Geographic Considerations

Mississippi encompasses nearly 47,000 square miles, making it the thirty-first largest state by total area in the nation. The state is geographically located in the southeastern portion of the United States and is named for the river that flows along its western border. Mississippi is bordered by Tennessee to the north; Alabama to the east; Louisiana and a narrow coast on the Gulf of Mexico to the south; and across the Mississippi River, by Louisiana and Arkansas to the west. Mississippi's physical features are lowland with the hilliest portion located in the northeast section of the state, where the foothills of the Appalachians cross the border, Woodall Mountain rises to 806 feet. However, the mean elevation for

the entire state is only 300 feet. From east central Mississippi heading south, the land contains large concentrations of piney woods which give way to coastal plains towards the Gulf Coast. Southwest Mississippi tends to be quite rural with significant timber stands. The Mississippi Delta, the northwest section of the state, is technically an alluvial plain, created over thousands of years by the deposition of silt over the area during repeated flooding of the Mississippi River. The Delta is exceedingly flat and contains some of the world's richest soil. Mississippi leads the nation in catfish production and the Mississippi Delta is the birthplace of the Blues, which preceded the birth of Jazz, the only other original American art form.

The residents of Mississippi are dispersed throughout 82 counties and 298 incorporated municipalities. While three‐fourths of the state’s citizens reside in one of these incorporated places, most of these cities and towns are small. As of July 2018, Jackson, the state’s capital and largest city, has a population of 164,422, and the next largest city is Gulfport, with a population estimate of 71,705. The state is predominantly rural, where 65 (79.3%) of the 82 counties are considered rural areas. Mississippi has three standard metropolitan statistical areas (MSA): the Jackson Metropolitan Area (Hinds, Madison, and Rankin Counties) ; the Hattiesburg area (Forrest and Lamar Counties) ; and the Gulf Coast Region (Hancock, Harrison, and Jackson Counties). Desoto County, located in North Mississippi, is included in the Memphis, Tennessee MSA. All 82 counties in Mississippi are designated whole or in part as medically underserved areas, according to the Health Resources and Services Administration (HRSA).

Population and Demographics

Mississippi is the 32nd most populous state, accounting for just less than 1% of the U.S. population. In 2019, Mississippi had an estimated population of 2.986 million, with 51.5% being female and 48.5% being male.  Among people reporting on race alone, 59.1% identified as  “White, non-Hispanic”, the predominant racial/ethnic group, with “Black/African American, non-Hispanic” as the second largest group accounting for over 37.8% of the population; and Asian, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander accounting for less than 2% of the population. Mississippi has the highest percentage of residents identifying as “Black/African American” in any U.S. state. The immigrant populations, including non-citizens, continues to grow, as Latinos seek work in the poultry, forestry, and construction industries in the state. Those identifying as Hispanic or Latino account for 3.2% of the population. A relatively large Latino population is found in Scott County between Jackson and Meridian. The Mississippi Gulf Coast has a Vietnamese population that has grown since the 1980s when they began to settle along the coastlines of Louisiana, Mississippi, Alabama and Florida after leaving their native country.

Regarding the Maternal and Child Health (MCH) population, there are an estimated 589,546 women of reproductive age (15 to 44 years), 713,567children and youth (age 18 and younger), and 169,815 children and youth with special health care needs (0 to 17 years). According to the U.S. Census Bureau, approximately 51.5% of Mississippi residents are female, and 23.6% of residents are under 18 years old. In 2017 the fertility rate was 63.1 live births per 1,000 females aged 15‐44 years of age.

Note: Rate per 1,000 females aged 15-44

Source: MSDH, Vital Records and Public Health Statistics 

Education

Education is vital to the health and well-being of the state’s MCH population. Data from the U.S. Census Bureau identified that less than one fourth (21.3%) of all Mississippians age 25 and older have a bachelor’s degree or higher. Educational attainment among different racial and ethnic groups in the state was 24.7% for White, non‐Hispanics earning a bachelor’s degree or more, 14.6% Black/African Americans, and 12.9% of those identifying as Hispanic or Latino. Nearly 14% of those 25 or older with a bachelor’s degree and 8.6% with a graduate or professional degree in the state are women. According to the M.S. Department of Education, the 2019 high school graduation rate in Mississippi was 85%, higher than the previous year. The graduation rate for students with disabilities also increased, to 42.2% in 2019 from 36.4% the previous school year. The drop‐out rate dipped to 9.7% in 2019 from 10.6% the previous school year.

Employment

According to the 2020 County Health rankings, the top three counties with the highest number of unemployed individuals are Hinds (5,037), Harrison (3,9170, and Desoto (3,384). In comparison to other states, Mississippi’s unemployment rates are higher. In July 2020 the state had an estimated unemployment rate of 10.8% compared to the national rate of 10.2%. 

Income and Poverty

Income equality has a broad health impact that increases the risk of mortality, poor health outcomes, and other disease risks. Inequalities within the state can accentuate differences in social class and status. Mississippi ranks 51st for the percentage of people who had incomes below the poverty line in 2018.  19.7% of the population in the state is at or below the poverty level, compared to the nation at 11.8%. The state’s per capita income was $23,434 (2014‐2018). The median household income for the state was $43,567. Approximately 30% of Mississippi children live in poverty compared to 16% in the U.S. When looking at children below the federal poverty level by race, Black/African American children account for 49% compared to White, non‐Hispanic children at 16%.  

Food Security

Having access to nutritious food influences healthy eating habits. Individuals who live in neighborhoods where grocery stores are nor accessible have limited access to fresh, healthy food choices. All Mississippians have felt the effects of food insecurity and/or food deserts whether they are living rural or urban. Food deserts are areas with limited or no access to fresh, healthy foods. Statewide, Mississippians travel more than 30 miles to reach a grocery store, with rural counties such as the Mississippi Delta averaging one grocery store per 190.5 miles. This results in traveling long distances with often no public transportation systems in place in rural areas. According to America’s Health Rankings, in 2019, 17.2 % of Mississippians were unable to provide adequate food for one or more household members due to lack or resources.

Transportation

Transportation is vital for travel to work and school, access to medical care and healthy food, and fostering community connections. As aforementioned, Mississippi is majority rural resulting in limited transportation systems. Because transportation systems are limited, many Mississippians aren’t provided access to all communities which results in difficulty accessing resources. Direct transportation impacts an individual’s overall’s health.

Health Insurance

According to U.S. Census Bureau data, 85.6% of Mississippians under 65 years have health insurance of some kind, and 14.4% were uninsured. Among the uninsured population, 5.0% are under 19 years, 12.5% of the White non-Hispanic and 15.8% of Black/African Americans.

Health Indicators and Outcomes

The social determinants of health, such as geographical, economic, and social factors, contribute to the overall health and health equity of Mississippi’s MCH population. With the socioeconomic disadvantages facing many Mississippi residents, there are consistent poor health outcomes in communities, contributing to some of the nation’s highest rates across many health indicators. However, there has been some improvement in such areas such as the decreasing infant mortality and teen birth and pregnancy rates. The following provides a snapshot of key factors that relate to the MCH population, providing state-specific context for consideration of the challenges facing the state’s MCH population.

*Please See Chart in Appendix for additional details related to health indicators and outcomes.

State’s Strengths and Challenges

 Access to comprehensive, quality health care services is important for the achievement of health equity and  increasing the quality of a healthy life for everyone. Health care access impacts overall physical, social, and mental health status; prevention of disease and disability; detection and treatment of health conditions; quality of life; preventable death; and life expectancy.

 Mississippians receive health care from a variety of sources that provide a continuum of care. The health care delivery system in Mississippi includes services for long-term care, care for the aged and those with intellectual disabilities; mental health care, including psychiatric, chemical dependency, and long-term residential treatment facilities; perinatal care; acute care, including various types of diagnostic and therapeutic services; ambulatory care, including outpatient services and freestanding ambulatory surgical centers; comprehensive medical rehabilitation; home health services; and end stage renal disease facilities. Mississippi has 32 critical access hospitals, 19 rural hospitals with 49 beds or less, 21 Federally Qualified Community Health Centers, and 160 Rural Health Clinics.

 Efforts are being made to support and expand Mississippi’s MCH infrastructure and health care delivery system. Strengths include strong partnerships and collaboration with private sectors, other state agency and local departments; Increasing access to quality health care for mothers and children, especially for people with low incomes and/or limited availability of care; Health promotion efforts that seek to reduce maternal mortality, infant mortality, and teen pregnancy; and Family-centered, community-based systems of coordinated care for children with special healthcare needs.

According to America’s Health Rankings, in the past year, the percentage of infants exclusively breastfed for six months increased 17% from 11.1% to 13.0%, tobacco use during pregnancy decreased 13% from 10.2% to 8.9% of live births, teen births decreased 11% from 34.8 to 31.0 births per 1,000 females ages 15-19, meningococcal immunization among children ages 13- 17 increased 37% from 46.0% to 63.0%, Tdap immunization among children ages 13-17 increased 31% from 70.8% to 92.4%, and physical inactivity among women ages 18- 44 decreased 20% from 34.4% to 27.6%. These improvements show the progress of our state and Mississippi’s desire to improve its health rankings.

On the contrary, Mississippi has repeatedly ranked last in education nationally, but in the past five years Mississippi has achieved unprecedented academic success and student achievement. Mississippi’s rankings for the National Assessment of Educational Progress (NAEP) Gains from 2017-2019 were:

• No. 1 in 4th grade mathematics
• No. 1 in 4th grade reading
• No. 3 in 8th grade math
• No. 4 in 8th grade reading
• Only state with significant gains in three of four tested subjects

While it is clear that Mississippi has more improvement to make, it is clear that substantial progress has been made through the state’s steady achievement in education. Mississippi’s education narrative is changing for the better with greater support, bold initiatives, and the desire to achieve great things.

 Despite these strengths and efforts, significant challenges still exist. Mississippi is still ranked last among all states for overall health system according to the Commonwealth Fund. Mississippi ranks 45th for access and affordability, 46th for prevention and treatment, 50th for avoidable hospital use and costs, 34th for disparity, and 50th for healthy lives. Mississippians, including our children, are routinely ranked as the fattest in the country and we lead the nation in high blood pressure, diabetes, and adult inactivity. The Delta region which is well known for its poverty and rural characteristics in the country, is at even greater risk for health problems because of lack of accessibility and availability of medical care. An estimated 60% of residents live below the poverty level here. In 2018, as part of the Behavioral Risk Factor Surveillance System (BRFSS), 20.3% of Mississippians surveyed said they were unable to see a doctor at some point in the prior twelve months because of cost.

 Besides poverty, Mississippi’s healthcare system mal-distribution of providers contributes to the poor overall health. High quality health care services depend not only on an adequate supply of fully qualified health care professionals, but also require appropriate distribution of these providers for adequate

access. The HRSA Data Warehouse current listing of Health Professional Shortage Areas (HPSAs) for Mississippi includes 109 primary care (75 of which are single county designations), 110 dental (77 of which are single county designations), and 42 mental health (29 facility and 13 catchment areas).

 The state’s challenges particularly impact the state’s most vulnerable residents, including CYSHCN’s and their families, Medicaid recipients, the working poor, undocumented immigrants, and rural residents. Mississippi has a high percentage of CYSHCN, a high percentage of CYSHCN living in poverty, and more severe health care provider shortages than most states. In addition to those challenges are Medicaid changes to MCOs, closure of the Title V Children’s Special Health Services clinic, and the decision not to expand Medicaid within the state of Mississippi. Also, Mississippi still faces challenges as a result of health care reform with the rising cost of health care. In the absence of any intervention, the burden of high health care costs will worsen, as health care spending per capita in Mississippi is projected to nearly double between 2010 and 2020.

Components of the state’s systems of care

A careful study of the past several decades shows that Mississippi has consistently created components of a functional system of care, even with limited resources.  Mississippi has worked hard to build a system of care that engages the public through heightened organization and improved alignment of policies, practices, goals, financing, and accountability. The intent is to provide the services and supports needed to meet the needs of underserved and vulnerable populations, including CYSHCN.

Mississippi’s system of care model involves collaboration across agencies, community-based organizations, Federally Qualified Health Centers (FQHC’s) and various other entities. This approach provides a functional framework for making use of resources to optimize care. Planning, implementation and evaluation are deliberately designed to include relationships with other systems. The systems of care in Mississippi include but are not limited to:

• Mental Health System
• Alcohol/Drug Treatment System
• Education System
• Child Protection System
• Juvenile Justice System
• Vocational Rehabilitation Systems
• Health System

As of January 2020, Mississippi has 32 Critical Access Hospitals designated to preserve access to local primary and emergency health services. These hospitals are in rural counties with a high prevalence of populations that demonstrate higher rates of obesity, diabetes, preventable hospitalizations, cardiovascular deaths and cancer deaths as compared to state and national benchmarks. Additionally, these hospitals are in rural counties with fewer physicians and with a higher proportion of patients who live in poverty and are Medicaid recipients.

Eighty counties are federally designated as either whole or partial-county Health Professional Shortage Areas (HPSAs) for Primary Care (based on either the low-income population or geography). 79 counties are designated as federal Dental HPSAs and all, but four counties are designated as federal Mental Health HPSAs. All of the state’s 82 counties are designated as either whole or partial-county Medically Underserved Areas (MUA). There are 42 birthing hospitals in Mississippi.

In the state of Mississippi there are a total 124 hospitals, with 58 designated Government hospitals and 36 private hospitals. The total number of beds available in Mississippi is 14986, with 81 hospitals having Helipad facilities.

Mississippi has a total of 606,646 t Medicare enrollees with an enrollment to population ration of 20% compared to the national enrollment population ratio of 18%. In Mississippi the average length of hospital stay is 5 days compared to national average hospital stay of 4.55 days. There is only one children’s specialty hospital in the state located on the campus of University of Mississippi Medical Center.

Primary Care Physicians/Dentists/Psychiatrists Distribution

Source: PC Health HRSA Shortage Designation Management System (SDMS)

Source: 2020 MS State Health Plan

Source: Mental Health HRSA Shortage Designation Management System (SDMS)

Health Care Reform

With the passage of the ACA, MS has had the opportu43ity to make substantial changes in the availability of health insurance coverage to its citizens. MS’s present uninsured rate is forecasted to be near 12%. In 2017, the Center for Mississippi Health Policy commissioned researchers at the Social Science Research Center (SSRC) at Mississippi State University to survey non-elderly Mississippi adults to assess their knowledge, attitudes, and behaviors related to health insurance and the Affordable Care Act (ACA).  Key findings of this research included:

• Approximately 16 percent of survey respondents reported not being currently covered by health insurance, a drop from 23 percent in 2013.
• In a departure from previous surveys, more Mississippi adults expressed a positive opinion of the ACA than a negative one, with 47 percent supporting the law, 38 percent opposing the law, and 15 percent stating they were unsure.
• As in the previous surveys, respondents showed support for many of the components of the ACA, with the notable exception of the individual mandate penalty which has been repealed as of the end of 2018.
• While 40 percent forecasted in 2013 that they expected to be worse off as a result of the ACA, only 29 percent in 2017 said they were worse off due to the Act. Almost half (47%) said they were unaffected by the law.
• Most (62%) of those surveyed who did not have insurance had been uninsured for a year or more, and 43 percent had been uninsured for two or more years.

While the percentage of Mississippi adults who report being uninsured has dropped since 2013, cost is still the greatest barrier to obtaining health insurance coverage. The price of basic health insurance coverage with reasonable cost-sharing far exceeds the amount people are willing to pay without substantial subsidies. For those Mississippians with low-incomes, unaffordable private coverage and lack of access to premium assisted coverage through an employer, the Marketplace, Medicaid, or other source leave some with no other alternative than to remain uninsured.

In order to increase access to care, CYSHCN monitors and works closely with patients identified as not having medical health coverage. The program maintains a partnership with the states' Navigator office. Parents referred are expected to keep their appointments and to submit their letter of eligibility to the program in the processing of their application for services as verification of efforts to obtain affordable healthcare insurance.

Integration of Services

Children and youth with special health care needs (CYSHCN) are probably one the most vulnerable populations as health care delivery evolves. Timely access to comprehensive, coordinated patient/family-centered care in a medical home is critical for CYSHCN. It may potentially minimize the prevalence of chronic physical, developmental, behavioral, and emotional conditions, maximize their independence as they transition to adulthood and more importantly, improve their quality of life. The National Survey of Children with Special Health Care Needs estimates that MS has about 124,905 CYSHCN, and nearly 26.6% of MS CSHCN live below 200% of the Federal Poverty Level.

The CYSHCN Program provides quality care coordination services to meet clients' needs and preferences. Regional care coordinators and care coordinators recently secured by participating healthcare systems (federally qualified health centers (FQHC), rural health clinics, and UMMC hospital clinics) work within many settings to assist families and connect them to a medical home.

To broaden our reach, CYSHCN parents and caregivers are involved at every level of decision making, from the central office to clinical to hospital-based services. The CYSHCN Program increased its efforts in strengthening parent engagement with a CYSHCN Parent Consultant (PC) was hired (part‐ time) and housed within MSDH Central Office. The PC provides feedback on programmatic policies, strategic planning, educational material and designing and conducting parent surveys with other CYSHCN families. Approximately 40% CYSHCN parents serve as members/subject matter experts on the CYSHCN Leadership Team. Lastly, a CYSHCN PC was placed in each of the five participating CYSHCN Cares 2 healthcare systems. All PCs were trained as Community Health Workers and other parent leadership trainings will follow.

State Statutes Relevant to Title V

The Mississippi Legislature passed House Bill 494 in March 2017 authorizing the Mississippi State Department of Heath to establish the Maternal Mortality Review Committee to review maternal deaths and establish strategies to prevent maternal deaths. The Mississippi Maternal Mortality Review Panel is a multidisciplinary committee whose geographically diverse members represent various specialties, facilities and systems that interact with and impact maternal health. The panel

consists of approximately 8-10 members who commit to serve a 2-year term. Maternal Mortality Review Panel will review and make decisions about each case based upon the case narrative and abstracted data. The purpose of the review is to determine the causes of maternal mortality in Mississippi and identify public health and clinical interventions to improve health systems of care. Maternal mortality includes deaths occurring during pregnancy and up to one year after pregnancy. Information is gathered from death certificates, birth certificates, medical records, autopsy reports, and other pertinent resources. Records are abstracted by a trained abstractor and de- identified case narratives are reviewed by the committee of experts from diverse disciplines.