2021-2022 Update to theTexas State Health PlanAs Required byTexas Health and Safety CodeSection 104.021-104.026Statewide Health CoordinatingCouncilMarch 2021

Table of ContentsExecutive Summary . 1Background . 41. Vaccines . 5Measles, Mumps, and Rubella . 5Influenza . 6Tetanus, Diphtheria, and Acellular Pertussis . 7Human Papillomavirus . 8Strategies to Increase Vaccination Rates. 9Policy Recommendations . 102. Maternal Health . 12Health Conditions and Pregnancy. 12Cesarean Sections. 14Prenatal Care and Outcomes . 14Postpartum Health . 14Policy Recommendations . 153. Vaping . 18Background . 18Texas Vaping Data . 19Policy Recommendations . 204. The Importance of Nutrition and Physical Activity in Texas . 23Nutrition, Physical Activity, and Overall Health . 23Status of Nutrition in Texas . 25Children . 25Adolescents . 26Adults . 27Status of Physical Activity in Texas . 27Children . 27Adolescents . 28Adults . 28Policy Recommendations . 295. Rural Health in Texas . 33Health Outcomes in Rural Areas . 33Challenges for the Elderly in Rural Areas . 34Challenges for Low-Income and Uninsured Populations in Rural Areas . 34Hospital Closures and Nursing Facilities . 35Providers . 36Older Providers . 36Obstetric Services. 36ii

Policy Recommendations . 376. The Mental Health Workforce Shortage . 39Background . 39Texas’ Need for Mental Health Services . 41Children . 42Adolescents . 42Adults . 43Texas’ Mental Health Workforce . 43Overview of Mental Health Workforce by Profession . 44Policy Recommendations . 547. Challenges in Clinical Training Site Availability of Texas’ Schools ofHealth Professions . 60Background . 60Health Professions Education . 61Survey of Clinical Site Availability in Texas . 62Adequacy of Clinical Opportunities and Supervisors . 63Competition . 65Factors Affecting Creating New Sites. 68Selected Results by Profession . 70Post-Graduate Training Required for Licensure . 71Policy Recommendations . 72List of Acronyms . 73Appendix A. Statewide Health Coordinating Council Roster . 74References . 76iii

Executive SummaryBy November 1 of even-numbered years, the Statewide Health Coordinating Council(SHCC) directs and approves the development of the Texas State Health Plan or itsupdates for submission to the Governor. This plan, following the legislativelydetermined purpose of the SHCC,i seeks to ensure that the State of Texasimplements appropriate health-planning activities and that health care services areprovided in a cost-effective manner throughout the state.This update was due November 1, 2020. However, the SHCC determined thatadditional time was needed to further develop the policy recommendations includedin this update.This update builds on the 2017-2022 Texas State Health Plan and its 2019-2020Update. The 2017-2022 Plan focused on innovations in health care payment anddelivery systems and persistent challenges in providing high-quality and efficienthealth care in Texas. The plan identified challenges in ensuring health care accessand providing efficient service delivery and highlighted existing and projectedprimary care and psychiatry workforce shortages. In response to these challenges,the SHCC offered strategies to improve the efficiency of the state’s health caredelivery system, address shortcomings in its payment system, produce more healthcare providers in critical areas of need, and heighten patient satisfaction with thehealth care system. The 2019-2020 Update to the Texas State Health Plancontinued this work by seeking to improve access to the health care system, ensurequality in the system, and strengthen the system by guaranteeing a robust healthcare workforce.The current update carries forward the SHCC’s efforts, while addressing serioushealth problems in the state through a population health approach. Based on theevidence contained within each chapter, the SHCC makes policy recommendationsconsistent with its goal of ensuring that the State of Texas implements appropriatehealth-planning activities and that health care services are provided in a costeffective manner throughout the state. These recommendations include:iSee Texas Health and Safety Code §104 and §105.1

Vaccinations:o Maternal Health:o The state should monitor the effect of Senate Bill 750, 86thLegislature, Regular Session, 2019, on maternal health care and thequality of services provided to women in Texas.Vaping/Electronic Nicotine Delivery Systems Products:o The state should consider monitoring the impact of exemptions onvaccination rates and the health of Texans.The state should take concrete actions to deter the use of suchproducts by teens. Such actions include: The incorporation of appropriate educational materials intoschool health curriculum; The prohibition of flavored products; and The limitation of product marketing geared towards teens.Nutrition and Physical Activity:oThe state should support the scientific evaluation of community-basedinterventions for nutrition and physical activity, as well as support theinitiation of coalitions in local communities, especially in rural areas.oThe Legislature should require that students enrolled inprekindergarten through grade 12 perform at least 30 minutes ofmoderate or vigorous physical activity daily through the schooldistrict's physical education curriculum.oThe Legislature should require that students enrolled in grades ninethrough 12 at school districts in the state earn one health educationcredit in order to graduate.In addition to its population health concerns, the SHCC also identified avenues forimproving the state’s health care system. The SHCC’s recommendations include: Rural Health:2

oThe state should support the expansion and availability of telehealthand telemedicine, as well as remove barriers to telehealth andtelemedicine in rural Texas.oThe state should support new and innovative methods of hospitalfinancing.oThe state should monitor the impact of the coronavirus pandemic onthe number of uninsured people in Texas.Mental Health:oThe state should support efforts by school districts to increase accessto mental health services for students.oThe state should continue to support the work of the Texas ChildMental Health Care Consortium.oThe state should support efforts to increase the funding and stipendsavailable to students of the mental health professions as theycomplete their education and training, as well as support theexpansion of the Loan Repayment Program for Mental HealthProfessionals.Supporting Students of the Health Professions:oThe state should support actions to allow for the remote supervision ofhealth profession students.3

BackgroundWith an eye toward the innovations being introduced to health care payment anddelivery systems nationwide and throughout Texas, the 2017-2022 Texas StateHealth Plan provided guidance on how to achieve a high-quality, efficient healthsystem that serves the needs of all Texans. Specifically, the plan identifiedchallenges in ensuring that a population as large and diverse as Texas’ has accessto the health care system, that health care services are provided in an efficient andorderly manner, and that an ample health care workforce exists to provide theseservices. The 2019-2020 Update to the Texas State Health Plan continued this workby seeking to improve access to the health care system, ensure quality in thesystem, and strengthen the system by guaranteeing a robust health careworkforce.The current update is loosely divided into two sections, each with multiple parts.The first section is comprised of four chapters focused on promoting populationhealth in Texas. These chapters describe health challenges and propose solutionsrelated to achieving higher rates of vaccination among Texans, ensuring optimumhealth for Texas mothers, promoting informed choices and responsible practicessurrounding vaping, and devising better ways for Texans to eat healthy and stayactive.The second section of this update covers challenges faced by the state’s health caresystem. The three chapters that follow approach these issues from the perspectiveof rural health, mental health, and health professions education. However, theyshare similar goals of expanding efforts we know work, supporting the identificationand implementation of promising practices, and ensuring the Texas practiceenvironment remains welcoming to new and established providers.4

1. VaccinesVaccination has been proven effective in disease control through the reduction, andeven eradication, of multiple infectious diseases. Despite these successes, somevaccine-preventable diseases have seen a resurgence that may threaten the Texaspopulation given the state’s low vaccination rates relative to the United States. Toreduce the morbidity and mortality of infectious disease and to ensure there is nota resurgence of eliminated diseases, it is essential to increase Texas’ vaccinationrates.The Statewide Health Coordinating Council (SHCC) recommends improving thevaccination rates in the state through two mechanisms: monitor the impact ofexemptions on vaccination rates and, given the pending need to distributecoronavirus vaccines, expand support for the state’s vaccination programs. First,data from the Texas Department of State Health Services (DSHS) show that Texanshave increasingly sought exemptions that allow many Texas students to remainunvaccinated.1 To achieve state-level improvements in vaccination rates, the stateshould act to monitor the impact of non-medical vaccine exemptions. Second,Texas can increase its vaccination rate by working with providers to removebarriers to care. The existing Texas Vaccines for Children (TVFC) and Adult SafetyNet (ASN) programs are strong programs, but have the need for additionalpresence, especially in rural areas.Finally, although the SHCC recognizes the importance of coronavirus vaccination,this section focuses on four common vaccines: (1) measles, mumps, and rubella(MMR); (2) influenza; (3) tetanus, diphtheria, and acellular pertussis (Tdap andDTaP); and (4) human papillomavirus (HPV). The SHCC recognizes that strongerleadership on vaccination will improve Texans' willingness to be vaccinated, aneffect that will serve the state well for addressing the current coronavirus pandemicand future emerging infectious disease.Measles, Mumps, and RubellaThe MMR vaccine protects against three contagious, viral illnesses: measles,mumps, and rubella. Measles causes a variety of symptoms, including a rash, andcan result in hospitalization, brain swelling, and even death.2 Mumps can causeswelling of the salivary glands, testicles, ovaries, and brain, as well as meningitis,hearing loss, and death.3 Rubella, like measles, also causes a rash, and can result5

in miscarriage and birth defects.4 The Centers for Disease Control and Prevention(CDC) recommends children receive the first MMR dose at 12 to 15 months and asecond MMR dose at four to six years.5According to the CDC, vaccination has reduced measles and mumps cases in theUnited States by over 99 percent and eliminated rubella in the United States in2004.6,7,8 However, the national number of measles cases in 2019 was the highestit has been since 1992 at 1,282, largely affecting the unvaccinated population.9Texas had 22 cases of measles in 2019, which is an increase from the past fewyears.10 The importance of these measles rates can be demonstrated by the currentoutbreak in the Democratic Republic of the Congo that has claimed the lives ofmore than 6,000 people, highlighting the importance and urgency to increasevaccination rates.11Both Texas and the nation saw a large increase in mumps cases in 2016 and 2017,and Texas was among the states with the highest number of mumps cases as ofSeptember 2019.12,13 Texas had 17 mumps outbreaks in 2017, the largest of whichaffected school-aged children in Johnson County.14In 2017, 90.3 percent of Texas children between 19 and 35 months of age receivedat least one dose of the MMR vaccine, compared to 91.5 percent nationally,meeting the Healthy People 2020 target of 90 percent for this age group.15,16Among Texas public and certain private schools, the proportion of kindergartners(96.93 percent) and seventh graders (98.85 percent) with complete MMRvaccination in the 2018-2019 school year decreased from the prior year, and theproportion of conscientious exemptions increased to 1.99 percent of kindergartnersand 0.8 percent of seventh graders.17 The proportion of kindergartners withcomplete MMR vaccination exceeded the Healthy People 2020 target of 95percent.18InfluenzaThe influenza, or flu, vaccine protects against the influenza virus, a viral illnesswhich causes hundreds of thousands of hospitalizations and up to tens of thousandsof deaths each year.19 Though the flu vaccine may not always prevent flu infection,it may reduce the severity of illness and the risk of children dying from the flu. TheCDC recommends annual flu vaccines to everyone six months and older. Adults age65 and older are particularly vulnerable to the flu, accounting for up to 85 percentof flu-related deaths and over half of flu-related hospitalizations.20 As such, it isimportant individuals in this age group receive the flu vaccine annually.6

For the 2018-2019 flu season, Texas had comparable flu vaccination ratescompared to the national average across all age groups.21 However, Texas did seean increase in flu vaccination coverage from the prior flu season across all agegroups, with the majority being a significant increase. Despite this increase, all agegroups failed to meet the Healthy People 2020 target of 70 percent, withvaccination coverage estimates of 61.8 percent for children (six months to 17years) and 43.2 percent for adults (18 years and older).22,23 Adults 65 and older didhave a much higher vaccination rate than adults 18 to 64, 67.5 percent comparedto 37.7 percent.24The flu vaccine given during pregnancy may reduce illness severity in pregnantwomen, as well as protect their babies after birth.25 This is important since thevaccine is not recommended for infants under six months of age. Nationally,pregnant women with public insurance or those that were uninsured had lower fluvaccination rates each year compared to pregnant women with private insurancefrom 2012 to 2017, with all groups continuing to fall below the Healthy People 2020goal of 80 percent.26Tetanus, Diphtheria, and Acellular PertussisTdap and DTaP vaccines both protect against tetanus, diphtheria, and acellularpertussis (whooping cough). Tdap is for those aged seven and older, and DTaP isfor children under seven.27 Tetanus, caused by bacteria, can cause symptoms suchas jaw cramping (“lockjaw”), muscle spasms and stiffness, trouble swallowing, andmay even lead to death.28 Diphtheria is also caused by a bacteria and can causedifficulty breathing and swallowing, paralysis, and death.29 Whooping cough is acontagious, bacterial disease which can cause violent coughing and can be deadlyfor infants.30 The CDC recommends three doses of DTaP for babies with twoadditional booster shots prior to age seven; Tdap for preteens, pregnant women intheir third trimester, and adults who have never had Tdap; and a dose of Td(tetanus and diphtheria only) every 10 years for adults.31Texas had a whooping cough incidence rate lower than the national rate in 2018(4.07 versus 4.77 per 100,000 population, respectively), but Texas’ 1,167 casesaccounted for 7.5 percent of all cases nationally due to its population size.32According to the CDC, nearly all children who receive all five DTaP doses are fullyprotected against whooping cough within the first year after the last dose, androughly 75 percent of infants under two months born to women who received Tdapduring pregnancy are protected from whooping cough.33 Tetanus is rare in theUnited States, and cases tend to be among unvaccinated people and those who7

have not followed the recommended booster schedule.34 Diphtheria is also very rarein the United States due to vaccination, with fewer than five cases in the past 10years.35In 2017, 81.2 percent of children 19 to 35 months old in Texas had received four ormore doses of DTaP compared to the national average of 83.2 percent.36 This fellbelow the Healthy People 2020 target of 90 percent.37 Among Texas public andcertain private schools in the 2018-2019 school year, the proportion ofkindergartners (96.69 percent) with complete DTaP vaccination decreased and theproportion of seventh graders (97.03 percent) increased from the prior year.38 Theproportion of conscientious exemptions increased to 1.92 percent of kindergartnersand 1.22 percent of seventh graders. The proportion of kindergartners withcomplete DTaP vaccination met the Healthy People 2020 goal of 95 percent.39Though the proportion of women who received Tdap vaccination during pregnancyincreased each year from 2014 to 2017 in the United States, nearly half of pregnantwomen in 2017 did not receive the vaccine during their pregnancy.40Human PapillomavirusHPV is the most common sexually transmitted infection, and it can cause genitalwarts and cancers of the cervix, vulva, vagina, penis, anus, and back of thethroat.41 A recent survey found that the majority of adults in the United States “didnot know that HPV causes oral, anal, and penile cancers.”42 The CDC recommendsHPV vaccination for 11- and 12-year-olds, anyone not yet vaccinated through age26, and some adults through age 45 who are not already vaccinated, as they maystill benefit from the vaccine.43The annual cost of HPV-associated cancer treatment has been estimated to beabout 1 billion in 2010 United States dollars.44 In 2013, cancer treatment for HPVrelated cancers cost Medicaid over 51 million.45 In Texas, HPV-associated analcancer incidence rates increased significantly from 1995 to 2015, as did HPVassociated oropharyngeal cancer incidence rates in men.46 HPV-associated cervicalcancer incidence rates decreased in Texas women from 1995 to 2015.Among Texas adolescents ages 13 to 17 in 2017, an estimated 57.8 percent hadreceived at least one dose of any HPV vaccine and 39.7 percent were up-to-date;these rates were a significant increase from 2016.47 Despite this increase, Texasrates were below the 2017 estimated national rates of 65.5 percent for at least onedose and 48.6 percent up-to-date, as well as below the Healthy People 2020 targetfor 80 percent of adolescents ages 13 to 15 to have received the recommended8

number of HPV vaccine doses.48,49 In 2017, 13 percent of Texas adults ages 18 to49 had received at least one dose of HPV, up from 9.1 percent the prior year.50 Ofthose adults, 42 percent had completed all doses of the vaccination series, up from37.1 percent the prior year.Strategies to Increase Vaccination RatesTo increase vaccination rates, barriers to and disparities in vaccination must beaddressed. For children, barriers to vaccination include caregiver concerns aboutside effects, autism, or the large number of injections; moral or religious beliefs;costs or other factors which impede access to health care; and a lack ofinformation.51 Further, in 2003, the state education code was amended to allow forconscientious exemptions to vaccinations, and, in the years since, requests forvaccine exemptions have increased greatly.52 Barriers to adult vaccination includelow priority, lack of information, fear, and other accessibility issues such as cost orlack of transportation.53One strategy to increase vaccination rates would be to tighten policies regardingvaccine exemptions. “Easy nonmedical vaccine exemption policies” make states upto 190 percent more likely to experience a measles outbreak compared to stateswith stricter policies.54 Following a measles outbreak, California removednonmedical vaccine exemptions in 2016.55 An analysis concluded this policy changewas associated with a subsequent increase in MMR vaccination.To make vaccines more accessible to children, the TVFC Program offers all of thevaccines described in this section (and others) at a low cost to children (ages 0-18)who meet certain eligibility requirements.56 Similarly, the ASN Program provideslow-cost vaccines for uninsured adults over 18.57 Vaccines are provided to thenearly 3,000 TVFC providers and over 500 ASN providers at no cost.58,59Improving access to vaccination may include expanding hours or allowing walk-in orsame-day appointments.60 For example, federally qualified health care centers andrural health care centers enrolled in the TVFC and ASN programs offer expandedhours for immunizations.61 Studies have shown these types of strategies result inincreased adult vaccination rates and may also be an effective intervention forparents.62,63To address lack of information about vaccines and lack of access, it is vital forhealth care providers to discuss concerns, recommend, and even offer vaccinationsto their patients or caregivers of patients. In a recent survey, pregnant women9

were twice as likely to receive a Tdap vaccination if a medical professional offeredto vaccinate (70.4 percent), compared to those who just received arecommendation for the vaccination (36.9 percent).64 Less than 1 percent ofwomen who were not offered the vaccine and did not receive a recommendation forthe vaccine were vaccinated.One study showed the attitudes of both parents and non-parents about vaccinationcould be altered positively by their health care providers informing them of thedangers of not vaccinating their children.65 Because parental attitudes aboutvaccines can reliably predict their child’s immunization status—with parents whodemonstrated higher vaccine hesitancy more likely to have children who were notup-to-date on the recommended vaccine schedule—interventions targeted atchanging parental attitudes should be implemented.66Policy RecommendationsThe Legislature, the Governor, and executive branch agencies shouldconsider monitoring the impact of exemptions on vaccination rates and thehealth of Texans.In the past five years, the number of individuals for whom conscientious exemptionaffidavits were requested in Texas have increased every year, increasing overallfrom 48,472 in 2015 to 77,329 in 2019, representing a nearly 60 percentincrease.67 Statewide, the mean proportion of students by school district with aconscientious exemption was 1.2 percent; the proportions vary within Texas bygeographic location.68 In 2019, metropolitan, non-border counties had a highermean proportion of students with conscientious exemptions (1.4 percent) comparedto metropolitan, border counties (0.2 percent) and non-metropolitan countiesoverall (1.0 percent). However, the top four counties were in non-metropolitan,non-border counties, with the proportion of students with conscientious objectionsranging from 3.9 percent to 10.4 percent.The Legislature, the Governor, and executive branch agencies shouldensure access to vaccination and vaccine outreach for vulnerablepopulations by supporting evidence-based strategies to increasevaccination rates in the state.In its 2018 biennial report regarding reducing vaccine-preventable diseases, DSHSoutlined its strategies to increase vaccine coverage rates in the state. Among these10

strategies were safety net programs (TVFC and ASN), educational outreach, andstakeholder engagement.69As of January 2020, there were 2,974 TVFC providers in 236 Texas counties and560 ASN providers in 165 counties (92.9 percent and 65.0 percent of the 254 Texascounties, respectively).70,71 The majority of counties without at least one enrolledprovider were in non-metropolitan areas (94.4 percent of counties with no TVFCprovider, and 87.6 percent of counties with no ASN provider).Texas Immunization Coalitions, supported by the Immunization Partnership andDSHS, are one approach to increase vaccination access and educational outreach atthe local level through stakeholder engagement. DSHS can provide funding,training, and resources, as well as has a downloadable toolkit for such coalitions onits website.7211

2. Maternal HealthMaternal and early child health affects new mothers and infants and hasramifications throughout an individual’s life. Recent legislative sessions have shownincreasing attention to the importance of maternal health issues, identifying areasof concern and implementing solutions to address the state’s shortcomings.The following section illustrates the current landscape of maternal, infant, and earlychild health in Texas, using national rates as a comparison. There are notabledisparities between outcomes in maternal mortality and chronic health conditionsthat affect maternal health in Texas.73 Black women have higher rates of maternalmortality than any other group, and black and Hispanic women are more likely tohave chronic health conditions affecting pregnancy and birth. Chronic healthconditions can have a cumulative effect on fetuses and maternal health, andchronic health conditions can worsen with pregnancy. For women on Medicaid, theyoften lose access to health care for those conditions two months after giving birth,since they would not have insurance normally.The SHCC recognizes the impacts that strong maternal and early childhood care canhave on the lives of Texas mothers and babies, throughout their lives. The SHCCbelieves that the state can maximize these impacts by streamlining the applicationprocess for public health coverage, ensuring that new mothers continue to receivethe care they need from the providers they trust, and ensuring that these providersare fairly compensated for the vital care they deliver.Health Conditions and PregnancyThere are several health conditions that occur before and/or during pregnancy thatcan affect maternal and fetal health. Obesity prior to pregnancy is a known riskfactor for developing hypertension, diabetes, and other complications duringpregnancy.74 The proportion of mothers with an obese body mass index prepregnancy has increased 26.3 percent from 2008 to 2017. Pre-pregnancy obesity ismost prevalent among black a

and Texas was among the states with the highest number of mumps cases as of September 2019.12,13 Texas had 17 mumps outbreaks in 2017, the largest of which affected school-aged children in Johnson County.14 In 2017, 90.3 percent of Texas children between 19 and 35 months of age received