This section presents an overview of the state’s geography and demographics, data on the social determinants of health affecting the MCH population, an overview of the infrastructure that supports the delivery of Title V services, and statutes and regulations related to MCH. For additional background data on the MCH population, see the MCH Snapshot.

Geography

Colorado is located in the Rocky Mountain region of the United States. Colorado has the highest mean elevation of any state with more than a thousand mountain peaks over 10,000 feet high including 58 that are over 14,000 feet. The Continental Divide runs from north to south through west central Colorado and bisects the state into the eastern plains and western slopes.

The state is further divided into five regions: the Front Range, the Western Slope, the Eastern Plains, the Central Mountains, and the San Luis Valley. Eighty-eight percent of the state’s population lives along the Front Range, which includes the metropolitan areas of Denver, Boulder, Fort Collins, Greeley, Colorado Springs and Pueblo, and in Grand Junction on the Western Slope.  In total, there are 64 counties in the state with 17 designated as urban, 24 rural, and 23 frontier counties. Frontier counties have a population density of six or fewer persons per square mile. In Colorado’s 47 rural and frontier counties, residents’ health may be impacted by more limited local provider options, lack of specialty health care, the difficulty of travel to health care due to long distances and weather conditions, limited public transit options, a scarcity of resources and services, and fewer economic opportunities.

Population and demographics

Colorado ranks 21st among states in population size. The total state population in 2019 was 5,765,527. Twenty-one percent of the state’s population are females ages 15-44 and 33 percent are children and youth ages 0-25. Of the overall population of children and youth, approximately 350,000 (18%) identified as having special health care needs. The two major racial and ethnic groups in Colorado are White non-Hispanic persons and persons of any race who are of Hispanic origin or ethnicity. Estimates from the American Community Survey (2017) of the U.S. Census Bureau show that 68.6 percent of Coloradans identify their ethnicity as White non-Hispanic and 21.3 percent identify their ethnicity as Hispanic. Categories by race include White (84.2%), Black/African-American (4.1%), Asian and Native Hawaiian/Pacific Islander (3.2%), American Indian and Alaska Native (0.9%), and people who report another race (4.1%) or more than one race (3.5%).

Approximately 17 percent of Colorado residents ages five years and older speak a language other than English at home; 68 percent of those speaking another language in the home speak Spanish. Three percent of households in Colorado are estimated to be linguistically isolated, i.e., all members 14 years and older have at least some difficulty with English.

Although Colorado is a mid-sized state, it has one of the fastest growth rates of all states and migration continues to be an important factor in the state's population growth. Between 2015 and 2020, Colorado's population is expected to grow from 5,444,871 to 5,838,181. While natural increase (births minus deaths) will contribute 136,020 persons, net migration will result in nearly twice as many people, contributing 257,290 to the total increase of 393,310.

Employment

Employment, income, housing, food security, and transportation are all closely linked to health and wellness and should be considered in understanding the overall health status of the MCH population in Colorado. As of January 2019, Colorado’s unemployment rate was 3.7 percent. This was lower than the national unemployment rate for the same time period, 4.0 percent.  Colorado’s unemployment ranking was the 23rd lowest in the nation. The state unemployment rate has been steadily rising since reaching a low of 2.6 percent in June 2017.

Income and poverty

Colorado has an income advantage. The median household income in Colorado is $69,117, higher than the national median of $60,336 which is the 11th highest among all 50 states. However, the median household income fluctuates significantly among Colorado’s counties. Douglas County, located just south of Denver along the Front Range, has the highest median household income at $111,154. Costilla County, located in Colorado’s San Luis Valley, has the lowest at $29,000.

When ranking the states by the percentage of persons living below 100 percent of the federal poverty level, Colorado has the 6th lowest poverty rate in the nation. When focusing on children living in families with incomes below 100 percent, 12 percent of children in Colorado live in poverty. This is lower than the national rate of 18.4 percent. Disparities in poverty exist by race, as 8 percent of White non-Hispanic children live in poverty, compared to 20.8 percent of American Indian or Alaska Native, 18.4 percent of Black, 17.0 percent of Hispanic, and 11.1 percent of Asian children.

Housing

Having safe, stable and affordable housing contributes to optimal health by allowing money to be directed to healthy food, recreation, and health care. Among occupied housing units in Colorado, 34.8 percent are rented. In renter-occupied units, half (51.7%) pay 30 percent or more of the household income to rent. The median rent in Colorado is $1,240. The median home value for owner-occupied units in Colorado is $348,900 (2017) compared to $255,200 in 2014. This is a 37% increase in median home value in three years.

Some communities are not able to find safe and affordable housing, which means they are more likely to live in poor quality homes. Poor housing conditions and environmental toxins can be detrimental to health, especially during early childhood. Severe housing problems are indicative of housing quality. Almost one in five (17%) households in Colorado experiences at least one of four housing problems (overcrowding, high housing costs, lack of kitchen facilities, or lack of plumbing facilities).

Food security

Having access to nutritious food influences healthy eating. People who live in neighborhoods where grocery stores are not being built have limited access to fresh, healthy food such as fruits and vegetables. Among women who recently had a baby, 7.8 percent ate less than they felt they should because of lack of money for food. Among Colorado families with children ages 1-14 years, 22.8 percent often or sometimes relied on only a few kinds of low-cost food because they were running out of money to buy food. Among low-income Coloradans, 5 percent do not live close to a grocery store. The Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are programs that have been demonstrated to positively impact food security and nutrition outcomes. Six in ten Coloradans who are eligible for SNAP are enrolled. This is lower than the national average of 73 percent for SNAP enrollment. Half (53%) of Coloradans eligible for WIC are enrolled.

Transportation

Transportation is necessary to travel to work and school, access healthy food and medical care, and foster community connections. When transportation systems don't provide access to all communities, some groups have a harder time accessing resources. Direct transportation and by-products can also impact health. Most Coloradans commute to work in a single occupancy vehicle (74.9%). Less than one in ten use public transport (3.2%), walk to work (2.7%), or bike to work (1.1%). About 2 percent of working Coloradans do not have a vehicle.

Air quality

Many forms of transportation lead to air pollution thus impacting air quality, especially in low-income neighborhoods. Coloradans who are Black experience the highest air pollution exposure (index of 64), while Coloradans who are Native American experience the lowest air pollution (index of 39). A recent report ranks two of Colorado’s metropolitan areas in the top 25 for poor air quality (based on ozone and particle pollution). Denver-Aurora is ranked 12th and Fort Collins is ranked 24th. Poor air quality can be a greater burden on older and younger populations, those with chronic conditions (asthma or other chronic lung disease, cardiovascular disease or diabetes), and those with low socioeconomic status.

Climate change

Colorado has shown signs of climate change. A changing climate results in warmer temperatures, drier air, and changing weather patterns. These changes increase the risk for fire, drought, and heat, which impact health. The Colorado Health Institute built a Health and Climate Index based on 24 variables related to health and climate. Southeastern Colorado is the state’s most vulnerable region (it is prone to heat and drought and has higher shares of sensitive populations). Southwestern Colorado is the state’s least vulnerable region.

Education

Education is critical to the health and well-being of the MCH population. Higher levels of education can lead to employment with strong incomes resulting in the ability to live in healthy neighborhoods. Overall, Colorado has a highly educated population. Two in five (41.2%) Coloradans age 25 and older have a college degree or more, and Colorado is ranked 2nd among all states in the percentage of the population with a college degree. Yet inequities in educational opportunities exist among different racial and ethnic groups. Many of these opportunities are affected by systemic inequities like community disinvestment and school poverty. Over half (52.4%) of Asians have a college degree or higher, as do 47.5 percent of White, non-Hispanics. One in four (28.2%) Black/African Americans, and one in six (16.1%) Hispanics have a college degree or higher.

While the prevalence of college graduates in Colorado is high among Asian and White non-Hispanics, the percentage of high school students who graduate overall is relatively low (44 states have higher rates of high school graduation). Disparities in graduation rates mirror the disparities in college graduation attainment among adult Coloradans, with American Indians or Alaska Natives having the lowest high school graduation rate and Asians having the highest. 

Social connectedness and civic engagement

Participation in civic life or religious organizations has been shown to positively impact individual longevity and well-being. In Colorado, seven in ten (68.2%) high school students participate in extracurricular activities. Two in five (43.6%) high school students participate in organized community services as a non-paid volunteer during the past 30 days.

Social and emotional support

Social support can help improve quality of life and decrease emotional distress, while limited social support can negatively impact well-being. Overall, 22.3 percent of Colorado family households are headed by a single adult and may lack needed support systems. The majority of Colorado parents (81.1%) report that they have someone to turn to for day-to-day emotional support with parenting or raising children. Hispanic parents are less likely to report having emotional support with parenting compared to White, non-Hispanic parents (71.7% vs. 90.0%, respectively). Three-quarters (73.5%) of high school students have an adult to go to for help with a serious problem,  which has been demonstrated in research as a critical protective factor in avoidance of risky behaviors.

Racism

Racism and discrimination are two other social determinants of health that negatively impact health, though the data describing these issues in Colorado is limited. Among high school students, one in ten (9.7%) have been a victim of teasing or name-calling because of their actual or perceived race or ethnic background, and one in twenty (4.9%) because of their actual or perceived sexual orientation in the past year.

Health insurance

A record number of Coloradans are insured, with 93.5 percent insured as of September 2017. In Colorado, 58.2 percent of residents have private insurance, 20.2 percent are enrolled in Medicaid or Child Health Plan Plus (CHP+), and 14.4 percent are enrolled in Medicare. The uninsured rate dropped by more than 50 percent from 14.3 percent in 2013 to 6.5 percent in 2017, compared to the national rate of 8.8 percent. Of the 6.5 percent who are uninsured in Colorado, 32 percent were insured for part of the year. The uninsured rate is highest among Coloradans ages 19-29 years at 12.3 percent. Only 3.0 percent of children ages 0-18 years are uninsured. The uninsured rate among White non-Hispanics is 5.4 percent. By contrast, 10.4 percent of Hispanics in Colorado are uninsured. The uninsured rate for Coloradans with incomes at or below 100 percent of the federal poverty level (8.1%) is double the rate among those with incomes greater than 400 percent of the federal poverty level (4.0%). Affordability of health care continues to be a challenge; on average, health care costs reflect 32% of median household income.

Several programs are available to reach low-income families and those without health insurance. Pregnant women and children living in households at or below 260 percent of the federal poverty level are eligible for health insurance coverage either through Child Health Plan Plus (CHP+) or Medicaid. As of February 2019, 543,945 children (age 20 and under) are enrolled in Medicaid and 80,456 children are enrolled in CHP+. Only 5.1% of those eligible for Medicaid or CHP+ are not enrolled.

While Medicaid eligibility for children was not expanded through the Affordable Care Act, the eligibility cutoff for adults with dependent children was raised from 100 to 138% of the federal poverty level. When newly eligible adults enrolled in Medicaid, those with children had the option to enroll them in the program, thus enrolling children who were previously Medicaid-eligible but uninsured. Beginning in 2014, with Medicaid expansion, children and youth with special health care needs in Colorado had the ability to be part of the Medicaid Buy-In Program for Children with Disabilities. This program allows qualifying families of children with a disability to “buy-into” Colorado Medicaid for that child. Family income must be below 300% of the Federal Poverty Level. Eligible families receive Medicaid benefits by paying a monthly premium on a sliding scale based on their adjusted income. As of February 2019, 1,018 children and youth participate in the program annually. Colorado’s Medicaid program also offers waivers for children and youth who meet certain criteria. This table provides an overview of the children’s waiver programs and this table shows adult waiver programs. There are currently no waitlists for any of Colorado Medicaid’s children’s waivers.

Other health care services available to low-income and uninsured persons in Colorado include 20 Community Health Centers that operate 202 clinic sites in 41 counties and provide care to patients living in 61 of the state’s 64 counties. Colorado Community Health Centers provide care to over 740,000 people (more than one in eight Coloradans). Ninety-three percent of patients at community health centers have family incomes below 200% of the federal poverty level. Children’s Hospital Colorado and the University of Colorado School of Medicine form the largest pediatric specialty care network in Colorado, serving over 200,000 children and youth annually, with roughly 50% enrolled in Medicaid or CHP+. Children and youth from every county in the state receive care either onsite at the main campus in metro Denver, and/or through approximately 40 Network of Care and Special Outreach locations, as well as through telehealth.

The state Medicaid program, located within the Department of Health Care Policy and Financing, implemented the Accountable Care Collaborative (ACC) program in 2011 to build a comprehensive statewide network to support a medical home infrastructure for all enrolled members. This program originally included seven Regional Care Collaborative Organizations (RCCOs) to support community-based solutions to care. The responsibility of each RCCO was  to develop a comprehensive network of primary care medical providers, build relationships with specialists, collect and analyze data to support population health, and provide care coordination for members. Beginning July 2018, new contracts integrated the RCCO infrastructure with the state’s Behavioral Health Organizations, creating a new regional network of Regional Accountable Entities (RAEs). Seven RAEs across the state now support a network of primary care and behavioral health providers; manage and coordinate member care; connect members with non-medical services; and report on costs, utilization and outcomes for their population of members.

In February 2015, the State of Colorado was awarded a 5-year $65 million grant from the Centers for Medicare and Medicaid Innovation to implement and test its State Innovation Model (SIM). Colorado’s State Health Care Innovation Plan created a system of clinic-based and public health supports to spur innovation. SIM has been focused on improving the health of Coloradans by: (1) providing access to integrated primary care and behavioral health services in coordinated community systems; (2) applying value-based payment structures; (3) expanding information technology efforts, including telehealth; and (4) finalizing a statewide plan to improve population health. In addition, SIM fosters partnership between public health, behavioral health and primary care sectors in Colorado.

See Section III.C. Five Year Needs Assessment Summary for more information on health.

Colorado’s MCH Program

Colorado’s MCH program implements strategies that have a population health impact on select state and national performance measures. The state’s MCH program is housed in the Prevention Services Division of the Colorado Department of Public Health and Environment (CDPHE), which is one of 19 Colorado state agencies comprising the executive branch under the direction of Governor Jared Polis.

The MCH program collaborates with programs in seven branches from across the Prevention Services Division:

• Children, Youth and Families Branch, which is responsible for the administration of the Title V block grant

• Health Services and Connections Branch (Title X Family Planning, Breast and Cervical Cancer Screening and School-Based Health Center programs)

• Nutrition Services Branch (WIC and Child and Adult Care Food Programs)

• Violence/Injury Prevention and Mental Health Promotion Branch (Injury, Suicide and Violence Prevention, Prescription Drug and Marijuana programs)

• Health Promotion and Chronic Disease Prevention Branch (Tobacco, Cancer, Cardiovascular and Pulmonary Disease programs)

• Fiscal, Contracting, Communications and Operations Branch

The MCH program also partners with CDPHE’s Center for Health and Environmental Data for epidemiology and evaluation support, as well as the Office of Planning, Partnerships and Improvement, which serves as the Department’s liaison with the state’s network of local public health agencies and the Colorado Association of Local Public Health Agencies. In addition, the MCH program works with the department’s newborn screening programs (bloodspot, hearing and critical congenital heart disease) to assure access to timely screening and follow up.

MCH block grant funding is allocated via formula to each of Colorado’s 54 local public health agencies to support local MCH implementation. Each agency is governed locally; the state has no formal organizational alignment or oversight over local jurisdictions.

Colorado’s MCH program works with other state agencies and programs, including: The Department of Health Care Policy and Financing (Medicaid and CHP+); Department of Human Services (MIECHV home visitation, Early Intervention, Child Maltreatment, Statewide Youth Development Plan, and Behavioral Health Treatment); Department of Education (Health and Wellness and Dropout Prevention); and the federal Healthy Start grant, administered by a non-profit partner. Please see Supporting Document – 2 for specific partners actively engaged in Colorado’s MCH priority areas.

MCH Priorities and the CDPHE Strategic Plan

MCH aligns with the CDPHE Strategic Plan with a shared focus on mental health and obesity.

The following includes a description of how the MCH program is organized to support priority implementation. See the MCH program infrastructure chart for more information about program roles, responsibilities and infrastructure. See also the Children, Youth and Family Branch, Prevention Services Division and CDPHE organizational charts.

MCH Core Team

The MCH Core Team provides guidance, oversight and accountability for the MCH program. The team includes the state’s MCH and CYSHCN Directors, as well as the Section Managers who provide leadership for the following teams: CYSHCN; MCH administration, contracting and operations; early childhood and maternal wellness; and MCH Workforce Development. MCH Implementation Teams consist of key internal and external partners who execute the state action plans associated with each priority. Teams are led by a state content expert for the priority area. Each team lead is responsible for achievement of outcomes within their action plan, while implementing activities to increase community engagement and reduce health inequities that impact that priority.

MCH Advisory Team

Colorado’s MCH Advisory Team is a forum for broader, shared decision-making among MCH staff across CDPHE. Meetings include monthly MCH priority reporting, peer-to-peer learning and input into the strategic direction of the program. The group consists of the MCH Core Team; MCH Implementation Team leads and their supervisors, MCH Fundamental Consultants, MCH Generalist Consultants and two local public health agency representatives.

MCH Fundamental Consultants

Performance Improvement Specialist: MCH employs a Performance Improvement Specialist who facilitated the incorporation of change management strategies and strengthened the capacity of MCH staff through an initiative branded “MCH Impact.” This effort resulted in more rapid identification and addressing of challenges, resulting in increased effectiveness and impact.

Evaluation Coordinator: MCH is committed to evaluating the short, medium and long term impact of priority efforts and funds an MCH Evaluation Specialist to work with each priority lead to develop and implement an evaluation plan. Progress on each priority is captured annually in the priority evaluation summaries.

Health Equity and Community Engagement Specialist: MCH has embraced health equity and community engagement as fundamental to quality implementation and achievement of outcomes. To help MCH staff integrate equity and engagement into their efforts, MCH funds support a Health Equity and Community Engagement Specialist.

MCH Generalist Consultants

Internal coordination of administrative, assessment, and planning functions, as well as contracting and consultation for local public health agency contracts are supported by MCH staff. A designated contracting work lead ensures adherence to state and federal requirements, including monitoring guidelines. The MCH Generalist Consultants, in partnership with the MCH priority leads, provide ongoing support for local public health agencies.

State Statutes and Regulations

The 2019 legislative session came to a close May 2, 2019. Included below are descriptions of new state statutes that were passed during the 2018-9 session that are most relevant to current Colorado MCH efforts. Click here for a full list of existing state statutes relevant to MCH efforts.

Children and Youth Behavioral Health

1. UPDATED: Consent for Outpatient Psychotherapy for Minors. [CRS §12-43-202.5] Lowers the age of consent to seek and obtain psychotherapy services with or without the consent of the minor’s parent or guardian to 12 (from 14).

Maternal and/or Child Fatality Prevention

1. NEW: Maternal Mortality Prevention Act. [CRS §25-52-101] Formalizes Colorado’s Maternal Mortality Review Committee to fully understand the complex nature of maternal deaths. Resources are allocated to allow for consistent and timely reviews, as well as make timely recommendations for public health and clinical interventions to reduce maternal deaths and morbidities.

Early Childhood Screenings

1. NEW: Colorado Child Abuse Response and Evaluation Network (CARENetwork) Act. [CRS §25-20.5-901] Established the Colorado child abuse response and evaluation network (CARENetwork) to provide medical exams and behavioral health assessments to children who are subject to physical or sexual abuse or neglect.

2. NEW: Children and Youth Behavioral Health System Enhancements. [CRS §25.5-5-801 to 804] Standardizes screening and assessments to identify potential behavioral health concerns earlier in life, so that children and youth can enjoy better long-term health outcomes; directs the implementation of cost-effective, “wraparound” services for eligible children; designs an integrated funding pilot to improve access to services.

School-Based Health

1. NEW: School Nurse Grant Program. [CRS §25-1.5-406] Created grant program within CDPHE to award grants on a five-year cycle to school districts for increasing the number of school nurses.

2. UPDATED: Child Nutrition School Lunch Protection Program. [CRS §22-82.9-104 to 105] Legislation passed during the 2019 session extends the grade of eligibility for the Child Nutrition School Lunch Program from 9th grade to 12th grade, now covering all grade levels.

Substance Use/Abuse

1. UPDATED: Clean Indoor Air Act.  [CRS §25-14-201 to 208] Addresses Colorado’s youth vaping epidemic by banning the use of e-cigarettes and similar devices indoors and removes certain exemptions for businesses.

2. UPDATED: Pregnant Women - Needs Assessment - Referral to Treatment Program. [CRS § 25.5-5-309 to 312] Amends existing programs that provide access to substance use disorder treatment to pregnant and parenting women (now defined as up to one year after birth); creates the child care pilot programs for parenting women engaged in substance use disorder treatment.

Sexual Health

1. UPDATED: Comprehensive Human Sexuality Education. [CRS §22-1-128 and 25-44-101 to 104] Sets additional requirements for school districts that offer comprehensive sex education, including offering a ban on just abstinence-only programs and a new requirement for offering information about consent.

Organizational Charts

To learn more about the Colorado MCH program, see MCH chart, Prevention Services Division chart, and overall CDPHE chart.