Introduction

Title V of the Social Security Act (SSA; P.L. 74-271, as amended; 42 U.S.C. §§701-709) permanently authorizes the Maternal and Child Health (MCH) Services Block Grant, which aims to support and improve the health and well-being of mothers, children, and families, particularly those with low income or with limited access to health care services. The program provides services to pregnant women, infants, children, and children and youth with special health care needs (CYSHCNs), though other individuals may also benefit from block grant-funded activities.¹ The MCH Services Block Grant is administered by the Maternal and Child Health Bureau (MCHB) in the Health Resources and Services Administration (HRSA), an agency within the U.S. Department of Health and Human Services (HHS).

SSA Section 501 permanently authorizes three activities within the MCH Services Block Grant program (hereinafter referred to as components):

• 1. State MCH Block Grants (§501(a)(1)).²
• 2. Special Projects of Regional and National Significance (SPRANS; §501(a)(2)).
• 3. Community Integrated Service Systems (CISS; §501(a)(3)).

The first and largest component is awarded directly to states and other jurisdictions (referred to hereinafter as states)³ through a formula-based, federal-state partnership. The State MCH Block Grant program aims to provide states the flexibility to meet the unique needs of its population of pregnant women, infants, and children. The remaining two components provide competitive grant funding to projects that intend to complement state efforts to improve access to quality MCH services. SPRANS projects focus on national or regional needs and priorities, including specific set-asides or directives that are typically established through annual appropriations acts. CISS projects aim to build comprehensive, integrated systems of care to improve access and outcomes for all children, including CYSHCNs.

History

Title V of the Social Security Act (SSA), enacted by Congress in 1935, authorizes funding for services and projects that are intended to improve the health of mothers and children. Originally, four separate grant programs were created under the previous SSA statutory heading, "Title V–Grants to States for Maternal and Child Welfare," two of which related to MCH. These programs aimed to (1) provide and improve health services for mothers and children, particularly those with low-income or who live in rural settings, and (2) provide and improve health care services for "children who are crippled or who are suffering from conditions which lead to crippling," respectively.⁴ Over time, additional categorical programs for low-income women and children were added to both the SSA and the Public Health Service Act (PHSA).

In 1981, seven of the aforementioned programs were combined with Title V through the Omnibus Budget Reconciliation Act of 1981 (OBRA 1981; P.L. 97-35).⁵ This consolidated and renamed statute, "Title V–Maternal and Child Health Services Block Grant," was intended to provide states additional flexibility in determining how to use federal funds to address state-specific MCH needs. It required each state to receive, at a minimum, the combined funding of the programs consolidated under OBRA 1981 and authorized a federal set-aside for discretionary grants—thereby establishing the SPRANS program.

The Omnibus Budget Reconciliation Act of 1989 (OBRA 1989; P.L. 101-239) made additional changes to the MCH Services Block Grant. These changes increased the amount of federal funding authorized, called for greater accountability, and created stricter application and reporting requirements for states, including the requirement for a statewide needs assessment to be conducted every five years in order to receive State MCH Block Grant Program funds. OBRA 1989 also introduced the requirement for states to maintain a level of state contributions equal to or greater than that of the state contributions in 1989, known today as the Maintenance of Effort level. Additionally, OBRA 1989 added Section 501(a)(3), which authorized federal funding to develop and expand a variety of community-based care coordination services to "promote the effective and efficient organization and utilization of resources to assure access to necessary comprehensive services for children with special health care needs and their families." This new authorization designated funding to such services when the amount appropriated to the MCH Services Block Grant exceeds $600 million; this component is now known as the CISS program.⁶ Most recently, the Maternal and Child Health Stillbirth Prevention Act of 2024 (P.L. 118-69) amended the State MCH Block Grant and SPRANS programs by clarifying that federal funds may be used toward programs or activities that aim to reduce the incidence of stillbirth, including research, screening and surveillance programs, and other evidence-based programs.

In addition to the three components of the MCH Services Block Grant, current Title V legislation authorizes funding for additional services and projects aimed to improve the health of mothers and children, many of which were added or amended by the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended). These include the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and other categorical grant programs such as those focused on personal responsibility and abstinence education.⁷ A brief discussion of these programs is available in Appendix J. This report focuses exclusively on the MCH Services Block Grant program (authorized in SSA §501 and referred to in SSA §§501-509), which receives the largest single federal appropriation of all programs authorized under Title V.⁸ Current law permanently authorizes $850 million across all three components of the MCH Service Block Grant program.⁹

Funding

Figure 1 displays the MCH Services Block Grant federal appropriation history by program component from FY2020 through FY2024. Additional federal appropriation history appears in Table A-1 in Appendix A.

SSA Section 502 mandates the following annual allocation formula (per fiscal year) for federal funds across each of the MCH Services Block Grant components:

• SPRANS: 15% of the appropriation that does not exceed $600 million, and 15% of funds remaining above $600 million after CISS funds are set aside.
• CISS: 12.75% of the appropriation that is above $600 million.
• State MCH Block Grants: remainder of the total federal appropriation.

Annual appropriations acts have frequently deviated from this formula. For example, the Consolidated Appropriations Act, 2023 (CAA 2023; P.L. 117-328), mandated that no more than $219.116 million of FY2023 funds would be made available to SPRANS and that $10.276 million would be made available for CISS, "notwithstanding sections 502(a)(1) and 502(b)(1) of the Social Security Act."¹⁰ Through this approach, Congress effectively increased the proportion and amount of FY2023 funds allocated to SPRANS ($219.116 million, compared with $119.5 million per the §502 formula) and decreased the amount appropriated to CISS ($10.276 million, compared with $28.394 million that would have been available under the §502 formula). Conversely, Congress has used this approach to decrease the proportion of funds for SPRANS and increase the proportion for CISS, such as in FY2014.¹¹

Figure 1. MCH Services Block Grant Funding, by Component FY2020–FY2024

Source: Figure created by CRS using final funding levels as reported in annual Department of Health and Human Services, Health Resources and Services Administration (HRSA) Congressional Budget Justifications for FY2020-2023. FY2024 figures reflect enacted totals, rather than final numbers, based on P.L. 118-47 and Congressional Record, vol. 170, no. 51, book II, March 22, 2024, p. H1887. Notes: MCH = Maternal and Child Health; FY = Fiscal Year. Amounts not adjusted for inflation.

State MCH Block Grant Program

The majority of MCH Services Block Grant funding is allotted to states through the formula-based, State MCH Block Grant program. The State MCH Block Grant program is the oldest federal-state partnership program and aims to "create partnerships that enable each state/jurisdiction to address the health service needs of its mothers, infants, and children, which includes children with special health care needs and their families."¹² State health agencies are typically responsible for the overall administration and supervision of activities implemented under the program.¹³

Purpose

Section 501(a)(1) of Title V establishes the purpose of the State MCH Block Grant program as aiming to enable each state to

• ensure access to quality health care services for mothers and children, particularly to those with low income or limited availability of care;
• reduce the number of infant deaths, preventable diseases, and children with disabilities;
• reduce the incidence of stillbirth;
• reduce the need for inpatient and long-term care services;
• increase the number of children receiving immunizations, health assessments, and follow-up diagnostic and treatment services;
• provide prenatal, delivery, and postpartum care for low-income, at risk-women;
• provide preventive and primary care services for low-income children;
• provide rehabilitation services for blind and disabled individuals under the age of 16 receiving benefits under Social Security Insurance (SSI) (Title XVI of the SSA),¹⁴ if the services are not provided under Medicaid (SSA Title XIX);¹⁵
• promote and provide family-centered, community-based coordinated care services for CYSHCNs; and
• facilitate the development of community-based systems of services for CYSHCNs and their families.

According to HRSA, all State MCH Block Grant programs are guided by four key principles that support the delivery of public health services and systems to address the needs of MCH populations.¹⁶ These principles are as follows:

• 1. Delivery of MCH services within a public health service model.¹⁷
• 2. Data-driven programming and performance accountability.¹⁸
• 3. Partnerships with individuals, families, and family-led organizations to ensure systems and services that support the interests of all MCH populations.
• 4. Health equity and assurance that all MCH populations achieve their full health potential.

Funding

The State MCH Block Grant program receives the remaining federal appropriation after federal funds for both SPRANS and CISS are allocated (see the "Funding" section above). All 50 states and nine jurisdictions may apply for State MCH Block Grant funds. Historically, all 59 have applied for and been awarded State MCH Block Grant funds since HRSA began administering the program in 1981.¹⁹ Each state is responsible for using block grant funds to meet the unique needs of its MCH populations in alignment with federal requirements.²⁰

Federal funds are annually allotted to individual state recipients using a formula-based approach that considers (1) the amount of federal funds historically allotted to each state, and (2) the proportion of low-income children in each state relative to the total number of low-income children nationwide. Specifically, the first $422 million of the annual federal appropriation is distributed to each state based on the amount it received under the consolidated maternal and child health program in FY1983.²¹ Remaining federal appropriations are distributed to each state using child poverty-based allotments.²² Historically, poverty allotments were calculated based on data reported in the U.S. Census Bureau's long-form decennial census. The annual American Community Survey (ACS) replaced the decennial census as the block grant's source for child poverty data in FY2013.²³ Historically, the U.S. Territories (American Samoa, Northern Mariana Islands, Guam, U.S. Virgin Islands, and Puerto Rico) and the Freely Associated States (Federated States of Micronesia, Marshall Islands, and Palau) have not been included in the ACS. For these jurisdictions, HRSA distributes funds in excess of the 1983 level in a manner proportionate to each jurisdiction's share of overall State MCH Block Grant funding in 1983.²⁴ This approach does not incorporate poverty-based allotments.

In FY2022, the year for which the most recent federal data are available, final federal allotments to individual states ranged from $150,340 (Palau) to $39.6 million (California).²⁵ The distribution of State MCH Block Grant federal funds by state in FY2022 is displayed in Figure 2 and is listed in Table B-1 in Appendix B.

Figure 2. State MCH Block Grant: Federal Allotments FY2022

Source: Figure created by CRS using final FY2022 federal funding allotments as reported in HRSA's FY2024 Congressional Budget Justification, pp. 198-200.

As part of a federal-state partnership program, each state is required to match at least $3 for every $4 of federal block grant funds allotted to the state.²⁶ States must also maintain a level of state contribution that is at or above the state's total contribution from FY1989, known as the Maintenance of Effort.²⁷ States are allowed to exceed the match requirement; this is called an overmatch.

HRSA categorizes the total funding for the State MCH Block Grant program as coming from five sources:²⁸

• 1. Federal Allocation: Federal funding provided to states under the MCH Services Block Grant.
• 2. State MCH funds: Nonfederal funds derived from the state that are used for program activities and meet the legislatively mandated match requirements.
• 3. Local MCH funds: MCH-dedicated funds from local governments or jurisdictions within the state.
• 4. Program Income: Funds collected by state MCH agencies from insurance payments, Medicaid, health maintenance organization (HMO) payments, private grants/entities, etc.
• 5. Other federal funds: Monies other than Title V funds that are under control of the person responsible for administering the Title V program (e.g., funds from Centers for Disease Control and Prevention [CDC]; Healthy Start; and the Supplemental Special Nutrition Program for Women, Infants, and Children [WIC]).

States are allowed to put all nonfederal funding sources toward meeting the state match requirement; that is, state MCH funds, local MCH funds, and program income may contribute to the required maintenance of effort total (items 2-4 above).

In FY2022, state MCH funds constituted the largest proportion of total State MCH Block Grant program funding (41.0%), whereas federal allocations accounted for 21.0% (see Figure 3). Combining all five funding sources, the State MCH Block Grant program totaled an estimated $2.65 billion in FY2022. Individual state totals across each of these five funding sources are presented in Table B-1 in Appendix B. Trends in program expenditures by service category and population group are discussed below (see "Expenditures by Service Category" and "Expenditures by Population Group," respectively). Unless otherwise noted, all expenditure data hereinafter are inclusive of all funding sources.

Figure 3. State MCH Block Grant Funding, by Source FY2022

Source: Figure created by CRS using final federal allocation data reported in HRSA's FY2024 Congressional Budget Justification, pp. 198-200. State funds, other local funds, and program income totals were extracted from individual state Application/Annual Reports, Form 2, FY2022 Expenditures column. Each state Application/Annual Report is located on HRSA's Title V Information System (TVIS); https://mchb.tvisdata.hrsa.gov/Home/StateApplicationOrAnnualReport. Notes: TVIS funding data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. The FY2022 expenditures presented above were reported in July 2023 and thus may not reflect final state, local, or program income expenditures. Not all states submit data on the "other funds" or "program income" categories.

Nonuse and Redistribution

According to SSA Section 502(d), if a state chooses not to apply for funds, is not qualified for such funds, or indicates that it does not plan to use its full allotment, that state's federal allotment is redistributed among the remaining states in the proportion otherwise allotted to the state.²⁹ All states have applied for and been awarded funds since HRSA began administering the program in 1981.³⁰ Each state has 24 months to expend its full federal allotment. MCHB staff monitor expenditure drawdown and identify expenditure plans with any states that have more than one-quarter of funds remaining at the 18-month mark. Any funds not expended at the end of the 24-month period are returned to the U.S. Treasury Department.³¹

Services Provided

States are required to use State MCH Block Grant funds "to provide and to assure [that] mothers and children (in particular those with low income or with limited availability of health services) [have] access to quality maternal and child health services."³² Specifically, states may use block grant funds for the provision of health services and related activities, which may include "planning, administration, education, and evaluation, including payment of salaries and other related expenses of National Health Service Corps personnel."³³ According to MCHB, State MCH Block Grant Programs are encouraged to incorporate the four key principles discussed in the "Purpose" section above and to ensure that MCH systems are family centered, community based, and culturally competent.³⁴

The MCHB provides a guiding framework, known as the MCH Pyramid of Services, to support states in identifying which MCH services and activities to fund with block grant resources. Broadly, pyramid structures are used in various public health capacities to visually communicate the potential impact of certain public health interventions, with the base of the pyramid reflecting interventions that reach larger populations at once. Interventions that aim to change individual contexts are presented in ascending order. The MCH Pyramid of Services is also referenced in states' Application/Annual Reports to measure program participation, reach, and expenditures across three service categories: (1) direct health care services, (2) enabling services, and (3) public health services and systems. Figure 4 contains definitions of each service category and an illustrative, nonexhaustive list of examples by service category.

In addition to the MCH Pyramid of Services, the MCHB provides an illustrative list of 11 strategies for states to use in their program planning. This list draws upon (1) the three core functions of public health, as defined by the Institute of Medicine; (2) the revised Ten Essential Public Health Services; and (3) legislative requirements for Title V services.³⁵ The full list of strategies is presented in Appendix C. States also have the flexibility to implement additional frameworks or health service models to better understand how various factors influence the health and well-being of a state's unique MCH population.

Service Requirements for Federal Funds

States are required to use at least 30% of federal allocations for preventive and primary care services for children and 30% for CYSHCNs.³⁶ These requirements may be waived by the HHS Secretary if the state (1) demonstrates "extraordinary unmet need" for either of the required populations, and (2) provides assurances that some funds will be allocated toward each required population by specifying the substitute percentages.³⁷ This waiver may be requested in the state's annual application.³⁸ Additionally, no more than 10% of federal allocations may be used for administrative costs.³⁹

Prohibited Services

Section 504 of the SSA prohibits the use of State MCH Block Grant funds for the following activities:⁴⁰

• inpatient services, other than for children with special health care needs, high-risk pregnant women, and infants, unless otherwise approved by the Secretary of HHS;
• cash payments to intended recipients of health services;
• purchase or improvement of land, buildings, or facilities (other than minor remodeling), or the purchase of major medical equipment;⁴¹
• to satisfy any requirement for the expenditure of nonfederal funds as a condition for the receipt of federal funds;⁴²
• research or training at a private, for-profit entity,⁴³ and
• payment for any item or service (other than an emergency item or service) furnished by an individual, entity, or physician excluded under Titles V, XVIII, XIX, or XX of the SSA.⁴⁴

Expenditures by Service Category

States are required to provide budgeted and actual program expenditure data as part of the Application/Annual Report.⁴⁵ This includes detail on all expenditures by service category (see Figure 4), in addition to other requirements. Across all states and all five funding sources, the largest proportion of FY2022 funds were expended on enabling services (40.7%), followed by public health services and systems (31.2%), and direct health care services (28.1%) (see Figure 5).

Figure 5. State MCH Block Grant Expenditures, by Service Category FY2022

Source: Figure created by CRS using data from HRSA's Title V Information System (TVIS); https://mchb.tvisdata.hrsa.gov/Financial/FundingByServiceLevel. Notes: TVIS funding data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. The FY2022 expenditures presented above were reported in July 2023 and thus may not reflect final expenditures.

Within the category of direct health care services, states report on the types of direct services provided using predefined categories; however, over half of direct services funds are allocated to the category of other services. For example, in Texas, other direct services included home health services, whereas Washington, DC, included adolescent mental health services under this category. Conversely, California did not fund any direct services with State MCH Block Grant program funding in FY2022. Additional detail on what other direct services include is available in FY2024 Application/FY2022 Annual Reports among those states that provide direct services with State MCH Block Grant funds. Figure E-1 in Appendix E displays FY2022 expenditures by service category with an additional disaggregation of expenditures by federal and all nonfederal funding sources.

From FY2018 to FY2019, direct services accounted for over 60% of total program expenditures; more recently, expenditures have increasingly shifted toward enabling and public health services and systems (see Figure 6). In FY2022, these two respective categories constituted over 85% of total expenditures. Additional information on program expenditures, including changes in specific dollar amounts, is available in Table F-1 in Appendix E.

Figure 6. State MCH Block Grant Expenditures, by Service Category, FY2018-FY2022

Source: Figure created by CRS using data from HRSA's Title V Information System (TVIS); https://mchb.tvisdata.hrsa.gov/Financial/FundingByServiceLevel. Notes: TVIS data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. State reporting on direct and enabling services does not include services that are reimbursed by Medicaid, CHIP, or other public or private payers. Figure reflects total program expenditures, inclusive of federal and nonfederal funds.

Populations Served

The populations served by the State MCH Block Grant include pregnant women, infants, children, CYSHCN, and others. HRSA defines these five population groups as follows:

• Pregnant Women. A female from the date of conception to 60 days after childbirth, delivery, or expulsion of the fetus.⁴⁶
• Infants. Children less than one year old.
• Children. Children from age 1 through 21 years old.⁴⁷
• Children and Youth with Special Health Care Needs (CYSHCN). CYSHCN are infants and children who have or are at risk of having a disability, chronic illness/condition, or educational/behavioral issue.⁴⁸
• Others. This category consists of women and men who are over 21 years of age.⁴⁹

Populations Reached

Using annual state-reported data, the MCHB publishes estimates of the number of individuals reached across each of the five population groups described above. These estimates are developed by (1) quantifying the number of individuals who received direct and enabling services (i.e., the top two categories in the MCH Services Pyramid; see Figure 4), and (2) estimating the proportion of each population group who were reached by State MCH Block Grant-funded services across all three service categories (i.e., direct, enabling, and public health services and systems).

States typically derive estimates of the number of individuals reached by direct and enabling services from reimbursement data or individual client service records. As part of the estimate, states outline the total number of individuals served, by population group, and indicate the types of health insurance coverage to ensure that only services funded by the State MCH Block Grant without full reimbursement from another source (e.g., Medicaid, private health insurance) are included in the final estimate.

Estimating the number of individuals reached through public health services and systems can be challenging. For instance, quantifying the number of individuals who were exposed to a mass media campaign, such as those promoting safe newborn sleep practices, can be difficult since public health promotion activities do not typically measure the discrete number of individuals who heard, saw, or were otherwise influenced by the message. With the design of public health campaigns in mind, HRSA's reporting forms guide recipients through the development of these estimates using various denominators and data sources.⁵⁰ To avoid double-counting, states are encouraged to focus on the programs and services that have the largest reach for a given population and approximate percentages for each numerator. States describe their methods, data sources, and the specific programs or services that were included in the estimate as part of the Application/Annual Report.

Across all three MCH service categories—direct, enabling, and public health services and systems—over 108 million individuals were estimated to have been reached by State MCH Block Grant activities in FY2022 (see Figure 7). The majority of recipients across the three service categories were children aged 1-21 years (51%), followed by "others," which includes men and women over age 21 (34%). When examining population groups reached by direct and enabling services only (11.9 million individuals), children continued to make up the majority of individuals reached (51%). Combined, pregnant women, infants, children, and CYSHCN made up a larger share of the population reached by both direct and enabling services (81%) compared with their share across all three service categories (65%). This demonstrates that State MCH Block Grant-funded direct and enabling services tend to focus primarily on pregnant women, infant, and child populations (81%); however, a relatively larger proportion of other groups (34%) and a larger overall population (108 million individuals compared with 11.9 million) is reached when examining block grant activities across all three types of services, particularly since public health services and systems aim to reach a broader population than that of direct and enabling services.

Figure 7. State MCH Block Grant Distribution of Populations Reached, by Service Category FY2022

Source: Figure created by CRS using data from HRSA's Title V Information System (TVIS); https://mchb.tvisdata.hrsa.gov/, see "Reporting Domains." Notes: TVIS data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. For example, FY2022 data were reported in July 2023 and may not reflect final totals of individuals reached. TVIS provides estimates only across these two aggregated categories; separate totals by individual service category are not available. State reporting on direct and enabling services does not include services that are reimbursed by Medicaid, CHIP, or other public or private payers. The figure reflects individuals reached across all program activities, inclusive of those funded by federal and nonfederal funds. "Others" include men and women over age 21.

Both of these estimates can be found in TVIS; however, TVIS does not provide individual estimates for each of the three service categories. Rather, estimates are totaled across (1) direct and enabling services, and (2) direct, enabling, and public health services and systems. Considerable variation exists across individual states.

Expenditures by Population Group

In addition to annually reporting on expenditures by service category, states are also required to report on program expenditures by each population group. In FY2022, children composed the largest proportion of total expenditures (36.3%; see Figure 8). Notably, CYSHCN accounted for nearly one-third (29.6%) of all program expenditures, yet this group accounted for 8.3% of the total individuals served across all service categories (see "Populations Reached"). Conversely, others accounted for the lowest proportion of expenditures (7.3%) despite representing over one-third (34.5%) of individuals reached. Considerable variation in program expenditures by population group exists across all states.

Figure 8. State MCH Block Grant Distribution of Expenditures, by Population Group FY2022

Source: Figure created by CRS using data from HRSA's Title V Information System (TVIS); https://mchb.tvisdata.hrsa.gov/Financial/FundingByIndividualsReached. Notes: TVIS funding data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. The FY2022 expenditures presented above were reported in July 2023 and thus may not reflect final expenditures. "Others" include men and women over age 21. CYSHCN refers to children and youth with special health care needs.

Figure G-1 in Appendix G displays FY2022 expenditures by population group with an additional disaggregation of expenditures by federal and all nonfederal funding sources.

From FY2018 to FY2019, CYSHCNs accounted for approximately 70% of total program expenditures; more recently, expenditures have increasingly shifted towards children, with smaller increases towards pregnant women and infants (see Figure 9). Additional information on expenditures by population group, including changes in specific dollar amounts, is available in Table H-1 in Appendix H.

Figure 9. State MCH Block Grant Expenditures, by Population Group, FY2018-FY2022

Source: Figure created by CRS using data from HRSA's Title V Information System (TVIS); see https://mchb.tvisdata.hrsa.gov/Financial/FundingByIndividualsServed. Notes: TVIS data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. For example, FY2022 data were reported in July 2023 and may not reflect final expenditures. The figure reflects individuals reached across all program activities, inclusive of those funded by federal and nonfederal funds.

Application and Reporting Requirements

All block grant recipients must annually submit a combined application for the forthcoming fiscal year along with an annual report for the prior fiscal year (hereinafter referred to as the Application/Annual Report). This section provides a brief overview of some of the Application/Annual Report requirements, including information on the program's national performance measurement framework.⁵¹

Section 505(b) of the SSA requires the Application/Annual Report to be developed by, or in consultation with, the state MCH agency, and SSA Section 506(a) requires the standardized report to be submitted to the Secretary of HHS. States must solicit public comments (including from community members and other federal or public agencies) throughout the Application/Annual Report development process. A description of this process, including how public comments were addressed, must be discussed in the Application/Annual Report.⁵² In addition, state MCH and CYSHCN Directors attend an annual Application/Annual Report review meeting, which provides an opportunity for HRSA staff to assess each state's progress relative to its selected performance measures and to discuss the state's plan for the coming year. Reviewers also include information on former state and federal MCH leaders, MCH experts and academics, and family/parent reviewers. During the review process, states can request additional technical assistance from HRSA to support activity planning and implementation; however, HRSA does not provide additional funding to support technical assistance.⁵³

As part of the Application/Annual Report, states must submit standardized information including an overview of all funding sources, program participation and reach, program expenditures and other budget data, standardized MCH measures, and a narrative update on state MCH data systems and infrastructure. States must also perform a biennial independent audit of all program expenditures.⁵⁴ Specific requirements, templates, and additional guidance are published on HRSA's TVIS, which also publishes each state's final Applications/Annual Reports.⁵⁵

Needs Assessment and State Action Plan

Each state is required to conduct and submit a comprehensive statewide needs assessment once every five years.⁵⁶ The needs assessment must identify statewide goals that align with national health objectives, including the need for preventive and primary care services for pregnant women, mothers, infants, and children, and services for CYSHCN.⁵⁷ This process includes data collection and analysis regarding a state's MCH capacity and infrastructure, needs and desired outcomes, and relevant legislative mandates, among other topics. The needs assessment process is intended to be a systematic and collaborative process that includes MCHB, a state's department of health, families, health care practitioners, and other agencies, organizations, and state MCH stakeholders.

Findings from the needs assessment are submitted in the form of a Needs Assessment Summary, which drives the development of a state's annual application for block grant funds. These needs assessment results also inform the development of a five-year State Action Plan, which outlines 7-10 priority needs and statewide objectives and strategies, typically compiled in a table format.⁵⁸ The plan must also convey areas of alignment between the priority needs, objectives, and strategies and performance measures (see "Performance Measurement Framework").

In each of the four interim years following the needs assessment, states must include Needs Assessment Interim Updates as part of the Application/Annual Report process. These updates may reflect changes to program strategies, demographics, and/or other emerging MCH issues. Figure 10 summarizes the annual reporting cycle based on the five-year needs assessment.

Figure 10. State MCH Block Grant Application/Annual Report Timeline

Source: Figure created by CRS using example deadlines provided in HRSA's Title V Maternal and Child Health Services Block Grant to State Program. Guidance and Forms for the Title V Application/Annual Report.

Relationship with Medicaid

The State MCH Block Grant program and the Medicaid program (SSA Title XIX) share a common goal of improving health for the MCH population through the provision of affordable health care delivery systems and adequate coverage. Section 509(a)(2) of the SSA cites the need to promote "coordination at the Federal level of activities authorized under this title [Title V] and under title XIX." Further, SSA Section 1902(a)(11) requires state Medicaid agencies to enter into Inter-Agency Agreements (IAAs) with agencies administering programs authorized under SSA Title V, including those agencies that receive State MCH Block Grant funding.

Medicaid law further clarifies that the Medicaid program should serve as the payor of first resort for services covered under both Title V and Medicaid. This means that State MCH Block Grants cannot be used to reimburse a claim for a service otherwise covered under Medicaid. HRSA's MCHB encourages robust IAAs that outline specific areas of program collaboration. The goal of this partnership and collaboration is to allow for the effective leveraging of federal and state resources to help ensure that MCH populations receive necessary preventive services, health examinations, treatments, and follow-up care. IAAs are publicly available in the TVIS.

As part of the Application/Annual Report, states are required to provide a detailed description of the existing relationship between the State MCH Block Grant program and the Medicaid program to build upon the IAA. This includes information on program outreach and enrollment, health care financing, waivers or state-specific amendments that affect the MCH population, joint policy-level decision-making, and Medicaid Core Set measures.⁵⁹

Relationship with Other Programs

States are required to describe partnerships with other federal, state, and local entities and how such collaboration may address priorities identified in the Needs Assessment (see the "Needs Assessment and State Action Plan" section). Every five years (at minimum), states must describe the relationship between the State MCH Block Grant program and other programs, including (1) other MCHB investments (e.g., Maternal Health Innovation Grants); (2) other HRSA investments (e.g., HIV/AIDS programs); (3) other federal investments (e.g., CDC-funded programs); (4) local programs and organizations (e.g., local health departments); (5) other State Department of Health programs (e.g., health promotion activities); (6) other governmental agencies (e.g., the State Children's Health Insurance Program (CHIP);⁶⁰ (7) tribes, tribal, and urban Indian organizations; (8) related public health universities and educational programs; and (9) relevant nongovernmental organizations.

Performance Measurement Framework

The State MCH Block Grant program uses a three-tiered performance measurement framework to track annual progress toward MCH goals. The framework consists of Evidence-based or -informed Strategy Measures (ESMs), National Performance Measures (NPMs), and National Outcome Measures (NOMs). According to the program guidance, ESMs are structural and process measures that influence the NPMs, which are short- and medium-term indicators. NPMs are hypothesized to influence NOMs, the longer-term, population-level MCH indicators. Table 1 displays the relationship of these measures as identified in the performance measurement framework; each measure category is further described below.

Evidence-Based or Informed Strategy Measures

ESMs quantify and assess outputs related to NPMs and support states in setting improvement objectives across the five-year reporting cycle. States are required to develop and report on at least one ESM for each NPM. States must detail the ESM's relationship to state priorities, describe of the scientific evidence informing the measure and its significance, and present additional considerations about data availability and measure definition.⁶¹

National Performance Measures

NPMs are short- and medium-term measures that are intended to improve NOMs. NPMs are considered to be more directly modifiable by the specific activities that states implement with block grant funds.⁶²

The 20 NPMs are organized across five MCH population domains—(1) Women/Maternal Health, (2) Perinatal/Infant Health, (3) Child Health, (4) Children with Special Health Care Needs, and (5) Adolescent Health—as well as across three measure domains. Measure domains were introduced in the most recent guidance and reflect different ways in which a health strategy or activity may improve NOMs. These include (1) clinical health systems, (2) health behaviors, and (3) social determinants of health. The full list of measures, including each measure's population and measure domain, is available in Appendix I. States must report on a minimum of five NPMs, with at least one NPM for each of the five MCH population domains. Two of the mandatory five NPMs are "Universal NPMs," which all states are required to report on.⁶³ The Universal NPMs, Postpartum Visit and Medical Home, were introduced in the 10^th version of the guidance in January 2024 (see Appendix I and text box, right). According to MCHB, these NPMs were selected for their ability to measure access and quality of primary and preventive care specific to maternal health and improving care networks for CYSHCN.⁶⁴

National Outcome Measures

NOMs are longer-term measures of health status that the block grant program aims to improve overall. For instance, NOMs can reflect measures about quality of life at the population level, such as preventable morbidity and mortality, emerging health priorities, and health across the life course.⁶⁵ States do not individually report on NOMs; rather, MCHB prepopulates NOM data across all states using a variety of federal and state data sources (see the "Selected Federally Available Data Sources" text box below) to better monitor the impact of the State MCH Block Grant without duplicating federal data collection efforts. The full list of 33 NOMs is available in Appendix J.

If state priorities are not adequately reflected by NOMs or NPMs, states may use unique State Outcome Measures (SOMs) or State Performance Measures (SPMs). States may develop these measures independently or use a list of Standardized Measures provided by HRSA. States provide a detailed overview of unique measure definitions, data sources, and multiyear data points in the Application/Annual Report.

Performance Measurement Considerations

The 10^th version of the Application/Annual Report Guidance notes that the performance measurement framework underwent a revision to better address the social determinants of health,⁶⁶ provide more choices for NPMs across population domains, and introduce optional standardized SPMs.⁶⁷ In addition to the new Universal NPM requirement, the revised guidance allows states to select priority populations for each NPM and includes NOMs to reflect emerging priorities such as stillbirth rates, among other changes.⁶⁸ MCHB notes the revised guidance puts a greater emphasis on health equity as a guiding principle.⁶⁹ MCHB updated the guidance following consultation with state MCH agencies, MCH leaders and stakeholders, and the public—a process implemented in past iterations.⁷⁰

While the measures are designed to standardize reporting across states and capture progress toward state and national health objectives, variation exists among states in terms of capacity for collecting and reporting data. MCHB and individual states may use federally available data sources, in addition to state-collected data, to track NOMs, NPMs, and ESMs. A selection of MCH data sources is presented in the text box below. States are required to provide an update on data capacity and enhancement activities every five years.⁷¹

Additional Reporting Requirements

In addition to the components discussed above, states must submit standardized information including an overview of all relevant funding sources, program participation and reach, program expenditures and other budget data, standardized MCH measures, and a narrative update on state MCH data systems and infrastructure. This also includes reporting on an annual "MCH Success Story," which highlights the contributions of the State MCH Block Grant, as well as narratives on the broader health of MCH populations in each state and the context of the state's health care system. States must also perform a biennial independent audit of all program expenditures.⁷²

Reports to Congress

Section 506(a)(3) requires HRSA to annually compile the information reported by states and to present reports to the House Committee on Energy and Commerce and the Senate Committee on Finance. This report must include a summary of the information reported to the Secretary of HHS by the states and a compilation of specified maternal and child health indicators at both the national and state levels. All information included in this requirement can be found in the publicly accessible TVIS.⁷³

Special Projects of Regional and National Significance (SPRANS)

The SPRANS component of the MCH Services Block Grant competitively provides federal funds to projects aimed at driving innovation, improving systems of care for MCH populations, and addressing emerging needs, priorities, or issues.⁷⁴ SPRANS funding complements other Title V MCH Services Block Grant components, as well as other federal and state efforts, by building capacity through pilot programs, research, training, data collection, quality improvement, and workforce development.⁷⁵

SPRANS authorizing legislation specifically mentions the following focus areas: (1) MCH research and training; (2) genetic disease testing, counseling, and information dissemination; (3) comprehensive hemophilia diagnostic and treatment centers; (4) newborn screening and follow-up services, including sickle cell and other genetic disorders; (5) evidence-based programs, activities, and research to reduce the incidence of stillbirth.⁷⁶

Grant Recipients

Unlike the State MCH Block Grant program, SPRANS funding can be competitively awarded to and administered by other entities beyond state health agencies. Typically, projects funded through the SPRANS component are open to public or nonprofit private institutions of higher learning that train health care personnel (particularly those focused on MCH populations), or public or private nonprofit organizations or institutions of higher learning that conduct MCH research. Community-based organizations, tribal organizations, and faith-based organizations may also be eligible to receive SPRANS funding. Since SPRANS funding is competitively awarded into discrete projects, eligibility requirements, application timeframes, and reporting requirements may vary by project.⁷⁷

Funding and Program Topics

The total amount of MCH Services Block Grant funding for SPRANS (per fiscal year) is made available under the following formula:

• SPRANS: 15% of the annual federal appropriation that does not exceed $600 million, and 15% of funds remaining above $600 million after CISS funds are set aside.⁷⁸

Annual appropriations acts have frequently deviated from this formula. For example, the Consolidated Appropriations Act, 2023 (CAA 2023; P.L. 117-328), mandated that no more than $219.116 million of FY2023 funds would be made available to SPRANS and that $10.276 million would be made available for CISS, "notwithstanding sections 502(a)(1) and 502(b)(1) of the Social Security Act."⁷⁹ Through this approach, Congress effectively increased the proportion and amount of FY2023 funds allocated to SPRANS ($219.116 million, compared with $119.5 million per the §502 formula) and decreased the amount appropriated to CISS ($10.276 million, compared with $28.394 million that would have been available under the §502 formula).

Historically, parameters for SPRANS funding have been outlined through authorizations and appropriations for specific programs or activities, including funding set-asides for particular priority issues. Table 2 outlines specific SPRANS set-asides and directives from FY2022 to FY2024. Appropriations have historically been provided for oral health, epilepsy, sickle cell, and fetal alcohol spectrum-related projects; in FY2024, these accounted for 8% of total SPRANS funding. Other SPRANS set-asides may reflect areas of interest identified by HRSA in the annual budget justification process or other areas of congressional interest laid out in appropriations reports. In FY2024, Congress directed approximately 59% of total SPRANS funding to address specific priority issues in appropriations report language.

Other priority areas for SPRANS funding may be highlighted by Congress in committee reports. For example, the FY2023 House Committee on Appropriations highlighted concerns with the rising prevalence of congenital syphilis and encouraged HRSA to expand prenatal screening and testing opportunities with SPRANS funding.⁸⁰ Remaining SPRANS funds support additional activities as authorized by statute.

SPRANS authority has been used to mandate the development and funding of separate programs. For example, the Family-to-Family Health Information Centers (F2F HIC) program was established through the Deficit Reduction Act of 2005 (DRA; P.L. 109-171). The DRA amended Title V to authorize and appropriate mandatory funding for F2F HIC in all states through FY2009.⁸¹ Subsequent laws have provided mandatory appropriations for this program in each year since. Most recently, the Consolidated Appropriations Act, 2024 (CAA 2024; P.L. 118-42), appropriated funds through the first quarter of FY2025. According to SSA Section 501(c)(2), funds are required to be appropriated to F2F HICs to provide information, education, technical assistance, and peer support to families of CYSHCN and health professionals who serve such families. For additional funding history, see Table K-1 in Appendix J; for more information about this program, see CRS Insight IN12317, Family-to-Family Health Information Centers: Current Status and Policy Considerations.

Community Integrated Service Systems (CISS)

The CISS component of the MCH Services Block Grant provides federal funds to projects that seek to increase local service delivery capacity and build comprehensive and integrated community service systems for mothers and children. In particular, CISS funding supports the development, innovation, and expansion of services in rural areas or for MCH populations with special health care needs.⁸²

CISS authorizing legislation mentions the following topic areas: MCH home visiting and case management, health education and social support services, health workforce participation under Medicaid and Title X, integrated MCH delivery systems, and programs focusing on rural populations and CYSHCN. SSA Section 502 also requires HRSA to give preference to applicants that demonstrate that a CISS project will be carried out in an area with a high infant mortality rate.⁸³

Grant Recipients

Similar to the SPRANS component, CISS funding can be awarded to and administered by other entities beyond state health agencies. Public and private entities, including faith-based and community-based organizations, may be eligible to receive CISS funding. Since CISS funding is typically partitioned into discrete projects, eligibility requirements, application timeframes, and reporting requirements may vary by project.⁸⁴ According to HRSA, there were 26 CISS awards as of FY2024.⁸⁵

Funding and Program Topics

The total amount of federal MCH Services Block Grant funding for CISS (per fiscal year) is made available under the following formula:

• CISS: 12.75% of the annual federal appropriation that is above $600 million.⁸⁶

The first tranche of CISS funding was allocated in FY1993 ($6.4 million). Since then, Congress has not appropriated less than $600 million to the Title V MCH Services Block Grant. Since FY2006, CISS levels have remained relatively consistent (see Table A-1 in Appendix A) with appropriations acts often deviating from the above formula. For example, the Consolidated Appropriations Act, 2023 (CAA 2023; P.L. 117-328), mandated that no more than $219.116 million of FY2023 funds would be made available to SPRANS and that $10.276 million would be made available for CISS, "notwithstanding sections 502(a)(1) and 502(b)(1) of the Social Security Act."⁸⁷ Through this approach, Congress effectively increased the proportion and amount of FY2023 funds allocated to SPRANS ($219.116 million, compared with $119.5 million per the §502 formula) and decreased the amount appropriated to CISS ($10.276 million, compared with $28.394 million that would have been available under the §502 formula). Conversely, Congress has used this approach to decrease the proportion of funds for SPRANS and increase the proportion for CISS, such as in FY2014.⁸⁸

One of HRSA's longest-standing CISS projects is the Early Childhood Comprehensive Systems (ECCS) program. Since 2002, ECCS have helped states improve access to and the quality of preventive health services for young children and families. The current iteration, ECCS: Health Integration Prenatal-to-Three, focuses on promoting early developmental health and well-being, increasing family-centered access to care, and building MCH systems that are equitable, sustainable, comprehensive, and inclusive.⁸⁹ HRSA currently awards $5.1 million annually (FY2021-FY2026) to 20 state-level ECCS entities.⁹⁰

Issues for Congress

Recent congressional attention has increasingly been directed toward maternal, infant, and child health topics, particularly as the number of maternal deaths in the United States remains higher than comparable high-income countries and amid recent increases in infant mortality.⁹¹ Current executive branch initiatives, such as the Biden Administration's White House Blueprint for Addressing the Maternal Health Crisis, highlight rising maternal morbidity and mortality rates and ongoing racial disparities across both measures. Moreover, the improvement of various maternal, infant, and child health indicators is considered among the high-priority objectives in the Healthy People 2030 framework, which aims to "promote, strengthen, and evaluate the nation's efforts to improve the health and well-being of all people."⁹²

The MCH Services Block Grant can support a variety of services, activities, and public health efforts to prevent maternal and child mortality and improve the overall health and well-being of MCH populations. This section outlines selected policy issues Congress may consider in the current MCH landscape relevant to the MCH Services Block Grant, should Congress wish to explore changes to the MCH Services Block Grant or maintain the status quo.

Funding

Allocation Trends. The State MCH Block Grant program has historically received the largest proportion of federal MCH Services Block Grant funds (see Table A-1 in Appendix A). This proportion has decreased since FY2017 as increasingly larger amounts are reserved for SPRANS activities. For example, in FY2013, State MCH Block Grant funds accounted for 86.1% of total program funding and SPRANS accounted for 12.3%; in FY2024, the State MCH Block Grant and SPRANS components accounted for 72.9% and 25.8%, respectively. Similarly, the FY2025 HRSA Budget Justification reflects a $16 million increase to SPRANS, while State MCH Block Grant levels remain consistent with FY2024.⁹³ Congress may consider whether this shift in the proportion of funds across components aligns with national MCH priorities.

Allocation Formulas and Set-Asides. Congress may wish to examine the relevance of the federally defined allocation formula across all three programs in the MCH Services Block Grant, given that appropriation laws frequently deviate from these requirements (see "Funding"). For example, a CRS analysis of final MCH Services Block Grant funding levels from FY2013 to FY2024 revealed that across this 12-year period, there were seven years where the CISS program received an allocation greater than that specified by the formula and six years where SPRANS received an allocation greater than that specified by the formula.⁹⁴ Congress may also consider whether the federal allotment formula for the State MCH Block Grant adequately allots federal funds to individual states. The formula directs the first proportion of funds based on historical individual state allotments in 1983 and directs remaining funds based on child poverty statistics. However, U.S. Territories and Freely Associated States do not receive child poverty-based allotments due to a historical lack of ACS data in these jurisdictions – instead receiving a second proportion of funds that is proportionate to each jurisdiction's share of overall State MCH Block Grant funding in 1983. Congress may examine whether these formulas and approaches adequately achieve program goals and if other MCH-related disparities, measures, data sources, or factors should be taken into consideration.

The State MCH Block Grant program is distinct from various other federal health and human services block grants, in that there is no mandate or set-aside to fund services specifically for tribal populations. Whereas some federal block grant programs reserve a proportion of funds for tribal entities (e.g. MIECHV, Tribal Opioid Response Grants), and may also allow federally recognized tribes to operate such programs (e.g. Temporary Assistance for Needy Families), the State MCH Block Grant does not specify, nor request states to report on, the extent to which funds are specifically used to support tribal populations.⁹⁵ In addition, tribes cannot specifically operate their own State MCH Block Grant program, but must instead coordinate with states for funding. Congress may examine the extent to which tribal populations are reached by State MCH Block Grant services, or assess the degree to which these populations face gaps in MCH services that could be fulfilled by the State MCH Block Grant program. Such considerations may also be framed within the program's overarching goal of improving the health and well-being of MCH populations, particularly those with low income or limited access to health services.

State Contributions. State contributions to the State MCH Block Grant program have decreased following the COVID-19 pandemic (see Table D-1 in Appendix D). In FY2019, nonfederal, state-matched and overmatched funds totaled over $5 billion, representing nearly 91% of program funds totaled across all sources. In FY2020, state contributions decreased by 63.3% to $2 billion. Although there is no evidence to suggest that any states did not fulfill the required match of $3 for every $4 in federal funds, this decrease drove the total program funding from over $6 billion in FY2019 to $2.5 billion in FY2020. As of FY2022, State MCH funds, local MCH funds, and program income contributions have not returned to prepandemic levels, and federal contributions have remained relatively flat. Congress may choose to examine barriers or facilitators that have affected nonfederal funding sources following the COVID-19 pandemic. Congress may also consider examining trends in nonfederal contributions to the State MCH Block Grant across the near future to assess whether funding and/or spending patterns eventually reflect pre-pandemic totals. Congress may also consider whether supplemental federal funds are needed to support states that face ongoing or acute MCH issues.⁹⁶

State MCH Block Grant: Relationships with Related Programs

Coordination and Monitoring. State MCH Block Grant programs must coordinate with other programs and stakeholders through both formal and informal partnerships. These partnerships may include other MCHB investments (e.g., Healthy Start grants), other HRSA programs (e.g., community health centers), and other federal investments (e.g., Maternal Mortality Review Committees), among others. Congress may consider examining how federally funded programs coordinate and avoid duplication of MCH-related efforts, including the degree to which existing programs address MCH needs in various settings or contexts.

Financing and Implementation. Congress could also examine how changes to other federal programs potentially affect how State MCH Block Grant programs are financed or implemented. For example, as discussed in the "Relationship with Medicaid" section, State MCH Block Grant funds should be used as a "payor of last resort" for direct health care expenditures and specifically cannot be used to reimburse a claim for a service covered under Medicaid.⁹⁷ Recent changes to Medicaid policy may affect how State MCH Block Grant programs utilize their funding. For instance, under the Families First Coronavirus Response Act (FFCRA; P.L. 116-127), as amended by the CARES Act (P.L. 116-136), states were required to implement continuous Medicaid enrollment during the COVID-19 public health emergency as a condition of receipt of enhanced Medicaid funds. This, along with other related federal and state policies (as well as economic and social factors), led to substantial increases in Medicaid enrollment.⁹⁸

From FY2019 to FY2022, the proportion of State MCH Block Grant funds used toward direct services substantially decreased, from over 60% to less than one-third of the total program funding (see Table F-1 in Appendix F). While the overall use of preventive and primary direct health care services declined as some individuals delayed or missed medical care during the acute phases of the pandemic, this shift in the types of services funded with State MCH Block Grant Funds may also reflect increased Medicaid enrollment. From FY2020 to FY2022, State MCH Block Grant Funds were increasingly used toward enabling and public health services and systems.

The Consolidated Appropriations Act of 2023 (CAA 2023; P.L. 117-328) ended the continuous Medicaid enrollment condition on March 31, 2023. The law specified a process for redetermining eligibility for all Medicaid enrollees and terminating coverage for individuals who are no longer eligible. Congress may consider how State MCH Block Grant funds could be leveraged to address potential gaps in coverage following the redetermination process, and to assess whether current federal funding levels adequately meet the needs of MCH populations. Congress may also consider closely examining current and future State MCH Block Grant spending patterns. For instance, if State MCH Block Grant funds are increasingly used toward direct services in a state that previously expanded public health service activities in FY2021, such activities may face financial constraints and need to be scaled back. Congress may consider the degree to which such situations occur and how, if at all, they affect national MCH needs.

Oversight and Accountability

State MCH Block Grant Performance Measurement Framework. In January 2024, MCHB released updated State MCH Block Grant program guidance, which included a revised performance monitoring framework. As discussed in the "Performance Measurement Framework" section, NOMs and NPMs track progress toward state and national health priorities. However, individual State MCH Block Grant programs are not the only factors affecting these measures, and thus changes to NOMs and NPMs are not necessarily directly related to impact of a singular program. Other federal and state programs (e.g., Title X programs, Healthy Start, MIECHV, Medicaid), as well as interrelated societal issues, may affect the health and well-being of certain populations. Due to the flexibility of funding and multifaceted nature of MCH issues, determining the impact of a single funding stream on certain health indicators is challenging. These estimates should be interpreted by policymakers accordingly.

The updated performance monitoring framework requires all states to report on two "universal NPMs," thereby attempting to "accelerate progress on federal and state priorities."⁹⁹ The implementation of universal NPMs will facilitate the first estimate of two nationwide performance measures, since all states were not previously required to report on specific NPMs. Congress may choose to monitor the success of this new requirement and assess whether such reporting supports a more comprehensive snapshot of State MCH Block Grant performance. Additionally, the current framework does not assess the quality of health services provided under State MCH Block Grant programs. Congress may consider whether additional oversight is needed in this area.

SPRANS and CISS. Although the State MCH Block Grant program implements a formalized Application/Annual Report across all recipients, reporting requirements can vary widely across individual SPRANS and CISS grants depending on the topic and type of program being implemented. As such, no centralized or structured reporting is available for all SPRANS- or CISS-funded activities. A recent Government Accountability Office (GAO) report similarly highlighted the need for improved standardization of performance metrics across other related HRSA programs (i.e. MIECHV, Healthy Start, State MCH Block Grant)—a recommendation that was agreed upon by HHS.¹⁰⁰ Congress may consider whether current program monitoring activities across MCH Services Block Grant programs, and the monitoring of new MCH initiatives, are complementary or duplicative to the overarching goals of the MCH Services Block Grant.

Appendix A. MCH Services Block Grant Federal Funding History

Appendix B. State MCH Block Grant Funding, by State

Appendix C. Essential Public Health Services for MCH Populations

Appendix D. State MCH Block Grant Funds, by Source (FY2018-FY2022)

Appendix E. State MCH Block Grant Expenditures, by Service Category and Funding Source

Figure E-1. State MCH Block Grant Expenditures, by Service Category and Funding Source FY2022

Source: Table prepared by CRS using data from state Annual Reports, found on HRSA's Title V Information System; https://mchb.tvisdata.hrsa.gov/Financial/FundingByServiceLevel. Notes: "Federal" funds reflect federal allotments from the State MCH Block Grant. "Non-Federal" funds may include state, local, program income, and other funds, which may also include federal funds from other programs under the control of the agency administering the State MCH Block Grant program (see "Funding"). TVIS funding data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. FY2022 expenditures were reported in July 2023 and may not reflect final state, local, or program income expenditures.

Appendix F. State MCH Block Grant Expenditures, by Service Category (FY2018-FY2022)

Appendix G. State MCH Block Grant Expenditures, by Population Group and Funding Source

Figure G-1. State MCH Block Grant Expenditures, by Population Group and Funding Source FY2022

Source: Table prepared by CRS using data from state Annual Reports, found on HRSA's Title V Information System; https://mchb.tvisdata.hrsa.gov/Financial/FundingByIndividualsServed. Notes: "Federal" funds reflect federal allotments from the State MCH Block Grant. "Non-Federal" funds may include state, local, program income, and other funds, which may also include federal funds from other programs under the control of the agency administering the State MCH Block Grant program (see "Funding"). TVIS funding data are estimates/projections that are collected once each year at the time of application and are not meant to be the final fiscal record of note. FY2022 expenditures were reported in July 2023 and may not reflect final state, local, or program income expenditures.

Appendix H. State MCH Block Grant Expenditures, by Population Group (FY2018-FY2022)

Appendix I. State MCH Block Grant National Performance Measures

Appendix J. State MCH Block Grant National Outcome Measures

Appendix K. Family-to-Family Health Information Centers (F2F HIC): Legislation and Appropriation History

Appendix L. Other Title V Programs

In addition to the MCH Services Block Grant, Title V of the Social Security Act contains a number of sections that were added or amended by the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended). This appendix provides a summary of those sections and references to other CRS reports, where relevant.

SSA §510, Separate Program for Abstinence Education

This program provides funding to states for abstinence education. This program was formerly known as the Title V Abstinence Education Grant Program, as authorized by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA; P.L. 104-193). The Bipartisan Budget Act of 2018 (BBA; P.L. 115-123) renamed the ACA-reauthorized program to the Title V Sexual Risk Avoidance Education Program. The program focuses on implementing sexual risk avoidance, meaning voluntarily refraining from sex before marriage. Grantees may set aside funds to conduct rigorous and evidence-based research on sexual risk avoidance.

The authorization and funding have been extended multiple times, most recently through FY2024 in the Consolidated Appropriations Act, 2024 (CAA 2024; P.L. 118-42). For more information on this program, see CRS Report R45183, Teen Pregnancy: Federal Prevention Programs.

SSA §511, Maternal, Infant, and Early Childhood Home Visiting Programs (MIECHV)

The MIECHV program provides grants to states, territories, and tribal entities for the support of evidence-based early childhood home visiting programs. The program seeks to provide and strengthen home visiting services to families residing in at-risk communities and to improve coordination of supportive services. MIECHV is collaboratively administered by the Maternal and Child Health Bureau within HRSA and the Administration for Children and Families.

The authorization and funding have been extended multiples times, most recently through FY2027 under the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022 (Section 6101 of the Consolidated Appropriations Act, 2023; CAA 2023; P.L. 117-328). For more information on this program, see CRS In Focus IF10595, Maternal, Infant, and Early Childhood Home Visiting Program.

SSA §512, Services to Individuals with a Postpartum Condition and Their Families

This program provides grants for epidemiologic research, improved screening and diagnosis, clinical research, and public education to expand understanding of the causes and treatments for postpartum depression and related conditions. The ACA authorized funding of $3 million for these grants for FY2010, and such sums as necessary for each of FY2011 and FY2012. No funds have been appropriated for this program.

SSA §513, Personal Responsibility Education

The Personal Responsibility Education Program (PREP) is administered by the Administration for Children and Families. PREP is defined as a program designed to educate adolescents on both abstinence and contraception for prevention of pregnancy and sexually transmitted infections, including HIV/AIDS, and at least three of the six stipulated adulthood preparation subjects. The adulthood preparation subjects are (1) healthy relationships, (2) adolescent development, (3) financial literacy, (4) parent-child communication, (5) educational and career success, and (6) healthy life skills.

Established in 2010 by the ACA (P.L. 111-148, as amended), PREP funding and authorization have been extended multiple times, most recently through the first fiscal quarter of FY2025 by Division G of the Consolidated Appropriations Act, 2024 (CAA 2024; P.L. 118-42). For more information on this program, see CRS Report R45183, Teen Pregnancy: Federal Prevention Programs.

Appendix M. Abbreviations Used in This Report