This overview provides information about the Commonwealth of Massachusetts to contextualize the Title V program structure and approaches described in the Application/Annual Report. It describes Massachusetts’ demographics, geography, and economy; health care environment; the state public health structure; roles and responsibilities of the state health agency; and state statutes and regulations relevant to Title V.
Demographics, Geography, and Economy
Massachusetts has 7 million residents[1] and is the fourth most densely populated state in the U.S.[2] It is often thought of as urban because of the dense concentration of people in metro-Boston and other cities; however, as of 2017, 160 cities and towns in Massachusetts (45%) are considered rural based on the definition set by the Massachusetts Department of Public Health (MDPH) State Office of Rural Health.[3]
An estimated 80.1% of Massachusetts residents identify as White, 9.8% as Black or African American, 12.3% as Hispanic, 8.0% as Asian, 0.9% as American Indian or Alaska Native, 0.2% Native Hawaiian and Other Pacific Islander, and 8.2% some other race.[4] Immigrants make up 17% of the state’s population, and one-fifth of the Massachusetts labor force is foreign born, with immigrants supporting the state’s healthcare, science, and service industries, among others. The top countries of origin for immigrants were China (8%), the Dominican Republic (8%), India (7%), Brazil (7%), and Haiti (5%).[5] During 2019, 31.3% of births were to non-US-born women.[6] Nearly a quarter (24.5%) of people speak a language other than English at home, the most common being Spanish.[7]
In 2021, the median age was 39.9 years. An estimated 19.5% of the population was under 18 years, 9.9% was 18-24 years, 26.8% was 25-44 years, 26.4% was 45-64 years, and 17.5% was 65 years and older.[8]
Massachusetts is a center of higher education and is home to leading research universities and private research laboratories. Massachusetts is also a global leader in life sciences, from public health, pharmaceuticals, and medical devices to diagnostics and nanotechnology. Massachusetts has a high proportion of college graduates, with 46.6% of the population aged 25 years or older having a Bachelor’s degree or higher, compared to 35.0% nationally.[9] In January 2022, the unemployment rate was 4.8%, down from a high of 17.1% in April 2020 during the COVID-19 pandemic, but above the 3.0% unemployment rate in January 2020.[10] During 2021, 10.4% of people were in poverty; an estimated 12.6% of children under 18 were below the poverty level.[11] The median household income is $89,645, higher than the U.S. household median ($69,717).[12] Despite the high median income, Massachusetts is an expensive state in which to live. Many households are cost-burdened; 29.5% of homeowners and 48.9% of renters spent more than 30% of their household income on housing.[13]
Approximately 11.7% of the population has one or more types of disability, including visual, hearing, ambulatory, cognitive, self-care, and independent living disabilities.[14] In 2019, 41.4% of Massachusetts adults aged 18-64 years with a disability were employed (+3.2% from 2018), compared to 81.7% of adults without a disability. Furthermore, 27.8% of people with disabilities lived below the poverty line, compared to 10.5% of people without disabilities.[15]
An estimated 12-18% of reproductive-aged women have a disability.[16] Compared with women without a disability, women with a disability are as likely to desire a future pregnancy, be sexually active, and experience pregnancy.[17],[18],[19] However, women with a disability are less likely to report utilization of reproductive health care and more likely to experience pregnancy complications and adverse birth outcomes.[20] A supplemental questionnaire on disability was added by selected Pregnancy Risk Assessment Monitoring System (PRAMS) sites and data collection began in 2019 to address a gap in population-based data on disability among women with a recent live birth. During 2020, 5.5% of women with a recent live birth in Massachusetts reported having a disability (defined as having “a lot of difficulty” or “cannot do at all” on one or more of the following: remembering, seeing, hearing, communicating, walking/climbing stairs, or self-care).
Health Care Environment
Insurance Coverage
According to the 2021 Massachusetts Health Insurance Survey (MHIS),[21] published in July 2022, the uninsurance rate remained low at 2.4%, well below the national rate based on estimates from the National Health Interview Survey. MA children aged 0-18 years had an uninsurance rate of 0.7%. A higher percentage (8.6%) of the Hispanic population was uninsured compared with other racial/ethnic groups (Black, non-Hispanic 5.8%, Other/multiple races, non-Hispanic 4.7%, Asian, non-Hispanic 1.9%, White, non-Hispanic 0.9%). Most respondents to the 2021 MHIS reported a usual source of care other than the emergency department (88.1%, including 92.9% of children) and a visit to a general doctor in the past 12 months (81.3%). This represents a decrease in both estimates from 2019 (91.0% of respondents, including 95.4% of children, reported a usual source of care and 86.4% reported a visit to a general doctor in the past 12 months in 2019). In addition, 17.5% of respondents visited a mental health professional over the past 12 months. Hispanic (81.3%), Black (81.2%), and Asian (82.1%) residents were less likely to report having a usual source of care than White residents (90.8%).
Despite the high rate of insurance coverage, health care costs remain a concern for many families. Forty-one percent (41%) of 2021 MHIS respondents reported affordability issues over the past 12 months. Almost a third (31.2%) reported experiencing any family unmet need for health care in the past 12 months because of the cost of care and almost a quarter (23.3%) had a family member receive a medical bill where the health insurance plan paid much less than expected or did not pay at all.
In Massachusetts, Medicaid and the Children’s Health Insurance Program (CHIP) are combined into one program called MassHealth. MassHealth provides coverage to more than 2 million members – 30% of Massachusetts residents. This high level of enrollment contributes to Massachusetts’ low uninsurance rate.[22] The MassHealth 1115 waiver that began July 1, 2017 aimed to transform the delivery of care for MassHealth members and to change how care is paid for, with the goals of improving quality and establishing greater control over spending. The waiver implemented the most significant re-structuring of the program in two decades, shifting the delivery system toward value-based care. Through an Accountable Care Organization (ACO) model, MassHealth partners directly with provider organizations to deliver coordinated and quality care to its members. There are 17 ACOs (including one pediatric ACO) that are held financially accountable for cost, quality, and member experience. The 1115 waiver also contributed to maintaining near universal health care coverage for the Commonwealth, supported the Commonwealth’s safety net, and expanded access to substance use disorder services. MassHealth submitted a request to Centers for Medicare and Medicaid Services (CMS) in June 2021 to renew the 1115 waiver for five years (from July 1, 2022 – June 30, 2027), and the renewal was granted in September 2022.[23] Waiver amendments aim to expand eligibility for the Medicare Savings Programs to comply with state law, launch a >$2 billion initiative over five years to hold ACOs and ACO-participating hospitals accountable for reducing disparities in health care quality and access including a focus on maternal health, authorize postpartum coverage for members not otherwise eligible due to immigration status, enhance services for specialized populations such as care coordination for children with medical complexity, and provide flexibility related to place of services. In addition, it invests $115 million per year in primary care through a new value-based sub-capitation model that includes specific requirements and standards for team-based, integrated care for children and youth. For more information about the MassHealth 1115 waiver and Title V collaboration with MassHealth, see the Health Care Delivery System section.
Workforce and Infrastructure
According to the MDPH Healthcare Workforce Center, as of 2017 (the most recent data available), there were 28,428 physicians in Massachusetts with an active license, with 52% reporting a maternal and child health (MCH)-related specialty (e.g., pediatrics, family medicine, obstetrics and gynecology, and child and adolescent psychiatry). Of these, 8.8% (3,769) were pediatricians. Although Massachusetts has the highest number of physicians per population in the United States, these providers are not equitably distributed across the state. Over one third (38%) of physicians with an MCH-related specialty practice in Suffolk County (including Boston), which is home to just 11% of the state population. Many areas in the state, including rural communities, lack adequate access to care.
Massachusetts is home to a world-class pediatric hospital (Boston Children’s Hospital) and nine other tertiary care hospitals that provide Level III neonatal care. There are 52 community health centers (CHCs) that have more than 300 total access sites across the state.[24] CHCs are integral to providing high quality medical, dental, vision, pharmacy, behavioral health, addiction services and other community-based services to residents regardless of their insurance status or ability to pay. CHCs work to eliminate inequities in health outcomes by hiring multilingual and multicultural staff at every level of their organizations, deploying community health workers to help patients navigate the complex health system, and assisting residents in accessing health care coverage. CHCs also represent a major source of care for medically underserved women and children. According to the Statewide Economic Impact of Massachusetts Community Health Centers released in December 2020,[25] CHCs served 1,037,086 patients, including 221,611 (21%) children and adolescents. In addition, 75% of patients were low income, 74% identified as an ethnic or racial minority, 1% were veterans, 1% were agricultural workers, and 4% were homeless. CHCs accounted for 24% lower costs for health center Medicaid patients, $1.1 billion in savings to Medicaid, and $1.8 billion in savings to the overall health system.
Overall Health Status
Massachusetts is consistently recognized for good health status in national rankings. According to America’s Health Rankings 2022 Annual Report,[26] Massachusetts has a ranking of #2 overall and ranks #1 in clinical care, #3 in health outcomes, #4 in social and economic factors, and #8 in behaviors (e.g., nutrition and physical activity, sexual health, sleep health, smoking tobacco use). Strengths include a low premature death rate, high reading proficiency among fourth grade public school students, and low uninsured rate. Identified challenges included high prevalence of excessive drinking, high income inequality, and high percentage of housing with lead risk. MDPH and Title V recognize that good health in Massachusetts is not equally shared. Persistent health inequities in access to services and in economic and health outcomes across demographic characteristics, most notably by race and ethnicity, point to historical and structural systems of oppression that continue to disadvantage people of color in the state. For example, 10.4% of the Massachusetts population lives below poverty level; however, only 7.8% of White residents live below the poverty level compared with 23.6% of Hispanic residents, 17.1% of American Indian and Alaska Native residents, 15.3% of Black residents, and 10.9% of Asian residents.[27]
Impact of COVID-19
The COVID-19 pandemic both exacerbated pre-existing public health concerns and created new health crises to address. Even people who did not become sick with COVID-19 were managing stress, uncertainty, and isolation during this challenging time. In fall 2020, MDPH staff and stakeholders conducted the COVID-19 Community Impact Survey (CCIS) to better understand the immediate and long-term health needs, including social and economic consequences facing the Commonwealth. MDPH used these data to prioritize resources and inform policy actions to help address these impacts.
Findings from the survey are publicly available through the COVID-19 Community Impact Survey Data Dashboard and cover topics including access to healthcare, risk mitigation and access to COVID-19 testing, discrimination and race, social determinants of health, employment, housing security, intimate partner violence, mental health, and substance use. Findings were organized by population, including parents and families, caregivers, youth, young parents, people with disabilities, sexual orientation and gender identity, essential workers, and rural communities. The pandemic substantially impacted normal healthcare operations, put stress on healthcare capacity, and disrupted healthcare capacity even for people who normally face few barriers to care. It impacted people’s ability and willingness to access critical and essential healthcare services. Concerns were felt most acutely by populations who already faced healthcare barriers prior to the pandemic, and who also have the highest rates of delayed urgent care now. Although 60% of respondents who needed care could access it via telehealth, technology-related barriers remain a challenge for many populations.
The CCIS highlighted the impact of the pandemic on social determinants of health and their effects on MCH populations. Results showed that Massachusetts parents were 50% more likely than non-parents to worry about housing. Parents who were concerned about expenses or childcare were more likely to report poor mental health compared to parents who were not worried about expenses or childcare. Sub-groups of parents who were more likely to worry about expenses, basic needs, and poor mental health included: non-binary, transgender, questioning, queer, and bisexual/pansexual people, people of color, parents under the age of 35, and parents of children and youth with special healthcare needs. CCIS findings suggest that parents, including parents of CYSHN, could benefit from targeted supports accessing basic needs such as housing, food, and mental health resources.
In summer and fall of 2023, MDPH will conduct a second iteration of the CCIS. This survey, renamed the Community Health Equity Survey (CHES), aims to better understand the most pressing health needs facing Massachusetts residents, including social, economic, and environmental needs. CHES explores the root causes of health and aims to identify community strengths and gaps, health needs, concerns, inequities, and unintended consequences of decisions related to public health crises. Survey topics include access to basic needs like health care and transportation, physical and mental health and wellbeing, experiences with COVID-19, experiences with housing, education, and work, and demographic information, such as age, gender, and race. Findings will again be organized by population, including parents and families, caregivers, youth, young parents, people with disabilities, sexual orientation and gender identity, essential workers, and rural communities.
See the State Action Plan Narrative by Domain for discussion of CCIS data related to specific Title V priorities.
Public Health Structure
Public health in Massachusetts is a statewide commitment to ensure that all residents have the opportunity to experience the best health and well-being regardless of race, ethnicity, socioeconomic status, geographic location, physical ability, or other characteristic. This vision is supported by a strong health care delivery system and public health infrastructure, led by MDPH. MDPH provides outcome-driven, evidence-based programming to prevent illness, injury, and premature death; ensure access to high quality health and health care services; respond quickly to emerging public health threats; and promote wellness and health equity for all residents of the Commonwealth.
Established in 1869, MDPH was the first state board of health in the United States. Throughout its history, MDPH has been a pioneer in the development and implementation of public health programs and strategies, including being the first state to establish a childhood lead poisoning prevention program and universal newborn screening program. With over 3,200 employees, MDPH uses a variety of approaches including screening, education, research, regulation, inspection, and the provision of funding to local programs and interventions to promote health for all residents in the Commonwealth.[28]
Massachusetts has a decentralized public health system, with each of its 351 cities and towns having its own governing body and health board with authority to provide public health services to its residents. These local public health authorities work in partnership with the MDPH Office of Local and Regional Health and others to deliver a core set of services. Local public health authorities are charged with a broad set of responsibilities for enforcement of state sanitary, environmental, housing, and health codes, such as protection of the food supply through inspections of restaurants and other food establishments; inspections and permitting of septic systems, landfills, and other solid waste facilities; and developing, testing, and building awareness of emergency preparedness plans for a wide range of hazards. Unlike many other states, Massachusetts does not provide base funding to local public health authorities for core public health services. Local public health services are primarily funded by local property tax revenues and fees.[29]
Massachusetts is a national leader in MCH programs and policy. The state’s commitment to the MCH population is demonstrated by matching of federal Title V funds. While states are required to match every $4 of federal Title V money with at least $3 of state and/or local money, Massachusetts provides a substantial overmatch. The philosophy of the Title V program is to address the health needs of pregnant people, parents, and children, focusing on a life course approach and addressing the impact of structural racism on MCH. Efforts in Massachusetts focus on the policies, systems, programs, and services needed to optimize the health of the entire family.
The MDPH Bureau of Family Health and Nutrition (BFHN) administers the Title V program. The Title V Director, also the BFHN Director, reports to the MDPH Deputy Commissioner. MDPH is housed within the Executive Office of Health and Human Services (EOHHS), the largest secretariat in state government. EOHHS is comprised of 12 agencies, including Medicaid, Department of Children and Families, Department of Developmental Services, and MDPH. This structure provides Title V with capacity to promote systems of service, coordinate initiatives, and work collaboratively across a range of partners necessary for a comprehensive approach to Title V goals. The context of Title V within MDPH and EOHHS means that priorities and initiatives are synergistic and collaborative.
State Health Agency Roles and Responsibilities
In April 2023, Dr. Robert Goldstein was appointed MDPH Commissioner, replacing Margret Cooke who had served as Commissioner since June 2021. Prior to coming to MDPH, Dr. Goldstein was a Senior Policy Advisor at CDC, an infectious disease physician at Massachusetts General Hospital, and a faculty member at Harvard Medical School. Dr. Goldstein has identified five strategic priorities for the Department, which include: a continued focus and commitment to health equity; strengthening our emergency response and preparedness function; building the public health infrastructure necessary for the 21st Century; supporting the public health workforce, promoting recovery and resilience; and deepening the Department’s engagement with the public and staff’s collective dedication to service.
Dr. Goldstein has developed a plan to reorganize the Department to better support these priorities, develop strategies, set direction, facilitate collaboration, and ensure accountability. Major aspects of the new structure include the following:
- Establishment an Assistant Commissioner for Health Equity within the Commissioner’s Office to provide increased visibility and accountability for the Department’s heath equity work. The MDPH offices and initiatives that will be overseen by the new Assistant Commissioner are the Office of Health Equity, the Vaccine Equity Initiative (VEI), the work of the secretariat-wide Interagency Health Equity Team, and the Office of Problem Gambling.
- Establishment of a new role of Deputy Commissioner who will oversee the operations of the four facilities that comprise the MDPH Public Health Hospital System and the State Office of Pharmacy Services.
- The current Deputy Commissioner, Jen Barrelle, will continue overseeing much of the programmatic work that takes place in our bureaus, including providing oversight for the Bureaus of Family Health and Nutrition and Community Health and Prevention.
- The Office of Preparedness and Emergency Management will move directly under the Commissioner, consistent with the Department’s commitment to emergency response.
- The Office of Local and Regional Health will move directly under the Commissioner to strengthen the coordination and collaboration between and among the many local public health departments across the state, as well as with internal and external public health stakeholders.
- Policy, Legislative Affairs, and Communications will continue to be situated in Commissioner’s Office, providing perspective, guidance, and oversight in these three critical areas and helping to promote smooth cross-agency coordination.
- Finally, the Bureau of Environmental Health will be renamed the Bureau of Climate and Environmental Health to highlight the effects and potential consequences of climate change on health and environment and reflect the Bureau’s role as the only state agency dedicated to understanding and addressing the health impacts of climate change.
An updated MDPH organizational chart is included in the Attachments.
Data Access and Capacity
An important resource providing easily accessible public health and racial equity data in Massachusetts is the Population Health Information Tool (PHIT),[30] which launched in June 2019. PHIT is a web-based compendium of health data that is available to the public to inform community health needs assessment, program planning, and policy making. PHIT provides community-specific health data framed by six social determinants of health – education, employment, violence, social environment, housing, and built environment – to support help communities identify and address upstream contributors to poor health. PHIT users can access data dashboards and community-specific health priority reports, as well as contextual information to interpret the data and identify health inequities.
PHIT integrates data from myriad sources, including but not limited to Pregnancy Risk Assessment Monitoring System, Pregnancy to Early Life Longitudinal Data System, Behavioral Risk Factor Surveillance System, Vital Statistics, Injury Surveillance System, Birth Defects Monitoring Program, Substance Addiction Services, Early Hearing Detection and Intervention, WIC, and Early Intervention. Also included in PHIT are the Health Equity and Neonatal Abstinence Syndrome (NAS) Data Dashboards. The Race and Hispanic Ethnicity Health Equity Dashboard provides health outcome data from across MDPH in a centralized location. Key findings supplement charts to help viewers gain introductory level understanding of the impact of race on the health of Massachusetts residents. The NAS Dashboard includes data that address measures across three key time periods – pregnancy, birth, and infancy – for clinical providers, public health workers, and community agencies to monitor the care of families affected by perinatal substance use. Title V is currently collaborating with PHIT to establish a Title V Dashboard to provide readily accessible data on key MCH measures including Title V performance measures to inform decision-making and action planning.
Through a partnership with the Center for Health Information and Analysis (CHIA), MDPH also assembles and manages the Public Health Data Warehouse (PHD), a unique surveillance and research tool that provides access to linked, multi-year longitudinal, individual-level data to enable analyses of health priorities and trends. MDPH created the PHD in 2017, in an unprecedented effort to link data sets across state government to effectively address public health priorities, with an initial focus on opioid overdoses. Public and private partnerships help the MDPH Office of Population Health identify and answer key questions to inform public health responses and policymaking.
Another MDPH priority for the use of the PHD was to generate new, actionable information that will help Massachusetts address inequities in MCH outcomes, especially those across racial groups and other social factors. In 2018 a workgroup identified the MCH datasets to be included in the PHD (such as WIC, Department of Children and Families, Early Intervention, and the Massachusetts Immunization Information System), and designed research questions of interest to Title V and MCH in Massachusetts. The workgroup proposed an initial focus on three MCH topics: maternal morbidity and mortality, preterm birth and infant mortality, and adolescent health and wellness. Staff reassignments during the COVID-19 pandemic resulted in delays securing data use agreements and accessing the data sets comprising PHD. The datasets have now been assembled, and a workgroup has recently released a data brief on severe maternal morbidity (SMM) “An Assessment of Severe Maternal Morbidity in Massachusetts: 2011-2020" (released July 2023). This data brief highlights the increasing trend of SMM from 52.3 per 10,000 deliveries in 2011 to 100.4 per 10,000 deliveries in 2020. The brief also highlights the growing disparity in SMM among Black birthing people compared to White birthing people with data from 2011-2020 showing 63.7 SMM events per 10,000 deliveries among White non-Hispanic birthing people compared with 146.1 SMM events per 10,000 deliveries among Black non-Hispanic birthing people. Planned upcoming data briefs include a deeper analysis of SMM among pregnant people by insurance status, presence of substance use disorder, housing instability, and mental health history.
In addition to PHIT and the PHD, MDPH has access to the Massachusetts All Payer Claims Database (APCD), a comprehensive source of health claims data from public and private payers in Massachusetts. Administered by CHIA, it is used by health care providers, health plans, researchers, and others to address a variety of issues, including price variation, population health and quality measurement. APCD data have been used in an evaluation of MDPH home visiting programs.
Performance Management and Quality Improvement
MDPH is committed to continuous performance management (PM) and quality improvement (QI) as a proven way to enhance the Department’s performance. The Department’s PMQI efforts help guide funding decisions, identify priorities, and analyze results to ensure that public monies are strategically invested in effective programs and services. The Office of Performance Management and Quality Improvement (PMQI) oversees the integration of QI culture at MDPH and convenes the PMQI Council. The PMQI Council meets bi-monthly to implement the department’s QI plan which involves annually assessing the QI culture, communicating PMQI efforts and successes across MDPH, and building PMQI capacity on all levels. The PMQI Team and Council integrate their efforts with the Department’s mission to achieve health equity, improve health outcomes, work collaboratively with its partners, and offer trainings on QI models and tools.
With its robust performance measurement framework and focus on implementing evidence-based practices and promising innovations, Title V is a leader in MDPH’s PMQI efforts. Title V staff continue to regularly participate in and help to provide instruction at Lean Six Sigma White, Yellow, Green and Black Belt trainings. In addition, Title V staff have always been members of and significant contributors to the PMQI Council.
BFHN has established a Racial Equity and Family Engagement Strategic Plan as an overarching framework for promoting and sustaining equity for BFHN staff and the communities and families we serve by dismantling structural racism and co-creating healing-centered policies, practices, and social norms. In April 2023, BFHN initiated a Learning Community to accelerate progress, nurture innovation, and build collective will towards the four primary drivers named in the strategic plan: 1) racial equity as a strategic priority, 2) antiracist infrastructure that centers families’ lived experience and community context, 3) family-centered antiracist service delivery, and 4) relationships and collaborations within and beyond BFHN center families’ needs. Using the MIECHV Health Equity CoIIN key driver diagram (KDD) as a foundation, BFHN Leadership and BFHN’s Racial Equity Strategy Team modified the MIECHV Health Equity KDD to develop primary and secondary drivers and change strategies that align with the Bureau’s overarching aim. The Learning Community provides a forum for sharing best practices related to the secondary drivers and projects aimed at testing and spreading change ideas.
Public Health Accreditation and State Health Assessment
In 2017, MDPH was awarded national accreditation by the Public Health Accreditation Board (PHAB). Since that time, MDPH has maintained its accreditation status by submitting annual PHAB reports and building capacity in PMQI. Title V staff actively contributed to achieving initial PHAB accreditation, including developing the State Health Assessment to ensure alignment of MCH priorities and objectives, and have since been contributors to the PHAB Annual Reports. These contributions are often noted by PHAB evaluators as important accomplishments that should be shared with other accredited health departments (e.g., Racial Equity Data Road Map, home visiting program QI projects, the MA MIECHV needs assessment and program planning process). MDPH will maintain its national accreditation and is currently preparing for our application for reaccreditation which will take place in 2023.
COVID-19 Pandemic Response
Title V staff and programs have supported pregnant people, infants, children, youth, children and youth with special health needs, and their families through the COVID-19 pandemic in a variety of ways, such as:
- Offering services virtually (e.g., home visiting).
- Raising awareness for families and providers of the importance of emergency care planning and providing a variety of resources for this purpose.
- Facilitating access to concrete supports (e.g., unemployment benefits, diapers, transportation, groceries, personal protective equipment).
- Coordinating an information and referral pipeline for families of CYSHN.
- Creating a mechanism for emergency family support funding to low-income families of CYSHN who have experienced unexpected financial hardships related to job or income losses, hospitalizations, the death of a child or family member, and other similar catastrophic events.
- Establishing a surveillance system to monitor outcomes for pregnant women with lab-confirmed COVID-19 and their infants and adding COVID-related questions to the PRAMS survey.
- Using CCIS findings to respond to the needs of youth and families (e.g., addressing the impacts youth are experiencing beyond educational delays).
- Influencing prioritization of family caregivers of medically complex CYSHN to receive vaccinations as “unpaid essential” home health care workers during Phase 1 of the Massachusetts COVID-19 Vaccination Plan.
- Serving as site managers at UMass Chan Medical School’s VaxAbilities clinics for children with disabilities.
- Serving as community liaisons, vaccine ambassadors, and communications project managers for the VEI
- Leading the Pediatric and Family Workstream of the VEI
- Linking Massachusetts Immunization Information System (MIIS) and birth certificate data to better understand vaccination uptake among pregnant people
In 2021, MDPH was awarded CDC funding to address COVID-19 and advance health equity in racial and ethnic minority groups and rural populations within Massachusetts. Grant activities fall into four categories – COVID-19 mitigation, data metrics, community engagement and support, and social determinants of health. There is a strong emphasis on building the state’s data infrastructure.
- Data metrics: The funds support health equity data collection, analysis, dissemination, and management, allowing MDPH to understand the public health needs of the communities hardest hit by COVID-19. Examples of projects include using an innovative Community Evaluator model to collect qualitative data to assess the needs of priority population groups related to COVID-19; increasing the number of products for which there are translations, accessibility, and plain language materials; and developing a Fatherhood and Second Parent survey to assess the experience of fathers during pregnancy and the birth of their child, and their experiences with COVID-19 testing, vaccination, health status, social determinants of health, mental health and racism during the COVID-19 pandemic.
- COVID-19 mitigation: The funds support COVID-19 activities in rural communities including testing, COVID-19 outreach and educational services, assistance to individuals who face barriers to isolating or quarantining, vaccination, and connecting residents to local and state resources for social needs.
- Community engagement and support: The funds support health equity capacity building of MDPH staff, local boards of health, and other public health professionals using a population health approach and will engage racial and ethnic minority populations and rural communities in developing improved approaches to testing and contract tracing.
- Social determinants of health: Funds support grants to local communities to address the social determinants of health with a focus on the key drivers of the disproportionate impact of COVID-19 on priority populations, as well as community outreach on the Federal Emergency Management Administration's (FEMA) funeral assistance program.
State Statutes and Regulations Relevant to Title V
Title V priorities are contextualized within state statutes and other regulations to improve population health through the most effective and efficient mobilization of available resources. There are no statutes in Massachusetts directly related to the establishment or operation of a Title V program as defined by HRSA/MCHB. There are, however, many statutes and regulations that address issues related to MCH and CYSHCN. Examples of relevant statutes and regulations, many of which involved leadership or significant input by Title V, include:
- extend eligibility for postpartum coverage on MassHealth to 12 months
- establish a MassHealth benefit for doula services (Fall 2023)
- launch the MassHealth Coordinating Aligned, Relationship-centered, Enhanced Support (CARES) for Kids Program, a targeted case management benefit for children with medical complexity, effective July 7, 2023
- established a commission to make policy recommendations to eliminate racial inequities in maternal health
- expanded birth defects monitoring and surveillance regulations
- postpartum depression legislation
- expanded newborn blood screening regulations
- expanded public health practice for dental hygienists
- expanded breastfeeding in public places
- required periodic measurement of BMI in schools
- training for physicians, nurses, and other providers on domestic and sexual violence
- medical review and approval of short and long-term respite care for complex medical conditions in skilled nursing facilities
- formation of a PANS/PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections/Pediatric Acute-onset Neuropsychiatric Syndrome) Advisory Council to the MDPH Commissioner
- bullying prevention in schools
- sports concussion policy and management in schools
- junior operator law and primary child passenger restraint law for children under age 14
- lowering the regulatory definition of blood lead poisoning to 10µg/dL
- MassHealth coverage of long-acting reversible contraceptive devices inserted in the immediate postpartum period separate from the global delivery fee
- paid family and medical leave legislation
- pay equity legislation that clarifies unlawful wage discrimination and makes workplaces fairer and more equal.
The COVID-19 pandemic changed both the lives of families and children and the public health system in innumerable ways. The Title V priorities, set before the pandemic began, are more important – and in many ways more challenging – to address than ever. However, the Title V program is well positioned in the state’s public health and health care environment learn from the response and recovery from the COVID-19 pandemic and be prepared to address any future emerging threats to MCH population in Massachusetts.
[1] US Census Bureau, 2021 American Community Survey 5-Year Estimates, Massachusetts.
[2] US Census Bureau, U.S. and World Population Clock
[4] US Census Bureau, 2021 American Community Survey 5-Year Estimates
[5] American Immigration Council, Immigrants in Massachusetts, 2020
[7] US Census Bureau, 2021 American Community Survey 1-Year Estimates
[8] US Census Bureau, 2021 American Community Survey 1-Year Estimates
[9] US Census Bureau, 2021 American Community Survey 1-Year Estimates
[11] US Census Bureau, 2021 American Community Survey 1-Year Estimates
[12] US Census Bureau, 2021 American Community Survey 1-Year Estimates
[13] US Census Bureau, 2016-2020 American Community Survey 5-Year Estimates, Narrative Profile
[14] US Census Bureau, 2021 American Community Survey 1-Year Estimates
[15] Massachusetts Rehabilitation Commission, 2020 Disability Facts & Statistics
[16] Okoro CA, Hollis ND, Cyrus AC, Griffin-Blake S. Prevalence of disabilities and health care access by disability status and type among adults — United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67:882–887. doi:10.15585/mmwr.mm6732a3
[17] Bloom TL, Mosher W, Alhusen J, Lantos H, Hughes RB. Fertility desires and intentions among U.S. women by disability status: Findings from the 2011-2013 National Survey of Family Growth. Matern Child Health J. 2017;21(8):1606-1615. doi:10.1007/s10995-016-2250-3.
[18] Mitra M, Clements KM, Zhang J, Smith LD. Disparities in adverse preconception risk factors between women with and without disabilities. Matern Child Health J. 2016;20(3):507-15. doi:10.1007/s10995-015-1848-1.
[19] Mitra M, Clements KM, Zhang J, Iezzoni LI, Smeltzer SC, Long-Bellil LM. Maternal characteristics, pregnancy complications, and adverse birth outcomes among women with disabilities. Med Care. 2015;53(12):1027-32. doi:10.1097/MLR.0000000000000427.
[20] Mitra M, Clements KM, Zhang J, Iezzoni LI, Smeltzer SC, Long-Bellil LM. Maternal characteristics, pregnancy complications, and adverse birth outcomes among women with disabilities. Med Care. 2015;53(12):1027-32. doi:10.1097/MLR.0000000000000427.
[21] Center for Health Information and Analysis, Findings from the 2021 MA Health Insurance Survey
[22] MassHealth, https://www.mass.gov/doc/ma-1115-extension-factsheet-july-2021-pdf/download 1115 Demonstration Waiver Extension Proposal – Factsheet
[26] America’s Health Rankings, 2022 Annual Report
[27] US Census Bureau, 2021 American Community Survey 1-Year Estimates
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