A recently released report, The Role of the Title V MCH Services Block Grant in Improving Maternal and Infant Health, examines the fiscal investments for pregnant women and infants made by Title V Maternal and Child Health (MCH) Services Block Grant programs in the 59 states and territories. Co-authored by Arden Handler, myself, and Nautica Farrell, the report provides a detailed view of how Title V programs are investing federal and state dollars for the perinatal population.
Enacted by Congress as part of the Social Security Act of 1935, Title V is distinguished in history as the nation’s oldest federal-state partnership with the purpose of supporting and improving the health of women, children and families. The program has a long history of success in anchoring the MCH activities in states, through creation of service systems, MCH health status monitoring, and partnership development. (More details about the Title V program can be found in a recent report by the Congressional Research Service).
As with most non-entitlement programs, the Title V MCH Block Grant program depends on funds appropriated by Congress and secured by states. (See trend data here). The new report analyzes each state’s Title V budget, including both federal and non-federal funds. Non-federal funds may come from: 1) state funds, 2) local funds, 3) program funds (e.g., Medicaid payments for services delivered by health departments), or 4) other sources. In most states, the primary source of non-federal funds is state dollars, most often from general revenues.
Title V law sets some parameters on use of the federal grant funds. Since 1989, states have been required to use at least 30% of their Title V federal block grant allocations for preventive and primary care services for children and at least 30% for children with special health care needs (CSHCN). In addition, administrative expenditures from federal grant dollars are capped at 10%. This means that 30% of a state’s federal Title V Block Grant allocation is available for additional funding to support service delivery, quality improvement or capacity building for either of these required/designated groups of children or for other populations and activities.
Our analysis found that state budgets disproportionally allocate less of their federal Title V Block Grant dollars to the population of pregnant women and infants as compared to the federal Title V Block Grant dollars budgeted for the designated child populations of: 1) preventive and primary care for children 1-21 years, and 2) CSHCN. Only 8 states and 2 US territories budgeted the flexible 30% of their federal Title V block grant funds for pregnant women and infants. Combining the federal and non-federal Title V funds, 20 states and 5 US territories budgeted at least 30% to meet the needs of pregnant women and infants.
At first glance, given the terms of the Title V block grant, it may not be surprising that few states maximize flexible Title V dollars to support pregnant women and infants. But the nation’s perpetually dismal maternal and infant mortality and morbidity rates begs the question as to why states aren’t compelled to do more.
So how did Title V budgeting align with maternal and infant outcomes? Our analysis also compared Title V investments in support of pregnant women and infants to state maternal and infant mortality rates. Most of the states (14) with higher-than-average Black-to-White infant mortality ratios were among the 21 states budgeting under 30% of combined funding for pregnant women and infants. Twenty states have measurable maternal mortality rates greater than the US average of 23.5 per 100,000 (2018-2021). Of these 20, 14 states were among those who budgeted less than 30% of their combined federal and non-federal Title V funding for pregnant women and infants (See Map 2).
One important strategy for addressing the US maternal and infant health crisis is to ensure adequate Title V investments at both the federal and state levels. The last decade brought small amounts of federal funds from the Maternal and Child Health Bureau focused specifically on maternal health (e.g. the Alliance for Innovation on Maternal Health (AIM), the Maternal Health Innovation (MHI) Program, the National Maternal Mental Health Hotline). But these small initiatives do not match the scale of the Title V MCH block grants, which remain the single largest source of funding to address maternal and infant health outside of Medicaid. And Title V also serves to make Medicaid’s investments work more effectively by supporting state capacity-building, coordination, or other activities that improve the quality, accessibility, and effectiveness of health care services.
Our analysis suggests that increased dedicated focus on mothers and infants is overdue. Accordingly, the report recommends that state Title V agencies should increase investment of both federal and state dollars in pregnant women and infants. This may be easier said than done, as we also recognize that Title V is underfunded overall and states are doing their best to make scarce resources stretch across their MCH populations. Continued and expanded funding for the Title V MCH Block Grant is not only warranted, but essential. Title V must be strengthened and fully supported at both the federal and state levels to provide communities with the tools they need to address the maternal and infant health crisis.
Watch for more Title V. In the coming weeks, the Say Ahhh! health policy blog will review a companion report that takes a wider look at Title V budgets, including how states meet their matching requirements and what they invest in for all of the three populations (women and infants, children 1-21, and CSHCN).