Section III.B. Overview of the State  

 

North Dakota is a rural state located in the geographic center of the United States (U.S.). It encompasses significant landmass (69,001 square miles) and is the 19th largest state by geographic size. According to the U.S. Census Bureau, North Dakota is the second least populated state in the nation (762,077 residents) with a population density of approximately 10 persons per square mile. Most North Dakota counties possess a population base below 5,000 residents, including 36 counties considered “frontier,” defined as having a population density of six or fewer residents per square mile. North Dakota’s health status is confronted by a variety of challenges, including the unique geography and climate, socioeconomic factors and demographics of the state.

North Dakota has traditionally been one of the leading agricultural producers in the nation. According to the U.S. Department of Agriculture (USDA), North Dakota ranked ninth in the nation for the value of crops sold (2017 Census of Agriculture). Energy development also plays a large role in North Dakota’s economy. Top industries for jobs in North Dakota include government (16.9%), education and health (15.6%), retail trade (10.8%), leisure/ hospitality (9.6%), professional/ business services (7.8%) and construction (6.6%).

 

Over the last decade, North Dakota has had one of the fastest growing economies in the nation, as measured by Gross Domestic Product (GDP). The 2000-2018 compound annual growth rate for North Dakota’s real GDP of 3.6%, was slightly higher than the national average (2.9%) for this period (ND Compass, 2019). From 2008-2018, oil and gas extraction and production taxes have raised almost 18 billion for the state, which accounts for almost 44% of total tax revenues collected by the state during that period. Over the last five years alone, oil and gas extraction and production taxes accounted for more than 50% of all tax revenues collected by the state (North Dakota Department of Mineral Resources, 2019).  

 

For decades, North Dakota experienced out-migration of its young adult population, leaving it an older-population state with about three-fifths of its population in the eastern half of the state. North Dakota has experienced a dramatic population change over the last several years. According to the U.S. Census Bureau, the state has grown by over 13.3% between 2010 and 2019, making it the second fastest population growth of all states during that time. The rapid population changes in the state are the result of an influx of people coming to work in energy development and related industries in the western part of the state. This influx of people has changed North Dakota from being an older-than-average state to one of the youngest. The median age was 35.3 in 2019, making North Dakota the fourth youngest state. The population growth in the state, especially among young adults, has strengthened North Dakota’s workforce and revitalized the state’s natural increase through more births. Age distribution data from 2018 estimates that approximately 7.1% of the North Dakota population is less than five years of age, 23.6% is under 18 years of age and 15.7% of the population is elderly (65 years of age or older) (U.S. Census Bureau, 2019).

 

Racial and ethnic diversity continues to grow in North Dakota. The increase in the non-White population from 2010 to 2018 was the greatest percentage of any state. The population of color saw a 68% increase from 2010 to 2019 compared to the U.S. population of color increase of 17.5% during the same time (ND Compass, 2020). Despite the increase in the population of color, North Dakota was less racially diverse than most states (44 out of 50 states). The White, non-Hispanic population comprised 83.7% of all residents statewide in 2019, which is down from 88% in 2000 (U.S. Census Bureau, 2017). Among the racial and ethnic groups in North Dakota, the Black/African American population had the largest increase from 1.2% in 2010 to 3.3% in 2019. The Hispanic population increased from 2.0% in 2010 to 3.5% in 2019. The American Indian (AI) population continues to make up the largest minority population in North Dakota and remained constant as a percentage of the total population at 6.6% from 2010 to 2019 (U.S. Census Bureau,2019).

 

There are five-federally recognized Tribes and one Indian community located at least partially within North Dakota. The five tribes include the Mandan, Hidatsa and Arikara Nation (Three Affiliated Tribes), the Spirit Lake Nation, the Standing Rock Sioux Tribe, the Turtle Mountain Band of Chippewa Indians, the Sisseton-Wahpeton Oyate Nation and the Trenton Indian Service Area. As of 2017, the median age of North Dakota’s AI was 27.5, approximately eight years younger than North Dakota’s overall median age of 35.3 years (U.S. Census Bureau, 2019). Unemployment and poverty continue to be an issue on the reservations in North Dakota. Disparities facing the AI population include higher rates of diabetes, cancer, addiction, heart disease and other public health issues, including unintentional injuries. The average age at death for AI is 54.7 years, compared to 75.7 years for the White population (ND Compass, 2019). According to the 2020 County Health Rankings, all 12 North Dakota counties identified as “least healthy,” are either within a tribal reservation or designated as rural/frontier.

 

Differences in poverty exist by race/ethnicity. Nationally, 25.4% of AI’s were estimated to be in poverty both in 2007 and in 2018. In North Dakota, the percent of poverty of AI’s was 35.1%, reaching its highest point during this timeframe in 2011 of 46%. The 2018 estimate of 35.1% is the lowest annual estimate (U.S. Census Bureau, 2019). According to the Current Population Survey (CPS), North Dakota has the fourth lowest unemployment rate in the nation at 2.4%. The U.S. poverty rate was estimated to be 13.1%. North Dakota’s rate was 10.3%, putting the state among the 10th with the lowest rates of poverty for 2019. Since 2007, while the U.S. poverty rate climbed at one point to nearly 16%, North Dakota’s never exceeded 13%, reaching the highest point in 2009 and generally declining since. The state’s rate of poverty has trended down over the past 10 years. In 2007, North Dakota had an estimated poverty rate of 12.1%, just under the national estimate of 13%. North Dakota ranked 27th lowest of the 50 states in that year (U.S. Census Bureau, 2017).

 

There is a direct correlation between the rate of poverty for a given area and the percentage of house­holds receiving public assistance. According to the 2015 “Growing North Dakota by the Numbers: Public Assistance Programs Tracked by the Census” report by the North Dakota Department of Commerce, from 2009-2013, the percentage of North Dakota households receiving Supplemental Security Income (SSI), cash assistance such as Temporary Assistance for Needy Families (TANF) or Supplemental Nutrition Assistance Program (SNAP) benefits, ranged from over 40.6% in Sioux Coun­ty (AI reservation area) to 2.2% in Bill­ings County (an oil-producing county). Counties with the highest rates of public assistance all had a high AI population. These same counties had the highest rates of poverty in the state.

 

The health care delivery system in North Dakota consists of 52 hospitals – 36 smaller Critical Access Hospitals (CAHs) with 25 or fewer acute-care beds, six larger general acute-care hospitals located in the four largest cities, three psychiatric hospitals, two long-term acute-care hospitals, two Indian Health Service hospitals, and one rehabilitation hospital – and about 300 ambulatory care clinics. There are 34 facilities or programs statewide that provide mental health services and 96 licensed substance abuse programs. There are 52 federally certified rural health clinics and five federally qualified health centers with 18 clinic locations between them. All hospitals, including all 36 CAHs, except for one IHS hospital, are designated as trauma centers. Each of the “Big Six” hospitals, located in the four largest cities in North Dakota, are home to a Level II trauma center. Most emergency medical service support in the state is ground-based and provide basic services; which is under duress because of its dependence on volunteers and funding challenges. There has been an expansion across the state in the deployment and use of electronic health records, but financial and other barriers to full implementation remain (Health Issues for the State of North Dakota, 2019, University of North Dakota).

 

Local public health units also provide valuable health care in North Dakota. The public health system is made up of 28 single and multi-county local public health units; all are autonomous and not part of the Department of Health. Services offered by each health unit vary, but all provide services in the areas of maternal and child health (MCH) (Health Issues for the State of North Dakota, 2019, University of North Dakota).

 

Like the rest of the country, North Dakota is facing a major health care delivery challenge – how to meet a burgeoning need for health care services now and in the future, with a supply of health care professionals that is not keeping pace with the growing demand; thereby, impacting the health status and needs of the MCH population. If the population increases to 800,000 by 2040 as predicted, 500 additional physicians will be needed in the state. Part of the challenge in North Dakota is an inadequate number of providers; however, a larger portion of the challenge is a maldistribution of providers who are disproportionately located in the larger urbanized areas of the state. People in rural areas of the state are often older, poorer, have less or no insurance coverage than people in non-rural areas, all of which are challenges to providing adequate health care. Frontier areas of the state face greater difficulties than rural areas in maintaining their health care workforce. These thinly populated regions cannot easily compete with the wages and amenities offered to health care providers by hospitals and clinics in urbanized areas. Even communities that do have adequate staffing are often one doctor or nurse away from a shortage (Health Issues for the State of North Dakota, 2019, University of North Dakota).

Census Bureau Health Insurance statistics break the population into major age cohorts: children under age 18, workforce age (18 through 64) and those age 65 and above. In 2018, an estimated 93.7% of children in the state had health insurance, very similar to the national rates. North Dakota children who are White have insurance at a rate higher than the state’s average (96%), while AI children are insured at rates substantially lower that the state’s average, at 93% although this rate has increased from 80% in 2012.

 

According to the American Community Survey (ACS) for 2018, most North Dakotans have some form of health insurance. The ACS shows that about 92.7% were insured in North Dakota, 79.7% are privately insured, 26.5% are on public insurance, and approximately 7.3% are uninsured. As of 2018, 8.4% of residents under age 65 in North Dakota lacked health insurance coverage (91.6% had some form of health coverage). The Kaiser Family Foundation estimates based on the ACS for 2018 provided insurance rates broken down by race. Out of the North Dakota residents lacking insurance under age 65, White residents made up the highest percentage rate at 58%, while AI’s accounted for 18% of the uninsured rate. However, the AI population comprised 25%of North Dakota residents who are living in poverty. Nonelderly adults between the ages of 19-64 were least likely to be covered by a type of health insurance, making up approximately 10% of the total uninsured population for the state. Males tended to have lower rates of coverage than females in this age range, regardless of race or ethnicity. Due to Medicare coverage, nearly 100% of residents age 65 and over were estimated to have health insurance.

 

Approximately 7.1% of North Dakota adults under the age of 65 have a disability. North Dakotans with disabilities, compared to those without disabilities, were more likely to be of AI descent at 13.6% (ACS 2014-2018). According to the 2017-2018 National Survey of Children’s Health (NSCH), North Dakota provided slightly more coordinated and comprehensive care services within a medical home to children with special health care needs (CSHCN) (47.4%), compared to the national average (42.7%). Also, in the 2017-2018 NSCH, only 36.5% of North Dakota families with CSHCN felt they received effective care coordination if they needed it, and 25.2% of families with CSHCN, ages zero through 17, reported to have difficulty paying medical or health care bills in the last twelve months. These results indicate the dynamic need for medical homes and adequate health insurance within the state.

 

As of April 2020, according to state health facts from the Kaiser Foundation, North Dakota has enrolled 92,690 individuals in Medicaid and CHIP (Children’s Health Insurance Program). Out of all North Dakota Medicaid/CHIP enrollment, 48% of these individuals are children. This can be compared to the U.S., where an average of 51% of Medicaid/CHIP enrollees are children.

According to healthinsurance.org, there are three major carriers that offer plans in the North Dakota exchange. Blue Cross Blue Shield of North Dakota (Noridian), Sanford Health Plan and Medica offer coverage statewide. In addition, United Healthcare began offering small group health plans in North Dakota in 2019. Open enrollment for 2020 health plans has ended, although North Dakota residents with qualifying events (including loss of employer-sponsored coverage) can still enroll or make changes to their coverage for 2020. The next open enrollment period, for plans effective in 2021, will begin November 1, 2020. Noridian holds the majority of the market share in the North Dakota exchange, with about two-thirds of the states’ enrollees. Starting in 2020, North Dakota has a reinsurance program. As a result, premiums for 2020 (before any subsidies are applied) are lower than they were for 2019, and significantly lower than they would otherwise have been in 2020. Enrollment in North Dakota’s exchange increased every year from 2014 through 2018, going from 10,597 to 22,486 enrolled. Through the North Dakota exchange during open enrollment for 2020 plans, 21,666 people enrolled in private plans.

North Dakota was one of only a handful of states where exchange enrollment increased every year from 2014 through 2018. In most states that use HealthCare.gov, peak enrollment occurred in 2016, and enrollment numbers have declined since then. In North Dakota, the first decline came in 2019.

 

In 2019, insurer participation returned to what it had been in 2017, with Sanford once again offering plans statewide, and Medica offering plans in all but a few northwestern counties. Blue Cross Blue Shield of North Dakota continues to offer plans statewide in the exchange, as they have since 2014.

 

Three organizations in North Dakota received a total of nearly $637,000 in navigator grants in 2016 that were used for outreach, education and enrollment assistance to consumers eligible for coverage through the Marketplaces and through Medicaid. In 2017, organizations in North Dakota received funding of $208,524, a reduction of 67%. However, when navigator grants were announced in September 2018, only one organization in North Dakota, Family HealthCare Center, received $85,000.

 

The Family HealthCare Center has served as a navigator since 2015 and partners with Valley Community Health Centers to reduce the number of uninsured in North Dakota.  They also provide outreach and education to seven northeastern and southeastern North Dakota counties with focus on consumers at or below 200% of the federal poverty level (FPL), new Americans and refugees, pregnant women and new mothers, AI’s, the justice-involved population, disabled consumers and Medicaid-eligible populations.

 

Knowledge and awareness of CSHCN has been an asset in supporting access to affordable care for families. Navigators who were supported in the past with ACA funding were employees of organizations that understood programs that could assist families of CSHCN. When approached by a family for health care options, they still provide navigational support and link families to resources.

 

There are still gaps that exist, in that some children need services that are not available through current benefit plans. Service limits may also pose a challenge. Lower income families may not be able to afford a plan that covers the needs of their children or the associated co-payments for services.

 

In addition to private plan enrollments, North Dakota expanded its Medicaid program under a provision of the Affordable Care Act. In February 2012, Governor Dalrymple favored the expansion, and the state House approved the measure. Enrollment in Medicaid in North Dakota increased by 30 percent from the end of 2013 to December 2018. There were approximately 21,000 people enrolled in North Dakota’s expanded Medicaid as of October 2019. North Dakota previously followed a unique public-private partnership model of Medicaid expansion, allowing private health insurance carriers to bid for the opportunity to provide health insurance coverage to the state’s newly eligible Medicaid population using federal Medicaid funds. The decision to bring North Dakota’s Medicaid expansion and Children’s Health Insurance Program (CHIP) in-house to North Dakota Medical Services was passed during the 2019 Legislative Session. This transition took effect on January 1, 2020.

 

North Dakota’s CHIP and North Dakota Medicaid have been effective public programs in reducing the number of uninsured, low-income children in the state. CHIP provides premium-free, comprehensive health, dental and vision coverage to uninsured children up to 19 years old who do not qualify for standard North Dakota Medicaid. The income eligibility limit is at 175% of the Federal Poverty Level (FPL). Modest co-payments apply for certain services, which are waived for AI children. North Dakota Medicaid covers children ages 0 to 6 (thru the month they attain age 6) at 152% of the FPL and children ages 6 through 18 (through the month they attain age 19) at 138% of the FPL. North Dakota Medicaid has some limitations or restrictions for some covered services. As of April 2020, as indicated by Medicaid.gov, North Dakota had a total of 90,377 individuals enrolled in North Dakota Medicaid and 2,313 children enrolled in CHIP. It was estimated in October 2019 that approximately 26% of CSHCN were covered by North Dakota Medicaid according to the Kaiser foundation.

 

1-877-KIDS-NOW is a toll-free resource line that helps uninsured families learn about low-cost and free health care coverage programs in North Dakota. A seamless eligibility process for health coverage programs has helped to assure coverage for North Dakota’s children. In February 2019, the combined monthly child enrollment in Medicaid and the CHIP in North Dakota was 47%, compared to 51% in the U.S.

 

Program data from the North Dakota Department of Health (NDDoH), Division of Special Health Services (SHS), indicated that in Federal Fiscal Year 2019, 82% of the 1,988 children served by SHS had a source of healthcare coverage. Of these, about 51% were privately insured (1,017); 30% were insured by North Dakota Medicaid; 0.4% were covered by CHIP, 1.6% had no source of coverage, and 17% were unknown. 

 

The information provided below defines the roles, responsibilities and targeted interests of the state health agency and the influence of the delivery of Title V services:

Legislative activity serves to determine priorities and to identify current and emerging issues. NDDoH leadership is very supportive of allowing staff to provide testimony on key public health issues. Title V staff monitored, tracked and/or testified on close to 100 bills during the 2019 Legislative Session. The North Dakota legislature did not meet in 2020, as legislative sessions are biennially and will not convene again until January 2021. Due to the COVID response, the Interim Legislative Health Care Committee has been cancelled and has not been rescheduled at the time of the grant application. However, the following MCH related updates will be given:

• A report from the Department of Human Services, State Department of Health, Indian Affairs Commission and Public Employees Retirement System before June 1 of each even-numbered year on their collaboration to identify goals and benchmarks, while also developing individual agency plans to reduce the incidence of diabetes in the state, improve diabetes care and control complications associated with diabetes (NDCC § 23-01-40);
• A report from the State Department of Health on the status and progress of implementing a public awareness campaign to provide information, public service announcements and educational materials regarding abandoned infants and approved locations for abandoned infants (2019 House Bill No. 1285, § 2); and
• An update on E cigarettes and tobacco.

Behavioral health is a critical issue for the NDDoH, and partnership with the NDDHS, Behavioral Health Division, along with other key partners (e.g., Sanford Health, Family Voices of North Dakota, Children’s Advocacy Center, medical systems), is essential to address these issues. In September 2018, North Dakota was awarded the Pediatric Mental Health Care Access (PMHCA) grant. The primary goals/objectives of North Dakota’s PMHCA Program are to: 1) increase tele-behavioral health services to children and adolescents living in underserved areas of the state; 2) to extend knowledge to pediatric primary care professionals across the state for the early identification, diagnosis, treatment and referral of mental health disorders; 3) to include direct school-based delivery of tele-health services due to the shortage of healthcare providers and the lack of an infrastructure for primary care clinics, and 4) to enhance existing partnerships and develop new relationships with entities that have similar goals and expectations to this program.

   

The NDDoH engaged in a strategic planning process on December 10, 2018. Because of this effort, the department's mission, strategic initiatives, key objectives and indicators have been updated. The NDDoH’s Strategic Plan Map (2019-2021) can be found at: http://www.ndhealth.gov/ch/Strategic_Map_2019-2021.pdf

 

The strategic plan is reviewed and revised annually and assists the department in communicating with partners, setting direction, motivating employees, making decisions, determining priorities and budgets and monitoring progress and impact. The Title V Director and Health Equity/MCH Grant Coordinator are members of the Strategic Planning Committee. All department programs have been linked to the strategic plan goals and objectives.

 

Title V programs align with the following NDDoH goals and objectives:

Goal: Create Healthy and Vibrant Communities

 

• Reduce the risk of infectious disease
• Prevent and reduce chronic disease
• Support communities in building resiliency
• Promote community driven wellness
• Increase healthy lifestyles and behaviors

 

Goal: Enhance and Improve Systems of Care

 

• Improve access to care in underserved and rural areas
• Enhance healthcare through technology
• Ensure access to and affordable health and preventative services
• Appropriately regulate and educate workforce to enhance quality and safe care
• Drive health-in-all policy agendas
• Establish system level partnerships across continuums of care

 

Goal: Strengthen Population Health Actions

 

• Prevent and reduce tobacco and other substance misuse
• Prevent violence, intentional and unintentional injury
• Reduce the risk of vaccine preventable diseases
• Reduce adverse health outcomes through early detection of disease
• Achieve a healthy weight for children and adults

 

Overarching Goal: Improve Health Equity and Assess Impacts of Social Determinants of Health

Overarching Goal: Manage Infrastructure for Optimal Outcomes

Overarching Goal: Integrate a Data-Driven Best Practices Approach

 

In addition to the core mission of the agency, the NDDoH is engaged in Governor Doug Burgum’s Five Strategic Initiatives for North Dakota: Main Street Initiative, Behavioral Health and Addiction, Transforming Education, Tribal Partnerships and Reinventing Government. A description of the partnership and leadership role of the NDDoH and Title V in these initiatives can be found in III.E.2.a State Title V Program Purpose and Design.   

 

The NDDoH recognizes the importance of public health accreditation and the alignment of accreditation efforts throughout the public health system in order to strengthen performance across the state. In April 2020, the NDDoH celebrated three years as a nationally accredited health department through the Public Health Accreditation Board (PHAB). 

 

To increase the effectiveness of strategic planning and accreditation, the NDDoH has developed and implemented a performance management system and continuous quality improvement (QI) process. These efforts assist to systematically monitor and improve the quality of programs, processes and services in order to achieve high levels of efficiency and effectiveness, as well as internal and external customer satisfaction.

 

Title V program staff have varying roles and responsibilities within the department’s priorities and initiatives. The Title V Director holds a senior management position within the NDDoH and is actively involved in strategic planning and accreditation activities. As a result, Title V issues are included in department discussions, planning and decision-making processes. In addition, the Title V, CSHCN Director and the Health Equity/MCH Grant Coordinator provide regular updates to staff to seek input and feedback on department issues.

 

State Specific Statues:

Priority setting also is determined by state mandates; see Supporting Document – Title V-MCH State Mandates. A State Performance Measure has been developed to address the Title V responsibilities related to these mandates titled “Implement North Dakota State Mandates Delegated to the North Dakota Department of Health Title V/Maternal and Child Health Program.” Information regarding these mandates is discussed in III.E.1. Five-Year State Action Plan Table and III.E.2.c State Action Plan Narrative by Domain – Cross-cutting/Systems Building.

 

The NDDoH’s organizational chart can be found in VI. Organizational Chart.