Geography

Missouri is comprised of 115 jurisdictions (114 counties and one independent city, St. Louis) covering an area of 69,704 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 2017 U.S. Census population estimate for Missouri was 6,113,532 residents. From 2007 to 2017 the state's population increased by 3.84%, including a 4.2% increase for males and a 3.5% increase for females. Among over 6 million Missouri residents, 2.07 million, or 34%, live in rural areas. While the amount of growth varies among individual counties, population increases are occurring in both rural and urban areas. Overall, the population in rural areas increased by 0.7%, while urban areas increased by 5.5% during the past decade.2

 

Missouri's population reflects a dichotomy between its largest metropolitan statistical areas (MSAs) (St. Louis in the east and Kansas City in the west) and its more rural areas. There are large differences in population distribution across Missouri, with over half of the state’s population (55%) falling inside the MSAs of St. Louis (35%) and Kansas City (20%). Missouri has six other cities designated as MSAs by the Census Bureau, listed in order of size: Springfield, Columbia, Joplin, Jefferson City, St. Joseph and Cape Girardeau.

 

The population density of Missouri was estimated at 88.9 individuals per square mile in 2017. The City of St. Louis and 15 other counties were considered urban areas. The largest urban counties by population were St. Louis County (996,726) and Jackson County (698,895). The greatest population density was in St. Louis City with 4977.8 people per square mile. The lowest population density was in Worth County with 7.7 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 21.9 persons per square mile. In total, 46 of Missouri’s counties had a population density below 25 persons per square mile.3

 

Age

In 2017, the average Missourian was just over 38 years old.4 Nearly 23% of the state’s population (1,382,971) was less than 18 years old, and 16% of the population (1,007,033) was age 65 or older. Missouri's estimated MCH population including women of childbearing age (15-44), infants, children, and adolescents (1-19) was 2,711,281. This accounted for more than two-fifths (44%) of the state’s entire population. This estimate represents 1,171,775 women of childbearing ages (15-44 years), 73,107 infants (under 1) and 1,469,002 children and adolescents (ages 1-19 years). There were 298,327 children between the ages of 0 and 17 that had special health care needs.5 In 2017, there were 73,017 Missouri resident live births, of which, 15.8% were African-American and 78.4% were White. Hispanic births in Missouri decreased by 11%, from 2007 to 2017 (4,665 and 4,152 respectively).6

 

Diversity/Language

Missouri residents are predominantly white (80.6%) with a significant African-American (12.3%) population and smaller Asian/Pacific Islander (2.3%) and American Indian (0.5%) resident populations. Over 75% of Missouri’s African-American population groups are located in the three largest counties (St. Louis City, St. Louis County, and Jackson County). Hispanics represent a small but growing segment of the population (4.2%), which is more broadly dispersed throughout the state. Population growth for Hispanics in Missouri was 38.2%, between 2007 and 2017 (an increase of 71,654 persons), compared to 27.6% for Hispanics nationally.7

 

In 2017, native-born United States citizens comprised 95.8% of the Missouri population. More than 4 million Missouri residents (66.04%) were born in the state of Missouri. Of the 257,102 residents that were not born in the United States, 39.89% came from Asia, 28.85% from Latin America, 18.87% came from Europe, 9.16% came from Africa, and 3.23% came from other world regions. Only 3.1% of Missouri residents lived in a different state or country the previous year, while 84.6% lived in the same house.8

 

According to the 2017 American Community Survey (ACS), 343,526 (6.0%) Missourians age five and above spoke a language other than English at home. Of that group, 122,608 persons (2.2% of the total Missouri population) spoke English less than 'very well'. An estimated 146,225 (2.6%) Missourians used Spanish as the primary language at home.9 The Missouri Department of Health and Senior Services translates program materials and health messages in a variety of languages, 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 2016, the infant mortality rate (age <1 year) for African American babies (12.6 per 1,000) was more than double that of white babies (5.2 per 1,000).10 Though minority populations tend to cluster near urban centers, granting better access to health services than many rural non-minorities, ability to secure care can remain a challenge.

 

Education

The 2017 ACS estimates of Missourians over the age of 25 who graduated from high school was 89.7%. This was higher than the national average of 88.0%. However, the percentage of Missourians that have a bachelor’s degree or higher 29.0% was slightly less than the U.S. average (32.0%).11

 

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 2016 agriculture, forestry and related industries had an economic impact of $88.4 billion and generated 378,232 jobs.12 Missouri's median household income in 2017 was estimated at $53,578, which was $6,758, less than the national median household income of $60,336.13

 

Missouri’s unemployment rate increased from 3.7% in March 20182015 to 3.9% in March 2019 (not seasonally adjusted).14 Missouri’s economy saw its sixth consecutive year of Annual Real GDP growth in 2017 with GDP growth continuing into Quarter 1 of 2018. The largest industries were Health Care & Social Assistance (461,800 employees), Retail Trade (313,900), and Manufacturing (265,900). The Missouri economy added 34,300 jobs from June 2017 to June 2018 with Health Care & Social Assistance, and Professional, Scientific & Technical Service jobs leading the job growth. The Administration and Support Services sector was the industry with the largest job decline.15

 

Poverty

 According to the 2017 ACS estimates, 13.4% of Missourians had incomes at or below 100% of the federal poverty level (FPL) compared to 14.0% in 2016. Missouri’s child poverty rate was 18.6%, higher than the state overall rate; this means that more than 795,000 individuals affected by poverty and 252,041 Missouri children lived in poverty.16

 

A key indicator of childhood poverty is children eligible for free/reduced lunch. In Missouri, 2,443 schools participate in a free/reduced lunch program. Of the 927,108 students enrolled in schools, 48.98% participate in the free/reduced lunch program.17 Missouri had the 12th-highest food insecurity rate in the country from 2014-2016. Food insecure families are at a higher risk for chronic diseases, diabetes, hypertension and weight gain.18 Missouri’s 2017 food insecurity rate was 14.2%, meaning 865,400 people in Missouri were food insecure (matching the 2014-2016 rate). The national average rate of food insecurity was 13%. In 2017, food insecurity was highest in the Southeastern (Bootheel) counties (average of 21.5%) and St Louis City (23.3%).19 The overall child food insecurity rate was also 14.2%.20  According to the USDA 2015-2017 Economic Research Service report, the household prevalence for very low food security was 4.8%, which was greater than the national average of 4.5%.21

 

Homelessness

On a single night in 2018, there were roughly 553,000 people experiencing homelessness in the United States: for every 10,000 people in the country, 17 were experiencing homelessness. Approximately two-thirds (65%) were staying in emergency shelters or transitional housing programs, and about one-third (35%) were in unsheltered locations. In 2018, one-fifth of people experiencing homelessness were children (20% or 111,592), 71% were over the age of 24, and 9% were between the ages of 18 and 24.

 

The 2018 Missouri rate of homelessness was 10 per 10,000 (5,883 persons) which was less than the national rate of 17 per 10,000. The 2018 Annual Homeless Assessment report indicates that between 2017 and 2018, individual homelessness in Missouri decreased by 154 individuals, or 2.6%.22

 

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. Therefore, any home built before 1978 may contain leaded paint. About 18.9% of existing housing stock in MO was built before 1950, and 56.5% was built before 1980.23

 

The MO Childhood Lead Poisoning Prevention Program (CLPPP) within the Division of Community and Public Health (DCPH) 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, RSMo 710 required Department of Health and Senior Services (DHSS) to promulgate 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.

 

Over the last 10 years, the annual percent of Missouri's children younger than six years old tested for lead exposure remained consistent, ranging from a high of 20.41% in 2010 to a low of 18.88% in 2017. The number of children tested, however, has fluctuated more dramatically, ranging from 92,363 in 2008, to a high of 95,562 in 2010, and back down to 84,834 in 2017. These fluctuations tend to closely follow fluctuations in the state’s birth rate. Of the number of children tested, the percentage found to have blood lead levels of 10 μg/dL or greater has declined steadily from 1.19% (1,097) in 2008 to 0.64% (543) in 2017. This decrease mirrors a nationwide decrease in children's blood lead levels. Similarly, the trend for children who tested with blood lead levels greater than or equal to 5 μg/dL, the 2012 “reference value” recommended by the CDC, has decreased from 8.84% (8,161) in 2008 to 3.24% (2,749) in 2017.24

 

Transportation

In 2018, Missouri had the seventh largest highway system in the nation.25 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. In 2016, approximately 6.3% of the population in rural Missouri did not have access to a vehicle.26

 

There was a 2% decrease in vehicle fatalities from 2007 to 2017 with 999 fatalities in 2016 and 994 reported vehicle fatalities in 2017.27 Missouri’s rural traffic fatality rate was nearly three times higher than the fatality rate on all other roads in the state. It is estimated that roadway features are likely a contributing factor in approximately one-third of all fatal and serious traffic crashes. Between 2010 and 2017, 6,940 people were killed in traffic crashes in Missouri, an average of 867.5 fatalities per year.28 Missouri’s overall traffic fatality rate of 1.26 fatalities per 100 million vehicle miles of travel in 2017 was slightly higher than the national average of 1.16.29

 

The MO Department of Transportation works with safety advocates across the state with a goal of 700 or fewer fatalities. In 2017, rural deaths made up 50% of motor vehicle deaths.30  The safety belt usage rate in Missouri (84%) was below the national average of 90%. Missouri does not have a primary seatbelt law and only ten states ranked lower in safety belt use. Drivers, front seat passengers and children under the age of 16 are required to buckle up.

 

Health Infrastructure

There are five predominant schools that train new physicians in Missouri. The Kansas City University of Medicine and Biosciences and the University of Missouri – Kansas City operate in the northwest portion of the state. The University of Missouri in Columbia operates centrally. Saint Louis University and Washington University in St. Louis operate in the eastern portion of the state.

 

Over 3,800 Osteopathic Physicians, and over 22,500 Medical Physicians and Surgeons are licensed in Missouri. There are 907 certified OBGYNs in Missouri. Of these, 18 specialize in OB/GYN surgery. There are 1,981 physicians in Missouri that are certified in pediatrics and another 582 specialized pediatricians (e.g. pediatric pulmonology, pediatric emergency medicine, pediatric cardiology, etc.).31

 

As of May 2019, there were 163 licensed hospital facilities in the state of Missouri spread across 71 counties. Of these facilities, 18 are specifically licensed as psychiatric hospitals. The majority of hospitals (94) are located in urban counties. There are 30 trauma (12 I-R, 9 II-R, and 9 III-R) facilities and 65 stroke (12 I-R, 25 II-R, 25 III-R, and 3 IV-R) facilities in Missouri. Over 21,500 beds are available in Missouri hospitals, including 830 are dedicated pediatric beds and 882 NICU beds.32 In addition, there are four VA Medical Centers and one VA Health Care System in the state of Missouri.  This does not include 29 community based outpatient clinics and five veterans centers.33

 

A Rural Health Clinic (RHC) must be located in a non-urban area and in a federally designated or certified shortage area. In 2017, there were 373 RHCs in Missouri. Nine rural counties did not have an RHC.34 A Federally Qualified Health Center (FQHC) is a community-based and patient driven care center designed to help people with limited access to care. In 2017, there were 291 FQHCs in Missouri with 27 rural counties lacking an FQHC.35

 

Health Indicators

Missouri was ranked the 38th healthiest state in 2018, according to the America's Health Rankings 2018 Annual Report published by the United Health Foundation. Some of the indicators for which Missouri had the best rankings were high school graduation (6), disparity in health status (8), air pollution (31), and primary care physicians (15). Some of the worst rankings for Missouri were smoking (40), violent crime (44), dentists (41), and cancer deaths (40). Regarding birth outcome indicators the state of Missouri was ranked 35th for low birth weight, and was ranked 33rd regarding infant mortality.36

 

Health Insurance Coverage

Overall, the percentage of uninsured Missourians decreased from 10.5% in 2013 to 8.4% in 2017. In 2017, an estimated 7.6% of children (under 18) and 11.7% of women (ages 18-44) were without health insurance in Missouri. The percentage of children under 18 without health insurance in Missouri (7.6%) was slightly above the national rate (5.3%).37

 

The MO HealthNet for kids (Medicaid) program provides health insurance coverage for children under age 19 whose monthly family Modified Adjusted Gross Income does not exceed 196% of Federal Poverty Level (FPL) for children under age one, and 148% of FPL for children ages 1-18.38 Approximately 618,878 low-income Missouri children were enrolled in 2017.39 Overall, Medicaid covered 45.0% of Missouri's children and paid for about 38.0% of all births in the state for 2018. Children represent the largest demographic group served by Missouri HealthNet, with 57% of all Medicaid enrollees being age 18 or younger.  Approximately 549,214 low-income MO children have health insurance coverage through this program. MO HealthNet also pays for 65% of all nursing home care in the state.40

 

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.41 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. Premiums paid per family per month range from $14 to $544.42 In SFY2018, about 28,522 children had coverage under the CHIP program in Missouri.43

 

Pregnant women whose family income does not exceed 196% of the FPL for their household size qualify for Medicaid coverage under the MO HealthNet for pregnant women program. Qualification under this category includes 60-day postpartum coverage even with subsequent increases in family income. Approximately 26,600 women received insurance benefits under this program during SFY2016.44 A list of Family Healthcare Programs is available.

 

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 MO HealthNet populations, while improving predictability of the costs associated with providing care. Missouri initially used managed care plans to deliver Medicaid benefits to children, families, and pregnant women across a specific geographic corridor of 54 counties that spanned the center of the state and included the cities of St. Louis, Columbia, Jefferson City, and Kansas City.”

 

On May 1, 2017, Missouri expanded Medicaid managed care to include all 114 counties and the city of St. Louis for that same population (children, families, and pregnant women). In preparation for the expansion, Missouri revised its MO HealthNet Health Plan request for proposals and issued new contracts with three managed care companies. The MO HealthNet managed care plans include: Home State Health Plan (Centene), Missouri Care (WellCare), and United Healthcare. Prior to the statewide expansion, Missouri also contracted with Aetna Better Health of Missouri which covered an estimated 55 percent of people enrolled in the MO HealthNet managed care system.45

 

“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.”

 

In SFY 2018, there were 97,582 low-income custodial parents and 620,294 low-income children covered by MO HealthNet.46 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. The MO HealthNet Managed Care program operates statewide through contracts between the MO DSS MO HealthNet Division (MHD) and three Managed Care health plans. 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.

 

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.

 

DHSS Priorities

In Missouri, the Title V Maternal and Child Health program is located within DHSS. The mission of 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 has been accredited through the Public Health Accreditation Board since 2016.

 

Randall Williams, MD, FACOG is the director of DHSS. He is an obstetrician and gynecologist who previously served as both the Deputy Secretary for Health and State Health Director in the Department of Health and Human Services in North Carolina. Dr. Williams was selected by peers and presently serves on the Board of Directors for the Association of State and Territorial Health Officials (ASTHO). DHSS accomplishments to date with Dr. Williams include first major redesign of Missouri’s almost billion dollar Home Community Based Services and Consumer Directed Services programs since 1982 to reflect changes in care during that time period; first Opioid Emergency Response Center in Missouri created in conjunction with the City of St. Louis and multiple additional agencies to respond in real time to opioid overdoses, increasing availability of treatment and wraparound services; coordinated first ever Governor’s Rural Health Care Summit as part of Governor Mike Parson’s Health Care Week; and first real time review of maternal mortality—as opposed to historical review—by Pregnancy Associated Mortality Review (PAMR) Board and initiated application for national membership in the Alliance of Initiatives in Maternal Health in conjunction with Missouri Hospital Association.

 

DHSS has developed strategic management priorities, which are available through a one-page “placemat.” This placemat sets common goals, defines roles, priorities and direction for DHSS. These priorities include a set of change initiatives DHSS is pursuing to improve performance and outcomes for the citizens of Missouri. It sets forth what DHSS plans to achieve, how it will be achieved, and how to know if it has been achieved. The aspiration set by DHSS is to protect health and keep people of Missouri safe. Four themes identified to reach this aspiration are to reduce opioid misuse, improve the health and safety of Missourians most in need, enhance access to care, and foster a sustainable, high-performing department. There are specific initiatives to address each theme that are usually completed in one year or less. Initiatives include addressing infant & maternal mortality and expanding access to care in rural/under-served areas.

 

DHSS is organized into three programmatic divisions: Regulation and Licensure, Senior and Disability Services, and Community and Public Health (DCPH). This last division administers programs and initiatives addressing public health issues such as communicable disease control, chronic disease management, genetic health conditions, cancer, pregnancy, vital statistics and health care access. The division also assures the continuity of essential public health services to all citizens of and visitors to the state of Missouri. Within DCPH is the Section for Women’s Health (SWH), which is responsible for administering the Title V block grant, working with multiple programs throughout the division to address maternal and child health needs. SWH staff are involved in setting the strategic priorities for DHSS to ensure alignment with the national and state priority measures identified by Missouri in the Title V block grant.

 

Title V Administration

Missouri’s Title V program is led by the Title V MCH Director, Martha J. Smith, MSN, RN, LNHA and the Chief of the Bureau of Special Health Care Needs, Lisa Crandall. DCPH upper management, who play a key role in implementing strategies of the MCH State Action Plan, compose the MCH Advisory Committee. These committee members developed the vision for Title V of ‘positive health outcomes for the Missouri MCH population’ and the mission ‘to be the leader in improving MCH outcomes through partnerships and services.’ The Title V team includes DHSS staff as well as Local Public Health Agencies and community agencies who work to provide positive health outcomes for the MCH population.

 

Major Legislative Initiatives

Forty-Six House Bills and Forty-Five Senate Bills were Truly Agreed To and Finally Passed (TAFP) during the 100th General Assembly, 1st Regular Session (2019). As of August 27, 2019 the Governor had vetoed six bills. Provided below is a list of bills and provisions that impact DHSS and Missouri families:

 

• House Bill (HB) 126 – Modifies provisions relating to abortion.
  • The “Missouri Stands for the Unborn Act”

This bill specifies that an abortion shall not be performed or induced upon a woman at eight weeks gestational age or later, except in cases of medical emergency. A person who knowingly violates these provisions shall be guilty of a class B felony, as well as subject to suspension or revocation of his or her professional license. A woman upon whom an abortion is performed or induced in violation of these provisions shall not be prosecuted.

 

• HB 138 – Establishes “Simon’s Law” which prohibits health care facilities from instituting a do-not-resuscitate order for any child without oral or written permission of at least one parent or legal guardian.

 

• HB 397 – Modifies laws relating to the protection of children.
  • Establishes “Simon’s Law” provisions are the same as those in HB 138.
  • Creates “Nathan’s Law” which modifies several of the child-care licensing laws.

 

• Senate Bill (SB) 514 – Modifies several provisions related to health care.
  • Establishes the “Task Force on Substance Abuse Prevention and Treatment”.
  • Adds Psychologists to the Health Professional Student Loan Repayment Program.
  • Establishes the PAMR Board. It is designated to improve data collection and reporting regarding maternal mortality and to develop initiatives that support at-risk populations. Before June 30, 2020, and each year thereafter, the board shall submit a report on maternal mortality in the state and proposed recommendations to the director of the Centers for Disease Control and Prevention, the director of the DHSS, the governor, and the general assembly.
  • Modifies laws relating to infection data reporting requirements.
  • Allows for the use of electronic prescriptions to pharmacies.
  • Changes provisions related to Hospital Inspectors or Surveyors.
  • Training programs for Certified Nursing Assistants (CNA).

 

Each year there are efforts to repeal Missouri’s requirement for motor cycle riders to wear a helmet. SB 147 would have allowed qualified motorcycle and motorcycle operators, 18 years or older, to operate without a helmet if they had both medical insurance and proof of financial responsibility. Despite these efforts, the bill was vetoed by the governor.

 

Fiscal Year 2020 appropriations worth noting include the following:

• Provides a 3% salary increase for all state employees beginning January 1, 2020.
• Additional funds for women’s health services.
• Additional Federal funds to strengthen Missouri’s oral healthcare system and improve access to underserved areas.
• Additional General Revenue to support our Local Public Health Agencies.

 

For references, please refer to the references in the supporting document attachments.