Demographics, Geography & Economy

Arizona’s population was estimated to be 7,421,401 in 2020 by the U.S. Census Bureau.1 Arizona is one of the fastest growing and most diverse states in the nation—8th in the nation for overall population growth from 2010 to 2019 (13.9% growth)2, and 2nd in the nation for population growth from 2019 to 2020 (1.8% growth).1 Arizona is expected to experience an additional growth of at least 30% by 2055.3 Geographically, Arizona is the 6th largest state in the nation with 113,594 square miles total area1, sharing a 389-mile international border with the states of Sonora and Baja California in Mexico.

Approximately 46% of Arizona’s population belongs to a racial or ethnic minority group. The racial and ethnic makeup of the state is different from the nation. Arizona has a higher proportion of Hispanics and Native Americans and a lower proportion of African American compared to the nation. In 2019, Arizona’s population was 31.7% (compared to 18.5% nationally), 5.2% African American (compared to 13.4% nationally) and 5.3% Native American (compared to 1.3% nationally).4 (Note: Detailed 2020 population data is not yet released, since it was a full decennial census count.)

The racial makeup of Arizona varies by age group. Among older age groups, the population is predominantly white, while younger populations are more racially and ethnically diverse. Over 45% of those younger than five are Hispanic compared to 11% of people 75 and older.5

Poverty is a social determinant of health and a critical concern in Arizona.  According to 2018 Kaiser Family Foundation estimates, Arizona has the country’s 15th highest poverty rate (18.7%) among children.6  In a five-year estimate for 2015-2019, 15.1% of Arizonans lived in poverty—up from 14% in 2000, and higher than the current national poverty rate of 13.4%— and 26.9% of those without a high school diploma lived below the poverty line.9 Poverty varies dramatically by county within Arizona. The highest rates of poverty are in Apache and Navajo counties with rates of 35.5 and 27.9%, respectively. The lowest rates are in Greenlee (13.3%), Yavapai (13.0%), Pinal (13.2%) and Maricopa (13.8%) counties.7 U.S. Department of Agriculture, Economic Research Service 2019 estimates show that poverty in rural Arizona (24.2%) far exceeded the rate in urban areas of the state (13.0%).8

In addition to rural communities, poverty disproportionately impacts women and children. In Arizona in 2019, 21.5% of children under age 18 lived below the poverty line.9 Arizona has the 21st highest nonelderly adult female poverty rate in the country (13.6%).6 Over half a million women live in poverty in Arizona.9 The Arizona Foundation for Women notes that gender wage gaps are detrimental to women’s and families’ well-being, leading to more children and families in poverty. They cite a national analysis completed by the Institute for Women’s Policy Research that demonstrated equal pay across genders would cut poverty among working women and their families in half.10

Median household income in Arizona has historically tended to be lower than national averages. According to the U.S. Census, Arizona’s median household income in 2019 was $58,945 compared to the national median income of $62,843. Median household income also varies widely by county and type of household. At $64,468, Maricopa County had the highest median household income; Apache County had the lowest at $32,508. Median household income also varies by type of household, with married couple families earning $83,360, families with children under 18 earning $64,745, and female-headed, single-parent families earning $30,416.17

Arizona’s unemployment rate ranged 4.5–5.0% from mid-2017 until March 2020, when it quickly spiked due to the emerging global pandemic; reaching a high of 14.2% in April 2020 with 504,698 unemployed. It has since decreased to rates of 6.7-6.9% during the first half of 2021. Unemployment varies across the state of Arizona. In 2020, Greenlee county had the lowest unemployment rate (5.5%), while Yuma county had the highest (17.1%).18

In addition to individuals, poverty is calculated for families with children under the age of 18. In a five-year estimate for 2015-2019, 17.3% of families in Arizona with children were below the poverty line; over two percentage points higher than the national average (15.1%).19 Rates of poverty for families with children vary widely by ethnic background. The National Center for Children in Poverty reports that in Arizona in 2018, 27% and 29% of Asian and white children, respectively, lived in low-income families compared to 72% of Native American children, 62% of Hispanic children, and 56% of black children.20

There is also wide variation in the proportion of households receiving assistance such as Supplemental Security Income, Cash Assistance, or Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program) in Arizona. The most recent American Community Survey data shows that in 2019, 11.1% of households in Arizona received SNAP assistance (or food stamps). The lowest is 8.6%, in both Greenlee and Yavapai Counties, compared to a high of 25.9 and 25.8% in Apache and Santa Cruz Counties, respectively.21 Household food insecurity is often a consequence of poverty. Food insecurity, to paraphrase the USDA definition, is “limited or uncertain availability of food.” Low food security results in a reduced quality, variety or desirability of diet. Very low food security is classified as multiple indications of disrupted eating patterns and reduced food intake.22 Food insecurity is slightly higher in Arizona than in the United States as a whole (11.7 vs. 11.1%), but has decreased significantly—nearly 3 percentage points—over the past five years. In 2017-2019, 4.2% of Arizona households had very low food security.23

As children, Arizonans also face other challenges as well. A 2020 America’s Health Rankings report placed Arizona with the 17th highest rate of adverse childhood experiences (ACEs) and 17% of Arizona’s children experienced two or more ACEs last year (compared to 14.7% nationally). This is a significant improvement over 2019, when 27% children in Arizona reported experiencing two or more ACEs (third worst in the country).11 ACEs include abuse (e.g., sexual abuse, physical abuse or verbal abuse) and household dysfunction (e.g., drug use, violence between adults, and separation/divorce). ACEs are associated with negative impacts in adult life, such as poor health, heavy drinking, smoking, and depression.

The number of children living in foster care in Arizona increased nearly 40% in the past decade. The Children’s Action Alliance reports that in 2019, 13,200 children were in foster care.12 In an independent review of the newly established Department of Child Safety, Chapin Hall reported that the increase in children in foster care was the result of an increase in abuse and neglect reports, especially since 2009; specifically, in a six-year period, there was a 44% increase in reports. They note that this dramatic increase in abuse and neglect reports, along with a weakening of other safety net supports (such as child care subsidies) during a time of economic recession, put substantial strain on public welfare agencies. The Chapin Hall report also noted that Arizona, compared to other states, places more children in foster care following a substantiated allegation of maltreatment. All these factors place pressure on the foster care system and out-of-home placements have increased dramatically.13

Arizona consistently ranks among the lowest in the nation in per pupil spending on education. The National Center for Education Statistics reported that Arizona spent $8,296 per student compared to the national average of $12,485 per student in fiscal year 2018.14 The U.S. Census ranked Arizona 48th of the 50 states and the District of Columbia in public per pupil spending in fiscal year 2018.15 The National Assessment of Educational Progress (NAEP) is an assessment of what America’s students know. In 2019, eighth grade students in Arizona public schools performed the same as 20 other states and jurisdictions, had higher performance than five states and jurisdictions, and were below 26 states and jurisdictions in NAEP reading scores. In 2019, 30% of Arizona eighth graders tested below basic skill level for their grade compared to the national rate of 28%. This was an increase in 5 percentage points from 2017.16

Unique Strengths & Challenges

Arizona’s unique geographical, cultural, and political climate impact women’s and children’s health status in a variety of ways.

Provider Shortages

Arizona experiences a shortage of medical providers. Large sparsely populated areas make distribution of providers difficult. Recruiting providers to rural areas is often challenging due to the appeal of higher salaries and better school districts and community amenities that urban areas can offer. Even in urban areas, Arizona’s healthcare workforce has not kept pace with the state’s rapid population growth. These challenges are quantified by the total of 587 federally designated Health Professional Shortage Areas (HPSAs), which includes 220 primary care, 211 dental, and 213 mental health HPSA designations. There are also 37 Medically Underserved Areas and 10 Medically Underserved Population designations in the state. Arizona needs an additional 558 full-time primary care physicians, 381 dentists, and 182 psychiatrists statewide to eliminate the existing HPSAs.24

Arizona's Primary Care Areas (PCAs) serve as the state's rational service area boundaries for shortage designation purposes and are used by ADHS and other state agencies for health data analysis. Of Arizona's 126 PCAs, 41 have a population-to-primary care physician ratio of greater than 5,000:1 or no primary care physicians in their community at all. Of these, 24 are rural areas, 7 are tribal, 6 are frontier, and 4 are urban. Travel distance to the nearest primary care physician ranged from 2 to 78 miles. Of the six PCAs with the longest travel distance, half are tribal areas and all are rural or frontier.24

Lack of Health Insurance

As of April 2021, there are 2,200,141 enrollees in the Arizona Medicaid Program (AHCCCS)—an increase of over 278,000 in the past year.  While the number of people without insurance fell in Arizona over the past several years (from 19% in 2013 to 11.3% in 2019), it remains higher than the national average (9.2%) with about 808,643 people uninsured. Included in this number are 161,330 uninsured children and youth under the age of 19 (9.2%). This figure is substantially higher than the national average of 5.7%.25 While Arizona’s percentage of uninsured children has decreased from a high of 15% in 2008, decreases in uninsured children have not been as consistent as national changes.

Transportation

There are few major highways in Arizona, and the state’s striking geographical features—including mountain ranges, valleys, canyons, and rivers—present significant barriers to transportation.  The Phoenix-area metro transit system is very limited for an urban area of its size, and public transportation is nonexistent in rural areas of the state.  Outside of the Phoenix metro area, Arizona’s population is dispersed among remote rural and frontier communities.  Arizona’s population per square mile is just 56.3, compared to 87.4 nationally.4  Rural residents often have to endure long drives, sometimes over dirt roads, to access health care.  Concerns over travelling through border patrol road checkpoints present additional barriers to some families.

Education Level

Education level can impact an individual’s health literacy and self-efficacy in accessing health care.  Nationally, 41.1% of adults aged 25 years and older with at least a high school education report their health is very good or excellent compared to only 22.8% with less than a high school education.  With Arizona ranking in the bottom three nationally for high school graduation rates, this is a significant contributor to women’s and children’s overall health status.11

Language and Culture

More than a quarter (27.1%) of Arizonans reported speaking a language other than English at home, compared to 21.6% nationally, and this rate is 79.7% in one Arizona/Mexico border county.4  Culturally and linguistically appropriate health care services are lacking in many communities in Arizona.

One unique aspect of Arizona’s geographic and cultural landscape is its large American Indian population.  Arizona is home to 21 federally recognized tribes and has the largest total American Indian population of any state—over 378,000 individuals.4  In addition, the majority of the Navajo Nation, the largest reservation in the U.S., lies in Arizona, and five of the top ten largest reservations in the United States are located in Arizona. Over a quarter of the state is designated as reservation land.  American Indians experience significant disparities compared to whites for many health indicators.  The infant mortality rate among American Indians was 6.9 (per 1,000 live births) in 2019, as compared to 5.4 Arizona average.26 Between 2016-2019, 9.8% of severe maternal morbidity events in Arizona were among American Indian women—despite only 3.9% of births during that period being to American Indian women.27

MCH Health Disparities

While infant and maternal outcomes are better than average overall in Arizona, this is not true across all populations within the state.  The overall infant mortality rate is 5.4 (per 1,000 live births)—below the national average of 5.8—but this rate jumps to 10.1 for African Americans and 8.5 for American Indians within Arizona.11  Similarly, while the percent of births that are low birthweight across all races in Arizona (7.6%) is lower than the national average, a much higher percentage (12.3%) of African American babies are born low birthweight.11

The Healthy Smiles Healthy Bodies Survey indicated that more than half (52%) of Arizona's kindergarten children have a history of tooth decay, higher than the national average for 5 year olds (36%), and almost two in three third grade children (64%) have a history of tooth decay compared to 52% of third grade children in the general U.S. population.28

Arizona’s vaccine coverage rates continue to decrease. Non-medical exemption rates—the percentage of students exempt from one or more vaccines—increased across all age categories.  Arizona's percentage of 19-35 month olds being adequately immunized has remained below our 90% target at 70.7%—ranking us 43rd in the nation.11

Women of color (Hispanic, black, and Native Americans) are disproportionately affected by severe morbidity and mortality in Arizona. Like much of the country, Arizona’s maternal mortality rate continues to increase. The latest maternal mortality rate for Arizona was estimated at 27.3 deaths per 100,000 live births; ranking Arizona 29th in the nation (where a rank of 1 is best). As we see with other MCH indicators, American Indian and African American women are disproportionately impacted by maternal mortality, with rates of 53.7 and 43.3, respectively.11

Impact of COVID-19

As in most places, public health—and life in general—has been impacted substantially by the COVID-19 pandemic. As of May 7, 2021, there have been 867,443 cases and 17,391 deaths due to COVID-19 in Arizona.29 That is a rate of 12,066 cases per 100,000 population— currently the sixth highest rate among all states.30 COVID-19 cases surged in early January 2021, with over 12,000 cases in a single day reported in Arizona. At this point, between the needs of COVID and non-COVID patients, only 7-10% of the ICU beds in the state were available.29

Fortunately, the number of cases per day, hospitalizations, and percent positivity have been dropping steadily over the past months as vaccines have been rolled out. As of mid-July 2021, over 6.6 million doses of COVID-19 vaccine have been administered in the state, and half of Arizonans have been vaccinated. COVID-19 vaccination rates vary quite a bit by county; from 17.6% in rural Apache county in the far northeast of the state to 66.8% in tiny Santa Cruz county along the Mexico border. Maricopa county, by far the most populous county in Arizona, has a vaccination rate of 35.5%.29

In Arizona, as we have seen across the nation, the COVID-19 pandemic has laid bare long-standing inequities in health outcomes and provision and shown us the true cost of our indifference to these disparities. In particular, there has been a disparate impact of COVID-19 deaths on the Navajo Nation and other tribal lands. The main contributing factors to this disproportionate impact are health care quality, accessibility, and cultural-relevance; infrastructure challenges (e.g., homes with no running water, multi-generational housing, etc.); and underlying health conditions (e.g., disparate burden). We have also seen a disparate burden of COVID-19 incidence and deaths among essential workers (e.g., health care workers, meat packers, prison guards, etc.) and the communities in which they live.

The COVID-19 pandemic created some emerging and unique public health issues for Arizona’s MCH populations, apart from the immediate impact of the disease.  For some women and children, the stay-at-home order meant that they were isolated with an abusive partner or caregiver. The City of Phoenix Police reported that domestic-violence related deaths during the first half of 2020 were up 140% compared to that time frame the previous year, and that domestic violence calls had doubled since the start of the pandemic.

In addition, stay-at-home orders and social distancing measures implemented to mitigate the spread of COVID-19, unfortunately, did result in increased feelings of isolation for many people. The impact of this isolation could be mediated or exacerbated, depending on factors like living situation (e.g., alone or with others), alternative means of access to family and friends (e.g., comfort or access to virtual technology), and underlying mental health issues. While it is still early to understand fully the impact the pandemic may have had on diseases of despair, Arizona continues to monitor suicide and injury data to assess this impact.

There is also a concern that people have been deferring preventative and essential care during the pandemic. Specific to our MCH populations, we have observed a decrease in attendance of well-child visits. The childhood immunization rate has also gone down during the pandemic, an issue that goes hand-in-hand with the decrease in well-child visits, and it is unclear whether parents will take their children in for their recommended vaccines once the epidemic abates. In addition, the pandemic decreased the number of providers in some areas and, although most providers are now reopened, increased cleaning requirements and social distancing have decreased the number of children that can be seen in a day. There is difficulty getting appointments, especially in rural areas where there is a lack of providers overall.

Some other changes that Arizona’s Title V Program has observed with respect to our MCH populations are:

• Fewer referrals and more refusals by clients for referrals for behavioral health services and tobacco cessation services
• Fewer developmental screenings completed for children
• Potential for youth engaging in more risky behaviors due to lack of peer support, isolation, and increased exposure to unhealthy coping behaviors and environments

These secondary impacts of the pandemic are likely to last for a while, and it will be important to identify and address them with targeted actions and resources in the years to come.

Roles, Responsibilities, and Targeted Interests of State Health Agency

The Arizona Department of Health Services (ADHS) is one of the executive agencies that report to the Governor. By statute it has been designated the Title V agency in Arizona. The Bureau of Women’s and Children’s Health (BWCH) is a component of the ADHS Public Health Prevention Services Division. Patricia Tarango, Chief, Bureau of Women’s and Children’s Health, serves as the Title V Administrator and the state’s Maternal and Child Health (MCH) Director. Laura Luna Bellucci, Chief, Office of Children’s Health, serves as the Children with Special Health Care Needs (CSHCN) Director. In Arizona, the Office of Children’s Health oversees programming within ADHS for children and youth with special health care needs (CYSHCN). Please refer to III.E.2.a. State Title V Program Purpose and Design and VI. Organizational Chart for more detail.

ADHS adopted a five-year strategic plan and map for 2018-2023. The Strategic Priorities for this plan are:

• improve health outcomes;
• promote and support public health and safety;
• improve public health infrastructure;
• maximize agency effectiveness; and
• implement the Arizona Health Improvement Plan.

In 2014, ADHS conducted the first State Health Assessment (SHA), and an updated SHA was released in April 2019. ADHS used a variety of primary and secondary data sources to produce the analysis for this assessment. Input on the SHA was collected from many stakeholders, including local health officers and tribal partners. The 2019 State Health Assessment is structured around the themes of Healthy People, Healthy Communities, focusing on health outcomes across the lifespan, examining issues in maternal and infant health, child and adolescent health, healthy adults, and healthy aging.

ADHS used this assessment to set priorities and performance objectives for the Arizona Health Improvement Plan (AzHIP), published in 2021. Development of the 2021-2025 Arizona Health Improvement Plan (AzHIP) has taken place over the past year and reflects the commitment to improving public health of public health professionals, advocates and community stakeholders at the state, county and community levels. The 2021-2025 plan consists of 5 priorities: 1. Health Equity, 2. Health in All Policies/Social Determinants of Health, 3. Mental Well-being, 4. Rural & Urban Underserved Health, and 5. Pandemic Recovery & Resiliency. Each priority has defined strategies, tactics, and action plans which are led by a variety of community partners. The Title V Director co-chairs the Rural & Urban Underserved Health Core Team.

In addition, as a condition of the block grant, HRSA requires each state’s Title V Program to complete a needs assessment every five years, and to track emerging issues and identify how they affect the MCH population in Arizona on an ongoing basis. For the 2020 Title V Needs Assessment, ADHS partnered with the University of Arizona, Diné College of the Navajo Nation, and the Inter Tribal Council of Arizona (ITCA) to conduct the assessment. In addition to collecting and analyzing quantitative MCH data from national and state data sources, the assessment was designed to engage families and the public through a public survey, focus groups, and community forums to capture qualitative and quantitative data that draws on the experience and knowledge of the communities we serve.

Arizona’s Title V Program developed our new maternal child health (MCH) priorities by collecting and analyzing data from the 2020 Needs Assessment, sharing that data with community members and other MCH stakeholders on our Needs Assessment Steering Committee, and soliciting their input to identify priority areas in line with the intent of the Title V Maternal Child Health Block Grant.  A key component of this analysis was disaggregating the data to expose disparities that might not be obvious in the aggregated data. For instance, although Arizona’s infant mortality is below the national average at 5.4 (per 1,000), there is a disparity between white non-Hispanic and black infant mortality—and each of these rates need improvement to meet the Healthy People 2030 goal of 5.0 (per 1,000).

Prescription drug abuse and subsequent neonatal abstinence syndrome (NAS) are an ongoing challenge. In June 2017, Arizona Governor Doug Ducey declared the opioid crisis a public health emergency and in the four years since that declaration, there have been 9,345 opioid deaths, 68,204 opioid overdoses, and 2,640 babies born with NAS in Arizona.31  In the upcoming year, ADHS will be responsible for the development and implementation of four Governor Goal Council Breakthrough Projects–Suicide Prevention Action Plan, Sexually Transmitted Diseases Control Action Plan, Increasing Immunization Coverage Rates in Arizona Action Plan, and Maternal Mortality Action Plan. BWCH will continue to be the lead on Maternal Mortality and have strong participation in the other Goal Council Projects.

Components of State’s System of Care

Medicaid aims to ensure access to health care for low-income individuals, and 21% of Arizona’s population is covered by the Arizona Health Care Cost Containment System (AHCCCS), the state Medicaid program. AHCCCS also offers medical treatment, rehabilitation, and related support services to qualifying children with special health care needs through the Arizona Children’s Rehabilitative Services (CRS) program. Other sources of health insurance for Arizona residents include private via employer or non-group (45%), Medicare (16%), and other public coverage such as VA or military (2%).  However, this leaves 11% of Arizona’s population completely uninsured and vulnerable.32

In Arizona, the Primary Care Office is housed within the Bureau of Women’s and Children’s Health and Arizona’s Title V Program supports programming to meet the needs of uninsured and underinsured Arizonans. For example, BWCH maintains, annually updates, and publishes a list of primary care, dental, and behavioral health providers in Arizona that offer a sliding fee schedule to under- or uninsured individuals. There are currently over 400 sites utilizing a sliding fee scale in Arizona that offer some combination of primary care, dental, and/or behavioral health services. In addition, Arizona has a number of community health centers, rural health clinics, Federally Qualified Health Centers (FQHCs), and Critical Access Hospitals that offer essential lower cost care to vulnerable Arizonans. In 2020, Arizona’s Title V Program partnered with the Arizona Alliance for Community Health Centers (AACHC), Arizona’s Primary Care Association (PCA), to educate communities about programs and resources that can help recruit healthcare professionals in areas with significant challenges with recruitment and to improve the coordination of rural recruitment efforts between the ADHS’ Primary Care Office, PCA, and the State Office of Rural Health (University of Arizona’s Center for Rural Health). In addition, Title V partnered with AACHC to help support and expand clinical rotation and internship opportunities for healthcare providers at community health centers focused on maternal and child health.

The Medical Services Project, funded through Title V and implemented by the Arizona Chapter of the American Academy of Pediatrics, works to increase the statewide network of pediatric providers and pediatric subspecialists willing to take a limited number of patients without insurance or AHCCCS to ensure that Arizona’s children have necessary acute health care. Title V-funded Family Planning Clinics, administered by 12 local county health departments in Arizona, make family planning and reproductive health services available to uninsured and/or low-income families in Arizona.

Arizona’s system of care also includes a Level III Neonatal Care Center and wide variety of pediatric specialists through the Phoenix Children’s Hospital, eight Level III Perinatal Care Centers, seven Level IIE Perinatal Care Centers, 15 Level II Perinatal Care Centers, and seven Level I Perinatal Care Centers. These hospitals offer not only critical health care for children and families but also an opportunity for education. In fiscal year 2020 alone, 63,042 families of newborns left the hospital with tools to help them support their child’s health and learning.33

Arizona’s Children’s Health Insurance Program (CHIP), or KidsCare, serves children in households earning too much to qualify for AHCCCS but earning under 200 percent of the federal poverty level (FPL). Over the last ten years, there have been a number of changes in federal and state policy affecting Arizona’s CHIP program. Figure 4 illustrates policy changes occurring within the past years that have directly impacted insurance status and access to care for children living in Arizona. Arizona was at risk for an automatic freeze on KidsCare if federal funding fell below 100% two years ago, but the state budget fully funded KidsCare and eliminated that legislative language that would have frozen the program as federal match requirements changed. This was a major public health win in Arizona, securing health insurance coverage for more than 53,000 children currently.

Figure 4. Health Care Policy Changes Affecting Children, 2010 – 202034,35

On January 1, 2014, two policy changes impacting Medicaid eligibility for childless adults went into effect. The first policy change was the restoration of Proposition 204, extending eligibility to childless adults earning between 0 and 100 percent FPL. The second change was Arizona’s expansion of Medicaid eligibility to include childless adults earning between 100 and 133 percent FPL. Proposition 204 eligibility had been frozen since 2011. Expanding coverage to the new adult group was an opportunity provided by the Affordable Care Act (ACA) and supported by then-Governor Janet Brewer. With these policy changes, these eligibility programs provided Medicaid coverage for 566,752 individuals in May 2021. With unemployment and economic hardship on the rise due to the COVID-19 pandemic, the number of Arizonans covered by the adult expansion program increased 83% in the past year.36

Over the past decade, there was an overall 64% increase in SOBRA enrollments for eligible pregnant women. Amended under Title VI of the Sixth Omnibus Budget Reconciliation Act (SOBRA) of 1986, the Act gave states the option of extending coverage to women requiring pregnancy-related medical services beyond previously set income eligibility thresholds established by states. SOBRA enrollments for pregnant women decreased by about 4,000 (21%) in the past year. SOBRA services for children under the age of 18 also increased over 600% in the past decade, and grew by 7% over the past year.36

At the close of the 2021 open enrollment period, 154,504 Arizonans selected marketplace plans through the federally-facilitated exchange.37  Figure 5 illustrates characteristics of the individuals selecting marketplace plans in Arizona.

Figure 5. Marketplace Plan Selection Characteristics – Arizona, Close of 2021 Open Enrollment Period37

In summary, recent federal and state health policy changes have increased the number of Arizonans covered by insurance. Counting marketplace plan selections (154,504) with the Proposition 204 restoration population (417,557) and the childless adult expansion population (149,195), 721,256 additional Arizonans have health insurance who may not have had it prior to the policy changes being implemented. This increase in covered individuals has also lowered the percent of uninsured in Arizona from 19% in 2013 to 11% currently, not including effects of employer-based and other non-marketplace/Medicaid-insured populations.

The efficiencies and benefits of integration of physical and behavioral health care has been an issue often discussed in Arizona over recent years, prompting AHCCCS to create a new integrated system of care called “AHCCCS Complete Care” (ACC).  ACC began on October 1, 2018, joining physical and behavioral health care services together to treat all aspects of members’ health care needs under one chosen health plan.  Improved coordination between providers within the same network is expected to result in better health outcomes for AHCCCS members.

Over two-thirds of the nearly $12.8 billion Arizona budget for Fiscal Year 2022 is for K-12 education, AHCCCS, and the Department of Corrections. Forty-six percent (46%) of the general fund goes to elementary and secondary education (approximately $5.9B), about 15% for AHCCCS (approximately $1.9B), and about 10% for corrections (approximately $1.3B). ADHS receives less than 1% of the general fund expenditures ($105M).38

The 2021 Arizona Legislative Session lasted for 171 days, the third longest session on record. There were several successful bills that will improve public health, including legalizing overdose and disease prevention programs (such as syringe access programs), requiring mental health lessons be included in K-12 health education curriculum, requiring telehealth services be paid at the same rate as in-person services, establishing Graduate Medical Education (GME) programs at health centers to encourage providers to practice in rural and underserved communities, and establishing a new Area Health Education Center specifically focused Arizona’s American Indian health system.

Relevant Statutes

There are several Arizona statutes that impact and support MCH and CYSHCN programs.  Arizona Revised Statute (A.R.S. 36-691) formally accepts Title V and designates ADHS as the Title V agency accepting the conditions of Title V of the Social Security Act, entitled "grants to states for maternal and child welfare," enacted August 14, 1935, and as amended.

Additional state statutes authorize a number of MCH programs or functions not specific to Title V. The statutory list of functions (A.R.S. 36-132) of ADHS includes: encourage and aid in coordinating local programs concerning maternal and child health, including midwifery, antepartum, and postpartum care; infant and preschool health and the health of school children, including special fields such as the prevention of blindness and conservation of sight and hearing; and encourage, administer, and provide dental health care services and aid in coordinating local programs concerning dental public health, in cooperation with the Arizona Dental Association. Subject to the availability of monies, develop and administer programs in perinatal health care. Some of these programs are managed outside of the Bureau of Women’s and Children’s Health (BWCH); in those instances BWCH staff remain involved by coordinating closely with agency colleagues.

Amended rules (R9-101-117), effective July 1, 2014, were adopted for the licensing of lay midwives in Arizona. The new rules include a change to the scope of practice to include the delivery of frank breech and vaginal delivery after caesarean section under certain prescribed circumstances. The rule changes also add clear requirements for reporting, transfer of care, and emergency action plans. Title V leadership was involved in the rulemaking process.

State statute (A.R.S. 36-697) authorized the Health Start program, administered by BWCH. The program, serving pregnant women, children and their families, is required to be statewide, based in identified neighborhoods, and delivered by lay health workers through pre-scheduled home visits or group classes that begin before the child's birth or during the postnatal period and may continue until the child is two years of age.

Lay health workers, or Community Health Workers (CHWs), will soon have the opportunity to apply for voluntary certification through ADHS.  Bill H2324 was passed in the 2018 Arizona Legislative Session requiring ADHS to adopt rules prescribing the scope of practice, minimum qualification, education and training standards, and criteria for certification of community health workers.  A nine-member Community Health Workers Advisory Council was established and is currently working through this rule-making process.

BWCH also manages the Oral Health Fund established by ARS 36-138. Funds received as reimbursement from the state’s Medicaid program contractors for dental services provided by BWCH are put into the Oral Health Fund, which is then used to fund additional dental health services.  Additionally, Bill H2235 was passed in the 2018 Legislative Session requiring ADHS, in consultation with the Board of Dental Examiners, to conduct a study by December 31, 2023 on the impact of licensing Dental Therapists on patient safety, cost effectiveness and access to dental services in Arizona.

State statute (A.R.S. 36-899.01) also requires ADHS, through BWCH, to administer a program of hearing evaluation services to all school-aged children.

Vision screening legislation (SB1456) was passed on August 17, 2019. This bill requires vision screening of children in Arizona upon initial entry to school as well as not more than two additional grade levels in a district or charter school that provides preschool and/or K-12 instruction. The vision screening law is now officially in the Arizona Revised Statutes and can be found at: ARS §36-899.10. Official rulemaking for vision screening has not yet been established under A.R.S. 36-899.10. The timeline for rulemaking is on hold at this time due to COVID-19. The ADHS Sensory Screening Program is committed to developing screening rules that follow national guidelines, which will support early detection and intervention of children with vision impairments. Until the rules are completed and approved, there are no official requirements in place for vision screening regarding training, screening, and reporting of data to ADHS.

The Child Fatality Review Program, authorized by state statute (A.R.S. 36-3501), requires the State Child Fatality Review Team to conduct an annual statistical report on the incidence and causes of child fatalities and submit a copy of this report, including its recommendations for action, to the Governor and legislative leadership on or before November 15 of each year. This report also includes recommendations from the committee for the public. The Program is housed in the BWCH and the Bureau Chief is a legislatively required member of the State Team.

The Arizona Revised Statute (A.R.S. § 36-3501) was amended in April 2011 to establish the Arizona Maternal Mortality Review Committee (MMRC) as a subcommittee to the Child Fatality Review (CFR) Program. Though unfunded, Arizona Maternal Mortality Review Program (MMRP) has convened an MMRC since June 2012 to review all identified maternal deaths in the State. In 2019, ADHS was officially awarded $450,000 per year for five years from the Centers for Disease Control and Prevention's Preventing Maternal Deaths: Supporting Maternal Mortality Reviews grant. ADHS is using this funding to strengthen the current structure and data collection processes of the Arizona MMRC and to build a just, strong, sustainable and focused effort to systematically increase access, quality of care and overall health for all women in Arizona. MMRP details can be found in the 2019 Women’s Health Report of this application.

During the 2015 legislative session the Governor signed into law HB 2643, which prohibits the state and its political subdivisions from using any personnel or financial resources to enforce, administer, or cooperate with the Affordable Care Act in many ways with the exception of public health prevention programs.

Senate Bill 1040 was passed into law during the 2019 legislative session and was repealed on July 1, 2021. The bill delegated authority to the Arizona Department of Health Services to designate a chair and appoint the committee members. The bill established an advisory committee on maternal fatalities and morbidity and dictates the advisory committee composition. The primary role of the advisory committee was to recommend improvements to data collection regarding the incidence and causes of maternal fatalities and severe maternal morbidity.  The statute also directed the advisory committee to submit two reports to the House of Representatives, Senate and the Governor’s Office.  The first report was due and submitted in December 2019 with recommendations regarding improvements on data collection.  The second and final report was submitted December 2020, providing an account on the incidence and causes of maternal fatalities and morbidity for 2016–2018. The Arizona MCH Director served as the Committee Chair and the MCH program staff provided data analysis for the committee.

Senate Bill 1011 establishing a Maternal Mental Health Advisory Committee to be conducted through the state Medicaid program, AHCCCS, was passed in 2021. The committee will recommend improvements for screening and treating maternal mental health disorders. Initially ADHS Title V was not given a seat on the Committee, however through an amendment to the bill, ADHS Title V maternal health program representation on the advisory committee is required.

Senate Bill 1181 was passed in 2021 which allows for voluntary certification of Doulas. The bill requires the Department (ADHS) to establish an advisory committee made up of at least nine Director-appointed Doulas that represent diverse and underrepresented communities along with other experts. The committee will be tasked with creating a scope of practice and core competencies that are essential to expand health and wellness, to reduce health disparities and to promote culturally relevant practices within diverse communities.

Senate Bill 1680 was passed in 2021 and requires the Newborn Screening Program (Program) to include all congenital disorders included on the Recommended Uniform Screening Panel (RUSP). Passing of the bill allows for an automatic update of the state required newborn screening list any time the federal government adds more conditions to its recommended list. The passing of this bill will expand Arizona's screening list from 31 conditions to all 35 conditions as federally recommended.  Additionally, this bill requires the Program to include all congenital disorders included on the RUSP for both core and secondary conditions. The bill also requires that the state automatically update the required newborn screening list any time the federal government adds more conditions to its recommended list.

House Bill 2126 passed on March 23, 2021 added the following language to the Arizona State Loan Repayment Program Rules, “An applicant who works at an Indian Health Service or tribal facility is not required to provide a sliding fee scale to be eligible for the program.” Many tribal and IHS facilities do not implement Sliding Fee Schedules because they do not charge IHS-eligible clients for health care services rendered. This exemption allows these entities to have greater participation in the Arizona State Loan Repayment Program without having to implement a Sliding Fee Schedule.