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story.lead_photo.caption In an effort to show students how painless it is to receive a flu shot, Missouri Department of Health Director Randall Williams receives a shot from Jaime Young, RN, from the Cole County Health Department, in September 2018 at South Elementary School. Photo by Julie Smith / News Tribune.

The health of Missourians seems to move one step forward, then two steps back.

The state had some improvements to health, according to the Commonwealth Fund's annual scorecard of states' health. However, it also backslid in areas.

Most other states had similar results in the annual health assessments. And overall, Missouri dropped two spots to 43rd of 51, including the District of Columbia.

The Commonwealth Fund — a private foundation that aims to promote a high-performing health care system that achieves better access, improved quality and greater efficiency — produces the scorecard every year to give a snapshot of how states are doing in terms of improving the health of their citizens.

Missouri, for example, improved significantly over about four years by reducing the number of home-health patients who suffered with limited mobility.

During the same time frame, the state reduced the number of residents in nursing homes who required anti-psychotic medications.

And the number of children hospitalized with asthma dropped about 38 percent.

However, gains were overcome by declines.

Deaths within 30 days of somebody being hospitalized, or within 30 days of patients having had a coronary artery bypass graft — known as "hospital 30-day mortality" — increased.

The number of children and adults who went without dental visits increased.

The number of adults who went without a usual source of health care increased.

Filling the gaps

Missouri's shortage of some medical services can be witnessed at the Samaritan Center, said Ben DeFeo, the Jefferson City center's operations manager.

The center serves as a food pantry and offers seasonal clothing, blankets and household items for community members. It also provides a free clinic for people without Medicaid or other insurance.

After passage of the Affordable Care Act (also known as Obamacare), the number of clients the center sees for medical visits dropped. And when people began receiving the government-required insurance, the number of clients the center services was reduced.

However, the number has begun to tick up again.

"We see enough to keep us fairly busy," DeFeo said. "A lot are coming in on maintenance situations — blood pressure, diabetes and similar conditions."

The clinic is serving a number of people who are on medication regimens and will remain on them for the rest of their lives, he said. And, they can't afford their prescriptions. The clients need diabetes blood test strips, blood pressure medication, thyroid medication and other medicines.

"We do a lot of prescription support — different methods that we go through. There are reduced-income availabilities through pharmaceutical companies," DeFeo said.

Clients have to contend with stacks of paperwork when applying for the programs, but the center provides volunteers who can walk them through the process, he said.

"Once you've done (the paperwork), it's like renewing a license plate — every so often you have to do something, but not the full litany," DeFeo said.

The Samaritan Center clinic is staffed by volunteer physicians and dentists. Dental services are available by appointment only. Clients are asked to come during pantry hours — 9:30-11 a.m. Mondays through Thursdays — to make appointments. The medical clinic is open 4-5:30 p.m. Thursdays.

"The best we can do to fill the gaps of those medical or dental needs," DeFeo said. "It's what we try to accomplish. The pharmaceutical part is a huge part."

A statewide issue

Missouri was 49th (of 51, including the District of Columbia) for adults having potentially avoidable emergency department visits (those considered preventable or treatable with appropriate primary care).

The number of adults who are obese increased.

Central Missouri has many of the same issues as the state overall, said George Carr, a family practice physician with Jefferson City Medical Group.

"When you're talking about a statewide problem — you're talking about not only St. Louis and Kansas City — you're talking about the whole state, with a very large rural area," Carr said.

The report card said suicides jumped up.

"Deaths from suicide, alcohol and drugs are a national crisis, but affect states in different ways," the report concludes. States are losing ground. "From 2005 to 2017, every state had increases in all three types of death."

The increases were "far from uniform," the report states.

"For the most part, mental health has been a problem as long as I can remember," Carr said. "For the 30 years I've been here, they've had a declining ability to take care of psychiatric health. That has always been an issue in this state, and it has gotten worse over time, such that family medicine and internal medicine — the primary care guys — have to do a lot of psychiatric care, a lot of mental health."

It's something that can be done but is not a specialty for physicians.

Missouri has been hard-hit by the opioid epidemic.

"Drug overdose mortality has risen the most, more than doubling in 26 states (including Missouri)," according to the report.

In the most recent data, Missouri was found to have had 23.4 overdose deaths per 100,000 population. The national average was 21.7 per 100,000. The state is 42nd-ranked in that category.

It falls behind most states in other categories — it was 46th in adult 30-day hospital readmissions, 50th for adults going without age- or gender-appropriate cancer screenings and last for children without age-appropriate medical care.

Overall, the state improved six spots (to 37th) for prevention and treatment and one spot (to 38th) for general health.

However, it declined a spot (to 45th) for "avoidable use and cost (of medical services)," two spots (to 51st) for health care disparities — the disparity between health care for poor and those above poverty — and six spots (to 33rd) for access and affordability.

Strategies for improvement

"Simple things, like even dental health," Carr said. "That's a big issue. If you have people with poor dental care, they are going to have more illnesses and more complications after surgeries, too."

Small changes in care can make a big difference in people's overall health, he added.

One possibility for improvement, the report states, was to expand Medicaid.

Missouri — which calls its Medicaid program MO HealthNet — is one of only 14 states that have not expanded Medicaid to include coverage for all people with incomes up to 138 percent of the federal poverty level. (Voters in Utah, Idaho and Nebraska have passed ballot initiatives for expansion, but the programs have yet to be implemented.)

According to the U.S. Department of Health and Human Services, the poverty level for a single person in a home is $12,140 (138 percent would be $16,753), for a two-person household is $16,460 (138 percent is $22,714), and for a three-person household is $20,780 (138 percent is $28,676).

On Thursdays, when Christopher Case, the JCMG doctor who treats the Samaritan Center's diabetic patients, is receiving them, the center fills up, DeFeo said. Expansion of Medicaid would certainly benefit many of the clients, he said.

However, they would also benefit from access to more information and to healthy foods.

"A lot of these folks exist off a high-carb, high-sugar diet," DeFeo said. "It's the typical American problem. Folks who wonder where their next meals are coming from don't have the means to find healthy foods."

If the United States is able to attain top rates of performance — like those set by Hawaii, Massachusetts, Minnesota, Washington and Connecticut, the top-performing states — 18 million more adults and children would be covered by health care, 27 million more adults would have a usual source of care, 14 million fewer would skip care, 11 million more would receive recommended cancer screenings and 808,000 more children would receive recommended vaccinations annually, according to the report.

That performance, the report concludes, may be gained by expanding Medicaid to all people at 138 percent of the poverty level, ensuring the Affordable Care Act's reinsurance program can reduce premiums and protect against unexpected high claims, and incorporating single-payer or Medicare-for-all programs that assure lower costs.

"Several states are using value-based purchasing in their Medicaid and state employee benefits programs in order to promote higher-quality, lower-cost care," the report states. "Colorado, Michigan and Oklahoma are changing the way they pay for prescription drugs in Medicaid by requesting federal waivers to negotiate with drug-makers based on how well the drug works, rather than accepting market pricing."

Other states are working to build an adequate primary care workforce — especially in under-served areas — by offering tuition assistance, changing the scope of practice laws, raising the primary care reimbursement rate and taking other steps, according to the report card.

The University of Missouri does a good job of getting primary care doctors out to communities. However, rural communities may lack a lot of specialties who would provide other needed services, Carr said.

"When you look at our state, it's mostly rural," he said. "There are big populations in St. Louis, Kansas City, Springfield and Columbia. When you drive around the state, there are lots of people living in smaller towns who don't have the access to care."

DeFeo said the scope of people suffering from mental illness in the community is illustrative of "an epidemic."

A large percentage of the people who use the services offered by the Samaritan Center have some degree of mental illness, DeFeo continued.

"The lack of support for (their mental illness) prevents them from living at society in a self-supporting level," DeFeo said. "It is no fault of their own. They are just falling through the cracks."

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