2021: The State of Public Health in Missouri

Significant Events in Healthcare in Missouri in 2020–2021

• A historic whole government approach to a novel emerging virus with unprecedented collaboration in Missouri with national, state and local public, private, and academic partners

• Development of mRNA vaccines in a 10-month period with leadership from scientists at Pfizer in Chesterfield, Missouri, with first patients getting vaccine on December 14, 2020

• Development of the new HCBS and CDS Program

• Passage of the Medicaid Expansion Initiative in August 2020

• Implementation of the Medical Marijuana Program as per the Missouri Constitution

COVID-19 and Impact on Healthcare

2020 was a year of historic challenges and achievements in healthcare internationally, nationally, and in Missouri as a result of COVID-19.

I gave a commencement speech in December 2019. There, I told the graduates, “Adversity does not build character; it reveals character.” The Governor and I have discussed many times that we will remember all those in Missouri who showed their character by how hard they worked to help get us to a better place. From the scientists at Pfizer in Chesterfield, the members of the Missouri State Medical Association who faithfully gave me feedback and insight at 8 a.m. every Saturday morning, the infectious disease doctors who shared their insight with the Governor’s team at 10 a.m. every Saturday morning, and most importantly, all the physicians and other health care providers who are on the frontlines taking care of patients each day: your character was revealed—you do not run from trouble but rather run toward it to help others.

Your compassion, resilience, resourcefulness, and courage while working tirelessly has and will need to continue during this unprecedented time. I do believe with your help, that we are on a path to a better place, but like any path, we have to walk, if not run along that path, to get to that better place.

I was privileged to represent Missouri at a small gathering at the White House with President Trump, Vice President Pence, and the President’s entire health care team on December 8 as we rolled out Operation Warp Speed. Only three state health directors were present, and it is a testament to Missouri’s implementation of that plan that we were one of the states invited. We now have increased resources in testing, knowledge and vaccines, but we also have more burden of disease. We, like everyone else, are now facing cold weather, flu season, and the fatigue of fighting this virus for nearly a year.

I will always be thankful for Governor Parson green lighting our vaccination planning which started earnestly this past July. I vividly remember being challenged by some who said this was not the best use of resources since a vaccine would not be available until April of 2021. With a robust plan, we are now providing first doses to you and other healthcare workers, plus our long-term care staff and residents. The prioritization of these populations is incredibly important. Nursing home residents accounted for just 4.26% of our cases here in Missouri but 43.9% of our deaths (as of November 1, 2020).

The Governor led efforts to address concerns raised by hospitals by signing a deal with hospitals and the State of Missouri to use CARES Act funding to have Vizient address the staffing issues, especially among nurses, that they were facing.

We have continued to be innovative in inviting the CDC to come to Missouri and work with Saint Louis University and Washington University to voluntarily test students in two different settings to observe the outcomes—those who mask and, thus, continue to come to school if exposed at school, and those who don’t mask at school and, thus, do not come to school for their full quarantine period.

We have always been mindful that a balanced approach recognizes the importance of public health to a community’s well-being, but also that decreasing poverty and increasing educational opportunities improves public health.

Medicaid Expansion

In any other year, the passage of Medicaid Expansion would be the major healthcare development in a state. Missouri joined 38 other states when voters approved Medicaid expansion in August 2020. We are meeting regularly and are committed to working with stakeholders and the General Assembly in implementing this to fulfill our constitutional duty.

Missouri Dept. of Health and Senior Services Randall Williams, MD, addresses coronavirus questions during the Governor’s daily breifing. Dr. Randall reaches out to MSMA physicians every Saturday morning during a Q & A session beginning at 8 a.m. Details are at msma.org/events.

Medical Marijuana

Missouri became the thirty-third state to legalize medical marijuana, and the first product was dispensed to qualified patients at a state-licensed dispensary on October 17, 2020. This is a regulated medical program, and we have treated it as such with patients being our north star since the program’s inception. Missouri was one of the fastest states to implement a medical marijuana law—sixth out of 33 states, and we have met every deliverable as required by the Missouri Constitution.

Home and Community-Based Services

Four years ago, eligibility for Home- and Community-Based Services (HCBS) and Consumer Directed Services were a topic of much discussion in the legislature, and we made a commitment to look at a program that had not changed since 1982, realizing much had changed in medicine since then. The Department is enhancing access to care for Missourians in need of long-term services and support through the HCBS Level of Care Transformation. This endeavor will alter eligibility guidelines for the first time since the HCBS program’s inception in 1982. The transformation will allow state Medicaid resources to be allocated to those most in need as the state’s elderly population continues to grow. These needs are measured through a blend of point and automatic eligibility triggers based on certain characteristics of need.

Time Critical Diagnosis Program

Steve Bollin, a healthcare executive with over 20 years of healthcare experience, brought his expertise to the public sector when he became Director of the Division of Regulation and Licensure. His hiring is consistent with our vision of increasing the Department’s subject matter expertise. Steve has taken a personal interest in getting our Time Critical Diagnosis program to a better place and has a 12-month plan to make improvements that reflect the importance of this program, especially in a rural state.

Telehealth

2021 is now a year of challenges, and Governor Parson has always prioritized the state’s workforce and infrastructure to improve the lives of all Missourians. COVID-19 has likely transformed the role of telehealth and telemedicine for all of us. We allied with our academic partners and MSMA partner, Karen Edison, MD, to hold four health ECHOs on patient management, and I think we will see more of that in the future.

Inter-State Cooperation

I have worked closely with my counterparts in other states, especially Lee Norman in Kansas, and I think you will see more of that cooperation continue in the future with our neighbors. Data acquisition and analysis were brought to the forefront with COVID-19, and we have acquired EpiTrax to further our capabilities in this area. We have worked with our internal and external partners probably more than ever before. The collaboration with the MHA, MSMA, and academic partners, to me, is the wave of the future. To this point, I recently participated in a research project that studied where we are nationally and where we ought to go as we integrate state-level medicine in public health.

Role of Public Health

The role of public health in quarantining and isolating people to prevent the spread of infection has been brought to the general public’s attention in a way that has never occurred in any of our lifetimes. I anticipate there will be debate upon where that authority should be, and with that should come a discussion of the future of public health funding in this state. Missouri has historically been at the bottom of nationwide rankings for state funding of public health. The intensity of the criticism locally and nationally has led to a huge turnover in leadership at every level of public health in this country.

A Thought Leader in Public Health

Missouri should be a national thought leader in public health and healthcare through its work with the Association of State and Territorial Health Officials (ASTHO) and other organizations. I am the first Missouri State Health Director in 75 years to serve in a leadership role with ASTHO, and I hope this will be the beginning of a long line of State Health Directors who serve in this way and represent Missouri. Our state lab has done a superb job during the crisis, and we were enormously helped by having Laboratory Director, Bill Whitmar, serve as president of the American Public Health Laboratory Association.

Summary

It is clearly our intent to create a culture of subject matter expertise, using internal and external partners, that benefits Missourians and integrates with our national partners to serve our citizens and the country. The historian, Vegetius, said that courage is proportional to the knowledge of one’s profession, and we always want to have the expertise and, thus, the courage to act to protect the health and safety of all Missourians.

I must say people stop me all the time to offer gratitude for what the Governor and all of us are doing to help protect their health and safety. For all of us in state government, it is truly a privilege to serve and we join you as a valued partner in that service.