Demographics, Geography, and Economy

Geographically, Wyoming is the tenth largest state in the U.S., spanning 97,813 square miles. Wyoming is a rural/frontier state with 23 counties ranging in ecoregion 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. 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 fewer than six people per square mile. These 17 counties are home to 46% of the population (Wyoming Economic Analysis Division, 2020).

Wyoming is the least populous state in the U.S. with a July 2019 estimated population of 578,759, an increase of 0.18% from July 2018 (U.S. Census Bureau, 2020). The population is predominantly White alone (92.6%). The remaining population is Black or African American alone (1.3%), American Indian and Alaska Native alone (2.7%), Asian alone (1.1%), Native Hawaiian and Other Pacific Islander alone (0.1%), two or more races (2.2%), and Hispanic or Latino (10.1%). In 2018, 93.0% of the population aged five years and older spoke only English at home and 7.0% spoke a language other than English. Overall the minority population has grown 19.2% since 2010, and 1.3% in one year from 2018 to 94,379 in 2019. This counted for nearly all the growth in Wyoming from 2018 to 2019 (U.S. Census, 2020).

Nearly one quarter (23.1%) of the population is under the age of 18, and 17.1% is over the age of 65. Wyoming is a rapidly aging population, where the population of those 65 years and older increased by 3.8% in just one year from 2018 to 2019, and since 2010 this population saw an increase of 41.5%. Ninety-three percent of people over the age of 24 have a high school education or higher, with 26.9% of this group having at least a bachelor’s degree. The median household income is $62,268, just slightly more than the median household income in the U.S. of $61,937. Persons in poverty are estimated to be 11.1% of the population, compared to 11.8% nationally (U.S. Census, 2020).

After experiencing a rebound in the economy from the fourth quarter of 2018 to the third quarter of 2019, employment in Wyoming barely grew in the fourth quarter of 2019 compared to the previous year, and the state unemployment rate (2019, Q4) remained at 3.7%, just slightly higher than the U.S. level. Wyoming’s growth in employment (only 350 jobs) was much slower than the job growth for the U.S during this period. (Wyoming Economic Analysis Division, 2020). During the spring and summer of 2020, Wyoming’s economy faced a significant downturn due to the COVID-19 pandemic and lessened value of its natural resources, and the long-term impacts are uncertain.

Strengths and Challenges

According to the 2019 Annual America’s Health Rankings Report, Wyoming ranks 19th in the nation in overall health and was listed as one of three states making the largest improvements in rankings from the previous year. These improvements were driven by an increase in high school graduation prevalence (80.0% in 2018 to 86.2% in 2019, U.S. Department of Education), and a significant decrease (25.7% in 2018 to 21.7% in 2019, Behavioral Risk Factor Surveillance System) in adult physical inactivity. The listed strengths for Wyoming in the report include low levels of air pollution, low violent crime rate, low levels of children living in poverty, and low prevalence of diabetes. Challenges include high rates of smoking and occupational fatalities, in addition to a high rate of uninsured and a low rate of primary care physicians.

As noted, Wyoming is considered a rural/frontier state, which presents unique challenges. According to the Health Resources and Services Administration’s (HRSA) Designated Health Provider Shortage Areas (HPSA) Quarterly Summary Report, Wyoming had a total of 47 Primary Care HPSA designations, with 187,903 residents residing in primary care shortage areas. There were 31 dental HPSA designations in the state with a total of about 49,650 Wyoming residents residing in these areas. Finally, the entire state (comprising five regions) is considered an HPSA for mental health. Per HRSA's Designated HPSA Quarterly Summary (12/31/18), only 31.5% of the mental health needs are being met and 25 full-time psychiatrists are needed to meet the needs of the population.  

According to the Wyoming Office of Rural Health, in 2020 there are currently 62 physicians practicing obstetrics and gynecology (OB/GYN) in Wyoming and 58 practicing pediatricians. Ten counties have no OB/GYN and 12 counties have no pediatrician. Over 14,500 Wyoming women of childbearing age (15-44) live in a county with no practicing OB/GYN and approximately 28,000 Wyoming children and youth (<18 years of age) live in a county with no practicing pediatrician (Centers for Disease Control and Prevention (CDC) Wonder, 2020).

There are 172 family practice physicians in the state. Twenty-seven individuals practice in Natrona County, 24 in Laramie County, 15 in Park County, and 12 in Fremont County. Nine counties have fewer than five family practice physicians (Wyoming Office of Rural Health, 2020).

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. The LOCATe tool has since been revised and may be administered again with Wyoming facilities in the future.

Access to care is a challenge in Wyoming given the rural/frontier nature of the state, especially pertinent to the MCH population given the absence of Level III facilities, few specialist providers, and a high uninsured population. In 2018, 11.4% of Wyoming residents had no health insurance coverage, down slightly from the previous year, but still making Wyoming ranked as seventh highest in the nation compared to 8.8% of the population nationally. The percent of children ages 18 and under with no health insurance decreased from 9.5% in 2017 to 7.1% in 2018, compared to 5.2% of this population nationally (U.S. Census, 2020). Wyoming is one of twelve states that have not expanded Medicaid. Health insurance options in the Federal Health Insurance Marketplace for Wyoming are limited to one insurer, Blue Cross Blue Shield.

According to the 2020 Robert Wood Johnson County Health Rankings & Roadmaps, Wyoming fares better than the nation for the proportion of children in poverty, with 13% of children in poverty versus 18% nationally. However, within Wyoming the proportion of children in poverty varies widely by county, with rates ranging from 7% (Teton County) to 22% (Fremont County). When race and ethnicity are examined, disparities are also observed with child poverty rates ranging from 6% for Black children to 28% for American Indian and Alaskan Native children (Small Area Income and Poverty Estimates, 2018).

Racial and ethnic disparities are also observed to exist in regard to high school graduation rates. Wyoming’s overall high school graduation rates have risen steadily over the past five years from 78.6% (2013-2014) to 82.1% (2018-2019). However, while  83.8% of White youth graduated from high school in the 2018-2019 school year, only 77.1% of Hispanic youth and 58.7% of American Indian youth graduated during the school year (Wyoming State Four-Year Graduation Rates). Educators report that the four-year graduation rate for Native American youth increased substantially from the previous period but recognize that more work needs to be done.

The definition used for health equity by Healthy People 2020 (HP2020) is the “attainment of the highest level of health for all people.” Health equity removes barriers such as poverty and discrimination and 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 minority populations) at the state and county levels make stratification by geographic region, race, and ethnicity challenging. Wyoming continually monitors 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. During the 2021-2025 Title V cycle, WY MCH will work intentionally to operationalize all of its core values with specific emphasis on health equity.

Agency Organizational Structure and Role

The Maternal and Child Health Services Title V Block Grant is managed by the Maternal and Child Health Unit (WY MCH) within the Community Health Section (CHS) and Public Health Division (PHD) of the Wyoming Department of Health (WDH). The mission of WDH is to “promote, protect, and enhance the health of all Wyoming residents.” The mission of PHD is to “promote, protect, and improve health and prevent disease and injury in Wyoming.”

PHD is one of four divisions within WDH, joining the Aging, Behavioral Health, and Health Care Financing (i.e. Wyoming Medicaid) Divisions. Please see the attached organizational chart for a visualization of PHD’s structure. WDH is an executive branch State agency, with an appointed director, that has been granted authority and responsibility to govern health services through Wyoming statutes §§ 9-2-101 through 9-2-127. Specific to PHD, Wyoming statutes §§ 35-1-201 through 35-1-244 contain provisions for public health and safety responsibilities. Various other statutes offer provision for public health services carried out by PHD.

PHD employs approximately 265 staff in a mostly-centralized public health system. All but four Public Health Nursing (PHN) offices are administered through a State-county partnership. The remaining four are independent local health departments. PHD provides a wide range of services that promote, protect, and improve health and prevent disease and injury in Wyoming. The following list outlines PHD’s key services, which are in line with the 10 Essential Public Health Services:

• Community Health Section
  • Immunizations
  • Maternal and Child Health
  • Prevention and Health Promotion
  • PHN
  • Women, Infants, and Children
• Health Readiness and Response Section
  • Emergency Medical Services
  • Public Health Preparedness and Response
  • Rural and Frontier Health
• Public Health Sciences Section
  • Chronic Disease and Maternal Child Health Epidemiology
  • Communicable Disease Prevention, Surveillance, and Treatment
  • Infectious Disease Epidemiology
  • Public Health Lab

A summary of the PHD organizational structure is included below.

PHD is working toward public health accreditation and completed a State Health Assessment (SHA) in 2018. A member of the MCH Epidemiology Program is on the SHA Leadership Team. Efforts to develop a State Health Improvement Plan (SHIP) are underway but have been delayed due to COVID-19.

PHD has set several strategic priorities:

●     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

●     Build a sustainable, cohesive organization

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

WY MCH provides leadership for state and local level efforts that improve the health of the MCH population and administers the Title V MCH Services Block Grant. Structurally, the unit’s programs are divided according to the population groups they serve: women (ages 15-44) and infants (ages <1), children (ages 1-11), 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.

WY MCH envisions a Wyoming where all families and communities are healthy and thriving. The mission of WY 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. WY MCH core values include:

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

The 2020 MCH Needs Assessment resulted in the selection of seven priorities for 2021-2025:

1. Prevent Maternal Mortality (Women/Maternal Domain)
2. Prevent Infant Mortality (Perinatal/Infant Domain)
3. Promote Healthy and Safe Children (Child Domain)
4. Prevent Adolescent Motor Vehicle Mortality (Adolescent Domain)
5. Prevent Adolescent Suicide (Adolescent Domain)
6. Improve Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN Domain)
7. Strengthen MCH Workforce Capacity to Operationalize MCH Core Values (Cross-Cutting Domain)

WY MCH benefits from participating in and aligning with the PHD SHA and SHIP. The SHA identified three top health priority recommendations important to Wyoming citizens: Behavioral Health, Access to Healthcare, and Unintentional Injury. These overall WDH priorities were used to guide WY MCH’s 2021-2025 needs assessment and strategic planning.

Systems of Care and Services for Vulnerable Populations, Including CSHCN

In Wyoming, about 26,977 (19.4%) of children ages 0-17 have a special health care need. The prevalence of CSHCN being reported as receiving care in a well-functioning system in Wyoming is 9.7% (2017-2018), compared to 13.9% of CSHCN in the U.S. overall, and a decrease from 16.6% from 2016 to 2017 (NSCH).

WY MCH’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 (CYSHCN, 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/or the Federal Marketplace. The program provides reimbursement to eligible providers for covered services provided to eligible clients. In FFY19, CSH actively served 640 clients. Of all enrolled clients, 533 were CYSHCN, 83 were high-risk infants, and 24 were high-risk pregnant women.

WY MCH works with partners such as Public Health Nursing, Medicaid, and Kid Care CHIP (Child Health Insurance Program), in-state and out-of-state primary care and speciality providers, early intervention providers, and home visiting providers to assure vulnerable populations, especially CSHCN, have access to health insurance, a primary care provider or ideally a certified medical home, speciality care services, and other supports and services based on identified family needs.

Strengthening partnerships with out-of-state providers and neighboring Title V agencies help to build Wyoming’s health services infrastructure. For example, the Wyoming Newborn Screening and Genetics Programs contract with the Colorado Department of Public Health and the Environment (CDPHE) for newborn screening laboratory and short-term follow up services and the University of Utah, Department of Pediatrics for in-person and telehealth genetics services and consultation. Additionally, WY MCH partners with the well-established Utah Perinatal Mortality Review Committee, a project of the Utah Department of Health, to build capacity to review maternal deaths in Wyoming.  A planned assessment of the National Standards for Systems of Care for CSHCN in Wyoming will help identify further gaps and opportunities for improvement to assure CSHCN have access to a comprehensive, coordinated, and family-centered system of care.

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 WDH’s budget reduction. The decision closed the following programs: Dental Sealants Program, 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 Specialty Clinic. Despite a lack of state-level leadership on oral health, WY MCH continues to participate in a Wyoming Oral Health Coalition led by the Wyoming Primary Care Association.

State Statutes Relating to MCH

Three state statutes directly impact the work of WY 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. WY MCH’s NBS and Genetics Programs fulfill this statutory requirement in partnership with families, providers (including midwives), hospitals, CDPHE (laboratory services and short-term follow up contractor), and a contracted courier service. The Wyoming NBS and Genetics Coordinator is funded by both Title V and State Trust and Agency funding, demonstrating the partnership between Title V and 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. This statute directs PHN to contact eligible women to offer home visitation services as part of the Healthy Baby Home Visitation (HBHV) Program. The initial intent of the legislation was to implement Nurse Family Partnership (NFP), an evidence-based home visiting model, in all 23 counties. Due to challenges meeting growing fidelity requirements and a small birth cohort in many communities limiting the number of women eligible for the program, NFP sites have reduced significantly over the past ten years. As of July 1, 2020, NFP is no longer delivered in Wyoming. A year-long search to identify a new evidence-based home visitation model ended in early 2020 with a workgroup of PHN and WY MCH staff selecting the Maternal Early Childhood Sustained Home-Visiting (MECSH) program for implementation in FFY21. This program is funded by Temporary Assistance for Needy Families (TANF) funding, and the program also receives State General Funds that count toward the required Title V match.

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. WY MCH supported gap-filling contraceptive purchases for counties with little to no Title X services in State Fiscal Year (SFY) 2016 and through SFY17 but discontinued support in SFY18 in order to reevaluate the best strategies for increasing access to the wide range of contraceptive options. WY MCH will continue to partner closely with Wyoming’s Title X grantee, the Wyoming Health Council, and PHN to improve access to family planning services.