Demographics, Geography, Economy, Urbanization and Government: New Hampshire (NH) is one of the oldest states in the country; it was originally a land grant in 1623 and became a state in 1775. NH’s population of 1.36 million live in 9,351 mostly forested (81%[1]) square miles bordered by Canada on the north and by Massachusetts on the south. On the east is the Atlantic Ocean and Maine and on the west is Vermont. With its 1,300 lakes and ponds, 40,000 miles of river and 18 miles of seashore NH is the 45th largest state at 190 miles long and 70 miles wide. The state’s landscape lends itself to many different types of outdoor recreation. However, that same topography lends itself to difficult driving and long distances between places, particularly in the winter months.
With its ten counties, approximately 47% of the population and 84% of the landmass in NH is considered rural; most of the land area lies north and west of the capital Concord. The three (3) most urban or metro areas are Manchester, Nashua and Concord, all located in the state’s southern tier where the majority (53%) of the population lives.
New Hampshire’s Title V Program consists of the Maternal and Child Health Section (MCH) located in the Bureau of Population Health and Community Services in the Division of Public Health Services (DPHS), and the Bureau for Family Centered Services (BFCS), formerly Special Medical Services, located in the Division of Long Term Supports and Services (DLTSS). Many factors guide its efforts.
Both DPHS and DLTSS reside within the New Hampshire Department of Health and Human Services (DHHS), the state’s largest agency made up of approximately 10,000 employees and the bulk of the state’s budget (with Medicaid being the most costly line item). A Commissioner oversees the NH DHHS, appointed by the Governor for what typically is a four-year term. Both MCH and BFCS are physically located in the capital city of Concord. However, much of their Title V work takes place in funded agencies across the state in the form of community health centers, specialty health clinics, human services agencies that provide home visiting and the like. The Title V Program focuses on the ever-changing landscape of the state in which it serves.
New Hampshire has the largest bicameral legislature in the English-speaking world,[2] with 24 Senators and 400 Representatives, and operates under a unique Governor and Council (G&C) system. Five Executive Councilors, each representing 1/5 of the population are elected separately from the Governor, though for the same two-year term. All state departments and agencies must seek approval of both receipt and expenditure of state and federal funds, budgetary transfers within the department and all contracts with a value of $25,000 or more. The current Governor of NH is Christopher Sununu, who started serving his second term in 2019, up for re-election in November 2020, and is a Republican. Title V policy and funding is heavily influenced by both the Legislature and G&C.
However, on March 13th, 2020, the Legislature, consistent with the date the Governor declared his first State of Emergency order and opened up the Emergency Operations Center, suspended activity due to the COVID 19 pandemic. Both the House and Senate did no legislative business through any venue until late April when a few, but not all, Senate and House Committees began meeting remotely. This has delayed all legislation and any changes including those pertinent to the Title V population until recently. Both the Senate and House met for the first time in person on June 11th, 2020 in different venues.
NH House/Whittemore Arena/UNH
NH Senate/Representatives Hall
However, the outcomes of the two sessions proceeded very differently. The Senate reviewed and voted on bills, some passing, some bipartisan, some not. The Senate also created some very large omnibus bills, putting several unlike bills together in case the climate in the House was like they expected. The House, however, needed a two-thirds affirmative vote to extend the timeline so bills could be heard past the mid-March deadline (where crossover to the other legislative body occurs) and to amend the World War II emergency order allowing the Legislature to continue working (past June 30th) only when attacked by the enemy. These votes came up several times during the in-person House session, but were voted down by partisan lines (Senate passed them. The House acted exactly as the Senate thought). This essentially stalled and/or eliminated some of the bills that were initiated in the House during the 2020 State Legislative Session. However, the House did pass some of the Omnibus bills that came from the Senate on their second in person session on June 26, 2020. November of 2020 is an election, as stated previously, for both the Governor and the full Legislature, both the House and Senate.
Fortunately, the State Fiscal Committee (which has both Senators and Representatives), which approves all new funding and any changes such as a budgetary redirection before it goes to G & C, as well as the G & C itself, met and are meeting remotely throughout the pandemic to enable the continuation of all State work, including that of Title V.
Unfortunately, the Governor has instituted a hiring freeze during the pandemic for both federal and state funding job opportunities, necessitating a long waiver process for any position that is not COVID 19 related. Both MCH and BFCS have vacant positions, which now have to go through this lengthy and tedious procedure.
The population of the State of New Hampshire is primarily non-Hispanic white (90%), but its residents of color (Asian, 2%; Black, 2%, Hispanic, 4% and other at 2%) are increasing.[3] Diversity is geographically uneven in New Hampshire.[4] Many square miles of the State are uniformly white, while the more urban part in southern New Hampshire is more diverse as is the Hanover/Lebanon area in the Upper Valley and a few areas of the Seacoast. In Manchester and Nashua, more than 30% of the population under 18 are minorities. [5]
Rising as well is the 5.9% of the state’s population born outside of the United States, with a 10.5% growth just between 2010 and 2014.[6] The results of the 2020 Census will be interesting to note for any significant change. The State also has one of the most mobile populations in the country. Only 42 percent of the state’s residents were born in New Hampshire, far less than the average across the US (57 percent).[7] In 2019, the State’s population increased even though it was only one of four states where deaths outnumbered births.
With fewer births than deaths, migration accounted for all of NH’s population increase in 2019 and is critical for future population growth.[9] Fewer births because the number of women of child-bearing age has decreased, and greater deaths because of the growing older adult population.[10] The COVID 19 pandemic has accentuated this as the majority of deaths have been in the long-term care population. The State also still has a large incidence of opioid related overdose deaths, primarily in young adults, but still contributing to the overall numbers.
New Hampshire is a rapidly aging state. Approximately 18% of the state is 65 and older compared with 16% nationally.[11] The state routinely is amongst the top five for the highest percentage of its population enrolled in Medicare.[12] As a result, the state’s older population will more than double over the next 20 years. As with its diversity, older populations are not represented evenly within the State; the percentage of older adults is greatest in the North Country, while the majority of older adults live in the Southern part of the state which is the most populated.
New Hampshire is a low-revenue, low-expenditure state. Its revenue structure is distinctive in that the state lacks a broad-based personal income or sales tax, and its biggest single source of revenue is local property taxes. The funding of New Hampshire’s school districts is largely at the local level through property taxes, which has led to disparities across the state in property poor districts.[14]
New Hampshire has a diverse mix of industries which usually makes its economy more resilient than that of states that are dependent on fewer industries. The State’s jobs are most heavily concentrated in retail (14 percent), health care (14 percent), government (13 percent), and manufacturing (10 percent). The State’s percentage share working in retail is the highest in the country.[15]
New Hampshire’s unemployment rate usually is well below that of the United States as a whole (hovering around 2 to 2.5 % for over a decade). Part of that is due to consistently having a more educated workforce.[16] However, with the advent of the COVID 19 pandemic, New Hampshire, like the rest of the nation is experiencing a significant increase in its incidence of new and sustained unemployment claims, around 97,914 continuing claims as of the week ending June 6th, 2020. That is down from May 6th of that year, but still up substantially from 2019.[17]
The statewide decline in continuing claims reflects progress in the re-opening of businesses and return to work of residents. Younger workers are disproportionately found in several of the industries with the most layoffs and furloughs during the pandemic, particularly the retail industry.
As of May 19th, 2020 and because of the job losses due to the COVID 19 pandemic, nearly half of all NH residents had lost household income and 16% were unsure whether or not they were going to be able to pay rent or mortgage. It is hoped that the decline in unemployment claims
previously stated, bodes well for the future. In previous typical years, NH has had the lowest poverty rate in the country at around 7.7%[20] which varied across the state with the numbers increasing the further away from the more population dense areas in the South. Poverty is defined as having an income below a certain level based on the size and composition of the household. For 2018, the federal poverty thresholds were less than $13,064 for a single person under age 65, $17,308 for a household under 65 with one child, and $25,465 for two adults with two children.[21]
Geographic poverty disparities are greatest among children with about one in five children in Coos County and one in 15 estimated to be living poverty in Rockingham County (the most heavily populated and in the South). [22] That distribution is also reflected in the Free and Reduced Priced Lunch (FRPL) program which is often used as a proxy for “low-income”. To be eligible, children must live in families below 185 percent of the poverty guideline. With many children in Coos County being eligible, there are also variations within counties in the southern part of the State, particularly Hillsborough County (where the cities of Manchester and Nashua are located) which has two of the five districts with the lowest FRPL percentages and four of the five districts with the lowest. [23] This has been particularly relevant during the COVID 19 pandemic, when children are home from school. There have been focused statewide and localized efforts on food insecurity specifically for these children.
In addition, there are also racial, family and living situation disparities with respect to poverty in the State. Non-Hispanic whites were the least likely to be in poverty from 2014 to 2018. One out of five Black residents and one of every six Hispanics were in poverty during that time frame. Individuals who were female, under age 18, or foreign born also faced higher poverty rates than the overall population.[25] Families with single female householders were more likely to be in poverty than families overall. Roughly one out of three of these families with a child under five years old lived in poverty. Individuals in non-family households also faced relatively higher poverty rates.[26]
Unique strengths that impact the health status:
Historically, New Hampshire has often been in the top tier in rankings of its overall well-being and in the social determinants of health.[28],[29],[30],[31] Scores are based on a composite index of metrics that give a snapshot of the health of a population or its health care, such as rates of infant and maternal mortality (both of which NH scores well on). The State also scores high because some of its key social determinants of health such as economic stability, quality of education and public safety generally are good.
Components of the state’s systems of care and Title V populations:
New Hampshire’s Title V population is served by its 26 acute care hospitals. Thirteen of the 26 are designated as critical access hospitals, which have 25 beds or less and are the smaller, rural systems. Five specialty hospitals provide psychiatric and rehabilitative care with 498 beds. Dartmouth Hitchcock is the largest medical system in the state with its flagship hospital having the only Level 1 designated trauma classification. It also offers the state’s only comprehensive, full-service children’s hospital, the Children’s Hospital at Dartmouth-Hitchcock (CHaD).
New Hampshire has a highly concentrated health care delivery system. Acute care hospital systems are more than just inpatient and emergency room services. Many of NH’s hospitals have evolved to include the majority of the medical and primary care practices in the state as well as ownership of ambulatory surgery centers, health centers, assisted or skilled nursing care facilities and home care and hospice. In the past two years, most of the hospitals in the state have also merged and affiliated with one another and across stateliness joining hospital and health care systems in Maine, Vermont and Massachusetts and even on a national level. Thus, even narrowing the healthcare delivery system to a handful of players.
There are 10 Federally Qualified Health Centers (FQHCs), one FQHC look-alike and 14 Rural Health Clinics (RHCs), most of which are hospital-affiliated. Through MCH, Title V helps to support the efforts of the majority of the FQHCs, the FQHC look-alike and one RHC.
With the advent of the COVID 19 pandemic in early 2020, hospitals and health systems have had many systemic changes, with a significant difference in the way of managing their care and a tremendous reduction in financial resources, despite the state and federal finances and executive orders and oversights focused on them (e.g. payment of telehealth services, etc.) early on Hospitals are as of this writing just now getting back to doing elective procedures, four months after having stopped all non-emergent measures. However, even those on solid financial footing at the beginning of the pandemic, may not have the reserves to hold up under a prolonged fiscal depression.
A recent analysis commissioned by Bi-State Primary Care Association reported that 43% of NH’s FQHCs would exhaust all of their operating reserves if fiscal help didn’t continue indefinitely and the same percent less than 30 days of cash on hand.[35] Most expect a significantly depressed source of revenue even as systems re-open as payer mixes change and fear and distrust of the health systems remain.[36]
A particular concern to the MCH population is the closure of nine-hospital labor and delivery units in the past 17 years, two within 2018 alone. There are only 17 hospital birthing units and four (one new one opened up just this past year; Birth Cottage in Salem) non-hospital birthing centers in NH. Only six of the critical access hospitals now offer obstetrical services presenting a distance issue. This is not unique to NH. Obstetrical services have high fixed costs and low reimbursement rates.[37] Small volume hospitals (like critical access) in NH typically have a higher percentage of patients that give birth paid for by Medicaid (up to 62%).[38]
Research has shown there is a reason to be concerned with closures precipitating increases in births that occurred in hospitals without obstetric services (higher for counties not adjacent to urban areas), increases in out-of-hospital births (including those that occurred in homes and freestanding birth centers) and decreased outpatient prenatal care.[39]
MCH along with colleagues statewide are working on the issue of labor and delivery closures. An initial analysis of unplanned and out of hospital births, used as a proxy to reflect the effect of labor and delivery closures, was completed and presented at the Northern New England Perinatal Quality Improvement Collaborative (NNEPQIN-Northern New England’s PIN) January 2020 meeting. An algorithm was designed to detect unplanned location and out of hospital births using inconsistencies found in the vital records data. The inconsistencies included:
- Inactive birth hospital (based on closure dates) +3 points
- Attendant title literal search +3 points (e.g. EMT, EMR, FIRE, PAR, etc.)
- Child place of birth code Other or Unknown +1 points
- Planned birthplace field not blank +1 points
- Child place of birth = home or unplanned (code or literal; also vehicle, car, parking lot, etc.)
The rate of unplanned location births per 1,000 live births over time is shown in the graphic below for the period of 2005 through 2019. There is a spike in 2012 and again in 2018. Again, this is not a definitive causal effect of closed labor and delivery hospital floors.
Increases in the unplanned location birth rate were found across time and geographical regions as noted in the graphic below. Home-unplanned (56.6%) and enroute (30.7%) accounted for 87.3% of unplanned delivery location types.
The map below shows the current and closed birth hospitals in New Hampshire. Vermont and Maine birth hospitals are also included on the map for context (note the closure of a birth hospital in Vermont just over the border where the NH closure pattern meets).
The graphic below displays 2019 birth data for remaining birth hospitals, and the most recent complete year of data for the hospitals that most recently closed their birthing units. It is notable that many of the lower volume birth hospitals with a high proportion of Medicaid-paid births are among the closures. Interestingly, the lowest volume hospital in the remaining open group also has the highest proportion of Medicaid-paid births. There has been a supplemental payment policy in place with NH Medicaid that has likely helped to keep this unit open. Policy options statewide are being explored further.
Over the last decade, Medicaid has consistently paid for approximately one quarter of all NH births. [44]
There is also recent prospective data that indicates that births may be going up in the four birthing centers in the state from April through the current day 2020 as evidenced by the midwives’ increased requests for the number of filter papers as compared to 2019. This may more be likely due to the COVID 19 pandemic than hospital labor and delivery closures. Again, MCH staff will be analyzing birth certificate data to see if this is indeed accurate.
As with the population of NH in general, the health care workforce is aging. In a 2019 report from the NH Health Professions Data Center, male physicians make up over 80% of the workforce 50 years and older leading to an expected fifty percent of the current available physician capacity (by FTE) to decrease in five years.[46] In July of 2019, Governor Sununu signed RSA 126-A:5, a law mandating workforce survey participation by participating health professions’ boards and requiring completion of the survey or opt-out form as a condition of license renewal. This will ensure accurate data is captured by the Health Professions Data Center. Title V is working with colleagues at DHHS’s Office of Rural Health and Primary Care with participation in activities such as the Legislative Commission on Primary Care Workforce Issues and the NH Health Professions Data Center.
Financing of services for the MCH population: NH Medicaid utilizes a managed care model for medical services. On March 26, 2019, the Governor and his Executive Council approved three insurance plans to serve as recipients of Medicaid Care Management that began September 1st of 2019. Two, NH Healthy Families and Well Sense were already MCOs providing services for enrolled clients. One, AmeriHealth Caritas, was a new MCO provider.
NH’s Medicaid expansion program, called the Granite Advantage Health Care Program, continues with participants having a choice of the current MCO’s. The enrollee must also remain under 138% of the Federal Poverty Level to remain eligible for coverage. Granite Advantage’s work/community engagement requirement, approved by CMS, was temporarily delayed by the Governor in early July of 2019 after more than two-thirds of beneficiaries, nearly 17,000 people, were in compliance (as of July 1st) and at risk of losing their health insurance. Interestingly, several weeks later, a federal judge blocked the implementation entirely of NH’s requirement stating that “CMS did not adequately factor the potential coverage losses from the waivers into its approval decision”. [47] The case is under appeal and has been for almost a year.
As of the end of May 2020, approximately 190,988 New Hampshire residents, nearly 14% of the state’s population, were on Medicaid (up 1% from the same time in 2019), including 57,758 people who were added to the rolls with Medicaid expansion.[48] Children continue to make up the greatest proportion of the NH Medicaid roster with the expansion population second.
The State also operates a partnership health insurance exchange with the Federal government (https://www.nh.gov/insurance/consumers/documents/2020-nh-plan-comparison.pdf), with the Department of Insurance having control over plan management and consumer assistance functions on the federal Marketplace. There are three (3) medical carriers with 17 plans for individuals and 12 for small groups, having 25 of the 26 acute care hospitals in-network for the enrollment period, which starts again in November of 2020. Memorial Hospital in Conway, New Hampshire became part of Maine Health and like other providers in Carroll County is not covered under some, not all, of the offered plans.
Many of these changes have helped to address financial barriers to care. A survey of Title V funded CHCs found that in 2018, between 10 to 50% of their patients were uninsured at the first encounter or visit. [50] UDS data of the same agencies report from 2019 that between six and 26% of the patient population were still uninsured at the last visit.[51] From the five year time frame of 2013 to 2018, the uninsured rate in NH decreased by almost five percent, landing at an overall uninsured rate of approximately 5.9% uninsured for all ages. [52]
Employer-based coverage was the most common coverage type for children under 19, with less than three percent uninsured during 2018. Over 27% of children in NH were covered by Medicaid in that same time period.[54] In 2018, almost 11% of the 19-34 population was uninsured, which was a higher percentage than any other age group; the 35-64 year-old population had the highest rates of employer sponsored insurance (71%) of any age group.[55] There is a lot of concern that the percentage of uninsured will spike as unemployment will continue to some extent as the COVID 19 pandemic continues.
Challenges that impact the health status: NH continues to have a high rate of opioid overdoses and deaths plaguing the state for more than a decade and severely straining the health care system as a whole. In 2018, NH had a drug overdose rate of 35.8 compared with a national rate of 20.7.[56] The mortality rate has increased significantly since 2010.
For the MCH population, this has been particularly tragic. One of the leading causes of maternal mortality in the state is accidental drug overdose.[58] MCH’s surveillance tool, the Pregnancy Risk Assessment Monitoring System (PRAMS), released a report entitled “Perinatal substance use among New Hampshire Women, 2013 -2017”[59] in December of 2018. It found that the prevalence of perinatal use of tobacco and marijuana was higher in those with less educational attainment, young and with less income.[60] PRAMS data from 2018 concurred. [61] Use decreased during pregnancy, but for some it resumed after giving birth. [62] MCH’s PRAMS added opioid use questions to the 2019 survey.
MCH is the lead on the CDC’s Overdose to Action grant, which fund several opioid overdose surveillance and prevention strategies including the collection of real-time emergency department overdoses; the collection and dissemination of data related to overdose deaths; the development of overdose surveillance systems such as the Opioid Overdose Dashboard; the enhancement of the State’s Prescription Drug Monitoring Program; the provision of care navigators to help families connect to services when children are separated from their parents due to parental substance use disorder; the provision of education about syringe services to reduce harm and the education of health care providers and support health care systems related to best practices around prescribing opioid medications.
Title V staff in coordination with statewide colleagues on the Perinatal Substance Exposure Task Force, developed and have now implemented a Plan of Safe Care[63],[64], to be developed collaboratively by the new mother and her health care providers. The MCH Perinatal Coordinator will be focusing on the Plan of Safe Care in conjunction with the Title V National Performance Measure #14. For the last three years, MCH has been collecting drug exposure on its situational surveillance fields on the birth certificate. Now, the questions are permanent parts on the birth certificate work sheets, are aggregated, de-identified and submitted to DHHS’s Division of Children, Youth and Families (DCYF; the State’s Child Protection Agency) for its federal CARA/CAPTA notification requirements. Mandatory reporting is required under NH RSA 169-C: 29 whenever anyone has a reason to suspect child abuse and/or neglect. The fact an infant is born with prenatal exposure to drugs and/or alcohol does not itself require a mandatory report.
In 2019, NH’s DCYF released its first aggregated data book in late 2019. [65] During that year, the DCYF Central Intake Unit fielded 30,993 calls, the most ever received. These calls resulted in a record high number of child abuse and neglect assessments (12,231) and a record high number of family service cases (1,685.) However, despite the record volume across the child protection system, data also show a plateauing of the number of children in out-of-home care following years of drastic increases, as well as a marked increase in the number of children being cared for in their own homes and with their own families. In fact, for the first time since 2014, exits from out of home care began to outpace entries.[66]
But then COVID 19 came along and dramatically altered daily life for everyone, but particularly for New Hampshire’s most vulnerable residents.
The deferral of preventative care; the increase of substance misuse, family violence and food insecurity have all been increasing in the State since the pandemic hit. [67] There has, as in the rest of the United States, disproportionate impacts of COVID 19 on racial and ethnic minority residents.
Both nationally and in New Hampshire, there was a significant decrease in pediatric vaccine ordering from mid-March through May, due to the disruptions in preventative services as a result of the COVID-19 response.[69] Since the NH Immunization Program provides all of the pediatric vaccines to providers, there remains close oversight and regular communications with NH practices to ensure vaccine safety and accountability. Currently, it appears that the drop in orders was as the result of an initial stall in mid-March as offices closed or merged or split well and sick visits among sites. Once new ways of operating were established, such as delivering vaccines in parking lots or through mobile health vans, the state has been seeing an uptick in ordering since mid-May.[70]
A recent report by two researchers at Dartmouth, however, found that across Northern New England in general, there was a “robust integrated response (to COVID 19) by health systems, social service organizations and communities to protect medically and socially vulnerable populations. There were significant efforts to identify and engage with isolated elders, individuals with chronic illness, homeless populations, and individuals with behavioral health challenges”.[71]
Telehealth’s rapid expansion in NH during the early days of the COVID 19 pandemic and its continued use today, aided by Medicaid and other insurers reductions of limitations, has demonstrated its potential for advancing health equity through its reduction of geographical barriers to care, particularly in behavioral health.[72] MCH’s Pediatric Mental Health Care Access Program (PMHCAP) is designed to increase NH increase NH pediatricians’ and primary care providers’ capacity to address behavioral health needs of children 0-21 years of age by utilizing Project ECHOTM as their implementation strategy and enrolled 15 practices in its first cohort beginning in early 2020. With braided funding, the project was also able offer a Project ECHOTM miniseries from May through June of 2020 entitled, “Telehealth for Special Populations during COVID-19 and Beyond” with over 100 participants.
Title V staff, even with the COVID 19 pandemic, continue in the joint implementation of NH DHHS’s “10-Year Mental Health Plan” (the plan). [73] The plan, for the first time, provides a focus on children as well as the prevention of suicide. NH’s suicide rates were up 48.3% from 1999-2016, third behind Vermont and North Dakota.[74] MCH has played a pivotal role in suicide prevention with its staff co-founding the Youth Suicide Prevention Assembly more than 20 years ago and its leadership positions on the current NH Suicide Prevention Council. Title V funds have enabled the integration of behavioral health and primary care, a strategy that is highlighted in the plan. MCH and its funded colleagues helped to pioneer this concept over a decade ago and continue to do so today.
Statutes and other regulations that have passed or are in process within the last year and have relevance to the Title V program:
RSA 132:41 created a child fatality review committee, replacing a previous one that had been established by Governor’s Executive Order, not legislation. This Order did not provide enough privacy guarantees for information shared at the review meetings. Oversight over the child fatality review committee resides within MCH, who also currently chair the SUID and SDY review committees. SUID and SDY were written as subcommittees of child fatality under the new legislation and benefit from its privacy protections. MCH will be recruiting this year for a Child Health Nurse Consultant, who will have the responsibility of the child fatality review (the Infant Surveillance Coordinator oversees SUID and SDY).
In July 2019, RSA 186-C: 32 established a Deaf Child's Bill of Rights to assure that “children who are deaf or hard of hearing have the right to appropriate screening and assessment of hearing and vision capabilities and language and communication needs at the earliest possible age… and have a right to early interventions…” [75] consistent with MCH’s early hearing screening efforts and BFCS’s early supports and services. At the same time, RSA 186-C:35 established an Advisory Council including representatives from MCH and BFCS. The Council is charged with “advising the Department of Education and the DHHS on the needs and services provided to deaf and hard of hearing children in NH…the council shall determine…the types of services being received, the types of services requested by parents or guardians, and areas of need.”[76]
RSA 170 G:XX states that DHHS “…shall develop and administer an array of community-based, evidence based parental assistance programs that are designed to reduce child maltreatment, improve parent-child interactions, improve skills for regulating behavior and coping adaptively, and facilitate improved coordination of services and referrals… in public health regions with the highest need as determined by the rates of poverty, child maltreatment, and other appropriate measures of social vulnerability.[77] This also supported additional general funding for the SFY20-21 biennium into DCYF’s budget. DHHS’s early childhood integration team (ECIT) determined the utilization of the funding, which resulted in additional support for several Title V-led initiatives including expansion of MIECHV and Community Collaborations, the addition of the full ACES module into the 2021 BRFSS questionnaire, the provision of home child safety equipment through the Injury Prevention Center contract, and the state’s developmental screening system.
RSA 167:68-a[78] reversed restrictions, put into place over the last decade, on Medicaid’s ability to reimburse for home visiting. These restrictions targeted first time mothers under the age of 21, but left many families who would benefit from home visiting programs ineligible and providers who served these ineligible families unable to be reimbursed through Medicaid. Title V staff have been working with Medicaid and other partners to update the current Medicaid rule to support greater levels of reimbursement for and expansion of home visiting in NH.
On a federal level, the authority to make MIECHV grants to support the provision of home visiting services to eligible families is § 511(c) (42 U.S.C. § 711(c)). Section 50601 of the Bipartisan Budget Act of 2018 extended appropriated funding for the MIECHV Program through FY 2022. However, it also requires grantees to continue to track and report information demonstrating that the program results in improvements for the eligible families participating in the program in at least four out of the six benchmark areas specified in statute that the service delivery model, in NH’s case Healthy Families America.
[1] Division of Forests and Lands, New Hampshire Department of Natural and Cultural Resources. Retrieved on 06/01/20 from https://www.nh.gov/nhdfl/reports/forest-statistics.htm.
[2] Citizens Count New Hampshire (2020) Retrieved on 06/02/20 from http://www.lfda.org/issues/legislative-process.
[3] United States Census Bureau (2020). Quick Facts New Hampshire. Retrieved on 06/02/20 from https://www.census.gov/quickfacts/fact/table/NH/RHI225218#RHI225218.
[4] University of New Hampshire, Carsey School of Public Policy (2019). What is New Hampshire? Demography. Retrieved on 06/22/20 from https://carsey.unh.edu/what-is-new-hampshire/sections/demography.
[5] Ibid.
[6] New American Economy (2016). The Contributions of New Americans in New Hampshire. Retrieved on 06/22/20 from http://www.newamericaneconomy.org/wp-content/uploads/2017/02/nae-nh-report.pdf.
[7] University of New Hampshire, Carsey School of Public Policy (2019). What is New Hampshire? Demography. Retrieved on 06/22/20 from https://carsey.unh.edu/what-is-new-hampshire/sections/demography.
[8] Ibid.
[9] Johnson, Kenneth; University of New Hampshire, Carsey School of Public Policy (2020). New Hampshire Population Grew Last Year, Even Though Deaths Exceeded Births. Retrieved on 06/23/20 from https://carsey.unh.edu/publication/snapshot/NH-population-grew.
[10] Ibid.
[11] United States Census Bureau (2020). Quick Facts New Hampshire. Retrieved on 06/23/2020 from https://www.census.gov/quickfacts/fact/table/NH/PST045219.
[12] Kaiser Family Foundation (2018). Medicare Beneficiaries as a Percent of Total Population. Retrieved on 06/23/2020 from https://www.kff.org/medicare/state-indicator/medicare-beneficiaries-as-of-total-pop/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
[13] University of New Hampshire, Carsey School of Public Policy (2019). What is New Hampshire? Demography. Retrieved on 06/22/20 from https://carsey.unh.edu/what-is-new-hampshire/sections/demography.
[14] United States Census Bureau (2020). Quick Facts New Hampshire. Retrieved on 06/23/2020 from https://www.census.gov/quickfacts/fact/table/NH/PST045219.
[15] University of New Hampshire, Carsey School of Public Policy (2019). What is New Hampshire? Economy. Retrieved on 06/22/20 from https://carsey.unh.edu/what-is-new-hampshire/sections/economy.
[16] U.S. News and World Report (2020). Education Rankings, Measuring How Well States Are Educating Their Children. Retrieved on 06/24/2020 from https://www.usnews.com/news/best-states/rankings/education.
[17] New Hampshire Employment Security (2020). COVID 19 Unemployment Update. Retrieved on 06/25/20 from https://www.nhes.nh.gov/documents/new-claims-release-061820.pdf.
[18] Ibid.
[19] New Hampshire Fiscal Policy Institute (2020). The COVID 19 Crisis in New Hampshire: Initial Economic Impacts and Policy Responses. Retrieved on 06/29/2020 from http://nhfpi.org/wp-content/uploads/2020/04/The-COVID-19-Crisis-in-New-Hampshire-Initial-Economic-Impacts-and-Policy-Responses.pdf.
[20] United States Census Bureau (2020). Quick Facts New Hampshire. Retrieved on 06/29/2020 from https://www.census.gov/quickfacts/fact/table/NH/RHI225219#RHI225218.
[21] New Hampshire Fiscal Policy Institute (2020). The COVID 19 Crisis in New Hampshire: Initial Economic Impacts and Policy Responses. Retrieved on 06/29/2020 from http://nhfpi.org/wp-content/uploads/2020/04/The-COVID-19-Crisis-in-New-Hampshire-Initial-Economic-Impacts-and-Policy-Responses.pdf.
[22] United States Census Bureau (2020). Quick Facts New Hampshire. Retrieved on 06/29/2020 from https://www.census.gov/quickfacts/fact/table/NH/RHI225219#RHI225218.
[23] Boege, Sarah and Carson, Jessica; University of New Hampshire, Carsey School of Public Policy (2020). Free and Reduced Lunch Eligibility by New Hampshire State Legislative District. Retrieved on 06/23/20 from https://scholars.unh.edu/cgi/viewcontent.cgi?article=1393&context=carsey.
[24] Ibid.
[25] New Hampshire Fiscal Policy Institute (2020). New Hampshire’s Numbers: Resource Inequities by County and Population Group in 2014-2018. Retrieved on 06/29/2020 from http://nhfpi.org/research/state-economy/new-hampshires-numbers-resource-inequities-by-county-and-population-group-in-2014-2018.html.
[26] Ibid.
[27] Ibid.
13 United Health Foundation (2019), America’s Health Rankings. Retrieved on 06/24/2020 from https://www.americashealthrankings.org/learn/reports/2019-annual-report/findings-state-rankings.
[29] McCann, A. (2019). Best and Worst States to Have a Baby. Retrieved on 06/24/2020 from https://wallethub.com/edu/best-and-worst-states-to-have-a-baby/6513/#methodology.
[30] U.S. News and World Report (2019). Best States 2019. Retrieved on 06/24/2020 from https://www.usnews.com/news/best-states.
[31] Annie E. Casey Foundation (2020). 2020 Kids Count Data Book: State Trends In Child Well-Being. Retrieved on 06/23/2020 from https://www.aecf.org/m/resourcedoc/aecf-2020kidscountdatabook-2020.pdf.
[32] Ibid.
[33] NH Hospital Association (2020). Map of Hospitals. Retrieved on 07/05/2020 from https://nhha.org/index.php/nh-hospitals/map-of-hospitals.
[34] Hodder, Lucy (2019). The Ever Changing Health Care Landscape, September 26, 2019. Presentation to the Legislative Commission on Primary Care Workforce Issues. Retrieved on 07/10/2020 from https://www.dhhs.nh.gov/dphs/bchs/rhpc/leg-comm/documents/2019-09-26.pdf.
[35] Stoddard, Kristine (2020). Primary Care Safety Net, April 23, 2020. Presentation to the Legislative Commission on Primary Care Workforce Issues. Retrieved on 07/10/2020 from https://www.dhhs.nh.gov/dphs/bchs/rhpc/leg-comm/documents/2020-04-23.pdf. https://www.dhhs.nh.gov/dphs/bchs/rhpc/leg-comm/documents/2020-04-23.pdfhttps://www.dhhs.nh.gov/dphs/bchs/rhpc/leg-comm/documents/2020-04-23.pdf
[36] Ibid.
[37] Kozhimannil, K. et al. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. JAMA. 201; 319(12):1239-1247.doi:10.1001/jama2018.1830.
[38] Medicaid Claims Data/Vital Records Data analyzed by MCH, 07/05/2020.
[39] Kozhimannil, K. et al. Association Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural Counties in the United States. JAMA. 201; 319(12):1239-1247.doi:10.1001/jama2018.1830.
[40] Vital Records Data analyzed by MCH, 07/05/2020.
[41] Ibid.
[42] Ibid.
[43] Ibid.
[44] Ibid.
[45] Ibid.
[46] Weiss, Danielle (2019). 2018 Physician Workforce Data Report. Retrieved on 07/10/20 from https://public.tableau.com/profile/danielle.weiss#!/vizhome/2018PhysicianWorkforceReport/TableofContents.
[47] Goldstein, Amy (2019). Washington Post; Federal judge strikes down New Hampshire’s Medicaid work requirements. Retrieved on 07/10/2020 from https://www.washingtonpost.com/health/federal-judge-strikes-down-new-hampshires-medicaid-work-requirements/2019/07/29/a8e7fb6c-b237-11e9-951e-de024209545d_story.html.
[48] NHDHHS, Office of Quality Assurance and Improvement (2020). New Hampshire Medicaid Enrollment, Demographic Trends and Geography, April 2019. Retrieved on 07/10/20 from https://www.dhhs.nh.gov/ombp/medicaid/documents/medicaid-enrollment-05312020.pdf.
[49] Ibid.
[50] Personal Communication with MCH Quality Assurance/Quality Improvement Nurse Consultant, 07/11/2020.
[51] Ibid.
[52] Institute for Health Policy and Practice (2020). Covering the Care: Health Insurance Coverage in New Hampshire: 2019 Update. Retrieved on 07/10/2020 from https://chhs.unh.edu/sites/default/files/media/2019/12/health_insurance_coverage_in_nh_2019_update.pdf#:~:text=Covering%20the%20Care%3A%20Health%20Insurance%20Coverage%20in%20New,People%20of%20any%20age%20with%20End-Stage%20Renal%20Disease.
[53] Ibid.
[54] Ibid.
[55] Ibid.
[56] Centers for Disease Control and Prevention (2020). Drug Overdose Mortality by State. Retrieved on 07/16/2020 from https://www.cdc.gov/nchs/pressroom/sosmap/drug_poisoning_mortality/drug_poisoning.htm.
[57] New Hampshire Drug Monitoring Initiative, New Hampshire Information and Analysis Center (2020). 2019 Report. Retrieved on 07/10/2020 from https://www.dhhs.nh.gov/dcbcs/bdas/documents/dmi-april-2020.pdf.
[58] Division of Public Health Services (2020). Annual Report on Maternal Mortality to the New Hampshire Health and Human Services Oversight Committee, Annual Report 2019.
[59] Maternal and Child Health, PRAMS (2018). Perinatal substance use among New Hampshire Women, 2013-2017. Retrieved on 07/16/2020 at https://www.dhhs.nh.gov/dphs/bchs/mch/prams/documents/perinatal-substance-use.pdf.
[60] Ibid.
[61] Maternal and Child Health, PRAMS (2019). NH PRAMS Data Summary 2018. Retrieved on 07/16/2020 at https://www.dhhs.nh.gov/dphs/bchs/mch/prams/documents/2018-data-summary.pdf.
[62] Maternal and Child Health, PRAMS (2018). Perinatal substance use among New Hampshire Women, 2013-2017. Retrieved on 07/16/2020 at https://www.dhhs.nh.gov/dphs/bchs/mch/prams/documents/perinatal-substance-use.pdf.
[63] NH Governor’s Commission on Alcohol and Other Drugs, Perinatal Substance Misuse Task Force (2019). Plans of Safe Care. Retrieved on 07/16/2020 from https://nhcenterforexcellence.org/governors-commission/perinatal-substance-exposure-task-force/plans-of-safe-care-posc/.
[64] NH Governor’s Commission on Alcohol and Other Drugs, Perinatal Substance Misuse Task Force (2020). Plans of Safe Care Through an Implementation Lens. Retrieved on 07/16/2020 from http://1viuw040k2mx3a7mwz1lwva5-wpengine.netdna-ssl.com/wp-content/uploads/2020/07/POSC-Through-an-Implementation-Lens_SLIDES-FOR-PRINT.pdf.
[65] NH DHHS (2019). Annual Data Book 2019. Retrieved on 07/16/2020 from https://www.dhhs.nh.gov/dcyf/documents/data-book-2019.pdf.
[66] Ibid.
[67] Carpenter-Song, E. & Sosin, A. (2020). COVID 19 & Rural Health Equity in Northern New England. Retrieved on 07/16/2020 from https://0d380f87-4454-46aa-8aec-968050bf9444.filesusr.com/ugd/81cf43_c78f942f13504693a5947b6073071f24.pdf.
[68] NH DHHS (2020). COVID-19 Summary Dashboard, July 15, 2020. Retrieved on 07/15/2020 from https://www.nh.gov/covid19/dashboard/summary.htm.
[69] Personal communication from the Immunization Section, Bureau of Infectious Diseases, Division of Public Health Services, NHDHHS, 07/16/2020/
[70] Ibid.
[71] Ibid.
[72] Ibid.
[73] NH DHHS (2019). New Hampshire Ten-Year Mental Health Plan. Retrieved on 07/16/2020 from https://www.dhhs.nh.gov/dcbcs/bbh/documents/10-year-mh-plan.pdf.
[74] Stone DM, Simon TR, Fowler KA, et al. Vital Signs: Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States, 2015. MMWR Morb Mortal Wkly Rep 2018; 67:617–624. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a1.
[75] http://www.gencourt.state.nh.us/rsa/html/xv/186-c/186-c-mrg.htm accessed on 06/01/20.
[76] https://www.gencourt.state.nh.us/rsa/html/XV/186-C/186-C-35.htm accessed on 08811/20.
[77] http://www.gencourt.state.nh.us/rsa/html/xii/170-g/170-g-mrg.htm accessed on 06/01/20.
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