Demographics, Geography and Economy

As of 2019, the U.S. Census reported Arizona’s population at an estimated 7,278,717.1 Arizona is one of the fastest growing and diverse states in the nation—eighth in the nation for overall population growth from 2010 to 2019 (13.9% growth)2, with an expected additional growth of 30% between 2018 and 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 than the nation. In 2019, the proportion of the population that is Hispanic in Arizona was 31.7 percent compared to 18.5 percent nationally. In addition to having a higher proportion of Hispanics, Arizona’s population also has a smaller proportion of African Americans (5.2 percent compared to 13.4 percent nationally) and a higher proportion of Native Americans (5.3 percent compared to 1.3 percent nationally).1

The racial makeup of Arizona varies by age group. Among older age groups, the population is predominantly white, while the proportion of the population represented by Hispanics is highest among the younger groups. Over 45 percent of those younger than five are Hispanic compared to 11 percent of people 75 and older.4

Poverty is a social determinant of health and a critical concern in Arizona.  According to 2018 Kaiser Family Foundation estimates, Arizona has the country’s 14th highest poverty rate overall among children.5 In a five-year estimate for 2014-2018, 16.1 percent of Arizonans lived in poverty—up from 14 percent in 2000, and higher than the current national poverty rate of 14.1 percent. Poverty varies dramatically by county within Arizona. The highest rates of poverty are in Apache and Navajo Counties with rates of 35.3 and 28.5 percent, respectively. The lowest rates are in Greenlee (11.9 percent), Yavapai (14.0 percent), Pinal (14.2 percent) and Maricopa (14.7 percent) Counties.6 The U.S. Department of Agriculture, Economic Research Service 2018 estimates show that poverty in rural Arizona (26.9%) far exceeded the rate in urban areas of the state (13.4%).7

In addition to rural communities, poverty disproportionately impacts women and children. In Arizona in 2018, 22.8 percent of children under age 18, and 28.3 percent of those without a high school diploma, lived below the poverty line.8 Nearly 300,000 women live in poverty in Arizona. The Arizona Foundation for Women notes that this rate of poverty is related to women being more likely to be singularly responsible for children. Over a quarter of Arizona’s families are single mothers with children under the age of 18 living at home, and 77 percent of these single mothers are eligible for but not receiving child support.9 Arizona has the seventh highest nonelderly adult female poverty rate in the country.5

As children, Arizonans also face challenges. A 2019 America’s Health Rankings report placed Arizona as the third worst state in the country for adverse childhood experiences (ACEs). Over 27% of Arizona’s children experienced two or more ACEs last year, as compared to 20.5% of children nationally.10 ACEs include: abuse, such as sexual abuse, physical abuse or verbal abuse, and household dysfunction, such as 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 hit a fifteen year high in 2016, and has been declining since then. The Children’s Action Alliance reports that in March 2020, 14,167 children were in foster care.11 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 percent 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.12

Arizona consistently ranks among the lowest in the nation in per pupil spending. The National Center for Education Statistics reported that Arizona spent $8,053 per student compared to the national average of $12,258 per student in fiscal year 2017.13 The U.S. Census ranked Arizona 48th of the 50 states and the District of Columbia in public per pupil spending in fiscal year 2018.14 The National Assessment of Educational Progress (NAEP) is an assessment of what America’s students know. In 2019, eighth grade students in Arizona public schools performed the same as 20 other states and jurisdictions, had higher performance than 5 states and jurisdictions, and were below 26 states and jurisdictions in NAEP reading scores. In 2019, 30 percent of Arizona eighth graders tested below basic skill level for their grade compared to the national rate of 28 percent. This was an increase in 5 percentage points from 2017.15

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 2018 was $56,213 compared to the national median income of $60,293. Median household income also varies widely by county and type of household. At $61,606, Maricopa County had the highest median household income; Apache County had the lowest at $32,963. Median household income also varies by type of household, with married couple families earning $79,677, families with children under 18 earning $61,784, and female-headed, single parent families earning $28,683.16

In Arizona overall, unemployment was consistently in the 4.5 to 5.0 range from mid-2017 until March 2020 when it quickly spiked due to the emerging global pandemic. Arizona’s unemployment rate reached a high of 13.4 in April 2020 with 473,766 unemployed, and has decreased to a rate of 10.0 in June 2020. Prior to the impacts from the pandemic, unemployment varied across the state of Arizona. In 2019, Greenlee and Maricopa Counties showed the lowest rates (3.9 and 4.0 respectively), while Yuma County suffered the largest percentage of unemployment (16.4).17

In addition to individuals, poverty is calculated for families with children under the age of 18. In a five-year estimate for 2014-2018, 18.4 percent of families with children were below the poverty line in Arizona. This was 2.5 percentage points higher than the national average of 15.9 percent.18 Rates of poverty for families with children vary widely by ethnic background. The National Center for Children in Poverty reports that in Arizona in 2016, 12 and 13 percent of Asian and White children, respectively, live in a poor family compared to 45 percent of Native American children, 35 percent of Hispanic children, and 30 percent of Black children.19

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 2018, 11.8 percent of households in Arizona received SNAP assistance (or food stamps). The lowest is in Greenlee County at 7.6 percent, compared to a high of 25.6 and 27.3 percent in Apache and Santa Cruz Counties, respectively.20 Household food insecurity is often a consequence of poverty. The USDA definition of food insecurity can be paraphrased as: a limited or uncertain availability of food. Low food security is food insecurity without hunger. Very low food security is food insecurity with hunger.21 Food insecurity is similar but slightly higher in Arizona than in the United States as a whole and has increased in the past 10 years, notably between 2007 and 2008. In 2016-2018, 12.4 percent of Arizona households had limited or uncertain food availability and 5.1 percent of those were hungry.22

Unique Strengths and 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 for a variety of reasons. Large sparsely populated areas make distribution of providers difficult. Recruiting providers to rural areas is often challenging due to the appeal of higher salaries, school districts and community amenities that urban areas can offer. Even in urban areas, Arizona’s healthcare workforce has not kept pace with the state’s rapid population growth. These challenges are quantified by the total of 587 federally designated Health Professional Shortage Areas (HPSAs).  This includes 201 primary care, 192 dental, and 194 mental health HPSA designations. There are also 36 Medically Underserved Areas and 11 Medically Underserved Population designations in the state.23 Arizona needs an additional 560 full-time primary care physicians, 380 dentists, and 181 psychiatrists statewide to eliminate the existing HPSAs.24

Lack of Health Insurance

As of August 2020, there are 2,041,990 enrollees in the Arizona Medicaid Program (AHCCCS) – an increase of over 150,000 in the past year.  While the number of people without insurance fell in Arizona over the past couple years (from 19% in 2013 to 10.6% in 2018), it remains higher than the national average (8.9%) with about 749,977 people uninsured. Included in this number are 146,284 uninsured children and youth under the age of 19 (8.4%); this figure is substantially higher than the national average of 5.2 percent.25 While Arizona’s percent of uninsured children has decreased from a high of 15 percent 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.1  These residents often have to endure long drives, sometimes over dirt roads, to access health care.  Concerns over travelling through border patrol road checkpoints present additional barriers to some families.

Education Level

Education level can impact an individual’s health literacy and self-efficacy in accessing health care.  Nationally, 41.1 percent 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 percent with less than a high school education.  With Arizona ranking in the bottom three nationally for high school graduation rates, this is a significant contributor to women’s and children’s overall health status.10

Language and Culture

More than a quarter (27.2%) of Arizonans reported speaking a language other than English at home, compared to 21.5% nationally.  This rate is 79.7% in one Arizona/Mexico border county.1  Culturally and linguistically appropriate health care services are lacking in many communities in Arizona.

One unique aspect of Arizona’s geographic and cultural landscape is its large American Indian population.  Arizona is home to 21 federally recognized American Indian tribes and has the largest total American Indian population of any state – over 385,000 individuals.1  In addition, the majority of the Navajo Nation, the largest reservation in the U.S., and the Tohono O'odham Nation, the second largest, are 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 9.3 (per 1,000 live births) in 2018, as compared to 5.8 Arizona average,26 and post-neonatal mortality rate among American Indians was over double the state average (4.6 vs 2.1).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 5.6 (per 1,000 live births)—below the national average of 5.8—but this rate jumps to 9.2 for African Americans and 9.3 for American Indians within Arizona.10  Similarly, while the percent of births that are low birthweight across all races in Arizona (7.5%) is lower than the national average, a much higher percentage (12.5%) of African American babies are born low birthweight.10

The Healthy Smiles Healthy Bodies Survey indicated that more than half (52%) of Arizona's kindergarten children have a history of tooth decay, higher than the national average for 5 year olds (36%), and almost two-of-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 66.5%—ranking us 44th in the nation.10 

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. This ranks Arizona 29th in the nation (where 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.10

Impact of COVID-19

As in most places, public health—and life in general—has been impacted substantially by the COVID-19 global pandemic. As of August 28, 2020 there have been over 200,000 cases and nearly 5,000 deaths due to COVID-19 in Arizona.29 That is a rate of 2,791 cases per 100,000 population – currently the third highest rate among all states.30 In late June and early July, Arizona was an epicenter of the pandemic. Fortunately, the number of cases per day, hospitalizations, and percent positivity have been dropping steadily over the past month.

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.

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. The Chief of the Bureau of Women’s and Children’s Health serves as the Title V administrator and currently serves as the Director for both Maternal and Child Health and for Children with Special Health Care Needs. The Office of Children’s Health oversees all programming for children and youth with special health care needs (CYSHCN). Please refer to VI. Organizational Chart for more detail.

ADHS adopted a five-year strategic 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 first conducted a State Health Assessment (SHA), and an updated SHA was released in April 2019. ADHS used a variety of primary and secondary data sources to produce the analysis for this assessment, and input on the SHA was collected from many stakeholders including local health officers and tribal partners. The 2019 State Health Assessment is structured around the themes of Healthy People, Healthy Communities. ADHS focused on health outcomes across the lifespan, examining issues in Maternal and Infant Health, Child and Adolescent Health, Healthy Adults, and Healthy Aging. ADHS will use this assessment to set priorities and performance objectives for the next iteration of the Arizona Health Improvement Plan (AzHIP), which will be released in 2021.

Arizona’s Title V Program developed our 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 5.6, below the Healthy People 2020 goal, there is a disparity between White non-Hispanic and Black infant mortality.

The Title V program is responsible for tracking emerging issues and identifying how they affect the MCH population in Arizona. 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 three years since that declaration, there have been 6,857 opioid deaths, 49,753 opioid overdoses, and 2,188 babies born with NAS in Arizona.31 In the upcoming year, ADHS will be responsible for the development and implementation of four Governor Goal Council Breakthrough Projects – Adverse Childhood Experience & Trauma Informed Trained Agency, Sexually Transmitted Diseases, Immunizations, and Maternal Mortality.  BWCH will be the lead on Maternal Mortality and have strong participation in the other Goal Council Projects.

In addition, 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, and there is emerging evidence to suggest that incidence of domestic violence may have risen during the pandemic. There is also a concern that people have been deferring preventative and essential care during the pandemic. In Arizona, the immunization rate has gone down during the pandemic, and it is unclear whether parents will take their children in for their recommended vaccines once the epidemic abates. In addition, COVID-19 infections have been found to present differently in children than adults, with children experiencing a lower mortality rate but higher incidence of Kawasaki disease-like inflammation.

Components of State’s System of Care

As described above, Arizona has one of the highest poverty rates in the country.  Among children within certain racial/ethnic groups in Arizona—including African American, Hispanic and Native American—59-74 percent live in low-income families.19  Thus, low-income families are one of the largest underserved populations in Arizona.

Arizona Health Care Cost Containment System (AHCCCS) is the state Medicaid program that aims to ensure access to health care for low-income individuals, and 22% of Arizona’s population is covered by Medicaid. 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 (16%), and other public coverage such as VA or military (1%).  However, this leaves 11% of Arizona’s population completely uninsured and vulnerable.32

A strong infrastructure is in place within Arizona to improve access to preventive and primary health care for these vulnerable low income and uninsured populations through Title V subcontractors, Community Health Centers, and Rural Health Clinics.  Sliding fee schedule clinics are another critical resource in providing access to care to underserved populations.  ADHS 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.

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 2019 alone, 64,190 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 nine years, there have been a number of changes in federal and state policy affecting Arizona’s CHIP program. Figure 5 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%, but last year’s 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’s legislative session last year, securing health insurance coverage for more than 42,000 children.

Figure 5. Health Care Policy Changes Affecting Children, 2010 – 202034,35

On January 1, 2014 two policy changes impacting Medicaid eligibility for childless adults went into effect. The first policy change was the restoration of Proposition 204, extending eligibility to childless adults earning between 0 percent and 100 percent FPL. The second change was Arizona’s expansion of Medicaid eligibility to include childless adults earning between 100 percent 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 ACA and supported by then-Governor Janet Brewer. With these policy changes, these eligibility programs provided Medicaid coverage for over 470,000 individuals in August 2020. 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 35% in the past year.36

Over the past decade, there was an overall 78% increase in SOBRA enrollments for eligible pregnant women. Amended under Title VI of the Sixth Omnibus Budget Reconciliation Act (SOBRA) of 1986, the Act gave states the option of extending coverage to women requiring pregnancy-related medical services beyond previously set income eligibility thresholds established by states. SOBRA enrollments for pregnant women decreased by about 2,000 (11%) in the past year. SOBRA services for children under the age of 18 also increased over 500% in the past decade, but stayed relatively steady over the past year.37

At the close of the 2020 open enrollment period, 153,020 Arizonans selected marketplace plans through the federally-facilitated exchange.37  Figure 6 illustrates characteristics of the individuals selecting marketplace plans in Arizona.

Figure 6. Marketplace Plan Selection Characteristics – Arizona, Close of 2020 Open Enrollment Period37

In summary, recent federal and state health policy changes have increased the number of Arizonans covered by insurance. Counting marketplace plan selections (153,020) with the Proposition 204 restoration population (368,091) and the childless adult expansion population (104,969), 626,080 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 percent in 2013 to 14 percent currently, not including effects of employer-based and other non-marketplace/Medicaid insured populations.

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

Over two-thirds of the nearly $11.8 billion Arizona budget for 2021 is for K-12 education, AHCCCS, and the Department of Corrections. Forty-four (44) percent of the general fund goes to elementary and secondary education (approximately $5.2B), about 15 percent for AHCCCS (approximately $1.8B), and about 10 percent for corrections (approximately $1.2B). ADHS receives less than one percent of the general fund expenditures ($97M).38

The 2020 Arizona Legislative Session lasted for 135 days, but was suspended for nearly half of that time due to the COVID-19 pandemic. This session was a unique one—with more bills introduced than ever before, but also the fewest number of bills signed into law in history. There were a couple of successful bills that will improve public health, particularly behavioral health. One increases suicide prevention training for school counselors and social workers and mandates provision of information related to mental health resources to students. The other is a mental health parity bill to expand access to mental health care services.

Relevant Statutes

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

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

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

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

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

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

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

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

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

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

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

Senate Bill 1040 was passed into law during the 2019 legislative session and is repealed on July 1, 2021. The bill establishes an advisory committee on maternal fatalities and morbidity and dictates the advisory committee composition. The primary role of the advisory committee is to recommend improvements to data collection regarding the incidence and causes of maternal fatalities and severe maternal morbidity.  The statute also directs 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 is due December 2020 and will provide an account on the incidence and causes of maternal fatalities and morbidity for 2016–2018.

Senate Bill 1040 delegated authority to the Arizona Department of Health Services Director to designate a chair and appoint the committee members.  The Arizona MCH Director served as the Committee Chair and the MCH program staff provided data analysis for the committee.