II. A. Overview of the State

Indiana is nestled in the Midwestern United States. It is the 38th largest state by area and the 17th most populous state in the United States. It is bordered by Illinois, Michigan, Ohio, and Kentucky. It has a diverse economy with a gross domestic product of $353 billion in 2022. Indiana is the largest steel producing state – accounting for 27% of all US steel production. It is also home to many other manufacturing businesses including pharmaceuticals, chemical products, medical devices, automobiles, and more. Most of the state consists of farmland and Indiana is the eighth largest agricultural exporter in the nation. It leads the nation in hardwood production and is also known for its production of soybeans, poultry, and corn. Over half the state’s cropland consists of planted corn for animal feed and popcorn. In fact, Indiana produces more than 20% of the United States’ popcorn supply. Indiana is also well known for sports and is home to the NCAA. It’s known as the birthplace of baseball; home to the Colts, Pacers, Fever, Fuel, and Indy Eleven; and hosts the Indianapolis 500 race every Memorial Day weekend. The state is a popular destination for other large events and conferences every year, bringing in visitors from around the nation.

Indiana is home to 6.8 million residents, known as Hoosiers. They live among 92 counties, including 16 metropolitan and 25 micropolitan areas. Its capital city, Indianapolis (Marion County), is in the center of the state and is home to nearly 900,000 people. According to the U.S. Census Bureau in 2021, the Indianapolis Metropolitan Area is among the fastest-growing metropolitan areas in the US, with significant growth centering in and around Marion County. The population consists of 6% children under 5 years old, 23.3% youth under 18 years, and 50.4% female, and over 2.1 million women ages 10 – 59 years. By race and ethnicity, the population is 77.5% non-Hispanic white, 10.2% non-Hispanic Black, 2.7% Asian, 2.3% two or more races, and 7.7% Hispanic. Indiana has limited cultural diversity outside of its metropolitan areas, with over two-thirds of its counties reporting more than 85% non-Hispanic white populations. This differs with Indiana's largest county, Marion County, which has a non-Hispanic Black population of 28.9%, Hispanic population of 10.6 %, and non-Hispanic white population of 64.0%.

The median household income is $61,944, with a per capita income of just $32,537 according to the 2020 census data. According to the Bureau of Labor Statistics, as of April 2022, the unemployment rate in Indiana was 2.2% Overall, the unemployment rate has steadily decreased over the past two years and is currently at its lowest rate in the past twenty years. Despite that statistic, it is estimated that almost 12% of the population across Indiana is living in poverty. Approximately 270,000 families living in poverty have a female head of household, 11% of children live in families where the head of household does not have a high school degree, and 14.7% of children in Indiana described having trouble accessing basic needs based on family income. Just under 7,000 Hoosier families receive Temporary Assistance for Needy Families (TANF), and 656,297 individuals receive Food Stamps. All schools offered free and reduced school lunches throughout the pandemic, but this did not continue in the 2022 – 2023 school year. Approximately one in seven children were facing food insecurity according to the Indiana Department of Education in December 2022.

In 2022, there were 79,675 live births. Among Indiana live births in 2022, the majority (68.9%) were to White, Non-Hispanic women, followed by births to Black, Non-Hispanic women (12.5%) and to Hispanic women of any race (12.4%). The other 6.2% of live births were to mothers of another race (including women identifying as Asian, Pacific Islander, American Indian, or Alaska Native and those who indicated multiple races on the birth certificate) or where race and ethnicity were unknown. Most recent census data reveals that approximately 23.0% of Indiana’s population is under the age of 18, 5.9% are under the age of 5, and 16.9% are 65 and over. The life expectancy of Indiana residents is 75 years, and the population is 50.3% female and 49.7% male. Although only 4.5% of Indiana’s population are considered LGBTQ+, 24% of children and youth identify as a sexual minority.

The Indiana Department of Health

The Indiana Department of Health (IDOH) serves as the state’s central, standalone public health agency within the executive branch of government. Department employees work to improve the health of the population in a wide variety of ways, including health promotion programming, public health preparedness, data collection and dissemination, food protection services, health facility licensing, and many other infrastructure building programs. The agency supports Indiana's economic prosperity by promoting, protecting, and providing for the health of Hoosiers in their communities.

IDOH is an accredited department of health through the Public Health Advisory Board (PHAB). The department recently updated its strategic plan, the State Health Assessment, and the State Health Improvement Plan. These documents help guide the approach of the Title V team, and the entire agency, to improve the health and well-being of Hoosiers of all ages.

In 2020, IDOH adopted the following mission and vision:

• Mission: To promote, protect, and improve the health and safety of all Hoosiers.
• Vision: Every Hoosier reaches optimal health regardless of where they live, learn, work, or play.

IDOH also provides services guided by these Core Values:

• Health Equity: We place equity at the center of our work to ensure every Hoosier, regardless of individual characteristics historically linked to discrimination or exclusion, has access to social and physical supports needed to promote health from birth through end of life.
• Communication: We provide stakeholders and the public accurate and up-to-date scientific data and provide education and resources regarding utilization of evidence-informed practices in a timely manner.
• Innovation: We continue to learn, research evidence-informed practices, advance ourselves, and be open to new methods, ideas, and products that help build and expand upon the services we provide.
• Integrity: We are honest, trustworthy, and transparent. We uphold our standards and do the right things to achieve the best public health and safety outcomes.

Dr. Lindsay Weaver, MD, FACEP, transitioned from her role as the Chief Medical Officer to Indiana’s new state health commissioner on June 1, 2023. Dr. Weaver joined the agency in February 2020 – plunging immediately into the job as the COVID-19 pandemic spread across the state. Dr. Weaver is an assistant professor of clinical emergency medicine at the Indiana School of Medicine and practices emergency medicine at Methodist Hospital of Indianapolis. She is board certified in both emergency medicine and hospice and palliative care. She earned her undergraduate degree in biology from the University of Kentucky and graduated from the University of Louisville School of Medicine. She has served as the president of the Indiana Chapter of the American College of Emergency Medicine Physicians. She also chairs the Indiana Commission for Women. Other executive leadership includes: two Chiefs of Staff, six Assistant Commissioners, the Deputy Health Commissioner of Local Health Services, a Chief Communications Officers, and Chief Medical Officer. The department is organized into six commissions led by assistant commissions. They include Health and Human Services, Public Health Protection, Laboratory Services, Consumer Services and Regulation, Epidemiology, and a newly formed commission for Women, Children, and Families. One Chief of Staff, Jon Ferguson, leads the various teams which provide internal, cross-agency support, such as the Office of Legal Affairs, Technology, Human Resources, Finance, and Minority Health. The other Chief of Staff, Amy Kent, provides support strategy oversight to the agency and oversees Legislative Affairs, the Healthy Hoosiers Foundation (the department’s 501(c)(3)), the Office of Performance Excellence, Vital Records, and the Data and Analytics teams. The Deputy Health Commissioner of Local Health Services, Pam Pontones, will be overseeing the team supporting local health departments as part of Health First Indiana. HFI is a historic initiative approved and funded in the 2023 legislative session to exponentially increase state funding to local public health that will be dedicated to “core public health services” including maternal and child health.

The Maternal and Child Health (MCH) and Children’s Special Health Care Services (CSHCS) divisions both fall under the umbrella of the newly formed Women, Children, and Families (WCF) Commission at the Indiana Department of Health. This Commission has connected teams working specifically with and for families: MCH, CSHCS, Fatality Review and Prevention; WIC, and the Center for the Deaf and Hard of Hearing Education. These teams regularly collaborate to further our mission and vision for the state of Indiana and carry out the work of the Title V Block Grant.

The Title V Maternal and Child Health Block Grant is the backbone to Indiana’s efforts to improve the health and well-being of families and supports work across the agency. Block grant dollars support staffing, infrastructure, workforce development, and local investments through sub-grants. Below is a description of each division and its responsibilities within the Block grant:

MCH:  The Maternal and Child Health Division administers and houses many federal and state grant programs. The MCH Director oversees the Title V MCH Block Grant administration and works with the MCH Programs Director to fund community-based organizations across the state. The MCH team also administers the Maternal Infant Early Childhood Home Visiting (MIECHV) program, Newborn Screening – including NBS Propel, Early Hearing Detection and Intervention (EHDI), State Systems Development Initiative (SSDI), Maternal Deaths Due to Violence, Rape Prevention and Education, Sexual Risk Avoidance Education (SRAE), Maternal Health Innovation (MHI), the CDC PQC grant, Autism and Development Disabilities Monitoring (ADDM), and administers the Youth Risk Behavior Survey (YRBS) and School Health Profiles Survey. It also has a plethora state-funded programs and projects administered statewide. New federal grants this year include AIM Data Capacity and has integrated the Pregnancy Risk Assessment Monitoring System into surveillance done out of IDOH. The team also oversees the Indiana Perinatal Quality Improvement Collaborative (IPQIC), hosts an annual Infant Mortality Summit known as Labor of Love, and uses other team expertise to reach our Title V goals. MCH provides a coordinated effort to eliminate health disparities, improve birth outcomes, and improve the health status of women, infants, children, adolescents, and families in Indiana. Using evidence-based and data-driven practices, we support the delivery of direct services, linkages and referrals, population-based supports, education, monitoring and quality oversight, and policy and systems development.

CSHCS: The Children with Special Healthcare Services Division (CSHCS) provides supplemental medical coverage to help families of children who have serious, chronic medical conditions, age birth to 21 years of age, who meet the program's financial and medical criteria and pays for treatment related to their child's condition. The supplemental coverage program is a payer of last resort, which means that participants must exhaust coverage from Medicaid and/or private insurance before the program will pay a claim. Title V funding ensures that the CSHCS division meets the state requirements in terms of policy and procedures for the program. The staffing areas covered by these funds include system developers, eligibility, nursing, care coordination, grant management, and claims staff. Currently, the CSHCS program has $14.7 million state funds that also support this work. This is an increase from past years due to increased prescription drug costs and a demonstrated need for the increase. In addition, the CSHCS division receives dedicated state funds for sickle cell and visual impairment. The visual impairment funds teachers who work directly with caregivers of children 0-3 throughout the state. The sickle cell fund is divided into two categories: 0-21 and over 21 population. The sickle cell funds multiple efforts throughout the state in terms of caring for the population, resources, and trainings. The funds also ensure that coordination occurs between all grantees.

Current and Emerging Issues

Challenges in meeting evolving language needs in MCH programming

Indiana’s evolving demographics:

Emerging populations include individuals and families of the Marshallese and Haitian-Creole cultures who have emigrated to the rural part of southern Indiana; Central Americans have arrived in Indiana’s north-central region, driven mainly by the meat-packing industries. Families from Burma have settled in central and north-eastern Indiana, making up the largest population of Burmese individuals outside of Burma. The state and local health departments have been working on solutions to provide improved access to care and services to these families framed around cultural humility.

MCH sees this acutely in our My Healthy Baby system as we are proactively calling and connecting families enrolled in Medicaid to home visiting providers. Many of our home visiting providers are at capacity for non-English speaking families which leaves those families who may speak a different language without care. Or, if they are receiving care, home visitors must rely on translation services which can be a protracted and clumsy method to build relationships with families. Some providers have had success with recruiting and training community health workers and staff from the population that best represents their clientele. MCH hopes to continue to support this model of workforce development to not only meet the needs of families, but also increase capacity of the MCH workforce.

Financial health of hospitals; rural hospital closures

Another notable and emerging public health concern is the closure, consolidation, and/ or reduction of delivery services in ten delivery facilities in the past three years. This has resulted in longer drive times for many Hoosier families seeking appropriate perinatal care.  Shortages in nursing staff, OBGYNs, and ancillary staff are being cited for the difficulty in keeping services open and available. IDOH MCH continues to partner closely with the Indiana Hospital Association to provide support and technical assistance; however, the clinical team continues to monitor many other facilities that have indicated concerns about keeping their delivery services going.

Reproductive healthcare

In August of 2022, as a result of the landmark decision overturning Roe v. Wade, Indiana became the first state in the nation to approve abortion restrictions. With the passage of senate enrolled act (SEA) 1, the legislature limited the timeframe during which pregnant women can receive an abortion, with few exceptions. Abortions would be permitted in cases of rape and incest, before 10-weeks post-fertilization, to protect the life and physical health of the mother, and if a fetus is diagnosed with a lethal anomaly. In addition to the passage of SEA 1, the legislature passed SEA 2 which provided a considerable investment in the Maternal and Child Health division, Perinatal Centers, home visiting programs, child welfare programs, access to LARC and contraceptive care, doulas, childcare, and other programming and policies to support families.

Unwinding of public health emergency and insurance status

Medicaid enrollment in Indiana is significantly higher now than it was before the COVID-19 pandemic, with nearly 2 million Hoosiers currently relying on Medicaid for their health coverage, compared to 1.5 million in February 2020. Enrollment reached a peak of 2.3 million in April 2023. This increase can be attributed to the federal health coverage protections introduced during the pandemic, which encouraged states to maintain continuous enrollment by covering additional costs.

In April 2023, the Family and Social Services Administration (FSSA) Office of Medicaid Policy and Planning began a yearlong redetermination process to reassess eligibility for Medicaid beneficiaries, a process that was completed in April 2024. As a result, approximately 371,000 individuals were disenrolled, but 20-25% of these individuals were re-enrolled within 90 days after submitting additional information. Indiana's disenrollment rate is close to the national average, with procedural disenrollments being a significant issue early on, although these have decreased over time due to better communication and responsiveness from FSSA.

FSSA-OMPP has been working closely with sister state agencies, such as the Department of Health, to help get the word out to constituents across the state. MCH and CSHCS have sent numerous communications to partners to help in this effort as well. In addition, the scripts and prompts utilized by the Moms Helpline have been adjusted to ask about callers’ knowledge on their Medicaid status, home visiting partners have been educated on how they can refer their clients for additional support, and funded grantees have been recruited to help educate their clients.

Advocacy groups like Hoosier Action have emphasized that the pandemic exacerbated economic and health challenges, increasing the need for Medicaid. They highlighted the importance of Medicaid in providing essential health care services during crises. Improved communication between FSSA and stakeholders, including advocacy groups and beneficiaries, led to quick corrections and better support for those navigating the redetermination process.

Despite these efforts, challenges remain in understanding the current coverage status of those no longer enrolled in Medicaid, as the state’s Medicaid system and the federal marketplace are not linked. It is unclear how many individuals transitioned successfully to other forms of coverage. The return of premiums for some Medicaid members, specifically POWER Account contributions for those in the Healthy Indiana Plan, is another concern.

Overall, while Indiana has made strides in managing Medicaid enrollment and redetermination, ongoing challenges and uncertainties highlight the need for continued support and improvements to ensure health coverage for all eligible Hoosiers

Congenital Syphilis

The number of congenital syphilis cases in Indiana has increased by 2,300% from 2018 to 2023. Nationally, there has been a 755% increase in congenital syphilis cases between 2012 and 2021. The Centers for Disease Control and Prevention's recent analysis shows that almost nine in 10 cases of newborn syphilis in 2022 might have been prevented with timely testing and treatment during pregnancy. More than half of cases were among mothers who tested positive for syphilis during pregnancy but did not receive adequate or timely treatment, and nearly 40 percent of cases were among birthing mothers who were not receiving prenatal care.

The Indiana Department of Health has created an agency-wide task force dedicated to reducing the number of congenital syphilis cases in Indiana. This task force has developed provider education surrounding testing and treating syphilis in pregnant women, published a dashboard with information updated twice a week, and authored and distributed a “Dear Colleague” letter from Dr. Weaver, Indiana’s State Health Commissioner. As of June 2024, the MCH Division and the STI team partnered to employ an advertising firm to develop marketing material to drive more people to get tested for syphilis. The campaign will run into 2025.

Public Health Landscape in Indiana

In 2021, as a response to identified challenges exposed during the pandemic, Governor Eric Holcomb and his administration passed a bill calling for an official commission examining the public health infrastructure in the state. A Public Health Commission was formed, reviewed data and infrastructure, and reported on the need for a more sustainable way to support Indiana’s 94 local health departments. Public health is ‘home ruled’ in Indiana, meaning that IDOH does not have oversight or control over local health departments. Local health departments have historically been limited to funding from tax revenues, which means their budgets vary significantly - impacting staffing, services provided, and trust within their communities. A historic bill passed by the Indiana state legislature in April 2023, creating a blueprint for the most dramatic investment in public health infrastructure in a generation.

The Health First Indiana (HFI) initiative gave each county the individual opportunity to ‘opt-in’ through a vote from their county commissioners. If they do opt-in, they agree to serve their communities with an expanded set of core services. Their work must include MCH-related work such as providing warm referrals to additional care services, improving birth outcomes, participating in county-level fatality reviews, hiring school-based health liaisons, and implementing many other upstream prevention strategies. New investments in local public health will be equitable and based on population size, as well as social vulnerability indices. Counties must ‘match’ state dollars with at least 20% of locally identified investments. Out of the 92 Indiana counties 86 opted-in to the first year of Health First Indiana; as of June 2024, all 92 counties have opted in, meaning Hoosiers in every part of the state will be serviced by local public health departments resourced to meet the needs of their communities. MCH and Title V staff from across the agency have been meeting with local heath departments to provide technical assistance on how they can begin work on critical strategies to improve the health and well-being of the families in their counties. The team has shared significant data and connected LHDs to resources such as MCHB’s website, CityMatCH, MCH Evidence Center, and the IDOH site. HFI recently hired three regional MCH Specialists, who will serve as connectors between LHDs and IDOH and act as an extension of the MCH team.

Health Status and Health Needs of Hoosiers

1. Racial and ethnic disparities

Minority populations make up more than 20% of the population in Indiana. Like the rest of the United States, Indiana is growing more culturally, racially, and ethnically diverse and has started to see a decrease in the non-Hispanic White population with a corresponding increase in other racial and ethnic groups. Specifically, Indiana has experienced growing populations of families from Haiti, Central American communities, and Burmese refugees. Census data estimates that 5.3% of Hoosiers are foreign-born. The immigrant population continues to grow as families relocate to Indiana to work in the growing meat packaging/processing industry.

In Indiana, the Non-Hispanic Black population has consistently poorer health outcomes as compared to Non-Hispanic White population. The 2022 infant mortality rate for Non-Hispanic Black individuals (14.1 per 1,000 live births) is two and a half times that of the white non-Hispanic population (5.6 per 1,000 live births). The 2022 percentage of low-birth-weight infants for Non-Hispanic Black infants (15.1%), is nearly double that of the Non-Hispanic White infants (7.6%). The Maternal Mortality Review Committee found differences in the ratio of mortality by race and ethnicity, with Black, non-Hispanic women experiencing the highest ratio of mortality (156.3 deaths per 100,000 live births) and Hispanic women of all races experiencing the lowest ratio of mortality in 2021 (79.4 deaths per 100,000 live births). The percentage of mothers receiving early, and adequate, prenatal care is 70.9% in 2022. The discrepancy is considerably more evident among Black women (57.1 %) than white women (76.6 %). The percentage of Non-Hispanic Black mothers in 2022 who are breastfeeding at hospital discharge (77.5 %) is well below that of the non-Hispanic white mothers (84.6 %). In the 2023 Youth Risk Behavior Survey, 18% Hoosier youth have somehow been treated or judged unfairly due to their race or ethnicity (1.7% always, 2.2% most of the time, and 14.1% sometimes). This information has helped guide the judicious allocation of scarce Title V resources. According to data compiled by HRSA for Region V, if Indiana continues the current trends for Non-Hispanic White and Non-Hispanic Black infant mortality rates, Non-Hispanic Black infants will have to wait 38 years to achieve the 2019 Non-Hispanic White infant mortality rate. In other words, even though the rates continue to decline, Indiana must do more to close the wide gap between population groups.

A social determinant of health analysis conducted in 2020 identified that many Indiana’s residents experienced a lack of access to care and poor language access. As a response to this analysis, the MCH division hired Spanish-speaking staff who provide interpretation and translation support for initiatives within the MCH division and across the agency. With 10.3% of Indiana families speaking languages other than English in the home and nearly 27,000 children having no one over age 14 who speaks English “very well,” the MCH language access professionals are vital to the health and well-being of Hoosiers. It should be noted however, that over 260,000 Hoosiers speak languages other than English or Spanish, including Arabic, Burmese (including multiple dialects such as Chin and Karen), and Mandarin. Currently, there is a shortage of translators Indiana to help meet the needs of these families.

The department has relied on partnerships with health coalitions such as the Indiana Minority Health Coalition, and the Northern Indiana Hispanic Health Coalition to help serve as a connector and trusted partner to individuals and families of color. These organizations have been instrumental in improving access to healthcare through health fairs, community doula programs, and public education.

Another strategy the agency employs to improve access to healthcare is hosting the annual Black and Minority Health Fair. This event held every year in July provides over $3,500 worth of free health screenings, testing, vaccinations, information, and more. It is open to anyone in Indiana and will have translation services for many different languages.

Indiana is home to 35,000 individuals from Burma—the most in the United States, with Indianapolis having the largest community at 24,000. Neighborhoods, health departments, schools, and other non-profits have been quickly working to improve access to culturally relevant services. Most work with the Burmese population has been slow due to lower literacy levels and many different dialects. MCH has partnered with its internal team of refugee health experts as well as organizations that work directly with the Burmese population to understand the health needs of families, create educational materials and resources, and incorporate them into existing platforms such as the Liv Pregnancy Mobile App, home visiting, and MOMS Helpline.

Indiana has the third-largest Amish population in the world, yet it accounts for less than 1% of its population. The Amish communities span across rural areas of 32 counties in Indiana. Communication barriers exist as they do not have telephones in the home, English is often a second language, and health literacy is low. The Amish also experience financial barriers and transportation barriers. They are often reluctant to obtain health insurance or drive vehicles. Therefore, they often opt for alternative medical practices. While services are available and MCH has partnered with clinics to address these barriers, more work to address health disparities is needed.

Indiana has no federally recognized tribe within its borders. However, IDOH recognizes the importance of working with the citizens of tribes residing within the state. Specifically in the northern region, where the Potawatomi Tribe has recently built a casino and new housing, including a health center. The Title V program looks forward to engaging with this community in conjunction with other IDOH staff and local partners.

2. Geographical Disparities

In Indiana, 70% of the population lives in a metropolitan area, while 30% reside in a rural area. Currently, 63% of Indiana’s counties are considered rural; this is equivalent to two-thirds of the state’s counties. According to the Indiana Rural Health Association, rural communities have higher rates of chronic illness, disability, and poorer overall health status than urban communities. Rural residents also tend to be older and poorer than urban residents. Eighteen percent of rural residents are over 65 compared to 15% of urban residents, and more rural residents live below the poverty level compared to urban residents. Injury-related deaths are 40% higher in rural communities than in urban communities. Cancer rates are higher in rural areas. People living in rural areas are less likely to use preventive screening services, exercise regularly, or wear safety belts. These disparities among rural and urban Hoosiers may be due to several factors, including:

Lack of Transportation

Over 6% of Indiana households do not have a vehicle, including an estimated 30,000 households in Indianapolis (Marion County) alone. Public transit outside of Marion County is sparse, and inside Marion County there are still obstacles for people who need to commute to work: bus lines do not go everywhere. Many individuals must choose jobs they can access with public transit or within walking distance, which may not provide adequate health coverage. In addition, families are limited with lack of access to medical care and treatment because of cost prohibiting factors, weather, hours of operation, unable to get to a specific geographic area, and/or because the patient is too sick to use available options. Lack of transportation also limits access to nutritious foods and acts as a barrier to earning a stable income, this barrier is especially prevalent in rural communities.

Differences in Urban vs. Rural

Within Indiana, metropolitan areas experienced population gains, while other areas experienced population declines. Differences in health outcomes by rural vs urban:

• The MCH Epidemiology 2015 - 2019 linked data analysis showed that residents in counties that are considered rural made up a slightly higher percentage of infant deaths (23.0%) compared to their share of the births (21.9%), while residents of urban counties made up a slightly lower percentage of infant deaths (77.0%) compared to their share of the births (78.1%).
• In an attempt to look further than only rural/urban designation, the MCH Epidemiology Team also assesses births and infant deaths by categorizing counties by presence of OB services, lack of inpatient services, or no hospital. When looking at these designations, there are minimal differences in infant death percentages. While these designations did not have a high influence on infant death distribution, infant morbidity may likely be more impacted than infant mortality.
• While birth rates in Indiana have been steadily declining for years, the rural teen birth rate (22.9 in 2020) continues to be several percentages higher than the urban teen birth rate (17.6 in 2020). This trend has been consistent for ten years. These rates are for female teens aged 15-19 and calculated per 1,000 live births.

The MCH division notes, however, that populations cannot be placed in to ‘clean and simple’ categories, and individuals are multi-layered, and identities intersect.

3. Healthcare Workforce & Coverage

Limited Providers & Services:

Indiana does have 27 Federally Qualified Health Centers (FQHCs), eight Federally Qualified Health Center Look-a-Likes, and eight Rural Health Clinics that are Auto-HPSA designations (only for facilities).  However, Indiana is still facing a severe shortage of providers. In 2021, 47.3% of Hoosiers lived in areas where there was a physician shortage, and Indiana is in the 90th percentile for its primary care physician ratio. As of today, 67 of Indiana’s 92 counties have a Medically Underserved Area or Population Designation. Fifty-four counties do not have enough dental/oral health providers, 64 counties have primary care shortages, and 83 counties have mental health provider shortages. There is also a critical shortage of physicians who provide substance use treatment for pregnant individuals, and treatment centers are only located in select parts of the state. In 2020, 34 counties (two-thirds of the state) lacked a delivery hospital, and 20 counties had no prenatal care providers. The number of delivery hospitals decreased from 86 in 2021 to 75 in July 2024. A large swath of residents, especially in the western part of the state, are located outside of a thirty-minute drive time to a delivery hospital or prenatal care provider. Approximately two out of every five infant deaths can be tied to lack of prenatal care, making access to these services vital to infant health.

Children and youth with special health care needs are greatly impacted by limited providers. Families must often travel to Indianapolis or out-of-state to receive their specialty care. General primary care physicians and pediatricians have limited time and knowledge to coordinate effective care coordination for this population. This results in ineffective care and inadequate resources. Another issue is lack of knowledge about specific diagnoses. Many physicians statewide are not adequately trained to meet the needs of their patients with complex medical needs. This causes poor service delivery and frustration for caregivers. Indiana also has 14 autism hubs throughout the state to ensure that young children can be diagnosed before age three and offer early intervention services. However, due to the increase in physician and parental awareness, all hubs are currently operating on a waitlist. In addition, the demand for early intervention service providers is not proportionate to the need.

Medicaid Providers

Indiana has a risk-based managed care system for all MCH populations on Medicaid. Providers in some counties have refused to participate in Medicaid reimbursement for pregnancy and infant care until the infants are on the Children’s Health Insurance Program (CHIP). These counties tend to have poorer pregnancy outcomes. Currently, there are just under 140,000 children enrolled in CHIP, and this number decreased in 2019 for the first time in four years. Over the past few years, a serious challenge has been not only the number of physicians who do not accept Medicaid reimbursement but also challenges for Medicaid enrollment among pregnant women

To overcome the noted enrollment challenges for pregnant women, Indiana Medicaid began Presumptive Eligibility (PE) on July 1, 2009. Even so, there are areas of the state where providers are less likely to accept Medicaid reimbursement. Per Indiana Medicaid’s directory website (http://www.indianamedicaid.com/ihcp/ProviderServices/ProviderSearch.aspx), seven of Indiana’s 92 counties are without a single provider participating in Presumptive Eligibility. Furthermore, although the remaining 85 counties have PE-qualified providers, MCH has found that by comparing the MOMS Helpline extensive database records and speaking with individual callers, certain providers that are listed as accepting PE do not, and some no longer have OB/GYN staff. IDOH is partnering with providers across the state to clarify the intent of PE is to bridge the gap until Medicaid is in place and that they will be paid for services rendered.

In a positive move, as of April 2022, Indiana Medicaid made permanent the ability for postpartum individuals to stay enrolled for 12 months after delivery. MCH is hopeful this extended timeline will enable individuals to receive care for critical health needs such as substance use treatment, mental health consultations, chronic disease, and inter-conception care. This is also critical to address preventable maternal mortalities across the state.

Insurance

In comparison to other states, the health insured status of Hoosiers is below average.  In 2022, 8.3% of Indiana adults, ages 18 to 64, lacked health insurance. Additionally, 5.5% of Indiana children under the age of 18 lacked health insurance coverage. From 2021 to 2022, just 73.2% of insured children received preventative care. Although Indiana’s children and youth rank higher in insurance coverage, there is still more work to ensure they are properly covered. Children and youth with special health care needs require specialized care and equipment that often place caregivers in financial hardships due to lack of proper preventative coverage.

Looking Ahead

Indiana has many strengths; however, MCH & CSHCN recognize the need for continuous improvement when it comes to the overall well-being of Hoosier infants, children, children with special healthcare needs, adolescents, mothers, and families. We reaffirm our commitment to all current NPMs and SPMs and the Title V program; and have already begun exploring the needs of the population and target areas for improvement with our 2025 Needs Assessment. Changing circumstances for families require quick interventions and new partnerships. Relying on the nimble and flexible Maternal and Child Health Block Grant is essential for not only remaining steadfast in long-term population health improvement, but also providing support for current and emergent needs. Indiana is excited for the future of Maternal and Child Health.