The Keystone State

Pa. is a vast, increasingly diverse state comprised of large rural areas and concentrated urban centers which are both evolving economically and socially. Located in the northeast, Pa. is the fifth most populous state, home to nearly 13 million people. In addition to its rural and urban composition divide, the state is physically divided in half by a large swath of rural forest created by the Appalachian Mountains.

Pa. is anchored by two urban counties, Allegheny in the west and Philadelphia in the east. Urban counties are those with a population density higher than the state population density, while rural counties have a lower density. Harrisburg, the capital and headquarters for the Department of Health (DOH), is situated in the southcentral part of the state.

Demographics

Following a national trend, Pa. is becoming more racially and ethnically diverse. From 2010 to 2021, the minoritized population increased from 36 to 42% nationally, and from 21 to 26% in Pa. From 2017-2021, non-white residents made up more of the population in urban areas (30%) than in rural areas (11%). From 2010 to 2021, the Hispanic identifying population increased in Pa. by 50.7%, and the Black/African American identifying population increased by 6.2%. From 2000 to 2021, the rural population became more racially diverse, as the non-white or Hispanic rural population increased from five percent of the total population to 11%. As of 2019, approximately one in three Pa. children are children of color. With the total minoritized population projected to double between 1990 and 2025, the responsibility and challenge of the Title V program is to understand their diverse backgrounds and how services and Title V programming can adapt to their needs.

In general, Pa. is growing older. In 2021, more than 23% of Pennsylvanians were under the age of 20 and 33% were 55 and older. The percentage of population aged 65 and older was greater in Pa. (18.2%) than the US overall (16.8%). From 2010-2021, Pa.’s population grew only two percent with the number of residents under 18 years old decreasing four percent and the number of residents 65 and older increasing more than 25%. Counties with large elderly populations could face the possibility of diverting resources from MCH populations toward their older residents.

Of the approximately 5.2 million households in the state in 2021, nearly 3.3 million of these households were defined as families, with an average size of 3.01 members. The U.S. Census Bureau categorizes families as: married-couple families, male householder (no spouse present) and female householder (no spouse present). While married families are most common, over 71% of non-married families are female-led. These households have slightly larger family sizes, are more likely to have members less than 18 years of age and are more likely to live in multi-unit structures. Nearly eight percent of all households in Pa. are single parent households with children under 18 and no spouse present. Pa. had a lower percentage of households with children (24%) than the national figure (26%). The population of children under age 18 is evenly distributed across age groups for each family type. Of the 2.66 million children in the state, approximately 1.77 million live in a married family. Over 220,000 children live in male-led families; and over 656,000 children live in female-led families, which are less likely to have an unmarried partner present.

The racial distribution varies between types of households with children. While 74% of children in married families are identified as white, 64% of children in male-led families and 42% of children in female-led families identify as white. Nearly 58% of Black/African American children and over 40% of Hispanic children live in female-led families compared to only 15.8% of white children. Female-led families are more likely to have grandchildren in their households and are more likely to have a child with a disability in their household when compared to other households.

In Pa., three percent of people identify as Lesbian, Gay, Bisexual, Transgender (LGBT) with 27% raising children; the U.S. numbers are four and 29%, respectively. As with same-sex couples, most of the LGBT population is white (72%). Pa. ranks 38th in percentage of LGBT individuals. Over a quarter (28%) of LGBT individuals have an income less than $24,000 as compared to non-LGBT individuals (21%). More non-LGBT (90%) individuals have health insurance than LGBT individuals (86%). The percentage of non-LGBT and LGBT individuals having a college education is nearly equal. As of 2018, five percent of the Pa. workforce is LGBTQ. As of 2021, Pa. has 42,577 same sex households (sixth nationally), 53.8% of whom are married.

LGBTQ residents face ongoing health inequities in terms of their absence in statewide surveillance systems and discrimination by healthcare providers, in the workplace, and in social situations. Over half of LGBTQ individuals have reported discrimination at some point based solely on sexual orientation or gender identity, which is not explicitly banned in Pa. There are few laws protecting LGBTQ families regarding insurance coverage, hospital visitation rights, and powers of attorney. Members of LGBTQ groups have health needs both regular and specific to their sexual orientation and gender identity that often go unmet. In response to a range of discriminatory laws being passed in other states, Governor Wolf signed executive orders in April 2016 stating, “no agency under the governor’s jurisdiction shall discriminate on the basis of sexual orientation, gender expression, and identity, among other areas.” These orders pertain to commonwealth employees, and the commonwealth grants and procurement process. Over 50 municipalities have passed separate ordinances to prohibit discrimination based on sexual orientation and gender identity.

Economy, Income, and Poverty

As of November 2022, Pa.’s 19 large counties (counties where 75,000 or more are employed) accounted for 76.5% of total employment within the state. All but two of those counties are considered urban. In 2021, 80% of the state gross domestic product was produced by urban counties. Pa. has the sixth largest economy in the nation but, as of December 2022, had a seasonally adjusted unemployment rate that was higher than the national average. In 2021, 26% of Pa.’s population was low income (under 200% federal poverty level or FPL), and, in 2020, more than half of Pa.’s Medicaid expansion population worked a job that did not offer health benefits. The industry with the greatest number of employees in Pa. in 2021 was educational services, health care, and social assistance, growing eight percent since 2010. Employment in agriculture, forestry, and fishing (which includes farming) increased from 2010-2020. Median income varies by county from $43,615 to $109,969; for families with children, it is $88,347. However, there are stark differences in median income when considering family type. The median income for married families is $119,089, $50,659 for male-led families and $31,826 for female-led families. In addition, female-led families are slightly larger in size than male-led or two-parent families, but their median income is much lower. Women’s income is also affected by the wage gap. In 2020, women in Pa. earned 79 cents for every dollar a man earned, less than the 83 cents national average. The wage gap is even greater for women from minoritized populations.

In 2019, a slightly smaller percentage of Pa. residents (12.1%) lived in poverty compared to the national rate (12.8%). However, there are still large swaths of the population living in poverty, as 24.8% of Pa.’s Black/African American residents and 22.5% Hispanic residents lived in poverty and families with Black/African American or Hispanic householders were more than three times as likely to be living in poverty than white households. Of the 1.39 million families with related children under 18, 13.9% were living below the poverty level during the previous year. Female-led families were more likely than married or male-led families to be living below the poverty level. For families with children under 18, female-led families were more than twice as likely to be living below the poverty level. The highest rates of poverty were for families with a householder having less than a high school education. However, at all levels of educational attainment, the percentage of female-led families living below the poverty line was higher than other families, more than double in most cases.

Future earnings are related to a person’s level of educational attainment. In 2021, there were approximately 820,000 adolescents (15 to 19 years old) in Pa., with nearly 88% of them enrolled in school. School enrollment among adolescents is consistent by race and ethnicity, with Hispanic adolescents having the lowest enrollment at 82.7%.For the more than 9.1 million people aged 25 years and over in Pa. in 2021, nearly 92% have a high school diploma or equivalent or higher, varying a bit by county, and more than 34% have a bachelor’s degree or higher. For this same population for whom poverty status is determined, the rate of poverty for those with less than a high school diploma or equivalency is 25.1% and decreases with educational attainment. The median annual income for those aged 25 years and older is $47,140 and ranges from $28,562 for those with less than a high school diploma or equivalency to $78,261 for graduate or professional degree holders. Of the approximately 1.13 million individuals ages 18 to 24-years, 36.8% have earned a high school diploma or equivalent as their highest educational attainment, 40.9% are enrolled in college or graduate school, and 13.8% have a bachelor’s degree or higher. Females in this age group are enrolled in college or graduate school at a higher rate than males.

Health Care and Health Insurance

The health care delivery system in Pa. is made up of many interlocking pieces; hospitals, Federally Qualified Health Centers (FQHC), primary health care providers, general acute care hospitals, critical access hospitals (CAH), County/Municipal Health Departments (CMHDs), and state health centers, among others, all play a part in providing care to Pa.’s citizens. Another significant piece of health care delivery in Pa. is Medicaid, administered by the Department of Human Services (DHS) through Managed Care Organizations (MCOs).

The delivery of health care services is significantly impacted by the distinctive rural and urban characteristics across the state. While 48 of PA’s 67 counties are considered rural, as of 2021, nearly three-quarters of Pa.’s residents live in urban counties. The concentration became even more pronounced from 2010-2020, as most of the population growth in Pa. occurred in urban counties. In 2020, there was one primary care provider in direct practice for every 1,002 residents in urban counties, as compared to one primary care physician for every 1,483 residents in rural counties. Of the 15 counties without an FQHC, all but one are rural. As of September 2022, an estimated 580,050 residents lived in a designated Primary Care Health Provider Shortage Area. Small areas of several urban counties are considered medically underserved. In 2021, there were 61 general acute care hospitals, with a total of 7,404 beds, in rural Pa. Nine rural counties had no hospitals. On average, there were 2.18 hospital beds for every 1,000 rural residents compared to 2.85 hospital beds for every 1,000 urban residents.

Across the state in 2021, the 147 general acute care hospitals (including 16 Critical Access Hospitals [CAH] as of January 2022) with over 34,690 licensed beds handled over 1.34 million admissions. CAHs are rural hospitals that provide 24-hour emergency services with an average daily census of 25 patients or less. These hospitals serve as key providers in areas with sparse populations, geographic barriers to care, and significant health professional shortages to address populations who are generally older and poorer. Besides anchoring a broad range of health and human services in their communities, many of these hospitals continue to be the top employers in their county and major contributors to local economies. An additional 83 federal and specialty hospitals handled over 140,000 admissions. There are eight children’s hospitals in Pa., four of which are in either Philadelphia or Pittsburgh. The other four are in Allentown, Bethlehem, Danville, and Hershey. They may be inaccessible to children who live in rural areas or in areas not near these hospitals.

Supplementing the hospitals are over 350 FQHCs or rural health center delivery sites providing primary care services in 44 counties. FQHCs are an important resource for groups in Pa. that have been economically and socially marginalized. In 2020, 87% of FQHC patients were at or below 200% FPL, 48% were on Medicaid, and 54% were members of a racial or ethnic minoritized population.

Other important partners in the delivery of services within the MCH system of care are the CMHDs and state health centers. The eleven CMHDs are in urban areas and tailor services to the needs of their local communities. The newest, in Delaware county, launched in January 2022 in response to community needs observed during the COVID-19 pandemic. It was approved by the DOH to act in its official capacity as a health department on April 2, 2022. The Delaware County Health Department is the first one established in Pa. in 33 years. Primary and secondary preventive health services are emphasized and geared to improve the community’s health through direct health services, education, and leadership. CMHDs are funded by Act 315, Pa.’s Local Health Administration Law, with additional funding from state, federal, and local government going toward local office priorities. At a local level, CMHDs currently cover nearly 46% of Pa.’s population. In addition, several CMHDs have either applied for or achieved public health accreditation through the Public Health Accreditation Board. As a result, those communities have access to higher-quality programming and services.

Counties without CMHDs have state health centers, operated by the DOH, that provide and support public health programs. To organize the state health centers, Pa. is divided into six community health districts, each covering a geographic region of the state. Each health district has a district office that helps coordinate activity throughout the district. Through the use of community health assessments and outreach, the centers focus on five core functions: communicable disease investigation and prevention, immunizations, public health education, human immunodeficiency syndrome/sexually transmitted disease services, and tuberculosis investigation and treatment.

Health insurance is a key factor for health care access. In 2021, 5.5% of the approximately 12.8 million civilian noninstitutionalized population in Pa. was uninsured. By gender, 6.5% of men were uninsured compared to 4.6% of women. Only 4.6% of white persons were uninsured compared to 6.1% of Black/African American persons and 12.6% of Hispanic persons. More than 10% of 26 to 34-year-olds were uninsured, the largest proportion of any age group. As educational attainment increased, the percentage insured increased.

The Affordable Care Act (ACA) has brought some insurance relief with the introduction of the federal Marketplace. While the uninsured rate ranges from 5.1% to 13.0% across counties, the uninsured are primarily working families with incomes below 400% of the FPL, unemployed or employed less than full-time, less than a high-school graduate, and non-white. In 2021, over 337,000 residents selected a Marketplace plan, of which 70% received financial assistance. While the uninsured rate has fallen for most racial and ethnic groups because of the ACA, as of 2021, white persons are still more likely to be insured than Black/African American persons.

A key component in the MCH system of care is Medicaid, administered in Pa. by the DHS. Medicaid eligibility is determined by having a special condition or belonging to a particular group such as pregnant women, children, low-income adults, elderly adults, or disabled adults and meeting financial and citizenship requirements. Children and pregnant women have the highest income limits for Medicaid eligibility in Pa. and both limits are higher than the median United States rate.

Medicaid also has special programs for specific medical conditions and waiver programs available for those who require assistance with activities of daily living or who meet functional requirements (such as those with AIDS, on home ventilators, or who are autistic). Although these waivers provide a wide array of services (such as home health aides, transportation, and case management), they are not an entitlement and there is no guaranteed entrance.

In addition to covering basic Medicaid services, Pa. covers 24 optional benefits, including prescription drugs, vision, dental, physical therapy, home health, and hospice care. Pa.’s Medicaid expansion coverage includes the ACA’s ten essential health benefits and expanded mental health and substance use treatment services. According to the 2019-20 National Survey of Children’s Health, 22.7% of children in Pa. have special health care needs. Children and their families may encounter multiple barriers to perform daily life functions and often need services from multiple systems of care which can be challenging for families to navigate. Children with special health care needs (CSHCN) are served by Special Needs Units (SNU) within Medicaid. SNU are housed within physical health MCOs and ensure CSHCN receive services and supports in a timely manner. SNU also assist CSHCN with access to services and information, coordinate between physical health and behavioral health and other systems, and staff a dedicated special needs hotline. Each physical health MCO has a full-time SNU coordinator. SNU staff of MCOs also work in close collaboration with the SNU housed within DHS.

Individuals not eligible for Medicaid may qualify for Children’s Health Insurance Program (CHIP), also administered by DHS. CHIP provides free or low-cost health insurance to uninsured children and teens up to age 19 in families with incomes over the Medicaid limit (133% FPL). As of May 2023, there were 123,714 children enrolled in CHIP. In February 2023, CHIP and Medicaid combined provided health and long-term care coverage to almost 3.7 million in Pa. Medicaid is also a major source of funding for safety-net hospitals and nursing homes, and most Medicaid spending in Pa. is for the older Pennsylvanians and people with disabilities. In State Fiscal Year (SFY) 2019, Medicaid accounted for 59% of all federal funds received by Pa. and 36% of total state expenditures.

With an increasingly diversifying population, it is important to consider how people of color experience Pa.’s system of care, signified by key MCH indicators. More specific data are discussed throughout this Application/Report, especially the Needs Assessment, Women/Maternal Health, and Cross-Cutting sections. With the projected increase in minoritized populations, unaddressed health inequities have the potential to place a greater burden on these populations and the health care system.

Statutes and Regulations

Pa.’s MCH system of care is further augmented by state statutes mandating programs serving the MCH populations and requiring the resources of Title V in both staff and funding.

• The Newborn Child Testing Act (35 P.S. § 621, et. seq. and amended by Act 36 of 2008 and Act 133 of 2020) establishes a program providing for the screening tests of newborn children and follow-up services related to case management, referrals, confirmatory testing, assessment, and diagnosis of newborn children with abnormal, inconclusive, or unacceptable screening tests results. The Pennsylvania newborn screening program mandates screening for thirty-six conditions and aligns with the national Recommended Uniform Screening Panel. 
• Act 87 of 2008 mandates the Child Death Review (CDR) Program, which provides for statewide and county-based multidisciplinary CDR teams to conduct reviews of all deaths of children aged 21 and under. The Act also requires an annual report on the information, distribution, and causes of child deaths in Pa. and reflects information collected during the CDR process from collaborative processes between the DOH and local CDR teams.
• The Pennsylvania Code (028 Pa. Code § 27.22 and 028 Pa. Code § 27.34) requires laboratories and providers to report blood lead test results to the DOH.
• Act 24 of 2018 establishes a Maternal Mortality Review Committee to conduct multidisciplinary reviews of maternal deaths and develop recommendations for the prevention of future maternal deaths.

Planning, Priorities, and Emerging Issues

The Secretary of Health’s priorities combined with the State Health Improvement Plan (SHIP) and the DOH’s Strategic Plan guide the agency and illuminate areas for Title V to implement work to improve the health of populations in Pa. The 2023-2028 SHIP was developed in partnership with a broad representation of public health system stakeholders. The 2023-2028 SHIP includes the current evidence-based strategies for each SHIP priority, the activities planned to implement the strategies, the target populations, collaborators, targets, and data sources. The SHIP priorities are: 1) health equity; 2) chronic disease prevention; and 3) whole person care.

The State Health Assessment (SHA), which reports on the health status of Pa.'s population, factors that contribute to health issues, and resources that can be mobilized to address population health improvement, was recently updated. The Department released the 2022 SHA in March 2022.

The DOH 2020-23 Strategic Plan consists of the following five key strategies: 1) Maintain and enhance emergency services and public health preparedness; 2) Continually develop our talents to significantly advance public health in Pa.; 3) Promote public health with awareness, prevention and improvement of outcomes where the need is greatest; 4) Use data, measures, and technology to enable public health performance; and 5) Improve staff, customer, and partner experience with consistent, efficient, and effective services and work processes. These Department strategies closely align with the work of Title V in Pa. and the Bureau of Family Health (BFH), as the Title V administrator, will continue to emphasize evidence-based and data driven decision-making within its programming while increasing the integration of quality improvement techniques throughout its work.

In March 2019, the DOH achieved national public health accreditation per notification from the Public Health Accreditation Board. Accreditation ensures that the DOH is meeting national evidence-based standards and providing Pa. residents with the best programs and services available. Accreditation can help the BFH improve collaborations between staff and stakeholders and further the Title V mission and programming through increased accountability, quality service delivery, and institutionalized processes, such as the use of evidence-based practices and integration of quality improvement techniques. The Department is currently developing an 18-month plan to aid in the preparation of documents for re-accreditation, due in March 2024.

Impacting Pa. residents, the health care system, and the broader landscape of the MCH system of care are several important, emerging issues. In January 2023, there was a change in administration following the end of Governor Wolf’s second term. He was succeeded by Josh Shapiro, previously the Attorney General. More directly impacting the Pa. DOH, Dr. Deborah Bogen, previously the director of the Allegheny County Health Department, was appointed acting Secretary of the Department. Dr. Bogen’s priorities, reflecting the SHIP, are health equity, whole-person care, and chronic disease prevention. Governor Shapiro has also proposed funds to expand maternal health programming and study ways to reduce maternal mortality and morbidity, access to mental health services, and increase Supplemental Nutrition Assistance Program benefits.

The 2019 novel coronavirus (COVID-19) pandemic has presented an unprecedented challenge. COVID-19 prompted the federal declaration of a nationwide emergency and, in Pa., the activation of a command center at the Pennsylvania Emergency Management Agency and a disaster declaration. Pa. continues to monitor COVID-19 cases and fatalities across the state and is actively engaged in supporting the public health and medical systems with the response. The DOH continues to focus on outbreak prevention and management, vaccine promotion and distribution, and supporting hospitals, long-term care facilities, schools, and vulnerable populations by focusing resources on communities with high health disparities and low access to vital services. As of March 1, 2023, Pa. has had more than 3.52 million confirmed and probable cases, and more than 50,000 Pennsylvanians have died. Nearly 8.7 million Pennsylvanians are fully vaccinated, with more than 4.2 million Pennsylvanians having received an additional dose and nearly 2.1 million Pennsylvanians having received the bivalent booster dose. DOH, along with other state agencies, is transitioning out of emergency status with the end of the federal declaration of a nationwide emergency.

Another issue that will have effects on the health of Pennsylvanians are real or potential changes to insurance status and/or coverage, including the extension of Medicaid postpartum coverage for mothers and birthing people eligible because of their pregnancy, from 60 days after the pregnancy ends to one year postpartum, effective April 1, 2022, under the American Rescue Plan Act. Extending postpartum coverage for those covered through Medicaid will provide health care continuity, allowing birthing people to maintain uninterrupted relationships with and access to care providers through a critical period in their and their babies’ lives. Throughout the pandemic, The Centers for Medicare and Medicaid Services (CMS) issued a Public Health Emergency (PHE), under which some requirements and conditions for Medicaid, such as eligibility redeterminations and disenrollments, were waived. The waiving of these conditions allowed those on Medicaid to maintain continuous Medicaid coverage during the pandemic. However, with the passage of the Consolidated Appropriations Act of 2023, continuous coverage for MA and CHIP ended on April 1,2023, and DHS returned to normal eligibility processes. Recipients must complete an annual renewal application to avoid a loss of coverage. Title V will monitor changes in state and federal policies that could impact coverage and attempt to meet the needs of the insured and uninsured as necessary.

In addition to the aforementioned issues, the DOH recognizes racism is a public health crisis. As the Society for Public Health Education detailed in a presentation on Multiracial Health Equity, racism is theorized to be a fundamental cause of health disparities. However, research and advocacy primarily center on the experience of monoracial (single race) populations of color. The multiracial population is the fastest-growing racial-ethnic group in the US, increasing 36% in size from 2010-2020. In Pa., the multiracial population has changed considerably since 2010, growing from 237,835 people in 2010 to 902,765 people in 2021, a 280% increase. Although research has been inconsistent in its use of multiracial categories when comparing against monoracial populations, data suggests that disparities do exist between monoracial and multiracial populations. The DOH is evaluating policies and practices to identify and combat systemic racism. The DOH Antiracism and Health Equity Task Force (Task Force), established in 2021, was tasked by the Secretary’s office to develop action steps and initiatives to further this work. Title V-funded staff sit on the Antiracism and Health Equity Task Force and l look for opportunities to align the work of the Title V State Action Plan with Task Force initiatives. Additionally, Pa.’s Title V program participated in the Healthy Beginnings with Title V: Advancing Anti-Racism in Preterm Birth Prevention learning and practice cohort and intends to apply lessons learned to other Title V priority areas and share experiences with the Task Force.

Pa is a state of contrasts presenting unique challenges to the delivery of services and resources across the MCH system of care. An aging but diverse population will gradually force a system adjustment to meet geographic, programmatic, and cultural needs. Swaths of poverty are inseparable from gender, education, race, and ethnicity, with women-led families bearing an unequal burden. Systems of care are equipped to meet urban needs but not rural needs. This, however, is not as dire as it seems. There is strength in the access to care provided by Medicaid and CHIP, the local work of the CMHDs, and DOH development of strategic plans, initiatives, and programs to meet current and emerging challenges. The Pa. Title V program will have to be nimble and adaptable to meet the changing landscape of MCH service needs in Pa.