Title V of the Social Security Act (SSA) authorizes funding for services and projects that are intended to improve the health of mothers and children. These include the Maternal and Child Health (MCH) Services Block Grant; the Maternal, Infant, and Early Childhood Home Visiting Program; and other funding related to abstinence education, postpartum depression, and personal responsibility education programs. This report focuses on the MCH Services Block Grant, which receives the largest single appropriation under Title V. The MCH Services Block Grant is administered by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) in the Department of Health and Human Services (HHS). Title V was enacted by Congress in 1935 as part of the Social Security Act (SSA, P.L. 74-271) to promote and support the health of mothers and children. Two grant programs were established under the original Title V of the SSA, to enable states (1) to improve maternal and child health services, especially those in low-income and rural areas, and (2) to extend and improve services for crippled children. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA, P.L. 99-272 ) replaced the term "crippled" with the term "children with special health care needs." Children with special health care needs (CSHCN) are defined by HRSA as "those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally." Over time, additional programs targeting children with special health care needs and low-income women and children were added to the Public Health Service Act (PHSA) and the SSA, including certain services for children with disabilities who receive Supplemental Security Income (SSI, formerly §1615 [c] of the SSA); lead-based paint poisoning prevention programs (formerly §316 of the PHSA); genetic disease programs (formerly §1101 of the PHSA); sudden infant death syndrome programs (formerly §1121 of the PHSA); hemophilia treatment centers (formerly §1131 of the PHSA); and adolescent pregnancy grants ( P.L. 95-626 ). Title V was converted to the MCH Services Block Grant in 1981 by the Omnibus Budget Reconciliation Act (OBRA). OBRA 1981 consolidated the existing categorical programs listed above into a single block grant. The consolidated block grant was intended to give the states more flexibility in determining how to use federal funds to address maternal and child health needs. It required that each state receive, at a minimum, the combined funding of the programs that were consolidated under OBRA 1981. Additional changes were made to the block grant under the Omnibus Budget Reconciliation Act of 1989; these changes increased the authorization of appropriations, called for greater accountability, and created stricter rules for application and reporting requirements for the states, including the addition of a statewide needs assessment requirement. The MCH Services Block Grant currently has three components: block grants to states, a set-aside for Special Projects of Regional and National Significance (SPRANS), and another set-aside for the Community-Integrated Services Systems (CISS) program. The MCH Services Block Grant was appropriated $638.2 million in funding for FY2016. The majority of this funding is distributed to the 50 states, the District of Columbia, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, American Samoa, the Federated States of Micronesia, the Marshall Islands, and Palau (referred to collectively as "states" in this report) through the block grant to states. However, some of these funds are reserved for CISS grants, and others are devoted to research via the SPRANS grants. Title V of the Social Security Act established seven broad goals for the MCH Services Block Grant. Maternal and child health services, research, training, demonstrations, and other activities funded by the block grant must be linked to one or more of these goals. The seven goals are as follows: ensure access to quality health care for mothers and children, especially those with low income or limited availability of care; reduce infant mortality; provide and ensure access to comprehensive prenatal and postnatal care to women (especially low-income and at-risk pregnant women); increase the number of children receiving health assessments and follow-up diagnostic and treatment services; provide and ensure access to preventive and health care services for certain blind and disabled children, as well as rehabilitative services; implement family-centered, community-based systems of coordinated care for children with special health care needs; provide toll-free hotlines and assistance in applying for services to pregnant women with infants and children who are eligible for Medicaid. The primary use of funds under the MCH Services Block Grant, including formula grants to states, discretionary grants for Special Projects of Regional and National Significance (SPRANS), and discretionary grants for Community Integrated Services Systems (CISS), is to fill gaps in core public health services for low-income mothers and children. Projects funded by SPRANS include MCH workforce development, genetic services, and diagnostic and treatment services for hemophilia. CISS grants fund projects that support integrated maternal and child health services at the community level. The law provides that block grant funds are to be used by the states "to provide and to assure mothers and children (in particular those with low income or with limited availability of health services) access to quality maternal and child health services." States are required to use at least 30% of their block grant allocations for preventive and primary care services for children, 30% for services for children with special health care needs (CSHCN), and 40% for services for either of these groups or for other appropriate maternal and child health activities. Beyond these broad requirements, states determine the actual services provided under the block grant. Services funded by the block grant may include prenatal care, well-child care, dental care, immunization, family planning, and vision and hearing screening services. They may also include inpatient services for children with special health care needs, screening services for lead-based poisoning, and counseling services for parents of sudden infant death syndrome victims. Block grant funding is also used to support school-based health centers. Title V programs, including the Maternal and Child Health Services Block Grant, serve women and children who are covered by public and private insurance, as well as those who have no insurance coverage. For the purposes of allocating block grant funds for this program, low-income mothers and children are defined as those with family income below 100% of federal poverty guidelines. However, due to the broad reach of Title V programs and services, this definition is used only in the allocation formula, and not as a criterion for receiving Title V-funded services. There is no federally prescribed means test for recipients of services funded by the block grants to states. Block grants to states provide funding for core public health services provided by maternal and child health agencies. These core services are often presented as a four-level pyramid. The four levels of services are infrastructure building, population-based, enabling, and direct health care, as illustrated in Figure 1 . Infrastructure building services, which are at the base of the pyramid, are foundation-building activities that provide for the development and maintenance of health services systems. Infrastructure building services increase a health system capacity by supporting training and other workforce development activities, coordinating health care systems and data system architecture, providing funding for applied research, and developing guidelines. Population-based services promote core public health functions such as universal screening, health promotion, and disease prevention campaigns. Population-based services include newborn screening, lead screening, immunization, oral health, and injury prevention. Enabling services provide access to services for vulnerable populations, including those with special health care needs. Enabling services are services that facilitate access to care, such as case management, transportation, purchase of insurance, and coordination with other programs. Direct health care services provided under Title V are intended to fill the gaps in primary and preventive health care that are not otherwise available through other funding sources or providers, such as private insurance, Medicaid, or the State Children's Health Insurance Program (CHIP). In FY2015, the largest category of expenditures nationwide under the block grant was direct health care services for low-income mothers and children and children with special health care needs (63.3%), followed by enabling services (18.7%), population-based services (10.5%), and infrastructure (7.6%). Although the expenditures nationwide are inverse to their location in the MCH pyramid, the distribution of funds between service categories varies widely by state and depends on the needs of each state's population. Additionally, direct health care services may cost more per person served than other services. Distribution of funds depends on the needs of the states' populations, and the gaps left by other health and social service programs that are identified by the states. (Data on state and national indicators and funding are provided on HRSA's website, and summarized in the program participation and reporting section of this report.) Although the formula block grants to states are intended to fill gaps in a broad range of health services provided to women and children, certain uses of block grant funds are prohibited. Funds may not be used for inpatient services, other than for children with special health care needs, high-risk pregnant women, and infants (unless approved by the Secretary of HHS). States may not use the block grant funds to provide cash payments to recipients of health services, or for the purchase of land, facilities, or major medical equipment. Further, states may not use funds to satisfy any requirement for the expenditure of federal funds, and may not transfer block grant funds to any other program. Finally, block grant funds may not be used for research or training at a private, for-profit entity.