Celebrating Title V of the Past and Present, Looking to Title V of the Future
By Lauren Raskin Ramos, Director of Programs, AMCHP and Michael Fraser, CEO, AMCHP
On Monday, September 27, AMCHP sponsored a webinar, in partnership with the Maternal and Child Health Bureau (MCHB) to celebrate 75 years of the Title V Maternal and Child Health Services Block Grant (Title V MCH Block Grant). Joining the webinar to celebrate the legacy and speak about the past, present and future of Title V were Michael Fraser, Chief Executive Officer, AMCHP; Peter van Dyck, MD MPH, Associate Administrator, MCHB/HRSA; Donna Petersen, ScD MHS, Dean, College of Public Health, University of San Francisco; Phyllis Sloyer, RN, PhD, FAAP, Director, CMS, Florida DOH; Myrtis Sullivan, MD, MPH, FAAP, Director, Illinois Department of Health; and Sophie Arao-Nguyen, PhD, Executive Director, Family Voices. The webinar recognized the tremendous contributions Title V has made in the past and provoked thinking about its future. This article captures some of the highlights from the webinar.
Dr. van Dyck opened the webinar, noting that there indeed is a lot to celebrate, “For 75 years the federal government provided a means for states to care for the health and welfare of all of the mothers and children they serve. Seventy-five years later, Title V continues to support combined federal and state efforts to improve the health, safety and well-being of mothers and children nationwide — and it stands as one of our nation’s longest-lasting pieces of public health legislation.”
Dr. van Dyck encouraged participants to celebrate some upcoming milestones, including the Maternal and Child Health Bureau’s (MCHB) new Strategic Plan which will lay out MCHB’s objectives and strategies for supporting MCH activities for the next several years. Dr. van Dyck shared a glimpse of Title V of the future, explaining that “in the plan you will see a focus on new and exciting developments in MCH, such as an increased emphasis on the life course perspective and what that will mean for state and local MCH programs.”
Dr. van Dyck also encouraged participants to continue the important work supported by Title V, stating “You are the future of Title V — whether you work in a state health agency, a local health department, the federal government, a university, a clinic, a hospital or national organization decided to the health of women and children...We need you — your energy, your creativity, your passion and caring — and your commitment to moving the partnership forward. You know how to Make Change Happen (MCH!) for the people you serve.”
What is the legacy of Title V?
Dr. Donna Petersen provided an historical overview of the Title V MCH Block Grant, explaining that authorized in Title V of the Social Security Act (Title V), it has provided a foundation for ensuring the health of our nation’s mothers and children. Among the rich history of Title V shared, Dr. Petersen explained that with the passage of the Social Security Act on August 23, 1935, the federal government, through Title V, pledged its support of state efforts to extend health and welfare services for mothers and children.
While we are all familiar with the legacy of Title V as the longest-standing public health legislation in American history, Dr. Petersen reminded us of the origins of a national focus on MCH populations in the early 1900s, where one in five children died before reaching their fifth birthday, and one mother died for every 150 live births. She shared the evolution of federal investments in MCH, highlighting the creation of the Federal Children’s Bureau, initially located in the Department of Labor, and the Maternity and Infancy Care Act (better known as the Sheppard -Towner Act), which was adopted by Congress in 1921 and resulted in federal grants-in-aid to states for child and adult health programs, including the development of full-time units of MCH services in state health departments and the first MCH training program. It was this act that set the pattern for state and federal cooperation that would re-emerge in Title V of the Social Security Act in 1935.
Dr. Petersen also recognized the amazing leadership of MCH heroines of the past - such as Julia C. Lathrop, who became the chief of the new Children’s Bureau and the first woman to be selected by a president to head a federal statutory agency, and Grace Abbott, who replaced Julia Lathrop as chief of the Children's Bureau and oversaw administration of the Sheppard-Towner Act.
Dr. Petersen reminded us that as a result of the Great Depression, cutbacks in federal health programs, and the declining health of mothers and babies, the Social Security Act was signed into law in August 1935 by President Franklin D. Roosevelt. With the passing of the Social Security Act, Title V would provide programs for maternity, infant and child care, as well as a full range of medical services for children. Funds were allocated to states to pay for maternal and child health and crippled children services, including physicians, dentists, public health nurses, medical social workers, and nutritionists. Title V was not an entitlement program like other sections of the Social Security legislation, meaning that funds for Title V need to be appropriated annually by Congress.
Title V of Today
Fast forward to the 1980s where the Title V we know today had its birth. In 1981, the Federal Omnibus Budget Reconciliation Act (OBRA) converted Title V to a Block Grant, combining seven programs: MCH/CSHCN, Supplemental Security Income, lead screening, hemophilia treatment centers, Sudden Infant Death Syndrome, genetic diseases, and adolescent programs. In 1987, Surgeon General Koop released a national report on Children and Youth with Special Health Care Needs (CYSHCN) and kicked off a campaign to improve the lives of children with special health care needs and their families through family-centered, community-based care. This formed the base of our efforts to address the needs of families and connect families and professionals to improve MCH programs nationwide.
While we all know the national MCH performance measures by heart, Dr. Petersen reminded us of their origins. In 1989, the Social Security Act was amended and the accountability of state programs for their block grant funds increased through the creation of performance measures and ultimately, the Title V Information System (TVIS). In 1990, MCHB was established within HRSA to administer Title V, and the Bright Futures program was established. Things we taken for granted today had their start just 20 years ago!
The legacy of accountability and high performance was recognized in September 2008, when Title V received the highest rating possible on the White House Office of Management & Budget’s Performance Assessment Rating Tool (PART). Programs such as the Title V MCH Block Grant that receive the highest PART rating of “effective” clearly show ambitious goals, achieve results, are well managed, and improve efficiency.
Although Title V has changed over 75 years, the principles of partnership and performance and a single focus on improving the health, safety and well-being of all mothers and children remain. The legacy of our state and federal partnership to improve maternal and child health is cause for great celebration — and continued commitment.
Today, the needs met by MCH programs are vast — over 2.5 million pregnant women, 4 million infants and nearly 30 million children every year are directly served by a program that touches the lives of all our nation’s women and children. The legislation authorizing Title V is broad, encompassing a wide array of direct services to individuals and population-based programs that serve everyone in a community.
Dr. Sloyer acknowledged the need for Title V today, noting that “Much as the Great Depression dictated the essential need for maternal and child health services in the early 1900s, the economic climate of our nation one century later reinforces the critical need for Title V programs.” Dr. Sloyer explained that, diversity in geography, race, ethnicity, income level and immigrant status are other key factors affecting family health. States are different, needs are different, and how state implement their MCH programs are different. All, however, have at their core the mission of improving the health of women, children and families.
Celebrating the legacy of Title V, Dr. Sloyer pointed out that, “Today, Title V remains the only federal program that focuses solely on improving the health of all mothers and children. Title V makes a special effort to build community capacity to deliver such enabling services as care coordination, transportation, home visiting, and nutrition counseling, which complement and help ensure the success of State Medicaid and SCHIP medical assistance programs. Title V funds support programs for children with special health needs to facilitate the development of family-centered, community-based, coordinated systems of care.”
Dr. Sloyer described how investments in Title V at the state level are determined, explaining that, “As a block grant, states program their Title V investments to meet their state-and territory-specific needs. Starting with a needs assessment and planning that includes stakeholder input and review of evidence-based practice and progress on performance measures, Title V programs determine strategies to meet identified MCH goals and objectives.” Today, a hallmark of Title V is that its programs provide data, expertise and assistance to other agencies to help shape policies or programs in their health department. “Using data and turning it into action, Title V programs are leaders and catalysts for systems change that address the needs of women, children and families,” explains Dr. Sloyer. “While the dollars for Title V may be a relatively small proportion of a state's total budget for family health programs, used effectively they have a big impact.”
As we think about Title V of today, Dr. Sloyer noted that recognition of and support for Title V isn’t always as forthcoming as we’d hope. With the economic downturn of recent years creating a host of challenges, a robust future for the funding of state maternal and child health programs is anything but certain. Further, while the health of women and families has dramatically improved over the last 75 years, chronic diseases, environmental factors and health inequities threaten to erode America’s health status. The differences in infant mortality rates by race and ethnicity are stark reminders that we have far to go in our quest to assure the health and well-being of all women and children in this nation.
A unique component of Title V is the focus on family participation. Dr. Sophie Arao-Nguyen acknowledged the importance of family participation in Title V and encouraged Title V programs to continue to involve families as partners and staff.
Title V is at a Crossroads – What is the Future of Title V?
Dr. Myrtis Sullivan provided insight into the future of Title V, provoking our thinking about the road ahead. With the expansion of health care services and new resources for access to clinical care in the historic passage of the Affordable Care Act (ACA), the role of Title V will continue to change in the states in the future. Dr. Sullivan explained that ACA requires all Americans to purchase health insurance, and includes subsidies for those who cannot afford to purchase health insurance and/or are not covered through their employers. ACA created new sections of Title V adding evidence-based home visitation and teen pregnancy prevention programs. These new sections of Title V acknowledge the state leadership role in address pressing MCH problems and provide a vehicle for states to link their existing MCH programs.
There are many questions about the future roles of Title V raised by the historic expansion of health care services. While we cannot predict the future, we do know that the most well designed insurance package will leave gaps in benefits or limits in coverage, especially for CYSHCN. As Dr. Sullivan pointed out, “As more people access primary care, the need for enabling services may actually increase — and these are services not traditionally covered by most insurers or providers.”
Additionally, state Title V programs are revisiting needs assessments and reviewing evidence-based research to identify unmet needs and opportunities for prevention and intervention. Dr. Sullivan noted that areas receiving increased attention in the early part of the 21st century include adolescent health, care coordination, especially for children with special health care needs, early childhood development and linking education, social services, and health for young children, home visiting, mental health, newborn screening, oral health, school health, and transition services to bridge child and adult health systems.
So, where will Title V need to focus in the coming years? Title V of the future will have a role in both direct care and enabling services. The new Title V Early Childhood and Maternal Home Visiting Program asserts state leadership in coordinating home visitation services in a state, and signals the need for continued support for Title V as this important program is implemented and evaluated. Dr. Sullivan noted that, “Population based services, such as promoting breastfeeding or reducing childhood injury, will continue to be needed even if everyone has health care and access to a physician or other health care provider.”
Title V programs currently support many population based public health interventions. These activities will continue to be part of state health agency efforts in the future. The ACA increased the resources available to states to carryout prevention work and included a number of provisions that support state health agency programs that address the needs of women, children, and families. “Those that led state MCH programs before faced similar challenges to those we’re confronted with today head-on and laid a strong foundation for our current federal-state MCH partnership,” stated Dr. Sullivan, and encouraging Title V staff going forward, “Let’s use the legacy of our MCH foremothers and forefathers to inspire our current work, and help us move forward to a healthier future.”
Those of us working in Title V know that no federal program other than Title V supports a state’s efforts to assess MCH needs, identify urgent MCH issues, and convene partners to address MCH challenges. While often unseen and underappreciated, the capacity building aspects of Title V are essential to its effectiveness and will no doubt be needed well into the future. For these, and many other reasons, AMCHP anticipates the need for Title V in the years to come. Will Title V of the future be exactly the same as it is today? No. But Title V of today is not the same as it was 75 years ago, either.
As we face massive changes in our health care and public health systems in the next several years and we have to be proactive in anticipating what those changes may mean for state and local MCH leaders. AMCHP is committed to that work, and looks forward to convening all of you to discuss these and other important issues! Together with the Bureau and all our MCH partners nationwide, AMCHP is looking forward to another 75 years or more of Title V and addressing the important needs of our nation’s women, children and families.
In case you missed the webinar, an archive is available here.