Title V State Maternal and Child Health (MCH) Block Grants

Overview

Title V of the Social Security Act (SSA; P.L. 74-121, as amended; 42 U.S.C. §§701-709) permanently authorizes the Maternal and Child Health (MCH) Services Block Grant, which aims to improve the health of pregnant women, mothers, and children, particularly those with low-income or limited access to health services. The MCH Services Block Grant consists of three programs: (1) State MCH Block Grants, (2) Special Projects of Regional and National Significance (SPRANS), and (3) Community Integrated Service Systems (CISS). More information about each of these programs is available in CRS Report R48088, Maternal and Child Health Services Block Grant: Overview and Issues for Congress; this CRS In Focus covers the State MCH Block Grant program.

Background

The State MCH Block Grant program, often referred to in short as "Title V," provides formula-based block grants to all 50 states and nine jurisdictions, which include American Samoa, District of Columbia, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and the U.S. Virgin Islands (collectively referred to hereinafter as states). This federal-state partnership aims to provide states the flexibility to address the unique health needs of its population of pregnant women, mothers, infants, and children, including children and youth with special health care needs (CYSHCN) and their families. The program is administered by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS).

Broadly, SSA Section 501 establishes the purpose of the State MCH Block Grant program as follows: to improve access to quality MCH services; reduce stillbirth, infant mortality, and child morbidity; increase access to routine diagnostic, immunization, treatment, and rehabilitation services; provide prenatal, delivery, and postpartum support; and provide specialized care to CYSHCN and their families.

Funding

Federal funding for the overarching MCH Services Block Grant program is discretionary and subject to the annual appropriations process. Federal funding allocations across each of the three individual programs are determined by formula; the State MCH Block Grant program receives the remaining funds after CISS and SPRANS funds are reserved (§501(c)). Although federal funding levels have remained relatively flat over time, the proportion of total MCH Services Block Grant funds appropriated to the State MCH Block Grant program has declined, indicating that a greater proportion of these funds are appropriated to topic-specific grant programs, specifically SPRANS. Table 1 displays total State MCH Block Grant appropriations relative to the total MCH Services Block Grant appropriations from FY2020 to FY2024.

Federal funds are allotted to individual states using a formula that considers (1) the amount of funds historically allocated to each state and (2) the proportion of low-income children in each state relative to the total number of low-income children nationwide (§502(c)). In the most recent available data in the Title V Information System (TVIS), FY2022, federal allotments to individual states ranged from $150,000 (Palau) to $39.6 million (California).

States are required to match at least $3 for every $4 of federal block grant funds received (§503(a)). States must also maintain a level of contribution that is at or above the state's FY1989 level (§505(a)(4)). MCHB calculates total program funding by adding federal and state funds with local MCH funds, program income (e.g., health insurance reimbursements), and other federal funds (Figure 1). In FY2022, the State MCH Block Grant program funding totaled over $2.6 billion across all five funding sources.

Figure 1. State MCH Block Grant Funding Sources

Source: Figure created by CRS using data from HRSA's Title V Information System (TVIS); https://mchb.tvisdata.hrsa.gov/. Note: TVIS funding data are annual estimates that are collected at the time of Application/Annual Report submission and do not reflect final expenditure totals.

Services Provided and Program Reach

State MCH Block Grant funds can be used broadly for the provision of health services and other activities, which may include administration, education, evaluation, and the payment of some provider or staff salaries. Federal law requires states to use 30% of federal funds for preventive and primary care services for children and an additional 30% for services specific to CYSHCN. Aside from these requirements, states have the discretion to determine which MCH services and populations to prioritize. State health agencies are typically responsible for the overall administration and supervision of program activities.

MCHB provides a guiding framework to support states in determining the types of MCH services to provide with program funds. This framework classifies MCH services in three categories: (1) direct health care services (e.g., primary, dental, or vision care); (2) enabling services (e.g., care coordination); and (3) public health services and systems (e.g., safe newborn sleep education). In FY2022, enabling services accounted for the majority (40.7%) of expenditures across all funding sources, though specific activities can vary widely across states (Figure 2).

Figure 2. Expenditures by Service Category

Source: Figure created by CRS using data from TVIS.

State MCH Block Grant funds are also tracked by population group. In FY2022, children collectively accounted for the majority of expenditures across all funding sources. Specifically, children aged 1-21 accounted for 36.3% of all expenditures, and CYSHCN accounted for 29.6% (Figure 3). "Others" include men and women over age 21.

Figure 3. Expenditures by Population Group

Source: Figure created by CRS using data from TVIS.

Prohibited Services

According to Section 504, State MCH Block Grant funds cannot be used for most inpatient services; cash payments to health service recipients; purchasing or improving land, infrastructure, or major medical equipment; research/training at private, for-profit entities; or payments for items or services furnished by providers excluded under health-related programs (e.g., Medicare, Medicaid). Funds cannot be used to satisfy other federal expenditure requirements. Administrative costs may not exceed 10% of federal allocations.

Coordination with Related Programs

State MCH Block Grant programs partner with federal, state, and local programs and stakeholders to address MCH needs. The program is intended to serve as a gap-filling resource and the payor-of-last-resort for services not covered by other federal programs. State Medicaid agencies are required to develop interagency agreements with Title V agencies, which detail how the programs collaborate.

Application and Reporting Requirements

Every five years, states are required to conduct a statewide needs assessment to identify priority MCH needs. This process involves a variety of stakeholders and drives the development of the State Action Plan. States submit these plans, summarize needs assessment findings, and outline specific goals and strategies along with other standardized reporting requirements in the combined Application/Annual Report, available in the TVIS.

States must also report annual performance data using a three-tiered performance measurement framework, which consists of National Outcome Measures (NOMs), National Performance Measures (NPMs), and Evidence-informed (or evidence-based) Measures (ESMs). NOMs are tracked by MCHB using a variety of federal data sources, whereas states choose at least five NPMs to measure short- and medium-term health outcomes, two of which are universal NPMs and required by all states. States develop ESMs to further quantify the progress of state-specific activities. A state's choice of ESMs and NPMs aligns with the activities, strategies, and goals outlined in the State Action Plan and represent a state's unique MCH priorities.

Considerations for Congress

The State MCH Block Grant program can support a wide range of services for millions of women and children. Given recent attention to the nation's adverse maternal and infant health outcomes, Congress may consider questions such as the following:

• Are current federal funding levels adequate to address state and national MCH priorities?
• Are high-risk populations being sufficiently reached? Are MCH services appropriately tailored to specific subgroups?
• Do State MCH Block Grant programs effectively partner with related programs and avoid duplicated efforts?