Arkansas Title V Maternal and Child Health Services Block Grant
2022 Report and 2024 Application
III.B. Overview of the State
Arkansas is in the southern region of the U.S. It covers an area of 53,178 square miles and is organized into 75 counties. Arkansas borders six other states (Missouri, Oklahoma, Texas, Tennessee, Louisiana, Mississippi). The Mississippi River forms the state borders to Tennessee and Mississippi in the east.
Geography: Of the 75 counties in the state, 54 are considered rural (72%), with 41% of residents living in rural areas compared to 14% in the U.S. The capital and largest city is Little Rock. Major population areas are Fort Smith, Hot Springs, Jonesboro, Pine Bluff, and Texarkana, Northwest Arkansas (Fayetteville, Springdale, Rogers, and Bentonville), and Little Rock/North Little Rock. The county with the highest population is Pulaski County, where Little Rock is located. Benton County had the greatest increase (20%) between 2010 and 2019. Phillips County decreased from 22,000 to 18,000, representing the largest decrease (18.3%). (Source: U.S. Census 2022 Quick Facts)
Counties in the Mississippi Delta are especially rural and poor. They have high concentrations of minority populations, especially African American. Counties along the state’s western border are mountainous and rural. The population of immigrant Hispanic families from Central and South America is high in these counties. Arkansas and Hawaii are home to the largest groups of Marshall Islanders living outside of the Marshall Islands.
Population: According to the U.S. Census 2022 Quick Facts, Arkansas is home to 3,045,637 residents. Arkansas’s population is primarily White (71.3%) with African American (15.7%) secondary. Other groups are Hispanic/Latino (8.3%), two or more races (2.3%), Asian (1.8%), and American Indian/Alaska Native (1.1%). Of the total population, 17.5% are age 65 and over, 23.2% are under age 18, and 6% children under age five.
Economy: The average family income in Arkansas is $52,123 per year. This is lower than the U.S. average of $76,000. Almost 40% of Arkansas households have incomes less than $25,000 per year, and 39% receive supplemental income. (Source: U.S. Census 2022 Quick Facts) Arkansas’ Gross Domestic Product (GDP) was $165,220 billion in 2022, representing 0.61% of the national GDP and making Arkansas the 35th largest state economy. Arkansas’s per-capita GDP in 2019 was $43,394.00, which was $21,847.00 lower than the national figure. However, the 2019 per-capita GDP was a 2.5% increase over 2016. The state’s GDP declined to $129 billion in 2022. Prior to 2020, the GDP had increased each year since 2009. (Federal Reserve Bank of St. Louis. Total gross domestic product for Arkansas. 2020)
The U.S. Census Bureau reports the majority (58%) of Arkansans ages 16 and older are in the civilian labor force. (Source: U.S. Census 2022 Quick Facts) Arkansas ranks 35th in business environment, which includes new business openings and the rate of patents for new inventions. Arkansas ranks 33rd in economic growth, determined by the growth of the young population in the state, growth by migration, and increased GDP. The disparity in earnings per job between rural and urban areas remains significant, with urban residents earning on average 19% more than rural residents. (Source: U.S. Census 2022 Quick Facts)
Unemployment: Arkansas’s unemployment rate has dropped to 2.8% as of April 2023, meaning that only 39,000 individuals are unemployed. This rate is less than a third of Arkansas’s pandemic unemployment of 10.1% in April 2020. Arkansas’s unemployment rate is lower than the national average of 3.4% and the state ranks 16th for lowest level of unemployment. (Source: Bureau of Labor Statistics)
Education: Education levels in Arkansas are lower than the U.S. average for both high school and bachelor’s level degrees or higher. Approximately 85% of Arkansans ages 25 or older finished high school or an equivalency exam compared to 88.9% nationwide. The discrepancy is wider between those who have a bachelor’s degree: 24.3% of Arkansas possess a bachelor’s degree compared to 33.7% in the U.S.
Poverty: Arkansas’s prevalence of poverty continues to be high. With 16.3% of people below Federal Poverty Level (FPL), Arkansas is the 4th highest in the U.S. In 2021, 22.4% of Arkansas’s children under the age of 18 lived in poverty compared to 16.9% in the U.S. The situation is worse for children under the age of five: 26.5% live in poverty compared to 18.3% nationally. Across the U.S. approximately 16.5% of children ages 5-17 live in poverty, but 20.9% of children in this age group in Arkansas live in poverty In the Coastal Plains and Delta regions of Arkansas, 36% of children live in poverty. (Source: U.S. Census 2022 Quick Facts)
The percentage of children living in poverty has been declining. However, 22% of Arkansas’s children live in poverty, compared to 17% nationwide. (Source: Annie E. Casey Foundation. 2021 Kids Count® Profile) Poverty is statistically linked to negative outcomes for children, from low birthweight and poor nutrition in infancy to increased risk of academic failure, emotional distress, and teen pregnancy. Access to food, adequate shelter, and transportation is limited for many Arkansans. More than 19% of Arkansas children experience food insecurity, tied with Oklahoma for the second worst in the country. (Source: Feeding America. Food Insecurity and Poverty in the US. 2020)
Health Professional Shortage: Of the 75 counties in the state, 54 are considered rural (72%) and 51 (68%) have Health Professional Shortage Areas (HPSAs) (Arkansas State Health Assessment 2020). The primary care physician (PCP) ratio in rural versus urban areas is 1:1.8 (73 PCPs per 100,000 people vs. 133 PCPs per 100,000 people), indicating a great need for the provision of primary healthcare in these HPSAs with limited or no access to preventive services. The HPSAs are mostly distributed in Southeast (SE), Southwest (SW), Northeast (NE) and Northwest (NW) Arkansas (Arkansas State Health Assessment 2020). Arkansas is a rural state in which limited access to healthcare is a primary factor in delays for diagnosis and treatment.
Health Rankings: According to American Health Rankings (2022), Arkansas ranks 48th out of 50 in overall health and 49th in health of women and children. A range of measures rank unfavorably when compared to other states. With 50 being the worst and one being the best, Arkansas ranks:
- 49th – adult obesity in women
- 49th – teen births
- 47th – physical inactivity in adult women
- 47th – adult women who smoke
- 47th – infant mortality
- 46th – child mortality
- 44th – low birthweight live births
- 44th – immunization form children
- 43rd – adverse childhood experiences
- 42nd – maternal mortality
- 41st – diabetes in adult women (Source: Behavioral Risk Factor Surveillance System-BRFSS 2021)
Arkansas ranks 43rd in child well-being, which has four domains: health, education, economic well-being, and community and family. Within these domains, Arkansas ranks 46th in community and family, 46th in health, 39th in economic well-being, and 34th in education. (Source Kids Count Data Book, 2022)
Social and Behavioral Health Determinates: The rural regions have higher rates of infant mortality, obesity, food insecurity, and child poverty than urban areas. Infant mortality rates range from 7.2 deaths per 1,000 live births in urban areas to 8.2 per 1,000 in the Delta. More than 50% of adults in the state are classified as overweight or obese. Arkansas ranks in the top five states for food insecurity. The disparity in earnings per job between rural and urban areas remains great, with urban residents earning on average 19% more than rural residents. Arkansas has 14 rural counties with “persistent poverty” and “persistent child poverty”. Persistent child poverty is defined as having child (<18 years old) poverty rates of at least 20% in all of the following sources: 1980, 1990, and 2000 decennial censuses, and 2007-2011 American Community Survey 5-year average. Each of the risk factors noted here contribute to significant socio-economic inequality.
Mortality: Arkansas and Tennessee ranked 45th in the nation for average life expectancy. In 2020, life expectancy was 74.4 years compared to 77 years nationally. Benton County (northwest) had the longest life expectancy: 78.8 years. Phillips County (eastern) had the shortest life expectancy: 68 years. This difference in life expectancy reflects the impact that the social factors and determinants noted above can have on the health of a population. COVID-19 had a large impact on life expectancy, with an estimated drop in life expectancy of 2.7 years between 2019 and 2021 across the U.S. The drop was especially felt among African American men.
Arkansas ranks 43rd in the nation for premature death, the leading causes of which are chronic diseases, accidents, influenza, and pneumonia. Heart disease, cancer, chronic lung disease, stroke, diabetes, and kidney disease are the leading causes of death associated with chronic disease. The state’s high rates of chronic disease can be linked to lack of physical activity combined with very high rates of obesity, high blood pressure, and tobacco use.
Unintentional injury is the fourth leading cause of death in the state. Accidents are the number one killer of Arkansans between the ages of 1-44 and the ages of 1-14. In 2021, death from influenza and pneumonia is the 13th most common cause of death in Arkansas. COVID-19 was the third leading cause of death in Arkansas for both 2020 and 2021.
In Arkansas, African Americans have higher rates of infant mortality compared to whites or Latinos. The infant mortality rate for African Americans in 2020 was 11.8 compared to 6.0 for whites and 6.0 for Latinos. The infant mortality rate is the annual number of babies per 1,000 live births who die before their first birthday. In 2020, 260 babies died in Arkansas before their first birthday. Both Arkansas and Alabama mortality rate was 47th in the U.S. at 7.3 per 1,000 live births. Prior to 2019, Arkansas had been in the top three states for highest infant mortality rate for three consecutive years (2016-2020). (Source: CDC. Infant Mortality Rates by State. 2021)
The leading causes of neonatal death in Arkansas are birth defects, prematurity, problems with the pregnancy, difficulty breathing, and bleeding. The leading causes of post-neonatal death are unintentional injuries, SIDS, birth defects, problems with blood circulation, lung problems, infection, and homicide. Additional numbers for 2021 show Arkansas were 5th in preterm birth rate (12.04 per 1,000) and 12th in low birthweight rate (9.52 per 1,000).
Challenges and Strengths: Arkansas has unique challenges that impact the health status of its MCH population. Availability of and accessibility to health care and preventive health services varies widely in Arkansas. Central Arkansas is relatively urban and well supplied with health services for women and children. However, even in these counties, low-income families experience barriers in access to care. Other regions are rural, and many are medically underserved as defined by the HRSA.
People in rural Arkansas have greater difficulty getting the health care services they need, in part due to cost. In general, 15.3% of Arkansans report that they were not able to see a doctor in the past 12 months due to the cost, compared to 13% in the U.S. In rural counties, more than 20% of residents were not able to see a doctor due to cost. In Arkansas, 25% of working-age adults have no health insurance. (Source: U.S. Census 2022 Quick Facts) In addition to cost, a shortage of health care services available is also a limiting factor.
Access to basic food, shelter, and transportation is limited for many Arkansans. There are 7,153 homes in the state lacking complete plumbing and 11,744 without kitchens. More than 12,221 homes are without phone service and 67,187 are without a method of transportation. As a result, families are limited in their ability to connect with others or access necessary goods and services.
Despite these challenges, Arkansas’s healthcare delivery improved as a result of the Medicaid expansion, which was vital to the health of the state’s MCH population. Many previously uninsured Arkansas women and children were able to enroll in a healthcare plan.
As of 2020, 1,512,266 (87%) people between the ages of 18-64 were enrolled in health care coverage. According to Small Area Health Insurance Estimates (SAHIE), 328,510 women (83.1%) ages 18-64 were insured with 66,880 (16.9%) women remaining uninsured. Ninety-six percent (651,502) of the total number of children (678,661) under 18 were insured.
No other state experienced a more rapid decline in its number of uninsured residents. The uninsured level fell from 16% in 2013 to 11% in 2022. (Source: U.S. Census 2022 Quick Facts) Arkansas’s Medicaid expansion efforts have been in the form of the Private Option, which allows Medicaid to fund private insurance companies for families at or below 138% of the Federal Poverty Level (FPL). The 1115 Medicaid Waiver that funded family planning services for women up to 250% of the FPL was ended in December 2013.
Defined Roles/Responsibilities and Targeted Interest: The Arkansas’s Title V MCH Block Grant Program relies on shared leadership between ADH’s Family Health Branch and the Arkansas Department of Human Services’ (DHS) Children with Chronic Health Conditions Program (CCHCP) to execute services statewide. The state Title V MCH leadership team makes program and policy decisions and ensures alignment across the programs and agencies. Designated Title V MCH staff manage state-level program and policy work and provide technical assistance and oversight to the local Title V grantees. (Section VI: ADH and CSCHN Organizational Charts)
The intricate roles of statewide coordinated services target the health interests of at-risk and vulnerable populations regardless of race, ethnicity, or national origin. Therefore, reducing health disparities throughout the state continues to be a major ADH focus. The ADH’s Office of Health Disparities and Elimination (OHDE) provides leadership in improving health outcomes by advocating for health equity for at-risk populations as defined by race or ethnicity, age, education, disability, geographical location, income, and sexual orientation for all MCH programming. The OHDE serves as the ADH’s coordinating office for consultative services and training in cultural and linguistic competency, coordination, partnership building, program development and implementation, and related efforts to address the needs of underrepresented populations. This office promotes the integration of Culturally and Linguistically Appropriate Services (CLAS) within health programs.
Multiple initiatives impact the state’s Title V directives. All highest priority services are provided in all 75 counties. High-priority services not provided through ADH’s Local Health Units are organized through ADH’s Central Office such as newborn metabolic and hearing screening, school health, and home visiting programs. Secondary services include basic preventive services that local health care systems may not have the capacity to provide, especially maternity care.
ADH proposed a statewide Strategic Plan for 2020-2023, which included goals and supporting strategies to address MCH population needs. The plan is designed to address four health conditions as priority areas: 1) Addiction/Mental Health/Suicide, 2) Maternal and Infant Health, 3) Vaccines/Infectious Disease, and 4) Obesity. (Source: Arkansas Department of Health. State Strategic Plan. 2021)
The Title V MCH and CSHCN administrators, along with MCH partners and ADH staff, utilize various methods to determine the importance, value, and priority of competing factors that impact health services delivery. The Title V program receives input and advice from partners, stakeholders, and other organizations. The overall goal of Arkansas's MCH program is to improve health and reduce disparities. Supporting that goal are five priority areas:
- Strengthen core services: Family Planning, Prenatal Care, WIC Program, Immunizations, and Home Visiting.
- Develop more effective population-based approaches: prevent injuries, reduce infant mortality, increase physical activity, and improve oral health.
- Communicate public health value and societal contribution: economic development, public awareness, and benefits of prevention.
- Secure adequate human and financial resources: workforce needs and training and funding acquisition.
- Increase departmental effectiveness and accountability: strengthen leadership, management systems, information technology, data use, and accountability.
Cross-cutting these areas is an emphasis on community engagement, partnerships, and policy development. The overall theme is to strengthen and improve traditional public health clinical services while focusing on program development, engaging more in public awareness and policy development, and retooling administrative processes to work more effectively and efficiently. The public is engaged through ADH’s Hometown Health Initiative (HHI), a community-driven process that empowers local communities to take ownership of health problems by working to identify and implement solutions.
Service Delivery: The Arkansas DHS houses programs that are important to improving MCH health in the state. DHS’s Division of Medical Services (DMS) administers the Medicaid Program, which serves approximately two-thirds of children in the state. Most children are covered based on income eligibility through ARKids First A or B, depending on income level. Medicaid funded almost half the births (44%) in Arkansas in 2020. Out of the 35,251 births in Arkansas in 2020, 15,352 were paid by Medicaid. Nationwide, 42% of births were funded by Medicaid in 2020.
Transitioning from pediatric to adult care is a priority of ADH for all youth and young adults in Arkansas, including those with disabilities, chronic health conditions, or other needs. The Arkansas Department of Human Services (DHS) is also home to the state’s Title V CSHCN program in the Division of Developmental Disabilities Services (DDS). ADH’s Title V Director is working to improve collaboration with this division, which includes maintaining an important partnership with the Division’s Medical Director. Services for CSHCN are closely associated with specialty services of the University of Arkansas for Medical Sciences (UAMS) Department of Pediatrics. The Division also supports the state's early intervention program (Part C), known as First Connections.
As the only medical school in the state, UAMS plays a critical role in Arkansas's health care system. Development of the UAMS College of Public Health in 2001 led to stronger links between state health-engaged agencies and the university system. UAMS’s pediatrics and obstetrics/gynecology departments partner with ADH to provide direct care to women and children and to carry out initiatives to improve systems of care.
Arkansas Children’s Hospital (ACH) in Little Rock plays an important role in the health care system. It is one of the largest children's hospitals in the U.S., attracting patients from around the region, other states, and other countries. The hospital provides most of the pediatric critical care in the state. The hospital’s administration is also committed to involvement in community and state level public health concerns such as infant mortality, injury prevention, home visiting, and school health initiatives.
Statewide Systems of Care: The state’s centralized healthcare system is in the capital city, Little Rock, with 6.54% of the state’s population. The city is situated in the middle of the state and is the site for the ADH Central Office, five large hospitals including the UAMS (the state’s only medical school), DHS, and other state agencies focused on improving the health of women and children. Cities of moderate size in the corners of the state are home to sizable medical communities and are the locations of UAMS’s Regional Programs.
The state’s Title V MCH administrative office is housed within the Family Health Branch of the Arkansas Department of Health’s (ADH). ADH provides programs and services statewide through 94 local health units, at least one in each of Arkansas’ 75 counties.
The current number of physician practices in Arkansas is inadequate to provide needed medical services to the population. Physician and other health care provider shortages are common. The average caseload for a Primary Care Physician (PCP) is 1,522 patients. Arkansas ranks 38th in the nation for number of PCPs (82.3 per 100,000 population). There are only 405 pediatricians and 289 obstetricians/gynecologists in the state. Arkansas ranks 50th in the number of dentists (40.9 per 100,000). (Source: U.S. Census 2022 Quick Facts)
UAMS is a centralized point of referral for all medically complicated patients and provides medical and health education for the entire state. Except for communities on the eastern border that depend on the city of Memphis, Tennessee, all state communities relate to UAMS and Little Rock hospitals as sources of highly specialized medical care. UAMS's Regional Programs provide family medicine residency training in communities around the state. These programs have improved the distribution of PCPs.
Arkansas Children’s Hospital (ACH) is that state’s only pediatric health system. ACH treats all children from birth to age 18 from across the state and surrounding areas. This private, nonprofit hospital works to meet the health needs of all children, but also supports efforts to improve the overall health and well-being of our youngest children. In 2018, a third satellite clinic of Arkansas Children’s Hospital (ACH) opened in Springdale in Northwest Arkansas. The clinic is in the fastest growing area of the state and allows more CSHCN access to pediatric specialty care.
Family physicians provide most of the state's medical care and are by far the most numerous specialty practitioners in Arkansas. Specialists in obstetrics, pediatrics, internal medicine, surgery, and others have practices in the more urban communities. While Arkansas is geographically of modest size compared to some other states, the distances from cities such as Fayetteville and Texarkana to Little Rock require two to four hours of travel time. For families with few resources, these distances represent significant barriers to access specialized care.
Arkansas’s Medicaid transitioned three years ago from a fee-for-service system to an organized care delivery model for the highest need behavioral health and developmental disability populations. The model, the Provider-led Arkansas Shared Savings Entity (PASSE) Program, provides care coordination services. The PASSE system went full risk March 2019. PASSEs are responsible for integrating physical health, behavioral health, and developmental disability services. Members are assigned a care coordinator who is responsible for creating a service plan for each individual. PASSE currently serves 55,000 Arkansas Medicaid clients.
Specific State Efforts: The former Governor, Asa Hutchinson initiated efforts that supported the MCH Block Grant purpose to promote the health of mother and infants by providing prenatal, delivery, and postpartum care for low income, at-risk pregnant, women, and to promote the health of children by providing preventive and primary care services for low-income children as defined in Section 501(a)(1)(b).
In December 2021, Arkansas’s Governor Asa Hutchinson announced his plan to fund additional Community and Employment Support (CES) Waiver slots and eliminate the waitlist, as it existed December 2021, by June 2025. The additional funding over the next several years will open slots for approximately 3,000 children and adults on the wait list for the CES Waiver. Arkansas Department of Human Services (ADHS) announced in February 2022 after receiving feedback from Medicaid clients and providers, that American Rescue Plan funding would be utilized in phase one to improve the recruitment and retention efforts to stabilize the workforce for this disabled population in their homes.
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