellence, passion and innovation, and inclusiveness and collaboration. These principles refer to a culture of continuous improvement and performance management, passion about MDPH’s work, developing creative solutions to complex policy issues and population health management strategies, learning from internal and external partners, and ensuring people with diverse experiences and skills are involved in decision making. Together, these principles lay a solid foundation to achieve MDPH’s mission and vision.
Data Access and Capacity
An important effort that ties together the Commissioner’s priorities is the development of the Population Health Information Tool (PHIT), which launched in June 2019. PHIT is a web-based compendium of health data that is available to the public to inform community health needs assessment, program planning, and policy making. PHIT is organized around six social determinants of health – education, employment, violence, social environment, housing, and built environment – to support Massachusetts in better addressing factors beyond clinical care that influence population health.
The first version of PHIT integrates data from 18 different sources, including Pregnancy Risk Assessment Monitoring System (PRAMS), Pregnancy to Early Life Longitudinal Data System (PELL), Behavioral Risk Factor Surveillance System (BRFSS), Vital Statistics, Injury Surveillance System, Birth Defects Data System, Substance Addiction Services, Early Hearing Detection and Intervention, WIC, and Early Intervention, among others. Also included in PHIT is the Neonatal Abstinence Syndrome (NAS) Data Dashboard, which includes data that address measures across three key time periods – pregnancy, birth, and infancy – for clinical providers, public health workers, and community agencies to monitor the care of families affected by perinatal substance use. PHIT users can access data dashboards and community-specific health priority reports, as well as contextual information to interpret the data and identify health inequities.
Based on the success of the 2015 Chapter 55 legislation, which permitted the analysis of different government datasets to better understand the opioid epidemic and to guide policy and programmatic decisions, new legislation (Chapter 111 Section 237) has given MDPH new and broader authority to assemble, link, and maintain data systems for the purpose of analyzing population health trends. Through a partnership with the Center for Health Information and Analysis (CHIA), MDPH is developing a Public Health Data Warehouse (PHD) that will improve surveillance capacity, increase availability of data for state and local public health activities and evaluation of key public health initiatives, and provide data to measure progress on the State Health Improvement Plan objectives. The MDPH Commissioner will establish priorities for the use of the PHD, and has chosen to start with MCH. Her vision is to generate new, actionable information that will help Massachusetts address inequities in MCH outcomes, especially those across racial groups and other social factors. A workgroup was convened in October 2018 to identify the MCH datasets to be included in the PHD (such as WIC, DCF, Early Intervention, and the Massachusetts Immunization Information System), and design research questions of interest to Title V and MCH in Massachusetts. The workgroup proposed, and the Commissioner accepted, an initial focus on three MCH topics: maternal morbidity and mortality; preterm birth and infant mortality; and adolescent health and wellness. The PHD will be operational in 2019.
In addition to PHIT and the PHD, MDPH has access to the Massachusetts All Payer Claims Database (APCD), a comprehensive source of health claims data from public and private payers in Massachusetts. Administered by CHIA, it is used by health care providers, health plans, researchers, and others to address a variety of issues, including price variation, population health and quality measurement.
Performance Management and Quality Improvement
MDPH and the Commissioner are focused on improving public health outcomes and reducing health care costs by linking clinical care to evidence-based community interventions and integrating quality improvement (QI) and performance management (PM) culture throughout MDPH. The Office of Performance Management and Quality Improvement oversees this work and a PM/QI Council supports MDPH leadership in building a QI culture throughout the organization. The Council provides support and guidance for building QI capacity on all levels, communicating and sharing QI activities and resources, and recognizing QI efforts and successes. With its robust performance measurement framework and focus on implementing evidence-based practices and promising innovations, Title V is a leader in MDPH’s PM/QI efforts. Many Title V staff have also participated in Lean Six Sigma White, Green and Black Belt trainings provided by the Office of Performance Management and Quality Improvement.
Public Health Accreditation and State Health Assessment
In 2017, MDPH was awarded national accreditation by the Public Health Accreditation Board (PHAB), marking the first time since the existence of the national accreditation program that the entire Department is nationally accredited. Three areas of excellence were highlighted in PHAB’s feedback: 1) workforce development with MDPH staff and local public health and public health systems, including community health workers; 2) commitment to health equity which includes addressing social determinants of health and having a dedicated Office of Health Equity to work across all MDPH bureaus; and 3) progressive attitude towards health education and health promotion by working in close collaboration with the program subject matter experts and stakeholders to ensure appropriate and accessible materials.
To achieve PHAB designation, MDPH prepared an updated State Health Assessment (SHA) in fall 2017. The SHA used a collaborative, systematic process to collect, analyze, and interpret available state-level data to provide context for the health of residents across Massachusetts and identifies the key resources, programs, and services that promote and protect the public’s health, including a chapter on MCH. The SHA informs state health improvement planning, including the MDPH Strategic Plan, Workforce Development Plan and the State Health Improvement Plan. Title V staff actively participated in the development of the SHA and worked to ensure alignment of MCH priorities and objectives.
MDPH maintains its national accreditation by submitting annual reports and applying for reaccreditation every five years. The First Accreditation Annual Report acknowledged MDPH’s commitment to and investment in quality improvement tools and training across all levels of managers and staff. These efforts have led to improvements in how MDPH maintains its accreditation and implements quality improvement measures in meaningful ways.
Substance Use
Access to prevention, intervention, treatment, and recovery support services for individuals, families, and communities affected by opioid use disorder across the Commonwealth is a key priority of MDPH and Governor Baker. MDPH estimates a 1% decrease in the rate of opioid-related overdose deaths in 2018 compared with 2017, according to the most recent quarterly opioid report. This follows an estimated 3% decline in the rate of opioid-related overdose deaths from 2016 to 2017.
Since assuming office in 2015, the Baker Administration has taken two major legislative actions to address the opioid crisis. The first bill, signed into law in March 2016 and titled “An Act relative to substance use, treatment, education and prevention,” included measures to reduce prescription drug and opioid abuse, most notably limiting first time opiate prescriptions to a seven day supply. In August 2018, Governor Baker enacted “An Act for prevention and access to appropriate care and treatment of addiction,” which builds the network of treatment and recovery services for pregnant and parenting women, expands access to the opioid reversal medication Naloxone, creates new pathways to treatment in the emergency department, and expands the use of medication assisted treatment. Other key statewide initiatives to address the opioid epidemic have included securing a $52.4 billion Medicaid waiver that includes the expansion of substance use treatment services; establishing core competencies for safe prescribing of opioids and treatment of substance abuse disorders with the state’s nursing, medical, dental, social work and physician assistant schools; increased surveillance and training for providers; and increased access to wrap around supports for pregnant women and their families and individuals re-entering the community from incarceration.
Title V plays a critical role in advancing state efforts to address substance use and curb the opioid epidemic, specifically related to the incidence of substance use disorders in pregnant women and infants with neonatal abstinence syndrome. One of Title V’s priorities is to address substance use among women of reproductive age. More information can be found in section II.E. Five Year State Action Plan: Maternal/Women’s Health.
State Statutes and Regulations Relevant to Title V
Title V priorities are contextualized within state statutes and other regulations to improve population health through the most effective and efficient mobilization of available resources. There are no statutes in Massachusetts directly related to the establishment or operation of a Title V program as defined by HRSA/MCHB. There are, however, many statutes and regulations that address issues related to MCH and CYSHCN. Examples of relevant statutes and regulations, many of which involved leadership or significant input by Title V, include:
- expanded birth defects monitoring and surveillance regulations
- postpartum depression legislation
- expanded newborn blood screening regulations
- expanded public health practice for dental hygienists
- expanded breastfeeding in public places
- required periodic measurement of BMI in schools
- training for physicians, nurses and other providers on domestic and sexual violence
- bullying prevention in schools
- sports concussion policy and management in schools
- junior operator law and primary child passenger restraint law for children under age 14
- lowering the regulatory definition of blood lead poisoning to 10µg/dL
- MassHealth coverage of long acting reversible contraceptive devices inserted in the immediate postpartum period separate from the global delivery fee
- paid family and medical leave legislation (effective 2021)
- pay equity legislation that clarifies unlawful wage discrimination and makes workplaces more fair and equal.
The Title V program is well positioned in the state’s public health and health care environment to improve outcomes for women, infants, children and adolescents, including children and youth with special health needs, and their families.
[1] US Census Bureau. 2017 American Community Survey 1-Year Estimates, Massachusetts.
[2] US Census Bureau, U.S. and World Population Clock, https://www.census.gov/popclock/
[3] Massachusetts Housing Partnership, “White Paper on Rural Housing Issues in Massachusetts,” December 2014, https://www.mhp.net/writable/resources/documents/rural.white.paper.final.pdf
[16] Massachusetts Technology Collaborative, http://www.masstech.org/index/talent/housing-affordability
[20] https://www.tfah.org/report-details/ready-or-not-protecting-the-publics-health-from-diseases-disasters-and-bioterrorism-2019/
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