Geography

Missouri is comprised of 115 counties (114 counties and one independent city, St. Louis), covering an area of approximately 69,707 square miles, and ranks 21st in size among all states in the nation.1 The state is centrally located in the heartland of the United States and shares borders with Arkansas, Kansas, Kentucky, Illinois, Iowa, Nebraska, Oklahoma, and Tennessee. The two largest rivers in the state are the Mississippi, which marks the eastern border of the state, and the Missouri, which flows across the middle of the state. Two large metro areas, Kansas City and St. Louis, are located on the western and eastern borders respectively, and are connected by the "I-70 Corridor."

 

Demography/Population Density

The 2020 U.S. Census population estimate for Missouri was 6,151,548 residents.2  From 2010 to 2020, the state's population increased by 2.6%, including a 2.8% increase for males and a 2.5% increase for females. Missouri was ranked 29th among the 50 states and the District of Columbia for population density with a population density of 89.7 people per square mile in 2021.3

 

The Missouri population has a noteworthy distribution pattern for its urban compared to rural areas. Missouri is a largely rural state, with 16 urban counties and 99 rural counties[*]. The City of St. Louis and 15 other counties are considered urban areas. Missouri has six other cities designated as Metropolitan Statistical Areas (MSAs) by the Census Bureau, listed in order of size: Springfield, Columbia, Joplin, Jefferson City, St. Joseph and Cape Girardeau. About 55% of Missouri’s population falls within the Metropolitan Statistical Area (MSA) of its two major cities, St. Louis and Kansas City. The St. Louis MSA accounts for 35% of the state’s population while the Kansas City MSA contributes almost 21%. Of Missouri’s more than 6 million residents, roughly 2,063,000 (34%) live in one of the 99 rural counties.

 

The largest urban counties by population are St. Louis County (991,163) and Jackson County (709,692). The greatest population density was in St. Louis City with 4,713.99 people per square mile. The lowest population density was in Worth County with 7.4 people per square mile. The largest county in the state by area was Texas County, with an area of 1,179 square miles, and a population density of 21.3 persons per square mile. In total, 47 of Missouri’s counties had a population density below 25 persons per square mile.4

 

Age

The estimated median age of Missourians for 2016 to 2020 was 38.7 years old.5 For 2020, nearly 22.3% of the state’s population (1,371,429) was less than 18 years old, and 17.7% of the population (1,089,714) was age 65 or older.2 Missouri's MCH population including women of childbearing age (15-44), infants, children, and adolescents (under 1-19) was 3,516,166.2 This accounted for more than half (57.2%) of the state’s roughly 6.15 million population. Among this MCH population, 2,379,451 were women of childbearing age (15-44 years), 69,277 infants (under 1) and 1,455,865 children and adolescents (ages 1-19 years).2 There was an estimated 288,780 children with special health care needs for the 2019-2020 time period.6 In 2020, there were 69,277 Missouri resident live births, of which, 16.4% were African-American and 77.4% were White.7 Hispanic births in Missouri increased by less than 1%, from 2010 to 2020 (4,334 and 4,469 respectively).7

 

Diversity/Language

Missouri residents are predominantly White (84%) with a significant African-American (12.6%) population and smaller Asian/Pacific Islander (2.6%) and American Indian (0.75%) resident populations.2 For 2020, the top three jurisdictions for proportion of population that is Black or African American alone or in combination are St. Louis City (45.4%), Pemiscot County (29.8%), and St. Louis County (26.3%).8 The Hispanic or Latino population comprises 4.9% of Missouri’s population.8 Population growth for Hispanics in Missouri was 42.6% from 2010 to 2020,8 compared to 23% growth for Hispanics or Latinos nationally.9

 

The U.S. Census Bureau, via the American Community survey, provides 2016-2020 5-year estimate data, suggesting the degree of diversity in Missouri. The 5-year estimate of native-born United States citizens comprising the Missouri population was 5,867,824 (95.8%).10 Furthermore, ACS data indicate 4.2% of the Missouri population was foreign born with an estimated population size of 256,336 for 2016-2020.10 Of the residents that were not born in the United States, 39.8% were from Asia, 28.6% from Latin America, 18.4% came from Europe, 9.7% came from Africa, and 3.6% from other regions of the world.11 Furthermore, 361,104 (6.3%) Missourians aged five and above spoke a language other than English at home. Of that group, 125,479 persons spoke English less than 'very well', which was 2.2% of the population 5 years and older. An estimated 149,698 (2.6%) Missourians 5 years and older spoke Spanish at home.12 The Missouri Department of Health and Senior Services contracts with a vendor to translate program materials and health messages in a variety of languages and up to 17 different dialects to reflect the growing diversity of the state population.

 

Addressing factors related to diversity that lead to adverse maternal-child health outcomes represents an ongoing challenge for public health in the state. Examining data from 2020, the infant mortality rate (age <1 year) for African American babies (11.7 per 1,000) was more than double that of white babies (4.5 per 1,000).13 Though minority populations tend to cluster near urban centers, granting better access to health services than many rural non- minorities, are able to secure care is an additional challenge.

 

Education

The 2016-2020 ACS estimated percentage of Missourians over the age of 25 that were high school graduates or higher was 90.6%.14 This percentage was higher than the national average of 88.5%.15 However, the percentage of Missourians in this age grouping that have a bachelor’s degree or higher (29.9%), was less than the U.S. average (32.9%).14,15

 

Economy

Missouri's metropolitan areas make up the largest portion of the state's economy. St. Louis County and Jackson County combined contribute nearly one third of the state's economy in terms of employment, personal income, and population. Regardless of population size, all regions of Missouri contribute to the state’s economic resources.

Missouri's rural areas are especially important for tourism and agriculture in the state. In 2021, agriculture, forestry, and related industries contributed estimates both in output of $93.7 billion and generated 456,618 jobs.16 Missouri's median estimated household income for 2016-2020 was $57,290, which was $7,704 less than the national median household income of $64,994.17,18

 

Missouri’s unemployment rate decreased from 3.9% in November 2021 to 3.4% in April 2022 (preliminary).19 Due to the COVID-19 pandemic, many industries were forced to furlough and lay-off workers. Data from the Department of Labor and Industrial relations (DOLIR) showed the total number of initial unemployment claims for Missouri in the month of April 2022 to be 18,008,   significant decrease from 32,746 in July 2021 and 81,454 in July 2020.20,21,22 Workforce development and economic stability were major focuses of Missouri’s COVID-19 response. Missouri’s receipt of federal grants for responding to COVID-19 has a positive impact on the state’s economic recovery and growth. The use of federal resources to surveil and control the spread of COVID-19 was essential in stabilizing Missouri’s economy and preventing further economic decline, while grants still being implemented will be essential in bolstering the state’s public health and healthcare infrastructure and workforce. These investments in infrastructure and workforce priorities provide not only short term economic benefits but also better prepare Missouri to protect from potential economic shocks from future health crises.

 

Poverty

The ACS provides poverty data for the population for whom poverty status was determined. Among this population of Missourians, the estimated percent of those below the poverty level for 2016-2020 (13.0%) was lower compared to the estimated percent (13.7%) for 2015-2019.23, 24 Furthermore, Missouri’s estimated 2016-2020 poverty rate for children under 18 years old was 17.4%, which was higher than the state overall rate. Nearly 773,000 Missourians were living below poverty and nearly 234,000 of them were children.23

 

Food insecurity is an important issue that can affect children and families and may be affected by having poverty-level income. Current Population Survey Food Security Supplement data suggests Missouri’s average 2018-2020 household food insecurity rate was 11.5%, which was higher than the national rate of 10.7%.25 Additionally, the 2019 estimated overall child food insecurity rate for Missouri was 14.8%.27 The 2018-2020 very low food security rate for Missouri was reported to be 5.1% compared to 4.1%, nationally.25

 

Homelessness

The 2021 Annual Homeless Assessment Report (AHAR) to Congress provides estimates of the number of people experiencing homelessness, homeless families with children, and unaccompanied homeless youth on any given night in January 2021. Overall, a total of 6,438 Missourians, 1,720 families with children and 338 unaccompanied youth were reported to experience homelessness on any given night in January 2021.28

 

Environment

Lead mining and smelting has been an important part of Missouri's history since the early 1700’s. Missouri has been the dominant lead-producing state in the nation since 1907. Though there are many possible sources of lead exposure, the most common sources of lead poisoning in MO are lead dust, lead in soil, and peeling, chipping or cracking lead-based paint. The highest risk of lead exposure for children, however, comes from homes built before 1950, when most paint contained a high percentage of lead. Lead-based paint was banned from residential use nationwide in 1978. Any home built before 1978 may contain leaded paint. About 18.55% of existing housing stock in MO was built before 1950, and 55.38% was built before 1980.

 

The MO Childhood Lead Poisoning Prevention Program (CLPPP) was established in 1993. The program's mission is to assure the children of MO a safe and healthy environment through primary prevention, detection, surveillance, and case management for lead exposures. There is no “safe” level of lead in the body. Inhalation or ingestion of even very small amounts of lead causes neurotoxic health effects, and can affect nearly every other body system. Very high blood lead levels may cause death. Passed in 2001, 701.340 RSMo required the promulgation of rules and regulations to establish a statewide lead screening plan. The rules and regulations define criteria for establishing blood lead testing and reporting requirements and for medical and environmental case management follow-up and treatment procedures.

 

The annual percent of Missouri's children younger than six years old tested for lead exposure decreased from the reported 20.4% for 2010 to around an estimated 14% for 2021.29  Among this same age group of children, the percentage found to have blood lead levels of 10 μg/dL or greater has declined from 0.97% in 2010 to 0.55% in 2021.29 Children who tested with blood lead levels greater than or equal to 5 μg/dL, the 2012 reference value recommended by the CDC, was 6.5% in 2010. Children who tested with blood levels greater than or equal to 3.5 μg/dL, the updated CDC-recommended reference value, was reported to be 4.75% for 2021.29

 

Transportation

In 2020, Missouri had the seventh largest highway system in the nation.30 The transportation infrastructure has three key measures: railroad mileage, waterway mileage, and airports. The Missouri highway system is comprised of nearly 34,000 miles of highways and more than 10,000 bridges. Additionally, the county road system adds 97,000 miles and nearly 14,000 additional bridges. The extent of this infrastructure gives Missouri residents and businesses efficient accessibility to major markets for distribution needs and telecommunication. However, in both urban and rural areas access to public transportation can be cumbersome.

 

There was a 23% increase in vehicle fatalities from 2010 to 2020.31 50% of motor vehicle crash deaths occurred in rural areas in 2020, and lack of seat belt use, distracted driving and driving too fast for the conditions continue to be common denominators in fatal crashes.32 Between 2010 and 2020, 9,877 people were killed in motor vehicle accidents in Missouri, an average of about 898 fatalities per year.31,33 For the first time since 2006, Missouri’s 2021 traffic fatality total surpassed 1,000. According to preliminary data, 1,017 people were killed in Missouri traffic crashes in 2021, a 3% increase over 2020, marking the second straight year of growing fatality totals after nearly a decade of steady decline.

 

The MO Department of Transportation works with safety advocates across the state with a goal of 700 or fewer fatalities. The reported safety belt usage rate in Missouri (88.0%) in 2020 was below the national average of 90.4% for the same year.34 Missouri has secondary seat belt law. There is primary enforcement of the seat belt requirement for children ages 8 to 15 years and secondary law for those ages 16 and above in the front passenger seat.35

 

Health Infrastructure

There are five predominant schools that train new physicians in Missouri: Kansas City University of Medicine and Biosciences, University of Missouri – Kansas City, University of Missouri - Columbia, Saint Louis University, and Washington University. Missouri Professional Registration Directories include 3,463 Osteopathic Physicians, and 25,388 Medical Physicians and Surgeons.36,37 Of these Osteopathic Physicians, Medical Physicians, and Surgeons, there are 922 Obstetrician/ Gynecologists and 16 specializing in Obstetric/Gynecologic surgery.36,37 Additionally, there are 2,066 physicians certified in pediatrics and 621 specialized pediatricians (e.g. pediatric pulmonology, pediatric emergency medicine, pediatric cardiology, etc.).36,37

 

As of June 1, 2022, there were 170 hospital facilities in the state of Missouri spread across 70 counties/jurisdiction.38 The majority of hospitals are located in urban counties. There are also 49 total hospitals with psychiatric beds39 and 29 trauma facilities in Missouri.40 There were 842 licensed pediatric beds in Missouri and 893 licensed NICU beds.41,42 In addition, there are four VA Medical Centers and one VA Health Care System in the state of Missouri, not inclusive of 27 community based outpatient clinics, 1 outpatient clinic, and five veterans centers .43 There are 343 Rural Health Clinics (RHC), which must be located in a non-urban area and in a federally designated or certified shortage area, and 28 Federally Qualified Health Centers (FQHC; 13 in rural areas only, 7 in urban areas only, 8 with sites in rural and urban areas, and 314 service delivery sites), which are community-based and patient driven care centers designed to help people with limited access to care.44

 

Health Indicators

Missouri’s three primary strengths, as identified in America's Health Rankings 2021 Annual Report published by the United Health Foundation, were its low prevalence of high-risk HIV behaviors, low percentage of severe housing problems, and high school graduation rate.45 Of note, nearly 90% of students graduated from high school. Though Missouri ranks 35th for smoking, data indicate a 14% decrease in smoking among adults from 2017 (20.8%) to 2020 (17.8%). Severe housing problems (determined based on the percentage of occupied housing units) decreased 10% from between 2009-2013 and 2014-2018. The 2021 Annual Report also identified notable challenges for Missouri, including poor exercise, avoiding care due to cost, and frequent physical distress. Approximately 12% of adults avoided care due to cost, 26.7% were physically inactive, and 11.4% of adults experienced frequent physical distress. In addition to physical distress, mental distress increasingly presents a challenge for Missourians, with a 31% increase in frequent mental distress among Missouri adults from 2014 to 2020. Nationally, Missouri ranked 36th for low birthweight and 35th for low birthweight racial disparity.45

 

Health Insurance Coverage

Overall, Current Population Survey estimates indicate an increase in percentage of uninsured Missourians from 7.7% in 2016 to 9.7% in 2020.46,47 Missouri’s estimated uninsured percentage for 2020 is higher than the 8.6% national estimate for the same year.48 Missouri’s estimated percent of children under the age of 19 without public or private health insurance for 2019 (6.5%) increased from 2018 (5.7%) and was higher than the national level for 2019 (5.7). An estimated 14.8% of Missouri women (ages 19-44) were without public or private health insurance in 2019 compared to 13.4% for 2018.50 The estimated percentage for 2019 was higher than the national level for the same year (12.9%).50

 

The Uninsured Women’s Health Services Program provides MO HealthNet coverage for women’s health services to uninsured women ages 18 up to but not including age 56 whose family’s modified adjusted gross income (MAGI) does not exceed 201% of the FPL for their household size. Covered Women’s health services include: approved methods of contraception; sexually transmitted disease testing and treatment, including pap tests and pelvic exams; family planning, counseling, education on various methods of birth control; and drugs, supplies, or devices related to the women’s health services described above, when they are prescribed by a physician or advanced practice nurse.

 

Medicaid and CHIP provide no-cost or low-cost health coverage for eligible children in Missouri. Using CHIP funding, states can opt to provide coverage for pregnant women and/or services through the “unborn child” coverage option, and Missouri provides coverage up to 300% of the FPL through the CHIP for pregnant women option and unborn child options. Medicaid spending for state fiscal year 2020 was around $10.8 billion in Missouri51, and 52% of Missouri Medicaid/MO HealthNet funds came from the federal government.52 Non-disabled adults with children qualify for Medicaid if their income is below 21% of the FPL, meaning a family of four must earn less than $5,550 a year. Medicaid and CHIP enrollment in Missouri was 1,064,287 in May 2021, and 87.1% of all uninsured eligible children in Missouri participate in Medicaid/CHIP. Children represent the largest demographic group served by Missouri Medicaid; 61% of all MO HealthNet enrollees are under the age of 19.51

 

The MO HealthNet for kids (Medicaid) program provides health insurance coverage for children under age 19 whose net family income does not exceed 196% of the FPL for children under age one, and 148% of the FPL for children ages 1-18. In state (S)FY 2020, MO HealthNet covered 533,202 low-income children.51 In SFY 2020, the MO HealthNet For Kids Program covered 497,104 low-income Missouri children, representing 57% of all MO HealthNet beneficiaries. Overall, Medicaid covered 37% of Missouri's children and paid for 39% of all births in the state for 2020.51 Children represent the largest demographic group served by MO HealthNet, with 61% of all Medicaid enrollees being age 18 or younger.51

 

Using the State Children’s Health Insurance Program (SCHIP) funds, Missouri expanded its existing Medicaid program for low-income children in 1998. This SCHIP expansion extended health coverage to low-income children with family income up to 300% of FPL.51 The SCHIP program provides the same health services as those covered under Medicaid, except that children covered by SCHIP are not eligible for non-emergency medical transportation. Based on an income scale, some individuals covered under Missouri's SCHIP program must pay premiums. For families of six or fewer, premiums paid per family per month range from $15 to $324.51 In 2020, monthly CHIP enrollment ranged from 98,828 to 108,559 participants in Missouri.53

 

The MO HealthNet for pregnant women program offers Medicaid coverage to pregnant women whose family incomes are up to 201% FPL. This program includes coverage up to 60-days postpartum even with subsequent increases in family income. In SFY 2020, an average of 23,363 women received benefits under the MO HealthNet for Pregnant Women Program.51

 

Statewide-Managed Care

The MO HealthNet managed care system (formerly known as MC+) started in 1995 when Missouri DSS first contracted with managed care plans in an effort to improve the accessibility and quality of health care services for Missouri’s Medicaid populations, while improving predictability of the costs associated with providing care. Missouri expanded Medicaid managed care in 2017 to include all 114 counties and the city of St. Louis for children, families, and pregnant women. The MO HealthNet Managed Care program operates statewide to provide health care services to enrollees through contracts between the Department of Social Services’ MO HealthNet Division (MHD) and Managed Care health plans. These include Home State Health Plan, Healthy Blue, Show Me Healthy Kids, and United Healthcare. Each Managed Care health plan has a network of doctors, hospitals and other providers across the state of MO that coordinate care to help individuals and families stay healthy.

 

In SFY 2020, there were 97,302 low-income custodial parents and pregnant women and 533,202 low-income children covered by MO HealthNet.53 The goal of the MO HealthNet Managed Care program is to improve health care quality and access to needed services, as well as increase the efficiency of health care delivery for covered low-income custodial parents, pregnant women, and children while controlling the program’s cost. All MO HealthNet recipients must enroll in a managed care health plan if they fit into one of the following eligibility categories:

• Parents/caretakers, children, pregnant women, and refugees;
• Other MO HealthNet children who are in the care and custody of the state and receive adoption subsidy assistance; and
• CHIP children.

 

Missourians who are aged, blind or disabled, including those Missourians with developmental disabilities served through the Missouri Department of Mental Health, will not be included in the MO HealthNet Managed Care program. They will continue to receive services through the traditional MO HealthNet Fee-for-Service (FFS) program. Certain participants (including a child with special health care needs) may also opt out of the managed care program and choose the FFS program.

 

Medicaid Expansion

Missouri experienced a long and complicated road to Medicaid expansion. In 2020, Missouri voters approved an amendment to the Missouri Constitution to expand Medicaid eligibility to persons 19 to 64 years old with an income level at or below 133% of the FPL (plus five percent of the applicable family size), effectively expanding Medicaid to those with incomes at or below 138% of the FPL as set forth in the Affordable Care Act. In 2022, that will amount to approximately $18,754 for a single individual, and $38,295 for a household of four (children were already eligible for Medicaid at higher income levels). Medicaid eligibility was previously set in state statute, but the amendment added Medicaid Expansion to Missouri’s constitution with an effective date of July 1, 2021. However, following the passage of this amendment, the MO legislature did not include funding for Medicaid Expansion in the SFY 2022 state budget, and Governor Parson subsequently announced the state would not implement expansion because the ballot measure did not include a revenue source and the MO legislature did not provide sufficient appropriations for expansion in the state budget. Following this announcement, individuals who would be eligible for expansion coverage under the Missouri Constitution filed a lawsuit against the state. The Missouri Supreme Court ruled the initiated amendment was valid under the state constitution, and the legislature’s existing budget appropriation authorized the state to implement expansion coverage.

 

The amendment prohibits any additional burdens or restrictions on eligibility for the expansion population and requires state agencies to take all actions necessary to maximize federal financial participation in funding medical assistance under Medicaid Expansion. Federal law requires states to fund a portion of the program in order to receive federal funding (state match). This amendment does not provide new state funding or specify existing funding sources for the required state match. The federal government is paying 90% of the cost of Medicaid expansion in Missouri, just as they do in other states that have expanded Medicaid. However, since Missouri’s expanded eligibility rules took effect after the American Rescue Plan was enacted, the state is also receiving an additional 5 percentage points above the regular federal matching rate for the next two years for the traditional (non-expansion) Medicaid population, amounting to $968 million in additional federal funding over two years. The state’s estimated share of the cost of Medicaid expansion for state fiscal year 2022 was approximately $156 million, and American Rescue Plan funding should offset the state’s costs in the short term.

 

The DSS began accepting applications for coverage in August 2021 and began processing applications after October 1, 2021. Coverage was backdated to July 1, 2021 for eligible applications submitted by November 1, 2021. More than 17,000 people applied for coverage by October 1st. Expansion was expected to result in 275,000 additional Missouri residents becoming eligible for MO HealthNet, but enrollment thus far is lagging behind expectations.

 

In 2018, Missouri lawmakers passed a provision to add some benefits, such as a year-long Medicaid extension, for low-income mothers with substance use disorder. The DSS contacted the Centers for Medicare and Medicaid Services in February 2022 asking to pause those benefits. State officials cited two main reasons for not moving forward: voter-approved Medicaid expansion was expected to decrease the number of women who could be served under extended postpartum coverage, and lawmakers were considering an expansion of postpartum coverage to allow for full benefits to be provided through the full first year after birth.

 

Missouri currently provides coverage to low-income mothers during pregnancy and up to 60 days after childbirth. The Missouri Pregnancy Associated Mortality Review Annual Report recommends that the state extend Medicaid coverage to one year after childbirth for all conditions, including medical, mental health and substance use disorder. In an effort to improve maternal health and address racial disparities, the American Rescue Plan Act of 2021 allows states to extend postpartum Medicaid coverage up to a full year after birth. The new option is available to states for five years, starting April 1, 2022. Bills introduced in this year’s legislative session sought to authorize the extension of postpartum coverage for a full 12 months after birth. The bills garnered significant bipartisan support and were eventually combined into a bipartisan bill. The bill’s fiscal analysis estimated $4.4 million in state costs for the 2023 budget year, with the federal government subsidizing the rest of the estimated $12.3 million total  cost. Although there seemed to be bipartisan consensus that expansion is necessary for Missouri’s mothers, due to threats of a (unrelated) filibuster, the bill did not progress through a vote in the Senate. According to the bill’s fiscal analysis, 4,565 women who received Medicaid benefits during pregnancy would likely have qualified for the extended coverage.

 

Department of Health and Senior Services (DHSS) Priorities

In Missouri, the Title V MCH Program is located within DHSS. Paula Nickelson was appointed March 1, 2022, as the Acting Director of DHSS and is responsible for the management of the Department and the administration of its programs and services. Ms. Nickelson has served within DHSS for more than 22 years and been a leader in several program areas, including maternal-child health, chronic disease prevention, and emergency preparedness and response.

 

Since 2016, DHSS has been accredited through the Public Health Accreditation Board. The DHSS is, “To be the leader in promoting, protecting and partnering for health’ in order to achieve the vision of ‘Healthy Missourians for life.” DHSS executes the following foundational responsibilities:

• Providing public health services and supports to all citizens.
• Ensuring regulation of facilities and service providers that deliver care to Missourians.
• Performing oversight of programs and protections for elderly and vulnerable residents.

 

Premiere DHSS Initiatives

Enhancing and Innovating Health Services for Missouri’s Women and Mothers

2019 legislation enhanced Missouri’s Pregnancy Associated Mortality Review (PAMR) Board implementation of clinical best practices and data-driven solutions to improve maternal health and mortality rates. Grants have been awarded to Missouri as part of the Alliance for Innovation on Maternal Health (AIM) quality improvement initiative to implement proven outcome based national models that improve maternal safety. The Department has also been awarded the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant to identify, review, characterize, and identify prevention opportunities within maternal deaths. DHSS is the first state health department in the nation to launch a Count the Kicks program to enhance education and awareness among expectant mothers of possible safety or health concerns of their unborn child.

 

Reconnecting Care in Rural Missouri

Beginning with the Governor’s Rural Health Summit in 2018, DHSS has been working to realign resources to address the state’s rural health issues. DHSS is working collaboratively with other public and not-for-profit entities to address Missouri’s rural care provider shortage to attract and retain additional health professionals in underserved areas. DHSS coordinated a robust response to COVID-19 outbreaks in rural Missouri, while also administering grants to address the opioid crisis in rural communities.

 

Strategic Management Priorities

The State of Missouri Cabinet team developed a management change agenda to improve how Missouri government operates. All 16 Cabinet Departments developed strategic management priorities, and a simple “placemat” summarizes these priorities. These priorities include a set of change initiatives DHSS is pursuing to improve performance and outcomes for the citizens of Missouri. DHSS’ aspiration is to protect health and keep people of Missouri safe. Themes identified to reach this aspiration are public health system building, infant and maternal, health behavior, emerging public health threats preparedness, social determinants of health, and whole person health access. Priority infant and maternal health initiatives include developing enhanced newborn screening and reporting capabilities to enable early public health intervention efforts, maintaining PAMR board engagement and oversight to improve infant and maternal health outcomes, and establishing the MCH Advisory Council to ensure efficient and effective use of grant funding.

 

Public Health Improvement & Transformation Effort: Making Long-Term Investments to Improve Missouri’s Public Health System

In 2021, the Governor’s Office, in coordination with DHSS, launched a team effort to improve and transform public health in the State of Missouri. State team members, public health experts, and key stakeholders convened to identify improvements, gaps, and needs in public health, and to further discuss how those improvements can fit into transformative public health models and potential funding efforts to ensure strategic and citizen-focused investments and help support and improve the public health system well into the future. DHSS leadership continues to engage with stakeholders to transform the state public health system, with lines of effort focused around Missouri’s Foundational Public Health Services Model (https://www.healthiermo.org/).

 

Office of Childhood: Promotes Effectiveness, Excellence, and Equity for Missouri Children

On January 28, 2021, Governor Parson signed Executive Order 21-02 officially establishing the new Office of Childhood, effective August 28, 2021. The new office is housed at the Department of Elementary and Secondary Education (DESE) and provides a comprehensive approach to early childhood care and education, including all state programs related to child care, home visiting, early learning, and early intervention. The transition to one office streamlines early childhood work across state government and ensures all Missouri children and families have access to more consistent, quality programs and services. The goal is to reduce duplication, improve coordination of services, and create a more effective early childhood system to provide all children in Missouri access to an equitable, improved early childhood care and education system where all children are safe, healthy and successful learners. The Office of Childhood consists of approximately 145 employees, including FTEs, programs and contracts funded in part or whole by Title V MCH.

 

Missouri State Board of Health and Senior Services

The State Board of Health and Senior Services advises the Department Director in planning for departmental activities and acts in an advisory capacity regarding rules promulgated by the Department of Health and Senior Services. Board members are appointed by the governor to help set the strategic direction for DHSS.

 

Missouri Women’s Health Council

The Missouri Women’s Health Council is an advisory board comprised of thought leaders with expertise in women’s health and the broad range of factors that affect health outcomes and wellbeing. Council members are appointed by the Department Director and reflect the geographic diversity of the state. The Council is charged with informing and advising the Department Director regarding women’s health risks, needs and concerns, and recommending potential strategies, programs, and legislative changes to improve the health and well-being of all women in Missouri. The Council consists of women from a variety of professions, including health care providers, researchers, healthcare administrators, social workers, and CEOs and executive directors of critical social services foundations serving women throughout Missouri. The following policy priorities reflect the shared vision of the Women’s Health Council:

1. Improve access to healthcare for women in rural, suburban and urban Missouri, and
2. Ensure safety for Missouri women and their families.

 

Missouri’s Title V MCH Program is involved with many DHSS initiatives and priorities. Title V MCH efforts to provide positive health outcomes for the MCH population align with the DHSS goal to improve the health of all Missourians. The national and state performance measures and strategies identified in the MCH State Action Plan assist in achieving DHSS objectives. The MCH Director and relevant Title V MCH team members participate in the PAMR Board meetings and discussion to reduce maternal mortality. The Title V MCH Program team also works with local public health agencies, the majority of which are located in rural communities, to ensure access to healthcare services for women and children.

 

Revised Statutes of Missouri (RSMo) Relevant to Title V MCH

Title XII Public Health and Welfare, Chapters 191, 192, and 201 include laws in place to benefit the MCH population. A few examples are listed below.

• §191.323 (1985) gives DHSS the power and duty to prevent and treat genetic disease and birth defects and
• §191.331 (2007) allows infants to be tested for metabolic and genetic diseases. This chapter also addresses prenatal and postnatal care and education for women and children, breastfeeding, and prenatal screening counseling.
• §192.002 (2001) and §192.005 (2018) established DHSS to supervise and manage all public health functions and programs. The department shall be governed by the provisions of the Omnibus State Reorganization Act of 1974, Appendix B, RSMo, unless otherwise provided in sections 192.005 to 192.014.
• §192.025 DHSS is designated as the official agency of the state to receive federal funds for health purposes.
• §192.067 authorizes DHSS to receive information from patient medical records for the purpose of abstracting data (i.e. PAMR).
• §192.070 (2001) states DHSS shall issue educational literature on the care of the baby and the hygiene of the child including, but not limited to, the importance of routine dental care for children; study the causes of infant mortality and the application of measures for the prevention and suppression of the diseases of infancy and childhood; and inspect the sanitary and hygienic conditions in public school buildings and grounds.
• §192.601 (2013) requires a toll-free telephone number established for the use of parents to access information about health care providers and practitioners who provide health care services under the Title V MCH Services Block Grant, the medical assistance programs, and other relevant health care providers, as required by 42 U.S.C. 705(a)(5)(E).
• §201.010 (2010) gives DHSS the authority to administer children’s special health care needs service, a program of service to children who have a physical disability or special health care need and to supervise the administration of the services that are included in this program. The purpose of this service is to develop, extend, and improve services for locating such children, especially in rural areas, and for providing medical, surgical, corrective and other services and care and facilities for diagnosis, hospitalization, and aftercare (§201.030).
• §192.990 (2019) establishes the "Pregnancy-Associated Mortality Review (PAMR) Board" within DHSS to improve data collection and reporting with respect to maternal deaths.

 

Code of State Regulations (CSR)

• 19 CSR 20-60.010 establishes criteria and procedures for reporting standardized assessments and levels of maternal and neonatal care designations for birthing facilities.

 

Major Legislative Initiatives

Provided below is a list of bills and legislative decision items with potential impact for Missouri families that were passed during the 102nd General Assembly, 2022 Regular Session, and signed by the Governor:

 

SB 683 Includes provisions creating the “Correctional Center Nursery Program.” The Missouri Department of Corrections is required to establish a nursery within a women’s prison by July 2025, allowing infants born to women in prison to stay with their mothers for the first 18 months of life.

 

SB 718 Modifies provisions relating to higher education, including provisions to: establish the “Dual Credit and Dual Enrollment Scholarship Act”, providing qualifying students a scholarship equal to the tuition and fees paid for dual enrollment courses; create the Workforce Diploma Program to help adults obtain a high school diploma; and require public higher education institutions to post the Suicide and Crisis Lifeline number on student ID cards.

 

SB 775 Modifies several provisions relating to victims of sexual offenses, including: amending the "Justice for Survivors Act" and the "Sexual Assault Survivors' Bill of Rights" to reflect input from healthcare providers and advocates in Missouri, and protects certain identifying information of survivors of sexual assaults.

 

SBs 681 & 662 Establish the "Get the Lead Out of School Drinking Water Act". Beginning in the 2023-24 school year, each school shall provide drinking water with a lead concentration below five parts per billion (5 ppb). On or before January 1, 2024, each school shall conduct an inventory of all drinking water outlets and outlets used for dispensing water for cooking or cleaning utensils in each school building, develop a plan for testing each outlet, and provide general information on the health effects of lead contamination to employees and parents. Before August 1, 2024, schools shall conduct testing for lead as specified in the bill. Within two weeks after receiving test results, schools shall make all testing results and any remediation plans available on the school's website.

 

SB 769 Creates provisions establishing four pilot recovery high schools for students in recovery from substance use disorder or substance dependency.

 

HB 2162 – Modifies provisions related to the Opioid Addiction Treatment and Recovery Fund, allowing additional state departments to access the moneys in the Fund to pay for opioid addiction treatment and prevention services and health care and law enforcement costs related to opioid addiction treatment and prevention. The bill also allows the Department Director to authorize a Missouri licensed physician to issue a standing order for Naltrexone.

 

HB 1738 & SB 710 Designated April 11th through 17th of each year as “Black Maternal Health Week”.

 

In response to the United States Supreme Court's ruling overturning Roe v. Wade, the governor signed a proclamation and the attorney general issued an opinion restoring state authority to regulate abortion, giving legal effect to Section 188.017, RSMo, and activating the "Right to Life of the Unborn Child Act." Section 188.017, or the "Right to Life of the Unborn Child Act," includes provisions to prohibit doctors from performing abortions unless there is a medical emergency; create criminal liability for any person who knowingly performs or induces a non-medical emergency abortion and subjects his or her professional license to suspension; and protect any woman who receives an illegal abortion from being prosecuted in violation of the Act. 

 

In July 2022, the Governor called for a special legislative session to pass tax relief, including reducing the individual income tax rate, increasing the standard deduction, and exempting the first $16,000 of income for single filers and $32,000 for joint filers from state income taxes.

 

SFY 2023 Budget Wins

Budget increase of $438,231 to address inflation costs and fund improvements to the Newborn Screening Program.

 

American Rescue Plan Act (ARPA) Grants:

• COVID-19: $108,681,193 for COVID-19 response and testing activities such as advanced molecular detection capacity, testing and support for people experiencing homelessness, distributions of vaccines in underserved and underrepresented populations, expanded testing in rural hospitals, and expanded data collection and reporting for travelers; and $767,004 for the National Initiative to Address COVID-19 Health Disparities, the ELC Enhancing Detection Expansion, and the STD Disease Intervention Specialists grants.
• Workforce Development: $45,242,682 to expand the public health workforce and infrastructure in the State of Missouri.

 

$530,000 to establish a perinatal quality collaborative, implementation of the Alliance for Innovation on Maternal Health bundle, a Neonatal Abstinence Syndrome project, and a safe sleep quality improvement project.

 

Rape Prevention Education Grant: $495,000 to provide outreach and education for adolescents to effect change on behaviors of sexual violence.

 

$2,500,000 to implement evidence-based strategies and innovative approaches to prevent youth from using tobacco products, eliminate second-hand smoke exposure, and promote tobacco cessation services.

 

$800,000 to purchase and distribute naloxone doses to first responders.

 

$200,000 for grant programs to provide access to physicians in underserved areas.

 

Primary Care Resource Initiative for Missouri (PRIMO) Expansion: $121,250 to increase the health care workforce by recruiting students into health care career paths.

 

$600,000 to replace x-ray fluorescent analyzers to benefit the Child Lead Prevention, Environmental Child Care, Waste Management, Superfund, and Brownfields programs.

 

Justice for Survivors Telehealth Network: $3,953,820 to provide access to sexual assault nurse examiner consultation services and guidance for medical providers to deliver forensic examination services via telehealth.

 

$14,404,834 to expand the Ryan White Program to provide services through local public health agencies and private providers to serve an additional 150 clients living with HIV.

 

For references, please refer to the References attachment.

 

 

[*] Using the definition described in the Biennial Rural Health report (https://health.mo.gov/living/families/ruralhealth/pdf/biennial2020.pdf) which assigns counties as rural or urban primarily based on meeting a population density of greater or less than 150 persons per square mile.