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.
Maine’s public health system has some unique strengths that lend themselves to a healthy population. Maine is divided into 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 Maine Center for Disease Control and Prevention (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. The team is composed of experienced epidemiologists who have a thorough understanding of maternal and child health in Maine.
Over the past three years Maine’s Maternal, Fetal and Infant Mortality Review Panel has undergone changes. The Panel resumed reviewing cases and a structure was created to help the Panel members through the reviews. A chair for the Panel was established to lead the group through the reviews. The Panel Coordinator performs the abstraction and works with the epidemiologist to determine which cases are reviewed during the meetings. These changes have allowed the membership to grow to ensure a diverse group of voices. While the Panel is still growing, the progress made has allowed the experts the opportunity to recommend system-level changes to improve the health of Maine people.
Another strength of Maine’s public health system are the partnerships developed over time. Maine is a very small state when it comes to health care and social service providers. This is an advantage because it presents opportunities to have voices from a variety of providers and consumers. The addition of virtual participation, where available, has allowed for direct and instant connections.
The State of Maine has many strengths that can be used to improve the health of Maine people. However, there are challenges that we are working to address. A significant challenge to note is that Maine has 33 hospitals and only 26 provide labor and delivery services. To compound the challenge, there are areas of the State where there are large geographic gaps for these services. This means families have to drive long distances to receive services.
In addition to having to drive long distances to find services, Maine’s Internet connection is weak or non-existent in areas. This limits the amount of telehealth opportunities in areas where the need is the greatest.
Maine CDC Role in Delivery of Title V Services
The Maine CDC, an Office of the Maine Department of Health and Human Services (Maine 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. The Maine CDC’s role is not only to deliver MCH-related services, but to also act as a connector between different State offices, providers and consumers.
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.
In 2018 and 2019, the Maine CDC partnered with MaineCare on The Medicaid Innovation Accelerator Program for the Maternal and Infant Health Initiative. This project served as a catalyst to additional projects and provided a mechanism for the Maine CDC and MaineCare to develop strong staff relationships. Additional collaborations include, MaineCare representation on 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.
Pediatric Care Capacity
Maine has one children’s hospital, The Barbara Bush Children's Hospital at Maine Medical Center located in the city of Portland. It has 116 beds, including 31 Level III NICU Beds, 20 Level II Continuing Care Nursery beds and 8 PICU beds.41
The American Board of Pediatrics tracks the number of diplomates (i.e., pediatricians who have passed the General Pediatrics Certifying Examination) currently in the pediatric workforce. As of December 2017, there were 229 general pediatricians age 70 or less in Maine, which represented a ratio of one general pediatrician per 1,112 children, compared to 1:1,282 nationally. The ratio of pediatric specialists age 70 or less was 1:855 compared to 1:989 nationally.42
The Maine DHHS has placed an emphasis on integrating physical, social and behavioral health services to ensure greater access to services as well as ensure the services are effectively coordinated. One example of this is the cleft lip and/ or palate clinics. Title V contracts with the two largest hospital systems to provide clinics for children who have a cleft lip and/ or palate. The clinics are responsible for providing integrated case management through a Cleft Team who provide optimal evaluations of newborns with craniofacial anomalies, and subsequent evaluations and recommendations through age twenty-one (21). The Cleft Team monitors short and long-term outcomes as well as develops and implements treatment plans for individual patients. The goal of the Cleft Lip and/ or Palate clinic is to ensure that patient care is provided in a coordinated, consistent manner with proper sequencing of evaluations and treatment within the framework of the patient’s overall developmental, medical, and psychological needs as recommended by the American Cleft Palate-Craniofacial Association Parameters of Evaluation and Treatment.
In 2017, Maine voters approved Medicaid expansion in a referendum vote, and in January of 2019 Governor Janet Mills approved the plan to fund the expansion. As of July, 2020, 57,665 people were enrolled through the MaineCare expansion, including 47,976 adults without children, 9,689 parents and caretaker relatives. While expansion numbers were smaller than anticipated (due to a strong economy), further growth is projected, as a comprehensive outreach campaign is planned for Fall 2020. [a]
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.
In 2019 there were 1.34 million people residing in the state of Maine.1 Between 2010 and 2019 Maine's overall population increased 1.2% compared to 6.3% nationally.1 During this period there were more deaths than births (-10,773 people), however domestic migration (+15,956) and international migration (+11,551) resulted in modest population growth and increased racial and ethnic diversity in the state.2 In contrast, net natural increases caused 60% of the U.S. population increase in this period.2
Maine has three metropolitan (metro) areas; Portland-South Portland (pop. 529,232), Lewiston-Auburn (pop. 107,444) and Bangor (pop. 151,748).3 Collectively, 59.2% of Maine's population resides in these three metro areas3 (compared to 79.0% of U.S. residents who live in metro areas).4 More than one third (37.3%) 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 (45.1 years) is nearly 7 years older than the U.S. (38.2 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 younger (27.8% vs 20.2%). 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%.7 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 2018, children under 18 years of age plus women ages 18-44 represented 34.0% of Maine's population.3 Children under 18 years of age comprised 18.6% of the state's population. Nationally, children under age 18 comprised 22.4% of the population.3
In 2018, the median age of women in Maine was 46.6 years.6 Women aged 15-44 years comprised 17.4% of Maine's population, compared to 20.3% nationally.6
Prevalence estimates of current disability or special health needs among Maine children differ depending on the definition used. According to the 2017-18 National Survey of Children’s Health there are nearly 56,062 children with special health care needs in Maine, representing 22.1% of children under age 18 years.8
Demographics
Family
According to estimates from the 2014-2018 American Community Survey (ACS) the average household size in Maine is 2.3 people and the average family size is 2.9.9 A little more than a quarter of households (25.5%) in Maine include one or more children under age 18, compared to about a third in the U.S. (31.4%).9 Of the households with a child under age 18, 20.4% are female-headed (no husband present) households and 10.0% are male-headed (no wife present) households. Of the households with a child under age 18 nationally, 21.2% are female-headed and 7.3% are male-headed.9 Of Maine women aged 15 years and over 49.5% are currently married, 25.1% have never been married, 15.0% are divorced, 9.4% are widowed and 1.1% are separated.9
Racial and Ethnic Diversity
According to the 2014-2018 ACS, Maine's population is 94.5% White, 0.6% American Indian or Alaska Native, 1.3% Black or African American, 1.1% Asian, and 2.2% are two or more races. People of Hispanic origin comprise 1.6% of the population.10 Of Maine's children under age 18, 88.6% are non-Hispanic White, 2.4% are Black or African American, 0.9% are American Indian or Alaska Native, 1.2% are Asian, 4.9% are two or more races and 2.7% 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 201012 and to 94.5% as of 2014-2018.10
Based on 2014-2018 ACS data 23,061 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.13 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).14
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.15 The Aroostook Band of Micmac Indians is estimated at 1,489+ members.16. The Houlton Band of Maliseet Indians is comprised of approximately 1,700 members.17 An estimated 2,398 members comprise the Penobscot Nation population.18
In 2014-2018, 3.6% of Maine residents were foreign-born; the proportion within Maine's counties ranged from 1.3% in Franklin County to 6.1% in Cumberland County.9 Of Maine's foreign-born population 28.2% were born in Asia, 23.7% in Europe, 20.2% in North America, 16.2% in Africa and 10.8% in Latin America.9 Among Maine's foreign born, 75.8% entered the U.S. before 2010. Slightly more than half (55.3%) of Maine's foreign-born are naturalized U.S. citizens. Across Maine, 6.3% of the population aged five and older spoke a language other than English at home; approximately 1.6% spoke English less than "very well."9
Emerging populations in Maine include people of Somalia, Sudan, Congo, Ethiopia, Burma, Iran and Iraq who are arriving in Maine as primary refugees or secondary migrants.19 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.20 In 2018, 147 refugee arrivals were initially resettled in Maine (21 from the Congo, 20 from Burundi, 17 from Rawanda, 4 from Sudan, 3 from Iraq). The total number of refugees in Maine has ranged from 60 to 761 people per year since 2008.19
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.19 In FY17 Catholic Charities Refugee and Immigration Services resettled approximately 66 primary refugees assisted 40 secondary migrants and 41 asylees.19
In 2019, an unprecedented number of asylum seekers, primarily African, arrived in Portland, Maine to await decisions on their status. City and state government, as well as local non-profit and for-profits organized a massive effort to feed, clothe and house over 600 asylees using private and public spaces for temporary as well as permanent housing. Over $900,000 in federal funding and $900,000 in private donations were obtained to help settle the asylees in Portland and surrounding communities.[b]
Educational Attainment
In 2014-2018, 92.3% of Maine residents age 25 and over were high school graduates, compared to 87.7% nationally.9 The county-specific proportion of high school graduates age 25 and older ranges from 87.5% in Aroostook County to 95.0% in Cumberland County.9 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 bachelor’s degree or higher (30.9% Maine vs 31.5% U.S.). Among Mainers 11.3% have completed an advanced degree.9 Among Maine women, 95.9% of those age 25-34 years and 95.7% 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 (92.7% and 90.0%, respectively).21
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 2019 for a two-parent (2-earner), two-child Maine family to meet their basic needs was $69,725 (a wage of $16.76/hour per adult).22 The county-specific livable wage for this family type ranged from $55,138 ($15.81/hour per adult) in Piscataquis County to $73,534 ($17.68/hour per adult) in Cumberland County. For single-parent Maine families with two children, the average annual income required is $64,854 ($30.70/hour) with county-specific estimates ranging from $59,885 ($28.79/hour) in Piscataquis County to $67,663 ($32.53/hour) in Cumberland County.22 The livable wage is considerably higher than both the federal poverty level (FPL) and the income of a minimum wage earner. As of March 2020, Maine's $12.00 per hour minimum wage is $4.75 cents higher than the federal standard of $7.25.23 In Maine, a full time year-round minimum wage worker will earn $480 per week or $24,960 per year. In 2020, the FPL for a family unit consisting of two people is $17,240 per year. The FPL for a family of four is $26,200.24 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 household incomes above the U.S. median, Maine's median household income is $6,335 less than the U.S. median ($55,602 vs. $61,937).25 There is considerable variation in income across Maine counties. In 2014-2018 the median household income ranged from $39,470 in Piscataquis County to $69,708 in Cumberland County.26
According to the 2014-2018 ACS, 16.8% of Maine people are at or below 125% FPL, 12.5% are at 100% FPL and 5.0% are at or below the 50% FPL.27 Poverty is inversely related to educational attainment; 26.8% of those with less than a high school diploma are below the FPL compared to 14.1% of high school graduates, 9.3% of those with some college, and 4.2% of those with a bachelor's degree or higher.27
The poverty rate among Maine children under age 18 is 16.3%.27 The county-specific proportions of children under age 18 below the FPL ranged from 9.7% in York County to 27.5% in Somerset County.27 Among female-headed households with children under 18 years of age, 28.7% lived in poverty (vs 30.0% U.S.) in 2014-2018.27 Among families with children under age five, 13.2% lived below poverty, and nearly half (47.8%) of female-headed households with children under five lived in poverty in 2014-2018; this is higher than similar households in the U.S. (42.2%).28
Labor Force and Employment
Maine's civilian labor force was estimated at 693,630 in 2019.29 The proportion of adults age 16 and over in the labor force ranges from 47.5% in Piscataquis County to 69.0% in Cumberland County.25 The proportion of children with all parents in the labor force is 71.1% in Maine, and ranges from 54.6% in Piscataquis County to 76.7% in Cumberland County.26 Among women ages 16 years or older, 59.5% are in the civilian labor force.26 Median earnings for women in 2014-2018 were 73% of men’s earnings ($26,968 vs. $36,795).30
The December 2019 seasonally adjusted unemployment rate for Maine was 3.0%, down 0.3% from the same period last year.29 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.26
Income Assistance
During 2014-2018 approximately 25.8% of children under the age of 18 lived in households that received Supplemental Security Income, cash public assistance income, or Supplemental Nutrition Assistance Program (SNAP) in the previous 12 months;31 this proportion varied by family type. Among children living in married couple family households, 16.2% had household income from one or more of these sources. Among children living in households with a female householder (no husband present) 50.7% received assistance, and among children living in households with a male householder (no wife present), 35.8% received assistance from one or more of these sources.31 SNAP assistance is one of the most wide-spread low-income benefit programs in Maine. According to 2018 data, approximately 12.9% of Maine's households were receiving supplemental nutrition assistance.32 The median household income of SNAP recipients in 2018 was $17,363.32 The monthly benefit per person in FY2018 averaged $108.33 During the 2019-2020 school year, 43.9% of Maine schoolchildren were eligible for the free and reduced meals program.34
Housing
According to 2014-2018 ACS data, 75.4% of Maine's housing units are occupied.35 Among Maine's 556,955 occupied housing units, 72.7% are owner-occupied and 27.8% are renter occupied.35 The median gross monthly rent is $831.00. Among renter-occupied units, 40% consume more than a third of renters’ household income.35 Among owner-occupied units, 62% have mortgages; and of those with mortgages, 21% have housing costs which consume more than a third of owners’ household income.35
Among Maine's occupied housing units, 7.3% have no vehicles available, 33.6% have one vehicle, and 59.1% have two or more vehicles available.35 1.9% of occupied housing units have no telephone service available. Of Maine's occupied housing units, 70.2% are detached single-unit structures and 8.3% are mobile homes. Nearly a quarter of housing units (24.2%) were built before 1940.35
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).36 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.36 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).36
Homelessness
Nationally, homeless children make up about a third of the homeless population.37 Compared to children with stable housing homeless children are more likely to have health problems, developmental delays, learning disabilities, emotional difficulties, and mental disorders.37
In January 22, 2019, the Maine State Housing Authority Point in Time Survey identified 1,120 homeless individuals in shelters, an 8% increase from 2018.38 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 In Maine’s FY 2018, the average number of nights spent in a shelter per person was 67, and the median was 40.39
According to the U.S. Department of Housing and Urban Development’s 2019 Annual Homeless Assessment Report, “Homeless describes a person who lacks a fixed, regular, and adequate nighttime residence.” That report estimated 2,106 individuals in Maine were homeless on a single night in January, an increase of 16.3% from 2018.40 Of those, 874 were people in families with children, and 125 were unaccompanied
homeless youth. According to that report, Maine has one of the lowest rates of unsheltered homeless people in the U.S (Maine: 7.5%; North Dakota: 0.8% (lowest) California 80.3% (highest).40
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 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 listing of state statutes that have relevance to the Title V program is included in Section V Supporting Documents.
[a] Maine Department of Health and Human Services. MaineCare Expansion Update. July 1, 2020. Accessed 7.15.20 from: https://www.maine.gov/dhhs/expansion.shtml.
[b] Maine Public. Asylum seekers. https://www.mainepublic.org/term/asylum-seekers
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