Demographics, Geography, and Economy

 

Geographically, Wyoming is the tenth largest state in the United States (U.S.), spanning 97,813 square miles. Wyoming is a rural/frontier state with 23 counties ranging in ecoregion from the Great Plains to the Rocky Mountains. The Wind River Indian Reservation (WRIR), located toward the center of the state, is home to two federally recognized tribes, the Eastern Shoshone and Northern Arapaho. Two counties, Laramie and Natrona, each have a town with over 60,000 people and are considered urban. Seventeen of the remaining 21 counties are considered frontier, with fewer than six people per square mile. These 17 counties are home to 46% of the population (Wyoming Economic Analysis Division (WY EAD), 2020).

 

Wyoming Counties by Rural, Urban, and Frontier Classification

 

Wyoming is the least populous state in the U.S., with a July 2021 estimated population of 578,803–an increase of 0.3% from April 2020 (U.S. Census Quick Facts, 2021). The population is predominantly White alone (92.5%). The remaining population is Black or African American alone (1.3%), American Indian and Alaska Native alone (2.7%), Asian alone (1.1%), Native Hawaiian and Other Pacific Islander alone (0.1%), two or more races (2.2%), and 10.1% of the population is Hispanic or Latino. In 2021, 93% of the population aged five years and older spoke only English at home, and 7% spoke a language other than English (U.S. Census Quick Facts, 2021). According to WY EAD, the minority population, and group other than single-race, Non-Hispanic White increased by 34.4% between 2010 and 2020, accounting for nearly all the growth in Wyoming from 2010 to 2020 (WY EAD, 2021).

 

Nearly one quarter (23.1%) of the population is under the age of 18, and 17.1% is over the age of 65. 93.2% of people over the age of 25 have a high school education or higher, with 28.2% of this group having at least a bachelor’s degree. The median household income in 2021 was $65,304, just slightly more than the median household income in the U.S. of $64,994. Persons in poverty are estimated to be 9.2% of the population, compared to 11.4% nationally (U.S. Census Quick Facts, 2021).

 

During the fall and winter of 2021, Wyoming’s economy had a small rebound as the Delta variant faded. Current supply chain bottlenecks, semiconductor shortage, rising energy prices, and inflation pressures add to the uncertainty in economic recovery. Employment in Wyoming increased 2.6% (7,000 jobs) compared with a U.S. decline of 4.3%. Unemployment in Wyoming decreased to 4.0%, which is lower than the national average (WY EAD, 2021).

 

Strengths and Challenges

 

According to the 2021 Annual America’s Health Rankings Report, Wyoming ranks 25th in the nation in overall health outcomes, and 34th in the nation in all health determinants (social and economic factors, physical environment, clinical care, and behaviors). The listed strengths for Wyoming in the report include low prevalence of non-medical drug use, low incidence of chlamydia, and low levels of air pollution. Also, the report highlighted flu vaccination increasing 13% from 36.5% to 41.3% of adults between 2019 and 2020. High health status increased 12% from 52.1% to 58.5% of adults between 2019 and 2020. The listed challenges in Wyoming include high rates of cigarette smoking and occupational fatalities, and a low prevalence of colorectal cancer screening. Also, the report highlighted low birthweight increasing 15% from 8.5% to 9.8% of live births between 2016 and 2019.

 

As noted, Wyoming is considered a rural/frontier state, which presents unique challenges. According to the Health Resources and Services Administration’s (HRSA) Designated Health Provider Shortage Areas (HPSA) Quarterly Summary Report (Second Quarter of Fiscal Year 2022, 3/31/2022), Wyoming had a total of 46 Primary Care HPSA designations, with 186,533 residents residing in primary care shortage areas. There were 31 dental HPSA designations in the state with a total of about 49,361 Wyoming residents residing in these areas. Finally, the entire state (comprising five regions) is considered an HPSA for mental health. Per HRSA's Designated HPSA Quarterly Summary, only 41.22% of the mental health needs are being met and 28 full-time psychiatrists are needed to meet the needs of the population.

 

According to the Wyoming Office of Rural Health, in 2022 there are currently 41 physicians practicing obstetrics and gynecology (OB/GYN) in Wyoming and 54 practicing pediatricians. 11 counties have no OB/GYN and 11 counties have no pediatrician. Over 18,500 Wyoming women of childbearing age (15-44) live in a county with no practicing OB/GYN, and approximately 26,000 Wyoming children and youth (<18 years of age) live in a county with no practicing pediatrician (CDC Wonder, 2022).

 

There are 248 family practice physicians in the state. 54 individuals practice in Natrona County, 55 in Laramie County, 15 in Park County, and 15 in Fremont County. Nine counties have fewer than five family practice physicians (Wyoming Office of Rural Health, 2022).

 

 

Total Number of Practicing Pediatricians by Wyoming County

Total Number of Practicing Obstetricians & Gynecologists by Wyoming County

 

 

Access to care is a challenge in Wyoming, given the rural/frontier nature of the state. This is especially pertinent to the MCH population, given the absence of Level III facilities, few specialist providers, and a high uninsured population. In 2021, 14.8% of Wyoming residents under the age of 65 years had no health insurance coverage, compared to 10.2% of the population nationally (U.S. Census Quick Facts, 2021). Wyoming is one of nine states that has not expanded Medicaid. During the 2022 Wyoming legislative session (a budget session), a Medicaid expansion bill (HB0020) was not considered for introduction. The bill proposed expanding Medicaid, contingent on the state continuing to receive a 90% federal match assistance percentage for the expansion population and at least 55% for the traditional Medicaid population. A similar bill in the 2021 session (HB0162) passed the Wyoming House, but subsequently failed a vote in the Senate Labor, Health, and Social Service Committee. Prior to the new American Rescue Plan Act incentive, the Wyoming legislature had rejected multiple Medicaid expansion bills during the 2020 and other previous legislative sessions. Health insurance options in the Federal Health Insurance Marketplace for Wyoming include Blue Cross Blue Shield and Mountain Health co-op.

Health Equity

 

According to the 2020 Robert Wood Johnson County Health Rankings & Roadmaps, Wyoming fares better than the nation for the proportion of children in poverty, with 12% of children in poverty versus 17% nationally. However, within Wyoming, the proportion of children in poverty varies widely by county, with rates ranging from 6% (Teton County) to 19% (Niobrara County) (Small Area Income and Poverty Estimates, 2021).

 

Racial and ethnic disparities are also observed to exist in regard to high school graduation rates. Wyoming’s overall high school graduation rates have risen steadily over the past seven years, from 78.6% (2013-2014) to 82.4% (2020-2021). However, while 84.5% of White youth graduated from high school in the 2020-2021 school year, only 78.3% of Hispanic youth and 52.9% of American Indian youth graduated during the school year (Wyoming State Four-Year Graduation Rates).

 

The definition used for health equity by the Robert Wood Johnson foundation is:

 

“Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”

 

Due to the unique nature of Wyoming, a number of barriers to measuring health equity exist. Small population numbers (particularly for minority populations) at the state and county levels make stratification by geographic region, race, and ethnicity challenging. Wyoming continually monitors MCH outcomes for minority populations through the calculation of rolling rates and data aggregation. Too often, even with multiple years, numbers are too small to report, which can contribute to the erasure of their experiences. During the 2021-2025 Title V cycle, WY MCH established a Title V priority to build workforce capacity to operationalize all of its core values, with specific emphasis on health equity. The operationalization of health equity will consider ways in which we can increase our capacity to present data through a health equity lens and mitigate the effects of small numbers.

 

In 2018, the WDH PHD completed a State Health Assessment (SHA) in pursuit of public health accreditation. From there, priorities were selected for the State Health Improvement Plan (SHIP) – Behavioral Health, Access to Healthcare, and Unintentional Injury. WY MCH aligns Title V and other MCH priorities and action to these priorities wherever possible.

 

Agency Organizational Structure and Role

 

The Maternal and Child Health Services Title V Block Grant is managed by the WY MCH within the CHS and PHD of the WDH. WDH’s mission is to “promote, protect, and enhance the health of all Wyoming residents.” PHD’s mission is to “promote, protect, and improve health and prevent disease and injury in Wyoming.”

PHD is one of four divisions within WDH, joining the Aging, Behavioral Health, and Health Care Financing (Wyoming Medicaid) Divisions. Please see the attached organizational chart for a visualization of PHD’s structure. WDH is an executive branch state agency, with an appointed director, that has been granted authority and responsibility to govern health services through Wyoming statutes §§ 9-2-101 through 9-2-127. Specific to PHD, Wyoming statutes §§ 35-1-201 through 35-1-244 contain provisions for public health and safety responsibilities. Various other statutes offer provision for public health services carried out by PHD.

 

PHD employs approximately 265 staff in a mostly-centralized public health system. All but four PHN offices are administered through a state-county partnership. The remaining four are independent local health departments.

 

PHD provides a wide range of services that promote, protect, and improve health and prevent disease and injury in Wyoming. The following list outlines PHD’s key services, which are in line with the 10 Essential Public Health Services:

 

• Community Health Section - optimizes quality of life through the promotion of health, protection of community health, and prevention of disease and injury
  • Cancer and Chronic Disease Prevention Unit
  • Community Prevention Unit (substance use, tobacco, and injury prevention)
  • Immunization Unit
  • Maternal and Child Health Unit
  • PHN
  • WIC Unit
• Health Readiness and Response Section - coordinates preparedness and response for public health emergencies; coordinates efforts to improve the health of rural, medically underserved residents; and maintains and enhances the Emergency Medical Services and Trauma Systems across Wyoming
  • Office of Emergency Medical Services
  • Public Health Preparedness and Response
  • Rural and Frontier Health
• Public Health Sciences Section - performs epidemiologic and disease control activities
  • Chronic Disease and Maternal Child Health Epidemiology
  • Communicable Disease Prevention, Surveillance, and Treatment
  • Infectious Disease Epidemiology
  • Public Health Laboratory

A summary of the PHD organizational structure is included below.

 

Public Health Division Organizational Chart

 

PHD is working toward public health accreditation. The division completed a SHA in 2018 and is nearing completion of the SHIP. Efforts to develop and finalize the SHIP were delayed due to COVID-19. A member of MCH Epi is on the SHA/SHIP Leadership Team.

 

PHD has set several strategic priorities, all of which are supported by foundational priorities to promote health equity and health literacy, ensure continuous quality improvement, and apply public health core functions and essential services. The remaining strategic priorities follow:

• Promote understanding of the relevance and value of public health
• Foster programmatic excellence
• Support the integration of public health and health care
• Foster a competent, flexible workforce
• Build a sustainable, cohesive organization

 

Several workgroups continue to address each of these PHD strategic priorities. For example, the workgroup working to foster a competent, flexible workforce facilitates a biennial assessment of the Core Competencies for Public Health Professionals by all PHD staff. This valuable tool helps staff identify opportunities for professional development related to public health practice.

 

Additionally, PHD is in the process of undergoing a strategic plan update. MCH WY staff are participating in the process wherever staff engagement opportunities are present.

 

WY MCH administers the Title V MCH Services Block Grant and provides leadership for state- and local-level efforts that improve the health of the MCH population. The unit’s programs are divided according to the population groups they serve. This structure aligns well with the Title V population domain framework and assures dedicated resources within each domain. Programs collaborate to ensure consideration of the life course perspective in program planning and decision making, and where domain populations overlap. WY MCH programs include:

• Women and Infant Health Program, focusing on women of reproductive age and infants through age one (Women/Maternal Health and Perinatal/Infant Health domains)
• CYSHCN Program, focusing on all children one through 21 years, including those with special health care needs (Child Health and Children with Special Health Care Needs [CSHCN] domains)
• Youth and Young Adult Health Program, focusing on the unique needs of youth and young adults ages 12-24 (Adolescent Health domain)

WY MCH Mission and Vision

 

WY MCH’s vision is a Wyoming where all families and communities are healthy and thriving. WY MCH’s mission is to improve the health and well-being of Wyoming families and communities by supporting and collaborating on public health activities that benefit the health of mothers, infants, children, youth, and young adults, including those with special health care needs, and their families. WY MCH core values include:

• Data-driven: WY MCH uses data, evidence, and continuous quality improvement
• Engagement: WY MCH cultivates authentic collaboration and trust with families and community partners
• Health Equity: WY MCH integrates an understanding of how differences in social, economic, cultural, and environmental factors across generations and throughout the lifespan impact health
• Life Course Perspective: WY MCH integrates an understanding of how risk and protective factors influence health across the lifespan and across generations
• Systems-Level Approach: WY MCH prioritizes work that addresses community structures, social norms, environment, and policies to maximize impact

 

The 2020 MCH Needs Assessment resulted in the selection of seven priorities for 2021-2025:

1. Prevent Maternal Mortality (Women/Maternal Domain)
2. Prevent Infant Mortality (Perinatal/Infant Domain)
3. Promote Healthy and Safe Children (Child Domain)
4. Promote Adolescent Motor Vehicle Safety (Adolescent Domain)
5. Prevent Adolescent Suicide (Adolescent Domain)
6. Improve Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN Domain)
7. Strengthen MCH Workforce Capacity to Operationalize MCH Core Values (Cross-Cutting Domain)

 

WY MCH benefits from participating in and aligning with the PHD SHA and SHIP. The SHA/SHIP process identified three priority issues: Behavioral Health, Access to Healthcare, and Unintentional Injury. These priorities were used to guide WY MCH’s 2021-2025 needs assessment and strategic planning.

 

Systems of Care and Services for CYSHCN

CYSHCN Program Overview and Population Served

In 2019-2020, approximately 24,064 (18.1%) of Wyoming children and youth ages 0-17 had a special health care need. The prevalence of CYSHCN whose parents reported receiving care in a well-functioning system in Wyoming increased to 12.7% from 8.6% in 2018-2019, but is still below the U.S. at 14.1% (National Survey of Children’s Health). Currently, WY MCH’s CYSHCN program activities are limited in systems-level scope and serve a small proportion of the overall CYSHCN population in Wyoming. The CYSHCN program will focus on assessing and improving systems of care for all CYSHCN.

WY MCH’s CYSHCN program (also known as the CSH Program) offers care coordination and limited gap-filling financial assistance as the payer of last resort for enrolled clients (CYSHCN ages 0-18 and high-risk pregnant women and infants requiring Level III care) who meet medical and financial eligibility criteria. In order to be eligible for assistance, families must first apply for Medicaid, Kid Care Children’s Health Insurance Program (CHIP), and/or the Federal Marketplace. The CSH program provides reimbursement to eligible providers for covered services provided to eligible clients. In FFY21, CSH actively served 484 clients. Of all enrolled clients, 398 were CYSHCN, 65 were high-risk infants, and 21 were high-risk pregnant women. Of those served, 92% were on Medicaid during the reporting year.

WY MCH works with partners such as PHN, Medicaid, Kid Care CHIP, in-state and out-of-state primary care and specialty providers, early intervention providers, and home visiting providers, to assure child populations, especially CYSHCN, have access to health insurance; a primary care provider or, ideally, a certified medical home; specialty care services; support for transitioning to adult healthcare settings; and other supports and services based on identified family needs.

Health Services Infrastructure and Integration of Services

Wyoming lacks a children’s hospital and has a significant shortage of pediatric specialists in the state, leading families to rely heavily on bordering states’ infrastructure for Level III hospital care and pediatric specialty care. WY MCH maintains an updated map of pediatric specialty clinics offered in Wyoming, and directly funds in-person and telehealth genetic clinic services due to an absence of an in-state geneticist and long wait times for out-of-state appointments.

 

Strengthening partnerships with out-of-state providers and neighboring Title V agencies helps to build Wyoming’s health services infrastructure. For example, the Wyoming Newborn Screening and Genetics Programs contract with the Colorado Department of Public Health and the Environment (CDPHE) for newborn screening laboratory and short-term follow-up services, and the University of Colorado Medicine for in-person and telehealth genetics services and consultation. Additionally, WY MCH partnered with the Utah Department of Health to apply for a CDC ERASEMM grant to expand the scope of the well-established Utah Perinatal Mortality Review Committee to include review of Wyoming cases. 

Financing of Services

Wyoming is one of two remaining states whose Medicaid payments are based on fee for service. Overall, children make up 67% of Wyoming residents covered by Medicaid and Kid Care CHIP. Wyoming Medicaid and Kid Care CHIP serve a large portion of Wyoming’s child population, including 100% of children in foster care, 55% of children who live in or near poverty, 34% of children with disabilities or special health care needs, and 29% of infants, toddlers, and preschoolers (Georgetown University Health Policy Institute Wyoming Snapshot 2019). The most current eligibility requirements for Wyoming Medicaid and Kid Care CHIP are as follows:

• Kid Care CHIP is available to the children of parents, whose income is below 200% of the federal poverty level (FPL).
• Wyoming Medicaid:
  • Children 0-5 whose family income is at or below 154% of the FPL
  • Children 6-18 whose family income is at or below 133% of the FPL
  • Pregnant women whose income is at or below 154% of the FPL

State Statutes Relating to MCH

 

Three state statutes directly impact the work of WY MCH.

The NBS statute, Wyoming Statutes (Wyo. Stat.) §§ 35-4-801 and 802, mandates newborn screening be available to all newborns, and that WDH provides necessary education on newborn screening to hospitals, providers, and families. WY MCH’s NBS and Genetics Programs fulfill this statutory requirement in partnership with families, providers (including midwives), hospitals, CDPHE (laboratory services and short-term follow up contractor), and a contracted courier service. The Wyoming NBS and Genetics Coordinator is funded by both Title V and state Trust and Agency funding (comprised of hospital fees charged for NBS services), which demonstrates the partnership between Title V and WDH to assure access to newborn screening statewide.  

Wyo. Stats. §§ 35-27-101, 102, 103, 104, Public Health Nurses Infant Home Visitation Services, was passed in 2000. This statute directs PHN to contact eligible women to offer home visitation services. The initial intent of the legislation was to implement Nurse Family Partnership (NFP), an evidence-based home visiting model, in all 23 counties. Due to challenges meeting growing fidelity requirements and a small birth cohort in many communities (limiting the number of women eligible for the program), NFP implementation in Wyoming reduced from statewide implementation to zero sites over the course of 20 years. Since 2021, the statute requirement is met by a new evidence-based home visitation model, Maternal Early Childhood Sustained Home-Visiting (MECSH), a model selected for its fit for Wyoming’s unique characteristics and needs. The newly named program, Wyoming Hand in Hand, launched in spring 2021 and is funded by TANF funding and State General Funds that count toward the required Title V match.

During the 2020 legislative session, Wyo. Stat. § 21-2-202 was updated to authorize the State Superintendent of Public Instruction to employ a state school nurse if/when non-state funds were available. Together, the WDE and WY MCH agreed to contribute funding for this position through September 10, 2024. The selected candidate started in June 2021. Through a Memorandum of Understanding (MOU), the state school nurse works closely with MCH to support and promote Title V priorities, identify and support professional development needs for Wyoming school nurses, educate school nurses and district boards on public health issues, collect aggregate data on a range of medical and health conditions impacting schools and students, develop best practice standards for school nursing, and assist in a range of other education and guidance development.