Demographics, Geography, Economy, Urbanization and Government: New Hampshire (NH) is one of the oldest states in the country; it was originally a land grant in 1623 and became a state in 1775. NH’s population of 1.36 million live in 9,351 mostly forested (81%[1]) square miles bordered by Canada on the north and by Massachusetts on the south. On the east is the Atlantic Ocean and Maine and on the west is Vermont. With its 1,300 lakes and ponds, 40,000 miles of river and 18 miles of seashore, NH is the 45th largest state at 190 miles long and 70 miles wide. The state’s landscape lends itself to many different types of outdoor recreation. However, that same topography lends itself to difficult driving and long distances between places, particularly in the winter months.
With its ten counties, approximately 47% of the population and 84% of the landmass in NH is considered rural; most of the land area lies north and west of the capital Concord. The three most urban or metro areas are Manchester, Nashua and Concord, all located in the state’s southern tier where the majority (53%) of the population lives.
NH’s Title V Program consists of the Maternal and Child Health Section (MCH) located in the Bureau of Population Health and Community Services in the Division of Public Health Services (DPHS), and the Bureau for Family Centered Services (BFCS), located in the Division of Long Term Supports and Services (DLTSS). Many factors guide its efforts.
Both DPHS and DLTSS reside within the NH Department of Health and Human Services (DHHS), the State’s largest agency made up of approximately 10,000 employees and the bulk of the State’s budget (with Medicaid being the most costly line item). A Commissioner oversees the NH DHHS, appointed by the Governor for what typically is a four-year term. Both MCH and BFCS are physically located in the capital city of Concord. However, much of the Title V work takes place in funded agencies across the State in the form of community health centers, specialty health clinics and human services agencies that provide home visiting and the like.
NH has the largest bicameral legislature in the English-speaking world, with 24 Senators and 400 Representatives, and operates under a unique Governor and Council (G&C) system. Five Executive Councilors, each representing 1/5 of the population are elected separately from the Governor, though for the same two-year term. All state departments and agencies must seek approval of both receipt and expenditure of state and federal funds, budgetary transfers within the department and all contracts with a value of $25,000 or more. Christopher T. Sununu, Republican, is the 82nd Governor of the State and is currently serving his third term, receiving in 2020 more votes ever than any candidate in state history.[2] Title V policy and funding is heavily influenced by both the Legislature and G&C.
On March 13th, 2020, the Legislature, consistent with the date the Governor declared his first State of Emergency order and opened up the Emergency Operations Center, suspended activity due to the COVID‑19 pandemic. Both the House and Senate did no legislative business through any venue until late April 2020, when a few, but not all, Senate and House Committees began meeting remotely. This continued, however with all Committees meeting remotely, throughout the next legislative session beginning in January of 2021. Full House sessions were all facilitated in-person, despite a lawsuit seeking to do them remotely.
Much of the legislative session was spent in the preparation and deliberation of the State Fiscal Years 22/23 biennium budget. The work actually began in the Summer of 2020 with DHHS and Title V staff developing their own budget for every separate accounting unit to set it on its course to be approved and vetted by the DHHS Commissioner, Governor and then with the Fiscal Committees of the Legislature in February of 2021. Title V staff had an opportunity to create presentations for executive level staff to present (e.g. “What is Title V and MCH, etc.”) at both the House and Senate Fiscal Committee deliberative budget sessions. Governor Sununu signed the biennium budget on June 28, 2021. Over the last decade, state general funds specifically for Title V (in the exact line item) have gone down approximately two million dollars, but are still above the required match. MCH in general lost almost a half a million dollars in general funds this year for its Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. The allocation for general funds for BFCS specifically, have been stable over the last decade, improving slightly through 2020, but then decreasing again in the current biennium budget a quarter of a million dollars.
At the end of April 2021, the US Census Bureau announced 2020 census data showed that the population of NH increased 4.6% in the decade from 2010. The release of this apportionment data, the first of the 2020 census, assures that the State will retain its two congressional districts.[3] From 2010 to 2019, the population of NH grew by about 43,000 people. Over 90% of this population growth was driven by individuals identifying as a race or ethnicity other than white and non-Hispanic.[4] The actual population of the State of New Hampshire is primarily non-Hispanic white (90% and one of the highest in the US), but its residents of color (Asian, 3%; Black, 2%, Hispanic, 4% and other at 1%) are increasing.[5] Diversity is geographically uneven in NH.[6] Many square miles of the State are uniformly white, while the more urban part in southern NH is more diverse as is the Hanover/Lebanon area in the Upper Valley and a few areas of the Seacoast. In Manchester and Nashua, more than 30% of the population under 18 are minorities.[7] It is interesting to note that of those under 18 statewide, children, only 84.5% identify as non-Hispanic white.[8]
Rising as well is the 6.1% of the State’s population born outside of the U.S., with a 10.5% growth just between 2010 and 2014.[9] The State also has one of the most mobile populations in the country. Only 42% of the State’s residents were born in NH, far less than the average across the U.S (57 percent).[10]
With fewer births than deaths, migration accounted for all of NH’s population increase in 2020 and is critical for future population growth.[12] Fewer births because the number of women of child-bearing age has decreased, and greater deaths because of the growing older adult population.[13] The COVID‑19 pandemic has accentuated this as the majority of deaths have been in the long-term care population ranking NH is in the top tier of the percentage of older people dying of COVID.[14] The State also still has a large incidence of opioid related overdose deaths, primarily in young adults, but still contributing to the overall numbers. Conversely, NH was only of one two states in the country not to have an increase in overdose deaths in 2020, although it did consistently have one of the highest rates.
Only 27% of all households in NH have one or more people under the age of 18.[15] NH is a rapidly aging state. Approximately 18% of the State is 65 and older compared with 16% nationally.[16] The State routinely is amongst the top five for the highest percentage of its population enrolled in Medicare.[17] As a result, the State’s older population will more than double over the next 20 years. As with its diversity numbers, older populations are not represented evenly within the State: the percentage of the population of older adults is greatest in the North Country, while the biggest number of older adults live in the Southern part, which is the most populated.
NH is a low-revenue, low-expenditure state. Its revenue structure is distinctive in that the State lacks a broad-based personal income or sales tax, and its biggest single source of revenue is local property taxes. The funding of NH’s school districts is largely at the local level through property taxes, which has led to disparities across the State in property poor districts. The largest tax revenue for the State level are those on business, tobacco, rooms and meals, real estate transactions and from the State enterprises selling liquor and lottery tickets.
NH has a diverse mix of industries which usually makes its economy more resilient than that of states that are dependent on fewer. The State’s jobs are most heavily concentrated in retail, health care, government, and manufacturing. The State’s percentage share working in retail is the highest in the country[18],[19] while it has the lowest minimum wage in New England at $7.25 an hour.
NH’s unemployment rate, pre-pandemic, was usually well below that of the U.S. as a whole (hovering around 2 to 2.5 % for over a decade). Part of that is due to consistently having a more educated workforce. However, with the advent of the COVID‑19 pandemic, NH, like the rest the country, experienced a significant increase in its incidence of new and sustained unemployment claims. The pandemic did indeed create newly vulnerable populations that because of the initial stay at home declarations, closures, health reasons and child care due to closed centers and schools, that had to address economic instability and unemployment for the first time. However, also like the rest of the country, NH’s current unemployment rate has been trending downwards since late summer 2020.
The statewide decline in continuing claims reflects progress in the re-opening of businesses and return to work of residents. Younger workers are disproportionately found in several of the industries with the most layoffs and furloughs during the pandemic, particularly the retail industry.
As of the latest US Census Household Pulse Survey ending July 5, 2021, only 5.6% of respondents in NH reported that they expected “someone in their household to have a loss of employment income in the next four weeks.” This is down from 27.7% a year prior. [21]
NH typically has one of the lowest poverty rates in the country, most recently at 7.3%,[22] which varies across the State. Poverty is defined as having an income below a certain level based on the size and composition of the household. For 2019, the federal poverty thresholds were less than $13,300 for an individual under age 65, $17,622 for a single adult under 65 with one child, and $25,926 for two adults with two children.
There are clearly racial, family and living situation disparities in poverty level within the State.
Single female-headed families face higher levels of poverty regardless of their identified race, ethnicity, number of children, education level, work status, or home ownership status compared to all families.[25]
Unique strengths that impact the health status: Historically, NH has often been in the top tier in rankings of its overall well-being and in the social determinants of health.[27],[28],[29] Scores are based on a composite index of metrics that give a snapshot of the health of a population or its health care, such as rates of infant and maternal mortality (both of which NH scores well on). The State also scores high because some of its key social determinants of health such as economic stability, quality of education and public safety generally are good.
Components of the state’s systems of care and Title V populations: NH’s Title V population includes a slightly increasing number of CYSHCN. According to the National Survey of Children’s Health (NSCH) from 2016 to 2019, the percentage of children whose parent identifies them as having special health care needs based on the CYSHCN Screener has increased from 20.5% in 2016-2017 to 23.7% in 2018-2019[31].
As the number of ASD diagnoses reported to the NH ASD Registry increased through 2018, they began to decrease with the onset of the COVID‑19 Emergency.
The number of child development clinics available to assess, evaluation, and diagnose children with suspected developmental delay continues to decrease since the availability of developmental pediatricians in NH remains very limited. According to the Title V-funded Child Development Clinic Network’s 2021 Annual Report. “Highly qualified psychologists, particularly those familiar with developmental differences in very young children have limited availability. Applied Behavioral Analysis (ABA) services are limited and constantly changing. Wait lists are long and availability varies greatly by region.”[32] Few service providers offer ABA in the home setting, making it difficult for children to learn daily living skills in their home and for parents to learn strategies to interact and teach their children. There is evidence that training parents to support developmental skill building is helpful. Few providers offer interpreters for families, making it nearly impossible for families to have equal access to services for young children with autism. “Child psychiatry, particularly for children having Medicaid, is also limited. Securing experienced behavioral health providers for children and parent counseling for challenging behavior is also difficult for families, complicated by waitlists at the community mental health centers.”[33] The BFCS has seen an increasing number of referrals for children presenting with “behavioral concerns” during the COVID pandemic.
According to BFCS’ Complex Care Network Coordinator, “the lack of nursing is very concerning and potentially dangerous. There are medically fragile children who have scripts for many hours of nursing who are unable to find coverage. In one case, the family was approved for 160 hours of nursing coverage and is receiving approximately eight hours per week.”[34]
NH’s Title V population is served by its 26 acute care hospitals. Thirteen of the 26 are designated as critical access hospitals, which have 25 beds or less and are the smaller, rural systems. Five specialty hospitals provide psychiatric and rehabilitative care with 576 beds (an increase of 78 beds). Dartmouth Hitchcock (DH) is the largest medical system in the State with its flagship hospital having the only Level 1 designated trauma classification. It also offers the State’s only comprehensive, full-service children’s hospital, the Children’s Hospital at DH.
NH has a highly concentrated health care delivery system. Acute care hospital systems are more than just inpatient and emergency room services. Many of NH’s hospitals have evolved to include the majority of the medical and primary care practices in the State as well as ownership of ambulatory surgery centers, health centers, assisted or skilled nursing care facilities and home care and hospice. As payment models shift from volume to value, hospitals are working to advance population health efforts within their institutions and improve the health of the communities they serve.[36] In the past two years, most of the hospitals in the State have also merged and affiliated with one another and across stateliness, joining hospital and health care systems in Maine, Vermont and Massachusetts and even on a national level. Only four of the 26 acute care hospitals have not been the subject of recent merger activity (Cottage, Speare, Valley Regional and St. Joseph). Thus narrowing the healthcare delivery system to a handful of players.
There are 11 Federally Qualified Health Centers (FQHCs), one FQHC look-alike and 14 Rural Health Clinics (RHCs), all but one them critical access hospital-affiliated. They provide services at 47 sites. Through MCH, Title V helps to support the efforts of the majority of the FQHCs, the FQHC look-alike and one RHC. NH DHHS also supports mental health services regionally through a network of 10 designated Community Mental Health Centers. There are also designated receiving facilities, or places that serve the acutely ill and provide 24/7 care, five for adults and one for children. NH’s substance misuse crisis system is the NH Doorway infrastructure with nine locations providing single points of entry for people seeking help for substance use, whether they need treatment, support, or resources for prevention and awareness.
With the advent of the COVID‑19 pandemic in early 2020, all health systems have had many systemic changes, with a significant difference in the way of managing their care and a tremendous roller coaster in financial resources. Currently, there are many federal grant opportunities specific to recovering from the COVID‑19 pandemic that will fiscally help to support the State’s healthcare system, particularly for FQHCs.
NH also has a network of 13 regional Public Health Networks (established in 2013 through emergency planning and drug and alcohol prevention funds) which seek to integrate multiple public health initiatives and services into a common network of community stakeholders for communities with comparable public health issues and priorities in order to improve health outcomes specific to these regions. These Public Health Networks took the lead along with DPHS in the State’s response to the COVID‑19 pandemic.
A State Health Assessment (SHA) and State Health Improvement Plan (SHIP) Advisory Council was established in July 2020. The SHA will describe the status of health and well-being in New Hampshire; utilize input from state and local level stakeholders obtained through public forums; identify disparities in social determinants that impact health, health outcomes, and access to care; map health care service delivery, utilization, inter-entity collaboration, and identification of gaps or redundancies; utilize existing data for statewide and local planning; and identify priorities for the SHIP. The SHA will be completed in fall of 2021.
The State Health Improvement Plan (SHIP) will guide the NH DHHS in assessing, planning, implementing, and monitoring improvement in the health and well-being of NH's population. The SHIP will focus on strategies to improve health outcomes and reduce inequities; and strengthen public health and human service delivery systems. The SHIP will identify priorities and evidence-based practices, integrate services, and leverage resources across the State. The SHIP will be completed by August 2022.
A particular concern to the MCH population is the additional closing of another birthing hospital (Parkland Medical Center) in the last year. That makes a total of ten closures over the past two decades leaving 16 birth hospitals and four birthing centers. Only six of the critical access hospitals now offer obstetrical services presenting a distance issue.
Obstetrical services have high fixed costs and low reimbursement rates.[37] Over the past several years, Title V staff have gathered with their colleagues across the State to review this issue, including the Northern New England Perinatal Quality Improvement Network (NNEPQIN). Small volume hospitals typically have a higher percentage of patients that give birth paid for by Medicaid (up to 59%). There has been a supplemental payment policy in place for the last few years with NH Medicaid with several of these units that have likely helped to keep them open.
Over the last decade and a half, Medicaid has consistently paid for approximately one quarter of all NH births.
Dartmouth Hitchcock (DH, parent organization of NNEPQIN) recently received a HRSA Rural Northern Border Regional Planning grant which will focus on access to obstetrical services in the most Northern part of the State: Coos County and upper Grafton County.
In addition, there has been a research project taking place over the past several years, funded by the Robert Wood Johnson Foundation and looking at the causes, consequences and opportunities of the rural labor and delivery closures in particular. Many of the initial findings,[39] from a combination of vital records data and key informant/patient interviews, have mirrored national studies. Rural labor and delivery closures were associated with:
- An increase in distance and time to the nearest open unit;
- Those with the most limited access had the least resources to mitigate any adverse impacts;
- An increase in the probability of giving birth in a location without standing labor and delivery;
- A temporary increase in cesarean deliveries and the probability of having ten or fewer prenatal visits in the year of closure.
Unit closures were often attributed to quality/safety concerns as well as financial viability. Yet these closures did not consistently improve hospital finances.[40] The project also reflected what the current group of stakeholders (aided by the new HRSA grant) is discussing, that regionalization and interdisciplinary teams could contribute to better coordinated care and retention of services.
Affecting the entire population as well as that in MCH, the healthcare workforce in the State is aging rapidly. In a 2019 report from the NH Health Professions Data Center, male physicians make up over 80% of the workforce 50 years and older leading to an expected 50% of the current available physician capacity (by FTE) to decrease in five years.[41] Title V is working with colleagues at DHHS’s Office of Rural Health and Primary Care with participation in activities such as the Legislative Commission on Primary Care Workforce Issues and the NH Health Professions Data Center. Several of the Title V funded community health centers are also involved as placements for new family practice, psychiatry and pediatric residencies and internships.
Financing of services for the MCH population: NH Medicaid utilizes a managed care model for medical services with three insurance plans, NH Healthy Families, Well Sense and AmeriHealth Caritas.
NH’s Medicaid expansion program, called the Granite Advantage Health Care Program, continues with participants having a choice of the current MCO’s. The enrollee must also remain under 138% of the Federal Poverty Level to remain eligible for coverage.
As of the end of June 2021, approximately 222,207 NH residents were enrolled with Medicaid, a little more than 16% of the state’s population (a large increase from the 12% in the previous year).[42] Children continue to make up the greatest proportion of the NH Medicaid roster with the expansion population second.
The State also operates a partnership health insurance exchange with the federal government (https://www.nh.gov/insurance/consumers/documents/2021-plan-comparison-tool.pdf), with the Department of Insurance having control over plan management and consumer assistance functions on the federal Marketplace. There are three (3) medical carriers with 14 plans for individuals and 15 for small groups. The total percent uninsured in NH was approximately 5.9% for all ages in 2019.[44] The percentage of children under the age of 19 with no health insurance coverage was 2.8%.[45] Figures during the COVID‑19 pandemic will be available in fall of 2021 which will reflect the effect the COVID‑19 pandemic has had.
Recently ended is NH’s five year (2016-2020) Medicaid Delivery System Reform Incentive Payment (DSRIP) 1115 waiver project, which took place to improve the care for beneficiaries with behavioral health disorders, by addressing workforce and infrastructure shortages, improving care transitions, and integrating physical and behavioral health. DSRIP featured funding of $150 million to seven Integrated Delivery Networks (IDNs) covering the whole State including incentive payments, performance-based funding distributions, and support for transitions to alternative payment models. Funding for project planning and capacity building, not typically covered by standard Medicaid, was a feature and included IDN participation in a variety of statewide and community-driven projects. In the interim progress report (a final report has not been completed), there was a reduction in emergency department (ED) visits (for the particular beneficiaries) which suggests an initial positive effect on service utilization.[46] Frequent (four or more) ED visits for clients with behavioral health disorder varied from a high of 17.9% in 2012 to a low of 14.7% in 2017. It is hoped that this is a potential early indicator of successful implementation of behavioral health/primary care integration efforts as the DSRIP focused on care coordination and transition planning. [47]
Challenges that impact the health status: The deferral of preventative care; the increase of substance misuse, family violence and food insecurity all increased in the State because of the COVID 19 pandemic and have only recently begun to go back to pre-pandemic numbers. However, since the Delta variant, NH has been like the rest of the United States, with a recent disturbing increase in cases.
As in the rest of the U.S., COVID‑19 has disproportionately affected the State’s racial and ethnic minority residents.
Title V staff have all been involved in the COVID‑19 pandemic response, helping to keep an ear to the ground on the needs of contractors as well as surveilling pregnant woman who are COVID positive, working on immunization efforts in the MCH and CYSHCN populations, just to name a few. At this point in time, Title V staff continue to be very involved in the day-to-day response of pandemic operations. However, no staff member is currently being deployed either full or part-time to the pandemic response unless part of their normal job responsibilities, such as aiding contractors in encouraging vaccines, particularly with the addition of pregnant women or reviewing messaging geared toward the Title V population, including CYSHCN.
At the time of writing, a little over half of NH’s eligible population is vaccinated.
During the COVID‑19 pandemic, the Title V population’s health care and social service providers in the State remained open, but had to alter their methods of providing care. Specialized outreach was done to make sure families did not forego routine care (i.e. child immunizations, treatment of chronic diseases, dental care, and well-child visits). This was accommodated through the expansion of hours, the ramp-up of telehealth visits, mobile health vans, increased transportation vouchers and on-call 24/7 health care by phone support. COVID‑19 testing and then immunization can now all be done at many of the Title V funded agencies, in particular the community health centers. As of July 1, 2021, all NH state-managed fixed vaccination/National Guard-run sites closed, and community health centers are vaccinating patients in regular office visits to offer the COVID‑19 vaccine in a similar way to how patients access other common vaccines.
In NH, Title V funded contract agencies also prioritized the social determinants of health, particularly during the COVID‑19 pandemic. Community health centers and home visiting agencies mitigate the impact of food insecurity on the State’s children and families by maintaining food pantries, delivering food to individuals experiencing homelessness and children usually supported by the free and reduced school lunch and breakfast programs.
Telehealth’s rapid expansion in NH during the early days of the COVID‑19 pandemic has continued through today, aided by Medicaid and other insurers reductions of limitations, has demonstrated its potential for advancing health equity through its reduction of geographical barriers to care, particularly in behavioral health. Several community health centers have documented that for the very first time they are seeing a 0% no-show rate for behavioral health.[51] Patients have also shared that telehealth means they do not miss as much time from work.[52] For these reasons and many more, health care providers including the health centers are making changes in their offices to accommodate for telehealth as the way of the future. The NH legislature has supported this through a telehealth law that made permanent the interim guidance from the original emergency order established by the Governor at the outset of the pandemic. In the State Fiscal Year 2020, House Bill 1623 including, among others, the following provisions:
- Ensure coverage and reimbursement parity, expand site of service, and enable all providers to deliver services through telehealth for Medicaid and commercial health coverage.
- Enable access to medication assisted treatment (MAT) in specific settings by means of telehealth services.
- Amend the Physicians and Surgeons Practice Act to expand the definition of telemedicine.
- Amend the Nurse Practice Act to expand the definition of telemedicine.
- Enable the use of telehealth services to deliver Medicaid reimbursed services to schools. Services.[53]
The NH Telehealth Alliance is a new organization, which MCH has joined along with DPHS’s Primary Care and Rural Health Section; its sole mission is to support better access and more cost effective benefits of telehealth activities within the State. It presents monthly professional education webinars on topics related to telehealth.
NH continues to have a high rate of opioid overdoses and deaths plaguing the State for more than a decade and severely straining the health care system as a whole. This has continued throughout the COVID‑19 pandemic but the deaths have leveled off the last two years. NH was only one of two states in the US that did not see an increase in opioid related deaths for 2020.[54] That being said, NH still has one of the highest rates of overdose deaths in the country. No increase could reflect the greater access to treatment as well as the proliferation of the availability of naloxone.
For the MCH population, this has been particularly tragic. One of the leading causes of maternal mortality in the State is accidental drug overdose.[57] MCH’s surveillance tool, the Pregnancy Risk Assessment Monitoring System (PRAMS) added opioid use questions to the 2019 survey. Data which just came out show that approximately 77% (CI=72.2-80.5%) used over-the-counter pain relievers during pregnancy, primarily acetaminophen (74%; CI=69.2-77.8%). And approximately 6% (CI=3.8-8.8%) used prescription (opioid) pain relievers, primarily oxycodone (2.7%; CI=1.5-4.9%). There were no significant differences in prevalence of opioid use according to maternal characteristics: race/ethnicity, maternal age, maternal education, household income, urban/rural residence, pregnancy intention, depression, use of marijuana, smoking cigarettes, domestic partner violence or insurance.[58]
MCH is the lead on the CDC’s Overdose to Action grant, which funds several opioid overdose surveillance and prevention strategies including the collection of real-time emergency department overdoses; the collection and dissemination of data related to overdose deaths; the development of overdose surveillance systems such as the Opioid Overdose Dashboard; the enhancement of the State’s Prescription Drug Monitoring Program; the provision of care navigators to help families connect to services when children are separated from their parents due to parental substance use disorder; the provision of education about syringe services to reduce harm, and the education of health care providers and support health care systems related to best practices around prescribing opioid medications.
Title V staff in coordination with statewide colleagues on the Perinatal Substance Exposure Task Force, developed and are now implementing a Plan of Safe Care[59],[60], developed collaboratively by the new mother and her health care and social service providers. The MCH Perinatal Coordinator will be focusing on the Plan of Safe Care in conjunction with the Title V National Performance Measure #14. For the last four years, MCH has been collecting drug exposure data on its situational surveillance fields on the birth certificate. Now, the questions are permanent parts on the birth certificate work sheets, are aggregated, de-identified and submitted to DHHS’s Division of Children, Youth and Families (DCYF; the State’s Child Protection Agency) for its federal CARA/CAPTA notification requirements. Mandatory reporting is required under NH RSA 169-C: 29 whenever anyone has a reason to suspect child abuse and/or neglect. The fact that an infant is born with prenatal exposure to drugs and/or alcohol does not itself require a mandatory report.
During State Fiscal Year 2020, the DCYF Central Intake Unit fielded 28,389 calls, down from the previous year (attributed to the pandemic), which resulted in 9,869 abuse and neglect assessments and 165 family service cases.[61] Data continue to show a plateauing of the number of children in out-of-home care following years of drastic increases, as well as a marked increase in the number of children being cared for in their own homes and with their own families. In fact, exits for the second year in a row show that out of home care continues to outpace entries.[62] For the first time ever, DCYF’s child protection workforce is approaching national caseload standards. Currently, the average number of assessments per Child Protective Service Worker is 16, down from 90 in 2016.[63]
Title V staff, even with the COVID‑19 pandemic, continued work on the joint implementation of NH DHHS’s “10‑Year Mental Health Plan” (the plan). [64] The plan provides a focus on children as well as the prevention of suicide. NH’s suicide rates were up 48.3% from 1999-2016, third behind Vermont and North Dakota.[65] It is the second leading cause of death for NH citizens ages 10- 44 and the fourth for those 45-54.[66] MCH has played a pivotal role in suicide prevention with its staff co-founding the Youth Suicide Prevention Assembly more than 25 years ago and its leadership positions on the current NH Suicide Prevention Council. Title V funds have enabled the integration of behavioral health and primary care, a strategy that is highlighted in the plan. MCH and its funded colleagues helped to pioneer this concept over a decade ago and continue to do so today.
Statutes and other regulations that have passed or are in process within the last year and have relevance to the Title V program: HB 600 will slightly alter RSA 132:10-a, which enables the newborn screening revolving fund to be self-supporting. Over the course of the last several years, four disorders were added to the screening panel, increasing the cost of the filter paper by $75 for a total of $146, a significant amount. The birthing hospitals pay, dependent upon number of filter papers ordered. Birthing hospitals typically get one overall fee for the birth of a baby. The change, initiated by the NH Hospital Association, reads “to be paid directly by hospitals in their entirety, acknowledging that fees may be offset by commercial insurance or Medicaid paid to hospitals for the tests required under paragraph 1. To the extent possible, the commissioner (of HHS) shall structure these fees to be reimbursable without out of pocket cost pursuant to 45 C.F.R. 147.130.” [67] This change will encourage insurers to break out the costs of birth, thereby reimbursing newborn screening fees separately. The change also initiates the process of changing the accompanying administrative rules, He-P 3008.
HB 1162 will require private insurance to include coverage for developmental services provided to children birth to three years (Part C - FCESS). Previously insurance was only covering medically necessary services, not developmental. However, there is still a gap as this does not apply to the self-funded insurance groups such as the coverage the State of NH provides.
HB 2, the State Fiscal Years 22 and 23 biennium budget trailer bill, contains language that will require that all reproductive health care facilities (family planning clinic sites) to undergo a detailed fiscal audit, done by MCH’s Women’s Health Program in addition to the DHHS audit team, every state fiscal year to ensure that abortion services are not directly or indirectly supported. This fiscal audit is now a requirement for family planning sub-recipients to receive any state funds. This review must be certified by the DHHS Commissioner and approved by the G & C on an annual basis.
NH passed the “Fetal Life Protection Act”, which bans abortion at or after 24 weeks gestation except in cases of a medical emergency. If abortions are performed at or after 24 weeks due to a medical emergency, providers are required to file a report with DHHS. Lastly, the act also requires that an ultrasound must be performed prior to a termination. NH is the first state in New England to mandate this imaging procedure. This mandate could end up requiring individuals to schedule an appointment before they can schedule an appointment to undergo an abortion and thus increase the total cost of the procedure.
[1] Division of Forests and Lands, New Hampshire Department of Natural and Cultural Resources. Retrieved on 07/21/21 from https://www.nh.gov/nhdfl/reports/forest-statistics.htm.
[2] https://www.governor.nh.gov/about retrieved on 07/21/21.
[3] U.S. Census Bureau (2021). 2020 Census Apportionment Results. Retrieved on 07/23/21 from https://www.nh.gov/osi/data-center/2020-census/index.htm#:~:text=The%20U.S.%20Census%20Bureau%20announced,4.6%25%20since%20the%202010%20census.
[4] NH Fiscal Policy Institute (2021). Demographics. Retrieved on 07/26/21 from https://nhfpi.org/assets/2021/05/Demographics-May-2021.pdf.
[5] U.S. Census Bureau (2021). Quick Facts New Hampshire. Retrieved on 07/23/21 from https://www.census.gov/quickfacts/fact/table/NH/PST045219.
[6] University of NH, Carsey School of Public Policy (2019). What is NH? Demography. Retrieved on 07/23/21 from https://carsey.unh.edu/what-is-new-hampshire/sections/demography.
[7] Ibid.
[8] NH Fiscal Policy Institute (2021). Demographics. Retrieved on 07/26/21 from https://nhfpi.org/assets/2021/05/Demographics-May-2021.pdf.
[9] New American Economy (2016). The Contributions of New Americans in New Hampshire. Retrieved on 07/23/21 from http://www.newamericaneconomy.org/wp-content/uploads/2017/02/nae-nh-report.pdf.
[10] University of NH, Carsey School of Public Policy (2019). What is NH? Demography. Retrieved on 07/23/21from https://carsey.unh.edu/what-is-new-hampshire/sections/demography.
[11] Johnson, Kenneth, University of NH, Carsey School of Public Policy (2021).
New Census Data Reveal Modest Population Growth in NH Over the Past Decade. Retrieved on 08/18/21 from https://scholars.unh.edu/cgi/viewcontent.cgi?article=1438&context=carsey.
[12] Ibid.
[13] Ibid.
[14] Kaiser Family Foundation (2020).What Share of People Who Have Died of COVID-19 Are 65 and Older – and How Does It Vary By State? Retrieved on 07/26/21 from https://www.kff.org/coronavirus-covid-19/issue-brief/what-share-of-people-who-have-died-of-covid-19-are-65-and-older-and-how-does-it-vary-by-state/.
[15] U.S. Census Bureau (2021). Quick Facts NH. Retrieved on 07/23/21 from https://www.census.gov/quickfacts/fact/table/NH/PST045219.
[16] Ibid.
[17] Kaiser Family Foundation (2021). Medicare Advantage in 2021: Enrollment Update and Key Trends. Retrieved on 07/26/21 from https://www.kff.org/medicare/issue-brief/medicare-advantage-in-2021-enrollment-update-and-key-trends/.
[18] University of NH, Carsey School of Public Policy (2019). What is NH? Economy. Retrieved on 07/21/21 from https://carsey.unh.edu/what-is-new-hampshire/sections/economy.
[19] NH Fiscal Policy Institute (2021). Demographics. Retrieved on 07/26/21 from https://nhfpi.org/assets/2021/05/Demographics-May-2021.pdf.
[20] NH Employment Security (April 1, 2021). COVID 19 Unemployment Update. Retrieved on 07/26/21 from https://www.nhes.nh.gov/documents/new-claims-release-040121.pdf.
[21] U.S. Census Bureau (2021). Household Pulse Survey. Retrieved on 07/26/21 from https://www.census.gov/data-tools/demo/hhp/#/?s_state=00033&periodSelector=10&measures=LFNEX.
[22] NH Fiscal Policy Institute (2021). Income and Poverty. Retrieved on 07/27/21 from https://nhfpi.org/assets/2021/05/Income-and-Poverty-May-2021.pdf
[23] Ibid.
[24] Ibid.
[25] Ibid.
[26] Ibid.
28 United Health Foundation (2020), America’s Health Rankings. Retrieved on 07/27/21 from https://assets.americashealthrankings.org/app/uploads/annual20-rev-complete.pdf.
[28] U.S. News and World Report (2019). Best States 2021. Retrieved on 07/27/21 from https://www.usnews.com/media/best-states/overall-rankings-2021.pdf.
[29] Annie E. Casey Foundation (2021). 2020 Kids Count Data Book: State Trends In Child Well-Being. Retrieved on 07/26/21 from https://www.aecf.org/m/resourcedoc/aecf-2020kidscountdatabook-2020.pdf.
[30] Ibid.
[31] Child and Adolescent Health Measurement Initiative. 2018-2019 NSCH data query. Data Resource Center for Child and Adolescent Health supported by the U.S. Department of Health and Human Services, HRSA, MCHB. Retrieved 08/20/21 from www.childhealthdata.org.
[32] Smith, J., LaFleur, L., Clark, J., & McLean, P. (2021). SMS Title V CDC Annual Report.
[33] Ibid.
[34] Smith, C. (2021). Complex Care Network Annual Report.
[35] NH Hospital Association (2021). Map of Hospitals. Retrieved on 07/27/21 from https://nhha.org/images/4154_NHHA_MAP_with-logo.pdf.
[36] NH DHHS (2021). NH Statewide Primary Care Needs Assessment. Retrieved on 07/30/21 from https://www.dhhs.nh.gov/dphs/bchs/rhpc/documents/pc-needsassesssment2021.pdf.
[37] Kozhimannil, K. et al. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. JAMA. 201; 319(12):1239-1247.doi:10.1001/jama2018.1830.
[38] Vital Records Data analyzed by MCH, 08/19/2021.
[39] Northern New England Perinatal Quality Improvement Network and the Urban Institute (2021). Labor and Delivery Unit Closures in Rural New Hampshire: Causes, Consequences and Opportunities (Draft Initial Findings). Presentation to small group of colleagues, May 2021.
[40] Ibid.
[41] Weiss, Danielle (2019). 2018 Physician Workforce Data Report. Retrieved on 08/18/21 from https://public.tableau.com/profile/danielle.weiss#!/vizhome/2018PhysicianWorkforceReport/TableofContents.
[42] NHDHHS, Office of Quality Assurance and Improvement (2021). NH Medicaid Enrollment, Demographic Trends and Geography, June 2021. Retrieved on 07/29/21 from https://www.dhhs.nh.gov/ombp/medicaid/documents/medicaid-enrollment-06302021.pdf.
[43] Ibid.
[44] U.S. Census Bureau (2021). American Community Survey. Retrieved on 07/29/21 from https://data.census.gov/cedsci/table?tid=ACSDP5Y2019.DP03&g=0400000US33.
[45] Ibid.
[46] Cutler Institute, Muskie School of Public Service (2020). Interim Evaluation Report by the Independent Evaluator for the NH DSRIP Program. Retrieved on 08/18/21 from https://www.dhhs.nh.gov/dphs/oqai/documents/dsrip-interim-eval-oct2020.pdf.
[47] Ibid.
[48] NH DHHS (2021). COVID 19-NH. Retrieved on 08/16/21 from https://www.covid19.nh.gov/#dash.
[49] NH DHHS (2021). NH COVID-19 Response: Equity. Retrieved on 08/15/21 from https://www.covid19.nh.gov/dashboard/equity.
[50] NH DHHS (2021). NH COVID-19 Response: Dashboard. Retrieved on 08/18/21 from https://www.covid19.nh.gov/dashboard.
[51] Bi-State Primary Care Association (2021). NH Primary Care Sourcebook 2021. Retrieved on 08/19/21 from https://bistatepca.org/public-policy/nh-public-policy/nh-primary-care-sourcebook.
[52] Ibid.
[53] State of NH (2020). NH Telemedicine Act. Retrieved on 07/21/21 from http://www.gencourt.state.nh.us/rsa/html/xxxvii/415-j/415-j-mrg.htm.
[54] NH Drug Monitoring Initiative, NH Information and Analysis Center (2021). Retrieved on 07/29/21 from https://nhvieww.maps.arcgis.com/apps/MapSeries/index.html?appid=fc64bc08d7724f0d8a47c128832a98a2&folderid=8056bfb06d3a4d7da45a32253ddb47d4.
55 Ibid
[56] Ibid.
[57] DPHS (2021). Annual Report on Maternal Mortality to the NH Health and Human Services Oversight Committee, Annual Report 2020.
[58] DPHS (2021). NH PRAMS 2019, Opioid Supplement Report (DRAFT FORM).
[59] NH Governor’s Commission on Alcohol and Other Drugs, Perinatal Substance Misuse Task Force (2019). Plans of Safe Care. Retrieved on 07/30/21 from https://nhcenterforexcellence.org/governors-commission/perinatal-substance-exposure-task-force/plans-of-safe-care-posc/.
[60] NH Governor’s Commission on Alcohol and Other Drugs, Perinatal Substance Misuse Task Force (2020). Plans of Safe Care Through an Implementation Lens. Retrieved on 07/30/21 from http://1viuw040k2mx3a7mwz1lwva5-wpengine.netdna-ssl.com/wp-content/uploads/2020/07/POSC-Through-an-Implementation-Lens_SLIDES-FOR-PRINT.pdf.
[61] DHHS, Division of Children, Youth and Families (2020). 2020 DCYF Data Book. Retrieved on 07/30/21 from https://www.dhhs.nh.gov/dcyf/documents/dcyf-data-book-2020.pdf.
[62] Ibid.
[63] Ibid.
[64] DHHS (2019). New Hampshire Ten-Year Mental Health Plan. Retrieved on 08/16/21 from https://www.dhhs.nh.gov/dcbcs/bbh/documents/10-year-mh-plan.pdf.
[65] Stone DM, Simon TR, Fowler KA, et al. Vital Signs: Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States, 2015. MMWR Morb Mortal Wkly Rep 2018; 67:617–624. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a1.
[66] NH Suicide Prevention Council (2021). NH Suicide Prevention Plan, 2021-2024. Retrieved on 08/16/21 from https://www.dhhs.nh.gov/dphs/bchs/spc/documents/2021-suicide-prevention-plan.pdf.
[67] Retrieved from http://gencourt.state.nh.us/bill_status/billText.aspx?sy=2021&id=97&txtFormat=html on 07/19/2021.
To Top
Narrative Search