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 the Massachusetts Department of Public Health (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 – with 2019 marking its 150th anniversary – 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. 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.
Massachusetts is a national leader in maternal and child health (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 women, parents and their 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 Associate 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. An MDPH organizational chart is attached.
Demographics, Geography, and Economy
Massachusetts has 6.8 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, 48% of Massachusetts’ landmass is classified as rural (fewer than 500 residents per square mile). Residents of these rural communities comprise 13% of the state’s total population.[3]
An estimated 81.2% of Massachusetts residents identify as White, 9.2% as Black or African American, 11.6% as Hispanic, 7.4% as Asian, 0.7% as American Indian or Alaska Native, 0.2% Native Hawaiian and Other Pacific Islander, and 4.7% some other race.[4] Immigrants make up 16% 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 (8.8%), the Dominican Republic (7.4%), India (6%), Brazil (5.6%), and Haiti (5.1%).[5] During 2016, 30.3% of births were to foreign-born women.[6] Nearly 25% of people speak a language other than English at home.[7]
The Commonwealth’s population is aging. Mirroring national patterns, from 2010 to 2018 the proportion of residents aged birth to 18 years has decreased from 21.6% to 19.8% and the percent of the population 65 years of age or older has increased from 13.8% to 16.5%. The median age in 2018 was 39.5 years.[8]
Approximately 11.6% of the population (including 6.4% of children ages 0-17) has one or more types of disability, including visual, hearing, ambulatory, cognitive, self-care, and independent living disabilities.[9] In 2017, 37.7% of Massachusetts adults aged 18-64 with a disability were employed, compared to 80.2% of adults without a disability. Furthermore, 25.5% of people with disabilities lived below the poverty line, compared to 8.2% of people without disabilities.[10]
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 pharmaceuticals and medical devices to diagnostics and nanotechnology. Massachusetts has one of the highest proportions of college graduates in the nation, with 42.9% of the population having a Bachelor’s degree or higher, compared to 31.5% nationally.[11] In March 2020, the unemployment rate was 2.8%, which increased to 16.6% in May 2020 as a result of the COVID-19 pandemic.[12] The median household income is $77,378, higher than the U.S. household median ($60,293).[13] Despite the high median income, Massachusetts is also an expensive state to live. In 2017, 46.5% of renters and 26.5% of homeowners in the state were cost-burdened, meaning they spent 30% or more of their income on housing.[14]
There are inequities in access to services and in economic and health outcomes across demographic characteristics, most notably by race and ethnicity, which point to historical and structural systems of oppression that continue to disadvantage people of color in the state. Approximately 11.1% of the Massachusetts population lives below 100% of federal poverty level (FPL); however, only 8.7% of White residents live below the FPL compared with 27.6% of Hispanic residents, 20.6% of Black residents, and 14.1% of Asian residents.[15] The median household income for White non-Hispanics was approximately two times that for Hispanic and American Indian/Alaskan Native residents, and 1.7 times that for Black non-Hispanic residents. Furthermore, the median household income for Hispanics in Massachusetts ($39,299) was 16% lower than that for Hispanics nationally ($46,627).[16]
Massachusetts is consistently recognized for good health status in national rankings. According to America’s Health Rankings 2019 Annual Report,[17] Massachusetts is the second healthiest state in the nation, with strengths such as low prevalence of obesity, high rate of mental health providers, and low infant mortality rate. The Report also ranked Massachusetts second in the health of women and children in part due to a low maternal mortality rate, low teen birth rate, and high prevalence of well-baby visits. Identified challenges included the high cost of infant child care, high prevalence of excessive drinking among women, and high prevalence of homeless families. MDPH and Title V recognize that good health in Massachusetts is not equally shared and that there are persistent health inequities that must be addressed.
Health Services Access, Infrastructure, and Financing
According to the 2019 Massachusetts Health Insurance Survey (MHIS),[18] the uninsurance rate remained low at 2.9%, 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 1.6%. The uninsured were disproportionately Hispanic, representing 30.7% of the uninsured population versus 11.6% of the general population in MA. The majority of respondents to the 2019 MHIS reported a usual source of care other than the emergency department (91.0%, including 95.4% of children) and a visit to a general doctor in the past 12 months (86.4%). This represents an increase in both estimates from 2017. In addition, 17.0% of respondents visited a mental health professional over the past 12 months. Hispanic residents were less likely than White residents to report a usual source of care (81.8% and 91.6%, respectively).
Despite the high rate of insurance coverage, health care costs remain a concern for many families. Nearly half of 2019 MHIS respondents (48%) reported affordability issues over the past 12 months. More than one in seven (14.6%) reported spending a high share of income on out-of-pocket costs (defined as spending 5% or more of income for families below 200% of the FPL or 10% or more for families at or above 200% of the FPL) and 37.2% of residents who were insured for all of the past 12 months had unexpected medical bills.
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 an MCH-related specialty (e.g. 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) across the state that are integral in 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 represent a major source of care for medically underserved women and children. CHCs also 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.
As of October 2017, 86% of Massachusetts CHCs had achieved patient-centered medical home (PCMH) recognition through an accredited organization, including the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Health Care Organizations.[19] This is an important asset to the MCH system of care, particularly for children and youth with special health needs. The Massachusetts Health Policy Commission, in collaboration with the NCQA, developed the PCMH PRIME Certification program which certifies Massachusetts-based federally qualified health centers for their integration of behavioral health – through formal agreements, co-location, or provider integration – and emphasizes the importance of integrating behavioral health into primary care.
A substantial restructuring of the Medicaid (MassHealth) program also aims to achieve more integrated and outcomes-based services for its 1.8 million members.[20] MassHealth has recently transitioned from a fee-for-service model to an Accountable Care Organization (ACO) model, in which it partners with provider organizations directly to deliver coordinated, quality care to members. There are 16 ACOs (including one pediatric ACO) that are held financially accountable for cost, quality, and member experience. A key goal of this new model is to improve integration of physical health, behavioral health and long-term services and support (LTSS). MassHealth is increasing investment in and support of community services for members with complex behavioral health needs or in need of LTSS, such as home health care, skilled nursing, and personal care attendants. ACOs are required to partner with certified community-based behavioral health and LTSS providers. To become a state-certified behavioral health or LTSS Community Partner, organizations must have expertise in care coordination and assessments as well as appropriate infrastructure and capacity. Furthermore, LTSS community partners must demonstrate expertise across multiple populations with disabilities. For more information about the ACO model, see the Health Care Delivery System section.
State Health Agency Roles and Responsibilities
The vision, mission, and priorities of MDPH, as identified by the Commissioner, Dr. Monica Bharel, are depicted in the graphic below. MDPH endeavors to provide timely access to data to reduce disparities and improve outcomes, address the social determinants of health, and eliminate health inequities. The principles underlying this work are everyday excellence, passion and innovation, and inclusiveness and collaboration. These principles refer to a culture of continuous improvement and performance management, passion about MDPH’s work, developing creative solutions to complex policy issues and population health management strategies, learning from internal and external partners, and ensuring people with diverse experiences and skills are involved in decision making. Together, these principles lay a solid foundation to achieve MDPH’s mission and vision.
Data Access and Capacity
An important effort that ties together the Commissioner’s priorities is the development of the Population Health Information Tool (PHIT),[21] 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 is organized around six social determinants of health – education, employment, violence, social environment, housing, and built environment – to support Massachusetts in better addressing factors beyond clinical care that influence population health.
PHIT integrates data from myriad sources, including but not limited to Pregnancy Risk Assessment Monitoring System (PRAMS), Pregnancy to Early Life Longitudinal Data System (PELL), Behavioral Risk Factor Surveillance System (BRFSS), Vital Statistics, Injury Surveillance System, Birth Defects Data System, Substance Addiction Services, Early Hearing Detection and Intervention, WIC, and Early Intervention. Also included in PHIT is the Neonatal Abstinence Syndrome (NAS) Data Dashboard, which 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. 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.
Based on the success of the 2015 Chapter 55 legislation, which permitted the analysis of different government datasets to better understand the opioid epidemic and to guide policy and programmatic decisions, MDPH has broader legislative authority (Chapter 111 Section 237) to assemble, link, and maintain data systems for the purpose of analyzing population health trends. Through a partnership with the Center for Health Information and Analysis (CHIA), MDPH developed the Public Health Data Warehouse (PHD) to improve surveillance capacity, increase availability of data for state and local public health activities and evaluation of key public health initiatives, and provide data to measure progress on the State Health Improvement Plan objectives. The MDPH Commissioner established priorities for the use of the PHD, and has chosen to start with MCH. Her vision is to generate new, actionable information that will help Massachusetts address inequities in MCH outcomes, especially those across racial groups and other social factors. A workgroup was convened in October 2018 to identify the MCH datasets to be included in the PHD (such as WIC, DCF, Early Intervention, and the Massachusetts Immunization Information System), and design research questions of interest to Title V and MCH in Massachusetts. The workgroup proposed, and the Commissioner accepted, an initial focus on three MCH topics: maternal morbidity and mortality, preterm birth and infant mortality, and adolescent health and wellness. Efforts to launch the PHD are pending signature of data use agreements, which have been established with multiple state agencies. The goal is for the PHD to be fully operational in 2020.
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.
Performance Management and Quality Improvement
MDPH and the Commissioner are focused on improving public health outcomes and reducing health care costs by linking clinical care to evidence-based community interventions and integrating quality improvement (QI) and performance management (PM) culture throughout MDPH. The Office of Performance Management and Quality Improvement oversees this work and a PM/QI Council supports MDPH leadership in building a QI culture throughout the organization. The Council provides support and guidance for building QI capacity on all levels, communicating and sharing QI activities and resources, and recognizing QI efforts and successes. With its robust performance measurement framework and focus on implementing evidence-based practices and promising innovations, Title V is a leader in MDPH’s PM/QI efforts. Many Title V staff have also participated in Lean Six Sigma White, Green and Black Belt trainings provided by the Office of Performance Management and Quality Improvement.
Public Health Accreditation and State Health Assessment
In 2017, MDPH was awarded national accreditation by the Public Health Accreditation Board (PHAB). PHAB highlighted three areas of excellence: 1) workforce development with MDPH staff and local public health and public health systems, including community health workers; 2) commitment to health equity, which includes addressing social determinants of health and having a dedicated Office of Health Equity to work across all MDPH bureaus; and 3) progressive attitude towards health education and health promotion by working in close collaboration with the program subject matter experts and stakeholders to ensure appropriate and accessible materials. Title V staff actively contributed to activities to achieve PHAB designation, including developing the State Health Assessment to ensure alignment of MCH priorities and objectives. MDPH maintains its national accreditation by submitting annual reports and applying for reaccreditation every five years.
COVID-19 Impact and Response
On March 10, 2020 Governor Baker declared a state of emergency, giving the Administration more flexibility to respond to the COVID-19 pandemic. Key steps taken by MDPH in response to the pandemic include:
- Creating an Incident Command Structure to include briefings with state health leadership to facilitate information sharing and decision-making.
- Keeping public health partners including local boards of health, school health personnel, Emergency Medical Services, college and university health systems, and health emergency preparedness teams informed with the latest federal guidance.
- Continually monitoring impacts to the supply chain of personal protective equipment such as gloves, face masks, and other equipment within the U.S. and providing hospitals and health systems with strategies to optimize these supplies.
- Continuing efforts by the State Public Health Laboratory staff and epidemiologic staff to perform surveillance of potential cases and contacts and respond to questions from clinicians, health departments, and the public 24/7.
- Launching the Community Tracing Collaborative, operationalized by MDPH, Partners In Health, and the Health Connector, to apply evidence-based contract tracing to mitigate the spread of COVID-19 in Massachusetts. This initiative is the first of its kind in the nation, and focuses on tracing the contacts of confirmed positive COVID-19 patients and supporting individuals in quarantine.
- Dramatically increasing COVID-19 testing capacity and output through the efforts of public and private laboratories and health care partners.
- Creating COVID-19 data dashboards that present daily and cumulative reports on Massachusetts COVID-19 cases, testing, and hospitalizations, and weekly or biweekly reports of nursing facility data, cases by city/town, residents subject to COVID-19 quarantine, and data from state facilities.
Examples of emergency orders and state actions of particular importance to the MCH population include:
- Guidance that requires all commercial insurers, self-insured plans, and the Group Insurance Commission to cover medically necessary telehealth services, whether related to COVID-19 or not. For COVID-19 treatment, insurers must do this without requiring cost-sharing of any kind, such as co-pays and coinsurance.
- CMS waivers to give the state more flexibility to respond to the COVID-19 public health emergency (e.g. extend retroactive coverage for individuals who qualify for MassHealth to allow individuals to be covered up to 90 days prior to submitting their application).
- The creation and operation of emergency residential programs and emergency placement agencies for children.
- An emergency order regarding collection of complete demographic information (including race and ethnicity) on patients with confirmed or suspected COVID-19 to address racial and ethnic inequities.
- Expanded access to high-speed internet for cities and towns throughout Massachusetts that do not yet have a completed last-mile broadband network.
- Launch of the Pandemic Electronic Benefit Transfer program under the Families First Coronavirus Response Act to support families with children who were receiving free and reduced-price school meals.
- Investing $56 million to combat urgent food insecurity for some families and individuals as a result of COVID-19.
- Launch of an awareness effort during May’s Mental Health Awareness month to help people cope with social isolation during the pandemic.
Title V staff are monitoring and responding to the impact of COVID-19 on pregnant women, infants, children, youth, children and youth with special health needs, and their families. MCH programs are supporting families in a variety of ways, such as:
- Facilitating access to concrete supports (e.g. unemployment benefits, diapers)
- Allowing flexibility in use of state and federal funding to respond to the pandemic, when possible (e.g. emergency funding to families of CYSHN served by Care Coordination who are affected by COVID-19 and live below 300% FPL)
- Ensuring policy- and decision-making consider MCH needs and interests; and
- Supporting data collection and surveillance activities (e.g. establishing a surveillance system to monitor outcomes for pregnant women with lab-confirmed COVID and their neonates and adding COVID-related questions to the PRAMS survey).
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:
- 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
- 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 (effective 2021)
- pay equity legislation that clarifies unlawful wage discrimination and makes workplaces more fair and equal.
The Title V program is well positioned in the state’s public health and health care environment to improve outcomes for women, mothers, fathers, infants, children and adolescents, including children and youth with special health needs.
[1] US Census Bureau. 2018 American Community Survey 5-Year Estimates, Massachusetts.
[2] US Census Bureau, U.S. and World Population Clock, https://www.census.gov/popclock/
[3] Massachusetts Housing Partnership, “White Paper on Rural Housing Issues in Massachusetts,” December 2014, https://www.mhp.net/writable/resources/documents/rural.white.paper.final.pdf
[4] US Census Bureau, 2014-2018 American Community Survey 5-Year Estimates
[7] US Census Bureau, 2014-2018 American Community Survey 5-Year Estimates
[8] US Census Bureau, American Community Survey 1-Year Estimates
[9] US Census Bureau, 2014-2018 American Community Survey 5-Year Estimates
[11] US Census Bureau, 2014-2018 American Community Survey 5-Year Estimates
[12] US Bureau of Labor Statistics, https://www.bls.gov/lau/
[13] US Census Bureau Quick Facts, https://www.census.gov/quickfacts/fact/table/US,MA/PST045219
[14] Massachusetts Technology Collaborative, http://www.masstech.org/index/talent/housing-affordability
[21] Population Health Information Tool (PHIT)." Mass.gov, https://www.mass.gov/orgs/population-health-information-tool-phit.
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