Long hours and service cuts: The pandemic’s toll on Missouri’s public health system

Editor’s note: This is the first in a three-part report on the challenges Missouri’s local public health departments are facing during the COVID-19 pandemic.


As COVID-19 continues to demand public health resources, some local public health departments have cut essential services like restaurant inspections, environmental inspections, childhood immunizations and CPR certifications.

Before this crisis, Missouri’s health departments were already working with limited resources.

Andrew Warlen, Cass County health department director and president of the Missouri Public Health Association, said even before the pandemic, it was hard for his staff of 13 to adequately serve the more than 105,000 people in the county.

Now, it’s pretty much impossible.

“We try to be inventive, we work hard, we’re passionate, but we just don’t have the resources to provide the foundational public health services required,” Warlen said.

As Missouri reopens and continues to report record counts of new COVID-19 cases, local public health departments face challenges with limited resources, ballooning workloads and difficult decisions about what services get cut.

Missouri ranks 50th in the U.S. for the amount of state funds dedicated to public health. The national median is $33.50 per person — Missouri’s state government spends about $6 per person.

Cass County ranks fourth from the bottom of all Missouri counties in terms of per-capita health care spending.

“Essentially what that really means is that we do not have the funding to do our typical public health services on a good day,” Warlen said.

During the pandemic, this has meant that each of his employees are doing the work of three to five people, he said.

Some services can’t be cut, increasing workloads for already overburdened employees.

“Initially, we could put off some other projects, but you can’t put them off long term,” said Melanie Hutton, nurse and health administrator for Cooper County’s health department. “There’s dog bites, E. coli, salmonella, syphilis, all that still. And those diseases can’t be put on hold.”

No relief funding

Fiscal concerns are a major barrier to effective public health responses in the state.

Missouri health departments are funded by a mix of local taxes, allocations from state and federal health departments and grants. Percentages vary by county, but in 2018, the latest year for which data is available, local health departments got about 63% of their funding from local taxes and funds, about 15% from the federal health department, about 17% from grants and other sources and less than 5% from the Missouri Department of Health and Senior Services.

About $521 million from the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act went to Missouri counties to reimburse pandemic-related expenses, including public health costs.

But the money went to county treasurers and commissioners, delaying aid to health departments.

“They’re like any other group coming to the county asking for dollars from this,” said Larry Jones, director for the Missouri Center for Public Health Excellence. “So it’s not been a smooth flow of dollars to local health departments. And so many of them have way overspent the money that they have and are hurting financially.”

Many health departments, like Hutton’s in Cooper County, have yet to see any of the federal funding.

So far, Hutton said all the assistance her department has gotten from the state and federal health departments comes in the form of five gallons of hand sanitizer made from prison labor.

And some programs that the health departments offer — like an education program about traumatic brain injuries — come with specific grant funding that must be used for that purpose.
With COVID-19 leaving less time for that work, this represents another source of lost revenue.

“Our time is dominated by something that has no extra funds,” Hutton said.

The work takes a personal toll.

“Some days you go home with the weight of the world on your shoulders,” she said. “I’m jealous when somebody’s like, ‘Oh, I’m so bored because I’m tired of staying at home, I want to get back to work.’ And I’m like, ‘Oh, I would love to have three months at home.’”

At the state level, much of the messaging has been about local control. When Gov. Mike Parson’s last statewide coronavirus order expired June 16, any sort of restrictions were left to local health departments. Many had not received federal coronavirus relief funding yet, and all lacked any sort of enforcement mechanism for those violating orders except taking offenders to civil court.

“Local public health agencies were the ones determining what’s an essential business and what’s not, doing all the press releases, answering all the questions,” Warlen said. “All the policy decisions about what was essential and what wasn’t. We’re doing all these things while we’re also trying to do the disease investigation. You know, that is a really difficult position to be in.”

Jan Morrow has worked for the Ripley County health department for 41 years. She’s still waiting to receive federal coronavirus relief funding for her department.

“We’ve had to fill out an application that was very lengthy and very time-consuming. We’ve had to submit to another agency so they can review it and then send it back to the county commission,” she said. “That’s not a process that should have happened, in my opinion. That funding should have been directly sent to the county health departments.”

As the Missouri Information Corps previously reported, counties have through Dec. 31 to allocate their federal coronavirus relief funding.

This story was produced by the Missouri Information Corps, a project of the Missouri School of Journalism. Have tips for us? Email: moinformationcorps@gmail.com.


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