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 2022 U.S. Census state population estimate was 6,177,957 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 (90.26 people per square mile in 2022.3)

 

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 (983,327) and Jackson (720,902) counties. The greatest population density is in St. Louis City, with 4,473 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 is 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 have a population density below 25 persons per square mile.4

 

Age

The estimated median age of Missourians for 2022 was 39.1 years old.5 For 2022, nearly 22.1% of the state’s population (1,362,791) was less than 18 years old, and 18% of the population (1,113,136) was age 65 or older.5 Missouri's MCH population including women of childbearing age (15-44), infants, children, and adolescents (under 1-19) was 2,730,219.5 This accounted for 44.2% of the state’s roughly 6.17 million population. Among this MCH population, 1,200,128 were women of childbearing age (15-44 years) and 1,530,091 infants, children, and adolescents (ages 0-19 years).5 There was an estimated 287,294 children with special health care needs for the 2021-2022 time period.6 In 2022, there were 68,594 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 2022, Missouri residents are predominantly White (84.6%) with a significant African-American (12.5%) population and smaller Asian (2.9%) and American Indian/Alaskan Native (2.2%) resident populations.2 For 2022, the top three jurisdictions for proportion of population that is Black or African American alone or in combination are St. Louis City (46%), Pemiscot County (28.3%), and St. Louis County (26.1%).8 The Hispanic or Latino population comprises 4.7% of Missouri’s population.2 Population growth for Hispanics in Missouri was 31.7% from 20129 to 2022,8 compared to 22.18% for Hispanics or Latinos nationally in the same time span.10,11

 

The U.S. Census Bureau, via the American Community survey (ACS), provides 5-year estimate data, suggesting the degree of diversity in Missouri. The 2022 5-year estimate of native-born United States citizens comprising the Missouri population was 5,896,220 (95.8%).12 Furthermore, 2022 ACS 5-year estimates indicate 4.2% of the Missouri population was foreign born with an estimated population size of 258,202.12 Of the residents that were not born in the United States, 39.0% were from Asia, 29.3% from Latin America, 17.5% came from Europe, 10.5% came from Africa, and 3.6% from other regions of the world.13 Furthermore, 6.3% Missourians five years and older spoke a language other than English at home.12 Of the group that spoke a language other than English at home, 2.1% persons spoke English less than 'very well'.12 An estimated 155,827 (2.7%) of Missourians 5 years and older spoke Spanish at home instead of English.14 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 led to adverse maternal-child health outcomes represents an ongoing challenge for public health in the state. Examining data from 2022, the infant mortality rate (age <1 year) for African American babies (13.2 per 1,000) was more than double that of white babies (5.5 per 1,000).1 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 2022 ACS 5-year estimates indicate 91.3% of Missourians over the age of 25 are high school graduates or higher.16 This was higher than the national average of 89.1%.17 However, the percentage of Missourians in this age group that have a bachelor’s degree or higher (31.2%), was less than the U.S. average (34.3%).16,17

 

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.18 Missouri's median estimated household income was $65,920, which was $9,229 less than the national median household income of $75,149.19,20

 

Missouri’s unemployment rate increased from 3.3% in November 2023 to 3.4% in April 2024 (preliminary).21 Data from the Department of Labor and Industrial Relations showed the total number of initial unemployment claims for Missouri in the month of April 2024 was 10,363, a slight increase from 9,162 in April 2023 but a significant decrease from 18,008 in April 2022.22,23,24 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 had 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.

 

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 2022 (12.8%) was lower compared to the estimated percent (14.2%) for 2018.25,26 Furthermore, Missouri’s estimated 2022 poverty rate for children under 18 years old was 16.6%, which was higher than the state overall rate. 25 Approximately 766,582 Missourians were living below poverty, with 223,732 children under 18.25

 

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 overall 2020-2022 household food insecurity rate was 12.2%, which was higher than the national rate of 11.2%.27 Additionally, the 2022 estimated overall child food insecurity rate for Missouri was 18.7%, an increase from 12.8% in the previous year.28,29 The 2020-2022 very low food security rate for Missouri was reported to be 5.7%, a statistically significant difference compared to the national rate of 4.3%.27

 

Homelessness

The 2023 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 2023. Overall, 6,708 Missourians, 1,851 families with children and 506 unaccompanied youth were reported to experience homelessness on any given night in 2023.30

 

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. 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’s (CLPPP) 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 2021.31 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 2021.31 Children whose blood levels were greater than or equal to 3.5 μg/dL, the 2021 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 2010.31

 

Transportation

In 2023, Missouri had the seventh largest highway system in the nation.32 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. 32 Additionally, county roads and city streets add 97,000 miles and nearly 14,000 additional bridges. 32 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 2021.33 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.34 Between 2011 and 2021, 10,094 people were killed in motor vehicle accidents in Missouri, a rate of 14.79 deaths per 100,000 residents.33 In 2020, for the first time since 2007, the motor vehicle fatalities total (1,031) was over 1,000.33 Missouri saw an increase in total motor vehicle deaths from 2020 to 2021. The increase in Missouri motor vehicle deaths from 1,031 in 2020 to 1,051 in 2021 was a 2.3% increase.33 This marked 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 (87.0%) in 2023 was below the national average of 91.9% for the same year.35 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.36

 

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.37,38 Of these physicians, there are 922 Obstetrician/ Gynecologists and 16 specializing in Obstetric/Gynecologic surgery.37,38 Additionally, there are 2,066 physicians certified in pediatrics and 621 specialized pediatricians (e.g., pediatric pulmonology, pediatric emergency medicine, pediatric cardiology, etc.).37,38

 

As of June 3, 2023, there were 168 hospital facilities in Missouri spread across 69 counties/jurisdictions.39 The majority of hospitals are located in urban counties. There are also 48 hospitals with psychiatric beds.40 There were 818 licensed pediatric beds and 904 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 2023 America’s Health Rankings Annual Report published by the United Health Foundation, were its high volunteerism rate, high prevalence of colorectal cancer screening, and low percentage of households experiencing severe housing problems. Nearly 90% of students graduated from high school (ranked 23rd), and Missouri ranked 12th for low rates of severe housing problems. Some of the most challenging issues facing Missouri are high levels of excessive drinking (20.2%; ranked 41st), high homicide rate (12.3 per 100,000; ranked 45th), and high household food insecurity (12.2%; ranked 41st). Obesity in adults decreased from 37.3% to 36.4% between 2021 and 2023. Nationally, Missouri ranked 32nd for low birthweight and 35th for low birthweight racial disparity, improving from 34th and 47th, respectively, in 2022.45

 

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 decreased from 2019 (6.9%) to 2021 (5.9%) but remained higher than the national level (5.4%).49 An estimated 13.7% of Missouri women (ages 19-44) were without public or private health insurance in 2021 compared to 14.7% in 2019.50 The estimated percentage for 2021 was higher than the national level for the same year (11.8%).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. 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. Medicaid spending for state fiscal year (SFY) 2022 was approximately $12.6 billion in Missouri51, and approximately 63% 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. Children represent the largest demographic served by Missouri Medicaid; 59% of all MO HealthNet enrollees are under the age of 19.51Medicaid and CHIP enrollment in Missouri was 1,064,287 in May 2021, and 87.1% of all uninsured eligible children in Missouri participated in Medicaid/CHIP. In SFY 2022, 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

 

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 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. Coverage is available for full Medicaid benefits for the duration of the pregnancy and for one year following the end of the pregnancy.  In SFY 2022, 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

 

Note: Discussion related to the unwinding of the Medicaid continuous enrollment provision is included in Section III.C. Needs Assessment Update.

 

Statewide-Managed Care

The MO HealthNet managed care system started in 1995 when Missouri Department of Social Services (DSS) first contracted with managed care plans 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 fitting into one of the following eligibility categories must enroll in a managed care health plan:

• 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 children and youth with special health care needs) may also opt out of the Managed Care Program and choose the FFS Program.

 

Medicaid Expansion

Missouri’s road to Medicaid expansion was long, but, 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 2024, that amounts to approximately $20,782 for a single individual and $35,631 for a household of three. Medicaid eligibility was previously set in state statute, but the amendment added Medicaid Expansion to Missouri’s constitution, effective July 1, 2021. However, the ballot measure did not include a revenue source for Medicaid Expansion, and the Governor announced the legislature did not provide sufficient appropriations for expansion in the SFY 2022 state budget. 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 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. Nearly 312,000 individuals were enrolled via Medicaid expansion by early 2023, peaking at a little more than 350,000 and then dropping during the “unwinding” of the continuous coverage rule. By late June 2024, the number of people enrolled had dropped to under 300,000. DHSS encourages MCH partners to leverage the Boundary Spanning Leadership (BSL) concepts of Direction, Alignment and Commitment to collectively address the ongoing issue of Medicaid disenrollment among Missouri’s MCH populations due to procedural issues, as elevated during a virtual BSL Booster session in late 2023.

 

Medicaid Extension

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.

 

Department of Health and Senior Services (DHSS) Priorities

Missouri’s MCH 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 previously served as the Acting Director of DHSS since March 1, 2022, and has more than 23 years tenure with DHSS, leading in several program areas, including maternal and 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 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

Public Health Accreditation Board (PHAB) Accreditation

In furthering the commitment to improving public health infrastructure and championing performance improvement and innovation, DHSS applied for reaccreditation through the PHAB in January 2024. This national public health accreditation program assesses a health department’s capacity to carry out the 10 Essential Public Health Services and the Foundational Capabilities as well as serving as a marker for health departments to commit to promoting public trust and demonstrating an ongoing commitment to quality and performance improvement. DHSS’ commitment to meeting PHAB standards outlined in Version 2022 for reaccreditation assures increased capacity to respond to public health emergencies, encourages the use of equity as a lens to identify health priorities, builds the health department’s capacity to better serve communities, and assures stakeholders the health department is delivering Foundational Capabilities.

In April 2024, DHSS received its Pre-Site Visit Report, wherein the PHAB Assigned Accreditation Specialist may reopen any measures for clarification or new examples. Out of 126 measures, DHSS only had eight measures reopened, well below the average. New materials and examples were submitted to PHAB within the required 45-day window, and selected Peer Reviewers will now assist the Assigned Accreditation Specialist to conduct a virtual site visit, interview key staff and the governing entity and ask further questions on any narrative or example submitted. The date for the virtual site visit is anticipated for late summer or early fall 2024. DHSS has committed resources to ensure reaccreditation maintenance and accountability, including implementing a State Health Improvement Plan (SHIP) Accountability Plan, creating a department-wide Lean Six Sigma team dedicated to completing quality improvement projects and fostering a culture of continuous improvement, and measuring progress for department-wide plans such as the Strategic Plan, Workforce Development Plan, and SHIP, all also required by PHAB, in the department’s performance management system, AchieveIt. Specifically, the SHIP Accountability Plan identifies co-leads from various divisions of the department to work with stakeholders to collect data on the progress made towards the goals outlined in the SHIP and input the data into AchieveIt to create public dashboards and annual progress reports.

 

DHSS also recognizes the crucial role of public health accreditation as a systems-building strategy for local public health agencies (LPHAs). While the state-level agency works to maintain its reaccredited status under the PHAB standards and measures, DHSS is utilizing grant funding to support LPHAs on their accreditation journeys as well. Achieving initial accreditation can be a major commitment for LPHAs, demanding expertise, staff time, and funding. To eliminate these barriers, DHSS offers multi-faceted support to LPHAs. Local agency administrators are free to pursue accreditation under the accrediting body of their choice, either PHAB at the national level or the Missouri-specific Missouri Institute for Community Health (MICH) standards. DHSS established a contract with the Missouri Center for Public Health Excellence (MOCPHE) to provide a wide range of technical assistance activities to LPHAs pursuing accreditation. MOCPHE offers accreditation learning communities, cohorts, special events and training opportunities, and hands-on assistance for LPHAs in pursuit of initial accreditation or reaccreditation. DHSS is also contracting directly with PHAB to provide access to their readiness assessment for all LPHAs at no cost. This assessment and the accompanying training provide a deep dive into an agency’s current status to understand which PHAB program is right for the agency at the time of completion. Those not quite ready to pursue full accreditation are steered towards the Pathways Program and given resources on next steps. Those ready for accreditation are encouraged to engage with MOCPHE and peer networks and granted access to advanced training materials to set them up for success. Through cost reimbursement contracts, DHSS is providing funding to LPHAs pursuing accreditation to support any activity necessary for accreditation. LPHAs may contract with entities for more advanced assistance, hire new staff, train existing staff, pay for staff time dedicated to accreditation activities, and/or purchase necessary supplies and software to meet requirements. Lastly, DHSS secured state general revenue funding to provide incentive payment options to LPHAs to encourage and reward public health service delivery. LPHAs may claim incentive payments for participation in accreditation-related training sessions, completion of the PHAB readiness assessment, or by providing evidence of current accreditation under PHAB or MICH.

 

Missouri Foundational Public Health Services (FPHS)

Two key elements of DHSS’ efforts to transform and elevate the public health system across the State of Missouri are the ongoing project to adopt the Missouri FPHS model and support LPHAs as they work towards achieving public health accreditation. These vital projects are reflected in goals included in the first priority issue in the Missouri State Health Improvement Plan, titled “Public Health Systems Building”.

 

DHSS is pursuing a multi-year, statewide project to understand the cost of fully implementing the FPHS model across the public health system. A capacity assessment in 2020 highlighted a gap in the public health workforce and supporting funding that negatively impacts the public health system’s ability to deliver the services necessary to adopt the FPHS model. To address this gap, DHSS is partnering with the University of Missouri to launch a costing tool to all 115 LPHAs in the State of Missouri. With training and support, LPHA administrators will complete the costing assessment tool to report precise dollar amounts necessary for each jurisdiction to adequately deliver services based around the FPHS model. Using the findings from the costing assessment averaged over two program years, DHSS will prepare a request for enhanced state funding to build up and sustain the public health system at the state and local levels. DHSS will also support local jurisdictions as they request additional local funding to enhance support and ensure additional sustainability measures.

 

A key component of this costing project is the development and adoption of an accountability plan to assure transparency and reporting around the use of additional funds and their impact on the citizens of Missouri. A set of proven performance measures, reporting requirements for LPHAs, and accountability reports to stakeholders at the federal, state, and local levels will ensure transparency around the project and build a foundation for potential future increases in funding.

 

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, the Interagency Maternal Health Consortium, convened by DHSS, engages key stakeholders to strategize potential solutions and approaches to address the barriers and challenges.

 

Missouri’s MCH leadership is involved with many DHSS initiatives and priorities. 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 MCH team members participate in the PAMR Board meetings and discussion to reduce maternal mortality. The 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.

• §192.025 (1951) DHSS is designated as the official agency of the state to receive federal funds for health purposes.
• §191.323 (1985) gives DHSS the power and duty to prevent and treat genetic disease and birth defects and
• §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.
• §192.070 (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.
• §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.
• §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).
• §192.601 (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).
• §192.067 (2019) authorizes DHSS to receive information from patient medical records for the purpose of abstracting data (i.e., PAMR).
• §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.§163.048 (2023) 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.
• §191.1720 (2023) 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.
• §208.662 (2023) provides extended postpartum coverage for eligible mothers to receive medical assistance benefits during the pregnancy and during the twelve-month period that begins on the last day of the woman's pregnancy and ends on the last day of the month in which such twelve-month period ends.
• §701.340-701.342 (2023) requires all children under 72 months of age be screened for lead risk factors using the Healthy Child and Youth (HCY) Lead Risk Assessment Guide. If a parent/guardian answers yes or no response to any question, the child should receive a blood lead test. All parents of a child under age 4 shall be provided lead education annually, and every child under age 4 shall be offered a blood lead test annually. All children receiving Medicaid benefits must have lead testing at 12 and 24 months of age.

 

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

28 bills were Truly Agreed To and Finally Passed (TAFP) during the 2024 regular session of the Missouri Legislature. Provided below is a list of bills and legislative decision items with potential impact for Missouri families that were passed during the 104th General Assembly, 2024 Regular Session. The deadline for the Governor to act on the TAFP legislation is July 14.

 

SB 895 Modifies provisions relating to landlord-tenant actions, including eviction proceeding moratoriums and filings for transfers of real property with outstanding collectible judgments.

 

SB 1111 makes it unlawful for any person to establish, maintain, or operate a prescribed pediatric extended care facility (providing medically necessary multidisciplinary services to children under 6 years of age with complex medical needs requiring continuous skilled nursing intervention of at least 4 hours a day under a physician's order) without a license and sets forth the authority of DHSS to issue, suspend, or revoke such licenses, as well as conduct inspections and investigations and promulgate rules for implementation. Prescribed pediatric extended care facilities shall also be licensed child care providers.

 

HB 2062 The bill prohibits any county, municipality or political subdivision from imposing or enforcing a moratorium on eviction proceedings unless specifically authorized by state law.

 

HB 2634 makes it unlawful for any public funds to be expended to any abortion facility, or to any affiliate of such abortion facility. This bill was signed into law by the Governor on May 9, 2024.

 

SFY 2025 Budget Wins

The Missouri SFY 2025 operating budget is approximately $50.5 billion, including $14.9 billion in general revenue.

 

Critical infrastructure projects:

• $1.5 billion for broadband investments in rural and underserved areas.
• $577.5 million to pave the way for I-44 expansion from St. Louis to Joplin.
• $290 million to boost road and bridge projects within the Statewide Transportation Improvement Program.
• $27 million to upgrade Missouri's airports.

 

Investments in education and workforce development systems:

• $367.7 million to continue higher education capital improvement projects.
• $361.4 million to fully fund school transportation needs. 
• $121 million to fully fund the K-12 Foundation Formula.
• $69.3 million for the Career Ladder program to reward educators who go above and beyond normal duties.
• $54.4 million for MoExcels projects and employer-driven workforce training investments.
• $33.4 million for the Teacher Baseline Salary Grant Program - baseline K-12 educator pay increase to $40,000 per year (participating schools no longer have a grant match requirement).
• $32.5 million core funding increase for state higher education institutions.
• $10 million to invest in semiconductor production research, development, and skills training.
• $4.2 million for Jobs for America's Graduates (JAG-Missouri).
• $3.1 million for Missouri Youth Apprenticeships.

 

Support for early childhood programs:

• $56 million for public and charter schools to provide Pre-Kindergarten programs to all students qualifying for free and reduced lunch.
• $54.8 million to increase rates for child care providers to the 100th percentile for infants and toddlers and the 65th percentile for preschoolers and school-aged children.
• $26 million for private child care providers to offer Pre-Kindergarten programs to students qualifying for free and reduced lunch.

 

Investments in state team members and needed upgrades in state services:

• $134 million to maintain, repair, and renovate state facilities.
• $111 million to provide a 3.2% salary increase for all state team members, including a 1% increase for every two years of service (capped at 10%) for certain employees working in congregate care facilities.
• $19.4 million for statewide technology upgrades.
• $8 million for addressing behavioral health care and other health care staffing shortages.
• $7.2 million for Maternal Mortality Prevention, including:
  • $316,401 for women’s health and wellness programs and services.
  • $1.87 million to implement a statewide Fetal and Infant Mortality Review (FIMR) Network.
  • $923,766 for minority health initiatives.
  • $2.21 million for a statewide telehealth network for forensic examinations of victims of sexual offenses.
  • $500,000 for the Cora Faith Walker Doula Training Program to train pregnancy and postpartum doulas.
  • $4.35 million to continue implementation of the Maternal Mortality Prevention Plan.

 

Note: 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.