The Wisconsin Title V Program is administered by the Family Health Section (FHS) in the Bureau of Community Health Promotion (BCHP). The Bureau resides within the Division of Public Health (DPH) and the Division sits in the Department of Health Services (DHS). Wisconsin DHS has a simple but powerful vision: Everyone Living Their Best Life. This is accomplished through the Title V Program’s mission of protecting and promoting the health and safety of the people of Wisconsin. Building a sustainable system of equitable access to MCH/CYSHCN services and improving MCH/CYSHCN outcomes throughout Wisconsin is a fundamental building piece of this mission and a critical element in accomplishing this vision. The goal of the Title V Program is to ensure that all families in Wisconsin have access to a coordinated, integrated, and sustainable system of services and supports focused on health promotion and prevention. The Title V Program works with local and tribal health agencies, community-based organizations, statewide organizations, and other partners to provide and/or ensure quality health services are delivered to mothers, children, and families in Wisconsin. Title V funds are directed towards building systems that better coordinate and integrate services across programs and providers, while investing in community-based prevention, health promotion, developmental support services, and the delivery of consistent information to families.

 

Principal Characteristics of the State

 

The US Census Bureau estimates Wisconsin’s 2019 population to be 5,822,434, an increase of 2.4% since the 2010 Census. Wisconsin’s population is spread across 72 counties, and served by 87 locally-controlled local health departments and 11 tribal health agencies. Although Wisconsin is perceived as a predominantly rural state, it is becoming increasingly urbanized with fewer than 30% of the population living in rural counties.

 

Detailed US Census Bureau population estimates for 2019 by demography will not be available until August 2020, so the following data come from the 2014-2018 American Community Survey 5-Year Estimates. Females constituted an estimated 50.3% of the population, and females of reproductive age (15-44 years) made up approximately 37.3% of the total population. An additional 18.3% of the state’s population was under 15 years of age, and 16% was 65 years and older. The median age was 39.3 years, slightly higher than the national average. Nearly 98% of the population self-identified as one race and 2.4% self-identified as two or more races. Of the total estimated population, 85.6% identified as White only, 6.4% identified as Black only, and 2.8% identified as Asian only. Of the total estimated population, 6.7% were of Hispanic ethnicity. During 2014-2018, over 68% of non-Hispanic Blacks and more than 36% of Hispanics in Wisconsin lived in Milwaukee County.

 

In addition, Wisconsin is home to 11 Federally-recognized tribes and approximately 92,282 individuals identifying as American Indian/Alaska Native either alone or in combination with other races. According to the Young Center for Anabaptist and Pietist Studies at Elizabethtown College in Pennsylvania, Wisconsin has the 4th largest Amish/Mennonite population in the US, which is estimated at 21,020 individuals. Wisconsin is above the national average (87.3%) for high school graduation but slightly below the national average for higher education. In Wisconsin, over 91% of the population ages 25 years and older have a high school education or higher with only 29.5% receiving a bachelor’s degree or higher.

 

The Bureau of Labor Statistics estimates that Wisconsin’s 2018 unadjusted unemployment rate for the civilian and noninstitutionalized population 16 years of age and over was lower than the national rate at 2.3%, down from 3.0% in 2016 and a 30-year high of 9.2% in January 2010. In 2019, Wisconsin had 6 counties with annual unemployment rates above 5%: Menominee, Iron, Bayfield, Burnett, Adams, and Forest, all of which are in the northern, more rural half of the state. The cities of Racine (5.2%), Beloit (4.6%) and Milwaukee (4.5%) topped the list of city unemployment rates; these rates represent a slight increase over 2018. Unemployment in 2020 is expected to be much higher due to the economic upheaval in the wake of the COVID-19 pandemic.

 

The 2014-2018, the American Community Survey found the median household income in Wisconsin to be $59,209. Approximately 11.9% of the population had income in the past 12 months below the Federal Poverty Level. The percentage of children under 18 years of age living in poverty was 15.9%. Children who live in poverty are at greater risk for school failure, health problems, shorter life expectancy, teen parenthood, unemployment, and lower lifetime earnings than their peers who do not grow up in poverty. This issue is of paramount importance in Wisconsin.

 

Birth data for 2018 indicate that out of 64,143 live births to women residing in Wisconsin, 37.2% were to women not married at the time of birth. Moreover, 3.8% of births were to women under the age of 20, bringing the teen birth rate in Wisconsin to 13.2 births per 1,000 females ages 15-19.

 

Unique Assets and Challenges

 

A report by the Brookings Institution using 2013-2017 American Community Survey data noted that Milwaukee, the most populous city in Wisconsin, was the most racially segregated metropolitan area in the United States. The legacy of redlining and racialized city planning and public investments is strong in Wisconsin, and continues to affect the health and well-being of Wisconsin’s communities. Wisconsin is home to diverse people, including 11 federally recognized Native American tribes and significant populations of Hispanic, Black, and Asian individuals. Specifically, Wisconsin has been receiving a steady flow of refugees and has a sizable Hmong population. These groups are not equally represented in the healthcare workforce and therefore do not always receive culturally and linguistically appropriate care. Additionally, about 30% of Wisconsin residents live in rural areas, and many parts of the state have shortages of most types of health care providers, from primary care providers to mental health care providers. Income inequality in Wisconsin is increasing and certain groups, including urban-dwelling people of color, continue to experience higher rates of unemployment than their white peers. Quality employment, in turn, affects access to health insurance, as well as resources to meet families’ basic needs.

 

Moreover, social and political polarization between urban and rural areas, as documented in K. Cramer’s book, “The Politics of Resentment,” influences policymaking at the state level, including state funding for public health infrastructure, which has is currently $55 per resident, one of the lowest in the country. However, Wisconsin benefits from active community leaders and organizations representing people living with disabilities, families with children with special healthcare needs, Tribal nations, and communities of color. These leaders provide consultation to the state Department of Health Services and also create innovative programs in their own communities to promote health.

 

Health Status of the Population

 

The United Health Foundation’s State Health Rankings (2019) place Wisconsin 23rd overall based on 33 measures of physical and social determinants of health and 19th for the health of women and children, ranking higher for women’s health (15th) compared with infant and child health (24th and 20th, respectively). The measures on which Wisconsin is faring the worst relative to other states are excessive drinking pertaining to adults (50th overall and 49th among adult women), infectious disease, especially pertussis (46th), teen suicide (34th), and percentage of children with adequate health insurance (70%, ranked 42nd). Structural challenges in Wisconsin highlighted in the rankings include low public health funding per capita (ranked 46th) and insufficient mental health providers (34th). Positive trends include a decrease in violent crime, an increase in the proportion of infants who are breastfed exclusively for six months, and an increase in HPV vaccination among males 13-17.

 

The Annie E. Casey Foundation Kids Count Data Center (2020) ranks Wisconsin 11 out of all states for overall child well-being, a composite rank based on ranks for economic well-being, education, health, family, and community factors. According to Kids Count data, 4% of minors in Wisconsin did not have health insurance in 2018. Wisconsin’s birth outcomes are similar to those in the US overall. However, there are stark differences by race. Kids Count data for 2018 show that 16% of babies born to Black women had a low birthweight compared to 7.7% overall. The 2017-2018 National Survey of Children’s Health depicted that 93% of Wisconsin children reported excellent or very good health, but only 83% of Black children in Wisconsin enjoyed excellent or very good health. Approximately 230,000 kids or 17.5% of Wisconsin children under age 18 had a special health care need, including 7% of White kids, 24% of Black kids, and 21% of Hispanic kids. An estimated 3% of children live in homes where the primary caregiver is not their parents.

 

There were 53,680 deaths of Wisconsin residents in 2018, occurring at a rate of 928.6 deaths per 100,000 population. According to vital records, the leading causes of death for all ages were heart disease (22.5%), cancer (21.3%), and accidents (7.0%). Among children and youth between 1 and 17 years of age, accidents were the leading cause of death, followed by intentional self-harm.

 

Infant mortality is a high priority issue in Wisconsin. The Centers for Disease Control and Prevention (CDC) reported that Wisconsin had an overall infant mortality rate (IMR) higher than the US average in 2017 (6.4 compared to 5.8 deaths per 1,000 live births), and has been increasing over the past few years. Another CDC report showed that in Wisconsin between 2013 and 2015, the non-Hispanic White IMR was 4.76 deaths per 1,000 live births compared to a non-Hispanic Black IMR of 14.28 deaths per 1,000 live births, corresponding to a Black/White infant mortality ratio of 3.0—one of the largest disparities out of all reporting states and Washington D.C.

 

The 2019-2020 needs assessment for the Wisconsin Title V Block Grant program utilized multiple data sources including CDC Wonder, Vital Statistics, Wisconsin’s Interactive Statistics on Health (WISH), Hospital Discharge data, Pregnancy Risk Assessment Monitoring System (PRAMS), American Community Survey, Wisconsin Sexually Transmitted Diseases (STD) program, Behavioral Risk Factor Surveillance System (BRFSS) survey, Youth Risk Behavior Surveillance System (YRBSS) survey, National Survey of Children’s Health and National Immunization Survey for Children (NIS-Child) to uncover the following trend for the Title V population domains:

 

Infant/Perinatal: The birth rate in Wisconsin is similar to that of the US. Overall, Wisconsin has significantly fewer Medicaid-paid births than the US, though when compared to NH White women, Medicaid-paid births are 3.2 times higher among NH Black women and 2.8 times higher among both NH American Indian and Hispanic women. Similarly, while Wisconsin has a lower teen birth rate than the US overall, teen birth rates are more than 5 times higher among NH Black women and more than 3 times higher among NH American Indian and Hispanic women compared to NH White women. Wisconsin has similar preterm birth and low birthweight rates to the US. However, NH White women experience much lower rates of preterm birth and low birthweight than each of the other race/ethnic groups. NH Black women have the highest rates of preterm birth and low birthweight.

 

Wisconsin infants fare equally to the US overall in preterm-related deaths (2.2 per 1,000 live births). While Wisconsin’s overall rate of Neonatal Abstinence Syndrome (NAS) is not much higher than the US rate, the disparity found between racial and ethnic groups is vast. NH American Indian newborns have a NAS rate 5.7 times higher than Hispanic newborns (p<0.0001). The percentage of infants that are seen by a physician within a week of leaving the hospital is on par with the US average and does not vary significantly across race/ethnic groups. Compared to the US (78%), a higher proportion of infants in Wisconsin (86%) are put to sleep on their backs, however NH Black infants (74%) fare significantly worse in this area than their White counterparts (88%) (p<0.0001). The proportion of infants placed to sleep on a separate approved sleep surface is similar for all Wisconsin racial/ethnic groups. The proportion of infants placed to sleep without loose objects is significantly higher for NH White infants in Wisconsin than other race/ethnic groups, but not by a substantial percentage (p=0.007). The sleep-related Sudden Unexpected Infant Death (SUID) rate for Wisconsin is very similar to that of the US (less than 1 per 1,000 live births). However, the sleep-related SUID rate among NH Black infants in Wisconsin is about 3 times that of their NH White counterparts. Wisconsin’s percentage of infants ever breastfed is lower than the US (76.7% compared to 83.2%). The percentage of NH Black infants ever breastfed is about half that of NH White infants in Wisconsin. The infant mortality rate in Wisconsin is equivalent to the US infant mortality rate (6 per 1,000 births), however NH Black families experience the loss of a child prior to their first birthday at a rate 2.6 times that of NH White families.

 

Analysis showed that Wisconsin is doing better than the nation in regards to infants being put to sleep on their backs (85.9% compared to 78.4%). The subpopulations at greatest risk for a poor outcome related to the Safe Sleep NPM include NH Black babies (74%). Wisconsin is also doing better than the U.S. at infants ever breastfed (88% compared to 86.5%). Wisconsin is doing worse than the nation in regards to percent of cesarean at first birth (26.4% compared to 21.9%). The populations most at risk for this include American Indian and NH other race/ethnicity women.

 

Children: Compared to the US (74.4%), a significantly lower proportion of Wisconsin children have adequate health insurance (69.6%). NH Black children have the highest proportion of adequately insured kids at about 81%. Wisconsin children ages 0-14 have a higher rate of injury-related hospital admissions than the US (89.2 compared to 82.4 per 100,000). Ninety-seven (97%) of Wisconsin children are reported to live in a safe neighborhood. While disparities among racial/ethnic groups for this factor are not vast, they do exist. Fifteen percent more NH White children live in a safe neighborhood than do NH Black children.

 

In Wisconsin, 21% of children ages 0-17 have experienced one Adverse Childhood Experience (ACE), slightly lower than the national average of 24.6%. More than 1 in 5 Wisconsin children experience 2 or more ACEs, which is similar to the US percentage. A higher proportion of NH Black children experience ACEs than any other represented racial/ethnic group in Wisconsin. The proportion of children living in supportive neighborhoods is about 1.8 times higher for NH White children than Hispanic children. While Wisconsin has a lower percentage of its children living in poverty compared to the national average (16.7% compared to 20.3%), there are stark disparities among racial/ethnic groups. There are 3.5 times fewer NH White children living at 200% below the poverty level than there are NH Black children. NH American Indian and Hispanic children are also disproportionately living in poverty compared to NH White children.

Wisconsin has a similar proportion of children 10-17 years of age who are overweight or obese than the US overall (27.6% and 31.0% respectively). Similarly to the US, about a quarter of Wisconsin children are physically active for 60 minutes every day. However, the proportion of NH American Indian children who fulfil this performance measure is less than half the state’s overall percentage. Wisconsin and the US have a similar proportion of children that experience second-hand smoke in the home (2.5% and 2.3% respectively). Wisconsin’s child (ages 1-9) mortality rate, 14.6 per 100,000, is slightly lower than the overall rate for the US of 17.2 per 100,000.

 

Among all children, Wisconsin is doing better than the nation in regards to having no medical home (33.6% compared to 45.6%). Wisconsin subpopulations at higher risk of having no medical home include children 12-17 (36.5%), children living below 200% of the federal poverty level (43.7%), children with special health care needs (38.6%), and NH Black (48.6%) and Hispanic (49.4%) children. Analysis of transition to adult health care was focused on youth with special health care needs. Within this population, Wisconsin is doing better than the nation. Those without a medical home and those ages 15-17 are more likely to have a poor transition to adult care, 58.2% and 63.8%, respectively. Children with special health care needs make up about 18% of Wisconsin’s child population, which is similar to the overall US figure. However, there are a disproportionately higher number of NH Black children in Wisconsin with special health care needs (28.7%). In fact, the proportion of NH Black children with special health care needs is 7 times higher than the group with the lowest proportion, NH American Indian children (3.9%). The proportion of Wisconsin children (ages 3-17) that are diagnosed with autism spectrum disorder is similar to that of the US at about 3%. Wisconsin has a significantly lower proportion of children diagnosed with ADD/ADHD compared to the US. NH Black children, however, experience ADD/AHDH diagnosis at a rate 2.4 times that of Hispanic children. Similar to the nation, just 51.7% of children with a mental/behavioral condition receive treatment in Wisconsin.

 

Adolescent: The proportion of Wisconsin adolescents (31.6%) ages 12-17 who have experienced two or more ACEs is slightly higher than the US (27.7%). Wisconsin (53.8%) is doing similarly to the US (56%) among adolescents (ages 12-17) who report living in a supportive neighborhood. About 9 out of 10 Wisconsin adolescents report being in excellent or very good health in Wisconsin, which is similar to the US overall. Oral health for Wisconsin teens is similar to that of the US as a whole when reporting on the presence of decayed teeth or cavities in the past 12 months (8% and 10%, respectively). Nearly 80% of adolescents in Wisconsin (ages 12-17) report receiving a preventive medical visit in the past year. Greater than 1 in 4 Wisconsin adolescents felt sad or hopeless nearly every day for at least two weeks in the past year, which is slightly lower than the rest of the nation (31.5% US). Similarly to the US, 16.4% of Wisconsin teens report having seriously considered suicide. The proportion of Wisconsin youth (16.4%) who report consuming 5+ alcoholic drinks in a row during the past 30 days is similar to the US (17.7%).

 

The percentage of Wisconsin teens (1.8%) who report smoking cigarettes is 6 times lower than the US. More than 1 in 10 Wisconsin adolescents report using a prescription drug without a prescription. This is similar to the US overall. Among sexually active teens in Wisconsin, 7.8% did not use contraception, while the US average is higher (13.8%). While Wisconsin has a lower teen birth rate than the US overall, teen birth rates are more than 5 times higher among NH Black women and more than 3 times higher among NH American Indian and Hispanic women compared to NH White women. The rate of STIs per 1,000 teens (ages 15-19) is similar for Wisconsin and the US at 22.9 and 25.1 respectively. However, there are stark racial/ethnic disparities among WISCONSIN teens. The STI rate among NH Black youth is about 11 times higher than NH White youth. Only 14% of teens in the US and 17% of Wisconsin teens received the necessary transition to adult care.

 

Nearly 94% of Wisconsin adolescents (ages 13-17) have received at least one dose of TDAP, compared to 91.6% of the US as a whole. Among Wisconsin adolescents, 100% of both Hispanics and NH others received at least one dose of TDAP. Only 54.17% of Wisconsin adolescents (ages 13-17) have received at least one dose of the meningococcal conjugate vaccine, compared to the 57% of the US as a whole. Of White adolescents, the Hispanic population is faring the worst with only 37.5% having received at least one dose of the meningococcal conjugate vaccine. Overall, Wisconsin is doing comparably to the US (52.2%) in teens that have received the HPV vaccine at 54.5%, however only 40.6% of the Hispanic population in the state have received the vaccine.

 

In Wisconsin, more teens report being bullied at school than the US (24% and 19%, respectively). Wisconsin’s rate (196.7) of adolescent injury-related hospital admissions per 100,000 is nearly double the US (95.5). Significantly more Wisconsin teens report texting or emailing while driving compared to the US (45.7% and 39.2% respectively). 17.4% of Wisconsin teens reported riding with a driver who had been drinking alcohol, which is 3 times higher than the US (5.5%). Wisconsin (10.2%) and the US (9.7%) fare similarly in percent of adolescents who report experiencing dating violence. Wisconsin and the US have a similar rate of adolescent deaths caused by motor vehicle crashes at about 11 deaths per 100,000 youth ages 15-19. Wisconsin (13.7) and the US (13.3) fare similarly in the rate of adolescent suicide per 100,000. The rate of death among Wisconsin youth ages 10-19 is very similar to the US rate at 33.4 per 100,000.

 

Women/Maternal: Although Wisconsin and the US compare similarly in lack of health care coverage (9.75% and 10.4%, respectively), it is notable that the Hispanic population’s lack of health care coverage in the state is nearly 3 times the state and national averages at 29%. According to respondents within PRAMS data, nearly 60% of Wisconsin women had a preventive visit within the past year. According to the Behavioral Risk Factor Surveillance System, only 68.3% of Wisconsin women have had a preventive visit compared to 74.7% of women nationwide. Over 80% of NH Black women in Wisconsin had a preventive visit in the past year.

 

While Wisconsin’s percent of unintended pregnancy (27%) is better than the US as a whole (34.2%), the percentage of NH Black women in the state who have an unintended pregnancy (55.94%) is over 2.5 times that of NH white women in the state. At 7.8 per 1,000 population, Wisconsin women have a similar rate of sexually transmitted infections (STIs) Chlamydia and Gonorrhea compared to US women overall at 8.3 per 1,000. Wisconsin (71%) and the US (70%) compare similarly in women who report using highly/moderately effective contraception. Wisconsin fares only slightly better (43.9%) than the US (38.7%) in folic acid/multivitamin use, with a vast disparity between the NH Black population (25%) and the NH White population (50%). Although physical abuse prior to pregnancy in Wisconsin (1.8%) is less than the US as a whole (2.3%), physical abuse prior to pregnancy in NH Black women in the state is nearly 5 times higher than NH White women and nearly 4 times higher than Hispanic women. 26.1% of women living in Wisconsin have experienced 3 or more adverse childhood experiences (ACEs), with the Hispanic population faring the worst (30.9%) and the NH Black population faring the best (22.2%).

 

The US and Wisconsin fare similarly in physical abuse during pregnancy. However nearly 5% of NH Black women in Wisconsin experience physical abuse during pregnancy, which is nearly 3.5 times the state percentage and over 2 times that of the US. In Wisconsin, 5 % of women report being emotionally or sexually abused during pregnancy, with NH Black women reporting well above the state average (13.1%). According to Wisconsin Pregnancy Risk Assessment Monitoring System (PRAMS), about 23% of NH Black women experience being emotionally upset as a result of how they were treated based on race in the twelve months prior to giving birth. Almost 26% (25.9%) of Wisconsin women report feeling stressed during their pregnancy. A substantially higher proportion of NH Black women (44%) in Wisconsin report feeling stressed during pregnancy than the state overall. Women in Wisconsin (27.9%) report enrolling in WIC during pregnancy less than US women (38.1%), where NH White women are faring worse (18%) and NH American Indian women are doing best (60%). Nearly 95% of Wisconsin women receive a perinatal depression screening. Eleven percent of all women report smoking during pregnancy in Wisconsin. This is 1.5 times that of the US (6.9%). The proportion of NH American Indian women in Wisconsin that report smoking during pregnancy is nearly 3.5 times higher than the state at 38%.

 

Gestational diabetes occurs in almost 9% of Wisconsin pregnancies, with Hispanic women reporting the highest percentage around 15%. The proportion of NH Black women who experience hypertension during pregnancy is 13%, which is nearly double the Wisconsin percentage. However, the proportion of NH White and Hispanic women report hypertension during pregnancy is less than half that of NH Black women. Over 46% of NH White women report excessive weight gain during pregnancy, where just 36% of Hispanic women did. Nearly 80% of Wisconsin women receive first trimester care, with 83.4% of NH white women receiving care within the first trimester. NH Black and NH American Indians receive first trimester care just over 60% of the time. Women in Wisconsin (50.5%) are faring similarly to the US (48.3%) among those who report having a dental visit during pregnancy. However, the proportion of NH Black women who have a dental visit during pregnancy is 20% lower than that of NH White women.

 

Just 49.6% of Wisconsin women received postpartum paid leave, where 24% more NH White women received paid leave than NH Black women. Overall, Wisconsin fares slightly better (11.5%) than the US as a whole (12.8%) for the percentage of women who experience postpartum depression. There is a striking difference between NH White and NH Black women in Wisconsin where NH Black women experience postpartum depression over 2 times that of NH White (9.0% and 21.2%, respectively). Nearly 7% of NH Black women in Wisconsin report using prescription pain relievers before pregnancy, while just 2.9% of Hispanic women do. Over 7% of NH Black women report using prescription pain relievers during pregnancy, while only 2.4% of Hispanic women do. Nearly 82% of Wisconsin women report using postpartum contraception, which is slightly better than the US (78%). More women in Wisconsin compared to the US overall are waiting the recommended inter-pregnancy interval of 18 months or more before beginning their next pregnancy (79.3% and 75.6%, respectively). Almost 93% of Wisconsin women receive a postpartum check-up, which is comparable to the US (90%). Nearly 95% of NH White women in Wisconsin receive a postpartum check-up, but only 87% of NH Black women do. Compared to the US, Wisconsin is doing well in postpartum health care coverage. The proportion of women in Wisconsin without coverage postpartum is about half that of the US. However, the proportion of Hispanic women without health care coverage postpartum is 8 times higher than NH White women. While Wisconsin (6) is doing better than the US (14) when looking at the maternal death rate per 100,000 live births, stark racial/ethnic disparities exist in Wisconsin, where NH Black women die at nearly 8 times the rate of Hispanic and NH White women.

 

Overall, Wisconsin (55%) is doing better than the US (60%) with regards to its population that is obese or overweight. However, there are racial disparities, with nearly 70% of the NH Black population and 65% of the Hispanic population currently considered obese or overweight. Wisconsin is faring better in physical activity than the US (29%), with only 18% of Wisconsin women reporting no physical activity. However, when examined by race, the difference is striking, with nearly 35% of NH Blacks reporting no physical activity in the past 30 days other than their job. Wisconsin is faring similarly to the US for fruit and vegetable consumption among women. Twenty-six percent (26%) of Wisconsin women eat less than one serving of fruit per day (US 33%) and 16% eat less than 1 serving of vegetables per day (US 17%). Fourteen percent (14.2%) of US women report they are current smokers, while 17.6% of Wisconsin women do. Nearly 19% of NH White women in the state are current smokers. More than 1 in 4 women in Wisconsin report binge drinking (consuming 4+ drinks on one occasion) in the past 30 days. That’s more than double the proportion of US women who report binge drinking. Also, the proportion of NH White women who binge drink is almost 4 times that of Hispanic women.

 

State Agency Role Current Priorities/Initiatives

 

Wisconsin is a “home rule” state, giving local and tribal health agencies jurisdictional precedence in consultation with their local boards of health or Tribal leadership. This context has informed the Wisconsin Title V program’s approach to implementing block grant activities; by funding local and Tribal agencies to implement the strategies informed by our needs assessment, we leverage the local knowledge and relationships to improve public health systems, while honoring the authority of local agencies.

 

DHS is required by Wisconsin Statute, Wis. Stat. § 250.07, to develop a state public health agenda at least every 10 years. DHS completed a State Health Assessment over 2019-2020, incorporating information collected in the Title V Needs Assessment, and will be creating a State Health Improvement Plan in the next year, identifying priorities for the next five years.

 

State Health Systems for Meeting the Needs of Underserved and Vulnerable Populations

 

The 2018 American Community Survey provides information on health insurance coverage in Wisconsin. The American Community Survey indicates that 94.5% of the civilian non-institutionalized population had some form of health insurance coverage—33% with public coverage and 75% with private coverage. Of Wisconsin children under age 6, 3.5% had no health insurance coverage and 3.9% of children ages 6 to 18 were uninsured. Seven percent (7%) of persons employed in Wisconsin were uninsured. Eighteen percent (18%) of the foreign-born population in Wisconsin was uninsured in 2018 compared to 4.8% of the native-born population. Wisconsin also has provider shortages in many parts of the state for primary care, mental health services, and dental services.

 

Despite these challenges, Wisconsin is home to 96 Federally Qualified Health Centers and four children’s hospitals:

Wisconsin Medicaid and BadgerCare: BadgerCare Plus is Wisconsin's Program for Title XIX (Medicaid) and Title XXI State Children's Health Insurance Plan providing health insurance coverage for all children up to age 19; pregnant women with incomes up to 300% of the federal poverty level; and parents, caretaker relatives, and other adults with qualifying incomes below 100% of the federal poverty level. BadgerCare covers services for children such as preventive care, vision care, prescription drugs, hospital services and speech and physical therapy. BadgerCare also covers pregnancy-related services such as labor and delivery, nurse midwifery services, dental care, and mental health services. High-risk pregnant women receiving Medicaid and BadgerCare Plus may also be eligible for Prenatal Care Coordination benefits, which include services such as help with access to care, personal support, health education, and help finding needed services in their community. BadgerCare Plus for adults covers services such as case management, dental care, family planning, hospice care, inpatient/outpatient hospital services, mental health treatment, optical services, physician services, prescription drugs, and many others.

 

Prior to the Affordable Care Act, a BadgerCare Plus Core Plan was implemented in 2009 for low-income and childless adults without health insurance. The number of applications submitted exceeded available funding for the capped program, so DHS suspended enrollment and established a waitlist. In 2010, legislation was enacted into law to implement a self-funded basic plan for those on the Core Plan waiting list, in the hopes that the basic plan would serve as a bridge to gaining coverage through the Federal Marketplace. The 2013-2015 State Budget Bill removed the enrollment cap and added nearly 100,000 childless adults below the federal poverty level to BadgerCare Plus, but did so by ending coverage for many parents/caregivers with incomes between 100% and 138% of the federal poverty level. These income limits were implemented in August 2014 and resulted in approximately 63,000 Wisconsinites transitioning from Medicaid to the Federal Marketplace or another form of health insurance coverage.

 

As of December 2018, there were a total of 767,478 Wisconsinites enrolled in BadgerCare Plus statewide. Of these, 132,227 were parents/caretakers, 18,145 were pregnant women, 147,643 were childless adults, and 416,271 were children. These numbers were stable compared to December 2017. The Medicaid expansion was again rejected by Wisconsin and changes were proposed in 2017 that would require childless adult enrollees to pay monthly premiums, pay higher premiums if they engage in unhealthy behaviors as determined by a health risk assessment, have eligibility limited to no more than 48 months, and pass drug screening. It is estimated that 155,000 childless adults will be affected by these changes. The budget also removed a 3-month waiting period in enrollment for women and children after the cessation of private insurance coverage and added licensed midwifery services to the list of covered services for pregnant women. Of the 12 states that have not yet expanded Medicaid, Wisconsin is the only one that offers coverage to all adults under the federal poverty level.

 

Wisconsin Medicaid also supports Family Planning Only Services (FPOS) through a State Plan Amendment that provides family planning services to both men and women of low-income and reproductive age to prevent unplanned pregnancies. The average monthly enrollment for FPOS is around 38,000. The 2015-2017 State budget increased FPOS funding to $31,000,000 for the biennium to accommodate the continued need for FPOS access among Wisconsin women and men.

 

Enrollment in Wisconsin public assistance programs is facilitated by ACCESS, a set of online tools developed by DHS for FoodShare, Medicaid, BadgerCare Plus, FPOS, and Child Care that allows prospective and current customers to assess eligibility for programs, apply to programs online, check case benefits, and report case changes.

 

Home Visiting Services: Since 2011, the statewide Wisconsin Family Foundations Home Visiting Program has supported pregnant women and families, and helps parents of children from birth to age five to engage with resources and develop the skills to raise children who are physically, socially, and emotionally healthy and ready to learn. The Maternal, Infant, and Early Childhood Home Visiting grant offered through the federal Maternal Child Health Bureau provides the majority of Family Foundations Home Visiting Program funding. A portion of funding for the Family Foundations Home Visiting Program comes from the Temporary Assistance for Needy Families grant and General Purpose Revenue from the State of Wisconsin. The Family Foundations Home Visiting Program is led by the Wisconsin Department of Children and Families in collaboration with the Wisconsin Department of Health Services. The Family Foundations Home Visiting Program is building a strong partner base to enhance supports for medical care, mental health care, early childhood systems, safety, and parenting in order to foster optimal programming and avoid costly service duplication. The Wisconsin Title V team includes a home visiting nurse consultant who bridges the home visiting programs (situated in the Wisconsin Department of Children and Families) and the Title V Program to identify opportunities for alignment and collaboration.

 

Along with federally funded home visiting programs in other states, the Family Foundations Home Visiting Program is working to improve outcomes in six focus areas:

 

1. Improved maternal and child health
2. Prevention of child injuries, child abuse, neglect and maltreatment
3. Increased school readiness and achievement
4. Reduced domestic violence
5. Improved family economic self-sufficiency
6. Greater coordination and referrals for other community resources and support

 

Wisconsin Medicaid also includes a Prenatal Care Coordination benefit for Medicaid-eligible pregnant women with a high risk for adverse pregnancy outcomes during pregnancy through the first 60 days after delivery. Prenatal Care Coordination services include: outreach, initial assessment, care plan development, care coordination and monitoring, and health education and nutrition counseling services (as appropriate). The Title V program supports regional communities of practice for Prenatal Care Coordination providers and ongoing professional development and training opportunities to improve the quality of services. Strengthening Prenatal Care Coordination services is identified as a strategy to advance State Performance Measures related to African American Infant Mortality and High Quality Perinatal Care.

 

Regional Centers for Children and Youth with Special Health Care Needs: Wisconsin has five Regional Centers dedicated to supporting families with children and youth with special health care needs and the providers who serve them. The Centers are staffed by specialists who can help get answers, find services, and connect you to community resources. Their services are free and private. Physicians may refer a child with special health care needs to a Regional Center using a Consent to Release Medical Information Form. Families with infants who screen positive for blood or hearing disorders are also given information on how to contact the regional centers and the services that are available.

 

Women, Infants, and Children (WIC): The Wisconsin WIC program is co-located with the Title V program in the Bureau of Community Health Promotion of the Wisconsin Division of Public Health. In addition to providing nutritional education and resources and breastfeeding support, Wisconsin WIC provides childhood lead testing, facilitates access to childhood vaccines, and supports community-based efforts to improve structural supports for breastfeeding.

 

State Statutes Relevant to Title V Program Authority

 

The Wisconsin Legislature gives statutory and administrative rule authority to its state and local government to promote and protect the health of Wisconsin citizens. In 1993, Wisconsin Act 27 created statute chapters 250-255 that significantly revised public health law for Wisconsin and created an integrated network for local and tribal health agencies and the State Health Division. In 1998, administrative rules related to public health, Wis. Admin. Code §§ DHS 139 and DHS 140, were completed. Wis. Admin. Code §DHS 139 outlines the qualifications of public health professionals employed by local and tribal health agencies and Wis. Admin. Code §DHS 140 details the required services necessary for local and tribal health agencies to reach level I, II, or III designations. In 2008, the 10 essential public health services were added to Chapter 250 as a requirement of state and local and tribal health agencies (Wis. Stat. § 250.03(1)(L)). These important public health statutes provide the foundation and capacity to promote and protect the health of all mothers and children including CYSHCN in Wisconsin.

 

Wis. Stat. ch. 250 defines the role of the state health officer, chief medical officers, the public health system, the power and duties of the department, qualifications of public health nursing, public health planning, and grants for dental services.

 

Wis. Stat. ch. 251 describes the establishment of local boards of health, its members, powers and duties, levels of services provided by local and tribal health agencies, qualifications, and duties of the local health officer, and how city and county health departments are financed.

 

 Wis. Stat. ch. 253 mandates a State MCH Program in the DPH to promote the reproductive health of individuals and the growth, development, health, and safety of infants, children, and adolescents. This chapter addresses: state supplemental food program for women, infants, and children, family planning, pregnancy counseling services, outreach to low-income pregnant women, abortion refused/no liability/no discrimination, voluntary and informed consent for abortions, infant blindness, newly added in 2010 newborn hearing screening, birth defect prevention and surveillance system, tests for congenital disorders, and Sudden Infant Death Syndrome.

 

Wis. Stat. ch. 254 focuses on environmental health and includes health risk assessments for lead poisoning and lead exposure prevention, screening requirements and recommendations, care for children with lead poisoning/exposure, lead inspections, lead hazard reduction, asbestos testing, abatement, and management, indoor air quality, radiation, and other human health hazards.

 

Wis. Stat. ch. 255 addresses chronic disease and injuries and outlines cancer reporting requirements, cancer control and prevention grants, breast and cervical cancer screening programs, health screening for low-income women, and the Thomas T. Melvin youth tobacco prevention and education program.

 

Effective July 3, 2014, the Wisconsin DHS adopted emergency rule (EmR1410), which added critical congenital heart disease and organic acidemias as conditions for which newborns must be tested. In 2015, critical congenital heart disease screening was added to the newborn blood screening panel by permanent rule and all conditions must now be listed individually rather than as categories of conditions. Wis. Stat. §  253.13(1), as amended by 2013 Wisconsin Act 135, now allows testing for congenital and metabolic disorders using other screening methods, including point-of-care testing.

 

In 2015, there were 10 Acts signed into law related to the state Heroin, Opioid Prevention and Education (HOPE) agenda that address Wisconsin’s prescription and illicit opioid abuse problem by improving the Prescription Drug Monitoring Program use and reporting, increasing regulation of pain management clinics, requiring detailed reporting from methadone clinics, criminalizing substance or devices that intend to circumvent lawfully administered drug tests, increasing access to opioid treatment facilities, requiring the development of guidelines for best practices in prescribing controlled substances by medical-affiliated boards, and funding Treatment and Diversion programs as alternatives to incarceration.

 

In 2017, the original Wisconsin Birth Defects Registry legislation and rules were updated. Wis. Stat. § 235.12 originally required parental permission to submit identifiers, such as name and address of child and parents to the Wisconsin Birth Defects Registry. Effective July 1, 2018, all submissions to Wisconsin Birth Defects Registry should include identifying information. However, parents will have the option to opt out of submitting personally identifying information. The revised legislation also simplifies the process of amending the list of Wisconsin Birth Defects Registry reportable conditions (the current list of conditions is available on the last page of the paper reporting form DPH F-40054).