The Missouri state flag is seen flying outside the Missouri State Capitol Building on Jan. 17, 2021 in Jefferson City (Michael B. Thomas/Getty Images).
In just the last three months, Missouri has come under fire from two federal agencies and a U.S. district court judge over how it administers programs designed to help the most vulnerable.
The state’s dysfunctional call centers serve to deny low-income residents food aid that is guaranteed to them by federal law, a judge ruled in May.
Missouri funnels mentally ill people into nursing homes, the Department of Justice concluded in June, rather than providing resources that could help them live in their communities.
And delays processing Medicaid applications, among the worst in the nation, violate federal rules — which pediatricians say is causing chronically ill kids to miss medications.
The issues are years in the making — a product of decades of underinvestment and workforce cuts, advocates say.
And they’re not in isolation: There are also foster kids being housed in hospitals, people waiting for months in jail to be transferred to psychiatric facilities, daycares struggling to remain open because of state payment delays and staffing issues that have caused backlogged child welfare investigations.
GOP candidates for governor, from left, Lt. Gov. Mike Kehoe, Secretary of State Jay Ashcroft and state Sen. Bill Eigel (official photos).
On Aug. 6, Missouri will hold primaries to nominate the next governor. Three Republicans are considered the frontrunners for gubernatorial nomination: Lt. Gov. Mike Kehoe, Secretary of State Jay Ashcroft and state Sen. Bill Eigel.
The two leading Democrats running are House Minority Leader Crystal Quade and businessman Mike Hamra.
The Independent asked each candidate what they would do about the various crises within the state’s fragile safety net.
Most agree that two broad issues lie at the root of these problems, particularly within the Missouri Department of Social Services: the fact that state workers aren’t paid enough and that the state has lagged in modernizing its technology.
The leading Republican candidates said they would invest more in workforce or technology, though at the same time all three want to slash the income tax.
Democrats want to make similar investments without that cut to state revenue.
“Regardless of who the governor is,” said Casey Hanson, deputy director of Kids Win Missouri, a coalition of organizations that advocate for children and families’ wellbeing, “we hope that they will come in with that mentality that we need to have systems that work in our state, so that when families need to access the safety net, they’re able to.”
Workforce considerations
On the Republican side, both Kehoe and Eigel said they’d be open to supporting raises for state workers.
The laundry list of safety-net issues is “not an acceptable situation,” Eigel said.
Broadly, Eigel said, more government spending has led to worse outcomes.
But asked about whether more money would be needed to, for instance, ensure child welfare workers have reasonable caseloads — which St. Louis Public Radio has most recently reported on — Eigel said: “No question and nobody’s proposing zero government.”
Eigel would support raising salaries of child welfare workers “up to $80,000 or $90,000 per person so we can really recruit at a level where we’re getting quality individuals to investigate child abuse.”
“…And to do that is a fractional line item in a multi tens of billions of dollar budget.”
Entry level child welfare workers start at salaries of just over $44,000, DSS spokesperson Baylee Watts said.
Eigel said several of the issues “may require more direct resources” but that he would also prioritize “getting rid of bureaucracy.”
In terms of state pay, Kehoe said Missouri has come a long way in the last few years. But the state must continue to remain competitive with the private sector.
Kehoe has lived in Jefferson City for more than 30 years, and he says he’s seen firsthand how some state employees struggle to get by.
“I’ve been at Schnucks and watched someone take out a SNAP or food stamp card to buy groceries,” he said, “And I knew that person had worked for the state for 25 years.
“Now, we shouldn’t have somebody work for the state of Missouri for 25 years and have to use an assistance card to buy bread at Schnucks,” Kehoe said.
The primary in August, where Crystal Quade and Mike Hamra will appear on the ballot, will be the first significant Democratic nomination contest for governor since 2004 (photos submitted).
Quade served as House minority leader, and said her experience in that job gives her insight into the issues plaguing Missouri’s social services. She led hearings looking into people being kicked off Medicaid, and says she has met with numerous frontline DSS staff to hear concerns.
“Year after year,” Quade said, “I have led the fight to increase funding, not only for staff, but also things like our call centers…I can’t count how many hearings I’ve been in where agency directors have begged for adequate funding so they can successfully help Missourians but have been ignored or disregarded,” she added.
Quade said if elected, she’d meet with frontline workers and families who “have been left behind to ensure our state is doing all we can.”
Hamra called the situation “unacceptable” and reflective of a lack of leadership.
“I will both provide staff the resources they need to do their jobs, and in return, demand that they provide the level of service Missourians deserve,” Hamra said. “I have a 20-year track record of running a large organization where I have put this approach into practice and would bring this same mindset to state government as governor.”
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Elsewhere in Missouri’s social services agency, benefits program workers in the Family Support Division start at just under $39,000 and youth services workers at the Division of Youth Services start at $42,000, Watts said. There are currently 252 job openings in the Family Support Division, 126 in the Division of Youth Services and 8 in Children’s Division, as of late May, Watts said.
And even if the agency could fill all its positions, it’d still be operating at a level far below where it used to be. Fifteen years ago, there were over 1,000 more staff members in the Department of Social Services than there are today, according to state budget documents — in part a result of substantial cuts under Democratic Gov. Jay Nixon.
Around one-fifth of the state’s population is on Medicaid. One-third of Missourians will interact with the Department of Social Services, according to agency leaders.
Watts said agency leaders “remain committed to advocating for higher pay” for staff.
The impacts of low staffing in the Family Support Division include delays for Missourians to access needed health and food assistance. A lack of benefits’ staff means various programs compete for resources, Missouri told the federal government.
And a decline in staff has coincided with shifts away from person-to-person interaction.
The agency several years ago moved from assigning caseworkers to each benefits participant and toward a call center model, said Sarah Owsley, advocacy director for the anti-poverty nonprofit Empower Missouri, which she argues hasn’t proven successful in other states.
“We would love to see some resources put back into local offices where families can have a personal contact, a person they’ve built a relationship with,” she said, adding that data shows the person-to-person model helps families secure benefits and move toward self sufficiency, rather than simply being denied access.
In Missouri, call center wait times can be hours long, and the remaining in-person offices sometimes direct clients back to the phones.
The agency is working toward “innovative ways to provide 24/7 self-service options for the public’s convenience,” Watts said.
She added that the agency is “actively monitoring and adjusting staffing to meet the demands of managing the call center and processing applications,” and has seen a reduction in wait times in recent weeks.
DSS “faces a challenge of increased workloads and call volumes while maintaining staffing levels for Medicaid applications and the call center,” Watts said.
Technology modernization
Ashcroft and Kehoe said technology is another area they think could be improved to help these safety net issues.
“The state needs to do a better job with information. The state needs to do a better job of making it easier for individuals to communicate and have their say,” Ashcroft said.
He would also undertake a broader reevaluation of state resources, he said — a “reset of government departments.”
Kehoe said Missouri hasn’t been able to keep up with technology compared to other states.
“We have to do that,” he said, “and I think we have to make sure we get to a point where the right people are getting the right help. eliminate as much of the fraud as we can and the people who actually are able to go to work, get them opportunities in the workforce.”
There have been longstanding tech problems within Missouri’s social services department, including antiquated software systems.
The Missouri Department of Social Services resource center in Poplar Bluff on July 17, 2023 (Clara Bates/Missouri Independent).
After the state launched a new eligibility verification system for Medicaid in 2018, it saw a huge drop in Medicaid enrollees. Officials largely attributed the decline in participation to improved economic conditions, but there turned out to be significant system glitches. Quade called for an investigation of those drop-offs at the time.
A report published in 2019 found Missouri’s Medicaid data system has around 70 components and was partially developed in a system that dates from 1979 — which is “not positioned to meet both current and future needs.” A 2020 report concluded that for participants trying to enroll in benefits, “the system feels like a secret and no one has the answer.”
Lately, the state has seen significant improvements in the number of Medicaid renewals it processes using existing data rather than requiring participant response, which it had long struggled with, called ex-parte renewals. Yet the remaining individuals who still need to send in their forms for processing and the advocates who assist them have reported a huge number of paperwork and tech issues, such as uploaded information being lost in the state’s online portal.
“To address children losing coverage,” Watts said, “we continue to educate community partners and participants on how to connect with FSD to apply, renew, and use the MyDSS portal, along with looking at ways to improve our ex-parte rates which will in turn decrease the numbers of renewal forms that must be sent out.”
Watts said one tool that is in the works would automate more data entry “to streamline processes and allow staff to focus on processing [applications] rather than manual entry.” The full benefits from this are expected by late fall, she added.
And the agency leadership are committed to continuing to advocate for tech upgrades, she said.
Late last year director Robert Knodell told the American Public Human Services Association that some of the problems that had plagued the agency included “decades of underinvestment,” legacy technology systems, and the challenges of bringing new participants onto Medicaid after the voters approved expansion.
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Advocates say they’re not just interested in governors’ policy proposals but what candidates think the purpose of these programs is.
They say one goal of public assistance is to help people become self-sufficient and the way to do that is to eliminate barriers to their getting help.
“When those systems aren’t functioning properly, it puts more stress on families, but it also puts more stress on the state and state workers,” Hanson said, pointing to the case of the education department’s child care subsidy system’s issues since late last year when it moved from the social services department. Those issues have caused day cares to struggle to stay afloat, and daycares to submit more and more payment dispute forms to the state.
“And then that creates a backlog, and then the already overburdened state staff are then faced with that backlog in addition to their regular work,” Hanson said.
And for families, she said, “we hear about parents who have to turn down work or turn down jobs because their subsidy wasn’t approved in time.”
Others have to wait hours on hold to access food benefits, sometimes missing work to do so.
Owsley said she hopes lawmakers think about what purpose it serves to impose barriers for people to access these programs.
“Families in poverty in Missouri needs support,” she said. “They don’t need more burden, and when they’re reaching out for that assistance, it’s because they need it.”
The Independent’s Jason Hancock and Rudi Keller contributed reporting.
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