Chapter 2: Title V at the National and State Levels
This chapter offers basic information about managing the Maternal and Child Health Block Grant, such as the strategic planning process of the Title V application, accountability, performance measures, budgets and helpful tips from Title V leaders who have "been there, done that."
An Important Tool for Building State Systems
While more accountability was introduced with the 1989 amendments, the Title V statute today continues to offer significant flexibility to build programs to meet your state's specific needs and to fit with your state's size, systems and cultures. This chapter provides more specific information on the federal and state components of Title V and how they work together.
As a senior manager with responsibility for Title V, it is important that you review the Title V legislation, as well as the current application and report guidance (see Chapter 6 for highlights). All of the requirements for state programs are contained in these documents; there are no regulations specific to Title V. As with every law, there are nuances and aspects that are open to interpretation. In addition to reading the tips included in this guide, talk to your counterparts in other states to learn from their experience. Federal MCH administrators can advise you within the context of the law, the guidance and federal policies.
How are State Systems Organized
Given the flexibility of Title V, there is great variation among MCH programs across the country. One (mostly) common denominator is that programs by law must be administered by the "state health agency." The exception to this rule is that a small number of CSHCN programs are located in other state agencies, usually universities, because the Title V legislation "grandfathered" existing programs.
Even with this common location there is great variety in the structure and hierarchy for state Title V programs. State executive branch agencies vary widely across the country, and their structure and responsibilities can change, especially with new administrations.
As the nation and states experienced great political shifts starting in the mid 1990s, a trend toward major reorganizations and consolidations occurred. The implications of these reorganizations on Title V and public health programs remain unclear. In larger agencies, some Title V programs, such as in Illinois and Michigan, underwent major restructuring, while others retained most of their previous structure and functions.
Today, MCH leaders usually work within larger public health agencies that include traditional areas such as epidemiology and health statistics, chronic disease prevention, and health promotion. The agency also may include environmental health, substance abuse prevention and treatment, mental health, developmental disabilities, health facilities management or regulation, and Medicaid. Whether Title V operates within or outside of the same agency, these programs can make a big difference in the ease of communication and coordination of efforts.
The units with direct responsibility for Title V programs may be called MCH, CSHCN or similar terms or may have a broader scope in family or community health. A fairly common structure is a bureau of family health (aka "big MCH") overseeing MCH preventive and primary services for women or pregnant women, children and youth (aka "little MCH"), as well as CSHCN. Related programs may be administered under or alongside these units. A 1999 AMCHP survey found that over two-thirds of state health agencies had a "family health" organizational unit, and over half of these states considered that to be the Title V unit. MCH or family health agencies commonly administer family planning programs and the supplemental food program for Women, Infants and Children (WIC). MCH or CSHCN may administer the federal early intervention program (Part C) or Medicaid waivers for home- and community-based services. Related state-funded programs, foundation initiatives and CDC programs - such as lead poisoning prevention, breast and cervical cancer screening, birth defects and developmental disabilities prevention - also often fall under the Title V unit's purview.
In some states, the scope of Title V programs may be even broader, reaching to adult-oriented programs, primary care or chronic disease prevention. States with broad units often organize, plan and link the programs in a lifespan framework. This approach can assure specific attention to children's and youths' needs, while maximizing opportunities for prevention and intervention at appropriate points across the lifespan.
Although the trend toward major, multi-agency restructuring may have accelerated recently, reorganization is a constant in public agencies, and something for which you should be prepared. While there is not one model for organizational structure and placement, some things to consider include:
- The agency's mission should support Title V's emphases on prevention, population-based and comprehensive approaches, special needs, and systems development.
- Children, youth and women, especially those with special health needs, each have unique needs that should be explicitly addressed in organizational structure.
- The agency must be competent in data collection and analysis for needs assessment, planning and evaluation, as well as program development for target populations
MCH leaders agree that it is critical for all states to have a division responsible for assuring the health of women, children, youth and families.
As with organizational structures, there is considerable variation in the education and experience of your colleagues across the country. MCH programs historically have promoted multidisciplinary teams, at the management as well as the local service level. Previous federal requirements for physicians to lead state programs were eliminated, but many states retain physicians on their senior leadership teams. These doctors, most commonly pediatricians, bring critical expertise, along with an ability to forge relationships with state physician groups that may be more difficult for non-physicians. Nurses, social workers and nutritionists also are commonly found in senior leadership positions. Clinical backgrounds are helpful in policy and program development and evaluation and offer a value often sought after by other agencies. Many clinicians in leadership positions have advanced degrees in public health or other relevant fields. With the growth of MCHB training programs, increasing numbers of Title V leaders have earned graduate degrees in MCH.
Increasingly, people with experience administering other public programs are bringing that experience to bear on family health. Community-based providers from both the public and private sectors are bringing their important ground-level knowledge to the state level.
You have the flexibility and opportunity under Title V to form a multidisciplinary team to reach your mission and goals.
State programs also play a leadership role in workforce development. One of the essential health services - assuring the capacity and competency of the public health and personal health work force - has become an urgent necessity. Shortages in key areas, particularly nursing, have been well documented. State senior managers can partner with schools of public health, other academic partners, and state and national public health associations to assure the availability of health workers. It is also important to train your staff in new areas, such as systems development and information technology.
What Do State Title V Programs Actually Do?
Within the broad and flexible scope of Title V, the mix of agency functions and community services varies considerably. Each agency has a unique history in the context of the state's political, cultural and socioeconomic characteristics. The states' health care delivery and financing systems, including the roles of private and public sectors, add to the variety. Diversity in geography, race, ethnicity, income level and immigrant status are other key factors affecting family health.
Southern states, often with highly diverse populations and high rates of poverty, historically play active roles in delivering health services through the public sector, often through local health departments. Northern states, especially on the coasts, tend to have high concentrations of academic and medical institutions and play a lesser role in public delivery of care. These states tend to play more of a role in financing and regulating health care. States in the middle of the country tend to have a mix of these roles.
Historically, MCH programs have played a significant role in delivering clinical preventive and primary care services to women, children and youth with state or local health agency staff. Many state provide specialty and therapeutic services for children with special health care needs in medical centers and mobile units. Other states rely on contracting with providers such as community health centers. Historically Title V programs were involved where services were not available or not accessible due to barriers such as lack of coverage.
xAs public insurance has expanded in recent decades, it has met more of the fundamental health needs of women, children and youth. In turn, the variation in the roles of MCH programs seems to have increased. Without universal coverage, there are still families who lack insurance, particularly among immigrants. Even with insurance, providers may not be available or accessible, and barriers such as culture, language or transportation may impede access. Title V programs still are charged with assuring access to preventive, primary and specialty care. But how programs do this is shifting in most states.
With the shift to managed care systems in the 1990s, many states decreased considerably their roles in delivering care directly with state or local health agency staff. Where gaps in coverage, availability or access persist, more state Title V programs have moved toward grants or contracts to support local agency services. State programs also have looked to influence policy and to leverage other resources to close the gaps. Drawing on assessment and evaluation data, and on population and program expertise, MCH leaders are seeking to work with Medicaid, SCHIP, managed care organizations, state policymakers and families to identify solutions for gaps in coverage and access.
As more children, youth and women gain access to private medical care, state MCH and CSHCN programs are working to assure that they receive comprehensive, multidisciplinary services, often in new ways. Some states have developed models and reimbursable bundles of services to "wrap around" basic medical care provided in office settings. These packages include services such as nutrition, social work, health and parent education, and therapies for special needs children and youth.
Additionally, state Title V programs are revisiting needs assessments and reviewing evidence-based research to identify unmet needs and opportunities for prevention and intervention. Areas receiving increased attention in the early part of the 21st century include:
- Oral health
- Mental health
- Newborn screening
- Home visiting
- Early childhood development
- Care coordination, especially for children with special health care needs
- School health
- Adolescent health
- Transition services to bridge child and adult health systems
State Title V programs are addressing these areas by applying core functions and building the infrastructure for population-based health services. Optimally 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 goals and objectives. These strategies may or may not entail extensive use of Title V resources. Providing data, expertise and assistance to other agencies may help shape a policy or program in another agency's jurisdiction. Funding and evaluating limited demonstration models may result in a new intervention with other funding sources. Title V programs can be leaders and catalysts for systems change.
What Is the Role of the Federal MCH Bureau?
As we saw earlier, federal leadership for maternal and child health dates back before Title V to the Children's Bureau. A reorganization in 1969 moved Title V to the Public Health Service. After a number of reorganizations and in response to advocacy led by the American Academy of Pediatrics (AAP), the modern day MCH Bureau was established in 1990. As of the early 21st century, MCHB was one of four bureaus within the Health Resources and Services Administration (HRSA).
The federal-state partnership for maternal and child health also predates Title V. The nuances of that relationship, and particularly the amount of federal oversight, have varied over the past century. The philosophy of the federal administration has a strong influence on the relationship, particularly since Title V became a block grant in 1981. In the 1980s, the Title V statute had very limited accountability provisions and the administration strongly emphasized state flexibility; accordingly there was limited direction from the federal MCH agency. Following the 1989 Title V amendments and with new federal leaders, more emphasis was placed on accountability and on assisting states to develop capacities. The strength of the federal-state MCH partnership over the past decade is evidenced in the collaborative effort of states and MCHB to develop and implement performance measures into the Title V program.
State Title V programs, through AMCHP, urged that the 1989 amendments address the federal as well as the state role in the Title V program. The result was legislation requiring the secretary to "designate an identifiable administrative unit with expertise in maternal and child health within the Department of Health and Human Services, which unit shall be responsible for:"
- Special Projects of Regional and National Significance (SPRANS) in Title V
- Federal-level coordination of Title V, Medicaid (especially EPSDT), related agriculture and education programs, health block grants, and categorical health programs, such as immunizations
- Information in areas such as preventive services and advances in care and treatment
- Technical assistance, on request, to states in areas such as program planning, establishment of goals and objectives, standards of care, evaluation, and consistent and accurate data collection
- In cooperation (and avoiding duplication with) the National Center for Health Statistics, collection, maintenance and dissemination of information on the health status and needs of mothers and children in the U.S.
- Preparation of reports to Congress on state Title V activities, accomplishments and information
- Assistance to states for developing care coordination services
- A directory of toll-free information lines established in states under Title V.
Like its state counterparts, the federal MCH agency has a broad mission based in Title V but extending beyond the specific provisions of Title V. Over the past decades, the federal agency has taken on a number of related programs including:
- Emergency medical services for children (EMSC)
- Traumatic Brain Injury (TBI) service programs
- Healthy Start, which is focused on community based infant mortality prevention
- Abstinence education, both Section 509 grants to state programs, as well as federal special project (SPRANS) funds
- Newborn hearing screening
- Poison control centers
- Women's Health Office.
The Federal-State Partnership in the 21st Century
As a result of the new accountability measures incorporated into Title V in the 1990s, one important aspect of the federal-state relationship now revolves around annual applications and reports. The review of block grant plans and performance measures provides an opportunity for feedback and identification of state needs. In the last decade, the review has broadened to include consumers, incorporating the Title V goal of being family-centered.
The federal MCH agency responds to needs identified in the block grant process and provides assistance to state programs. This assistance comes in many forms, and like many aspects of this program, has varied over time.
State Title V programs and AMCHP have played a critical role in advising the federal agency on state needs, with many specific initiatives developed in response.
Some of the ways MCHB provides assistance to state programs include:
- Directly from MCHB central or regional offices. Assistance is limited by numbers of staff, but funds are sometimes available to help states purchase technical assistance.
- National partnership conferences that include orientation for new leaders, information on priority issues, and opportunities to meet federal leaders.
- Policy, information and resource centers funded under the Title V grants for "Special Projects of Regional and National Significance" (SPRANS). Over time, the federal agency has funded many such centers with a range of programs, which may or may not have state Title V programs as a primary audience.
- SPRANS grants focused on state identified needs. The federal agency has flexibility in setting SPRANS priorities, although Congress has come to have strong influence. In response to states and AMCHP's identification of needs, the federal agency often has developed specific SPRANS projects, such as women's health systems.
- SPRANS grants to assist states at national or regional levels. The federal MCH agency has supported much of AMCHP's work in assisting states, specifically through conferences, workshops, publications, consultation and other tools. Other grantees, often university-based, have assisted states in specific regions.
- Continuing education institutes, also funded by SPRANS, for senior Title V leaders. These institutes focus on skill development in the context of Title V programs.
- CISS grants to assist all states in key program or system areas. Community Integrated Service Systems (CISS) grants are another Title V "set-aside" added in 1989. Developed in partnership with the federal Administration for Children and Families, the initiative helped build state interagency partnerships supporting family preservation goals in child welfare. For example, a national CISS initiative helped all states develop home visiting programs.