Maine CDC Role in Delivery of Title V Services
The Maine Center for Disease Control and Prevention (Maine CDC), an Office of the Maine Department of Health and Human Services (DHHS), is responsible for providing essential public health services that preserve, promote and protect the health of the State’s population. The State Health Improvement Plan, designed to improve the health of all Maine people, identified public health priorities and outlined objectives, strategies and outcomes for statewide action. As part of this planning process, the Maine Public Health Districts further defined goals, objectives, strategies and community partners unique to the population served.
Strengths and Challenges Impacting the Health Status of the MCH Population
Maine has a long history of effectively addressing public health issues and improving health outcomes within the MCH population. Over the last twenty years, Maine reduced tobacco use rates among the adult and adolescent population, reduced births among adolescents and reduced premature births. Maine achieved these improvements in health status through collaborative work with other organizations in the public, private and non-profit sectors.
In the past twenty years, the Maine CDC developed an MCH epidemiology team that conducts data analysis and provides technical assistance to programs and partners in the use of data to select and implement evidence-based strategies that address poor health outcomes. Maine also developed nine public health districts that bridge the gap between local and state public health infrastructure; this work continues with the integration of prevention, inclusive of MCH services There are eight county-based public health districts and one tribal health district with planning considerations given to unique geographic and population needs.
The provision of Maine’s MCH clinical services is primarily by the private sector with limited public clinical services in urban areas (such as Bangor and Portland public health).
Maine continues to engage in health care reform. There are several initiatives in Maine’s health reform that positively impact MCH: the patient centered medical home, health homes, behavioral health homes, and payment reform and grant opportunities through the Centers for Medicare and Medicaid Services.
Maine’s systems of care for meeting the needs of underserved and vulnerable populations span multiple DHHS offices including Maine CDC and the Office of MaineCare Services (OMS). Maine CDC houses various programs serving these populations that include WIC and children with special health needs (CSHN). Both MaineCare and WIC serve clients who meet Medicaid income guidelines, as well as other eligibility criteria. These programs provide medical and dental insurance to vulnerable families as well as food security. They play an important role in a pregnant woman’s prenatal care by ensuring proper nutrition to help the baby grow and ensuring they seek medical care when necessary. The WIC program provides breast pumps for nursing mothers, as well as formula for babies when needed. It also provides baby food and other nutritional foods for families. MaineCare provides medical coverage for children up to age 19.
The CSHN Program aims to ensure that families receive care coordination when a child does not pass a hearing screen, diagnosed with a cleft lip and/or palate, or diagnosed with a genetic condition. The CSHN Program connects families to specialty providers and clinics. The CSHN Care Coordinator, hired in April of 2019, is inventorying all resources available to clients with special health needs. Work is underway to enable the Care Coordinator to assist families experiencing health issues beyond hearing, cleft lip and/or palate and genetic conditions.
The Maine CDC and MaineCare continue to partner on the Medicaid Innovation Accelerator Program for the Maternal and Infant Health Initiative. This project links MCH to value-based purchasing. Maine’s project is to incentivize providers caring for pregnant women with substance use disorders to use the SnuggleME Guidelines (http://www.maine.gov/dhhs/SnuggleME/) to screen and refer them to treatment. The project requires Title V and the state Medicaid provider to work collaboratively and is now in its implementation phase. The team is assessing the number and those MaineCare providers using the screening billing code. The team will develop a plan to ensure provider notification of the opportunity and provide ongoing guidance regarding screening, referral and treatment of pregnant women with opioid use disorders.
The Medicaid Innovation Accelerator Program for the Maternal and Infant Health Initiative was a catalyst beyond the actual project implementation. It provided a mechanism for the Maine CDC and MaineCare to develop strong staff relationships. Since the projects’ inception, the Maine CDC and MaineCare have collaborated in other areas. For example, a MaineCare representative is a member of the MCH Domain Lead and Partner Team that meets monthly to coordinate MCH efforts across programs responsible for implementing the MCH Block Grant work plan. In addition, Maine CDC collaborated on the Centers for Medicare and Medicaid Maternal Opioid Misuse Model Grant proposal submitted by MaineCare. The Maine CDC Title V Director, attended planning meetings, connected MaineCare to other partners, provided viewpoints/resources and drafted narrative sections for inclusion in MaineCare’s application.
In 2017, Maine began using the CradleME referral system coordinated by Maine CDC Public Health Nursing staff. All Maine birthing hospitals, prenatal care providers, families and others are encouraged to submit a referral, so families can obtain needed services from Public Health Nursing or Maine Families Home Visiting at no cost.
The only children’s hospital in Maine, the Barbara Bush Children’s Hospital at Maine Medical Center, provides services ranging from well-child visits to advanced specialty services.
Financing of services
While many states expanded Medicaid coverage, a result of the federal Affordable Care Act, Maine’s then governor, Paul LePage, successfully vetoed the Medicaid expansion in Maine on five occasions. Governor LePage also passed reforms that tightened eligibility requirements for adults with dependents and elderly beneficiaries, resulting in 25,000 fewer MaineCare insured from 2014-2018.[a]
In 2017, Maine voters approved Medicaid expansion in a referendum vote, and in January of 2019, Maine’s current Governor, Janet Mills, approved the plan to fund the expansion. As of June 14, 25,477 people enrolled through the MaineCare expansion, including 20,648 adults without children, 4,829 parents and caretaker relatives.[b] We anticipate the number to grow but it is too early to determine the impact on Maine’s Title V programs.
Geography
NOTE: References noted throughout this section are documented in Section V: Supporting Documents.
Maine is the northernmost and largest state in New England and the easternmost state in the United States. Maine's population is growing at a slower rate than most of the U.S. and aging at a faster rate. The majority of residents reside in rural towns and small cities. The demographic and geographic factors that contribute to Maine's uniqueness among the New England states are the very same factors that create complex challenges for Maine's Title V agency as we strive to improve the health outcomes of the MCH population.
There are 1.34 million people residing in the state of Maine.1 Between 2010 and 2018 Maine's overall population increased 0.8% compared to 6.0% nationally.1 Maine experienced losses in population from natural causes (excess deaths over births; -7,412 people). Domestic migration (+7,959 people) and international migration (+10,343) caused Maine's population growth, resulting in increased racial and ethnic diversity within the state. In contrast, net natural increases caused 58% of the U.S. population increase in this period.2
Maine has three metropolitan (metro) areas; Portland-South Portland (pop. 532,083), Lewiston-Auburn (pop. 107,651) and Bangor (pop. 151,957).3 Collectively, 59.3% of Maine's population resides in these three metro areas3 (compared to 80.7% of U.S. residents who live in metro areas).4 More than one third (37.2%) of Maine's population lives in the two southernmost counties (Cumberland and York)3 that account for only 6% of the state's land area.5
The average population density of Maine is 43.1 people per square mile compared to 87.4 people per square mile in the United States.5 However, the population density of Maine varies dramatically across the state, from 337 people per square mile in Cumberland County where Maine's largest city (Portland) is located, to four people per square mile in Piscataquis County.5
The median age of Maine's population (44.7 years) is more than six years older than the U.S. (38.0 years) and is the highest in the country.6 Maine’s Office of Policy and Management projects that by 2034 a greater percentage of Maine's population will be age 65 years and older compared to 19 years and under (27.8% vs 20.2%).7 Between 2005 and 2034 Maine's population of 65 years and older residents will increase by 91.5% while the population under the age of 18 will decrease by 18.9%. Based on census projections Maine can expect a 1.8% decline in overall population in 2014-2034. Only three of Maine’s 16 counties (York, Cumberland and Penobscot) are projected to have positive population growth in that time.7
Maine's MCH populations (i.e., children, including those with special health needs and women of reproductive age) represent a significant proportion of the population. In 2017, children under 18 years of age plus women ages 18-44 represented 33% of Maine's population.3 Children under 18 years of age comprised 17.2 % of the state's population. Nationally, children under age 18 comprised 22.6% of the population.3
In 2017, the median age of women in Maine was 46.0 years.6 Women aged 15-44 years comprised 17.3% of Maine's population, similar to the proportion nationally (19.6%).6
Prevalence estimates of current disability or special health needs among Maine children differ depending on the definition used. According to the 2017 National Survey of Children’s Health (NSCH) there were nearly 58,171 CSHN in Maine, representing 22.9% of children under age 18 years.8
Demographics
Family
According to estimates from the 2013-2017 American Community Survey (ACS) the average household size in Maine was 2.3 people and the average family size was 2.9.9 A little more than a quarter of households (25.9%) in Maine included one or more children under age 18, compared to about a third in the U.S. (31.7%).9 Of the households with a child under age 18, 22.6% were female-headed (no husband present) households and 11.2% were male-headed (no wife present) households. Of the households with a child under age 18 nationally, 24.1% were female-headed and 8.1% were male-headed.9 Of Maine women aged 15 years and over 49.6% were currently married, 15.0% were divorced, 1.2% were separated, 9.3% were widowed, and 25.0% were never married.9
Racial and Ethnic Diversity
According to the 2013-2017 ACS, Maine's population is 94.6% White, 0.6% American Indian or Alaska Native, 1.3% Black or African-American, 1.1% Asian, and 2.1% are two or more races. People of Hispanic origin comprise 1.5% of the population.10 Of Maine's children under age 18, 89.1% are non-Hispanic White, 2.2% are Black or African American, 0.7% are American Indian or Alaska Native, 1.3% are Asian, 4.6% are two or more races and 2.5% are Hispanic.11 Although Maine's population is predominantly White, the state is gradually becoming more racially diverse. The proportion of the population that is White decreased from 97.3% on the 2000 Census to 95.6% in 201011 and to 94.6% according to the most recent Census estimates.10
Based on 2013-2017 ACS data 22,876 Mainers identify as American Indian alone or in combination with one or more other races.10 There are four federally recognized Indian tribes and five tribal communities in Maine today: Aroostook Band of Micmac Indians, Houlton Band of Maliseet Indians, Passamaquoddy Tribe of Indian Township, Passamaquoddy Tribe at Pleasant Point, and Penobscot Indian Nation.12 The majority of Maine's Native American population resides in or near the five small, rural communities of Indian Island (Penobscot Nation), Pleasant Point (Passamaquoddy tribe), Indian Township (Passamaquoddy tribe), Houlton (Houlton Band of Maliseet) and Presque Isle (Aroostook Band of Micmac Indians).13
A total of 3,369 Passamaquoddy tribal members are listed on the tribal census rolls, with 1,364 on the Indian Township census and 2,005 listed on Pleasant Point census.14 The Aroostook Band of Micmac Indians is estimated at 1,240+ members.15. The Houlton Band of Maliseet Indians is comprised of approximately 1,700 members.16 An estimated 2,398 members comprise the Penobscot Nation population.17.
In 2013-2017, 3.6% of Maine residents were foreign-born; the proportion within Maine's counties ranged from 1.8% (Somerset, Oxford, Franklin Counties) to 6.2% (Cumberland).8 Of Maine's foreign-born population 21.5% were born in North America, 11.0% in Latin America, 23.4% in Europe, 28.2% in Asia, and 14.9% in Africa.8 Among Maine's foreign born, 79.3% entered the U.S. before 2010. Slightly more than half (55.9%) of Maine's foreign-born are naturalized U.S. citizens. Across Maine, 6.2% of the population aged five and older spoke a language other than English at home; approximately 1.6% spoke English less than "very well."8
Emerging populations in Maine include people of Somali, Sudanese, Ethiopian, Burmese, Iranian, Iraqi, and Congolese ancestry arriving in Maine as primary refugees or secondary migrants.18 Refugees are individuals granted refugee status overseas by the U.S. Department of Homeland Security, are brought to the U.S. for resettlement by the U.S. Department of State, and are assisted with resettlement in U.S. communities through the Office of Refugee Resettlement and voluntary agencies.19 In 2017, 481 refugee arrivals were initially resettled in Maine (113 originating from Somalia, 100 from Iraq, 100 from Congo).18 The total number of refugees ranges from 60 to 761 people per year since 2008.
Secondary migration is a legal term that refers specifically to refugees placed for resettlement initially in one location in the United States and decide to relocate to another part of the United States. Although immigration data does not track secondary migration, it is the largest force affecting immigration into Maine. An estimated 75% of new Mainers are secondary migrants.18 In FY17 Catholic Charities Refugee and Immigration Services resettled approximately 323 primary refugees and assisted 37 secondary migrants and 86 asylees; 7 secondary migrants settled in Lewiston and 30 in Portland.18
Educational Attainment
In 2013-2017, 92.1% of Maine residents age 25 and over were high school graduates, compared to 87.3% nationally.8 The county-specific proportion of high school graduates age 25 and older ranges from 87.6% (Aroostook County) to 94.9% (Sagadahoc County).8 Although a slightly higher percentage of Maine residents over age 25 years completed high school compared to the U.S. a slightly lower percentage have a higher education degree (30.3% Maine vs 30.9% U.S.). Among Mainers with a bachelor's degree or higher, 10.9% have completed an advanced degree.8 Among Maine women, 95.7% of those age 25-34 years and 96.3% of Maine women age 35-44 years were high school graduates; both proportions were higher than those among women of these age groups in the United States (91.3% and 89.4%, respectively).20
Socioeconomic Indicators
Income and Poverty
A "livable wage" is the amount Maine families need to earn to make ends meet considering actual living expenses including housing, health care, child care, transportation, taxes, and necessities (clothing, personal care items, etc.). According to the Living Wage Calculator, designed by the Massachusetts Institute of Technology, the annual income required in 2018 for a two-parent (2-earner), two-child Maine family to meet their basic needs was $66,125 (a wage of $15.90/hour per adult).21 The county-specific livable wage for this family type ranged from $62,999 (an hourly wage of $15.10 Aroostook, Franklin and Piscataquis Counties) to $70,096 (an hourly wage of $16.85; Cumberland County). For single-parent Maine families with two children, the average annual income required is $60,341 (an hourly wage of $29.01) with county-specific estimates ranging from $57,014 (an hourly wage of $27.41; Aroostook, Franklin and Piscataquis counties) to $64,312 (an hourly wage of $30.92; Cumberland County).21 The livable wage is considerably higher than both the federal poverty level (FPL) and the income of a minimum wage earner. As of March 2019, Maine's $11.00 per hour minimum wage is $3.75 cents higher than the federal standard.22 In Maine a full time year-round minimum wage worker will earn $440 per week or $22,880 per year. In 2019, the FPL for a family unit consisting of two people is $16,910 per year. The FPL for a family of four is $25,750 and for a family of three is $21,330.23 While significant portions of the MCH population fall under the FPL, even higher proportions live in families that do not earn livable wages.
Although states in the Northeast tend to have median incomes above the U.S. median, Maine's median income is $4,059 less than the U.S. median ($56,277 vs. $60,336).24 There is considerable variation in income across Maine counties. In 2013-2017 the median household income ranged from $38,797 in Piscataquis County to $65,702 in Cumberland County.25
According to the 2013-2017 ACS, 15.2% of Maine people were at or below the 150% FPL, 7.6% were at or below the 125% level, and 1.7% were at or below the 50% FPL.26 Poverty is inversely related to educational attainment; 27.1% of those with less than a high school diploma were below the FPL compared to 14.6% of high school graduates, 9.6% of those with some college, and 4.2% of those with a bachelor's degree or higher.26
Across Maine, 12.9% of residents lived below the FPL between 2013 and 2017. The poverty rate among Maine children under age 18 was even higher at (17.9%).26 The county-specific proportions of children under age 18 below the FPL ranged from 9.9% in York County to 26.6% in Piscataquis County.26 Among female-headed households with children under 18 years of age, 37.2% lived in poverty (vs 38.7% U.S.) in 2013-2017.27 Among families with children under age five, 16.7% lived below poverty, and nearly half (48.0%) of female-headed households with children under five lived in poverty in 2013-2017; this is higher than similar households in the U.S. (43.7%).27
Labor Force and Employment
Maine's civilian labor force was estimated at 698,745 in 2018.28 The proportion of adults age 16 and over in the labor force ranges from 49.1% in Piscataquis County to 68.5% in Cumberland County.25 The proportion of children with all parents in the labor force is 70.4% in Maine, and ranges from 56.9% in Washington County to 76.4% in Franklin County.25 Among women ages 16 years or older, 59.8% are in the civilian labor force.25 Median earnings for women in 2013-2017 were 71% of men’s earnings ($27,081 vs. $38,180).29
The April 2019 seasonally adjusted unemployment rate for Maine was 3.3% unchanged from the same period last year.28 Unemployment figures do not reflect the number of underemployed and those who became discouraged and stopped looking for work. Based on U.S. Census data, Maine has a larger proportion of its jobs in education, health care, and retail trade sectors than in the U.S. overall, while a smaller proportion of its jobs are in manufacturing, wholesale trade, and administrative services sectors.25
Income Assistance
During 2013-2017 approximately 27.5% of children under the age of 18 lived in households that in the previous 12 months received Supplemental Security Income, cash public assistance income, or Supplemental Nutrition Assistance Program (SNAP);30 this proportion varied by family type. Among children living in married couple family households, 17.4% had household income from one or more of these sources. Among children living in households with a female householder (no husband present) 53.0% received assistance, and among children living in households with a male householder (no wife present), 39.2% received assistance from one or more of these sources.30 SNAP assistance is one of the most wide-spread low-income benefit programs in Maine. According to 2017 data, approximately 12.8% of Maine's households were receiving supplemental nutrition assistance.31 The median household income of SNAP recipients in 2017 was $17,457.31 The monthly benefit per person in FY2016 averaged $112.24.32
As of 2019, 46.2% of Maine schoolchildren are eligible for the free and reduced meals program. In 2010, 43.1% of Maine children were eligible for free and reduced meals and continues to trend upward.33
Housing
According to 2013-2017 ACS data, 75.3% of Maine's housing units are occupied.34 Among Maine's 554,061 occupied housing units, 72.0% are owner-occupied and 28.0% are renter-occupied.34 The median gross monthly rent was $808.00. Approximately 40% of renter-occupied units consume more than a third of renters’ household income.34 Approximately 62% of Maine's owner-occupied housing units have mortgages; 22% of owner-occupied housing units with mortgages have housing costs which consume more than a third of owners’ household income.34
Among Maine's occupied housing units, 7.4% have no vehicles available, 33.8% have one vehicle, and 39.9% have two or more vehicles available.34 Two percent of occupied housing units have no telephone service available. Of Maine's occupied housing units, 70.4% are detached single-unit structures and 8.4% are mobile homes. A quarter of housing units (24.5%) were built before 1940.34
Finding affordable housing is a challenge for some Maine residents. According to a 2018 Maine State Housing Authority (MSHA) Report on housing costs in Maine, the median price of homes increased 25% between 2014 and 2018. Maine's median income increased 14.6% during the same period (2014-2018).35 Currently, the most affordable communities are in the more rural parts of the state (Aroostook, Piscataquis, and Somerset) with the least affordable in the southern and coastal areas.35 Statewide, about 56% of Maine households are unable to afford a median home price ($212,500) and 57% cannot afford the rent for an average two-bedroom apartment ($998.00).35
Homelessness
Nationally, homeless children make up about a third of the homeless population.36 Compared to children with stable housing homeless children are more likely to have health problems, developmental delays, learning disabilities, emotional difficulties, and mental disorders.36
Maine's homeless population grew steadily from 2009 (871) to 2013 (1,175), attributable to such factors as decreasing funding for mental health and substance abuse programs and availability of affordable housing.37 However, data suggest that since then, homelessness in Maine may have reached a plateau (1,125 in 2018). In 2018, a total of 6,454 individuals stayed in Maine's emergency shelters, including domestic violence shelters; an 8.1% decline from 2017.38
A January 22, 2019 MSHA, Point in Time Survey identified 1,120 identified homeless individuals in shelters, a 9% increase from 2018.37 Of those surveyed, 259 had a mental illness, 107 were victims of domestic violence and 166 had a substance abuse problem. Twenty-three percent (279) of homeless people were under age 18, an increase of 2% from 2018.37 Maine has one of the lowest rates of unsheltered homeless people in the U.S (lowest: Maine 3.9% vs highest: California 68.9%).39
Statutes that have relevance to the Title V Program
Numerous state statutes inform Maine’s Title V Program and provide guidance on the parameters of the programs within Title V. For example, the family planning services statute requires that schools provide comprehensive sexuality education that includes accurate and age appropriate education on sexual health. To assist in meeting this requirement the Maine CDC funds two School Health Education Specialist positions within the Department of Education to work with local school districts in developing curriculum that meets the standards outlined in the statute. The Maine CDC’s Public Health Nursing program utilizes the Lead Poisoning Prevention statute to guide their work with the Lead Poisoning Prevention Program in responding to lead exposed or poisoned children and their families.
A full listing of state statutes that have relevance to the Title V program is included in Section V, Supporting Documents.
[a] Bangor Daily News. LePage digs in for Medicaid expansion funding battle. December 2017. https://bangordailynews.com/2017/12/11/politics/lepage-digs-in-for-medicaid-expansion-funding-battle/.
[b] Maine Department of Health and Human Services. MaineCare Expansion Update. June 14, 2019. Accessed 6-18-19 from: https://www.maine.gov/dhhs/expansion.shtml.
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