The Arkansas Department of Health (ADH) is the state public health agency with primary responsibility for protecting and improving the health and well-being of all Arkansans. ADH’s vision is optimal health for all Arkansans so they can achieve maximum personal, economic, and social impact. The state’s Title V Maternal and Child Health (MCH) Block Grant supports the ADH’s mission and vision by addressing emerging and priority needs, improving gaps in and barriers to access to care, and increasing the capacity of the public health and health care systems and workforce.

 

Arkansas’s Title V Maternal and Child Health (MCH) Block Grant Program relies on shared leadership between ADH’s Family Health Branch, within the Center for Health Advancement, and the Arkansas Department of Human Services’ (DHS) Children with Chronic Health Conditions Program, within the Division of Developmental Disabilities Services. The state Title V MCH leadership team makes program and policy decisions and ensures alignment across the programs and agencies. Designated Title V MCH staff manage state-level program and policy work and provide technical assistance and oversight to the local Title V grantees.

 

Demographics

The racial, ethnic, and cultural diversity of Arkansas’s population creates unique challenges and opportunities. The diversity makes Arkansas an interesting place to live, work, and play. People from diverse cultures contribute language skills, new ways of thinking, new knowledge, and different experiences.

 

According to census data from the Centers for Disease Prevention and Control (CDC), Arkansas is home to 3,017,084 residents, almost a quarter (23.2%) of whom are under age 18.1 Nearly one-fifth (17.4%) are age 65 and over. The majority of Arkansans are White and non-Hispanic (72.0%). The second-largest group is African American (15.7%). Other groups are Hispanic/Latino (7.8%), two or more races (2.2%), Asian (1.7%), and American Indian/Alaska Native (1.0%).1 Arkansas and Hawaii are home to the largest groups of Marshall Islanders living outside of the Marshall Islands.

 

Geography

Arkansas is located in the southern region of the U.S. It covers an area of 53,178 square miles and is organized into 75 counties. Arkansas borders six other states. The Mississippi River forms the state borders to Tennessee and Mississippi in the east. The capital and largest city is Little Rock in the center of the state.

 

Economy

The average family income in Arkansas is $58,000 per year. This is lower than the U.S. average of $76,000. Almost 40% of Arkansas households have incomes less than $25,000 per year, and 39% receive supplemental income.1 Arkansas’ Gross Domestic Product (GDP) was $130 billion in 2019, representing 0.61% of the national GDP and making Arkansas the 35th largest state economy.2 Arkansas’s per-capita GDP in 2019 was $43,394.00, which was $21,847.00 lower than the national figure. However, the 2019 per-capita GDP was a 2.5% increase over 2016. The state’s GDP declined to $129 billion in 2020. Prior to 2020, the GDP had increased each year since 2009.2

 

The U.S. Census Bureau reports the majority (57.9%) of Arkansans ages 16 and older are in the civilian labor force.1 Arkansas ranks 35th in business environment, which includes new business openings and the rate of patents for new inventions. Arkansas ranks 33rd in economic growth, determined by the growth of the young population in the state, growth by migration, and increased GDP. The disparity in earnings per job between rural and urban areas remains significant, with urban residents earning on average 19% more than rural residents.1

 

Arkansas’s unemployment rate dropped two percentage points in December 2020, bring it to 4.2%, which was the second-best improvement nationally.3 The drop means the state is 0.7% away from the pre-pandemic unemployment rate of 3.5% (December 2019). The state ranks 44th in overall employment, which is determined by a three-year average of job growth, unemployment rates, and labor participation rates.3

 

Arkansas’s prevalence of poverty continues to be high. With 17% of people below Federal Poverty Level (FPL), Arkansas is the 4th highest in the U.S.1 In 2018, 24.7% of Arkansas’s children under the age of 18 lived in poverty compared to 18% in the U.S. The situation is worse for children under the age of five: 29.5% live in poverty compared to 19.5% nationally. Across the U.S. and in Arkansas, approximately 20% of children ages 5-17 live in poverty. In the Coastal Plains and Delta regions of Arkansas, 36% of children live in poverty.1

 

The percent of children living in poverty has been declining. However, 22% of Arkansas’s children live in poverty, compared to 17% nationwide.4 Poverty is statistically linked to negative outcomes for children, from low birthweight and poor nutrition in infancy to increased risk of academic failure, emotional distress, and teen pregnancy. Access to food, adequate shelter, and transportation is limited for many Arkansans. More than 20% of Arkansas children experience food insecurity, the 2nd worst in the country.5

 

Urbanization

Arkansas is highly rural, with 41% of residents living in rural areas compared to 14% in the U.S.1 The capital and largest city is Little Rock. Major population areas are Fort Smith, Hot Springs, Jonesboro, Pine Bluff, and Texarkana, Northwest Arkansas (Fayetteville, Springdale, Rogers, and Bentonville), and Little Rock/North Little Rock. The county with the highest population is Pulaski County, where Little Rock is located. Benton County had the greatest increase (20%) between 2010 and 2019. Phillips County decreased from 22,000 to 18,000, representing the largest decrease (18.3%).1

 

Infant Mortality

The infant mortality rate is the annual number of babies per 1,000 live births who die before their first birthday. In 2019, 251 babies died in Arkansas before their first birthday.6 Arkansas’s mortality rate was 11th in the U.S. at 6.9 per 1,000 live births. Prior to 2019, Arkansas had been in the top three states for highest infant mortality rate for three consecutive years (2016-2018).6 Additional numbers for 2019 show Arkansas was 5th in preterm birth rate (11.9 per 1,000) and 12th in low birthweight rate (9.2 per 1,000).7

 

Access to Health Care and Preventive Health Services

Availability of and accessibility to health care and preventive health services varies widely in Arkansas. Central Arkansas is relatively urban and well supplied with health services for women and children. However, even in these counties, low-income families experience barriers in access to care. Other regions are rural, and many are medically underserved as defined by the HRSA.

 

Counties in the Mississippi Delta along the eastern border of Arkansas are especially rural and poor. These counties have high concentrations of minority populations, especially African American. Some western counties are mountainous and rural and have lower minority populations. A group of Marshallese families live in Northwest Arkansas. The Marshallese community has experienced outbreaks of infectious diseases including sexually transmitted infections, tuberculosis, and Hansen's disease. Counties along the southern border are also rural and poor and depend largely on income from farming and timber.

 

People in rural Arkansas have greater difficulty getting the health care services they need, in part due to cost. In general, 15.3% of Arkansans report that they were not able to see a doctor in the past 12 months due to the cost, compared to 13% in the U.S. In rural counties, more than 20% of residents were not able to see a doctor due to cost. In Arkansas, 25% of working-age adults have no health insurance.1 In addition to cost, a shortage of health care services available is also a limiting factor.

 

Title V Priorities and Initiatives

Multiple current initiatives impact the state’s Title V directives. The Title V MCH and CSHCN administrators, along with MCH partners and ADH staff, utilize various methods to determine the importance, value, and priority of competing factors that impact health services delivery. The Title V program receives input and advice from partners, stakeholders, and other organizations. The overall goal of Arkansas's MCH program is to improve health and reduce disparities. Supporting that goal are five priority areas:

 

1. Strengthen core services: Family Planning, Prenatal Care, WIC Program, Immunizations, and Home Visiting.
2. Develop more effective population-based approaches: prevent injuries, reduce infant mortality, increase physical activity, and improve oral health.
3. Communicate public health value and societal contribution: economic development, public awareness, and benefits of prevention.
4. Secure adequate human and financial resources: workforce needs and training and funding acquisition.
5. Increase departmental effectiveness and accountability: strengthen leadership, management systems, information technology, data use, and accountability.

 

Cross-cutting these areas is an emphasis on community engagement, partnerships, and policy development. The overall theme is to strengthen and improve traditional public health clinical services while focusing on program development, engaging more in public awareness and policy development, and retooling administrative processes to work more effectively and efficiently. The public is engaged through ADH’s Hometown Health Initiative (HHI), a community-driven process that empowers local communities to take ownership of health problems by working to identify and implement solutions.

 

MCH Core Partnership Linkages

The Arkansas DHS houses programs that are important to improving MCH health in the state. DHS’s Division of Medical Services (DMS) administers the Medicaid Program, which serves approximately two-thirds of children in the state. Most children are covered based on income eligibility through ARKids First A or B, depending on income level. Annually, almost 30,000 women in Arkansas receive pregnancy-related Medicaid coverage. In 2018, Medicaid paid for 68% of all births.1

 

Transitioning from pediatric to adult care is a priority of ADH for all youth and young adults in Arkansas, including those with disabilities, chronic health conditions, or other needs. The Arkansas Department of Human Services (DHS) is also home to the state’s Title V CSHCN program in the Division of Developmental Disabilities Services (DDS). ADH’s Title V Director is working to improve collaboration with this division, which includes maintaining an important partnership with the Division’s Medical Director. Services for CSHCN are closely associated with specialty services of the University of Arkansas for Medical Sciences (UAMS) Department of Pediatrics. The Division also supports the state's early intervention program (Part C), known as First Connections.

 

As the only medical school in the state, UAMS plays a critical role in Arkansas's health care system. Development of the UAMS College of Public Health in 2001 led to stronger links between state health-engaged agencies and the university system. UAMS’s pediatrics and obstetrics/gynecology departments partner with ADH to provide direct care to women and children and to carry out initiatives to improve systems of care.

 

Arkansas Children’s Hospital (ACH) in Little Rock plays an important role in the health care system. It is one of the largest children's hospitals in the U.S., attracting patients from around the region, other states, and other countries. The hospital provides most of the pediatric critical care in the state. The hospital’s administration is also committed to involvement in community and state level public health concerns such as infant mortality, injury prevention, home visiting, and school health initiatives.

 

ADH Strategic Plan

The proposed ADH Strategic Plan for 2020-2023 includes goals and supporting strategies to address MCH population needs. The plan is designed to address four health conditions as priority areas: 1) Addiction/Mental Health/Suicide, 2) Maternal and Infant Health, 3) Vaccines/Infectious Disease, and 4) Obesity.7

 

All highest priority services are provided in all 75 counties. High-priority services not provided through ADH’s Local Health Units are organized through ADH’s Central Office: newborn metabolic and hearing screening, school health, safe sleep CoIIN, and home visiting programs. Secondary services include basic preventive services that local health care systems may not have the capacity to provide, especially maternity care.

 

Reducing health disparities continues to be a major focus of ADH. The Office of Health Equity and HIV Elimination (OHEHE) provides leadership in improving health outcomes by advocating for health equity for at-risk populations as defined by race or ethnicity, age, education, disability, geographical location, income, and sexual orientation for all MCH programming. OHEHE serves as ADH’s coordinating office for consultative services and training in cultural and linguistic competency, coordination, partnership building, program development and implementation, and related efforts to address the needs of underrepresented populations. This office promotes the integration of Culturally and Linguistically Appropriate Services (CLAS) within health programs.

 

State Health Care System Infrastructure

The capital city, Little Rock, is the state’s largest and most populous, with 6.54% of the state’s population. The city is situated in the middle of the state and is the site for the ADH Central Office, five large hospitals including the UAMS (the state’s only medical school), DHS, and other state agencies focused on improving the health of women and children. Cities of moderate size in the corners of the state are home to sizable medical communities and are the locations of UAMS’s Regional Programs.

 

In addition to the hospitals in Little Rock, there are 97 other hospitals, 28 of which are identified as Critical Access, having no more than 25 acute care beds. The state has 12 Federally Qualified Health Centers (FQHCs) that provide services at 99 sites. There are also 76 rural health clinics. Forty-three community hospitals have fewer than 100 beds, and 39 counties are served by a single hospital. Eighteen counties are served by a single Critical Access Hospital. Twenty-three counties do not have a local hospital.1

 

The current number of physician practices in Arkansas is inadequate to provide needed medical services to the population. Physician and other health care provider shortages are common. The average caseload for a Primary Care Physician (PCP) is 1,522 patients. Arkansas ranks 43rd in the nation for number of PCPs (122.3 per 100,000 population). There are only 639 pediatricians and 340 obstetricians/ gynecologists in the state. Arkansas ranks 49th in the number of dentists (42.1 per 100,000).1

 

UAMS is a centralized point of referral for all medically complicated patients and provides medical and health education for the entire state. Except for communities on the eastern border that depend on the city of Memphis, Tennessee, all state communities relate to UAMS and Little Rock hospitals as sources of highly specialized medical care. UAMS's Regional Programs provide family medicine residency training in communities around the state. These programs have improved the distribution of PCPs.

 

Family physicians provide most of the state's medical care and are by far the most numerous specialty practitioners in Arkansas. Specialists in obstetrics, pediatrics, internal medicine, surgery, and others have practices in the more urban communities. While Arkansas is geographically of modest size compared to some other states, the distances from cities such as Fayetteville and Texarkana to Little Rock require two to four hours of travel time. For families with few resources, these distances represent significant barriers to access specialized care.

 

In March of 2018, a third satellite clinic of Arkansas Children’s Hospital (ACH) opened in Springdale in Northwest Arkansas. The clinic is in the fastest growing area of the state and allows more CSHCN access to pediatric specialty care.

 

Arkansas’s Medicaid has transitioned from a fee-for-service system to an organized care delivery model for the highest need behavioral health and developmental disability populations. The model, the Provider-Led Arkansas Shared Savings Entity (PASSE), began in February 2017 and provides care coordination services. The program began providing comprehensive services to members in January 2019. PASSEs are responsible for integrating physical health, behavioral health, and developmental disability services. Members are assigned a care coordinator who is responsible for creating a service plan for each individual.

 

State Plans and Priorities

In 2015, Governor Asa Hutchinson launched the Healthy Active Arkansas initiative.8 It is a statewide, public/private supported partnership. The collaboration brings together 12 state agencies, non-profit organizations, businesses, and entire communities to help children and adults make consistent, informed choices about healthy eating and active living. The initiative works closely with partners to leverage existing resources to maximize reach and impact. Encouraging physical activity and healthier food choices has a positive impact on birth outcomes and child health. Women who are healthier before and during pregnancy lessen the risk of maternal and infant morbidity and mortality.

 

ADH was involved in the development of the 10-year plan along with the Arkansas Center for Health Improvement (ACHI); Arkansas Coalition for Obesity Prevention, Arkansas Minority Health Commission, Baptist Health, UAMS, and the Winthrop Rockefeller Institute. The plan consists of nine priority areas: 1) Physical and Built Environment; 2) Nutritional Standards in Government, Institutions, and Private Sector; 3) Nutritional Standards in Schools: Early Child Care through College; 4) Physical Education and Activity in Schools: Early Child Care through College; 5) Healthy Worksites; 6) Access to Healthy Foods; 7) Sugar-Sweetened Beverage Reduction; 8) Breastfeeding; and 9) Marketing Program.8

 

Arkansas’s health care delivery environment improved as a result of the Affordable Care Act and Medicaid expansion. As of May 2020, more than 260,000 people had enrolled in health care coverage. No other state experienced a more rapid decline in its number of uninsured residents. The uninsured level fell from 16% in 2013 to 8% in 2018.1 Arkansas’s Medicaid expansion efforts have been in the form of the Private Option, which allows Medicaid to fund private insurance companies for families at or below 138% of the Federal Poverty Level (FPL). The 1115 Medicaid Waiver that funded family planning services for women up to 200% of the FPL was ended in December 2013.

 

Conclusion

Arkansas is a southern state with unique challenges and opportunities. Programs and partnerships can play a key role in improving the health of the state’s MCH population.

 

References

1. U.S. Census Bureau. Quick facts: Arkansas. 2021. Retrieved from https://www.census.gov/quickfacts/fact/table/AR/AFN120212#AFN120212.
2. Federal Reserve Bank of St. Louis. Total gross domestic product for Arkansas. 2020. Retrieved from https://fred.stlouisfed.org/series/ARNGSP.
3. Arkansas Economic Development Institute. State jobless rate hit 4.2% last month; Arkansas’ Figure 9th-lowest in U.S. 2021. Retrieved from https://youraedi.com/state-jobless-rate-hit-4-2-last-month-arkansas-figure-9th-lowest-in-u-s.
4. Annie E. Casey Foundation. 2021 Kids Count® Profile. Retrieved from https://assets.aecf.org/m/databook/2021KCDB-profile-AR.pdf.
5. Feeding America. Food Insecurity and Poverty in the US. 2020. Retrieved from https://www.feedingamerica.org/sites/default/files/2020-10/Brief_Local%20Impact_10.2020_0.pdf.
6. CDC. Infant Mortality Rates by State. 2021. Retrieved from https://www.cdc.gov/nchs/pressroom/sosmap/infant_mortality_rates/infant_mortality.htm.
7. Arkansas Department of Health. State Strategic Plan. 2021. Retrieved from https://www.healthy.arkansas.gov/programs-services/topics/state-strategic-plan.
8. Healthy Active Arkansas: A 10-Year Plan for Arkansas. 2018. Retrieved from https://healthyactive.org/wp-content/uploads/2018/01/HAA-10-Year-Plan.pdf.