The Wisconsin Title V Program is administered by the Family Health Section, in the Bureau of Community Health Promotion. This Bureau resides within the Division of Public Health, which is part of the Wisconsin Department of Health Services. The Wisconsin Department of Health Services has a simple but powerful vision: Everyone Living Their Best Life. This is accomplished through the Title V Program’s mission to protect and promote the health and safety of all the people of Wisconsin. Building sustainable systems that enable equitable access to health services, and improving health outcomes for mothers, children, and families are fundamental building blocks in this mission, and critical elements in accomplishing this vision.

 

The goal of the Title V Program is to ensure that all families in Wisconsin have access to a coordinated, integrated, and sustainable system of services and supports focused on health promotion and prevention. The Title V Program works with local and tribal health agencies, community-based organizations, statewide organizations, and other partners to provide and/or ensure quality health services are delivered to mothers, children, and families in Wisconsin. Title V funds are directed towards building systems that better coordinate and integrate services across programs and providers, while investing in community-based prevention, health promotion, developmental support services, and the delivery of consistent information to families.

 

Principal Characteristics of the State

 

The US Census Bureau estimates Wisconsin’s 2021 population to be 5,895,908, an increase of 3.7% since the 2010 Census. Wisconsin’s population is spread across 72 counties and is served by 87 locally controlled local health departments and 11 tribal health agencies. Although Wisconsin is perceived as a predominantly rural state, it is becoming increasingly urbanized, with fewer than 30% of the population living in rural counties.

 

Females constitute an estimated 50.2% of the population, and females of reproductive age (15-44 years) make up approximately 18.7% of the population. Approximately 21.7% of Wisconsinites are under 18 years old, and around 17.5% are 65 years or older. The median age is 39.9 years, slightly higher than the national average (38.5). Nearly 98% of the population self-identifies as one race, and 2.0% self-identify as two or more races. Of the total estimated population, 87% identified as White only, 6.7% identified as Black only, and 3% identified as Asian only. Of the total estimated population, 7.1% were of Hispanic ethnicity. From 2015-2019, 64.8% of non-Hispanic Blacks and 36.2% of Hispanics in Wisconsin lived in Milwaukee County.

 

Wisconsin is home to 11 federally recognized tribes and approximately 92,282 individuals who identify as American Indian/Alaska Native either alone or in combination with other races. According to the Young Center for Anabaptist and Pietist Studies at Elizabethtown College in Pennsylvania, Wisconsin has the fourth largest Amish/Mennonite population in the country, estimated at 23,195 individuals.

 

Wisconsin is above the national average for high school graduation, though slightly below the national average for higher education. In Wisconsin, 92.8% of the population ages 25 years and older have a high school education or higher (compared with 88.6% in the US), and 31.3% of this age group has received a bachelor’s degree or higher (compared with 33.1% nationally).

 

Wisconsin’s unemployment rate in March of 2020 was 3.8%, lower than the national average of 6%, and a 30-year Wisconsin high of 9.2% in January 2010. Wisconsin currently has 6 counties with unemployment rates above 5%: Menominee, Iron, Bayfield, Burnett, Adams, and Forest, all of which are in the northern, more rural half of the state. The cities of Racine (7.7%), Milwaukee (7.4%), and Beloit (6.2%) topped the list of city unemployment rates (not seasonally adjusted); these rates represent an increase over 2019, when the rates in those cities were 5.2%, 4.5%, and 4.2%, respectively. Unemployment in 2021 and 2022 is expected to decrease as businesses recover from the COVID-19 pandemic.

 

In 2021, the American Community Survey estimated the median household income in Wisconsin to be $63,293. Approximately 10% of the population had income in the past 12 months below the Federal Poverty Level.

 

Birth data for 2021 indicate that out of 60,615 live births to women residing in Wisconsin, 35.7% were covered by Medicaid, and 25.2% benefited from WIC during pregnancy.

 

Unique Assets and Challenges

 

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

 

Moreover, social and political polarization between urban and rural areas, as documented in K. Cramer’s book, “The Politics of Resentment,” influences policymaking at the state level, including state funding for public health infrastructure, which was $55 per resident as of 2018, one of the lowest in the country. However, Wisconsin benefits from active community leaders and organizations representing people living with disabilities, families with children with special healthcare needs, Tribal nations, and communities of color. These leaders provide consultation to the state Department of Health Services and create innovative programs in their own communities to promote health.

 

Health Status of the Population

 

The United Health Foundation State Health Rankings (2021) place Wisconsin 31st overall for health outcomes. The measures on which Wisconsin is faring the worst (ranked 50th) relative to other states are excessive drinking among adults and the low birthweight racial gap. Structural challenges in Wisconsin highlighted in the rankings include low public health funding per capita (ranked 49th), high school graduation racial disparity (46th), and drinking water violations (46th), homeownership racial disparity (42nd). Positive trends include a decrease in violent crime, an increase in the proportion of infants who are breastfed exclusively for six months, and a 14% increase in adults who report their health as very good or excellent from 2019 to 2020.

 

The Annie E. Casey Foundation Kids Count Data Center (2021) ranks Wisconsin 10th out of all states for overall child well-being, a composite rank based on ranks for economic well-being, education, health, family, and community factors. According to Kids Count data, 4% of minors in Wisconsin did not have health insurance in 2021. Wisconsin’s birth outcomes are similar to those in the US overall. However, there are stark differences by race. Kids Count data for 2019 show that 15.2% of babies born to Black women had a low birthweight compared to 7.6% overall. The 2019-2020 National Survey of Children’s Health estimated that about 90% of Wisconsin children reported excellent or very good health, but only 76.9% of Black children in Wisconsin enjoyed excellent or very good health. Approximately 254,000 kids or 20.1% of Wisconsin children under age 18 had a special health care need, including 18.7% of White kids and 14.6% of Hispanic kids. An estimated 13% of children have at least one parent who born outside the US.

 

There were 62,704 deaths of Wisconsin residents in 2020, occurring at a rate of 1,074.5 deaths per 100,000 people. According to vital records, the leading causes of death for all ages were heart disease (20.1%) and cancer (18.6%). Among children and youth between 1 and 17 years of age, accidents (unintentional injuries) were the leading cause of death, followed by assault (homicide).

 

Infant mortality is a high priority issue in Wisconsin. The Centers for Disease Control and Prevention (CDC) reported that Wisconsin had an overall infant mortality rate similar to the US average in 2020 (5.75 compared to 5.8 deaths per 1,000 live births). Another CDC report showed that in Wisconsin between 2013 and 2015, the non-Hispanic White infant mortality rate was 4.76 deaths per 1,000 live births compared to a non-Hispanic Black infant mortality rate of 14.28 deaths per 1,000 live births, corresponding to a Black/White infant mortality ratio of 3.0—one of the largest disparities out of all reporting states and District of Columbia.

 

The 2020 MCH Needs Assessment for the Wisconsin Title V Block Grant program utilized multiple data sources including CDC Wonder, Vital Statistics, Wisconsin’s Interactive Statistics on Health, Hospital Discharge data, Pregnancy Risk Assessment Monitoring System (PRAMS), American Community Survey, Wisconsin Sexually Transmitted Diseases program, Behavioral Risk Factor Surveillance System survey, Youth Risk Behavior Surveillance System survey, National Survey of Children’s Health and National Immunization Survey for Children to identify the following priority needs:

 

• Advance equity and racial justice

 

• Assure access to quality health services

 

• Cultivate supportive social connections and community environments

 

• Enhance identification, access, and support for individuals with special health care needs and their families

 

• Improve perinatal outcomes

 

• Foster positive mental health and associated factors

 

• Promote optimal nutrition and physical activity

 

State Agency Role in Current Priorities and Initiatives

 

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

 

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

 

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

 

The 2020 American Community Survey provides information on health insurance coverage in Wisconsin. The American Community Survey estimates that 94.5% of the population (non-institutionalized civilians) had some form of health insurance coverage. Of Wisconsin children under age 6, 3.8% had no health insurance coverage and 3.9% of children ages 6 to 18 were uninsured. Of employed persons in Wisconsin, 6.7% were uninsured; 18.4% of the foreign-born population in Wisconsin was uninsured compared to 4.7% of the native-born population being uninsured. Wisconsin also has provider shortages in many parts of the state for primary care, mental health services, and dental services.

 

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

 

Wisconsin Medicaid and BadgerCare

 

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

 

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

 

As of February 2022, there were a total of 1,084,536 Wisconsinites enrolled in BadgerCare Plus statewide, about a 13% increase over the previous year. Of these, 153,805 were parents/caretakers, 30,075 were pregnant women, and 410,446 were children. Of the 12 states that have not yet expanded Medicaid, Wisconsin is the only one that offers coverage to all adults under the Federal Poverty Level.

 

Wisconsin Medicaid also supports Family Planning Only Services through a State Plan Amendment that covers family planning services accessed by low-income, reproductive-aged people of all genders living in Wisconsin. The average monthly enrollment for Family Planning Only Services was around 43,000 in 2021. This is an increase by 6,000 average enrollees compared to the average monthly enrollment of 37,000 in 2020. The 2021-2023 State budget increased Family Planning Only Services funding to $40,600,000 for the biennium to accommodate the continued need for Family Planning Only Services access among Wisconsin residents. The Family Planning Only Services Medicaid Waiver in Wisconsin provides a much-needed safety net for low-income Wisconsin residents who are not eligible for Medicaid based on income but are still low-income to cover high-quality family planning and reproductive health services.

 

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

 

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

 

Home Visiting Services

 

Since 2011, the statewide Wisconsin Family Foundations Home Visiting Program has supported pregnant women and families and helps parents of children from birth to age 5 to engage with resources and develop the skills to raise children who are physically, socially, and emotionally healthy and ready to learn. The Maternal, Infant, and Early Childhood Home Visiting grant offered through the federal Maternal Child Health Bureau provides most of the Family Foundations Home Visiting Program’s funding. A portion of funding for the Family Foundations Home Visiting Program comes from the Temporary Assistance for Needy Families grant and General-Purpose Revenue from the State of Wisconsin. Additional funding in the 2019-2021 state biennial budget allowed Home Visiting to add two new programs in 2020, serving seven additional counties. The Family Foundations Home Visiting Program is a voluntary, home-based program led by the Wisconsin Department of Children and Families and collaborates closely with the Wisconsin Department of Health Services. The Family Foundations Home Visiting Program is building a strong partner base to enhance supports for medical care, mental health care, early childhood systems, safety, and parenting to foster optimal programming and avoid costly service duplication. The Wisconsin Title V team includes a home visiting nurse consultant who bridges the home visiting programs and the Title V Program to identify opportunities for alignment and collaboration.

 

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

 

• Improved maternal and child health

 

• Prevention of child injuries, child abuse, neglect, and maltreatment

 

• Increased school readiness and achievement

 

• Reduced domestic violence

 

• Improved family economic self-sufficiency

 

• Greater coordination and referrals for other community resources and support

 

Many planned collaborations between the Family Foundations Home Visiting Program and Title V Program were impacted by the COVID-19 pandemic in 2020, and data collection reflects this. The Family Foundations Home Visiting Program reports data to HRSA annually during the federal fiscal year (October 2020 through September 2021). Home visiting programs began providing services virtually in March 2020, with home visitors adapting to complete screenings and assessments in a virtual environment. The shift to virtual services required technological adaptations for both home visitors and the families they served. Limitations in internet and Wi-Fi capabilities continues to cause gaps in service for some home visiting programs. Due to the sensitive nature of some of the screening tools (i.e. intimate partner violence), there are limitations regarding the ability of a home visitor to accurately assess. In-person visits have since resumed which and will hopefully alleviate some of these virtual barriers.

 

Regional Centers for Children and Youth with Special Health Care Needs

 

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

 

Women, Infants, and Children (WIC)

 

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

 

State Statutes Relevant to Title V Program Authority

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

In 2017, the original Wisconsin Birth Defects Registry legislation and rules were updated. Wis. Stat. § 253.12 originally required parental permission to submit identifiers, such as name and address of child and parents to the Wisconsin Birth Defects Registry. Effective July 1, 2018, all submissions to Wisconsin Birth Defects Registry should include identifying information. However, parents will have the option to opt out of submitting personally identifying information. The revised legislation also simplifies the process of amending the list of Wisconsin Birth Defects Registry reportable conditions (the current list of conditions is available on the last page of the paper reporting form DPH F-40054).

 

Legislation: There were 69 bills passed into law during the 2019-2020 legislative session, some of which are directly relevant to the Title V Program:

 

• Act 1: Intellectual Disability Language - Deleted any phrase similar to the phrase "mental retardation," or "mentally retarded," from the state's administrative code, replacing these phrases with the term "intellectual disability."

 

• Act 24: Vaccines for Children - Pharmacists will now be allowed to administer vaccines to children under age 6 so long as the prescription order is issued within the last 29 days and the pharmacist has successfully completed an approved training course.

 

• Act 27: Driver's Education - Technical College and Department of Transportation-licensed private driver schools are now required to offer a commercial motor vehicle driver education course and provide instruction in the recognition and prevention of human trafficking.

 

• Act 56: Telehealth Services - The Wisconsin Department of Health Services is now required to treat telehealth services the same as in-person services. This ensures Medicaid can provide reimbursement for remote patient care and monitoring services and ensures Medicaid reimbursement for the same telehealth services that Medicare covers.