To understand maternal and child health (MCH) population needs in Pennsylvania (PA), it is necessary to learn the geographical, social, economic, and political traits of the Keystone State and its residents. PA is a vast, increasingly diverse state comprised of large rural areas and concentrated urban centers which are both evolving economically and socially. Located in the northeast, PA is the fifth most populous state, home to over 12.8 million people. In addition to its rural and urban divide, the state is physically divided in half by a large swath of rural forest created by the Appalachian Mountains.

PA is anchored by two urban counties, Allegheny in the west and Philadelphia in the east. Urban counties are those with a population density higher than the state population density, while rural have a lower density. Harrisburg, the capital and headquarters for the Department of Health (DOH), is situated in the southcentral part of the state. As of March 2018, PA’s 19 large counties (counties where 75,000 or more are employed) accounted for 77 percent of total employment within the commonwealth. All but two of those counties are considered urban. In 2016, slightly over 78 percent of the state gross domestic product was produced by urban counties. PA has the sixth largest economy in the nation, but as of March 2019, had a seasonally-adjusted unemployment rate that was slightly higher than the national average. In 2017, 28 percent of PA’s population was low income (under 200 percent federal poverty level or FPL), and 43 percent of the state’s Medicaid expansion population worked full or part time but made less than the eligibility threshold of 138 percent FPL.

The health care, social assistance, manufacturing and real estate sectors are major contributors to the economy. The industries with the greatest number of employees in PA were health care and social assistance in 2016, growing 6 percent since 2012. Employment in farming increased from 2012-2016, reversing a trend from 2001-2012. While 56 of PA ‘s 67 counties have at least 500 individuals employed in farming, six of the seven largest pockets of farm employment are along PA’s southern border.

The delivery of health care services is significantly impacted by the distinctive rural and urban characteristics across the state. While 48 of PA’s 67 counties are considered rural, nearly three-quarters of PA’s residents live in urban counties. The concentration has become even more pronounced since 2010, as most of the population growth in PA has occurred in urban counties. In 2014, there was one physician for every 266 residents in urban counties, as compared to one physician for every 586 residents in rural counties. Of the 16 counties without Federally Qualified Health Centers (FQHC), all but one are rural. As of 2014, of the estimated 435,921 residents experiencing a primary care provider (PCP) shortage, 52 percent lived in a rural county. Rural counties also represented all 29 counties where at least 15 percent of the population was experiencing a PCP shortage. In 2017, there were 70 general acute care hospitals, with a total of 8,154 beds, in rural PA. Seven rural counties had no hospitals. On average, there were 2.4 hospital beds for every 1,000 rural residents compared to 2.8 hospital beds for every 1,000 urban residents.

In addition to a general lack of healthcare resources, rural areas have other challenges: an aging population; a growing young minority population with higher rates of poverty and unemployment; and a lack of resources or training to meet the language and cultural needs of the growing immigrant populations. On average, rural PA residents are older than urban PA residents. In 2015, 18 percent of the rural population was 65 years old and older compared to 16 percent of the urban population. From 2010 to 2040, the number of senior citizens in rural PA is projected to increase by 54 percent.

Across the state in 2017, the 156 general acute care hospitals (including 15 Critical Access Hospitals [CAH]) with nearly 34,500 licensed beds handled over 1.45 million admissions. An additional 95 federal and specialty hospitals handled over 167,000 admissions. There are nine children’s hospitals in PA, six of which are in either Philadelphia or Pittsburgh. The other three are in Danville, Erie, and Hershey. Children who live in rural areas or in areas not near these hospitals may not have ready access.

Supplementing the hospitals are over 260 FQHC or rural health centers providing primary care services in 50 counties. FQHCs are an important resource for PA’s vulnerable populations. As of January 2019, 90 percent of FQHC patients are at or below 200 percent FPL, 50 percent are on Medicaid, and 55 percent are members of a racial or ethnic minority.

CAH are rural hospitals that provide 24-hour emergency services with an average daily census of 25 patients or less. These hospitals serve as key providers in areas with sparse populations, geographic barriers to care, and significant health professional shortages to address populations who are generally older, sicker, and poorer. Besides anchoring a broad range of health and human services in their communities, many of these hospitals continue to be the top employers in their county and major contributors to local economies. Of concern is that in FY 2016, nine of the CAH (60 percent) reported negative operating margins.

Other important partners in the delivery of services within the MCH system of care are the county/municipal health departments (CMHD) and state health centers. The ten CMHD are in urban areas and tailor services to the needs of their local communities.  Primary and secondary preventive health services are emphasized, and geared to improve the community’s health through direct health services, education, and leadership. CMHD are funded by Act 315, PA’s Local Health Administration Law, with additional funding by state, federal, and local government going towards local office priorities. At a local level, CMHD currently cover 41 percent of PA’s population. In addition, several CMHD have either applied for or achieved public health accreditation through the Public Health Accreditation Board (PHAB). As a result, those communities have access to higher-quality programming and services.

Counties without CMHD have state health centers who provide and support public health programs throughout PA. To organize the state health centers, PA is split into six community health districts, each covering a geographic region of the state. Each health district in turn has a district office that helps coordinate activity throughout the district.  Through the utilization of community health assessments and outreach, the centers focus on five core functions: communicable disease investigation and prevention, immunizations, public health education, HIV/STD services, and tuberculosis investigation and treatment.

Health insurance is a key factor for health care access. In 2017, 5.5 percent of the approximately 12.6 million civilian noninstitutionalized population in PA were uninsured. By gender, 6.4 percent of men were uninsured compared to 4.6 percent of women. Only 5 percent of whites were uninsured compared to 7 percent of blacks and 12.6 percent of Hispanics. Slightly more than 10 percent of 25-34-year-olds were uninsured, the largest proportion of any age group. As educational attainment increased, the percentage insured increased.

The ACA has brought some insurance relief with the introduction of the federal Marketplace. While the uninsured rate ranges from 4 to 13.2 percent across counties, the uninsured are primarily working families with an income below 400 percent of the FPL and white. As of January 2019, nearly 366,000 residents had selected a Marketplace plan, of which 86 percent received financial assistance. While the uninsured rate has fallen for all racial and ethnic groups because of the ACA, as of 2017, whites are still more likely to be insured than blacks.

A key component in the MCH system of care is Medicaid, administered in PA by the Department of Human Services (DHS). Medicaid eligibility is determined by belonging to a particular group such as pregnant women, children, low-income adults, elderly adults, or disabled adults; or by having a special condition, as well as meeting financial and citizenship requirements. Medicaid eligibility levels are highest in PA for children and pregnant women and both are higher in PA than the median U.S. rate.

Medicaid also has special programs for specific medical conditions and waiver programs available for those who require assistance with activities of daily living or who meet functional requirements (such as those with AIDS, on home ventilators, or with autism). Although these waivers provide a wide array of services (such as home health aides, transportation, and case management), they are not an entitlement and there is no guaranteed entrance.

In addition to covering basic Medicaid services, states can choose to cover up to 30 optional benefits. PA covers 24, including prescription drugs, vision, dental, physical therapy, home health, and hospice care. PA’s Medicaid expansion coverage includes the Affordable Care Act’s (ACA) ten essential health benefits and expanded mental health and substance use treatment services. Children with special health care needs (CSHCN) are served by Special Needs Units (SNU) within Medicaid. SNU are housed within physical health Managed Care Organizations (MCO) and ensure CSHCN receive services and supports in a timely manner. SNU also assist CSHCN with access to services and information, coordinate between physical health and behavioral health and other systems, and staff a dedicated special needs hotline. Each physical health MCO has a full-time SNU coordinator.  SNU staff also work in close collaboration with the SNU housed within DHS.

Individuals not eligible for Medicaid may qualify for Children’s Health Insurance Program (CHIP), also a part of DHS. CHIP provides free or low-cost health insurance to uninsured children and teens up to age 19 in families with incomes over the Medicaid limit (133 percent FPL). As of November 2018, there were 179,981 children enrolled in CHIP. CHIP and Medicaid combined provided health and long-term care coverage to more than 3 million in PA. Medicaid is also a major source of funding for safety-net hospitals and nursing homes, and most Medicaid spending in PA is for the elderly and people with disabilities. In State Fiscal Year (SFY) 2017, Medicaid accounted for 60 percent of all federal funds received by PA and 28 percent of the state general fund spending.

Following a national trend, PA is becoming more racially and ethnically diverse. From 2010-2016, the minority population increased from 36 percent to 39 percent nationally, and from 21 to 23 percent in PA. Minority residents make up more of the population in urban areas (30 percent) than in rural areas (9 percent). The population identifying as Hispanic increased in PA by 25 percent from 2010-2016, increasing by at least 7 percent in every county. From 2000 to 2015, the rural population became more racially diverse, as the non-white or Hispanic rural population increased from 5 percent of the total population, to 9 percent. As of 2017, approximately one in three Pennsylvania children are children of color. With the total minority population projected to double between 1990 and 2025, the responsibility and challenge of the Title V program is to understand their diverse backgrounds, and how services and Title V programming needs to adapt to their needs.

With an increasingly diversifying population, it is important to consider how people of color experience PA’s system of care, signified by key MCH indicators. In 2016, the infant mortality rate for whites was 4.6 per 1,000 live births. The rate for blacks was more than three times that, and for Hispanics, it was roughly 60 percent higher. For blacks, the disparity has persisted since at least 1999, and for Hispanics, since 2012. Preterm births are seen as a leading cause of infant death. In 2017, the percentage of preterm births for whites was 8.6 percent. Blacks had a percentage that was one and a half times that of whites (roughly 50 percent higher), and for Hispanics, the percentage was roughly 1.2 times that of whites. The disparity for preterm births for Blacks has been roughly the same since 2003. From 2012-2016, the maternal mortality rate for whites was 8.7 per 100,000 births. The rate for black mothers was more than three times the rate for whites. In 2016, one percent of white mothers had no prenatal care; for black mothers, it was nearly four times that, a disparity that has not changed since 2011. For Asian and Hispanic mothers, the percentage was approximately twice that of whites. That disparity has existed for Hispanic mothers since 2003. A lack of prenatal care has been linked to poor birth outcomes, including low birth weight and infant mortality. In 2016, the teen pregnancy rate for whites was 6.0 per 1,000 females aged 15-17. Despite teen pregnancy rates for blacks having dropped nearly 60 percent from 2010-2016, rates are still four times that of whites. Like blacks, despite a decline in teen pregnancy rates from 2015-2016, the teen pregnancy rate for Hispanics was nearly four times that of whites. That disparity has been roughly the same since 2010. With the projected increase in populations of color, if health disparities in these populations are not addressed, they have the potential to create a greater burden over time.

Overlapping the disparities are familial, educational and economic characteristics of the population that further define their interaction with the MCH system of care. In general, PA is growing older. The median age of PA residents is 40.8 years old, nearly three years older than the US median age. From 2010-2016, PA’s population grew less than 1 percent, the number of young residents (under 18) decreased 4 percent, but the number of residents 65 and older increased 13 percent. In 2040, an estimated 25 percent of the total rural population will be 65 and older. At that time, there will be more senior citizens than children and youth in rural PA. Counties with large elderly populations could face the possibility of diverting resources from MCH populations towards their elderly residents.

Of the approximately 5 million households in the state in 2017, nearly 3.2 million of these households are defined as families, with an average size of 3.1 members. The U.S. Census Bureau categorizes families as: married-couple families, male householder (no wife present) and female householder (no husband present). While married families are most common, over 71 percent of non-married families are female led. These households have slightly larger family sizes, are more likely to have members less than 18 years of age and are more likely to live in multi-unit structures. Eight percent of all households in PA are single parent households with children under 18 and no spouse present. PA had a lower percentage of households with children (25 percent) than the national figure (27 percent). The population of children under age 18 is evenly distributed across age groups for each family type. Of the 2.65 million children in the state, approximately 1.75 million live in a married family. Over 215,000 children live in male led families; and roughly 672,000 children live in female led families, which are less likely to have an unmarried partner present.

The racial distribution greatly varies between types of households with children. While nearly 82 percent of children in married families are identified as white, over 72 percent of children in male led families and over 54 percent of children in female led families identify as white. Over 59 percent of black adolescents and 40 percent of Hispanics live in female led families compared to only 19 percent of whites. Female led families are more likely to have grandchildren in their households, and more likely to have a child with a disability in their household when compared to other households.

According to the 2016-17 National Survey of Children’s Health, 19 percent of children in PA have special health care needs. Children and their families may encounter multiple barriers to perform daily life functions and often need services from multiple systems of care which can be challenging for families to navigate.

Median income varies by county from $37,100-$92,400; for families with children, it is $72,878. However, there are stark differences in median income when considering family type. The median income for married families is approximately $97,300, $42,500 for male led families and $26,300 for female led families. In addition, female led families are slightly larger in size than male-led or two-parent families, but their median income is much lower. Women’s income is also affected by the wage gap. In 2018, women in PA are earning the national average of 80 cents for every dollar a man makes. The wage gap is even greater if the woman is a minority.

In 2017, a smaller percentage of PA residents (12.5 percent) lived in poverty compared to the national rate (13.4 percent).  However, there are still large swaths of the population living in poverty, as 24.8 percent of PA’s black residents and 28.7 percent of PA’s Hispanic residents lived in poverty and families with black or Hispanic householders were more than three times as likely to be living in poverty than whites. Of the 1.36 million families with related children under 18, 13.5 percent were living below the poverty level during the previous year. Female led families were more likely than any other to be living below the poverty level, and more than twice as likely as all PA families with children under 18. The highest rates of poverty were for those families with a householder having less than a high school education. However, at all levels of educational attainment, the percentage of female led families living below the poverty line was higher than other families, more than double in most cases.

Adolescents (15 to 19 years) are an important sub-population within the MCH population, numbering approximately 823,000 with almost 88 percent enrolled in school in 2017. School enrollment among adolescents is fairly consistent by race and ethnicity, with Hispanics having the lowest enrollment at 84.1 percent. 

Future earnings are related to a person’s level of educational attainment. For the 8.96 million people aged 25 years and over, over 90 percent have a high school degree or higher, varying a bit by county, and over 31 percent have a bachelor’s degree or higher. For this same population, for whom poverty status is determined, the rate of poverty for those with less than a high school diploma is 24.1 percent and decreases with educational attainment. The median annual income for those aged 25 years and older is approximately $40,700 and ranges from $24,800 for those with less than a high school diploma or equivalency to $70,100 for graduate or professional degree holders.  Of the approximately 1.18 million 18 to 24-year olds, almost 34 percent have graduated high school; 44 percent are enrolled in college or graduate school and 13 percent have a bachelor’s degree or higher. Females in this age group are enrolled in college or graduate school at a higher rate than males.

According to a 2016 Williams Institute analysis of Census Bureau data, there are 22,340 same-sex couples in PA (sixth nationally) compared to 646,500 in the U.S. with almost 16 percent of these couples in PA raising children. Most same-sex couples in PA are women (56 percent) and 81 percent are white. The mean income for same-sex couples is higher than that of different-sex couples, $52,000 versus $46,000, and over half have a college education as compared to only 33 percent of different-sex couples. Ninety percent of same-sex couples have health insurance. In PA, three percent of people identify as Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) with 27 percent raising children; the US numbers are four and 29 percent. As with same-sex couples, most of the LGBT population is white (72 percent). PA ranks 38th in percentage of LGBT individuals. Over a quarter (28 percent) of LGBT individuals have an income less than $24,000 as compared to non-LGBT individuals (21 percent). More non-LGBT (90 percent) individuals have health insurance than LGBT individuals (86 percent). The percentage of non-LGBT and LGBT individuals having a college education is nearly equal. As of 2018, 4.1 percent of PA is LGBT, compared to 4.5 percent nationally, and PA has 32,719 same sex households (935,229 nationally), 58.6 percent of whom are married.

LGBTQ residents face ongoing health inequities in terms of their absence in statewide surveillance systems, discrimination by healthcare providers, in the workplace and in social situations. Over half of LGBTQ individuals have reported discrimination at some point based solely on sexual orientation, which remains legal in PA. There are few laws protecting LGBTQ families regarding insurance coverage, hospital visitation rights and powers of attorney. Members of LGBTQ groups have health needs both regular and specific to their sexual and gender orientation that often go unmet. In response to a range of discriminatory laws being passed in other states, Governor Wolf signed executive orders in April 2016 stating, “no agency under the governor’s jurisdiction shall discriminate on the basis of sexual orientation, gender expression, and identity, among other areas.” These orders pertain to commonwealth employees, and the commonwealth grants and procurement process. Over 40 municipalities have passed separate ordinances to prohibit discrimination based on sexual orientation and gender identity.

Impacting PA residents, the health care system and the broader landscape of the MCH system of care are several important issues. Like other states, the epidemic of opioid use is now a priority of both the Governor’s administration and the DOH. In 2017, PA’s mortality rate from opioid deaths was higher than the national rate (21.2 versus 14.9 per 100,000), and nearly double that of 2015 (11.2). According to the DEA’s PA Opioid Report, there were 5,456 drug-related overdose deaths in 2017, a 65 percent increase from 2015. That number also represents a rate of 43 deaths per 100,000, nearly doubling the national average of 22 per 100,000 in 2017. While there is a broad range of ages for these deaths, the typical decedent is male and between 25-34 years old. The distribution of overdose deaths by race in PA roughly corresponds to the state’s racial makeup, and 71 percent of all overdose deaths in PA were male. An additional impact of opioid use that affects the MCH population is that of Neonatal Abstinence Syndrome (NAS). According to data from the PA Health Care Cost Containment Council, in FY 2016-17, there were 3,883 reported newborn hospital stays with NAS, a rate of 15 per 1,000 newborn hospital stays. This puts an additional burden on the healthcare system, as the mean length of hospital stay for newborns with NAS during that time was 17.1 days, compared to 3.5 days for newborns without NAS.

Attempts to combat the drug problem are multi-faceted and range from improving prescribing practices to providing better and more widely available addiction treatment services. In January 2018, Governor Wolf declared the heroin and opioid epidemic a statewide disaster emergency, a first for a public health emergency. The declaration allowed for the creation of a command center that will track progress and enhance the coordination of health and public safety agencies, helping commonwealth agencies address the opioid epidemic. The command center is stationed at the Pennsylvania Emergency Management Agency and headed by an incident commander. In March 2019, the Governor signed a sixth consecutive 90-day renewal of the declaration extending the designation of the opioid epidemic as a disaster emergency. The Secretary of Health, Dr. Rachel Levine, is working to have the epidemic declared a public health disaster, which is an unprecedented step.

In 2018, the DOH prioritized the protection of access to health care in rural communities using a Rural Health Model, developed in coordination with the Centers for Medicaid and Medicare Services. Five hospitals and five payers will participate in year one of the model in 2019.  Another unique challenge related to PA’s status as a largely rural state is Lyme disease. PA has the most reported cases of Lyme disease of any state in the country. In 2018 DOH is formed an inter-bureau workgroup to pull together resources and knowledge to address it, focusing on a response to the disease and surveillance. The childhood obesity workgroup looked at a number of interventions, such as an excise tax on sugary beverages, working with WIC to help control childhood obesity and breastfeeding friendly workplaces. The year also saw the formation of a Public Health Workforce Interests and Needs Survey (PH WINS), workgroup, which has been gathering feedback and perspectives directly from DOH staff.

Additional priorities for the DOH in 2019 include:

• Implement recommendations of the nursing home taskforce and auditor general reports including the development of regulations
• Continue to build capacity to respond to public health threats through preparedness
• Maternal and Child Health
• Environmental Health
• Violence Prevention.

The Secretary’s priorities combined with the State Health Improvement Plan (SHIP) and the DOH’s Strategic Plan guide the work of the agency and illuminate areas for Title V to implement work. The DOH is currently in the middle of its SHIP for 2015-2020, developed in partnership with a broad representation of public health system stakeholders. The SHIP priorities are: 1) obesity, physical inactivity, and nutrition; 2) primary care and preventive services; and 3) mental health and substance abuse. Through the process of defining the SHIP priorities, five cross-cutting themes were also identified: health literacy, public health systems, health equity, social determinants of health and integration of primary care and mental health. 

The DOH 2016-2019 Strategic Plan consists of the following four key strategies: 1) Enable local, evidence-based action to improve public health and wellbeing of all Pennsylvanians; 2) Implement an evidence-based, data driven decision-making practice throughout the department to advance public health; 3) Maintain and enhance emergency services and public health preparedness; and 4) Transform PA DOH culture to be focused on continuous quality improvement in its approach to public health. These department strategies closely align with the work of Title V in PA and the Bureau of Family Health, as the Title V administrator, will continue to emphasize evidence-based and data driven decision-making within its programming while increasing the integration of quality improvement techniques throughout its work.

In March 2019, the DOH achieved national public health accreditation per notification from the Public Health Accreditation Board. Accreditation ensures that the DOH is meeting national evidence-based standards and providing PA residents with the best programs and services available. Accreditation can help the BFH improve collaborations between staff and stakeholders and further the Title V mission and programming through increased accountability, quality service delivery and institutionalized processes, such as the use of evidence-based practices and integration of quality improvement techniques.

PA’s MCH system of care is further augmented by state statutes mandating programs serving the MCH populations and requiring the resources of Title V in both staff and funding. The Newborn Child Testing Act (35 P.S. § 621, et. seq. and amended by Act 36 of 2008) establishes a program providing for the screening tests of newborn children and follow-up services related to case management, referrals, confirmatory testing, assessment and diagnosis of newborn children with abnormal, inconclusive or unacceptable screening tests results. Act 87 of 2008 mandates the Child Death Review (CDR) Program, which provides for statewide and county-based multidisciplinary CDR teams to conduct reviews of all deaths of children aged 21 and under. The Act also requires an annual report on the information, distribution and causes of child deaths in PA and reflects information collected during the CDR process from collaborative processes between the DOH and local CDR teams. The Pennsylvania Code (028 Pa. Code § 27.22 and 028 Pa. Code § 27.34) requires laboratories and providers to report blood lead test results to the DOH. And looking towards the future, Act 24 of 2018 establishes a Maternal Mortality Review committee to conduct multidisciplinary reviews of maternal deaths and develop recommendations for the prevention of future maternal deaths.

PA is a state of contrasts presenting unique challenges to the delivery of services and resources across the MCH system of care. An aging but diverse population will gradually force a system adjustment to meet geographic, programmatic, and cultural needs. Swaths of poverty are inseparable from gender, education, race and ethnicity with women led families bearing an unequal burden. Systems of care are equipped to meet urban needs but not rural needs. This, however, is not as dire as it seems. There is strength in the access to care provided by Medicaid and CHIP, the local work of the CMHD, and DOH development of strategic plans and newer programs to meet current challenges such as opioid addiction and maternal mortality. Title V resources will have to be nimble and adaptable to meet the changing landscape of MCH service needs in PA.