Geography, Demographics, and Economy

Michigan encompasses 56,804 square miles of land and is the only state made up of two peninsulas. Comprised of 83 counties, Michigan is the 10th most populous state and 11th largest state by total square mileage. Nearly 10 million people lived in the state in 2020. Michigan has seen a decrease in birth rates over the past 20 years, and according to the U.S. Census Bureau the state saw a 0.18% decline in population from 2019. Most of Michigan’s population resides in the southern half of the Lower Peninsula, with approximately half of the population residing in Southeast Michigan. The state’s largest cities are Detroit, Grand Rapids and Warren. Over 1.7 million people live in rural areas. The median age of the population is 39.7 years of age. Out of the total population, approximately 24% are ages 0-17 and 76% are ages 18 and over. Michigan’s population is 78.4% Caucasian, 13.7% Black or African American, 3.1% Asian and Pacific Islander, 2.9% two or more races, 1.4% other races, and 0.5% Native American. Out of the total population, 5% identify as Hispanic or Latino.

Over the nine years leading up to 2020, Michigan’s economy saw improvements. However, the COVID-19 pandemic had immediate impacts on Michigan’s economy and the long-term impacts are unclear. While the seasonally adjusted unemployment rate decreased from 14.9% in June 2009 to 4.0% in January 2019, it varied throughout 2020 and was 5.7% in January 2021. Michigan’s annual 2020 jobless rate was 9.7%, which is below the 13.7% jobless rate during the recession in 2008.

Prior to COVID-19, the state faced challenges that affect the maternal and child health (MCH) population. According to the 2020 ALICE (Asset Limited, Income Constrained, Employed) report, 43% of households in Michigan struggled to afford the basic needs of housing, childcare, food, technology, health care and transportation. In Michigan, 61% of jobs were low wage jobs, paying less than $20 per hour; two-thirds of those jobs paid less than $15 per hour. In addition to households below the federal poverty limit, this equates to more than 1.66 million households struggling to meet basic needs. According to the 2020 Kids Count, Michigan ranks 22nd in health, 30th in both economic and family wellbeing, and 40th in education for children. One in five children (19%) ages 0-17 live in poverty and certain areas of the state experience higher levels of poverty. Statewide, 50.5% of students are eligible for free or reduced-price lunches. Given this environment plus the impacts of COVID-19, family support programs—such as WIC, food and cash assistance, health care and childcare—are critical resources for Michigan families.

Roles and Priorities of the State Health Agency

The Title V program is administered by the Division of Maternal and Infant Health (DMIH) which is housed in the Bureau of Health and Wellness (BHW) within the Public Health Administration. DMIH includes Family Planning and reproductive health, the Maternal Infant Health Program, infant safe sleep, breastfeeding, and Early Hearing Detection and Intervention. In addition to DMIH, the BHW includes the Division of Child and Adolescent Health (DCAH); Women, Infants and Children (WIC) Division; Division of Chronic Disease and Injury Control; and Local Health Services.

For Michigan’s Title V program, the DMIH works in partnership with the Children’s Special Health Care Services (CSHCS) Division and DCAH. CSHCS includes the Family Center for CYSHCN, CSHCS customer support, policy and program development, and quality and program services. DCAH oversees Title V funding to Michigan’s 45 local health departments for local MCH work. These Title V areas work collaboratively with an array of programs within the Michigan Department of Health and Human Services (MDHHS) which oversees programs including but not limited to public health; Medicaid; environmental health; emergency preparedness and response; communicable and chronic disease; food and cash assistance; migrant and refugee services; child support; juvenile justice; child and adult protective services; foster care; and adoption.

The MDHHS vision to “Deliver health and opportunity to all Michiganders, reducing intergenerational poverty and promoting health equity” is supported by six priorities:

• Improve maternal-infant health and reduce outcome disparities.
• Reduce lead exposure for children.
• Reduce maltreatment and improve permanency in foster care.
• Expand and simplify safety net access.
• Reduce opioid and drug-related deaths.
• Ensure administrations are managing to outcomes and investing in evidence-based solutions.

Michigan’s Title V program aligns with several of these priorities. The 2020-2023 Mother Infant Health & Equity Improvement Plan (MIHEIP) focuses on the mother-infant dyad and provides a framework for expanding partnerships and strategies to enhance local and state efforts to address the root causes of adverse outcomes—social determinants of health and drivers of health inequity. In September 2020, a Year One Update was released to highlight stakeholder success, acknowledge the commitment of partners, and update indicator data. Annual updates will be released to highlight progress made on achieving the collective vision of “Zero preventable deaths, Zero health disparities.”

As the MIHEIP was developed collaboratively by MDHHS and stakeholders, efforts to implement the MIHEIP are also informed by input and feedback garnered from the Mother Infant Health and Equity Collaborative (MIHEC), Regional Perinatal Quality Collaboratives (RPQCs), Michigan families, MCH stakeholders, health care providers and community leaders. Implementation of the MIHEIP includes alignment of programs within MDHHS; implementation of quality improvement efforts within RPQCs; and external implementation through community partners and maternal infant health providers. Further alignment and action occur through Maternal Infant Health (MIH) Action Committees. The Action Committees are aligned with MIHEIP priorities and aim to impact system change through policy and practice change. They are co-chaired by content experts within the respective priority(ies) of focus.

Improving maternal and infant health outcomes is a priority of Governor Whitmer. In early 2020, Governor Whitmer released the Healthy Moms, Healthy Babies initiative to address health disparities and ensure all women have access to high-quality health care. The FY 2021 budget allocated funds to provide continuous Medicaid coverage to beneficiaries for 12 months postpartum, increase access for families to evidence-based home visiting programs, and provide increased access to behavioral health care. According to the Michigan League for Public Policy, initial proposals for the FY 2022 budget suggest similar allocations, with an increased emphasis on health equity.

Early childhood partnerships and systems building are also critical to supporting children and their families. The Office of Great Start (OGS) within the Michigan Department of Education (MDE) leads the integration of the state’s health, development, and early learning investments for prenatal to age 8. MDHHS collaborates with OGS and other partners to support the development of early childhood systems that meet the needs of children and families.

One example of Michigan’s cross-systems early childhood work is the Great Start Operations Team (GSOT). The GSOT convenes state agencies and partners to provide strategic direction for early childhood services integration and coordination for programs that serve Michigan's families and young children. Several MDHHS program areas, including Title V, serve on the GSOT. The GSOT work is grounded in Michigan’s four key early childhood outcomes, which include “children born healthy” and “children healthy, thriving, and developmentally on track from birth to third grade.” In 2020, the GSOT served as the state systems hub to inform components of the Preschool Development Grant (PDG), reviewing priorities and activities developed during the initial grant in 2019 and guiding the next stage of planning. The GSOT also works with the BUILD Initiative to identify strategies to strengthen Michigan’s early childhood systems. The BUILD Initiative partners with the GSOT to provide guidance, training and capacity building around early childhood systems building. The BUILD Initiative engages the GSOT in efforts to increase quality, alignment, and efficiency among systems serving children and their families.

Another example is the Home Visiting Advisory launched in 2019. The Advisory is charged with building an integrated home visiting system for Michigan’s families. Michigan’s evidence-based home visiting system currently includes the Maternal Infant Health Program (MIHP), Nurse-Family Partnership, Healthy Families America, Early Head Start-Home Based, Parents as Teachers, and Family Spirit. The Advisory is intended to have an active role in system development through discussions about centralized access, professional development, and equity. In 2020, the Advisory elected tri-chairs, designing the structure to include a state partner, a local program leader, and a parent leader.

Addressing and advancing equity is a priority both within the State of Michigan and MDHHS. At the state level, several new initiatives have been implemented to address implicit bias, racism, and racial disparities:

• Governor Whitmer issued an Executive Directive in July 2020 requiring implicit bias training for 26 licensed health professional classifications to address racial disparities. The Department of Licensing & Regulatory Affairs (LARA) has gathered information on best practices and implicit bias trainings to provide recommendations to the Michigan Legislature.
• In August 2020, Governor Whitmer issued an executive directive to all State Department Directors recognizing racism as a public health crisis. The directive establishes guidelines for state departments and their employees on data and analysis; policy and planning; engagement, communication, and advocacy; and training. State employees were required to complete an implicit bias training by the end of 2020. Contractual staff must complete the training by the end of 2021.
• In August 2020, the Governor issued an executive order to establish a Black Leadership Advisory Council to act in an advisory capacity to the governor to develop, review, and recommend policies and actions designed to eradicate and prevent discrimination and racial inequity in health care, housing, education, employment, economic opportunity, public accommodations, and procurement.

State-level initiatives to specifically address racial disparities witnessed during the COVID-19 pandemic are discussed later in this section.

At the departmental level, MDHHS is working to assess and change policies and programs to address discrimination and disparities in health outcomes. In 2020, MDHHS created the Race, Equity, Diversity, and Inclusion (REDI) Office to address racial, health, social and wealth disparities. The MDHHS Diversity, Equity and Inclusion Plan details the Department’s “commitment to eliminating systematic inequities and promoting diversity, equity and inclusion.” The MDHHS Office of Equity and Minority Health (OEMH) delivers an annual report to the state legislature on the Department's progress and health disparities among key populations within the state. The OEMH also provides training to the MDHHS workforce on unconscious bias, systemic racism, and community engagement. Other MDHHS equity activities include the following:

• A Diversity, Equity, and Inclusion (DEI) Council was created to promote and foster a culture that values diversity, equity, and inclusion throughout MDHHS and the diverse communities it serves. DEI Council activities include collaboration with OEMH to develop a Systemic Racism online training; administering the Government Alliance on Race and Equity Survey which was completed by 5,767 employees in Fall 2019 and will be used as a baseline for equity work; a DEI quarterly newsletter; and creation of a Countering Bias in the Interview training in 2020, which is now required for all interview panelists.
• To better support equity in hiring practices, starting in 2021 all MDHHS position postings require a Valuing Diversity and Inclusion competency in the posting questions plus inclusion of DEI questions in the interview.
• The “Introduction to Health Equity” and “Systemic Racism” trainings are required for all MDHHS staff. Introduction to Health Equity describes health equity and health disparities; factors that contribute to inequities; the impact of health inequities; and how MDHHS can help to achieve health equity for all Michiganders. The Systemic Racism training identifies how Michigan and MDHHS produce and/or perpetuate inequitable outcomes and explains how national systems may produce inequities. The training is open to MDHHS employees, contractors, and the public.
• MDHHS and the Michigan Department of Civil Rights developed a two-day workshop entitled Inside Our Mind: Hidden Biases. During 2019-2020, four workshops were completed at MDHHS and four workshops were completed with the OEMH’s capacity building grantees.
• In the Executive Directive announcing racism as a public health crisis, the Governor announced the piloting of an Equity Impact Assessment (EIA) process in MDHHS, with plans to expand use and potentially roll out to other state departments. The EIA process can be used to inform decisions when developing budgets, programs, projects, procedures, and policies. OEMH is leading the pilot in 2021 within three MDHHS administrations.
• Each administration within MDHHS has been asked to identify a disparity that can be reduced for racial and ethnic minority populations served by their programs. OEMH will provide oversight and consultation. Administrations will participate in individual and cohort learning opportunities to identify policy and practice changes and to share achievements and solutions.

Strengths and Challenges that Impact the MCH Population

The 2020 Title V needs assessment, which was completed prior to the COVID-19 pandemic, identified several strengths and challenges that impact the MCH population. These are discussed in detail in the FY 2021 application. Strengths include longstanding relationships with Michigan’s local public health; a robust home visiting network; commitment to addressing health disparities and pursuing equity within MCH systems; educational campaigns that leverage technology and community voice; recognition of the impact of social determinants on health; resources and services to meet basic needs; and elevation of family voices to serve CSHCN.

Challenges facing Michigan’s MCH system and families served include the impact of poverty coupled with system limitations to address poverty as a driver of health outcomes and disparities; gaps in capacity and access to services for basic needs like transportation, childcare, and healthcare; inconsistent distribution of culturally or linguistically relevant health information; gaps in respite care for caregivers of CSHCN; barriers to accessing mental and behavioral health services; and racism and other drivers of health inequity.

Over the past 16 months, the most significant public health challenge has been the COVID-19 pandemic. As part of ongoing needs assessment activities, the Title V program conducted an assessment to gauge the pandemic’s impact on the MCH population. Findings are included in the Needs Assessment Update (Section III.C.). The NPM/SPM annual reports and state action plans also include information about the impact of the pandemic on programs and service delivery.

Michigan’s first presumptive positive COVID-19 case was reported on March 10, 2020. Governor Whitmer declared a state of emergency on the same day. Comprehensive information on the State of Michigan’s COVID-19 response is available on the Coronavirus website. As of July 16, 2021, Michigan had 897,598 confirmed cases and 19,848 COVID-19 deaths. Cumulative data including trends, demographics, and testing information is available on the State’s COVID-19 Data Dashboard. The COVID-19 pandemic has disproportionately affected African Americans and individuals with pre-existing comorbidities and/or over the age of 60. For example, cases per million in Michigan are 74,328 for Black/African American in comparison to 64,294 for White (as of 07/16/21). Deaths per million by race are also highest for Black/African American (2,886 per million) and American Indian/Alaska Native (2,352 per million) compared to 1,667 per million for White (as of 07/16/21). While total cases per million by age group are currently highest among 20-29 years, deaths per million by age group are highest among 80+ years. According to Khazanchi, Evans and Marcelin[1], “Area-based studies have … revealed elevated COVID-19 infection and death rates in socially disadvantaged counties with larger racial and ethnic minority populations” (2020). Research by Lichtenberg and Tarraf (2021) indicates that the COVID-19 pandemic has also had a negative impact on Michiganders’ mental health, especially for people of color[2].

The COVID-19 pandemic has been a rapidly evolving public health crisis. The MI Safe Start Map, which monitors COVID-19 indicators and risk levels by Michigan Economic Recovery Council (MERC) regions, provided the following overview as of July 13, 2021:

Many metrics are at or near 52-week lows, however, early indicators are showing increases. The State of Michigan percent positivity (2.0%) has increased for two weeks. Positivity is up 14% since last week and the 52-week low was recorded on June 26 (1.2%). Positivity in all MERC regions is also increasing. The state’s 7-day average case rate is 16.8 cases per million and is at an elevated incidence plateau for the first time in three months. The state case rate is up 15% since last week, and regional case rates are increasing or plateaued in all regions except Grand Rapids and Kalamazoo. Statewide hospitalizations for COVID-19 are decreasing for 11 weeks. (MI Safe Start Map. (n.d.). Michigan Statewide Overview. Retrieved from https://www.mistartmap.info/.)

The key strategy to prevent the spread of COVID-19 is through vaccination. The first COVID-19 vaccinations were administered in Michigan on December 14, 2020. According to the COVID-19 Vaccination Dashboard, 4,925,913 residents have initiated vaccination (i.e., one or more doses of any vaccine) as of July 17, 2021, which is 57.3% of eligible residents (i.e., 12 years of age and older); 53.2% (4,579,291) have completed vaccination. In January 2021, MDHHS launched a paid media campaign to inform Michiganders about the safe and effective COVID-19 vaccines and is currently working on multiple initiatives to continue to increase vaccination rates. Local health departments, including Local MCH which receives Title V funding, have been critical partners in education, mitigation, tracing, and vaccination efforts.

The State of Michigan has utilized Executive Orders and MDHHS Orders (e.g., related to mask wearing and social distancing) to mitigate and contain the spread of COVID-19 and to prevent overwhelming the state’s healthcare systems. Other state-led actions to support Michiganders during the pandemic have included the following:

• Food assistance for 350,000 Michigan families has been extended.
• MDHHS launched a “Be Kind to Your Mind” campaign in October 2020 promoting free mental wellness counseling in response to COVID-19 related stress.
• The State’s Stay Well counseling line offers emotional support 24/7 to anyone who calls the state’s COVID-19 hotline.
• A statewide COVID-19 Exposure Alert App was rolled out in November 2020 and reached nearly half a million downloads in the first month.
• In December 2020, the Protect Michigan Commission was created by executive order to serve in an advisory capacity to the Governor and MDHHS and to provide leadership to elevate the COVID-19 vaccine.

State initiatives to address racial disparities during the COVID-19 pandemic include the following:

• Governor Whitmer signed an Executive Order on April 20, 2020, creating the Michigan Coronavirus Task Force on Racial Disparities. The task force investigates the causes of COVID-19 racial disparities to recommend actions to address those disparities, including transparency in data reporting; remove barriers to physical and mental health care; reduce the impact of medical bias in testing and treatment; mitigate environmental and infrastructure factors that contribute to increased exposure during pandemics; and develop systems for supporting long-term economic recovery and physical and mental health care.
• MDHHS collaborated with the Task Force to establish 22 Neighborhood Testing Sites in 15 communities. A data driven approach used the CDC’s Social Vulnerability Index and mortality data for six comorbid conditions associated with increased risk of adverse COVID-19 outcomes. MDHHS partnered with trusted churches and colleges to establish neighborhood testing sites. As of June 2021, over 110,000 tests have been done at the sites.
• MDHHS partnered with Wayne State University/Wayne Health (WSU/WH), Genesee Health Systems, and Ingham, Kent and Muskegon health departments to serve communities at the highest risk of infection via six mobile units serving rural and urban communities. Mobile test services include COVID-19 testing, vaccine administration, health care screenings, and social determinant assessments with linkage to social services and medical care (e.g., Medicaid, unemployment assistance, emergency food and shelter services). As of July 10, the WSU/WH Mobile Health Units have performed 12,919 COVID-19 tests and provided 10,310 vaccine doses.
• Through the Rapid Response Initiative, the Task Force awarded 32 community organizations with almost $20 million in funding to implement community-based interventions to address critical service gaps. Awardee organizations employed a health equity lens to address needs associated with the disparate impacts of COVID-19 and other health conditions on African Americans, other racial/ethnic minorities, and marginalized populations. The initiative supported health services, food security, financial and housing stability, emergency shelter, and public health data improvements. As of April 2, 2021, approximately 1,146,458 people had been reached across the state.

The economic impact of COVID-19 in Michigan has been significant. According to the Michigan Department of Technology, Management and Budget, "Reflecting the impact of the COVID-19 pandemic, Michigan’s annual jobless rate jumped from 4.1 percent in 2019 to 9.9 percent in 2020.” The Carsey School of Public Policy “COVID-19 Economic Crisis: By State” reports that from March 2020 to February 2021, Michigan lost approximately 320,100 jobs (a decrease of 7.2%). From 2019-2020, Michigan’s overall GDP also decreased by 5.4%. The immediate and long-term effects of the COVID-19 pandemic on Michiganders’ physical, mental, and economic well-being will continue to be revealed.

Components of the State’s Systems of Care

Health Services Infrastructure and Financing

Michigan’s health care infrastructure includes 178 hospitals, including 37 critical access hospitals that serve rural areas (Michigan Health & Hospital Association). The state has 80 birthing hospitals and 21 Neonatal Intensive Care Units. Michigan also has six children’s hospitals (Children’s Hospital Association). The health care system includes 42 Federally Qualified Health Centers (FQHCs) with over 250 delivery sites; over 120 school-based/school-linked health centers; 33 Family Planning agencies providing services at 79 clinic sites; and 192 rural health clinics. The public health infrastructure to protect and promote the health of communities is supported by 45 local health departments (LHDs) that serve all 83 counties in Michigan and the City of Detroit. MDHHS works closely with LHDs to provide comprehensive public health services. This decentralized structure allows for local efforts to remain connected to the state for support, funding, and other resources.

After the implementation of Medicaid expansion in 2014, coverage expansions under the Affordable Care Act (ACA) provided Michigan consumers with two new options: Healthy Michigan Plan (HMP) and Health Insurance Marketplace (Marketplace). In January 2014, eligible individuals above 133% of the FPL could enroll in private health insurance coverage through the Marketplace. In April 2014, Michigan expanded HMP to cover residents who were at or below 133% of the FPL and who were not previously eligible for traditional Medicaid. According to the HMP website, the plan provides health care coverage to Michigan residents who:

• Are age 19-64 years.
• Have income at or below 133% of the federal poverty level.
• Do not qualify for or are not enrolled in Medicare.
• Do not qualify for or are not enrolled in other Medicaid programs.
• Are not pregnant at the time of application.

As of May 3, 2021, 905,993 beneficiaries are enrolled in HMP (HMP County Enrollment Report). This is an increase over a 13-month period (from 674,853 beneficiaries on March 23, 2020). Under the Families First Coronavirus Response Act of 2020 the Medicaid program will keep Medicaid eligibility cases open until the end of the COVID-19 Public Health Emergency.

The benefit design of the Healthy Michigan Plan ensures beneficiary access to quality health care, encourages utilization of high-value services, and promotes adoption of healthy behaviors. HMP benefits include preventive/wellness services, chronic disease management, prenatal care, oral health, and family planning services. Most HMP beneficiaries are required to pay some level of cost-sharing via monthly contributions and co-pays based on income. Some populations are excluded from cost sharing, such as individuals enrolled in CSHCS, under 21 years of age, pregnant women, and those with no income. To promote the health and well-being of HMP beneficiaries, MDHHS developed a Health Risk Assessment which provides beneficiaries the opportunity to earn incentives for engaging with the health care system. HMP enrollees who complete a health risk assessment and agree to maintain or address healthy behaviors, as attested by their primary care provider, may be eligible for select cost-sharing reductions.

The ACA also provided significant funds through HRSA to expand access to primary care by increasing the number of Community Health Centers in Michigan. The number of FQHCs grew as additional centers were funded and look-alike sites were approved. According to the Michigan Primary Care Association, Michigan’s 42 FQHCs provide care at over 250 delivery sites and are health care homes to more than 615,000 individuals.

ACA consumer protections improved access to private insurance for CSHCN by eliminating preexisting condition exclusions and discrimination based on health status, the two most frequent enrollment barriers for families. The ACA also expanded access to parent employer coverage for adults 19-26 years of age. CSHCS/Healthy Michigan enrollment for December 2020 was 1,916 (MDHHS Health Services Data Warehouse, 5/5/2021). LHDs, Family Resource Centers and designated state staff work with families and community partners to help families understand and access private and publicly funded resources to meet needs.

CSHCN often require and use more health care services than other children. Specialty care and extensive, on-going, or long-term treatments and services may be required to maintain or improve health status. Financing these costs can pose significant challenges and burdens for families even with access to private insurance. Family health care costs can include deductibles, cost sharing and premium payments. Private insurance may not include any covered benefit for a specific, medically necessary service. In other cases, only a limited benefit may be available. Although ACA eliminated annual and lifetime dollar limits, other annual limits exist, and benefits may be exhausted for the current contract year even though needs continue. As such, CSHCS helps to limit costs to families and continues to be a significant resource for achieving appropriate and equitable health and specialist care. Steady CSHCS enrollment following ACA’s implementation reflects the value of CSHCS to families even when private insurance is available.

Integration of Services

MDHHS recognizes the importance of integrating physical health and behavioral health services across systems to improve health status and address individual or family needs. The COVID-19 pandemic has further highlighted the critical nature of behavioral health services and gaps in current systems. To better address behavioral and mental health needs, MDHHS initiatives include the following:

• In December 2020, MDHHS announced plans to pilot the Michigan Crisis and Access Line (MiCAL) through two pilot sites in the Upper Peninsula and Oakland County in 2021. MiCAL will be staffed 24/7 and will provide crisis and warm line services, informational resources, and coordination with local systems of care such as Community Mental Health Services Programs and Prepaid Inpatient Health Plans. MDHHS anticipates statewide rollout by the end of 2022.
• In February 2021, MDHHS announced an RFP to expand mental health services for youth in Michigan through the Expanding, Enhancing Emotional (E3) Health Program. E3 is managed by DCAH and provides on-site comprehensive mental health services in a K-12 school or on school grounds for children and adolescents 5-21 years. Currently 68 E3 sites reach 36 counties, with expansion plans underway. Services include assessments, brief intervention, ongoing therapy, referrals, tracking and follow-up. Services are available year-round in schools or on school grounds where access to behavioral health resources are limited in a community. In addition to existing sites, MDHHS anticipates issuing 12-15 new awards equaling $1.6 million through this RFP.
• In October 2020 MDHHS launched the statewide “Be Kind to Your Mind” campaign to promote the use of Michigan’s free, confidential Stay Well counseling line. The Stay Well initiative also offers free virtual support groups, wellness webinars, and behavioral health guides.
• In August 2020, MDHHS was approved for a two-year CMS Certified Community Behavioral Health Clinic (CCBHC) Demonstration. CCBHC demonstration sites are required to provide nine core behavioral health services, including formal care coordination with primary and other care providers, and must meet standards for service provision, staffing, quality and financial reporting, and governance. Fourteen sites are eligible to participate in the demonstration.
• MDHHS was awarded the Promoting Integration of Primary and Behavioral Health Care (PIPBHC) Grant in FY 2019. PIPBHC is a five-year grant to promote integration and collaboration in clinical practice between primary and behavioral health care, and to support improvement of integrated care models for primary and behavioral health care to improve the overall wellness of adults with serious mental illness (SMI) or children with serious emotional disturbance (SED). Grantees promote integrated care services related to screening, diagnosis, prevention, and treatment of mental and substance use disorders, and co-occurring physical health conditions and chronic diseases. MDHHS partnered with three sub-grantees which serve adults with SMI, and two of which serve children with SED. All sub-grantees are focused on comprehensive care including reduction in BMI, smoking cessation, increased physical activity, and nutrition.
• The Michigan Child Collaborative Care (MC3) was expanded to all 83 Michigan counties to increase access to mental health treatment for underserved children, adolescents and high-risk perinatal women. The program expansion is significant given the shortages of specialty providers, especially in rural areas. The MC3 program provides psychiatry support to primary care providers who have patients with behavioral health issues including children, adolescents, and young adults through age 26. It also includes women who are contemplating pregnancy, pregnant or postpartum. Behavioral Health Consultants are linked with or embedded in pediatric primary care practices to ensure children are assessed and linked to appropriate mental health services. MC3 also provides education for primary care providers to increase their understanding of mental health issues for children and families. MC3 is supported by the MDHHS Behavioral Health and Developmental Disabilities Administration.
• In FY 2021, MC3 for MOMs was launched to engage and enroll a larger population of Michigan’s perinatal providers and their patients in targeted areas of the state. The initiative is intended to improve perinatal providers’ knowledge of and comfort with perinatal behavioral health screening and treatment (e.g., mood and anxiety disorders, substance/opioid use disorders). The need for universal psychiatric screening is great given that as many as 25% of perinatal women experience depression and anxiety. Perinatal providers report that it is difficult to adequately screen women for mental and behavioral health conditions and report feeling ill equipped to manage these conditions. Behavioral Health Consultants will be specially trained in brief interventions to address behavioral health issues that impact the perinatal period. A perinatal resource and referral list will also be developed to help ensure that pregnant and postpartum women are referred to home visiting programs, have access to basic needs, and are enrolled in other relevant services (e.g., WIC).
• Michigan supports over 25 Children’s Multi-Disciplinary Specialty (CMDS) Clinics in seven tertiary care and teaching hospitals. These clinics offer a highly coordinated, interdisciplinary approach to the management of specified complex medical diagnoses, which include teams that consist of a specialist/pediatrician, nurse, social worker, and dietician. Families receive a comprehensive, patient-centered Plan of Care (POC). The POC includes an assessment and ongoing treatment plan which is monitored and updated. Patients also receive health education, transition, support and referral services.
• CSHCS and Behavioral Health and Developmental Disabilities Administration (BHDDA) continue their collaborative work to identify challenges accessing services experienced by populations served by the mental/behavioral health, intellectual/developmental disabilities, and physical health systems. The collaboration is working to provide cross-sector education, create tools to assist families, and address systemic issues that cause access challenges.

These and other coordinated, collaborative efforts will be critical to support the mental health and wellbeing of all Michiganders.

Title V and Medicaid

Michigan’s Title V and Title XIX programs are both housed within MDHHS and share the common goal to improve the overall health and well-being of the MCH population through implementation of affordable health care delivery systems, expanded coverage, and strategies to address social determinants of health and reduce health disparities. Areas of collaboration include maternal and infant care, perinatal care, child and adolescent health, developmental screening and referral, home visitation, oral health, and CSHCS. Key partnerships are discussed in the Title V–Title XIX section of this application.

In April 2021, 2,122,135 Medicaid beneficiaries were enrolled in the Medicaid Health Plans (MHPs) and 552,894 beneficiaries were enrolled in fee for service. Medicaid employs a population health management framework to build a Medicaid managed care delivery system that maximizes the health status of beneficiaries, improves beneficiary experience, and lowers cost. Medicaid contracts with 10 Medicaid Health Plans (MHPs) to achieve these goals through evidence- and value-based care delivery models; health information technology; strategies to prevent chronic disease; and coordination of care along the continuum of health that includes assessing social determinants of health such as transportation, housing, and food access. The Managed Care Plan Division (MCPD) in MSA requires MHPs to annually report the Healthcare Effectiveness Data and Information Set (HEDIS) and employs a Pay for Performance Incentive Program that includes access, process, and outcome metrics for all managed care populations, including women and children. Each MHP’s governing body must either have a minimum of 1/3 representation of Medicaid enrollees or the plan must establish a consumer advisory council that reports to the governing body. The council must include at least one Medicaid enrollee, one family member or legal guardian of an enrollee and one consumer advocate. In addition, MHPs must actively attempt to recruit CSHCS beneficiary parents/guardians to participate in its non-compensated governing bodies or consumer advisory council.

To help achieve integrated care, MHPs are required to work with MDHHS to develop initiatives to better align services with Community Mental Health Services Programs/Prepaid Inpatient Health Plans (PIHPs) to support behavioral health integration. Medicaid collaborates with the MDHHS Behavioral Health and Developmental Disabilities Administration (BHDDA) to incentivize performance by MHPs and PIHPs on shared metrics and shared populations. The MHPs must also provide or arrange for the provision of community health worker (CHW) or peer-support specialist services to enrollees who have significant behavioral health issues and complex physical co-morbidities. CHWs serve as a key resource for services and information needed for enrollees to have healthier, more stable lives. CHW services include conducting home visits; participating in office visits; arranging for social services; and helping enrollees with self-management skills.

The DMIH and Michigan Medicaid jointly manage several programs for the Medicaid-eligible MCH population. One of the largest collaborations is the Maternal Infant Health Program (MIHP), Michigan’s largest population-based home visiting program available to all Medicaid-eligible pregnant women and infants up to age one. Effective January 1, 2017, MIHP services provided to beneficiaries enrolled in an MHP are administered by the MHPs. In FY 2020, MIHP provided services to 12,187 women and 17,076 infants.

Another area of coordination is for CSHCN. In March 2021, program data for CSHCS indicate that 26,949 or 64.8% of CSHCS beneficiaries were dually enrolled in an MHP. MHPs are responsible for the medical care and treatment of CSHCS members while community-based services beyond medical care and treatment are provided through the LHD’s CSHCS office. MHPs are responsible for coordinating and collaborating with LHDs and the Children’s Multidisciplinary Specialty Clinics to make a range of essential health care and support services available to enrollees. MHPs are also responsible for the coordination and continuity of care for enrollees who require integration of medical, behavioral health and/or substance abuse services.

Information Systems

MDHHS utilizes CareConnect360 (CC360), a statewide web-based care management system that allows for the bi-directional exchange of health care information. CC360 allows for the identification and coordination of services to Medicaid beneficiaries—particularly in relation to physical and behavioral health information—by sharing cross-system information between state health plans and the Community Mental Health/Prepaid Inpatient Health Plans. CC360 makes it possible to analyze healthcare program data, manage and measure programs, and improve enrollee health outcomes. Within DMIH, CC360 helps to improve communication within MIHP by sharing care elements that can aid in successful case management so that MIHP home visitors are part of the care team. CC360 enables access to comprehensive Medicaid claims and encounter data for patients of record to support care coordination services. It will also allow for comparison of population health data across counties or regions.

MI Bridges is another important component of the MDHHS service platform to better interface with customers through technology and to make the service delivery system more focused on customer needs. MI Bridges is an online site managed by MDHHS that enables users to apply for benefits (including healthcare coverage, food assistance, cash assistance, childcare, and state emergency relief) and to find resources such as transportation, food, and utilities assistance. MI Bridges users can review and access their benefits information; renew benefits; and share beneficiary information with their specialist. For example, WIC and the Supplemental Nutrition Assistance Program (SNAP) both provide resources for families experiencing food insecurity. In the fall of 2020, new functionality was built in MI Bridges to include home visiting. This will allow families in need of home visiting to receive a custom list of models that are available in their community and, if selected, a referral to a specific model. This new feature launched in December 2020 and already averages over 300 referrals each week. Additional features and functionality are being added in 2021 to make the system more user-friendly and to provide more specific information on the home visiting models.

Lastly, MDHHS also uses multiple health information systems to support the care and services provided to the MCH population. The Michigan Care Improvement Registry (MCIR) allows for the identification of children who are not up-to-date on Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) well child visits according to the American Academy of Pediatrics Bright Futures Recommendations for Preventive Pediatric Health Care periodicity schedule. All MHPs have access to MCIR, and it is an approved data source for Medicaid Healthcare Effectiveness Data and Information Set (HEDIS) immunization and lead testing data. MIHP providers also have access to MCIR to facilitate referral and access to appropriate preventive services.

State Statutes Relevant to Title V (Effective September 30, 2020)

The Michigan Public Health Code, Public Act 368 of 1978, governs public health in Michigan. The law indicates that the state health department shall “continually and diligently endeavor to prevent disease, prolong life, and promote the public health through organized programs” (MCL 333.2221). Furthermore, it shall “promote an adequate and appropriate system of local health services throughout the state and shall endeavor to develop and establish arrangements and procedures for the effective coordination and integration of all public health services including effective cooperation between public and nonpublic entities to provide a unified system of statewide health care” (MCL 333.2224).

In FY 2021, state funding for MCH and CSHCS programs was appropriated through Public Act 166 Enrolled House Bill 5396 Health and Human Services of 2020. CSHCS is mandated by the Michigan Public Health Code, Public Act 368 of 1978, in cooperation with the federal government under Title V of the Social Security Act and the annual MDHHS Appropriations Act. State general fund dollars for MCH programs are itemized in Sec. 116, Family Health Services, of Public Act 166 of 2020, whereas CSHCS is addressed in Sec. 117. Additional MCH details are provided in Sec. 1301-1305; 1308-1317; 1319-1320. These sections identify how funding shall be used; MDHHS and contractor requirements; and requirements that some appropriated funding be used to implement evidence-based programs to reduce infant mortality, rural home visiting, continue development of an outreach program on fetal alcohol syndrome services, enhance education and outreach efforts to seek early prenatal care, allocate funds to the Michigan Dental Association to administer a volunteer dental program that provides dental services to the uninsured, and the provision of high-quality dental homes for seniors, children, and adults enrolled in Medicaid and low-income uninsured. Statutory requirements in the FY 2021 Health and Human Services budget for CSHCS included criteria in Sec. 1360 for MDHHS to provide services; and in Sec. 1361, the authorization that some of the appropriated funding be used to develop and expand telemedicine capabilities and to support chronic complex care management.

[1] Khazanchi, R., Evans, C., & Marcelin, J. (2020). Racism, Not Race, Drives Inequity Across the COVID-19 Continuum. JAMA Network Open.

[2] Slootmaker, E. (2021). Michigan grapples with COVID-19's disproportionate impact on people of color's mental health. Second Wave Michigan.