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 2021 U.S. Census state population estimate was 6,168,187 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 (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. 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 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 (997,187) and Jackson (716,862) counties. The greatest population density is in St. Louis City, with 4,778 people per square mile. The lowest population density at 7 people per square mile is tied between Knox, Reynolds, Shannon, and Worth Counties. The largest county in the state by area was Texas County, with an area of 1,179 square miles, and a population density of 20 persons per square mile. In total, 48 of Missouri’s counties had a population density below 25 persons per square mile.4

 

Age

The estimated median age of Missourians for 2017 to 2021 was 38.8 years old.5 For 2021, nearly 22.4% of the state’s population (1,383,537) was less than 18 years old, and 17.6% of the population (1,084,768) 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 2,535,028.2 This accounted for 41.1% of the state’s roughly 6.15 million population. Among this MCH population, 1,188,885 were women of childbearing age (15-44 years) and 1,540,293 infants, children, and adolescents (ages 0-19 years).2 There was an estimated 278,712 children with special health care needs for the 2020-2021 time period.6 In 2021, there were 69,269 Missouri resident live births, of which, 15.4% were African-American and 78.4% were White.7 Hispanic births in Missouri increased by 11.8% from 2011 to 2021 (4,110 and 4,593 respectively).7

 

Diversity/Language

Based on population estimates from 2021, Missouri residents are predominantly White (84%) with a significant African-American (12.6%) population and smaller Asian/Pacific Islander (2.6%) and American Indian (0.76%) resident populations.2 For 2021, the top three jurisdictions for proportion of population that is Black or African American alone or in combination are St. Louis City (46.1%), Pemiscot County (27.7%), and St. Louis County (25.9%).8 The Hispanic or Latino population comprises 4.7% of Missouri’s population.8 Population growth for Hispanics in Missouri was 30.5% from 2011 to 2021,8 compared to 20.9% for Hispanics or Latinos nationally.9

 

The U.S. Census Bureau, via the American Community survey (ACS), 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 aged 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 into 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 2021, the infant mortality rate (age <1 year) for African American babies (12.2 per 1,000) was more than double that of white babies (4.6 per 1,000).13 Though minority populations tend to cluster near urban centers, granting better access to health services than many rural non-minorities, their ability to secure quality care is an additional challenge.

 

Education

The 2017-2021 ACS estimates 90.9%of Missourians over the age of 25 are high school graduates or higher.14 This was higher than the national average of 88.9%.15 However, the percentage of Missourians in this age group that have a bachelor’s degree or higher (30.7%), was less than the U.S. average (33.7%).14,15

 

Economy

Missouri's metropolitan areas make up the largest portion of the state's economy. St. Louis and Jackson counties 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 approximately $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 2.7% in November 2022 to 2.5% in April 2023 (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 showed the total number of initial unemployment claims for Missouri in the month of April 2023 to be 9,162, a significant decrease from 13,348 in July 2022 and 32,746 in July 2021.20,21,22  Workforce development and economic stability were major focus areas 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, and 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 short-term economic benefits and better prepare Missouri to protect from potential economic shocks due to 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 2019-2021 household food insecurity rate was 12.1%, which was higher than the national rate of 11.0%.25 Additionally, the 2021 estimated overall child food insecurity rate for Missouri was 12.8%, a decrease from 14.1% in the previous year.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 2022 Annual Homeless Assessment Report to Congress provides estimates of the number of people experiencing homelessness, homeless families with children, and unaccompanied homeless youth on any given night in 2022. Overall, 5,992 Missourians, 1,680 families with children and 446 unaccompanied youth, were reported to experience homelessness on any given night in 2022. Missouri experienced a substantial 29.8% (198 youths) decrease in the number of unaccompanied youth experiencing homelessness from 2020-2022.28

 

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 Missouri are lead dust, lead in soil, and peeling, chipping or cracking lead-based paint. The highest risk of lead exposure for children 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 in Missouri was built before 1950 and 55.38% was built before 1980.

 

The Childhood Lead Poisoning Prevention Program (CLPPP) was established in 1993. The program's mission is to assure children a safe and healthy environment through primary prevention, detection, surveillance, and case management for lead exposure. 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 requires 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 20.4% in 2010 to around 14% in 2021.29  Among this same age group, the percentage found to have blood lead levels of 10 μg/dL or greater declined from 0.97% in 2010 to 0.55% in 2021.29 Children whose blood levels were greater than or equal to 3.5 μg/dL, the2021 CDC-recommended reference value, was 4.75% in 2021, compared to 6.5% of children whose blood lead levels were greater than or equal to 5 μg/dL, the 2012 reference value recommended by the CDC, in 2010.29

 

Transportation

In 2022, Missouri had the seventh largest highway system in the nation.30 The transportation infrastructure has three key measures: airports, railroad and waterway mileage. 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 27% increase in vehicle fatalities from 2011 to 2021.31 In 2020, 50% of motor vehicle crash deaths occurred in rural areas;  and lack of seat belt use, distracted driving and driving too fast for the conditions continued to be common denominators in fatal crashes.32 Between 2011 and 2021, 10,094 people were killed in motor vehicle accidents in Missouri, an average of about 918 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 from 2020, marking the second straight year of growing fatality totals after nearly a decade of steady decline.

 

The Department of Transportation works with safety advocates across the state to reduce fatalities to 700 or fewer. The reported safety belt usage rate in Missouri (88.9%) in 2022 was below the national average of 91.6% for the same year.34 Missouri has a secondary seat belt law, with primary enforcement of the seat belt requirement for children ages 8 to 15 years and secondary enforcement 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 and 25,388 allopathic Physicians.36,37 Of these physicians, 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 May 2, 2023, there were 169 hospital facilities in Missouri spread across 69 counties/jurisdictions.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 838 licensed pediatric beds and 903 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 Between 2022-2023, Missouri saw the closure of three birthing facilities: First Breath Birth and Wellness, Cox Monett Hospital, and Hedrick Medical Center.

 

Health Indicators

Missouri’s three primary strengths, as identified in the 2022 America’s Health Rankings 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 supply of primary care providers.45 Missouri ranks 39th overall among all states. Nearly 90% of students graduated from high school (ranked 9th), and Missouri ranked 10th for low rates of severe housing problems. Some of the most challenging issues facing Missouri are premature death rates in years lost before age 75 (10,247 per 100,000 population), household food insecurity (12%), and prevalence of smoking in adults (17.3%). Obesity in adults increased from 34.0% to 37.3% between 2020 and 2021. Nationally, Missouri ranked 34th for low birthweight and 47th for low birthweight racial disparity.45

 

Health Insurance Coverage

Overall, Current Population Survey estimates indicate an increase in percentage of uninsured Missourians from 6.0% in 2018 to 7.5% in 2021.46,47 Missouri’s estimated uninsured percentage for 2021 is lower than the 8.3% national estimate for the same year.48 Missouri’s estimated percent of children under the age of 19 without public or private health insurance increased from 2018 (5.7%) to 2019 (6.9%) and this was higher than the national level (5.6%). An estimated 14.8% of Missouri women (ages 19-44) were without public or private health insurance in 2019 compared to 13.4% in 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 18-55 whose family’s modified adjusted gross income does not exceed 201% of the Federal Poverty Level (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; 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 the Children’s Health Insurance Program (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. Missouri provides coverage up to 300% of the FPL through the CHIP for pregnant women and unborn child options. Medicaid spending for state fiscal year (SFY) 2022 was approximately $12.6 billion in Missouri51, and approximately 63% of Missouri Medicaid/MO HealthNet funds come 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 served by Missouri Medicaid; 59% 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 SFY22, MO HealthNet covered a monthly average of 689,063 low-income children.51 In SFY22, the MO HealthNet for Kids Program covered 650,967 low-income Missouri children, representing 57% of all MO HealthNet beneficiaries. Overall, Medicaid covered 48% of Missouri's children and paid for 39% of all births in the state for 2022.51 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 CHIP (SCHIP) funds, Missouri expanded its existing Medicaid program for low-income children in 1998. The 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 June 2022, an average of 33,366 children had coverage under CHIP in Missouri.51

 

The MO HealthNet for Pregnant Women Program offers Medicaid coverage to pregnant women whose family incomes are up to 196% FPL. This program includes coverage up to 60-days postpartum even with subsequent increases in family income. In SFY22, 57,892 women per month received benefits under the MO HealthNet for Pregnant Women Program.51 Additionally, a monthly average of 101,109 low-income custodial parents were covered by MO HealthNet.51

 

Statewide-Managed Care

The MO HealthNet managed care system (formerly known as MC+) started in 1995 when Missouri Department of Social Services (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 DSS-MO HealthNet Division (MHD) and managed care health plans. These include Home State Health, Healthy Blue, Show Me Healthy Kids, and United Healthcare Plans. Each managed care health plan has a network of doctors, hospitals and other providers across the state that coordinate care to help individuals and families stay healthy. 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
• Eligible for CHIP.

 

Missourians who are elderly, blind or disabled, including those 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 CSHCN) 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 amounted to approximately $18,754 for a single individual and $38,295 for a household of four. Medicaid eligibility was previously set in state statute, but the amendment added Medicaid Expansion to Missouri’s constitution effective July 1, 2021. However, following the passage of this amendment, the state legislature did not include funding for Medicaid Expansion in the SFY 2022 state budget. Governor Parson subsequently announced the state would not implement expansion because the ballot measure did not include a revenue source and the 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.

 

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. As of October 21, 2022, 257,581 adults have enrolled in the Adult Expansion Group (AEG), including approximately 180,000 newly eligible adults.

 

Medicaid Extension

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. 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 (PAMR) 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. The Missouri legislature passed SB 45 to extend MO HealthNet postpartum coverage from 60 days to 12 months postpartum for women who are either currently receiving or eligible to receive aid to families with dependent children, or eligible to receive benefits via the income eligibility standard. The Governor signed SB 45 into law on July 6, 2023. Pregnant women eligible for MO HealthNet and receiving mental health treatment for postpartum depression, related mental health conditions, or substance abuse treatment within sixty days of giving birth will remain eligible for benefits for those services for an additional 12 months. The extension of coverage for a full twelve months after delivery is estimated to cover more than 4,000 women who otherwise become uninsured two months after the end of pregnancy.

 

Department of Health and Senior Services (DHSS) Priorities

In Missouri, the Title V MCH Block Grant leadership is located within DHSS. Paula Nickelson was appointed as the Director of DHSS on June 01, 2023 and is responsible for the management of the Department and the administration of its programs and services. Ms. Nickelson had previously been appointed as the Acting Director of DHSS on March 1, 2022 and 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.

 

DHSS aims to achieve optimal health and safety for all Missourians, in all communities, for life by promoting health and safety through prevention, collaboration, education, innovation, and response while maintaining our values of excellence, collaboration, access, integrity, and accountability. DHSS has been accredited through the Public Health Accreditation Board since 2016.  The new DHSS Strategic Map (attached) details the five strategic priorities, two crosscutting priorities, and objectives under each category designed to ensure progress towards achieving our vision.

 

Strategic Priorities

• Invest in innovation to modernize infrastructure
• Re-envision and strengthen the workforce
• Build new and strengthen existing partnerships
• Clearly and consistently communicate to educate and build trust

• Resolve access issues for underserved areas and populations

 

Premier DHSS Initiatives

Missouri State Board of Health and Senior Services

For the first time in many years, the Board of Health and Senior Services began operating again in November 2022. State law stipulates the Board advise DHSS on rules & regulations, budget, and planning & operation. The board is comprised of nine members that are Governor appointed and Senate confirmed.

 

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 healthcare 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.

 

Rural Maternal Health

Access to healthcare stands as another significant barrier for rural Missouri women. Of the 166 licensed Missouri hospitals, 76 are located in rural areas, and 35 of these are Critical Access Hospitals with a limited range of services. Additionally, 98 rural counties are Primary Medical Health Professional Shortage Areas (HPSAs). In addition to the existing variety of programs established to assist women in making informed decisions about their health and increasing their access to preventative, primary and specialist care, DHSS has convened a Rural Maternal Health Care Workgroup, along with partners from the Governor’s Office, MO HealthNet, the Missouri Hospital Association, and the Missouri Primary Care Association, to engage stakeholders and strategize potential solutions and approaches to address the barriers and challenges.

 

Missouri’s Title V MCH leadership 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 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.
• §160.077 (2022) establishes the "Get the Lead Out of School Drinking Water Act", requiring schools to provide drinking water with a lead concentration below five parts per billion (5 ppb); 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 on or before January 1, 2024; and conduct specified testing for lead before August 1, 2024.
• §217.940 (2022) establishes the “Correctional Center Nursery Program” to establish a correctional center nursery in one or more of the correctional centers for women to promote bonding and unification between the mother and child. The program allows eligible inmates and their children born while in custody to reside together in the correctional center for up to 18 months post-deliver.

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 103rd General Assembly, 2023 Regular Session, and signed by the Governor:

 

In addition to extension of postpartum coverage, SB 45 also changed the requirements for blood lead testing for young children. Lead is a dangerous neurotoxin, and low doses of lead from paint dust and corroded water pipes can cause lasting damages, including reduced IQ, behavior disorders and increased risk of mortality from cardiovascular disease. Previously, all Missouri children younger than six who lived in — or spent more than 10 hours per week in — areas deemed high risk were required to be tested for elevated blood lead every year. Children not at high risk were to be screened for potential lead exposure with a questionnaire and tested if necessary. With the passage of SB 45, all children under six will now be assessed with a questionnaire and tested, if necessary, with guardian consent.

 

SB 186 modifies the definition of a "missing child" in the context of law enforcement searches of missing children to include persons under 18 years of age, foster children regardless of age, emancipated minors, homeless youth, or unaccompanied minors. Any agency, placement provider, including the Children's Division, parent, or guardian, with the care and custody of a child who is missing shall file a missing child complaint with the appropriate law enforcement agency within 2 hours of determining the child to be missing. The law enforcement agency shall immediately submit information on the missing child to the National Center for Missing and Exploited Children (NCMEC). The law enforcement agency shall institute a proper investigation, search for the missing child and maintain contact with the agency or placement provider making the complaint. The missing child's entry shall not be removed from any database or system until the child is found or the case is closed.

 

HB 115 modifies licensing and collaborative practice arrangements for advanced practice registered nurses (APRNs). Under this act, an APRN may prescribe Schedule II controlled substances for hospice patients, as described in the act. Additionally, collaborative practice arrangements between the APRN and the collaborating physician may waive geographic proximity requirements, as described in the act, including when the arrangement outlines the use of telehealth and when the APRN is providing services in a correctional center. Collaborating physicians or designated physicians shall be present with the APRN for sufficient periods of time, at least once every two weeks, to participate in chart reviews and supervision.

 

HB 402 modifies the "Outside the Hospital Do-Not-Resuscitate Act" by expanding the provisions to cover persons under 18 years of age who have do-not-resuscitate orders issued on their behalf by a parent or legal guardian or by a juvenile or family court under a current provision of law. Such orders shall function as outside the hospital do-not-resuscitate orders unless specifically stated otherwise. Persons who are not subject to civil, criminal, or administrative liability for certain actions taken upon the discovery of an adult outside the hospital do-not-resuscitate orders shall not be subject to such liability in the case of a minor child's do-not-resuscitate order. Emergency services personnel shall be authorized to comply with the minor child's do-not-resuscitate order, except when the minor child, either parent, the legal guardian, or the juvenile or family court expresses to such emergency services personnel in any manner, before or after the onset of a cardiac or respiratory arrest, the desire for the patient to be resuscitated.

 

SB 39 delineates what constitutes an acceptable official birth certificate and prohibits a private school, public school district, public charter school, or public or private institution of postsecondary education from allowing any student to compete in an athletic competition that is designated for the biological sex opposite to the student's biological sex as stated on the student's official birth certificate or other government record as described in the act.

 

SB 49 establishes the "Missouri Save Adolescents from Experimentation (SAFE) Act”, prohibiting health care providers from performing gender transition surgeries or prescribing hormones or drugs for the purposes of gender transition to Missouri children under the age of 18.

 

SFY 2024 Budget Wins

The Missouri SFY24 operating budget is approximately $51.8 billion, including $15.2 billion in general revenue. .

 

Needed upgrades and investments in state government services to continually improve services provided to citizens and increase opportunities for Missourians' success: 

• $300 million for a new mental health hospital in Kansas City;
• $33.3 million for reconstruction and reform at the Missouri Children's Division;
• $17 million for MO HealthNet eligibility redeterminations;
• $7.2 million for the construction of a new Division of Youth Services center in St. Louis;
• $4.35 million to implement the Maternal Mortality Prevention plan; and
• $4.3 million to increase the number of Youth Behavioral Health Liaisons statewide.

 

$248 million for broadband deployment in unserved and underserved communities.

 

$4.35 million to implement a Maternal Mortality Prevention Plan across the following domains of action:

1. Standardized maternal quality care protocols;
2. Perinatal Health access Project;
3. Standardized maternal care provider trainings;
4. Standardized postpartum plan of care; and
5. State Maternal & Child Health Dashboard (Improved maternal health data collection, standardization and harmonization).

 

$2.3 million for local public health agency core funding.

 

$3.8 million for local public health agency incentives funding (funding associated with completion of quality activities aimed at Administrator training, Board of Health Training, and Accreditation.

 

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.