To understand maternal and child health (MCH) population needs in Pennsylvania (Pa.), it is necessary to learn the geographical, social, economic, and political traits of the Keystone State and its residents. Pa. is a vast, increasingly diverse state comprised of large rural areas and concentrated urban centers which are both evolving economically and socially. Located in the northeast, Pa. is the fifth most populous state, home to over 13 million people. In addition to its rural and urban divide, the state is physically divided in half by a large swath of rural forest created by the Appalachian Mountains.

Pa. is anchored by two urban counties, Allegheny in the west and Philadelphia in the east. Urban counties are those with a population density higher than the state population density, while rural counties have a lower density. Harrisburg, the capital and headquarters for the Department of Health (DOH), is situated in the southcentral part of the state. As of June 2021, Pa.’s 19 large counties (counties where 75,000 or more are employed) accounted for 76.5% of total employment within the state. All but two of those counties are considered urban. In 2020, nearly 80% of the state gross domestic product was produced by urban counties. Pa. has the sixth largest economy in the nation but, as of December 2021, had a seasonally adjusted unemployment rate that was higher than the national average. In 2019, 27% of Pa.’s population was low income (under 200% federal poverty level or FPL), and, in 2020, more than half of Pa.’s Medicaid expansion population worked a job that did not offer health benefits.

The educational services, health care and social assistance, manufacturing, and retail trade sectors are major contributors to the economy. The industry with the greatest number of employees in Pa. in 2019 was educational services, health care, and social assistance, growing eight percent since 2010. Employment in agriculture, forestry, and fishing (which includes farming) increased from 2010-2019. In 2020, 53 of Pa.’s 67 counties had at least 500 individuals employed in agriculture, forestry, and fishing.

The delivery of health care services is significantly impacted by the distinctive rural and urban characteristics across the state. While 48 of PA’s 67 counties are considered rural, nearly three-quarters of Pa.’s residents live in urban counties. The concentration became even more pronounced from 2010-2020, as most of the population growth in Pa. occurred in urban counties. In 2018, there was one primary care provider in direct practice for every 1,075 residents in urban counties, as compared to one rural primary care physician for every 1,561 residents. Of the 15 counties without Federally Qualified Health Centers (FQHC), all but one are rural. As of September 2021, of the estimated 495,949 residents living in a designated Primary Care Health Provider Shortage Area (HPSA), the majority lived in a rural county. The only non-rural areas designated as HPSAs were in Allegheny, Beaver, Franklin, and York counties. Small areas of several urban counties are considered medically underserved. As of 2017, approximately 17.6% of Pa.’s population lived in an area designated as medically underserved. In 2020, there were 66 general acute care hospitals, with a total of 7,674 beds, in rural Pa. Eight rural counties had no hospitals. On average, there were 2.19 hospital beds for every 1,000 rural residents compared to 2.74 hospital beds for every 1,000 urban residents.

Across the state in 2020, the 151 general acute care hospitals (including 15 Critical Access Hospitals [CAH]) with over 33,700 licensed beds handled over 1.29 million admissions. CAHs are rural hospitals that provide 24-hour emergency services with an average daily census of 25 patients or less. These hospitals serve as key providers in areas with sparse populations, geographic barriers to care, and significant health professional shortages to address populations who are generally older and poorer. Besides anchoring a broad range of health and human services in their communities, many of these hospitals continue to be the top employers in their county and major contributors to local economies. As of January 2022, Pa. had 16 federally designated CAHs. An additional 82 federal and specialty hospitals handled over 133,000 admissions. There are nine children’s hospitals in Pa., four of which are in either Philadelphia or Pittsburgh. The other five are in Allentown, Bethlehem, Danville, Erie, and Hershey. They may be inaccessible to children who live in rural areas or in areas not near these hospitals.

Supplementing the hospitals are over 350 FQHCs or rural health center delivery sites providing primary care services in 44 counties. FQHCs are an important resource for groups in Pa. that have been economically and socially marginalized. In 2020, 87% of FQHC patients were at or below 200% FPL, 48% were on Medicaid, and 54% were members of a racial or ethnic minority.

Other important partners in the delivery of services within the MCH system of care are the County/Municipal Health Departments (CMHDs) and state health centers. The eleven CMHDs are in urban areas and tailor services to the needs of their local communities. The newest, in Delaware county, launched in January 2022 in response to community needs observed during the COVID-19 pandemic. It was approved by the Pennsylvania Department of Health to act in its official capacity as a health department on April 2, 2022. The Delaware County Health Department is the first one established in Pennsylvania in 33 years. Primary and secondary preventive health services are emphasized and geared to improve the community’s health through direct health services, education, and leadership. CMHDs are funded by Act 315, Pa.’s Local Health Administration Law, with additional funding from state, federal, and local government going toward local office priorities. At a local level, CMHDs currently cover nearly 42% of Pa.’s population. In addition, several CMHDs have either applied for or achieved public health accreditation through the Public Health Accreditation Board (PHAB). As a result, those communities have access to higher-quality programming and services.

Counties without CMHDs have state health centers that provide and support public health programs throughout Pa. To organize the state health centers, Pa. is divided into six community health districts, each covering a geographic region of the state. Each health district has a district office that helps coordinate activity throughout the district. Through the utilization of community health assessments and outreach, the centers focus on five core functions: communicable disease investigation and prevention, immunizations, public health education, human immunodeficiency syndrome/sexually transmitted disease services, and tuberculosis investigation and treatment.

Health insurance is a key factor for health care access. In 2019, 5.8% of the approximately 12.6 million civilian noninstitutionalized population in Pa. was uninsured. By gender, 6.5% of men were uninsured compared to five percent of women. Only 5.2% of white persons were uninsured compared to 6.9% of Black/African American persons and 12.5% of Hispanic persons. More than 10% of 26 to 34-year-olds were uninsured, the largest proportion of any age group. As educational attainment increased, the percentage insured increased.

The Affordable Care Act (ACA) has brought some insurance relief with the introduction of the federal Marketplace. While the uninsured rate ranges from 2.9% to 11.3% across counties, the uninsured are primarily working families with incomes below 400% of the FPL, unemployed or employed less than full-time, less than a high-school graduate and non-white. In 2021, over 337,000 residents selected a Marketplace plan, of which 70% received financial assistance. While the uninsured rate has fallen for all racial and ethnic groups because of the ACA, as of 2019, white persons are still more likely to be insured than Black/African American persons.

A key component in the MCH system of care is Medicaid, administered in Pa. by the Department of Human Services (DHS). Medicaid eligibility is determined by having a special condition or belonging to a particular group such as pregnant women, children, low-income adults, elderly adults, or disabled adults and meeting financial and citizenship requirements. Medicaid eligibility levels are highest in Pa. for children and pregnant women, and both are higher than the median United States (U.S.) rate.

Medicaid also has special programs for specific medical conditions and waiver programs available for those who require assistance with activities of daily living or who meet functional requirements (such as those with AIDS, on home ventilators, or who are autistic). Although these waivers provide a wide array of services (such as home health aides, transportation, and case management), they are not an entitlement and there is no guaranteed entrance.

In addition to covering basic Medicaid services, states can choose to cover up to 30 optional benefits. Pa. covers 24, including prescription drugs, vision, dental, physical therapy, home health, and hospice care. Pa.’s Medicaid expansion coverage includes the ACA’s ten essential health benefits and expanded mental health and substance use treatment services. Children with special health care needs (CSHCN) are served by Special Needs Units (SNU) within Medicaid. SNU are housed within physical health Managed Care Organizations (MCO) and ensure CSHCN receive services and supports in a timely manner. SNU also assist CSHCN with access to services and information, coordinate between physical health and behavioral health and other systems, and staff a dedicated special needs hotline. Each physical health MCO has a full-time SNU coordinator. SNU staff also work in close collaboration with the SNU housed within DHS.

Individuals not eligible for Medicaid may qualify for Children’s Health Insurance Program (CHIP), also a part of DHS. CHIP provides free or low-cost health insurance to uninsured children and teens up to age 19 in families with incomes over the Medicaid limit (133% FPL). As of February 2022, there were 144,230 children enrolled in CHIP. As of October 2021, CHIP and Medicaid combined provided health and long-term care coverage to more than 3.5 million in Pa. Medicaid is also a major source of funding for safety-net hospitals and nursing homes, and most Medicaid spending in Pa. is for the elderly and people with disabilities. In State Fiscal Year (SFY) 2019, Medicaid accounted for 61% of all federal funds received by Pa. and 36% of the state general fund spending.

Following a national trend, Pa. is becoming more racially and ethnically diverse. From 2010 to 2019, the minoritized population increased from 36 to 40% nationally, and from 21 to 24% in Pa. From 2016-2020, non-white residents made up more of the population in urban areas (30%) than in rural areas (nine percent). From 2010 to 2020, the Hispanic identifying population increased in Pa. by 45.8%, and the from 2010-2019, the Black/African American identifying population increased by 11.8%. From 2000 to 2019, the rural population became more racially diverse, as the non-white or Hispanic rural population increased from five percent of the total population to nine percent. As of 2019, approximately one in three Pa. children are children of color. With the total minoritized population projected to double between 1990 and 2025, the responsibility and challenge of the Title V program is to understand their diverse backgrounds and how services and Title V programming can adapt to their needs.

With an increasingly diversifying population, it is important to consider how people of color experience Pa.’s system of care, signified by key MCH indicators. In 2019, the infant mortality rate for white infants was 4.5 per 1,000 live births. The rate for Black/African American infants was nearly three times that, and for Hispanic infants, it was 31% higher. For Black/African American infants, the disparity has persisted since at least 1999, and for Hispanic infants, since 2012. Preterm births are a leading cause of infant death. In 2019, the percentage of preterm births for white infants was 9.1%. Black/African Americans had a percentage that was one and a half times that of white infants (roughly 50% higher), and for Hispanic infants, the percentage was 15% higher than that of white infants. The disparity for preterm births for Black/African American infants has been roughly the same since 2003. From 2015 to 2019, the maternal mortality rate for white birthing persons was 8.9 per 100,000 births. The rate for Black/African American birthing persons was nearly 2.5 times the rate for white birthing persons. In 2019, one percent of white mothers had no prenatal care; for Black/African American mothers, it was more than four times that, a disparity that has not changed since 2011. For Asian mothers, the percentage was approximately twice that of white mothers, and more than three times that of white mothers for Hispanic mothers. Since 2003, the rate for Hispanic mothers has been at least twice that of white mothers for every year except one. A lack of prenatal care has been linked to poor birth outcomes, including low birth weight and infant mortality. In 2019, the teen pregnancy rate for white persons was 3.2 per 1,000 females aged 15-17. Despite teen pregnancy rates for Black/African American persons having dropped over 67% from 2010-2019, rates are still more than three times that of white persons. Like Black/African American, despite a decline in teen pregnancy rates from 2010 to 2019, the teen pregnancy rate for Hispanic persons was more than five times that of white persons. That disparity has been roughly the same since 2010. With the projected increase in minoritized populations, unaddressed health inequities have the potential to place a greater burden on these populations and the health care system.

Overlapping the disparities are familial, educational, and economic characteristics of the population that further define their interaction with the MCH system of care. In general, Pa. is growing older. In 2019, about one-quarter of Pennsylvanians were under the age of 20 and one-third were 55 and older. The percentage of population aged 65 and older was greater in Pa. (18.7%) than the US overall (16.5%). From 2010-2019, Pa.’s population grew less than 1 percent, the number of young residents (under 18) decreased more than five percent, but the number of residents 65 and older increased more than 21%. Counties with large elderly populations could face the possibility of diverting resources from MCH populations toward their older residents.

Of the approximately 5 million households in the state in 2019, over 3.2 million of these households were defined as families, with an average size of 3.02 members. The U.S. Census Bureau categorizes families as: married-couple families, male householder (no wife present) and female householder (no husband present). While married families are most common, nearly 71% of non-married families are female-led. These households have slightly larger family sizes, are more likely to have members less than 18 years of age and are more likely to live in multi-unit structures. Over eight percent of all households in Pa. are single parent households with children under 18 and no spouse present. Pa. had a lower percentage of households with children (24%) than the national figure (26%). The population of children under age 18 is evenly distributed across age groups for each family type. Of the 2.62 million children in the state, approximately 1.7 million live in a married family. Over 221,000 children live in male-led families; and over 675,000 children live in female-led families, which are less likely to have an unmarried partner present.

The racial distribution greatly varies between types of households with children. While 81% of children in married families are identified as white, nearly 70% of children in male-led families and nearly 52% of children in female-led families identify as white. Over 59% of Black/African American children and over 42% of Hispanic children live in female-led families compared to only 18.4% of white children. Female-led families are more likely to have grandchildren in their households, and more likely to have a child with a disability in their household when compared to other households.

According to the 2019-20 National Survey of Children’s Health, 22.3% of children in Pa. have special health care needs. Children and their families may encounter multiple barriers to perform daily life functions and often need services from multiple systems of care which can be challenging for families to navigate.

Median income varies by county from $40,342 to $104,161; for families with children, it is $80,661. However, there are stark differences in median income when considering family type. The median income for married families is $108,305, $47,220 for male-led families and $30,665 for female-led families. In addition, female-led families are slightly larger in size than male-led or two-parent families, but their median income is much lower. Women’s income is also affected by the wage gap. In 2020, women in Pa. earned 79 cents for every dollar a man earned, less than the 83 cents national average. The wage gap is even greater for women from minoritized populations.

In 2019, a smaller percentage of Pa. residents (12.4%) lived in poverty compared to the national rate (13.4%). However, there are still large swaths of the population living in poverty, as 26% of Pa.’s Black/African American residents and 28.1% of Pa.’s Hispanic residents lived in poverty and families with Black/African or Hispanic householders were more than three times as likely to be living in poverty than white households. Of the 1.37 million families with related children under 18, 14.3% were living below the poverty level during the previous year. Female-led families were more likely than any other to be living below the poverty level. For families with children under 18, female-led families were twice as likely to be living below the poverty level. The highest rates of poverty were for families with a householder having less than a high school education. However, at all levels of educational attainment, the percentage of female-led families living below the poverty line was higher than other families, more than double in most cases.

Adolescents (15 to 19 years) are an important sub-population within the MCH population, numbering approximately 803,000 with more than 89% enrolled in school in 2019. School enrollment among adolescents is consistent by race and ethnicity, with Black/African American adolescents having the lowest enrollment at 87.3%.

Future earnings are related to a person’s level of educational attainment. For the more than 9 million people aged 25 years and over in Pa. in 2019, 91% have a high school degree or higher, varying a bit by county, and more than 32% have a bachelor’s degree or higher. For this same population, for whom poverty status is determined, the rate of poverty for those with less than a high school diploma or equivalency is 25.1% and decreases with educational attainment. The median annual income for those aged 25 years and older is approximately $42,225 and ranges from $26,350 for those with less than a high school diploma or equivalency to $73,800 for graduate or professional degree holders. Of the approximately 1.16 million 18 to 24-year old’s, 35.5% have graduated high school, 44.2% are enrolled in college or graduate school, and 13.5% have a bachelor’s degree or higher. Females in this age group are enrolled in college or graduate school at a higher rate than males.

According to a 2016 Williams Institute analysis of Census Bureau data, there are 22,340 same-sex couples in PA (sixth nationally) compared to 646,500 in the U.S. with almost 16% of these couples in Pa. raising children. Most same-sex couples in Pa. are women (56%) and 81% are white. The mean income for same-sex couples is higher than that of different-sex couples, $52,000 versus $46,000, and over half have a college education as compared to only 33% of different-sex couples. Ninety percent of same-sex couples have health insurance. In Pa., three percent of people identify as Lesbian, Gay, Bisexual, Transgender (LGBT) with 27% raising children; the U.S. numbers are four and 29%, respectively. As with same-sex couples, most of the LGBT population is white (72%). Pa. ranks 38th in percentage of LGBT individuals. Over a quarter (28%) of LGBT individuals have an income less than $24,000 as compared to non-LGBT individuals (21%). More non-LGBT (90%) individuals have health insurance than LGBT individuals (86%). The percentage of non-LGBT and LGBT individuals having a college education is nearly equal. As of 2018, 4.1% of PA is LGBT, compared to 4.5% nationally, and five percent of the Pa. workforce is LGBTQ. As of 2019, Pa. has 36,711 same sex households (980,276 nationally), 52.3% of whom are married.

LGBTQ residents face ongoing health inequities in terms of their absence in statewide surveillance systems, discrimination by healthcare providers, in the workplace, and in social situations. Over half of LGBTQ individuals have reported discrimination at some point based solely on sexual orientation or gender identity, which is not explicitly banned in Pa. There are few laws protecting LGBTQ families regarding insurance coverage, hospital visitation rights, and powers of attorney. Members of LGBTQ groups have health needs both regular and specific to their sexual and gender orientation that often go unmet. In response to a range of discriminatory laws being passed in other states, Governor Wolf signed executive orders in April 2016 stating, “no agency under the governor’s jurisdiction shall discriminate on the basis of sexual orientation, gender expression, and identity, among other areas.” These orders pertain to commonwealth employees, and the commonwealth grants and procurement process. Over 40 municipalities have passed separate ordinances to prohibit discrimination based on sexual orientation and gender identity.

The Secretary of Health’s priorities combined with the State Health Improvement Plan (SHIP) and the DOH’s Strategic Plan guide the agency and illuminate areas for Title V to implement work to improve the health of populations in Pa. The 2015-2020 SHIP was developed in partnership with a broad representation of public health system stakeholders. The SHIP priorities are: 1) obesity, physical inactivity, and nutrition; 2) primary care and preventive services; and 3) mental health and substance abuse. Through the process of defining the SHIP priorities, five cross-cutting themes were also identified: health literacy, public health systems, health equity, social determinants of health, and integration of primary care and mental health. In 2018, the DOH prioritized the protection of access to health care in rural communities using a Rural Health Model, developed in coordination with the Centers for Medicaid and Medicare Services. As of November 2021, there were 18 hospitals participating in the model. The  2021-22 SHIP annual plan includes the current evidence-based strategies for each SHIP priority, the activities planned to implement the strategies, the target populations, collaborators, targets, and data sources.

The State Health Assessment (SHA), which reports on the health status of Pa.'s population, factors that contribute to health issues, and resources that can be mobilized to address population health improvement, was recently updated. The Department released the 2022 SHA in March 2022.

The DOH 2020-23 Strategic Plan consists of the following five key strategies: 1) Maintain and enhance emergency services and public health preparedness; 2) Continually develop our talents to significantly advance public health in Pa.; 3) Promote public health with awareness, prevention and improvement of outcomes where the need is greatest; 4) Use data, measures, and technology to enable public health performance; and 5) Improve staff, customer, and partner experience with consistent, efficient, and effective services and work processes. These department strategies closely align with the work of Title V in Pa. and the Bureau of Family Health (BFH), as the Title V administrator, will continue to emphasize evidence-based and data driven decision-making within its programming while increasing the integration of quality improvement techniques throughout its work.

In March 2019, the DOH achieved national public health accreditation per notification from the Public Health Accreditation Board. Accreditation ensures that the DOH is meeting national evidence-based standards and providing Pa. residents with the best programs and services available. Accreditation can help the BFH improve collaborations between staff and stakeholders and further the Title V mission and programming through increased accountability, quality service delivery, and institutionalized processes, such as the use of evidence-based practices and integration of quality improvement techniques. The Department is currently developing an 18-month plan to aid in the preparation of documents for re-accreditation, due in March 2024.

PA’s MCH system of care is further augmented by state statutes mandating programs serving the MCH populations and requiring the resources of Title V in both staff and funding. The Newborn Child Testing Act (35 P.S. § 621, et. seq. and amended by Act 36 of 2008 and Act 133 of 2020) establishes a program providing for the screening tests of newborn children and follow-up services related to case management, referrals, confirmatory testing, assessment, and diagnosis of newborn children with abnormal, inconclusive or unacceptable screening tests results. Act 133 of 2020 mandates all diseases screened for via dried blood spots by the Pennsylvania newborn screening program are now mandated for screening. This list of disorders includes thirty-six core conditions recommended by the Health and Human Services committee that make up the national recommended uniform screening panel (known as the RUSP). In addition to the core conditions, Pennsylvania screens all babies for twenty-five medical disorders that can be detected in the differential diagnosis of the thirty-six core conditions. Act 87 of 2008 mandates the Child Death Review (CDR) Program, which provides for statewide and county-based multidisciplinary CDR teams to conduct reviews of all deaths of children aged 21 and under. The Act also requires an annual report on the information, distribution and causes of child deaths in Pa. and reflects information collected during the CDR process from collaborative processes between the DOH and local CDR teams. The Pennsylvania Code (028 Pa. Code § 27.22 and 028 Pa. Code § 27.34) requires laboratories and providers to report blood lead test results to the DOH. Act 24 of 2018 establishes a Maternal Mortality Review Committee to conduct multidisciplinary reviews of maternal deaths and develop recommendations for the prevention of future maternal deaths.

Impacting Pa. residents, the health care system, and the broader landscape of the MCH system of care are several important, emerging issues. The 2019 novel coronavirus (COVID-19) pandemic has presented an unprecedented challenge. COVID-19 prompted the federal declaration of a nationwide emergency and, in Pa., the activation of a command center at the Pennsylvania Emergency Management Agency and a disaster declaration. Pa. continues to monitor COVID-19 cases and fatalities across the state and is actively engaged in supporting the public health and medical systems with the response. As of February 2022, Pa. has had over 2.28 million positive cases and more than 43,000 Pennsylvanians have died. Over 7.2 million Pennsylvanians are fully vaccinated, and more than 3.2 million Pennsylvanians have received an additional dose. COVID-19 mitigation orders were lifted effective May 31, 2021. The order requiring universal face coverings was lifted statewide effective June 28, 2021. On December 10, 2021, the statewide school mask mandate in Pa. was lifted, though some schools opted to continue requiring them at the local level. However, DOH continues to urge Pennsylvanians to get vaccinated if eligible and to follow CDC guidance for wearing a mask where required by law, rule, and regulations, including healthcare, local business, and workplace guidance. While adults aged 65 and older as well as those who are immunocompromised or with underlying conditions are at highest risk of contracting the virus, the CDC also advises pregnant persons to take extra precautions. Many Pennsylvanians have reported delays and interruptions in their and their children’s routine health care visits as a result of COVID-19. Title V-supported programs offer important safety-net services during times of crisis when the health care system may be overwhelmed by caring for emergent cases.

Of further concern is the effect COVID-19 has had on the mental health of children and youth. In its Declaration of a National Emergency in Child and Adolescent Mental Health, the American Academy of Pediatrics mentions that rates of childhood mental health concerns and suicide rose steadily between 2010 and 2020, and by 2018 suicide was the second leading cause of death for youth ages 10-24. And according to the 2019 Youth Risk Behavior Survey, 36.7% of high school students reported being sad or hopeless every day for two weeks in a row, preventing them from doing some of their usual activities. The additional stress, disruption, and adversity experienced by families and children has exacerbated these trends that existed before COVID-19. This is borne out by the results of the CDC’s Adolescent Behaviors and Experience Survey (ABES), in which the percentage of high school students reporting being ‘sad or hopeless for two weeks” increased to 44.2%. In addition, ABES found that of the group that reported feeling sad and hopeless, one in two felt they were not connected with persons at school. ABES also found that students who felt connected to persons at school were less likely to report poor mental health during the pandemic (28.4%) compared to students that did not feel connected (45.2%). According to the Surgeon General’s Advisory on Protecting Youth Mental Health, a number of risk factors have contributed to youth mental health symptoms during the pandemic, such as having parents or caregivers who were frontline workers or at elevated risk of burnout, experiencing disruptions in routine, experiencing more adverse childhood experiences, or experiencing trauma such as losing a family member or caregiver to COVID-19. A wide and varied number of groups were mentioned in the Advisory as having been at higher risk of mental health challenges during the pandemic, such as youth who have intellectual/developmental disabilities, are in a racial and ethnic minority, identify as LGBTQ+, are low-income, live in rural areas or immigrant households, have been in the juvenile justice/child welfare systems, and/or are runaways or homeless. Title V will be monitoring trends and working to address the issue through its priority to improve mental health, behavioral health, and developmental outcomes for children and youth with and without special health care needs.

Another emerging issue is the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization, which effectively overturned Roe v. Wade and has potential to impact reproductive health and the Title V population, with health implications for pregnant people, children, and families. Abortion remains legal in Pennsylvania. There have been several bills passed during the current legislative session to restrict abortion access, but all were ultimately vetoed by the Governor.  According to the Robert Wood Johnson Foundation (RWJF), access to safe and high-quality reproductive medical care, including abortion, is an essential element of comprehensive healthcare and health equity, and restricting access to abortion compromises the health of pregnant people. RWJF goes on to say research has shown that states that have restricted access to abortion have increased their maternal mortality rates by nearly 40%, and women denied abortions are more likely to experience economic hardship and insecurity in later years. Ana Langer, professor of practice of public health and coordinator of the Women and Health Initiative at the Harvard T.H. Chan School of Public Health, stated laws restricting abortion access compel women and pregnant people to risk their lives and health by seeking out unsafe abortion care. According to the World Health Organization, 23,000 women die from unsafe abortions each year, and a recent University of Colorado study estimated that banning abortion in the U.S. would lead to a 21% increase in the number of pregnancy-related deaths overall and a 33% increase among Black women. According to the Association of Maternal & Child Health Programs (AMCHP), poor maternal health outcomes disproportionately impact women and birthing people with low incomes, women and birthing people of color, and women and birthing people in rural communities.

Another issue that will have effects on the health of Pennsylvanians are real or potential changes to insurance status and/or coverage. One change to insurance coverage is the extension of Medicaid postpartum coverage for mothers and birthing people who are eligible because of their pregnancy from 60 days after giving birth to one year after birth, effective April 1, 2022, under the American Rescue Plan Act. Extending postpartum coverage for those covered through Medicaid will provide health care continuity, allowing birthing parents to maintain uninterrupted relationships with and access to care providers through a critical period in their and their babies’ lives. Throughout the pandemic, The Centers for Medicare and Medicaid Services (CMS) issued a Public Health Emergency (PHE), under which some requirements and conditions for Medicaid, such as eligibility redeterminations and disenrollments, were waived. The waiving of these conditions allowed those on Medicaid to maintain continuous Medicaid coverage during the pandemic. With the PHE set to expire July 15, 2022, eligibility redeterminations and disenrollments would resume and those who are not otherwise eligible would lose their Medicaid coverage. DHS will track state and federal policy changes and adapting as needed. The impending change in administration could also have an impact on insurance coverage. There could be changes to Medicaid eligibility and/or the Medicaid expansion under the ACA dependent upon the new administration’s priorities. Title V will monitor changes in state and federal policies that could impact coverage and attempt to meet the needs of the insured and uninsured as necessary.

In addition to the aforementioned issues, the DOH recognizes racism is a public health crisis. As the Society for Public Health Education detailed in a presentation on Multiracial Health Equity, racism is theorized to be a fundamental cause of health disparities. However, research and advocacy primarily center on the experience of monoracial (single-race) populations of color. The multiracial population is the fastest-growing racial-ethnic group in the US, increasing 36% in size from 2010-2020. In Pa., the multiracial population has changed considerably since 2010, growing from 237,835 people in 2010 to 774,484 people in 2020, a 226% increase. Although research has been inconsistent in its use of multiracial categories when comparing against monoracial populations, data suggests that disparities do exist between monoracial and multiracial populations. The DOH is evaluating policies and practices to identify and combat systemic racism. The DOH Antiracism and Health Equity Task Force, established in 2021, has been tasked by the Secretary’s office with developing a series of action steps and initiatives to further this work over the next 18 months. Title V-funded staff sit on the Antiracism and Health Equity Task Force and will look for opportunities to align the work of the Title V State Action Plan and BFH Health Equity Committee with Task Force initiatives. Additionally, Pa.’s Title V program is participating in the Healthy Beginnings with Title V: Advancing Anti-Racism in Preterm Birth Prevention learning and practice cohort and intends to apply lessons learned to other Title V priority areas and share experiences with the DOH Antiracism and Health Equity Task Force.

Finally, in May 2021, the Wolf administration released the Pennsylvania Climate Impacts Assessment 2021. In the corresponding press release, Governor Wolf stated, “On our current path, the Pennsylvania our children and grandchildren inherit will be very different from the one we grew up in and continue to enjoy today…We simply cannot afford to ignore the warning signs, and this report underscores the critical need to take action to reduce emissions and do our part to address climate change.” Pennsylvania Climate Impacts Assessment 2021 uses federal, state, and local data to show the trend of rising temperatures and increasing rainfall and project how it will continue into midcentury (2041-2070) and beyond, if greenhouse gas emissions are not reduced. The extent of impacts, from limited to catastrophic, is projected for numerous aspects of life in Pa. Pennsylvanians living in disinvested communities ripe for resource development often face significant challenges exacerbated by climate change impacts. These challenges include living near industrial sites, living in older housing stock, often without air conditioning, and facing limited transportation options. Heat and extreme weather events caused by climate change can aggravate health conditions stemming from poor air quality and heat exposure. The Department of Environmental Protection’s Environmental Justice Office is urging state and local leaders to work proactively and intentionally with communities and other partners to reduce the significant risks of climate change and cultivate resources, health supports, and other development in communities disproportionately impacted these critical climate issues. The DOH is working to better understand and prepare for the adverse health effects of climate related events. In early 2022, the Acting Secretary of DOH formed a workgroup committed to climate change work as it intersects with public health; Title V staff participate on the workgroup.

Pa is a state of contrasts presenting unique challenges to the delivery of services and resources across the MCH system of care. An aging but diverse population will gradually force a system adjustment to meet geographic, programmatic, and cultural needs. Swaths of poverty are inseparable from gender, education, race and ethnicity, with women led families bearing an unequal burden. Systems of care are equipped to meet urban needs but not rural needs. This, however, is not as dire as it seems. There is strength in the access to care provided by Medicaid and CHIP, the local work of the CMHDs, and DOH development of strategic plans, initiatives, and programs to meet current and emerging challenges such as COVID-19, opioid addiction, racism, maternal mortality, and climate change. The Pa. Title V program will have to be nimble and adaptable to meet the changing landscape of MCH service needs in Pa.