Demographics, Geography & Economy
Arizona’s population was estimated to be 7,276,316 in 2021 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), and 2nd in the nation for population growth from 2019 to 2020 (1.8% growth).2 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 2021, Arizona’s population was 31.7% Hispanic (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
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. Nearly 46% 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 2019 Kaiser Family Foundation estimates, Arizona has the country’s 15th highest poverty rate (18.7%) among children.6 In a five-year estimate for 2016-2020, 14.1% of Arizonans lived in poverty—down from 15.1% in 2019, but higher than the current national poverty rate of 12.8%— and 24.5% of those without a high school diploma lived below the poverty line.7 Poverty varies dramatically by county within Arizona. The highest rates of poverty are in Apache (34.4%) and Navajo (25.3%) counties; the lowest rates are in Pinal (12.1%), Yavapai (12.6%), and Maricopa (12.7%) counties.7 U.S. Department of Agriculture, Economic Research Service 2020 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 2020, 20% of children under age 18 lived below the poverty line.7 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 2020 was $61,529 compared to the national median income of $64,994. Median household income also varies widely by county and type of household. At $67,799, Maricopa County had the highest median household income; Apache County had the lowest at $33,967. Median household income also varies by type of household, with married couple families earning $86,678, families with children under 18 earning $69,758, and female-headed, single-parent families earning $32,594.17
Arizona’s unemployment rate ranged 4.7-5.0% from mid-2017 until March 2020, when it quickly spiked due to the emerging global pandemic; reaching a high of 13.9% in April 2020 with 473,167 unemployed. It has since decreased to rates of 3.3-3.9% during the first half of 2022. Unemployment varies across the state of Arizona. In 2021, Greenlee county had the lowest unemployment rate (4.0%), while Yuma county had the highest (12.9%).18
In addition to individuals, poverty is calculated for families with children under the age of 18. In a five-year estimate for 2016-2020, 15.9% of families in Arizona with children were below the poverty line; 1.6 percentage points higher than the national average (14.3%).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 2019, 27% and 28% of Asian and white children, respectively, lived in low-income families compared to 71% of Native American children, 60% of Hispanic children, and 55% of black children.20
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 (11.0 vs. 10.7%), but has decreased significantly—over 4 percentage points—over the past ten years. In 2018-2020, 3.8% of Arizona households had very low food security.23
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 2020, 10.5% of households in Arizona received SNAP assistance (or food stamps). The lowest are 8.2% in Yavapai County and 8.6% in Greenlee County, compared to a high of 27.9 and 23.9% in Apache and Santa Cruz Counties, respectively.21
As children, Arizonans also face other challenges as well. A 2021 America’s Health Rankings report placed Arizona with the 16th highest rate of adverse childhood experiences (ACEs) and 17.3% of Arizona’s children experienced two or more ACEs last year (compared to 14.8% 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 $8,773 per student compared to the national average of $13,187 per student in fiscal year 2019.14 The U.S. Census ranked Arizona 48th of the 50 states and the District of Columbia in public per pupil spending in fiscal year 2020.15 The National Assessment of Educational Progress (NAEP) is an assessment of what America’s students know. 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 685 federally designated Health Professional Shortage Areas (HPSAs), which includes 238 primary care, 218 dental, and 229 mental health HPSA designations. There are also 37 Medically Underserved Areas and 11 Medically Underserved Population designations in the state. Arizona needs an additional 653 full-time primary care physicians, 406 dentists, and 217 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.39
Lack of Health Insurance
As of May 2022, there are 2,395,584 enrollees in the Arizona Medicaid Program (AHCCCS)—an increase of 178,452 in the past year.36 While the number of people without insurance fell in Arizona over the past several years (from 19% in 2013 to 10.6% in 2020), it remains higher than the national average (8.7%). There are about 747,778 people in Arizona without health insurance, of which 148,596 are children and youth under the age of 19. This is an 8.5% uninsured rate for this age group; substantially higher than the national average of 5.2%.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 about traveling 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 two 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 (26.7%) of Arizonans reported speaking a language other than English at home, compared to 21.5% nationally, and this rate is 78.8% 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 22 federally recognized tribes and has the largest total American Indian population of any state—over 385,000 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 5.6—but this rate jumps to 9.9 for African Americans within Arizona.6 Similarly, while the percent of births that are low birthweight across all races in Arizona (7.4%) is lower than the national average, a much higher percentage (13.0%) of African American babies are born low birthweight.6
The Healthy Smiles Healthy Bodies Survey indicated that more than half (52%) of Arizona's kindergartens 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 78%—ranking us 22nd 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 25, 2022, there have been 2,049,627 cases and 30,299 deaths due to COVID-19 in Arizona.29 That is a rate of 28,159 cases per 100,000 population—currently the twelfth highest rate among all states.30 Like last year, COVID-19 cases surged in January 2022, with over 150,000 cases in a single week reported in Arizona. At this point, between the needs of COVID and non-COVID patients, only 5% of the ICU beds in the state were available.29
Fortunately, the number of cases and hospitalizations have been dropping steadily over the past months. As of mid-May 2022, over 5 million Arizonans (71.2% of the population) had received at least one dose of COVID-19 vaccine. COVID-19 vaccination rates vary quite a bit by county; from 43-45% in a few rural counties to 100% in tiny Santa Cruz county along the Mexico border. Maricopa County, by far the most populous county in Arizona, has a vaccination rate of 66.3%.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 increased by 175% in 2020 over 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. A CDC analysis recently released highlighted that 37% of high school students reported experiencing poor mental health during the pandemic, and 44% reported feeling persistently sad or hopeless in the past year.40
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 also went down during the pandemic, an issue that goes hand-in-hand with the decrease in well-child visits. The immunization coverage rate for Arizona’s kindergarteners has been steadily decreasing each year, down to 90.6% in the 2021-2022 school year. 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. Laura Luna Bellucci, 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 and Children with Special Health Care Needs (CSHCN) Director. Patricia Tarango, former BWCH Bureau Chief, retired from state service on March 31, 2022. 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 the SHA was most recently updated in January 2022. 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 2021 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) 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. A BWCH staff member 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 five years since that declaration, there have been 7,597 opioid deaths and 16,571 non-fatal opioid overdoses in Arizona.31 ADHS is 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 (49%), Medicare (17%), and other public coverage such as VA or military (3%). However, this leaves nearly 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 2021, 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 10 local county health departments and one public health system 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 2021 alone, 48,384 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% three 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 65,000 children currently.
Figure 4. Health Care Policy Changes Affecting Children, 2010 – 202034,35
Date |
Federal/State Policy Change |
January 2010 |
KidsCare/CHIP enrollment freeze. Nearly 46,000 children are enrolled in KidsCare when the freeze goes into effect. KidsCare waiting list swells to more than 100,000 by July 2011. |
March 23, 2010 |
The Patient Protection and Affordable Care Act (PL 111-148) is signed into law. |
May 2012 |
Enrollment opens for Kids Care II, a time-limited alternative CHIP program for children up to 175% FPL (unlike original KidsCare eligibility limit of 200% FPL). KidsCare II was the result of an agreement with federal officials to re-open CHIP coverage for some children, with the idea that the program would end in January 2014 to correspond with the ACA’s new marketplace coverage options. |
November 2012 |
Kids Care II enrollment reopens for additional children. |
May 2013 |
Kids Care II returns income eligibility limit to 200% FPL. |
January 1, 2014 |
Federally facilitated marketplace insurance plans can be used to access health care services. |
January 1, 2014 |
Transfer of school-aged “stairstep” children from KidsCare to Medicaid. More than 26,000 children ages 6 through 18 enrolled in KidsCare and KidsCare II (the state CHIP program) with family incomes up to 138% FPL transferred to the Arizona Health Care Cost Containment System (AHCCCS, or Medicaid). |
January 31, 2014 |
Kids Care II ends, KidsCare enrollment freeze remains in effect. 14,000 children lose KidsCare II coverage and receive notices referring them to the ACA’s new federal health insurance marketplace where they could potentially purchase health insurance. |
May 6, 2016 |
KidsCare is re-instated, covering 30,000 additional children in families with incomes between 134-200% FPL. |
May 2018 |
The Arizona Legislature failed to pass an amendment that would eliminate the automatic freeze on KidsCare should federal funding drop below 100%. |
May 2018 |
KidsCare enrollment increased by 45% in the past year, reaching 28,761. |
October 2018 |
AHCCCS Complete Care (integrated physical and behavioral health) implemented. |
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 643,422 individuals in May 2022. 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 2021 and has leveled off over the past year (down 2%).36
Over the past decade, there was an overall 76% 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 increased by 2,668 (17%) in the past year. SOBRA services for children under the age of 18 also increased nearly 800% in the past decade, and grew by 2% over the past year.36
At the close of the 2022 open enrollment period, 199,706 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 2022 Open Enrollment Period37
Characteristics |
Number of Individuals |
Percentage of Total |
Total individuals with plan selections |
199,706 |
|
New consumers |
48,940 |
25% |
Plans eligible for financial assistance |
199,673 |
100% |
Younger than 18 years of age |
30,161 |
15% |
Aged 18-64 years |
167,245 |
84% |
In summary, recent federal and state health policy changes have increased the number of Arizonans covered by insurance. Counting marketplace plan selections (199,706) with the Proposition 204 restoration population (496,610) and the childless adult expansion population (146,812), 843,128 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, combining 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 $15.3 billion Arizona budget for Fiscal Year 2023 is for K-12 education, AHCCCS, and the Department of Corrections. Forty-five percent (45%) of the general fund goes to elementary and secondary education (approximately $6.9B), about 15% for AHCCCS (approximately $2.3B), and about 9% for corrections (approximately $1.3B). ADHS receives only about 1% of the general fund expenditures ($187M).38
The 2022 Arizona Legislative Session just recently adjourned on June 25. There were several successful bills that will improve public health, including expanding Medicaid coverage for pregnant women to include postpartum physical and behavioral health care for up to 12 months after the child is born, adding behavioral health providers as eligible provider types to the State Loan Repayment Program, funding a variety of programs intended to enhance the nursing workforce in the state, and development of new, secure behavioral health residential facilities across the state.
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. Approximately $50,000 in Title V funds were utilized in 2021 to support the development of the new CHW Licensing Database.
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 Program is actively working on the vision screening rules and is currently on its second draft phase. The Program, in conjunction with the Rules Department, has been reaching out to the public via surveys and virtual meetings to get their feedback on the drafted rules. 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 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.
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 established an advisory committee on maternal fatalities and morbidity and dictates the advisory committee composition. The bill delegated authority to the Arizona Department of Health Services to designate a chair and appoint the committee members. 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, passed in 2021, establishes a Maternal Mental Health Advisory Committee, which will be conducted through the state Medicaid program, AHCCCS. The committee will recommend improvements for screening and treating maternal mental health disorders. Initially, ADHS was not given a seat on the Committee; however, through an amendment to the bill, a “representative from the department of health services maternal health program” is now required on the advisory committee.
Senate Bill 1181, passed in 2021, 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, passed in 2021, requires the Newborn Screening (NBS) 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 NBS 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.
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