Demographics and Urbanization

According to the 2022 U.S. Census Bureau population estimates, Oklahoma is the 28th-most populated state in the nation, with approximately 4.0 million individuals and largely rural. Oklahoma has 77 counties and 3 main cities. Nearly 66% of the Oklahoma population resides in the metropolitan statistical areas (MSAs) of Oklahoma City (1,465,917; 36%) and Tulsa (1,032,331, 26%), while a much smaller proportion of the state’s citizens live in the Lawton MSA (126,215; 3%). The remainder of the Oklahoma population resides in rural cities and towns.

 

In 2020, Oklahoma’s population density was 57.7 persons per square mile which makes it the 37th densely populated state in the U.S.A. For administrative purposes, the state is divided into ten public health districts with an administrator located in each region. Figure 1 outlines the 10 public health districts; Oklahoma and Tulsa Counties are independent public health entities.

 

Figure 1. Public Health Districts and Directors – Oklahoma 2022

 

Oklahoma had the 8th lowest life expectancy at 74.1 years overall in 2020, with 76.9 years for females and 71.5 years for males. According to the 2021 Census Bureau population estimates, nearly a quarter (24.1%, 961,530) of the Oklahoma population was less than 18 years of age. Individuals aged 65 years and older made up 16.2% of the population, and roughly 60% of the population was between 18 and 64 years of age. The male-female ratio was about 1:1, with slightly more females (2.0 million) than males (1.98 million). Females of childbearing age (15-44 years) numbered 786,891, or about 20% of the total population. The number of females aged 15-19 years was 132,133, about 17% of childbearing age females. The number of women aged 30-34 increased by nearly 13% between 2010 and 2021, rising from 118,800 to 134,393.

 

Table 1. Distribution of Oklahoma Population

By Race and Ethnicity - 2010 and 2021

Note: Non-Hispanic NH. Individual race categories include

non-Hispanic population

 

Based on the 2021 population estimates from the U.S Census Bureau, 72.3% of the Oklahoma population were non-Hispanic (NH) white, 8.4% were classified as NH black, 9.7% as NH American Indian, 2.7% as NH Asian and 0.2% as NH native Hawaiian or other Pacific Islander. Nearly 6.7% of Oklahomans reported more than one race, this is an increase from 5.9% in 2020. The percent of Hispanics was 11.7% in 2021 compared to 8.9% in 2010. Non-Hispanic white population saw a decline from 75.3% to 72.3% between 2010 and 2021 (Table 1).

 

Oklahoma’s Native American Population

Oklahoma is home to 38 federally recognized tribes including members from the Five Civilized Tribes; the Cherokee, Choctaw, Chickasaw, Creek, and Seminole. The Oklahoma City Area Indian Health Service consists of 12 Service Units as shown in Figure 2 below.  A Service Unit is an administrative entity with the Indian Health Service. Each Service Unit in Oklahoma is comprised of multiple counties. The service units consist of federally operated hospitals, clinics and smaller health centers. The tribes operate five birthing hospitals in the state including Cherokee Nation WW Hastings Hospital, Chickasaw Nation Medical Center, Choctaw Nation Health Care Center, Claremore Indian Hospital, and Comanche County Memorial Hospital.

 

Figure 2. Indian Health System Service Units

 

At 71.8 years, American Indians and Alaskan Native individuals have the lowest life expectancy overall in the U.S compared with other races and ethnicities. This includes higher rates of death from chronic conditions, including diabetes, chronic liver disease, cirrhosis, mellitus, and suicide.

 

Education

Nearly 89% of Oklahomans 25 years or older had a high school diploma per the 2017-2021 ACS, this is similar to the U.S rate, but the percent of those 25 years or older with a Bachelor’s degree was lower than the U.S rate (26.8% vs 33.7%). According to the 2021 Kids Count report, Oklahoma was 45th nationally in education, with about 57% of young children ages 3 and 4 not attending school. The state’s $10,553 expenditure per student ranks 45th in the U.S and last in the region for 2020-2021 (National Education Association’s Rankings of the States 2021 and Estimates of School Statistics 2022).

 

Geography

Positioned in the South-Central region of the United States, Oklahoma has a diverse geography, with a quarter of its land mass covered by forests. The state is home to four mountain regions – the Arbuckle Mountains, in south-central Oklahoma; the Ouachita Mountains, in the southeast; the Ozark Plateau, in the northeast; and the Wichita Mountains, in the southwest part of the state. Oklahoma is one of only four states with more than 10 distinct ecological regions. To the west, the state has semi-arid plains, while in the state’s center, transitional prairies and woodlands give way to the elevated terrain of the Ozark and Ouachita Mountains, which stretch out to Oklahoma’s eastern border. Oklahoma is landlocked in the center of the 48 contiguous states, bordered by Arkansas, Colorado, Kansas, Missouri, New Mexico, and Texas.

 

Health Insurance

Oklahoma voters approved the Medicaid expansion initiative in June 2020 and the expansion took effect July 1, 2021, raising the annual income threshold to 138% of the federal poverty level. Additionally, extended pregnancy and postpartum coverage became effective January 1, 2023. This revision extends postpartum coverage up to 12 months post-delivery, and increases coverage to 205%FPL for this population. This may help lower the risk of pregnancy-related maternal deaths and complications. It may also help with ongoing care for chronic conditions such as diabetes, high blood pressure, heart disease, substance use disorder and depression.

 

The rate of Oklahoma children without health insurance decreased significantly – from 8.6 percent to 7.4 percent between 2019 and 2021, according to a report published from the Georgetown Center for Children and Families. As of December 2022, SoonerCare, Oklahoma’s Medicaid program covered 651,921 children and 354,394 adults were covered under the Medicaid expansion.

 

Economy

In 2022, Oklahoma’s real gross domestic product (GDP) was $197.0 billion, with a growth rate of 0.3% for five years 2017-2022. The state ranked 30th in overall GDP by 3rd quarter of 2022 and 42nd in the nation for the five-year GDP growth rate. The Mining, Real Estate and Rental and Leasing and Manufacturing sectors contributed the most to Oklahoma's GDP in 2022, representing a combined 41.8% of state GDP.

 

Gaming (lotteries and casinos) continue to be a major contributor to the state’s economy. The State of Oklahoma collected over $191.5 million in tribal gaming exclusivity fees in fiscal year 2022 under state-tribal gaming compacts. This is an 18% increase over the previous year. Those fees were based on $3.18 billion in tribal gaming revenue. Exclusivity fees were distributed to the Education Reform Revolving Fund ($168.3 million), the General Revenue Fund ($23 million), and the Department of Mental Health and Substance Abuse Services ($250,000). This distribution of fees is determined by Oklahoma statute.

 

Oklahoma has an average household size of 2.56 persons per household with a medium household income of $56,956, this is lower than the U.S median household income of $69,021 (ACS 2017-2021). Data from the U.S. Bureau of Economic Analysis indicate that Oklahoma’s per capita personal income was $53,870 in 2021, ranking 42nd among all states, and representing about 84% of the national average of $63,444.  Data from the Census Bureau show that 15.4% (599,003 people) of all Oklahoma residents and 20.5% of all children under 18 years were living in poverty in 2021. Poverty rates vary widely between races and Hispanic origin as shown in Table 2. Black residents have the highest poverty rates in the state (27.1%) followed by Hispanic residents (20.7%).

 

Table 2. Poverty rates by race and Hispanic origin-2021

Location	White	Black	Hispanic	Asian/Native Hawaiian and Pacific Islander	American Indian/Alaska Native	Multiple Races	Total
U. S	9.5%	21.7%	17.6%	10.2%	25.9%	14.1%	12.8%
Oklahoma	12.8%	27.1%	20.7%	16.1%	18.5%	17.0%	15.4%

 

Employment

Oklahoma’s unemployment rate at the end of 2022 was 3.2%, slightly lower than the U.S rate (3.5%) and ranking 22nd in the nation. The rate has returned to pre-pandemic levels, however during the pandemic (mid-2020) the unemployment rate was as high as 12.5%. The state’s top five employers continue to be the Department of Defense (U.S.), Wal-Mart Associates Inc, Amazon, Integris Health, and Hobby Lobby Store Inc.

 

Impact of the COVID pandemic

Oklahoma currently is beginning its transition toward the endemic phase of the COVID-19 pandemic. Since 2020, the pandemic impacted almost all dimensions including health, economic, social and fiscal sectors of the state, the most significant impact being in the health and healthcare sector. However, since then the state has seen some remarkable recovery in unemployment rate, manufacturing and construction have started to rebound with retail shifting to more online sales.

 

Oklahoma identified its first case of COVID-19 on March 6, 2020, and the first confirmed COVID-19 death on March 18, 2020. From the onset of the pandemic through mid-March 2023, more than 1,290,929 known cases and 17,827 provisional COVID-19 deaths have been recorded in the state. Since the initiation of the vaccine rollout in the state, approximately 2.4 million or 60% of the individuals have been fully vaccinated with more than 6.7 million doses administered. The Oklahoma Pandemic Center for Innovation and Excellence was founded in October 2020 by the Stitt administration as an initiative to protect Oklahoma residents from future pandemics.

 

Unique strengths and challenges that impact the health status of Oklahoma’s MCH population

 

Partnerships and Collaborations

Oklahoma’s MCH Service has developed close partnerships, both internal and external, to the Oklahoma State Department of Health (OSDH), including other state agencies and community organizations. Since 2009, with the inception of the Preparing for a Lifetime, It’s Everyone’s Responsibility, the statewide infant mortality reduction initiative, MCH has collaborated with OSDH service areas to staff the initiative, perform analyses, formulate and implement strategies, and develop MCH-related programming. Internal partners include the Chronic Disease Service; Injury Prevention Service; Family Support and Prevention Services; Screening and Special Services; Nursing Service; WIC Service; SoonerStart/Early Intervention; Tribal Liaisons, Center for Health Statistics; Immunization Service; and the county health departments (CHD). These service areas and CHDs have participated in other past and current state and national efforts as well, including the Maternal Health Innovation Program, CoIIN to Reduce Infant Mortality, the Oklahoma Perinatal Quality Improvement Collaborative, the Period of Purple Crying Program, the MCH Safe Sleep Project, and the Oklahoma Maternal Health Task Force, as well as other activities not mentioned here.

 

Joining the internal partners mentioned above were entities external to OSDH, who contribute in large and meaningful ways. Sister agencies like the Oklahoma State Department of Education (OSDE), Oklahoma Health Care Authority (OHCA), the state’s Medicaid agency, the Oklahoma Department of Human Services (DHS), the Oklahoma Commission on Children and Youth (OCCY), and the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) are frequent and routine collaborators on the many efforts to improve and promote health in the maternal, infant, and child populations. Other colleagues in MCH-related work include those from the Oklahoma Hospital Association, the Office of Perinatal Quality Improvement (OPQI), Tulsa Health Department, the Oklahoma City-County Health Department, the Oklahoma Family Network, and the Southern Plains Tribal Health Board (SPTHB). These relationships continued to be drawn on, as well as new ones created, to inform the 2021-2025 Title V MCH Five-Year Needs Assessment. The many partnerships and collaborations developed and maintained by Oklahoma Title V programs were essential for achieving MCH goals, particularly during the pandemic.

 

Oklahoma’s MCH population

 

Figure 3. Oklahoma at-a-glance

 

Births

As shown in Figure 3 above, in 2021 there were 48,412 resident live births, among which 54.7% were to non-Hispanic (NH) white mothers, 7.9% to NH Black mothers, 9.5% to NH American Indian mothers, 2.9% to NH Asian mothers, and 17.0% to Hispanic mothers. The state has seen an 8% decline in births since 2016, with fertility rates declining from 68.3 per 1,000 females aged 15-44 years in 2016 to 61.4 per 1,000 females aged 15-44 years in 2021.

 

Oklahoma has experienced a number of successes related to health outcomes and behaviors. Teen birth rate has reached an all-time low of 8.8 per 1000 for females aged 15-17 years, this is a 66% decline in rates from 25.9 per 1,000 females aged 15-17 years in 2010. According to data from the March of Dimes, approximately 53.2% of Oklahoma counties are maternity care deserts, however a number of targeted efforts to improve access to care in rural areas have resulted in the rate of women accessing prenatal care in the first trimester, increasing from 65.0% in 2010 to 72.9.% in 2021.

 

Oklahoma’s infant mortality rate (IMR) has decreased from 8.6 per 1,000 live births in 2007 to 6.9 in 2021, a relative decrease of 20% over the study period. Still, IMR varies sharply among race/ethnic groups in Oklahoma with African American infants dying at more than twice the rate of white infants. Moreover, the trend among those reporting other and multiple races and Hispanics show rising rates of infant mortality for the last two reporting periods. Maternal mortality rate has declined from 28.8 per 100,000 live births for the period 2016-2018 to 25.2 per 100,000 live births in 2018-2020, although disparities persist, with rates higher among NH black mothers.

 

Role of the state health agency and the delivery of Title V services

With Governor Kevin Stitt assuming office in January 2019, state health and human services were re-organized under the Cabinet Secretary of Health and Mental Health and the Cabinet Secretary of Human Services. Respectively, these positions are held by Kevin Corbett and Justin Brown. Health and Human Services agencies in Oklahoma include the OSDH, DHS, ODMHSAS, Department of Rehabilitation Services, Office of Juvenile Affairs, OHCA, OCCY, Office of Disability Concerns, and the J.D. McCarty Center.

 

The Oklahoma State Department of Health, created under Oklahoma Statute Title 63 § 1-105, is responsible for protecting and improving the public’s health status through strategies that focus on preventing disease. OSDH programs and services are configured under three Deputy Commissioner areas: Community Health Services, Quality Assurance and Regulatory Services, and Health Preparedness. Community Health Services (CHS) is comprised of the county health departments, Family Health Services, Personal Health Services, Nursing Services, and Records and Community Health Systems. Family Health is home to the MCH Service, along with Screening and Special Services, Family Support and Prevention Service, Dental Health Service, WIC Service, and SoonerStart. Services comprising Personal Health include Community Development, Chronic Disease Service, Injury Prevention Service, and Immunization Service.

 

Oklahoma administers the MCH Title V Block Grant through two state agencies, the OSDH and the DHS. OSDH, as the state health agency, is authorized to receive and disburse the MCH Title V Block Grant funds as provided in Title 63 of the Oklahoma Statutes, Public Health Code, Sections 1-105 through 1-108. These sections created the OSDH, originally charged the Commissioner of Health to serve under the Board of Health, and outlined the Commissioner of Health's duties as "general supervision of the health of citizens of the state." In 2018, legislation was enacted making the Board of Health an advisory body to the Commissioner of Health, who is now appointed by the state’s governor. Title 10 of the Oklahoma Statutes, Section 175.1 et. seq., grants the authority to administer the CSHCN Program to the DHS.

 

The MCH Title V Program is located in the OSDH within Family Health Services (FHS). Joyce Marshall, Director of the MCH Service, is directly responsible to the Assistant Deputy Commissioner of the FHS, Tina Johnson, who is directly responsible to the Deputy Commissioner of Community Health Services, Mendy Spohn. Ms. Spohn reports directly to the Commissioner of Health, Keith Reed, who was appointed by Governor Stitt upon the resignation of Lance Frye, MD, in October 2021. Gitanjali Pai, MD, is the Chief Medical Officer for the OSDH.

 

Programs administered in some part with Title V funds include: Preparing for a Lifetime, It’s Everyone’s Responsibility infant mortality reduction initiative; Maternal Mortality Review; Pregnancy Risk Assessment Monitoring System (PRAMS), The Oklahoma Toddler Survey (TOTS), and the Youth Risk Behavior Survey (YRBS) surveillance programs; adolescent pregnancy projects throughout the state; State Systems Development Initiative (SSDI); Fetal and Infant Mortality Review; School Health; Oklahoma Birth Defects Registry; Becoming Baby Friendly Oklahoma; and, other-related programs and initiatives.

 

The Title V CSHCN Program is located in the DHS within the Health Related and Medical Services (HR&MS) unit. HR&MS is organizationally placed under the Adult and Family Services Division. Aubrey McDonald, the CSHCN Director, is directly responsible to the Deputy Director of Programs Carla McCarrell-Williams, AFS Assistant Director for Program Operations Shawn Franks, and AFS Director Deborah Smith. Title V CSHCN provides funding for respite through periodic vouchers to caregivers and through short-term inpatient stays and camps at the J.D. McCarty Center, adaptive equipment, and supplemental formula not covered by Title XIX. Likewise, funding and supports are provided to several groups at the University of Oklahoma Health Sciences Center (OUHSC) and OU Children’s Medical Center to enhance services for CSHCN families. These groups include Oklahoma Family Network (family-to-family support), Family Support 360 Center (family health system navigation), Family Partners JumpStart Clinic (developmental and behavioral screening services), Sooner SUCCESS (comprehensive system of health and educational services), the Comprehensive Sickle Cell Pediatric Clinic (healthcare transition services) and the Oklahoma Infant Transition Program (family support for newborns in the NICU). Parent Promise Community Hope Center and Center for Children and Families, Inc. (CCFI) Community Hope Center recently began receiving funding to lift up families of CSHCN through social service network navigation and assistance with securing concrete supports. The Community Hope Centers (CHC’s) infuse the Science of HOPE and promote self-sufficiency and resilience. Title V CSHCN also collaborates with Child Welfare evaluation assessments not covered by Medicaid.

 

Components of the Oklahoma’s systems of care for meeting the needs of underserved and vulnerable populations

 

Population served;

Overall, in FFY 2022, 21,936 Oklahoma children with special health care needs received a direct or enabling service from a Title V partner. Per the National Survey of Children’s Health, there were an estimated 211,828 children in Oklahoma with a special health care need in 2020-2021.

 

Note: The number of children served is a conservative estimate intended to reduce the risk of duplication. Additionally, Title V representatives continue to encourage collaboration across partners and to reach out to families in under-served populations by speaking at family support group meetings and attending local health conferences that address children with special health care needs.

 

Health services infrastructure

The state has three Children's Hospitals – the Children’s Hospital at Saint Francis in Tulsa, the Children’s Hospital at OU Medical Center in Oklahoma City, and the INTEGRIS Children’s Hospital at Baptist Medical Center, also in Oklahoma City. The Children’s Hospital at Saint Francis is a 162-bed facility that provides comprehensive medical care through inpatient and outpatient services and a network of more than 100 pediatricians and 65 pediatric subspecialists covering eastern Oklahoma. The Children’s Hospital at OU Medical Center has 314 inpatient beds and is the only freestanding pediatric hospital in Oklahoma solely dedicated to the treatment of children. During the height of COVID, the hospital transitioned PICU beds to adult beds to accommodate needs. Its NICU contains 96 beds (level V NICU) providing the highest level of neonatal care in the state. INTEGRIS Children’s includes a 40-bed level III NICU, a 26-bed pediatrics unit, and a 10-bed pediatric intensive care unit.

 

According to the Oklahoma Board of Medical Licensure and Supervision, there were 690 active pediatricians in the state in July 2022.

 

OHCA administers two health programs for the state. The first is SoonerCare, Oklahoma's Medicaid program. SoonerCare works to improve the health of qualified Oklahomans by ensuring that medically necessary benefits and services are available. Qualifying Oklahomans include certain low-income children, seniors, the disabled, those being treated for breast or cervical cancer and those seeking family planning services. The second program OHCA operates is Insure Oklahoma, which assists qualifying adults and small business employees in obtaining health care coverage. Under certain circumstances, Insure Oklahoma extends coverage to dependents within the household, which may include children with special health care needs.

 

Service Integration

Oklahoma has 77 counties with 68 county health departments where families of children and youth with special health care needs can access reproductive health care, vaccines, and, in some cases, mental health services. Each county health department district also has a mobile unit to enhance community health outside the traditional brick and mortar setting. Some mobile units provide adult health services, family planning, child health and immunizations, depending on community need. This allows families affordable access to care, some services at no charge while others have sliding scale fees.

 

Oklahoma Systems of Care is a state-wide collaborative network involving members of local communities, organizations, agencies, facilities, centers and groups that serve the needs of children, youth, and young adults. Currently Systems of Care is active in 74 of the 77 counties. Additionally, 75 counties in Oklahoma have the traditional Systems of Care Wrap Around for youth experiencing serious emotional disturbance. Two counties have a modified version of the Wrap Around services. Wrap Around provides a Family Support Provider offering mentoring and systems navigation as well as a Care Coordinator supporting access to necessary medical, mental health, school and social services.

 

Oklahoma also has 18 Community Mental Health Centers, where free and sliding scale mental health services can be accessed, as well as, 225 Federally Qualified Health Center sites which provide medical care and, in many cases, dental, vision and mental health care.

 

Children and youth with special health care needs may also receive services while they are in school. There are 398 nurses across the state in schools providing a limited scope of services. Many school districts contract with mental health providers to provide services during and after the school day. All of these services add to the services available in the child's community.

 

Financing of services

Medicaid (SoonerCare) is managed by OHCA, Oklahoma's Medicaid agency. CHIP funding is blended with other Medicaid dollars to ensure better access for more children. Some examples include funding long-acting reversible contraceptives for adolescents and providing cribs to Medicaid-eligible families. In February 2023, Oklahoma had 1,026 children 18 years and under accessing SoonerCare via TEFRA. Additionally, 15,130 children received SoonerCare based on their Aged/Blind/Disability (ABD) status. Both groups, TEFRA and ABD, have high medical needs and/or significant disabilities and are better able to access needed medical/mental health services because of their access to SoonerCare. The OHCA also manages Insure Oklahoma, which is a premium assistance program for families of low-income status. In addition, several community, state and national programs provide access to grants and other funds to assist youth in receiving needed durable medical equipment, respite, co-pay assistance, etc. These vital funds fill gaps where families cannot afford to meet their child's needs.

 

On June 20, 2020, Oklahoma voters passed State Question 802 by a slim majority vote to expand Medicaid eligibility to adults aged 19-64 with income less than or equal to 138% of the federal poverty level. Eligible enrollees began signing up for the program on June 1, 2021. Although the original plan by the Governor was to implement managed care administered by private companies for those eligible for SoonerCare expansion in June 2021, the Oklahoma Supreme Court invalidated the plan because justices said it did not receive required legislative approval. More than 330,000 individuals have benefited from expanded eligibility in the last year.

 

Due to the COVID-19 pandemic, routine SoonerCare eligibility renewals were paused as part of the Public Health Emergency (PHE). OHCA alerted affected members in February 2023. Those members determined to be eligible will continue to receive SoonerCare benefits. Those members determined to be ineligible for benefits will be removed from SoonerCare in phases throughout the year using a compassionate risk-based approach, focusing on member utilization and critical health issues.

 

2023 State Legislation impacting MCH

MCH serves as a resource and provides education to state legislators and their staff prior to and during the legislative session each year to assist in the setting of state policy and procedure. Analyses of bills are accomplished each year during session to identify issues that may present obstacles to improving the health of Oklahoma's maternal and child health population. These written analyses are shared with legislators and their legislative staff by the Commissioner of Health and the OSDH Legislative Liaison. MCH also participates in state boards, task forces, work groups, and committees during and between sessions per request of members of the state legislature or as appointed by the governor. MCH is able to provide to the legislative process the latest in national health care policy and practice; information on national, regional, and state health care issues and practices; and the most recent available national, regional, and state data for the maternal and child health population.

 

The following is a list of some of the legislative bills that were monitored by OSDH and MCH during the 2nd regular session of the 58th legislature (2023). SB indicates a Senate bill, HB, a House bill.

 

HB 2799: Extends the existing Child Death Review Board until 2029. Signed by the Governor April 21, 2023.

 

SB147: Diabetes Management in Schools Act; allows a school district to stock glucagon without a medical order from a physician. Signed by the Governor May 11, 2023.

 

SB710: Allows a school nurse, or other authorized school personnel, to administer emergency opioid antagonist in an emergency regardless of whether there is a prescription or standing order in place. Signed by the Governor May 5, 2023.

 

SB458: Providing for independent prescriptive authority of Advanced Practice Registered Nurses who meet certain requirements. Did not pass.