The focus of Title V ongoing needs assessment activities in FY 2021 have been a COVID-19 Maternal and Child Health (MCH) Impact Assessment and a review of state action plans to assess health equity components. This section also discusses ongoing or emerging issues that impact the MCH population, including infant and maternal mortality, COVID-19 and pregnancy, health concerns specific to CSHCN, and the impact of COVID-19 on local health departments (LHDs).

COVID-19 MCH Impact Assessment

As part of Title V needs assessment activities, Michigan assessed the impact of the COVID-19 pandemic on women, mothers, infants, children, adolescents, and CSHCN. In addition to the immediate health threats posed by COVID-19, the pandemic required changes to many aspects of daily life to reduce rates of infection and death and to avoid overwhelming the healthcare system. As Michigan worked to control the spread of COVID-19 and save lives, employment became less stable, childcare options changed, school and other programs moved online, telemedicine was broadened, and healthcare access changed. These experiences illustrated both strengths and gaps in systems for meeting families’ needs. While there is still much to learn about the immediate and long-term impact of COVID-19, Michigan’s Title V program used several methods to identify the current impact on MCH. In coordination with the Michigan Public Health Institute (MPHI), these included an MCH program staff survey; key informant interviews; a focus group; and a literature review. Findings from each assessment are described below.

COVID-19 MCH Impact Survey

Through an online survey conducted in February 2021, MDHHS MCH program staff (including but not limited to Title V programs) shared feedback about the impact of COVID-19 on the populations served by their programs. Data (primarily open-ended questions) were analyzed by population domain.

Programs serving infants and women during the perinatal period identified several factors that threatened the well-being of this population during the pandemic. They noted that families have experienced inconsistent income and employment, making it difficult to meet basic needs. They also described challenges related to social isolation and mental health, as well as difficulties accessing childcare. Families with young children have also needed better guidance for safety protocols related to sanitation and mask wearing.

Program staff noted that accessing services and interacting with the healthcare system has been a source of stress for pregnant women and infants. For example, limiting the presence of support people during delivery was a source of anxiety for some women. Additionally, decreased hospital stays after delivery have limited time for safe sleep education and breastfeeding support. Program staff also described difficulty providing health screenings. Challenges related to WIC included a shortage of WIC-approved foods and the lack of an approved method for using WIC benefits online or for curbside or delivery services. Program staff also noted that staff shifts to respond to COVID-19 have limited the delivery of other programs and services, such as safe sleep outreach and education.

However, program staff also described several strategies for adapting service delivery that have been successful. Education and training programs have been adapted to an online format, including childbirth classes, breastfeeding, and lactation support. Use of social media to share resources and education has expanded on topics such as safe sleep. Programs were also able to support local shifts and innovations, such as delivering needed resources to families contact-free and supporting LHD staffing pivots to cover COVID-19 activities. Program staff noted that expanded reimbursement for telehealth services has benefited families, and WIC waivers allowed families to access nutrition resources. Michigan’s Regional Perinatal Quality Collaboratives also supported local innovation. For example, they provided blood pressure cuffs to high-risk hypertensive mothers to monitor blood pressure at home when access to clinical care was limited.

Program staff in programs serving children noted similar challenges faced by this population during the COVID-19 pandemic. They described how the pandemic has compounded the challenges that vulnerable communities across the state already face. Inconsistent income and employment and lack of access to basic needs created stress for families and impacted mental health and substance use. Families enrolled in WIC also had difficulty with food access, as noted above. Changes in service delivery created challenges, with the pivot to virtual services difficult for some programs. Preventive care screenings and education decreased (e.g., for lead exposure). Mental health services and several types of screenings (e.g., vision and hearing) can be more difficult to provide virtually. Programs that deliver services to students, such as school-based dental programs, temporarily could not reach children during school closures.

Despite these challenges, program staff noted that several innovations in service delivery were successful for some children and families. Virtual home visiting created increased accessibility for some families. Online health education programs also expanded reach of some health education services. As noted above, removal of the USDA/WIC in-person certification requirements and additional approved foods improved access to WIC.

Program staff who serve adolescents also identified challenges to adolescent mental and behavioral health due to the pandemic. They noted that the pandemic led to stress and trauma, as well as isolation and disconnect from peers. Staff noted that the stressors of the pandemic disproportionally affected adolescents in minority groups, reflecting and compounding health inequities, and some adolescents faced increased food insecurity, violence in the home, and transportation issues. Staff felt uncertain about the lasting impacts of virtual schooling for adolescents. However, they noted that the shift to remote learning impacted the delivery of public health programs and services that are typically provided in schools.

Telehealth and adapted curriculum for virtual learning have been successful strategies to mitigate these challenges. Additionally, allowing programs such as the SEAL! Michigan dental program to reach children and adolescents outside of the school setting allowed for expanded reach. Additional settings, virtual delivery of programs, and flexible use of funds have been beneficial to reaching adolescents.

The CSHCN population experienced a heightened level of fear of exposure to COVID-19 creating stress and isolation. Program staff indicated that fear impacted choices on who to allow into the home for care and if/when to participate in routine health care, which is necessary for disease prevention and management. Program staff identified barriers to delivering school-based programs, especially for children with intellectual/developmental conditions who need school-based services like physical, occupational, and speech therapies. Additionally, the health system that serves CSHCN has also suffered with the closure of many physician and dental services, reduced home visitation, and staff diversion to COVID-19 duties at LHDs.

Although these challenges exist, CSHCN policy and program adaptations enabled care delivery during the pandemic. Michigan issued policies to ease obtaining medications and durable medical equipment, personal protective equipment for some diagnoses, removing face-to-face requirements to enable telehealth, and modifications to prior authorization policies. The use of telehealth and removing prior barriers (such as needing time off from work/school, transportation logistics, and travel costs) have been successful strategies for the continuation of care for CSHCN.

Impact on MCH Capacity

A question on the COVID-19 survey was “How has the COVID-19 pandemic impacted the state’s delivery of MCH services?” Some MCH programs were expanded, and many were adapted to support increased need during the COVID-19 pandemic. For example, the SNAP program was expanded to serve more families and children; home visitation services shifted to be offered virtually; and breastfeeding and childbirth education classes were provided virtually.

Another change in MCH program capacity resulted from shifting MDHHS staff and local public health staff to support contact tracing and vaccination efforts as part of the state’s emergency response. An example was the shift of MCH epidemiology staff to support COVID-19 case and death reporting data. While this flexibility enabled public health to respond to critical needs and gaps from the COVID-19 pandemic, it also created challenges for existing MCH programs.

The lasting impact of these changes is yet to be determined. The pandemic revealed capacity gaps in programs and services not only in Michigan, but across the country. The development of lessons learned and capacity adjustments as states move out of the emergency response will be critical to ensure future MCH program capacity.

Key Informant Interviews & Focus Group

Three key informant interviews focused on women, children, and adolescents and one focus group focused on CSHCN were held with MCH leaders outside of MDHHS who could speak to the impacts of COVID-19 on these populations. For CSHCN, a focus group was held with the CYSHCN Family Leadership Network (a statewide group comprised of caregivers, family members, and parents of CYSHCN) to ensure family and caregiver voice were elevated for a population uniquely impacted by COVID-19. The key informant interviews and focus group lasted 60-90 minutes. The sessions were facilitated by an MPHI staff member and were recorded. Transcripts were analyzed for major themes using Nvivo software.

Participants identified many ways the pandemic impacted the MCH population. First, participants described how the pandemic exacerbated challenges families face in meeting their basic needs, which highlighted the importance of social determinants of health. Public health measures that were essential to the health and safety of residents, such as social distancing, remote learning, and working from home, led to social isolation and stress for some families. The pandemic also resulted in temporary closures of some businesses and services, which led to instability in employment and income, access to childcare, and access to transportation. These factors led to an increased need for concrete support, as well as social-emotional support.

Second, participants reported that telehealth programs were helpful and made access to care possible during times when in-person care was inaccessible. However, some participants noted concerns about the quality of care since tactile treatments could not occur via video and some changes in health may not be as visible when not in person. Participants noted that families delayed care due to concerns about exposure to COVID-19 and therefore experienced gaps in preventive care, such as immunizations, lead testing, hearing and vision screening, and dental care.

Third, participants noted that health information and guidance were extremely important during the pandemic. Participants identified challenges accessing reliable information that was culturally relevant, science-based, and up to date for all MCH populations. Participants also emphasized the need to continue to build trust with communities most impacted by the pandemic and in relation to vaccine hesitancy.

Literature Review

MPHI staff conducted a review of recent peer reviewed research, grey literature, and news articles about the impacts of COVID-19 on Title V populations at national, state, and local levels. Criteria for the search were those that referenced COVID-19 and one or more Title V population domains, with specific focus on articles that impacted Michigan directly. Additional key terms included service delivery, health equity, pregnancy, breastfeeding, vaccine, insurance, response and preparedness, mental health, housing, and substance use. Key findings from the review are highlighted below (see Supporting Document for full citations).

The review shed light on the severe economic and social impacts of the pandemic across all Title V population domains, resulting in increased “rates of poverty, food insecurity, homelessness, intimate partner violence, and child abuse and neglect” (NIHCM, 2020). Increased mental health concerns were also highlighted across population domains (NAMI, 2020), ranging from mothers experiencing trauma due to giving birth alone (Mayopoulos, 2021), to children and adolescents experiencing social isolation (St. George, 2021), and CSHCN struggling without their usual supports (Children’s, 2020). Other challenges include securing childcare, addressing medical needs or having to delay care, and securing stable internet for work or distance learning (Martin, 2021; Waxman, 2020; RWJF, 2020). These challenges have exacerbated existing disparities as they disproportionately impact Latino, Black, and Native American communities; people with disabilities; rural populations; and the LGBTQ community (RWJF, 2020; The Trevor Project, 2021). Research also suggests that while most providers are using patient portals to disseminate vaccine information and schedule vaccination appointments, the age, race, and socioeconomic groups most affected by COVID-19 are least likely to use these portals (Malani, 2021).

To address these disparities, the literature emphasizes the critical first step of collecting and monitoring COVID-19 data by race, ethnicity, and other demographic characteristics (CDC Data, 2021). The State of Michigan created the Michigan Coronavirus Task Force on Racial Disparities to engage diverse stakeholders in combating structural racism across Michigan, with special focus on improving testing infrastructure, primary provider connections, centering equity, telehealth access, and environmental justice (MDHHS, 2020). At the national level, the U.S. Strategy for the COVID-19 Response and Pandemic Preparedness also outlines goals related to advancing equity (Office of President, 2021), and Medicaid has allowed states to temporarily expand eligibility and lift rules to serve more women and children (AMCHP, 2021).

The review also highlighted insights for each MCH domain. Early studies suggest pregnant women have an elevated risk of severe illness from COVID-19 and that those with severe illness have a greater risk of adverse pregnancy and birth outcomes (CDC Investigating, 2021; NIH, 2021). However, transmission from mother to infant seems to be rare, so enhancing breastfeeding supports is critical during this time, as well as continuing life-saving interventions for the most vulnerable infants (NIH, 2021; Perrine, 2020; Rao, 2021).

Research on children revealed widespread mental health issues and a significant drop in reports of child abuse due to less access by mandated reporters (St. George, 2021). A recent COVID-19 modeling study indicated that school reopening was associated with a slight increase in COVID-19 infections and deaths, but most of the transmission could be attributed to adults aged 20-49 and could be mitigated by vaccinating this age group (Monod, 2021). Administration of standard immunizations for other diseases has decreased nationally during the pandemic (Martin, 2021), a trend consistent with data on Michigan’s child and adolescent vaccination rates (MDHHS).

Adolescents have faced unique challenges in receiving services for substance use, with less referrals from schools, and with providers having capacity barriers and needing to shift to address basic needs (Freese, 2021). Sexual health providers for adolescents and adults have also had to shift service delivery, including using telehealth visits, at-home specimen collection, and referrals to pharmacists to avoid clinic visits (CDC Guidance, 2020).

Resources focused on CSHCN described sub-populations that should be prioritized once vaccinations have been approved for children, such as children living in congregate settings, those at higher risk of illness due to COVID-19, and those experiencing greater difficulties with distance learning (Randi, 2021). Guidance for local health departments in Michigan urged those working with CSHCN to update Plans of Care to incorporate pandemic planning and outlined other supports that may be needed, including home health care concerns; telehealth support and safe clinical visits; childcare options; and distance learning support (Children’s, 2020).

Overall, this review emphasized the importance of meeting basic needs and providing mental health supports during this time. Data show that marginalized groups are disproportionately impacted by the pandemic, so continuing to collect and act on the data will allow for an equitable approach, especially for vaccine distribution. Unique needs of the MCH population include continuing postpartum supports for birthing people and infants, addressing distance learning challenges for children and adolescents, and providing equitable access to resources for CSHCN and their caregivers.

Conclusion

This assessment began to uncover the most immediate implications of the COVID-19 pandemic for the MCH population. COVID-19 created an unprecedented threat to the health and well-being of Michiganders, with trauma and loss experienced by many families. Additionally, the public health measures required to reduce the spread of COVID-19 and save lives changed how we work and live. Fear and isolation were experienced across communities. However, the most vulnerable communities experienced deeper impacts. The findings of this preliminary assessment highlighted the systemic gaps in safety nets for children and families, as well as inequities in policies and systems. Systems were often unprepared to quickly pivot and ensure income stability and access to basic needs in a severe crisis, especially at the onset of the pandemic; parents experienced serious challenges focusing on their essential role; and reliance on schools and childcare programs to support the economy has never been clearer. Moreover, this crisis illustrated the implications of defunding or underfunding governmental public health such that it does not have the surge capacity necessary to expand capacity and continue normal operations within a pandemic. These challenging times have also presented opportunities for innovation and evolution and will continue to present learning opportunities to strengthen public health and MCH infrastructure in service of families and children.

Health Equity Action Plan Review

The five-year needs assessment identified the need to “achieve equitable health outcomes” for the MCH population, which was established as a Title V pillar across population domains. To further operationalize this pillar, in FY 2021 all Title V state action plans were reviewed to provide feedback to program staff on resources and recommendations for strengthening health equity efforts and strategies. MDHHS partnered with MPHI to develop a rubric to review the plans. The rubric was designed to provide concrete examples from research literature to adapt objectives or strategies to tackle root causes and strengthen the focus on health equity, diversity, and inclusion.

MPHI completed a review of each state action plan and provided written feedback that detailed strengths, opportunities for improvement or expansion (both immediate and long term), and links to research and/or best practices. Completed health equity rubrics were shared with Title V program staff and one-on-one virtual review sessions were offered. Program staff then updated state action plans for the FY 2022 application. Transforming state action plans to increasingly focus on equity and root causes of disparities will be an iterative process. Additionally, not all equity-focused work within programs is included in the Title V application due to the specific focus of the plans. It was also a challenging year to make extensive revisions to state action plans, as many MCH staff were involved in COVID-19 response efforts.

Ongoing and Emerging Issues that Impact MCH

Infant and maternal mortality remain two critical public health issues. Other current issues include COVID-19 and pregnancy, substance use, issues that impact CSHCN, and the impact of COVID-19 on local public health.

Infant and Maternal Mortality

MDHHS continues to closely monitor infant and maternal mortality and has seen the following trends and emerging concerns. The infant mortality rate in Michigan for 2019 was 6.4 deaths per 1,000 live births, which is the lowest infant mortality on record for Michigan. This decrease in the statewide infant mortality rate can be attributed, in part, to a corresponding decrease in the infant mortality rate in the City of Detroit. From 2018 to 2019, the infant mortality rate in the City of Detroit dropped from 16.7 infant deaths per 1,000 live births in 2018 to 11.0 infant deaths per 1,000 live births in 2019. Although improving, racial and ethnic disparities remain a major contributor to Michigan’s reported infant mortality rates. The Black infant mortality rate has continued to be nearly three times that of the White infant mortality rate (most recently, 12.5 versus 4.9 per 1,000 live births in 2019). The pregnancy-related mortality ratio in Michigan for 2017 was 9.9 maternal deaths per 100,000 live births[1]. As with infant mortality, disparities between Black and White mothers are striking, with the Black pregnancy-related mortality ratio more than two times that of the White rate (21.3 versus 8.9 per 100,000 live births based on 2013-2017 data). In addition to maternal deaths caused by pregnancy-related issues, addressing pregnancy-associated mortality[2] remains an important component of Title V work: 32.0% of all pregnancy-associated, not related deaths from 2013-2017 were caused by accidental poisoning/drug overdose. Michigan’s maternal mortality committees have focused efforts on developing recommendations to help prevent current and expecting mothers from developing opioid use disorders.

COVID-19 and Pregnancy

Michigan is participating in the CDC COVID-19 Pregnancy and Neonate Surveillance Project. For this project, women who have received a confirmed diagnosis of COVID-19 during pregnancy are identified through the Michigan Disease Surveillance System (MDSS). This list is then linked monthly with birth and death certificates to track pregnancy outcomes. After each pregnancy outcome has taken place, medical records for both mother and infant are requested to obtain further details regarding the impacts of COVID-19 on the health of mother and infant.

As of early December 2020, 1,111 Michigan women were identified with a confirmed COVID-19 diagnosis during pregnancy. 564 (50.8%) of these women had a pregnancy outcome thus far. The majority of pregnancy outcomes were to White mothers (53.8%), while 28.5% were to Black mothers. All pregnancy outcomes were live births, with 16.5% of these live births classified as preterm births. The preterm birth percentage among this group is higher than the state average which is normally around 10%. Furthermore, the NICU admission percentage among this group is currently at 11.7%, which is higher than Michigan overall at 7.6%. Lastly, the infant COVID-19 positive rate is currently very low at 1.8% of live births to COVID-19 infected mothers. Additional statistics will be available as mothers who were infected within COVID-19 during their 1st trimester begin to have pregnancy outcomes.

In addition to this surveillance project, the Michigan Pregnancy Risk Assessment Monitoring System (MI PRAMS) has added several COVID-19 questions to the survey. These questions were added shortly after COVID-19 surfaced in Michigan and will continue to be included within the 2021 MI PRAMS survey.

Substance Use

Michigan continues to experience opioid use during pregnancy and, as a result, an increase in the number of infants diagnosed with Neonatal Abstinence Syndrome (NAS). Figure 1 details the incidence of NAS by region. As illustrated by the map, rural areas of Michigan have been hardest hit by this epidemic.

Figure 1. Map of 2019 NAS Rates by Prosperity Region

The number of drug exposed infants increased by 49% from FY 2010 to FY 2013, from 2,589 to 3,866 infants[3]. Additionally, infants hospitalized and treated for drug withdrawal symptoms has increased[4]. In 2010, 478 infants in Michigan had a diagnosis code of 779.5 (ICD-9-CM) and needed treatment for withdrawal from a drug, not specifically identified as opioids. In 2019, the number of infants with a diagnosis code of P96.1 (ICD-10-CM) increased to 673 infants. This represents a jump from 41.7 per 10,000 live births in 2010 to 62.4 in 2019. The opioid epidemic has also impacted maternal deaths. In 2011, 9% of maternal deaths were opioid related compared to 19% of maternal deaths in 2016[5].

MDHHS remains committed to supporting opioid use disorder prevention for pregnant and parenting women and women of childbearing age; increasing screening and identification; maintaining data collection and reporting; optimizing resource allocation to target resources to those in greatest need; developing a quality improvement system; and improving workforce development and training programs. MDHHS also has created many Opioid Resources to provide assistance and to decrease stigma related to opioid use and treatment.

The DMIH has also partnered with the MDHHS Office of Recovery Oriented Systems of Care to provide funding to three health systems to implement ‘rooming in’ programs in their birthing units. The rooming-in program is a family-centered model that encourages mother-infant bonding and utilizes non-pharmacological care of infants born substance-exposed, ensuring they remain with their mother or caregiver in a private hospital room that is less stimulating for the infant (i.e., room-darkening shades, softer flooring, etc.). The rooms are often equipped with murphy beds or sleeper chairs to enable an additional caregiver to stay at the hospital. Hospital staff provide education and support to the mother and family (e.g., for breastfeeding, skin-to-skin contact, calming techniques, and referrals to services like home visiting). The rooming-in program supports bonding between mother and infant, decreases the length of stay for babies diagnosed with NAS, and promotes positive parenting and recovery from substance use disorder.

Children with Special Health Care Needs

There is an emerging focus on Children with Medical Complexity (CMC) who suffer from one or more chronic conditions that affects three or more organ systems or one-life limiting illness or rare pediatric disease. Nationwide, CMC make up less than 4% of the total children’s population but are estimated to account for 40% of Medicaid’s pediatric spending. Using population, claims and encounter data, CSHCS is conducting an assessment within its program population to identify the number of children who meet this definition and would potentially benefit from a more intensive service array to improve their care coordination and quality of life. The Advancing Care for Exceptional (ACE) Kids Act should create opportunities for states to improve systems of care for CMC.

Efforts to apply a health equity lens have contributed to a greater awareness of disparities in access to health care experienced by individuals with sickle cell disease (SCD) which disproportionately affects African Americans. It is estimated that between 3,500 to 4,000 Michiganders are living with SCD. Of those, 798 are children enrolled in CSHCS and 2,317 are adult Medicaid recipients. Individuals with SCD are prone to higher rates of hospitalization, emergency room utilization, and premature death. In FY 2021, CSHCS partnered with the Lifecourse Epidemiology and Genomics Division to submit a proposal to the Governor’s Office to expand clinical services and enhance the system of care serving clients with SCD. The proposal was accepted and included in the Governor’s FY 2022 budget recommendation. The proposal will expand CSHCS coverage to adults, resulting in improved continuity of care and transition to adult providers, and will establish clinical pathways that address inequities in access to care.

Impact of COVID-19 on Local Public Health

Michigan’s 45 LHDs all reported challenges in 2020 related to the COVID-19 pandemic. Many LHDs had temporary closures for months during the state’s stay home order, others operated with reduced hours. Staff were shifted from their program areas to pandemic response such as testing, contact tracing, case investigation, hotline staffing, and addressing exposure sites. This shift in focus resulted in a domino effect. LHDs have reported projects or programs halted, less children immunized and screened for lead, decreased medical appointments, and decreased call volume for program assistance. School buildings closed which also limited the reach of LHD programs to children and adolescents. LHDs worked during the pandemic to adjust logistics and restructure programs and services to virtual platforms. LHD staff provided assistance through telephone calls, virtual platforms, and telehealth visits when possible.

[1] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management. Data source: Maternal Deaths in Michigan, 2013-2017 Data Update. MDHHS. Michigan Maternal Mortality Surveillance Program.

[2] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy due to a cause unrelated to pregnancy.

[3] Data from Michigan’s Services Worker Support System.

[4] Data from Michigan Inpatient Hospitalization Files.

[5] Division for Vital Records and Health Statistics, MDHHS.

Title V needs assessment activities in FY 2022 have focused on a second COVID-19 MCH Impact Assessment and a review of state action plans to assess family and community engagement. Ongoing or emerging issues that impact the MCH population are also discussed in this section, including infant and maternal mortality, COVID-19 and pregnancy, substance use, fluoridation, and health concerns specific to children and youth with special health care needs (CYSHCN).

COVID-19 MCH Impact Assessment

As the COVID-19 pandemic persisted, Michigan’s MCH and Title V programs continued to focus on identifying and responding to the needs of women, mothers, infants, children, and CYSHCN. The impact assessment used several methods to explore impacts in 2021, including an MCH impact survey, analysis of local MCH (LMCH) workplans, and a literature review. Findings are described below.

COVID-19 MCH Impact Survey

MDHHS MCH program staff completed an 18-item online survey in February 2022. The survey asked respondents to share their experiences and observations about the impact of COVID-19 on the populations served by their programs. Questions focused on provision of services and health information, workforce challenges, and emerging needs. Michigan Public Health Institute (MPHI) analyzed findings from 24 respondents which included, but was not limited to, Title V programs.

Figure 1. MCH Populations Served by Survey Respondents

Seventeen out of 24 respondents indicated their program provided information, technical assistance, or education on COVID-19 and/or COVID-19 vaccines to individuals, families, providers, or local grantees in 2021. In addition to COVID-19 information, programs indicated they provided guidance on telehealth services and resources on mental health and social isolation. Programs shared information via websites, flyers, newsletters, toolkits, and townhalls.

Notably, most state programs that received Title V funding indicated that they did not use funding for COVID-19 related activities in 2021.

Figure 2. Use of Title V Funding

COVID-19 presented challenges for MCH programs in service delivery and staffing capacity. Twenty-three respondents indicated that their program provided services virtually or via telehealth due to limited ability to provide in-person services, as indicated in Figure 3.

Figure 3. Service Provision

Programs such as home visiting, nutrition support, family planning, and mental health services adapted to virtual and telephonic delivery. Exemptions for telehealth reimbursement eased service delivery. Virtual programs made services more accessible for harder to reach populations, and some programs are interested in continuing to offer this option.

Most survey respondents noted workforce challenges and indicated they were most pronounced for local programs, as illustrated in Figure 4.

Figure 4. Workforce Challenges

In addition to staff shortages, turnover, and reassignment due to COVID-19, respondents indicated that other challenges included staff burnout and mental health concerns.

Struggles with social isolation, stress, job security, housing, and food access affected Michiganders across MCH domains centering the need for mental health support. Provider shortages impeded addressing this need. Programs leveraged technology to provide virtual case managers and therapy sessions to address the critical need. Most respondents indicated that COVID-19 impacted groups differently, as indicated in Figure 5.

Figure 5. COVID-19 Impact

These impacts are discussed below.

Findings by Population Domain

Programs that served women and infants identified persistent barriers to in-person activities, such as lactation and breastfeeding support, WIC redemption, and oral health services. Populations with low-income, people living in both rural and urban areas, and people of color had exacerbated experiences from the pandemic’s economic impacts. Job and food security, affordable housing, and childcare were common concerns. However, programs continued to provide concrete supports, such as pack and plays, through no contact means.

Child and adolescent programs reported a heightened need for mental and oral health services, in-person screenings, and academic supports. School closings, academic delays, and social isolation were noted as challenges. School restrictions also limited screenings and services for vision, hearing, blood lead testing, and oral health which particularly impacted low-income, rural, and urban youth. Adaptations extended the reach of school-based programs by connecting with target populations outside of school. For example, technology allowed case managers to meet with clients, deliver mental health services to youth, and use the Michigan Model for Health.

Programs that served CYSHCN reported challenges navigating the telehealth landscape and the stress of exposure at in-person visits, causing some families to delay medical care. Private nurses and respite care for families with CYSHCN were also more difficult to access. However, policies and exemptions reduced burdens for medication and medical equipment access, telehealth reimbursement, and vaccine administration. Collaboration was noted as a strength. For example, grants to local health departments promoted vaccine delivery to CYSHCN.

Local MCH Workplan Analysis

Year-end LMCH reports from Local Health Departments (LHDs) were analyzed with a focus on understanding the effects of the pandemic on the LMCH program, which is funded by Title V. Expenditures and persons served were quantified and categorized by performance measure, and workplans were analyzed for qualitative themes.

Across the state, LHDs addressed over 120 goals and served 360,850 individuals. Out of 45 LHDs,18 LHDs expended $892,060 (14.6%) in Title V funding to combat COVID-19, serving 187,799 clients. Over half of total individuals served by LMCH were reached with COVID-related services, most commonly vaccinations.

LHDs noted many challenges. For example, the pandemic forced programs to divert both funding and staff to address needs related to contact tracing, case investigation, testing, vaccination, and information hotlines. Limited in-person services were also a barrier to meeting goals. Virtual WIC appointments resulted in fewer immunizations, screenings, and lactation support services. Canceled community events also limited programs’ ability to implement outreach and education activities. While programs adjusted to provide services via telehealth, several programs reported difficulty sustaining virtual programming due to providers’ lack of comfort, poor phone access or internet connections (especially in rural areas), or patient preference. Collecting evaluation data also proved difficult in a virtual format.

LHDs shared successful efforts to serve their community despite limited in-person interaction. Many used alternative communication methods such as print and radio ads, and especially social media, to educate the public on COVID-19 and other health topics. Some programs used virtual events to engage community members. Several LHDs reported partnering with local providers and businesses to reach more people.

Literature Review & Annotated Bibliography

MPHI reviewed recent peer-reviewed and grey literature on the impacts of COVID-19 on MCH populations (see Supporting Documents for the Annotated Bibliography). Search criteria included COVID-19 references and one or more Title V population domains, with a focus on articles about Michigan. Other key terms were service delivery, health equity, pregnancy, breastfeeding, vaccine, insurance, mental health, and substance use.

The review reinforced prior findings on the physical, mental, and social impacts of the pandemic across all population domains and the disparities among demographic groups. In addition, emerging research highlights the direct and indirect long-term impacts on individuals and society.

Scholars continued to assess the phenomenon of ‘long COVID’ and ‘long haulers’ who experience symptoms for months after testing positive for the virus, which can include children (University of California Davis, 2022). A University of Michigan study found 27% of Michiganders who contracted COVID-19 in 2020 reported having a disability following their illness versus 15% before onset (Michigan News, 2022). In turn, specialty clinics have arisen to research and treat higher risk ‘long hauler’ adult and pediatric patients coping with multisystem inflammatory syndrome in children (Michigan Medicine, 2021).

COVID-19 vaccines saved lives in the U.S. and in Michigan (Gupta, 2021; Samson, 2021). Yet inequity and access barriers, mis/disinformation about the vaccine, and mistrust of healthcare systems affected the adoption of this intervention (Clay, 2021). As of March 30, 2022, 67% of Michigan residents had received their first dose—markedly lower than the overall U.S. rate of 82% (MDHHS, 2022; CDC, 2022). Rates vary by race in Michigan, with only 45% of Black residents having their first dose, compared to 56% of White residents (MDHHS, 2022).

Impacts on mental health continued in Michigan, often contributing to substance use issues (Slootmaker, 2022). From April 2020 to April 2021, Michigan opioid-related drug overdoses rose 19% over the prior year. Factors included “isolation, boredom, financial stress, loss of loved ones,” and lack of basic needs. Black, Indigenous, and Hispanic populations, people under age 24, people involved in the criminal justice system, and mothers and infants were especially affected by opioid use and deaths.

To address mental and other health concerns, telehealth options expanded, but access was inequitable. Income and insurance status limited access to telehealth, as did internet access (Darrat, 2020). To reduce inequities, the U.S. Department of Health and Human Services launched the Telehealth Broadband Pilot Program to expand access and improve broadband connectivity in rural areas of many states including Michigan (Augenstein, 2022).

In addition to these overarching impacts, the review highlighted insights unique to each MCH domain.

A Southeast Michigan study confirmed research that pregnancy elevates the risk of severe illness from COVID-19; suggests pregnant people have a higher risk of early preeclampsia after COVID-19 infection; and indicates that Black pregnant people are twice as likely as White pregnant people to contract early preeclampsia after COVID-19 (Ismailova, 2022). While studies have shown that COVID-19 vaccination of pregnant people is safe and effective (even in protecting the baby), the vaccination rate in this group has remained low.

A national study described the pandemic’s impact on birthing practices, including elevated emotional distress and adverse breastfeeding experiences due to lack of postpartum social support, shifting birthing plans due to hospital policy changes, a disconnect between expectation and reality, and some surprising benefits (such as better bonding with partner and infant) (Shuman, 2022). The pandemic “increased patients’ and policymakers’ interest in alternative care models like birth centers and doula services” over traditional interventions and hospitals (Burroughs, 2021). Expanding access to health insurance and telehealth can facilitate these options, and “expanding and diversifying the maternal health workforce is critical for promoting more culturally and linguistically effective care and addressing inequities” in birth outcomes.

Healthcare disruptions also impacted infants needing neonatal intensive care. Barriers to infants receiving care from NICU nurses included difficulty establishing skin-to-skin contact, problems caused by personal protective equipment, and fear of COVID-19 (Celık, 2021). Mothers faced barriers to providing care to their infants such as lack of family visits, interrupted kangaroo care, and difficulties breastfeeding.

Children also experienced barriers to healthcare during the pandemic. According to a national survey, “26.4% of households reported that ≥1 child or adolescent had missed or delayed a preventive visit because of COVID-19.” This was more likely among respondents who reported material hardships. Common reasons for missing or delaying preventive visits were concern about visiting a health care provider, limited appointment availability, and closed provider locations (Lebrun-Harris, 2022). Missed appointments led to fewer opportunities for lead testing, which decreased during the pandemic nationally and in Michigan (Michigan CLPPP, 2021; Courtney, 2020). Similarly, opportunities were missed to immunize children against vaccine-preventable illnesses. In May 2020 in Michigan, “vaccination coverage declined in all milestone age cohorts [year over year], except for birth-dose hepatitis B coverage…and coverage was lower for Medicaid-enrolled children than their peers” (Bramer, 2020).

As of March 30, 2022, COVID-19 vaccination of Michigan youth aged 5-19 was 41%, with a racial disparity of 40% of White youth compared to 28% of Black youth receiving at least one dose. Asian American and Hispanic/Latinx American youth rates were higher, 66% and 43% respectively, which increased the overall rate. Youth aged 5-11 lagged at 28% compared to 52% for youth aged 12-19 (MDHHS, 2022).

Abrupt school closures in 2020 worsened food insecurity for many students. States struggled to obtain and disburse funds for student meals due to administrative and data sharing barriers (Waxman, 2021). The adverse implications of distance learning on students were also documented (Harvard, 2021). Mental health care infrastructure for children has been overwhelmed by surges in emergency mental health needs and severe labor shortages. This unmet need is especially acute in rural areas of Michigan, such as the Upper Peninsula and northern Lower Peninsula (NIHCM Foundation, 2021; Erb, 2021).

As adult and pediatric COVID-19 cases and hospitalizations peaked due to the Omicron variant, hospitals were short-staffed and had difficulty providing surgeries for serious non-COVID illnesses (Fromson, 2022). Michigan Medicine found many Omicron cases were among younger children and adolescents displaying pneumonia and multisystem inflammatory syndrome.

Adolescents experienced increased mental health issues, with some groups at higher risk due to social and environmental factors (Office of the Surgeon General, 2021). These groups include youth with intellectual and developmental disabilities, racial and ethnic minority youth, youth who have low-income or live in rural areas, youth in immigrant households, foster care or justice system-involved youth, and youth who identify as LGBTQ+. The pandemic elevated stress levels among LGBTQ+ youth with almost half indicating their mental health counseling needs were unmet (The Trevor Project 2021).

Similarly, high school students reported increased “feelings of boredom, anxiety, depression, loneliness, worry, difficulty sleeping, and other negative mental health indicators since the beginning of the pandemic” (NIH, 2021). However, they also reported the largest single-year drop in substance use since the study began in 1975, including alcohol, marijuana, and vaped nicotine. Authors attributed this behavior change to changes in the daily life of adolescents related to “drug availability, family involvement, differences in peer pressure, or other factors.”

Parents of CYSHCN experienced increased stress caused by persistent challenges including “disruption in day care, health care, and employment, and loss of technological and therapeutic supports.” Many of these parents reported substance use including alcohol, cannabis, or other drugs (American, 2021).

Many policies improved CYSHCN access to health care by relaxing Medicare and Medicaid requirements, reducing administrative requirements for specialty services (Silow-Carrol, 2021). Expanded telehealth largely benefited CYSHCN, but low-income and rural families faced barriers such as lack of a device or broadband access. Experts emphasize the need to include CYSHCN and caregivers in emergency preparedness planning to reduce inequities and ensure that diverse needs are met. The U.S. Surgeon General also emphasized the need to address mental health needs, given unique pandemic challenges: “youth with intellectual and developmental disabilities…found it especially difficult to manage disruptions to school and services such as special education, counseling, occupational, and speech therapies” (2021).

Overall, this review emphasized the growing mental health crisis and the need for support. Groups that have been marginalized are disproportionately impacted by the pandemic, and efforts to address the impacts must target upstream social determinants and root causes. The unique needs of each MCH population require attention, including supporting new mothers and their infants, encouraging COVID-19 vaccination and childhood immunizations, and preventing and treating substance use.

Family and Community Engagement Action Plan Review

Michigan’s Title V five-year needs assessment identified three cross-cutting “pillars” that are critical across all MCH population domains. In 2022, Michigan focused on the pillar to “intentionally and routinely find opportunities to seek the knowledge and expertise of communities and families in all levels of decision making to build trust and create policies and programs that align with family and community needs.” To further integrate this pillar, MDHHS partnered with MPHI to review each Title V state action plan using a family and consumer engagement rubric. The aim was to identify strengths and opportunities to improve family and consumer engagement across plans.

MPHI reviewed all state actions plans and provided completed rubrics to Title V program staff. Feedback included examples and resources from the literature, and virtual technical assistance was provided upon request. During the TA sessions, program staff discussed the rubrics and ideas for integrating increased family and consumer engagement into FY 2023 state action plans or future activities.

Ongoing and Emerging Issues that Impact MCH

Infant and maternal mortality remain critical public health issues. Other current issues include COVID-19 and pregnancy, COVID-19 vaccination, substance use, community water fluoridation, and issues that impact CSHCN.

Infant and Maternal Mortality

MDHHS closely monitors infant and maternal mortality and has seen the following trends and emerging concerns. The infant mortality rate in Michigan for 2020 was 6.8 deaths per 1,000 live births, which represents a slight increase from 2019 (6.4 deaths per 1,000 live births). This increase in infant mortality could partially be attributed to a corresponding increase in the infant mortality rate within the City of Detroit. From 2019 to 2020, the infant mortality rate in the City of Detroit increased from 11.0 infant deaths per 1,000 live births in 2019 to 14.6 infant deaths per 1,000 live births in 2020. Although improving, racial and ethnic disparities remain a major contributor to Michigan’s infant mortality rates. The Black infant mortality rate has continued to be nearly three times that of the White infant mortality rate (13.6 versus 5.2 per 1,000 live births in 2020). The pregnancy-related mortality ratio in Michigan for 2018 was 10.9 maternal deaths per 100,000 live births[1]. As with infant mortality, disparities between Black and White mothers exist, with the Black pregnancy-related mortality ratio nearly three times that of the White rate (24.1 versus 8.5 per 100,000 live births based on 2014-2018 data). In addition to maternal deaths caused by pregnancy-related issues, addressing pregnancy-associated mortality[2] remains important: 36.1% of all pregnancy-associated, not related deaths from 2014-2018 were caused by accidental poisoning/drug overdose. Michigan’s maternal mortality committees have focused on developing recommendations to help prevent current and expecting mothers from developing opioid use disorders.

COVID-19 and Pregnancy

Michigan continues to participate in the CDC COVID-19 Pregnancy and Neonate Surveillance Project. For the project, women who have received a confirmed diagnosis of COVID-19 during pregnancy are identified through the Michigan Disease Surveillance System (MDSS) which is then linked with birth and death certificates to track pregnancy outcomes. After each pregnancy outcome has taken place, medical records for both mother and infant are requested to obtain details regarding the impacts of COVID-19 on the health of mother and infant.

For the 2020 cohort, 1,378 Michigan women were identified with a confirmed COVID-19 diagnosis during pregnancy. A pregnancy outcome was confirmed for 1,288 (93.5%) with the remaining 90 women (6.5%) lost to follow-up. The 1,288 documented pregnancy outcomes resulted in 1,316 live births and less than five fetal deaths. The majority of pregnancy outcomes were to White mothers (65.6%) while 18.9% were to Black mothers. Among the 1,316 live births, 10.4% were classified as preterm births, which is similar to the state average of 10%. The NICU admission percentage among this group was 9.3%, which is higher than Michigan overall at 7.5%. Lastly, the infant COVID-19 positive rate was very low at less than one percent of live births to COVID-19 infected mothers. Michigan recently started working on the 2021 cohort.

In addition to this surveillance project, the Michigan Pregnancy Risk Assessment Monitoring System (MI PRAMS) added COVID-19 questions to the survey. Results from the 2020 MI PRAMS COVID-19 questions indicate that an estimated 2.6% of new Michigan mothers reported that a health care worker told them they had COVID-19 during their most recent pregnancy, and it was confirmed through testing. When including mothers that were told by a health care worker that they had COVID-19 during their most recent pregnancy but they weren’t tested, this number increases to an estimated 3.7% (which represents 3,589 new mothers in 2020). Black, non-Hispanic mothers were nearly twice as likely to report COVID-19 during their most recent pregnancy when compared to white, non-Hispanic mothers.

COVID-19 Vaccination

The chart below provides Michigan COVID-19 vaccine coverage percentages by age group as of March 5, 2022. Initiation is defined as the percentage of Michigan residents who have received 1 or more doses of any vaccine, while completion is defined as the percentage receiving 2 doses of Pfizer or Moderna or 1 dose of Johnson & Johnson. Approximately one quarter of Michigan residents aged 5-11 years have either initiated or completed a COVID-19 vaccination. Initiation and completion rates increase to around 50% for those aged 12-29 years and increase to 60% or above for Michigan residents aged 30 years and above.

Substance Use

Opioid use during pregnancy and, as a result, an increase in the number of infants diagnosed with Neonatal Abstinence Syndrome (NAS) continues to be an issue in Michigan. Figure 1 details the incidence of NAS by region. As illustrated by the map, rural areas of Michigan have been hardest hit by this epidemic.

Figure 1. Map of 2020 NAS Rates by Prosperity Region

Additionally, infants hospitalized and treated for drug withdrawal symptoms has increased[3]. In 2010, 478 infants in Michigan received a diagnosis code of 779.5 (ICD-9-CM) which indicates a drug withdrawal syndrome, not specifically related to opioids. In 2020, 650 infants received a diagnosis code of P96.1 (ICD-10-CM), which indicates neonatal withdrawal symptoms from maternal use of drugs of addiction. This represents a jump from 416.7 per 100,000 live births in 2010 to 624.1 per 100,000 live births in 2020. The opioid epidemic has also impacted maternal deaths. In 2011, 9% of maternal deaths were opioid related compared to 32% of maternal deaths in 2018[4].

MDHHS remains committed to supporting substance use disorder (SUD) prevention for pregnant and parenting people and people of childbearing age; increasing screening and identification of SUD; maintaining data collection and reporting; optimizing resource allocation to target resources to those in greatest need; and improving workforce development and training programs.

DMIH has partnered with the MDHHS Office of Recovery Oriented Systems of Care to provide funding to three health systems to implement ‘rooming in’ programs in birthing units. The rooming-in program is a family-centered model that encourages parent-infant bonding and utilizes non-pharmacological care of infants born substance-exposed, ensuring they remain with their birthing parent or caregiver in a private hospital room that is less stimulating for the infant (e.g., room-darkening shades, softer flooring). The rooms are often equipped with murphy beds or sleeper chairs to enable an additional caregiver to stay at the hospital. Hospital staff provide education and support to the birthing parent and family (e.g., breastfeeding, skin-to-skin contact, calming techniques, and referrals to services). The rooming-in program supports bonding between parent and infant, decreases the length of stay for babies born substance exposed, and promotes positive parenting and recovery from substance use disorder.

Fluoridation

In 1945, Community Water Fluoridation (CWF) began in Grand Rapids, Michigan. Over the last 75 years, it has proven to be a safe and effective measure in the prevention of cavities. Over the past few years and during the pandemic, anti-fluoridation groups have attempted to tie faulty science to community water fluoridation. Nationally, municipal water systems that have had an interruption in their supply line for fluoride have come under pressure to stop fluoridating. In Michigan, three cities have seen a push to stop fluoridating. As an overlapping challenge, the once robust School Mouth Rinse Program has ended with the last manufacturer discontinuing production. CWF continues to be the most equitable form of oral public health. The removal of this fluoride delivery system would leave many children at risk of tooth decay and poorer oral health outcomes.

Children with Special Health Care Needs

There is an emerging focus on Children with Medical Complexity (CMC) who suffer from one or more chronic conditions that affects three or more organ systems or one-life limiting illness or rare pediatric disease. Nationwide, CMC make up less than 4% of the total children’s population but are estimated to account for 40% of Medicaid’s pediatric spending. To address the complex needs of this population, CSHCS is collaborating with the Michigan Health Endowment Fund, Michigan Medicine, University of Michigan, and other Michigan-based Children’s Hospitals to explore the establishment of a CMC Health Home in Michigan. The goals of the CMC Health Home are to improve patient outcomes, increase patient and family satisfaction, and reduce health care costs.

Efforts to apply a health equity lens have contributed to a greater awareness of disparities in access to health care experienced by individuals with sickle cell disease (SCD) which disproportionately affects African Americans. An estimated 3,500 to 4,000 Michiganders are living with SCD. Of those, 798 are children enrolled in CSHCS and 2,317 are adult Medicaid recipients. Individuals with SCD are prone to higher rates of hospitalization, emergency room utilization, and premature death. In FY 2021, CSHCS partnered with the Lifecourse Epidemiology and Genomics Division to submit a proposal to the Governor’s Office to expand CSHCS eligibility to adults with SCD, expand clinical services, and enhance the system of care serving clients with SCD. The proposal was included in the Governor’s FY 2022 budget recommendation and implemented on October 1, 2021. CSHCS continues to implement outreach strategies to reach adults who can benefit from the CSHCS eligibility expansion. In addition, CSHCS is implementing strategies to expand the CMDS clinic model to include adult clinics caring for patients with SCD and developing toolkits for transition programs to improve transition to adulthood in this population.

Improved access to respite care for families with children with special health care needs was identified as a need in the 2020 Needs Assessment. According to the 2019-2020 National Survey of Children’s Health, parents/caregivers of children with special health care needs in Michigan are five times more likely to have left a job, requested a leave of absence, or reduced their work hours due to the stress of their child’s health or health conditions. In response, CSHCS has convened a workgroup comprised of representatives from Program Review Division, CSHCS, Office of Medical Affairs, and the Managed Care Plan Division to assess the current landscape for respite care in Michigan and explore opportunities to expand the CSHCS respite benefit.

[1] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management. Data source: Maternal Deaths in Michigan, 2014-2018 Data Update. MDHHS. Michigan Maternal Mortality Surveillance Program.

[2] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy due to a cause unrelated to pregnancy.

[3] Data from Michigan Inpatient Database Files.

[4] Division for Vital Records and Health Statistics, Michigan Maternal Mortality Surveillance System, MDHHS.

Ongoing and emerging issues that impact the MCH population are discussed in this section, including infant and maternal mortality, COVID-19 and pregnancy, COVID-19 vaccination, routine childhood vaccination trends, the impact of the COVID-10 pandemic on local public health, the unwinding of the Public Health Emergency and Medicaid continuous enrollment, fluoridation, and health concerns specific to children and youth with special health care needs (CYSHCN). Additionally, Title V needs assessment activities in FY 2023 focused on assessing the public health workforce and broadband access for service delivery, which are also discussed in this section.

Ongoing and Emerging Issues that Impact MCH

Infant and Maternal Mortality

MDHHS closely monitors infant and maternal mortality and has seen the following trends and emerging concerns. The infant mortality rate (IMR) in Michigan for 2021 was 6.2 deaths per 1,000 live births, which is another lowest on record IMR. The last lowest on record IMR occurred in 2019. Racial and ethnic disparities remain a major contributor to Michigan’s infant mortality rates. The gap between the Black and white infant mortality rate widened in 2021. The Black infant mortality rate was more than three times that of the White infant mortality rate (13.6 versus 4.4 per 1,000 live births in 2021). The pregnancy-related mortality ratio in Michigan for 2019 was 23.2 maternal deaths per 100,000 live births[[1]]. As with infant mortality, disparities between Black and white mothers exist, with the Black pregnancy-related mortality ratio nearly three times that of the white rate (29.8 versus 10.7 per 100,000 live births based on 2015-2019 data). In addition to maternal deaths caused by pregnancy-related issues, addressing pregnancy-associated, not related mortality[[2]] remains important: 37.9% of all pregnancy-associated, not related deaths from 2015-2019 were caused by accidental poisoning/drug overdose. Michigan’s maternal mortality committees have focused on developing recommendations to help prevent current and expecting mothers from developing substance use disorders.

COVID-19 and Pregnancy

Michigan continues to participate in the CDC COVID-19 Pregnancy and Neonate Surveillance Project. For the project, women who have received a confirmed diagnosis of COVID-19 during pregnancy are identified through the Michigan Disease Surveillance System (MDSS) which is then linked with birth and death certificates to track pregnancy outcomes. After each pregnancy outcome has taken place, medical records for both mother and infant are requested to obtain details regarding the impacts of COVID-19 on the health of mother and infant.

For the 2020 cohort, 1,378 Michigan women were identified with a confirmed COVID-19 diagnosis during pregnancy. A pregnancy outcome was confirmed for 1,288 (93.5%) with the remaining 90 women (6.5%) lost to follow-up. The 1,288 documented pregnancy outcomes resulted in 1,316 live births and less than five fetal deaths. Black pregnant persons were 3.4 times more likely to have a COVID-19 complication than white pregnant persons. Infants of Black parenting persons that were diagnosed with COVID-19 during pregnancy were 2.5 times more likely to be low birthweight compared to infants of white parenting persons that were diagnosed with COVID-19 during pregnancy. Furthermore, birthing parent races other than white were 1.2 times more likely to be in the COVID-19 cohort than those without a COVID-19 diagnosis during pregnancy. Michigan is currently completing data collection for the 2021 project cohort.

In addition to this surveillance project, the Michigan Pregnancy Risk Assessment Monitoring System (MI PRAMS) added COVID-19 questions to the survey. Results from the 2020 MI PRAMS COVID-19 questions indicate that an estimated 2.6% of new Michigan mothers reported that a health care worker told them they had COVID-19 during their most recent pregnancy, and it was confirmed through testing. When including mothers who were told by a health care worker that they had COVID-19 during their most recent pregnancy but they weren’t tested, this number increases to an estimated 3.7% (which represents 3,589 new mothers in 2020). Black, non-Hispanic mothers were nearly twice as likely to report COVID-19 during their most recent pregnancy when compared to white, non-Hispanic mothers. Michigan is awaiting the final 2021 Michigan PRAMS data file from the CDC. Similar analyses will be conducted on the COVID-19 questions.

COVID-19 Vaccination

Table 1 provides Michigan COVID-19 vaccine coverage percentages by age group as of January 14, 2023. Initiation is defined as the percentage of Michigan residents who have received 1 or more doses of any vaccine; completion is defined as the percentage receiving 2 doses of Pfizer or Moderna or 1 dose of Johnson & Johnson, and up to date is defined as the percentage who have received the Pfizer or Moderna Bivalent Booster. Just over one quarter of Michigan residents aged 5-11 years have either initiated or completed their initial COVID-19 vaccinations, but less than 5% of this group are up to date on their COVID-19 vaccinations (i.e., received Pfizer or Moderna Bivalent Booster). Initiation and completion rates increase to around 50% for those aged 12-29 years and increase to 60% or above for Michigan residents aged 30 years and above. Most of the Michigan population is not up to date with COVID-19 vaccinations.

Table 1. COVID-19 Vaccine Coverage Percentages by Age Group

Priority Childhood Vaccinations

Table 2 provides Michigan child vaccination percentages for January through September 2022. When compared to the US average, Michigan reports lower immunization percentages for each of the main childhood vaccinations. Table 3 provides information on child vaccination percentages in Michigan over time. Since the first quarter of 2020 (January-March 2020), Michigan has experienced consistent decreases in each of the priority childhood vaccinations.

Table 2. Michigan Childhood Vaccination Rates in Comparison to US

Table 3. Michigan Childhood Vaccination Rates Over Time

*4313314(2): 4 DTaP, 3 Polio, 1 Measles/Mumps/Rubella (MMR), 3 Hib, 3 Hepatitis B, 1 Varicella, 4 PCV, (2 Hepatitis A)

Impact of COVID-19 on Local Public Health

In 2022, the MDHHS Division of Local Public Health held site visits with 40 of 45 Local Health Departments (LHDs) to obtain feedback about the impacts of COVID-19. Conversations with LHD staff revealed that both the immediate and longer-term impacts of the pandemic have been significant and far-reaching for staff, families, and communities. LHD staff described trauma in the form of battle fatigue, lost leave, threats to staff and leadership, heartbreak at the community response, and mental and behavioral health challenges. State and local staff turnover was another challenge that resulted in loss of institutional knowledge. LHD staff also noted the need to promote workplace flexibility and to rebuild relationships with the community. They suggested that flexibility in background and experience in hiring may also help to mitigate staff turnover.

Staff also described how LHDs have had to contend with misinformation. Additionally, the ending of the public health emergency impacted Medicaid, WIC, and MIHP eligibility. Essential worker funds have been exempted from LHDs all but one time, significantly impacting morale and retention. Reengagement with LPH services, including clinical services, especially WIC and Immunizations, has become necessary. After Action Reporting has been proposed to capture the response in a useful form for the future. Despite the many challenges, there have been positives, such as the Michigan National Guard (MING) partnership, establishment/strengthening of regional lab systems, volunteers in the community, and CDC Foundation surge staffing.

Unwinding of the Public Health Emergency and Medicaid Continuous Enrollment

During the COVID-19 Public Health Emergency (PHE), state Medicaid agencies were required to continue health care coverage for all medical assistance programs, even if a person’s eligibility changed. The end of the PHE on May 11, 2023, triggered the unwinding of the Medicaid continuous enrollment provision which ends on March 31, 2023. Starting in June, Michigan Medicaid beneficiaries will have to renew their coverage as the state resumes eligibility redeterminations. MDHHS has taken many steps to make beneficiaries aware of the redetermination requirements and to help individuals retain Medicaid coverage if eligible. MDHHS communications provide consistent messages about three key steps for Medicaid beneficiaries related to the redetermination process and avoiding gaps in coverage: make sure contact information is up to date; report any changes to a household or income; and complete a renewal packet by the due date, if eligible. A Medicaid Benefit Changes website provides information on the PHE, eligibility renewal timeline, an FAQ document, and resources for Medicaid providers and community partners. A stakeholder toolkit includes a “Get Ready” flyer in English, Spanish, and Arabic; a platform to request redetermination materials in English, Spanish, and Arabic (e.g., wallet cards, posters, and animated files); Medicaid renewal information; and a Beneficiary Renewal Alert Letter example. MDHHS will also launch a multi-media campaign with radio ads, mobile and social media ads, audio streaming, and outdoor ads.

MDHHS issued a press release about the unwinding on February 15, 2023, which included information related to individuals who are no longer eligible for Medicaid:

Michiganders who no longer qualify for Medicaid will receive additional information about other affordable health coverage options available, including on HealthCare.gov. Affected Michiganders will be able to shop for and enroll in comprehensive health insurance as they transition away from Medicaid, and many Michiganders can purchase a plan for less than $10 per month. Renewals for traditional Medicaid and the Healthy Michigan Plan will take place monthly starting in June 2023 and run through May 2024. Monthly renewal notices will be sent three months prior to a beneficiaries’ renewal date starting with June renewal dates.

To help ensure that the MCH population continues to receive Medicaid services and, if no longer eligible, avoids gaps in coverage, MCH programs have shared information about the unwinding with partners and program recipients. For example, the Child and Adolescent Health Center (CAHC) Program provided detailed information on the unwinding to school based/linked health centers and School Wellness Program sites. Information included MDHHS information and resources, a link to the MDHHS stakeholder toolkit, and tips for how CAHCs—since they provide Medicaid outreach and enrollment assistance onsite—can help families navigate the redetermination process.

The CSHCS program reached out to Medicaid partners to provide an overview of the unwinding and redetermination process for the CSHCS Advisory Committee. The Advisory Committee is comprised of organizations (providers, disease specific organizations, etc.) and parent/family members with a focus on children with special needs. A discussion about the redetermination process will focus on how CSHCS stakeholders can support clients with redetermination eligibility. Additionally, potential loss of Medicaid coverage due to the end of the PHE could have cost implications for the CSHCS program. CSHCS dual enrollment with Medicaid increased during the PHE. If dual enrollment numbers return to pre-Covid levels, it will lead to an increase in non-Medicaid costs for the CSHCS Title V medical care and treatment program.

Michigan’s MCH programs will continue to monitor the unwinding and redetermination processes and identify ways to assist partners and clients, so that everyone who is eligible for Medicaid benefits continues to receive them.

Fluoridation

In 1945, Community Water Fluoridation (CWF) began in Grand Rapids, Michigan. Over the last 78 years, it has been a safe and effective strategy in the prevention of cavities. The US Surgeon General states that CWF is one of the most cost-effective, equitable, and safe measures communities can take to prevent tooth decay and improve oral health. Over the past few years, anti-fluoridation groups have grown more visible. Nationally, municipal water systems that have had an interruption in their supply line for fluoride have come under pressure to stop fluoridating. In a northern Michigan community, the city council recently voted to discontinue community water fluoridation due to the lack of supply and increased costs despite community support of fluoridation. The once robust School Mouth Rinse Program has ended with the last manufacturer discontinuing production. The removal of this fluoride delivery system leaves many children at risk of tooth decay and poorer oral health outcomes.

Children with Special Health Care Needs

There is an emerging focus on Children with Medical Complexity (CMC) who suffer from one or more chronic conditions that affects three or more organ systems or one-life limiting illness or rare pediatric disease. Nationwide, CMC make up less than 4% of the total children’s population but are estimated to account for 40% of Medicaid’s pediatric spending. To address the complex needs of this population, CSHCS is collaborating with Michigan Medicaid, Michigan Medicine, Michigan-based Children’s Hospitals, and stakeholders to explore the establishment of a CMC benefit in Michigan. The goals of the CMC benefit are to improve patient outcomes, increase patient and family satisfaction, and reduce health care costs by enhancing the systems of care for CMC and, more broadly, CYSHCN.

Application of a health equity lens has contributed to greater awareness of disparities in access to health care experienced by individuals with sickle cell disease (SCD) which disproportionately affects African Americans. An estimated 3,500 to 4,000 Michiganders are living with SCD. Individuals with SCD are prone to higher rates of hospitalization, emergency room utilization, and premature death. In FY 2021, CSHCS partnered with the Lifecourse Epidemiology and Genomics Division (LEGD) to submit a proposal to the Governor’s Office to expand CSHCS eligibility to adults with SCD, expand clinical services, and enhance the system of care serving clients with SCD. The proposal was embraced by the Governor and enacted in the FY 2022 budget appropriation. In FY 2022, 421 adults were enrolled with CSHCS. The program continues to implement outreach strategies to reach adults who can benefit from the CSHCS eligibility expansion, while also partnering with colleagues in LEGD to enhance clinical capacity to serve individuals with SCD. In addition, CSHCS is implementing strategies to expand the CMDS clinic model to include adult clinics caring for patients with SCD and developing toolkits for transition programs to improve transition to adulthood.

Improved access to respite care for families with CSHCN was identified as a need in the 2020 Needs Assessment. According to the 2019-2020 National Survey of Children’s Health, parents/caregivers of children with special health care needs in Michigan are five times more likely to have left a job, requested a leave of absence, or reduced their work hours due to the stress of their child’s health or health conditions. In response, CSHCS engaged with Partners for Children which completed a survey of 15 states to identify respite gaps and reached out to the Catalyst Center for additional evidence to support a policy change for CSHCS respite. CSHCS convened an internal workgroup with representation from Program Review Division, CSHCS, Office of Medical Affairs, and other partners to review and revise existing CSHCS respite policy. The committee has identified eligibility criteria and is in the process of estimating the population that would benefit from this policy change.

Literature Review

In 2023, a literature review was completed to understand more about the public health workforce and broadband access in Michigan. The full literature review, including citations, is included as a Supporting Document to this application. Highlights are included below.

Public Health Workforce

The public health workforce is essential to protecting and promoting the health and wellbeing of Michigan’s population of over 10 million people. The workforce is responsible for a range of essential services, including disease prevention and control, environmental health, emergency preparedness and response, health education, and health policy development. The COVID-19 pandemic exerted significant pressure on the public health system, including the maternal and child health system, and highlighted gaps that were compounded by the lack of investment into the state’s public health infrastructure, which has been understaffed and underfunded for many years (Bridge Michigan, 2023).

The strain on Michigan’s public health infrastructure is further exacerbated by several other challenges facing the public health workforce. One of the biggest challenges is the shortage of public health professionals in the state. According to a report by the National Public Health Information Coalition (NPHIC), there is a significant nationwide shortage of public health professionals, especially among nurses (NPHIC, 2021). Michigan ranked 5th in the highest number of mental health HPSAs, after California, Texas, Arkansas, and Missouri. The state ranked 6th in the highest number of primary care HPSAs and 7th in the highest number of dental health HPAs (HRSA, 2022).

Figure 1. Primary Care Health Professional Shortage Areas (HPSAs)

Source: Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, 2022

According to 2022 data from the Health Resources and Services Administration (HRSA), 55 of 83 counties in Michigan (66%) were considered whole area dental care shortage areas. A higher percentage of counties (71%) were considered whole area primary care shortage areas, while 86% of counties in Michigan were considered whole area mental health shortage areas.

Figure 2. Dental Care, Primary Care, and Mental Health HPAs, by County, 2022 – Michigan

Source: Health Resources and Services Administration (HRSA), U.S. Department of Health & Human Services, 2022

Although these shortages were observed before the pandemic, they were exacerbated by stressors placed on the workforce during the pandemic. Several factors contribute to the shortage of public health workers in Michigan, including:

• Burnout, Stress, and Trauma
• Aging Workforce
• Lack of Funding and Low Pay

The need for additional specialized skills and training is another obstacle facing the public health profession in Michigan. Finally, there is a need for a more diverse public health workforce in Michigan. According to the PH WINS, the public health workforce is not representative of the communities it serves, particularly in terms of race and ethnicity. This lack of diversity can limit the effectiveness of public health programs and services in reaching and engaging communities of color.

To address workforce issues in the state, Michigan has implemented several initiatives to support the maternal and child health workforce and increase access to care for these populations. For example, the state has established loan repayment programs and other financial incentives to encourage mental health providers to provide direct service and physicians to practice in underserved areas. Additionally, Michigan has implemented telehealth programs to expand access to care in rural areas. Another potential solution includes increasing the number of healthcare professionals trained to provide maternal and child healthcare services in rural areas.

Broadband Access

Michigan is a state with diverse geography and population, ranging from urban areas like Detroit and Grand Rapids to rural and remote communities in the Upper Peninsula and Northern Lower Peninsula. Although more communities have access to broadband in recent years than in the past, significant disparities in broadband access remain. According to a report by the Michigan Department of Labor and Economic Opportunity (LEO), which houses the newly established Michigan High-Speed Internet Office (MIHI), an estimated 1.24 million Michigan households (31.5%) do not have a permanent, fixed internet connection at home and an additional 865,000 households face barriers related to cost, adoption, or digital literacy. The lack of access is more severe in rural areas and among low-income families, communities of color, and individuals with disabilities. According to LEO, “Black and Latino Michiganders are nearly half as likely to have a home broadband connection than non-Black or Latino residents” and “nearly 35% of households earning less than $20,000 annually do not have a broadband connection.” These disparities in access have implications for public health, as they can limit access to health information, public health services, telemedicine, and eHealth technologies, particularly for under-resourced communities and populations. The map below shows the availability of broadband service with speeds of at least 25 Mbps download in Michigan.

Figure 3. Broadband Service with Speeds of at Least 25 Mbps Download/3 Mbps Upload – Michigan

Source: Connected Nation Michigan, 2021

The lack of broadband access can have significant public health implications for residents of Michigan. Limited access to telemedicine can limit the ability of residents to receive timely and appropriate medical care. Initial data suggest that employing virtual care to replace some traditional in-person sessions, such as home visiting, may be a positive long-term alternative for some families and some types of services. Telemedicine can be particularly important for individuals living in rural areas or those with mobility challenges.

Strategies to Improve Broadband and Telehealth Access

Strategies have been proposed to address the digital divide and improve public health outcomes in Michigan. These strategies include:

1. Increasing broadband infrastructure in rural areas
2. Providing affordable internet and technology
3. Improving digital literacy and accessibility
4. Partnering with community organizations
5. Leveraging telehealth technology

Michigan has taken several steps to address the digital divide and promote public health broadband access, including the creation of the Michigan Broadband Roadmap, which was developed by the Michigan Department of Labor and Economic Opportunity (LEO) in collaboration with stakeholders from government, industry, and community organizations. The roadmap aims to identify gaps in broadband infrastructure and services, prioritize investment and deployment strategies, and promote public-private partnerships to expand access.

Broadband Funding Opportunities and Initiatives

Another important strategy for promoting public health broadband access in Michigan is the use of federal funding programs, such as the Connect America Fund (CAF) and the Rural Digital Opportunity Fund (RDOF). These programs provide subsidies and grants to broadband providers to expand their networks to unserved and underserved areas, including rural and low-income communities.

Other state-level programs include Connecting Michigan Communities (CMIC). The Michigan Department of Technology, Management, and Budget (DTMB) is offering a grant to extend broadband service to unserved Michigan areas. The grant funds are available for projects that demonstrate collaboration to achieve the area's community investment and economic development objectives. Statewide funding of $20 million was allocated to this grant program for the 2019 application year. The initial round of awards has been announced, and next year, approximately $15 million is anticipated to be allocated to this program.

Conclusion

The public health infrastructure in Michigan plays a critical role in promoting and protecting the health of communities. However, the public health workforce is facing a range of challenges, including an aging workforce, shortages of certain types of professionals, low compensation, stress and trauma, and a need for workforce development and training. By addressing these challenges and seizing these opportunities, Michigan can support a robust and effective public health workforce that is well-equipped to meet the needs of its diverse communities.

Technology and access to broadband can be leveraged to further strengthen public health infrastructure and access to services. Improving broadband access for people of childbearing age, pregnant people, infants, children, adolescents, and children and youth with special health care needs in Michigan is critical to improving public health outcomes and reducing health disparities for these populations.

By implementing innovative strategies, Michigan can improve public health outcomes for all residents, including those who are currently unserved and marginalized. By continuing to prioritize the public health workforce and broadband access as essential elements of an effective public health system, Michigan can make progress towards improving health outcomes and reducing health disparities for the MCH and CSHCN populations.

[[1]] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management. Data source: Maternal Deaths in Michigan, 2014-2018 Data Update. MDHHS. Michigan Maternal Mortality Surveillance Program.

[[2]] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy due to a cause unrelated to pregnancy.

Ongoing and emerging issues that impact the MCH population are discussed in this section, including infant and maternal mortality, Congenital Syphilis, COVID-19 vaccination, COVID-19 and pregnancy, priority childhood vaccinations, the unwinding of the Public Health Emergency and Medicaid enrollment, and fluoridation. Health concerns specific to Children and Youth with Special Health Care Needs (CYSHCN) are also discussed and include children with medical complexity, Sickle Cell Disease, and respite care for families with CYSHCN.

Michigan’s Title V program is in the process of implementing the next five-year needs assessment, which is due in July 2025. This has included developing the needs assessment framework, goals, structures, and processes and implementing assessment activities. Additionally, the Title V program has been identifying ways to address the new universally required National Performance Measures (Postpartum Visit in the Women/Maternal Health Domain; Medical Home in the Child Health Domain; and Medical Home in the CSHCN Domain) which are included as state action plans in this application and will also be included in the next five-year cycle for FY 2026-2030.  

Ongoing and Emerging Issues that Impact MCH

Infant and Maternal Mortality

MDHHS closely monitors infant and maternal mortality and has seen the following trends and emerging concerns. The infant mortality rate (IMR) in Michigan for 2022 was 6.4 deaths per 1,000 live births. This is a slight increase from the lowest on record IMR in 2021 at 6.2 deaths per 1,000 live births. Racial and ethnic disparities remain a major contributor to Michigan’s infant mortality rates. Although the gap between the Black and White infant mortality rate decreased slightly since 2021, when the Black infant mortality rate was more than three times greater than the corresponding White infant mortality rate, the 2022 gap is still higher than the disparity in 2020. In 2022, the Black Non-Hispanic infant mortality rate was 2.8 times that of the White Non-Hispanic infant mortality rate (13.3 versus 4.8 per 1,000 live births). The pregnancy-related mortality ratio in Michigan for 2020 was 43.2 maternal deaths per 100,000 live births[[1]]. As with infant mortality, disparities between Black and White mothers exist, with the Black pregnancy-related mortality ratio 2.2 times that of the White ratio (36.5 versus 16.3 per 100,000 live births based on 2016-2020 data). In addition to maternal deaths caused by pregnancy-related issues, addressing pregnancy-associated, not related mortality[[2]] remains important: 35.7% of all pregnancy-associated, not related deaths from 2016-2020 were caused by accidental poisoning/drug overdose.

Michigan’s maternal mortality review committee has focused on developing recommendations to help prevent current and expecting mothers from developing substance use disorders. In 2024, a new report Maternal Deaths in Michigan Data Update, 2016-2020 was released and provides a high-level overview of Michigan’s pregnancy-associated deaths, including determination of pregnancy-relatedness, demographics, disparities, causes of death, preventability and recommendations to prevent future deaths. Additionally, Michigan’s fatality review programs have been working together to create a process for coordinating, collaborating, and elevating aligned prevention recommendations. The newly released report Michigan Maternal Mortality Surveillance (MMMS) and Fetal Infant Mortality Review (FIMR) Aligned Recommendations is intended to amplify shared/aligned strategies for prevention of maternal, fetal, and infant deaths.

Congenital Syphilis

Michigan, like much of the nation, is experiencing an alarming increase in Congenital Syphilis (CS) cases. The debilitating outcomes of untreated Syphilis in utero include deformed bones, severe anemia (low blood count), enlarged liver and spleen, jaundice (yellowing of the skin or eyes), and brain and nerve problems including blindness or deafness. In 2023, Michigan saw an increase of 238% since 2019 with 54 cases, three stillbirths and one infant death reported. This vertical transmission, from mother to infant, parallels the increase in female syphilis cases due to increased heterosexual exposure. The geographic, race, and ethnicity distribution of these cases is 55% Black with 40% residing in Detroit, reflecting a large disparity among African Americans. The maternal age group most affected is 20-39. Michigan data suggest that a lack of adequate prenatal care is the most common factor contributing to CS, as two thirds of cases received little or no prenatal care.

CS is preventable if a pregnant person receives appropriate and timely testing and treatment. Early identification of syphilis through a serology test is crucial. Initiation of syphilis treatment in a pregnant person at least 30 days before delivery averts CS. Therefore, it is important for clinicians to adhere to Michigan’s Perinatal Screening Guidelines that require screening in the first trimester, again in the early third trimester (28 weeks), and at delivery if no record of previous testing or declination is documented.  Notably, this law applies to all pregnant persons in Michigan, and all settings where pregnant persons access medical care, not just traditional prenatal providers. 

MDHHS is committed to supporting community partners to prevent CS. Efforts include:

• Print resources for clinicians and their patients can be found here.
• Partner with MDHHS Medicaid Program to develop pregnancy screening performance measures that follow Michigan’s perinatal guidelines for managed health care plans.
• Fund an Electronic Medical Record (EMR) Best Practice Alerts (BPA) project in Southeastern Michigan. The alerts will indicate whether an emergency department patient may be indicated for an HIV, HCV, and/or syphilis test based on algorithms that will flag individuals most likely to benefit from related services.
• Support an HIV/syphilis clinician consult program through a major health system.
• Enhance patient follow up services to support clinicians.
• Awareness building by providing physician detailing and large group presentations for clinicians.

Michigan’s Maternal and Congenital Syphilis Fact sheet can be found here.

COVID-19 Vaccination

Table 1 provides Michigan COVID-19 vaccine coverage percentages by age group as of January 3, 2024. At Least One Dose is defined as the percentage of Michigan residents who have ever received any type of COVID-19 vaccine in their lifetime; Updated 2023-2024 is defined as the percentage being up-to-date based on the CDC recommendation for the 2023-2024 season. Nearly 33% of Michigan residents aged 5-11 years have had at least one COVID-19 vaccine in their lifetime, but only 5% of this group are up to date on their COVID-19 vaccinations for the 2023-2024 season.

The percentage of ever having received a COVID-19 vaccination increases steadily with age and is the highest, at 95%, among those aged 75+ years. The updated 2023-2024 percentage also increases with age, but at a slower rate. Less than 12% of Michigan residents aged 64 years or less are fully vaccinated based on the current CDC recommendations. Michigan residents aged 75+ years have the highest percentage for up-to-date COVID-19 vaccinations at just over 36%.

Table 1. COVID-19 Vaccine Coverage Percentages by Age Group

COVID-19 and Pregnancy

With the completion of the 2021 cohort, Michigan has concluded its participation in the CDC COVID-19 Pregnancy and Neonate Surveillance Project. For the project, women who received a confirmed diagnosis of COVID-19 during pregnancy during 2020 and/or 2021 were identified through the Michigan Disease Surveillance System (MDSS) which was then linked with birth and death certificates to track pregnancy outcomes. After each pregnancy outcome occurred, medical records for both mother and infant were requested to obtain details regarding the impacts of COVID-19 on the health of mother and infant.

For the 2020 cohort, 1,378 Michigan women were identified with a confirmed COVID-19 diagnosis during pregnancy. A pregnancy outcome was confirmed for 1,288 (93.5%) with the remaining 90 women (6.5%) lost to follow-up. The 1,288 documented pregnancy outcomes resulted in 1,316 live births and less than five fetal deaths. Black pregnant persons were 3.4 times more likely to have a COVID-19 complication than White pregnant persons. Infants of Black parenting persons that were diagnosed with COVID-19 during pregnancy were 2.5 times more likely to be low birthweight compared to infants of White parenting persons that were diagnosed with COVID-19 during pregnancy. Additional results from the 2020 cohort can be found within the full COVID-19 and Pregnancy factsheet. Plans are in place to analyze the 2021 cohort data and develop another factsheet.

Priority Childhood Vaccinations

Table 2 provides Michigan child vaccination percentages for July through September 2023. When compared to the US average, Michigan reports lower immunization percentages for each of the main childhood vaccinations. Table 3 provides information on child vaccination percentages in Michigan over time. Since the third quarter of 2021 (October-December 2021), Michigan has experienced consistent decreases in each of the priority childhood vaccinations.

Table 2. Michigan Childhood Vaccination Rates in Comparison to US

Table 3. Michigan Childhood Vaccination Rates Over Time

*4313314(2): 4 DTaP, 3 Polio, 1 Measles/Mumps/Rubella (MMR), 3 Hib, 3 Hepatitis B, 1 Varicella, 4 PCV, (2 Hepatitis A)

MCH Vaccination Efforts

To address and support COVID-19 vaccination as well as other routine vaccination among the MCH population, MCH program activities include the following:

• Child and Adolescent Health Centers (CAHCs) provide school-based or school-linked comprehensive primary and preventive health and mental health services for children and adolescents ages 5-21 years. CAHCs help students keep vaccination status up to date by providing any needed vaccines. CAHCs directly supported influenza and COVID-19 vaccination efforts during the pandemic. In FY 2023, CAHCs provided 23,674 immunizations to students.
• The Division of Maternal and Infant Health hired a Public Health Nurse Consultant (PHN) in 2021 within the Maternal Infant Health Program (MIHP) to focus on immunization efforts. In 2022, the PHN worked with a marketing firm to develop and launch a campaign to increase awareness of immunizations. In 2023, a training module was developed to provide education related to immunization among pregnant people, infants, and their families. This module is required for all MIHP home visitors and includes information related to immunization recommendations, motivational interviewing, vaccine hesitancy, and disparities in vaccination rates. The consultant also reviews and develops immunization content for the MIHP Bi-Weekly Update email newsletters and for the phone application Pregnancy+. To increase awareness and share resources, federal immunization awareness campaigns such as National Immunization Awareness Month and National Infant Immunization Week are shared. The PHN also provided an Immunization Update webinar in February 2024. Assessment of immunization status has been integrated into MIHP protocols and a Quality Assessment review that took place from 2023-2024. Additionally, a comprehensive vaccine education toolkit is under development in 2024 to provide home visitors with a user-friendly tool for enhancing communication with families.
• The CSHCS Vaccine Initiative addresses vaccination gaps in CYSHCN and their families. Funding was provided to LHDs to improve access to COVID-19 vaccines; expand vaccination education, messaging, and partnerships; and improve understanding of barriers to vaccination. The funding for this project ended in June 2023.

Unwinding of the Public Health Emergency and Medicaid Continuous Enrollment

During the COVID-19 Public Health Emergency (PHE), state Medicaid agencies were required to continue health care coverage for all medical assistance programs, even if a person’s eligibility changed. The end of the PHE on May 11, 2023, triggered the unwinding of the Medicaid continuous enrollment provision. Starting in June 2023, Michigan Medicaid beneficiaries had to renew their coverage as the state resumed eligibility redeterminations. MDHHS took many steps to make beneficiaries aware of the redetermination requirements and to help individuals retain Medicaid coverage if eligible. Those activities were discussed in detail in last year’s Title V application.

Current information on renewals is available on the Michigan Medicaid Renewals Data website. A press release issued by MDHHS on January 31, 2024, indicates that more than 1.1 million Michigan Medicaid beneficiaries had their coverage renewed six months into the renewal process. Several strategies have been used to ease the renewal process and mitigate the risk of coverage loss, including extending renewals to May 2024 for beneficiaries undergoing life-saving treatment and providing beneficiaries an extra month to submit paperwork. Michigan’s MCH programs will continue to monitor the unwinding and redetermination processes and assist partners and clients, as needed, so that individuals who are eligible for Medicaid benefits continue to receive them.

In particular, the potential loss of Medicaid coverage could have cost implications for the CSHCS program. The CSHCS program hosted Medicaid partners at a CSHCS Advisory Committee meeting to provide an overview of the unwinding and redetermination process. The Advisory Committee includes organizations (providers, disease-specific organizations, etc.) and parent/family members with a focus on children with special needs. The discussion included general information on the unwind process and the anticipated impacts on CSHCS clients. CSHCS continues to monitor enrollment trends closely. CSHCS dual enrollment with Medicaid increased during the PHE. Current data indicate total enrollment is trending toward pre-COVID levels with decreases in CSHCS clients dually enrolled in Medicaid.

Fluoridation

In 1945, Community Water Fluoridation (CWF) began in Grand Rapids, Michigan. Over the last 79 years, it has been a safe and effective strategy in the prevention of cavities. The US Surgeon General states that CWF is one of the most cost-effective, equitable, and safe measures communities can take to prevent tooth decay and improve oral health. Over the past few years, anti-fluoridation groups have grown more visible. In a northern Michigan community, the city council recently voted to discontinue community water fluoridation due to the lack of supply and increased costs despite community support of fluoridation. The once robust School Mouth Rinse Program has ended with the last manufacturer discontinuing production. The removal of this fluoride delivery system leaves many children at risk of tooth decay and poorer oral health outcomes. MDHHS is continuing to monitor fluoridation activities around the state.

Children with Special Health Care Needs

Nationwide, there is an emerging focus on Children with Medical Complexity (CMC) who suffer from one or more chronic conditions and experience high healthcare utilization. CSHCS estimates that CMC make up less than 4% of the CSHCS population but are estimated to account for 40% of Medicaid’s pediatric spending. To address the complex needs of this population, CSHCS is collaborating with Michigan Medicaid, Michigan Medicine, Michigan-based Children’s Hospitals, and stakeholders to explore the establishment of a targeted case management benefit for CMC in Michigan. The goals of the CMC program are to improve patient outcomes, increase patient and family satisfaction, and reduce healthcare costs by enhancing the systems of care for CMC and, more broadly, CYSHCN.

Sickle Cell Disease (SCD) is a chronic condition which disproportionately affects African Americans. An estimated 3,500 to 4,000 Michiganders are living with SCD. Individuals with SCD are prone to higher rates of hospitalization, emergency room utilization, and premature death. In FY 2021, CSHCS partnered with the Lifecourse Epidemiology and Genomics Division (LEGD) to submit a proposal to the Governor’s Office to expand CSHCS eligibility to adults with SCD, expand clinical services, and enhance the system of care serving clients with SCD. The proposal was embraced by the Governor and enacted in the FY 2022 budget appropriation. By FY 2023, 578 adults with SCD have been enrolled with CSHCS. The program continues to implement outreach strategies to reach adults who can benefit from the CSHCS eligibility expansion, while also partnering with colleagues in LEGD to enhance clinical capacity to serve individuals with SCD. In addition, CSHCS is implementing strategies to expand the CMDS clinic model to include adult clinics caring for patients with SCD. Since FY 2022, six CMDS clinics have been added with the hematology/oncology specialty type. Additionally, in FY 2023, the CSHCS transition specialist started working with LEGD and one clinic site to develop toolkits for transition programs to improve the transition to adulthood for SCD patients.

Improved access to respite care for families with CSHCN was identified as a need in the 2020 Needs Assessment. According to the 2019-2020 National Survey of Children’s Health, parents/caregivers of children with special health care needs in Michigan are five times more likely to have left a job, requested a leave of absence, or reduced their work hours due to the stress of their child’s health or health conditions. In response, CSHCS engaged with Partners for Children which completed a survey of 15 states to identify respite gaps and reached out to the Catalyst Center for additional evidence to support a policy change for CSHCS respite. CSHCS convened an internal workgroup with representation from Program Review Division, CSHCS, Office of Medical Affairs, and other partners to review and revise existing CSHCS respite policy. The committee has identified eligibility criteria and is in the process of estimating the population that would benefit from this policy change.

In FY 2023, MDHHS utilized American Rescue Plan Fiscal Recovery Funds to issue relief grants for family caregivers who provided continuous direct care support for a family member during the Public Health Emergency. CSHCS utilized claims data to identify families who met eligibility criteria between March 1, 2020, and May 11, 2023. The grant was provided to families to reimburse a caregiver of their choice for respite services or to help them afford a form of “relief or respite” that meets their needs. Approximately 3,000 CSHCS beneficiaries received a one-time payment of $2,840.

[[1]] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy from any cause related to or aggravated by the pregnancy or its management. Data source: Maternal Deaths in Michigan, 2016-2020 Data Update. MDHHS. Michigan Maternal Mortality Surveillance Program.

[[2]] Includes maternal deaths while pregnant or within 1 year of the end of a pregnancy due to a cause unrelated to pregnancy.