As I’ve written many times, during the COVID-19 pandemic, Missouri became one of the nation’s leaders in telemedicine access. Patients gained easier access to remote care, providers gained greater flexibility, and many Missourians discovered firsthand how technology can reduce barriers to healthcare.

Unfortunately, when the public health emergency ended, many of those reforms disappeared. Over the past several years, lawmakers have worked to restore some of that flexibility, and this year’s legislation represents another meaningful step forward.

There are currently several bills (House Bill 2372, House Bill 2974, and Senate Bill 1233), awaiting the governor’s signature that would accomplish a few things. Under current law, providers generally must establish a physician–patient relationship before treating someone through telehealth. The new legislation makes that process more flexible by allowing providers to determine when a relationship can be safely established remotely.

The bills also make telemedicine prescribing more practical by focusing on whether a provider has enough information to appropriately diagnose and treat a patient instead of relying on rigid restrictions surrounding questionnaires or telephone-only evaluations. Perhaps even more important, providers licensed through Missouri’s reciprocity system will have clearer authority to provide telehealth services to Missouri patients. That means patients are no longer limited to the providers located near where they live and can more easily connect with healthcare professionals across the country who are willing to treat Missouri patients.

These changes may sound technical, but their impact could be significant. Much of Missouri continues to face healthcare provider shortages, particularly people who live in rural communities or who require care in specialized fields. Patients often wait weeks for appointments, travel long distances for care, or delay treatment altogether. None of this is to say telemedicine can solve every healthcare access challenge, but it can help connect patients to providers more quickly without requiring new facilities or providers to relocate.

The reforms also demonstrate a reality that has become increasingly clear over the past decade: telemedicine is now a key part of the healthcare system. Patients routinely use remote care for follow-up appointments, consultations, behavioral health services, and many other healthcare needs. Providers have invested heavily in telemedicine technology, and patients increasingly expect those options to remain available. As healthcare technology evolves, state laws should continue adapting so Missourians can benefit from those innovations.

All this is to say there is still more work to do. Missouri should continue moving toward a more modality-neutral approach that focuses on the quality of care rather than the technology used to deliver it. Lawmakers should also continue expanding telemedicine options for providers working within their existing scope of practice and further remove barriers that prevent qualified out-of-state providers from treating Missouri patients remotely.

Missouri may not yet be the telemedicine leader it was during the pandemic, but this year’s reforms move the state further in that direction. Addressing Missouri’s healthcare access challenges will require moving beyond outdated assumptions about how care should be delivered and focusing instead on whether patients can safely access the care they need.

The post Missouri Continues Telemedicine Momentum appeared first on Show-Me Institute.

For years, the education establishment in Missouri has relied on a predictable playbook. Whenever state test scores drop or national rankings look bleak, we are told that the data don’t capture the whole picture, or that a new bureaucratic report card will soon show things are turning around. We are urged to wait, to invest more taxpayer money, and to trust the system.

But a newly released look at the numbers from a joint Harvard and Stanford project strips away the capacity for spin. According to the report, Missouri’s reading scores, which declined substantially during COVID, have continued to fall since 2022. We now rank 26th of 38 states (with usable data) in academic growth in math and 28th of 35 states in reading. In both reading and math, Missouri students are more than a half of a year behind where they were performing in 2019 (0.58 grade equivalent and 0.66 grade equivalent, respectively).

The authors point out that the pandemic slide was actually the acceleration of a trend that started around 2013. The pandemic simply poured gasoline on a fire that was already burning.

This scorecard release comes at a critical time for Missouri education policy. Recently, we’ve watched efforts to implement clear, transparent A–F school report cards go sideways in Jefferson City, bogged down by attempts to shift focus away from academic achievement and instead prioritize ambiguous school climate surveys. Fortunately, the governor’s executive order mandating report cards with letter grades will still be implemented.

Similarly, efforts to bring real accountability to early reading were derailed this legislative session. Lawmakers couldn’t commit to rigorously applying the science of reading or to making sure that students who can’t read aren’t socially promoted to grades where they will struggle to understand their textbooks.

If we want to reverse this generation-long decline, we must stop protecting the status quo. The folks in charge of public education need to be held to the highest standards of accountability. Furthermore, we must empower parents with robust educational choice, forcing the state system to compete and innovate rather than take families for granted. If we don’t make changes, we’ll only continue to fall further behind.

The post Missouri Students Continue to Fall Behind appeared first on Show-Me Institute.

Susan Pendergrass speaks with J.S. Onésimo “Ness” Sandoval, demographer and professor in the Department of Sociology and Anthropology at Saint Louis University, about what the data says about the future of the St. Louis region. They discuss record low birth rates and what they mean for school enrollment, why St. Louis is among the top regions in the country for deaths outnumbering births, how the region compares to Pittsburgh and Cleveland, and why suburbs like Chesterfield and St. Charles are aging faster than most people realize. They also discuss the role of housing supply, school choice, crime, and domestic migration in whether St. Louis can attract and retain young families, and more.

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Episode Transcript

Susan Pendergrass (00:00): Well, certainly not the first time we’ve spoken, Dr. Sandoval. At St. Louis University, you are such a fascinating demographer of the region, and I’ve been following your work as new census data has been released. You’ve been writing about it and creating what I think are really cool mapping tools that folks can look at to see how the St. Louis region is impacted. Thanks for coming on to talk about that. But first I want to sort of expand our view, because pretty sure that I read within the last week that the number of babies born in the United States was at an all-time low. Is that right?

Ness Sandoval (00:35): Yeah, so every year the United States will probably be breaking records. The data coming out for 2025 is a record low, and the data coming out for 2026 is even lower. The first few months of 2026, the provisional data that’s out shows even fewer. And this is what we expected. We call this a demographic shock, because in 2026, whenever you create an atmosphere of uncertainty and fear, rational people do not have children until they understand that their job is safe, there’s not a recession coming, and we’re not at war. When you create this sense of fear, young people do the rational thing and don’t have children. We saw this in 2020 with COVID. We saw this in 2008 with the Great Recession. Anytime there is uncertainty, young people will postpone births. And that’s what we’re seeing. This started in November. We started to see the decline in births, and it’s continued from November, December, January, February. And so this is what we’re going to see.

Susan Pendergrass (01:51): So next year is going to be lower. And when you look at the state of Missouri, I’ve been saying this ad nauseum for years that our K-12 school enrollment is declining and will decline because of that sort of peak in 2008, just before the Great Recession. So our biggest kindergarten class was around 2012, and our kindergarten classes have by and large declined ever since. And so those kids are moving through the system. You can project that we will just have fewer and fewer kids enrolled in our K-12 system in the state of Missouri.

Ness Sandoval (02:06): No, we peaked in 2008.

Susan Pendergrass (02:11): By and large declined ever since 2012. And so those kids are moving through the system. So you can project that we will just have fewer and fewer kids enrolled in our K-12 system in the state of Missouri.

Ness Sandoval (02:24): Yeah, this is true, and we have a pretty good chart. We make these for every city. We’re replacing very large cohorts of children who were born. I have a son who was born in 2007, just before the recession. That cohort that graduated in St. Louis was 40,000 students. The baby birth cohort is now 27,000 students. So that’s just in that one year a 13,000 decline. And it’s going to decline every year for the next 15 to 18 years, because we don’t know what the bottom is yet. It has not reached the bottom.

Susan Pendergrass (03:01): Right. People say where are the kids going? I’m like, they’re not going anywhere. They weren’t born. The St. Louis region, like Clayton is declining, Ladue was, I mean, all of these school districts, I think almost everyone in the county has fewer kids today than they had 10 years ago.

Ness Sandoval (03:07): They weren’t born. Yes, and it’s not just St. Louis County. St. Charles County is experiencing this. There are some parts that are growing, in the Wentzville area, O’Fallon, but if you look at the old St. Charles areas, they’re experiencing decline. Families with children are declining in those areas. We had made an interactive map that I think shocked a lot of people, of seniors outnumbering youth. People could not comprehend this. Like, my gosh, this is not 2000 where youth were dominating these neighborhoods. I live out here in Chesterfield. The entire Route 64 corridor is senior citizens dominating the youth in Chesterfield. People are shocked. More seniors lived in Chesterfield than youth in 2010, and that’s only grown since. This is happening throughout West County.

Susan Pendergrass (04:14): Wow. And your maps actually go down to the zip code, right? You have very granular data.

Ness Sandoval (04:27): Across into Illinois, yes. The only way you can turn this around is young people from across the United States deciding that they want to make St. Louis their home, have a family there, create a business there. This is what I promote. We have to get younger. We really should have a preferential option for families with children. And that’s a hard message for a lot of people because they’re like, wait a minute, we grew from 1970 to 2020. And I’m like, but all of that growth was driven by babies born. Over 1.8 million babies were born. And I tell people, just do the math. 27,000 babies per year times 50. That’s the back of the envelope for what’s coming over the next 50 years. Unfortunately, that’s not what’s going to come. It’s going to be a lot lower than that. People are starting to get it. We’re not going to have 1.8 million babies born over the next 50 years.

Susan Pendergrass (05:33): Yeah, and I think about things like individual school systems building new elementary schools when there have got to be a lot of buildings that are empty. And also, won’t there be more competition for public resources between children and older people?

Ness Sandoval (05:49): Yeah. At my previous job at Northwestern, we did a project on this in one of the suburbs because we were studying seniors. There was a debate about how to spend public money. Was it for transit for seniors or transit for children? This was 2006, and this was the debate happening in Chicago. How do you provide paratransit for senior citizens when that number is increasing? We’re just having this discussion because St. Louis is leading. We’re in the top three of regions. Pittsburgh leads the country, Cleveland is second, and St. Louis is third, tied with Tampa. More people dying than babies born. We simply don’t have the number of babies born for the size of our population. And it’s because we’re a very old region. We’re the ninth oldest region in the country.

Susan Pendergrass (06:58): Yeah, I mean, we used to have 800,000 people in the city of St. Louis, right? And now we’re 280,000 or something.

Ness Sandoval (07:05): Yeah, and I was just looking at the numbers. It is very possible within two years that Kansas City will have more babies born in absolute numbers than the St. Louis metro region. That’s how few babies. I’m talking about the region. Indianapolis is about 700 babies behind St. Louis. Nashville is about 800 babies behind. All of these smaller regions are having lots of babies, and young people are moving there. Your future depends on the number of children born. And when you look at population projections, I kind of know what this looks like. When you fall below Kansas City in number of births, at some point Kansas City will be larger than St. Louis. We can project this out. We’re talking absolute births, not birth rates. We had lots of babies born 10 years ago. We were fine 10 years ago.

Susan Pendergrass (08:09): Yeah, wow.

Ness Sandoval (08:29): We can go back and talk about what happened since 2010.

Susan Pendergrass (08:35): Yeah, please. I’m curious what did happen. I know you call it the death spiral when there’s more deaths than births, but how did we get into this?

Ness Sandoval (08:41): So I moved here for the Great Recession. I moved in 2008 to start my job at SLU. And there was hope when I got here. There was some positive momentum happening. I think the region took it for granted that it didn’t have to do anything. We just have to be St. Louis. We don’t have to do anything. Unfortunately, Nashville came on the scene. Then you started to see regions change. Regions thinking we need to get young. And St. Louis absolutely did nothing. Since I’ve lived here, there’s been a lot of resistance to economic development in the region. Nashville, I think it was the popularity of being young, being pro-development. I went to Nashville to actually look at it, like why are young people there? And I went to Vanderbilt. And I saw this really interesting integration between the city and Vanderbilt University. That does not exist here in St. Louis. Making it a vibrant, cohesive, urban experience.

Susan Pendergrass (09:47): Yeah. Right. Now you step off campus at SLU and you’re in an area you don’t want to walk at night.

Ness Sandoval (10:00): Yeah, and even if it was WashU, right. And then you can talk about the Loop. It never recovered from COVID, traffic is down. I think the region has really struggled to attract young people to stay here and live here.

Susan Pendergrass (10:13): Well, we’ve been looking into the issue of crime in St. Louis quite a bit, and I know it’s down and everyone’s celebrating that fact, but I’m not sure when you survey people and ask how they feel walking alone at night, that it’s changed all that much. Even if the number of murders are down, I don’t know that people feel safer walking alone at night, and that’s got to have an impact on whether you want to stay in St. Louis after you have kids.

Ness Sandoval (10:47): Yeah. I think in the city you move out to the suburbs. The challenge is they work and you live for affordability. So many suburbs are against new development, even though they can develop. We see these debates in Chesterfield, that debate in Creve Coeur, several debates out in St. Charles. They don’t even talk about Jefferson County, because they’re celebrating voting down housing. My point is if you don’t want to build housing, Indianapolis is going to build it. Columbus is going to build it. Nashville is building it. We are no longer in the top 50 in new housing permits in the country. We’re 58th.

Susan Pendergrass (11:34): Why though? Is it because there’s not demand, or is supply being constrained?

Ness Sandoval (11:42): Supply is being constrained. Part of it is, when I speak to people, they say it’s going to hurt my home values. People want supply down. But you understand there’s a consequence to this. And home values are always good in St. Louis. But again, we always say there’s a city that we can look to that’s our future, and that’s Pittsburgh. If you really study Pittsburgh and look at it, you’re like, wow, there’s a lot of things we can learn as a city, and say this is not what we want to be. Pittsburgh leads the country in discounted rates on home sales. When people offer their price, most people do not get the price that they want. It’s a significant discount because the demand’s not there. We are about 20 years behind Pittsburgh.

Susan Pendergrass (12:25): Wow. I think a lot, in what I do, about the educational offerings in the region. Before we were recording we were talking about Texas. Texas, number one, doesn’t have an income tax, and also you can pick your child’s school from the get-go. They have hundreds, if not thousands of charter schools. And now they have a private school choice program that I think 250,000 families apply to. And Missouri has an extremely limited private school choice program, maybe 6,000 or 7,000 kids in the state, and not even the ability within St. Louis County to go outside of these tiny little districts. You can’t even go from Clayton to Brentwood. People really feel strongly about this and fight the idea of opening up the county and letting kids go within the county to any school district, and then the legislature fights it every year. And I’m like, we are just becoming less and less competitive.

Ness Sandoval (13:36): I don’t think people understand. I do a lot of work with schools now. We’re going to lose at a minimum 100,000 children under 15 by 2045. This loss is built into the system based on 27,000 births right now. The numbers are starting to show up in kindergarten. We have a smaller kindergarten class, a smaller first grade class coming in. And so a lot of schools are like, wait a minute, what’s going on? This is just starting. You have another 20 years, because we have these large cohorts that were still born after the Great Recession that are going to be replaced by smaller cohorts coming in. And there is no significant migration of children coming into the region.

Susan Pendergrass (14:28): So there are going to be difficult staffing decisions, and people don’t want to hear it. Like, we cannot continue to hire more teachers.

Ness Sandoval (14:32): You have to close schools. You have to close schools, have to merge schools. I’m doing some work in Parkway. People should not be surprised. Parkway is having meetings this month about what Parkway looks like going forward, and people are discussing consolidation. Rockwood is talking about a 15% decline in 10 years. Go out another 10 years, Rockwood will be talking about school consolidation. St. Charles will be talking about school consolidation in the old St. Charles area, the city of St. Charles. This is coming. Everybody focuses on the city and says the city needs to close schools. But you will see a discussion, I think, between Clayton and Brentwood.

Susan Pendergrass (15:06): For sure. Clayton had 2,500 kids. Now they’ve got closer to 2,000. I mean, that’s teachers, that’s buildings. And I know in Indianapolis, I’ve talked to a superintendent in that area. All parents can pick a public school. And he was like, I had some under-enrolled elementary schools and it was great for me because I put a language immersion program in one to bring parents in. I think the resistance to this idea is all about not wanting kids who aren’t paying property taxes, but I think it’s going to flip. Then you’ll be like, we’ve got to fill these seats. We’re paying the same teacher for 18 seats that we could pay for 22 kids. At some point they’re going to have to start laying off teachers. So I think there are some very difficult decisions ahead that you can see now, and there are things that could be done now, like at least not filling open positions.

Ness Sandoval (16:16): I think universities are seeing this, because many of them are relying on tuition and those dollars are not coming in. A smart university has to make cuts because it doesn’t get any better next year or the following year. There will be fewer students coming in. So universities that want to survive are making necessary cuts to survive.

Ness Sandoval (16:45): Again, we don’t know what the bottom of the birth decline looks like. We just happen to live in a state and a region that has seen a significant decline in children. I keep saying we’re modeling the future for people, either as a good or bad thing. They’re like, we want to be like St. Louis, or we don’t want to do what they did.

Ness Sandoval (17:13): I think a lot of people are starting to understand this. It’s like, we’re letting our children go, and we’re not doing a very good job of trying to keep them here. When you had 1.8 million births, you had enough to let children leave your region, leave the state. You don’t have that luxury anymore. Our models show the region should have anywhere between 1.3 million to a million births coming in over the next 50 years. We hope it’s not a million births, because that means you have an 800,000 decline in your population under 50. Or it’s 1.3 million births, which is only a 500,000 decline. But that’s coming.

Susan Pendergrass (17:43): How does immigration factor into it? Because I remember the last time we talked, you said that St. Louis is not very immigration friendly. And of course, the current national environment is not very immigration friendly.

Ness Sandoval (18:03): Missouri and St. Louis cannot rely on immigration to save it. It’s not a state that immigrants are going to come to in large numbers. They’re going to go to Florida. Miami leads the country. Even though domestic migration has people leaving, international migrants are going there as their top destination. They’re going to Philadelphia, they’re going to New York. We get immigrants who come here, but it’s a very small number, like 6,000 a year. We’re not even in the top tier as a top 25 metropolitan region. And Missouri is not either. So Missouri has to rely on domestic migration.

The data will show that probably for the decade, there will be more people dying than babies born in Missouri. Missouri will start to have from a natural perspective more people dying than babies born. And 91 counties across the whole state will have more people dying than babies born. So Missouri will become dependent for growth on domestic migration.

Susan Pendergrass (19:29): Or do we just accept that we’re not going to grow anymore? What’s the impact of that?

Ness Sandoval (19:33): Again, it’s going to be specific. I do think the Springfield area is going to grow, the Branson area, there’s growth. Part of this is retirement, I think. Kansas City is growing.

Susan Pendergrass (19:42): Why Kansas City more than St. Louis? What’s attracting younger people to Kansas City that is not happening here?

Ness Sandoval (19:49): Kansas City is a younger region. St. Louis is a fairly old region. Kansas City is a lot younger and it has a large Latino population, and that’s the largest growing population in the country, birth-rate wise. Latinos are now the second largest population in Kansas City. They surpassed the Black population, which I think even shocked me, because we thought we knew this was coming, but we thought this was going to be post-2030. The fact that it already happened shows just how many Latinos are moving there. And then you have an exodus of Black residents leaving Kansas City as well as St. Louis. I always tell people, when you have young Black families leave or young Black adults leave, those children ultimately leave too. And so that’s part of the story.

Ness Sandoval (20:48): When young people leave, the children that traditionally were born to those young people are now being born in Charlotte, Atlanta, Houston. The number one challenge for St. Louis and the state is the decline in births. If that doesn’t change, then you’re going to see that decline start to show up in five to ten years in our schools.

Ness Sandoval (21:17): And the private schools will simply go out of business because that’s dictated by the private market. Or they’ll do what many of the Catholic schools are doing. They think, we’re going to have middle school now, or we’re going to be K through 12. But then what about the parochial schools? There’s no growth. They’re just taking children out of other schools and putting them in their school system.

Ness Sandoval (21:45): And so again, I go back to Pittsburgh. Pittsburgh is about how do we manage population decline? The city is growing a little bit, but 100% of the growth in terms of the losses is in the suburbs. And that’s going to happen in St. Louis. When this loss starts to show up in the demographic accounting, most of the loss is going to be outside of the city of St. Louis. It’s going to be in the Chesterfield areas. It’s going to be in St. Charles.

Susan Pendergrass (22:18): So what could be done from a policy perspective? Chesterfield is trying to have this arts and entertainment district. They put in Topgolf and the concert venues. They’re trying to attract younger people there. Is it working?

Ness Sandoval (22:34): It’s not working. I mean, they have the same slight increase. I just posted this yesterday. People are shocked. The growth is in non-family households in Chesterfield. If you look at the new development, I call it downtown West Chesterfield. These are million-dollar homes, very expensive. Very few families with kids are there. These are empty nesters or dual-income, no-kids households. It’s very expensive for young families to get into Chesterfield today, when your entry-level home that was $170,000 in 1980 is $600,000 today. These are the challenges.

Susan Pendergrass (23:23): So build more starter homes?

Ness Sandoval (23:32): You need more entry-level homes. I’m not even going to use the word affordable. You need attainable homes for two incomes. And they can be built. But what I’ve heard is that a lot of cities do not want these homes. They want the $600,000 to $700,000 homes because of taxes. And so there is this tension there.

Ness Sandoval (23:56): Parkway and Rockwood are going to look very different in 30 years. They were very attractive amenities for young families with children. But I look at the data, and my kids are in Parkway. These schools are under-enrolled. You go and objectively look at the classrooms, you’re like, there should be 30 kids in these rooms and there’s 15. It’s great for me as a parent. I’m glad there’s only 15 kids for my fourth grader. One of the classes in Parkway Central, in the middle school, in his math class, there are eight students. I love it as a parent, but as someone who looks at the data, this is not sustainable.

Susan Pendergrass (24:45): Yeah, lots of one-on-one. Yeah. I’m just trying to figure out what would cause a renaissance in St. Louis. It doesn’t feel super safe. It has some great amenities and a great food scene and now MLS soccer. What would it take? Well, number one, you do have the school system problem where the St. Louis public school system is kind of a dumpster fire. So people want to move out if they have small children.

Ness Sandoval (25:32): Yeah, the decision to move out is made within the first three years once the baby’s born. We can see that in the data. When we moved from Chicago, because we lived in the city of Chicago, we wanted to live in the city of St. Louis. I think most people who move from Philadelphia or Boston are living in the city. We thought the city of St. Louis would be offering the same amenities. Because of the Great Recession, I came a year before my family, and we soon realized the city of St. Louis was not the city of Chicago in terms of amenities. And so we ended up in St. Charles. And I think most people make that same decision.

Susan Pendergrass (26:25): Yeah, my husband and I moved right into the city.

Ness Sandoval (26:27): We see it in the data. People are moving into the city from Philadelphia, from Boston, from Houston. But then, like me, if you have children and you’re not going to pay for private school, because that’s a tax in many ways, they’re going to exit out. And then with the Catholic schools closing in the city, there are going to be fewer options.

Susan Pendergrass (26:50): Yeah. But the public transportation is no good. I mean, there are things.

Ness Sandoval (26:57): And it’s interesting. We did see a kind of experiment during COVID. When COVID happened, the Catholic schools in the county opened up. A lot of families wanted their children in face-to-face instruction. So they left the city. They did not stay. So we had kind of a quasi-experimental design there. Education was very important.

Ness Sandoval (27:26): A lot of people left the city because of that and never came back. And that started before COVID. But I think this idea of school choice is something where parents want it. We have enough anecdotal evidence. When Normandy closed, the school system closed, families moved to Normandy to get their kids into Francis Howell. There’s enough evidence to show that families want to make these decisions. The question would be, would Parkway accept all of the students that would want to be in Parkway?

Susan Pendergrass (27:56): Yeah, the law would have to say that they would have to. You couldn’t let them pick and choose.

Ness Sandoval (28:15): Yeah. And so the question is, you have a lot of people who would love to be in Parkway. I gave a talk at Marquette and I was shocked because a good percentage of the students there were saying those public school students, but the parents had left to get out to West County for their children. So the question is, do you just let the private market dictate this? Those who can leave the city will ultimately leave the city and get out to West County.

Susan Pendergrass (28:50): There’s movement out. And I think in terms of domestic migration, to get parents to move in, you can go to our northern border, Iowa. The state pays for private school tuition. Oklahoma to the south, the state pays for private school tuition. Kansas, you can go to any public school in the state. It’s 100% open enrollment. Arkansas is one of the strongest for school choice, both public and private. I think we’re going to be surrounded by it and just have our arms folded across our chest. Because Parkway doesn’t want all those kids coming, or Rockwood doesn’t want all those kids coming. Parents are simply going to move across the border to a state where they can pick any public or private school. I’ve talked to some parents who have reached out to say, I’m thinking about moving to the region, is it true I can’t pick a school? And I’m like, it is true. You cannot pick a school. And I think they’re like, forget it. I’m not going to make this big decision on where to buy a house. I think if we don’t do things that are family friendly, and if we don’t get crime under control in some way, or have a 911 system where when you call somebody responds, I think it’s interesting that St. Louis will become this example for the nation of what a dying city looks like.

Ness Sandoval (30:08): We have three examples today: Pittsburgh, Cleveland, and St. Louis. Tampa is kind of unique because it is a destination for retirees. The Wall Street Journal has an article today on Cleveland, the renaissance of downtown Cleveland. And Detroit too, it’s a renaissance.

Susan Pendergrass (30:29): Wow. What about Detroit now? So St. Louis hasn’t figured out our renaissance yet.

Ness Sandoval (30:49): And to be honest with you, I think it will be hard. I’m not pro anything, but I find this whole debate about the city and county interesting. I’m not from here, so I don’t have this history of growing up here. But I think objectively, when I look at the budget of the city of St. Louis and compare it to Pittsburgh, Pittsburgh is a little bit bigger. It’s got 25,000 more people. But their budget is significantly smaller than St. Louis City’s budget. Part of me wonders, because the city is both a city and a county, it doesn’t have enough people or revenue to operate as both. And this is what’s helping Pittsburgh out. This is what’s helping Cleveland out, because that county revenue is spread among more taxpayers. In St. Louis City, the county functions are spread among a dwindling number of taxpayers. The city probably cannot be a county anymore. There’s just too few taxpayers to provide both city services and county services.

Ness Sandoval (32:08): I looked at these budgets and I’m like, my gosh, why is St. Louis’s budget so much more? I’m talking not a little bit more, a lot more than Pittsburgh’s budget. Pittsburgh is having trouble. And I don’t see the long-term fiscal situation turning around for the city because it’s got to provide all of these services. The tax base is going to decline. The next three years are probably going to see population loss in the city. The numbers just came out in March, but we’ll get the numbers in May. It’ll probably lead the country again in population decline for large cities.

Susan Pendergrass (32:58): Are we still a top 20 city? We’re number one in population decline, but what about in population size?

Ness Sandoval (33:01): We’re number one in decline. Last year, St. Louis City was number one. We’re declining. We’re not in the top 20 yet, but we’re very close. If we go back to 2020, we’re smaller than we were in 2020. The only reason we’re not number one in decline is because we had so many immigrants that offset our domestic migration loss. But this will be an interesting 2030 census, because it’ll be the first time the region will go into a census with more people dying than babies born. In the last census, we had about 75,000 natural growth. We’re looking at about 25,000 to 30,000 natural decline going into this census without any domestic migration. I tell people that this story is just starting. We have 74 years of the century left.

Ness Sandoval (34:18): I’m just trying to get people to move from the mindset that this is 2010 St. Louis. You don’t have 36,000 births anymore. You have 27,000 and it’s declining, one of the fastest declines in the country. Because of it, we’re aging very fast, and so we have to shift. The region has to make a choice that we start to organize our economy around senior citizens. There’s lots of money to be made from senior citizens, but we will never be viewed as Nashville or Austin as a place for young people.

Susan Pendergrass (34:52): Absolutely. That Route 64 corridor is just going to be all retirement homes.

Ness Sandoval (35:04): We won’t be talking about single family homes anymore. We’ll be talking about senior housing. We’ll be talking about a workforce that’s going to work with seniors instead of a workforce for children. And there is money to be made in that economy. I’m not saying that this is a bad thing. But again, we can look at other parts of the country where this transition has happened. Local government spending is being consumed by senior citizens, the healthcare of senior citizens, the paratransit of seniors. Seniors will lose their ability to drive. That cost typically gets covered by local governments. And so you will not be providing buses for children. You’ll be providing paratransit to get seniors to their doctors. Churches will have to think about being accessible to seniors. I go to Church of the Ascension and they are not prepared. At Easter, one of the Masses, one-third of this section was senior citizens in wheelchairs. The churches are simply not prepared for a parish that’s going to be 50% of the population at 70 years old and older. Restaurants have to think about this.

Susan Pendergrass (36:30): Wow, that’s crazy. Well, interesting stuff. I hope you’ll come back and talk about this more. And certainly I’m very interested in reading everything that you write about what St. Louis can do. We need to figure out a renaissance.

Ness Sandoval (36:51): We’ve got to get younger. The kids are giving us a try. They’re coming to school, they’re coming here because they have hopes. We just have not responded the way we need to. A lot of companies are starting to recognize this. I talked to the mayor and said, you need to be a more proactive voice on this. But the region, this is not a city of St. Louis issue. This is a St. Charles issue, a Jefferson County issue, a Chesterfield issue. Most of the people live outside of St. Louis city. The loss we’re projecting is going to come from the suburbs. And that’s what’s happening in Pittsburgh, that’s what’s happening in Cleveland. 100% of the demographic loss is in the suburbs.

Susan Pendergrass (37:21): Yeah. Wow, that’s crazy. Well, fascinating. Thank you so much for explaining it. I don’t want to be depressed about it, but it’s not super optimistic. We’ll find a silver lining. Thanks, Dr. Sandoval.

Ness Sandoval (37:59): All right, thank you very much.

Produced by Show-Me Opportunity

The post St. Louis Demographics and the Future of the Region with Ness Sandoval appeared first on Show-Me Institute.

Neglecting a problem doesn’t make it go away, or cheaper to fix. Missouri is learning that lesson with regard to its IT systems right now.

As I’ve written before, many of Missouri’s government computer systems are critically out of date. COVID relief funds helped jumpstart long-needed modernization efforts, but the passage of the One Big Beautiful Bill last July means new federal requirements will soon depend on those upgrades.

Missouri’s Department of Social Services (DSS) has been tasked with integrating its Supplemental Nutrition Assistance Program (SNAP) and Medicaid eligibility systems while preparing for new community engagement requirements. This integration has been needed for years, but the new federal rules make it urgent. The goal is straightforward: simplify how benefits are administered while reducing costly errors. If Missouri cannot bring those error rates down, the state will be responsible for a larger share of program costs.

Some officials have warned that meeting the new requirements could force the department to shift resources away from other modernization work. There is no doubt funding plays a role. Modernizing large government IT systems can be expensive. But in this case, stronger systems are exactly what will make complying with new federal mandates possible.

There are reasons to worry about how this effort will go. This is not the first time DSS has faced a difficult administrative task, and the last major one did not go smoothly. When federal pandemic rules suspended Medicaid eligibility reviews, states had time to prepare for the return of normal operations. Missouri did not use that window to get ahead or fully modernize its systems. When eligibility reviews resumed and the state had to reassess hundreds of thousands of enrollees, Missouri struggled immensely.

More recently, Missouri’s experience with large IT modernization efforts across state government offers another warning. Lawmakers were told a few weeks ago that completing upgrades to the state’s financial management system will cost more than $250 million. This is a project that is already significantly behind schedule and over budget. It should be noted that Missouri’s difficulty with modernization is partly the result of how long these systems were allowed to fall behind. It‘s not surprising that the longer upgrades are delayed, the harder and more expensive they become.

The challenge Missouri faces now is that many of the policies it must implement depend on the very systems still awaiting modernization. Community engagement requirements require technology capable of tracking employment data. More frequent eligibility renewals require information that can move accurately between programs. Lower error rates require systems that can catch mistakes before they turn into federal penalties.

As lawmakers finalize Missouri’s budget in the weeks ahead, this issue should remain front of mind. Modernizing the systems that run the state’s safety net is not a project the state can afford to ignore any longer.

There’s no getting around the fact that Missouri will ultimately have to upgrade these systems. The only real question now is whether the state does it in time to avoid more costly mistakes and federal penalties.

The post Cost of Delaying Safety-Net Modernization appeared first on Show-Me Institute.

Kansas City’s new Bus Riders Union says city hall and the Kansas City Area Transportation Authority (KCATA) need to listen to riders.

On that point, it is right.

For years, KCATA has made major policy decisions without clearly anchoring them to what riders consistently say they value most. The most consequential example was the move to eliminate fares.

In late 2019, the Kansas City Council voted to subsidize fare-free bus trips tied to city service. In March 2020, as a COVID-era public health measure, fares were suspended regionally across RideKC partners. The pandemic decision effectively made the fare-free policy far broader than the original city-centered framing.

But fare-free did not make bus operations cheaper.

Before 2020, several Missouri-side municipal contracts operated under a net operating cost model: KCATA calculated operating costs, subtracted passenger revenue, and allocated the remaining loss among funding partners. In the year before fares were suspended, passenger revenue covered roughly $9 million of operating costs.

The fare-free policy eliminated that recurring revenue stream, but it did not eliminate operating costs. Fare-collection expenses declined modestly, but those savings were far smaller than the forgone revenue, and additional pressures—including ADA complementary paratransit demand—complicated the balance sheet.

During the pandemic, federal funds offset the lost fare revenue. But as one-time COVID-era funding dwindled, the structural question reemerged: who permanently pays for free fares and full service?

Multiple forces drove the budget stress that followed—expiring federal relief, post-pandemic inflation, and negotiated cost-sharing changes. Fare-free was not the only cause of rising costs, but it was a significant one.

Removing a revenue stream embedded in cost-allocation formulas increased the amount that had to be covered by subsidies. Without a dedicated replacement source, the system became more financially fragile. That coincided with contract disputes, service cut threats, and regional withdrawals—all of which riders experience as instability.

Just as important, fare-free did little to address passenger concerns. It did not fix whether the bus shows up on time or is clean and safe. It may have worsened these issues.

Research across major transit systems shows a similar pattern: riders tend to rank frequency, reliability, and safety above fare reductions as the changes most likely to increase their use.

Kansas City has tested fare-free transit. It proved impossible to sustain without stable, dedicated funding, making the service less attractive to other neighboring municipalities.

If the Bus Riders Union wants to ensure riders are heard, the focus now should be on what riders consistently say they need: buses that run frequently, arrive on time, and feel safe.

Unfortunately, KCATA’s past policy missteps have made this more difficult.

The post Kansas City’s Bus Riders Union Is Right about One Thing appeared first on Show-Me Institute.

Shortly before the end of last year, the auditor’s office released a report urging lawmakers to take “immediate action” to curb the trend of deficit spending before more drastic cuts become necessary. For longtime readers of the Show-Me Institute blog, this assessment will sound familiar. The report reinforces concerns that have been visible in Missouri’s budget data for more than half a decade.

Reviewing recent revenue and spending trends helps illustrate the problem. Between 2020 and 2025, Missouri’s general revenue collections increased by 45.8 percent, largely driven by income and sales tax growth. Over the same period, general revenue expenditures increased by 53.4 percent. That spending growth more than doubled the rate of inflation, which rose 24.5 percent during those years. Even strong revenue growth was not enough to keep pace.

This imbalance was made possible by a temporary windfall. Although Missouri operates under a constitutional balanced budget requirement, lawmakers were able to commit to higher spending because of a large influx of federal COVID relief funds, combined with stronger-than-expected tax collections. That surge produced a record general revenue balance of nearly $6 billion in 2023. Rather than treating those conditions as temporary, the state locked in higher ongoing spending through pay raises and program expansions, among other things. Since then, the surplus has been largely exhausted.

Looking ahead, fiscal pressures are likely to get worse. Governor Kehoe’s recent budget recommendations project a decline in expected revenues this fiscal year and only minimal growth in Fiscal Year 2027. The outlook deteriorates further when you consider the chance of an economic downturn. Using the worst three-year revenue decline Missouri experienced between 2003 and 2025, the auditor estimates the general revenue fund would be depleted by 2027. Under that scenario, the state would face a deficit exceeding $3.8 billion. And while Missouri’s Budget Reserve Fund (rainy day fund) holds approximately $950 million, as I’ve written before, constitutional restrictions sharply limit its usefulness in addressing an ongoing budget shortfall.

As the general assembly begins working on next year’s budget, the auditor’s report should remain front of mind. There’s still time to rein in the state’s out-of-control spending if Missouri’s lawmakers are willing to start making the tough decisions that right-sizing government entails. The question is no longer whether adjustment is needed, but instead how long until fiscal disaster strikes.

The post The Auditor Confirms Missouri’s Budget Problem appeared first on Show-Me Institute.

Unfortunately, that shocking finding is only one piece of the bad news included in the report. The same audit also revealed that thousands of people have remained enrolled on Missouri’s Medicaid program for up to ten years without the state checking whether they’re still eligible. Federal law requires annual eligibility reviews, but Missouri’s outdated IT systems somehow blocked the state’s Department of Social Services from checking the information of around 10,000 recipients for up to a decade. To be fair, some of these individuals might still qualify for benefits, but many probably do not. The point is that the state doesn’t know one way or the other.

The issues outlined in the audit are a perfect illustration of the many problems with Missouri’s Medicaid program that I’ve been writing about for years. This is an enormously expensive program that is riddled with waste and relies on outdated computer systems that are only making things worse.

Given Missouri’s budgetary uncertainty, it’s even more important that Medicaid benefits only go to people who are eligible for them. Eligibility reviews aren’t just bureaucratic hurdles with no purpose. Circumstances that make people eligible to receive welfare benefits change all the time. They find a job. They get married. They might even die. It’s essential that the state’s computer systems know this information as soon as possible to ensure that tax dollars aren’t being misspent.

Perhaps the worst part of the audit report is the recognition that these troubling findings aren’t new problems at all. Previous reports highlighted both the “death match” issue as well as the recipients who weren’t getting their eligibility checked. Some might remember that Medicaid eligibility redeterminations were a hot topic while they were paused during the COVID-19 pandemic, but it’s important to point out that these issues predate 2020, so we can’t just blame the pandemic.

This is another reason why some of the reforms I outlined from the One Big Beautiful Bill are so needed. Modernizing the state’s computer systems and improving eligibility verification so that errors like these don’t happen should be a top priority. Medicaid is far too expensive, and its costs are growing at far too an alarming rate for this level of waste to continue. What’s the point of having eligibility rules if they aren’t going to be enforced?

The post Checking Medicaid’s Pulse appeared first on Show-Me Institute.

As many Missouri businesses struggle to find workers, the state’s welfare programs are fostering government dependency.

The Solution

Seize the opportunity provided by the recent passage of the One Big Beautiful Bill Act to reform Missouri’s welfare programs.

Key Facts

• Recent passage of the One Big Beautiful Bill Act (OBBB) offers Missouri new opportunities to reform the state’s welfare programs.
• More than 1 in 5 Missourians are enrolled in government-sponsored health coverage through Medicaid.
• Estimates suggest that upwards of 20% of welfare enrollees may actually be ineligible to receive services.
• Missouri should take advantage of the new flexibility granted to states as the many provisions of the OBBB are implemented in the coming years, focusing on encouraging work and making the programs more efficient.

New Opportunities

After decades of creeping growth in government dependence, Missouri now has a golden opportunity to finally enact meaningful welfare reform. Following the recent federal passage of the One Big Beautiful Bill Act (OBBB), states will be tasked over the next several years with implementing the bill’s many provisions that relate to welfare programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP).

Drastically changing Missouri’s welfare programs will require significant, much-needed computer system upgrades. According to a recent report from the Missouri State Auditor’s Office, the state’s Medicaid agency continues to struggle with determining recipient eligibility. As a result, individuals who are ineligible to receive benefits have remained enrolled in the program for up to 10 years in some cases. State taxpayers have also been footing the bill for benefits for dead recipients due to a lack of sufficient system controls.

As Missouri is upgrading the state’s information systems as required by the OBBB, there’s no better time to address the existing eligibility system issues and take the extra step to further reform the state’s welfare programs to make them work better for program recipients and taxpayers alike.

Continuing Growth

As government spending has grown in recent years, so too has enrollment in Missouri’s various welfare programs. Today, Medicaid is Missouri’s largest government-run program, with more than 1.2 million Missourians—approximately one fifth of Missouri’s population—enrolled. This total represents an increase in enrollment of approximately 50% since the beginning of 2020. Medicaid is not the only program growing in size. Approximately 660,000 Missourians are enrolled in SNAP, otherwise known as food stamps. Estimates suggest that upwards of 20% of all welfare enrollees may not be legally eligible to receive services or are receiving benefits in excess of the amount to which they’re entitled.

Change Incentives to Change Outcomes

Welfare programs shouldn’t encourage dependency, but far too often they end up trapping recipients on government support. After years without enforcing the SNAP or Temporary Assistance to Needy Families (TANF) work requirements, the OBBB requires Missouri to implement “community engagement requirements” for able-bodied SNAP and Medicaid recipients starting in 2027. Missouri should ensure these new requirements are more than just a new bureaucratic hurdle recipients need to clear and are instead offering those who need temporary assistance a clear path back to the workforce.

Welfare Program Enrollment

Following the surge in program enrollment during the COVID-19 pandemic, more than 1.2 million Missourians remain enrolled in Medicaid and more than 660,000 are on SNAP (food stamps).

Reform Can’t Wait

Whether Missouri’s government is ready or not, as a result of the OBBB, substantial changes are coming to the Show-Me State’s welfare programs over the next several years. While many of the bill’s reforms focus on improving program integrity and establish new state requirements with firm deadlines for compliance, some reforms provide states considerable flexibility in how they’re implemented. In these cases, Missouri should take advantage of this newfound flexibility to tailor the reforms to best meet the needs of Missourians, with a focus on maximizing efficiency, minimizing waste, and encouraging work for recipients who are capable.

Policy Recommendations

• Take advantage of newly provided flexibility to meaningfully reform welfare programs in a manner consistent with the goals of the recently passed OBBB.
• Continue upgrading state information systems to encourage greater accountability by minimizing waste, fraud, and abuse.
• Dutifully implement provisions of the OBBB to maximize program integrity while ensuring that productive work is encouraged.

The post Welfare Reform appeared first on Show-Me Institute.

Healthcare supply is needlessly limited by regulations that often protect incumbent providers at the expense of patients.

The Solution

Enact free-market reforms to increase the availability of care across the state while also working to lower healthcare prices.

Key Facts

• Missouri needlessly restricts many medical professionals’ scopes of practice and has complex licensing requirements that reduce healthcare access.
• During the COVID-19 pandemic, Missouri was a national leader in waiving laws and regulations that placed unnecessary limits on healthcare access.

Remove Unnecessary Barriers

“Scope of practice” defines what medical professionals can do in a state, given their training. More treatment options for patients means more competition among providers, which is good for consumers in terms of service and price. This is especially true and important in rural areas where doctors may not always be available or nearby. While Missouri has made some incremental progress on broadening the scope of practice for nurses in recent years, the state still has more restrictive laws than most of the country.

“Telemedicine” is the provision of medical care over the telephone and the internet. For the sake of public health and because many patients felt more comfortable staying at home during the pandemic, Missouri temporarily loosened the regulations that govern who could see a physician online and under what circumstances. Despite the recent expansion of Missouri’s telemedicine laws to include audio-only technologies, there is still work to be done to safely expand telemedicine.

“Licensure” is the manner in which the state regulates certain professions. Unfortunately, licensure can often act as a barrier to entry, especially for qualified healthcare providers from other states. While Missouri’s passage of universal license reciprocity in 2020 was a step in the right direction, the state’s licensing laws are still unnecessarily limiting the number of qualified and willing providers who could otherwise be treating Missouri patients.

Repeal Certificate of Need

Missouri’s Certificate of Need law restricts healthcare competition by requiring many healthcare providers to get state approval before entering new markets or expanding services offered in existing facilities. This restriction hampers market newcomers and puts upward pressure on healthcare prices by restricting supply.

Retake a Top Spot

At the start of the COVID-19 pandemic, Missouri quickly became a national leader in expanding healthcare access. Governor Parson waived numerous laws and regulations regarding scope of practice, license reciprocity, telemedicine, and even Certificate of Need requirements. But in the years since, the waivers were allowed to expire, and Missouri’s legislature has taken minimal action to address the issue.

Missouri’s laws and regulations that specify what the state’s providers are allowed to do and where they can practice play a key role in the recruitment of new state residents and workers. Greater freedom for providers makes job opportunities in a state more desirable for prospective employees. If Missouri’s elected officials are serious about addressing the state’s healthcare access issues, making healthcare employment in Missouri more competitive is required.

Policy Recommendations

• Remove the unnecessary barriers to healthcare access that were previously waived during the COVID-19 pandemic, such as expanded providers’ scope of practice.
• Remove the statutory delays to reciprocity licensure and create additional pathways for licensed healthcare providers in other states to treat patients in Missouri.
• Repeal Missouri’s Certificate of Need laws.

The post Free-Market Healthcare Reform appeared first on Show-Me Institute.

Then, interest rates went up.

In a well-functioning market, the process should have reversed itself. The higher interest rates pushed the total price of purchasing a home back up, which surely lowered demand. At the same time, with house prices still far above the pre-pandemic level, builders should have been building like mad to bring homes to the market. These two forces should have resulted in a housing price correction. But this is not what happened. The higher interest rates have cooled demand, but prices remain high. Below is a chart I created using the Federal Reserve Economic Data (FRED) system. It shows the trend in the median U.S. home price since February 2020, just before the pandemic. The average price of a home in the United States grew by roughly $120,000, or about 38 percent, from the first quarter of 2020 to the third quarter of 2022. It has declined modestly of late, but not much.

The bizarre thing is that builders haven’t responded to the higher prices. In fact, FRED data show new housing starts today are lower than before the pandemic. Meanwhile, many existing homeowners are “locked in” with low-rate mortgages and reluctant to move, further constraining supply. Even with tempered demand due to the combination of high prices and high interest rates, the lack of supply is keeping prices elevated.

But what are the builders doing? They should be falling all over themselves to bring new houses to the market. Think of it this way: If it was profitable to build homes in Q1-2020, it should have been even more profitable by Q3-2022, continuing until today.

A recent issue of the Journal of Economic Perspectives (JEP) brings together several groups of economists to weigh in on the housing market. I read the issue with great interest. One of the most striking findings is that in many major markets, the price elasticity of housing supply is very low, which means builders barely respond to rising prices with new construction. This is odd. Normally, suppliers should respond strongly to higher prices, which put more money in their pockets. In fact, the invisible hand of the free market depends on it.

The articles discuss several reasons builders have responded so weakly to higher prices. With respect to the recent situation specifically, one might initially blame it on rising construction costs, but the articles suggest this is not the primary explanation. Rather, they emphasize the role of regulations and zoning. Local land-use rules, approval processes, and other restrictions make it slow and costly to build, even when market prices suggest that building more housing should be profitable.

Another interesting finding from the research is that we don’t need to focus on building low-income housing to make housing affordable. If we build higher-end homes, people will move into them from less desirable homes, which will then become more affordable. The effect of building homes at the higher end of the market cascades down.

In short, we just need to get out of the way of the market.

So, the next time you hear complaints about high home prices or a shortage of low-income housing, remember the biggest obstacle is the rules we’ve chosen for ourselves. Deregulating housing construction, and thereby expanding supply, offers the clearest path to putting homeownership in reach for more Americans.

The post What’s Wrong with the Housing Market? appeared first on Show-Me Institute.

So how did charter schools perform during and after the pandemic? New research from Adam Kho, Shelby Smith, and Ron Zimmer, using student data from both charter and traditional public schools in Tennessee, suggests that they performed quite well.

Their analysis shows that during the 2020–21 school year, at the height of the pandemic, students in both charter and traditional public schools performed similarly—i.e., poorly. All schools were a mess during the pandemic. But in the two years that followed—the 2021–22 and 2022–23 school years—student learning in charter schools rebounded much more quickly than in traditional public schools.

To put these results in context, the authors note that charter schools were already outperforming traditional public schools in Tennessee prior to the pandemic. Given this, they interpret their post-pandemic results as follows: “in the first post-pandemic year . . . the [existing] charter school advantage . . . quickly resurfaced. In the second post-COVID year, the charter effect was even greater . . . suggesting that charter schools have been able to recover from pandemic-induced learning loss at a quicker and more substantial rate.” [emphasis added]

This evidence supports the idea that the less restrictive environment in which charter schools operate enables them to respond more effectively to challenging circumstances. The COVID pandemic was an extreme situation, but the same logic likely applies to the smaller, everyday challenges schools face.

The post Charters Have Outperformed Traditional Public Schools Post-Pandemic appeared first on Show-Me Institute.

The slow road to recovery is illustrated in the recently released preliminary results of the 2025 Missouri Assessment Program (MAP). The most recent data indicate modest improvements in mathematics, and average scores in at least some grades that are finally eclipsing pre-pandemic levels. However, the state’s stagnant reading scores continue to be a source of concern, as reading scores remain below their pre-pandemic levels in all tested grades.

Figure 1 summarizes MAP trends in the Show-Me State, including preliminary scores from the 2024–2025 school year:

Figure 1: Missouri Assessment Program (MAP) English/Language Arts Mean Scale Scores by Grade Level, 2018–2025

Source: Missouri Department of Elementary and Secondary Education

In Figure 1, the mean scale scores represent the student body’s performance as a whole. There are several important takeaways from this figure:

• Across all grades, Missouri’s reading scores have yet to return to pre-pandemic levels.
• Except for scores in the 3rd and 5th grades, reading scores are lower now than they were in 2020–21, when the pandemic was still strongly affecting in-person schooling.

Clearly, there is still work to be done.

Potential Solutions

This post is not meant to be doom and gloom—there is hope. States such as Indiana, Mississippi, Louisiana, and Tennessee have shown that student literacy can improve substantially with the right reforms.

These states have adopted early literacy policies that are effective, though sometimes unpopular: mandatory third-grade retention, eliminating three-cueing for teaching reading, and ensuring teacher preparation programs teach evidence-based reading practices.

Other states have proved that early literacy reforms can work. The 2026 legislative session is an opportunity to take meaningful steps toward improving educational outcomes in Missouri by taking reading reform more seriously.

The post Missouri’s Stagnant Reading Scores appeared first on Show-Me Institute.

Senate Bill (SB) 79 will (if Governor Kehoe signs it), among other things, expand the definition of “telehealth” or telemedicine to include audio-only and audiovisual services. On its face, SB 79 may not seem like the biggest or most impactful change, but it addresses a major problem with Missouri’s telemedicine laws that has been needlessly restricting access to care for years.

A few months ago, I wrote about several ways in which healthcare access for Missouri residents could be improved, and abandoning the requirement for video in cases where it isn’t medically necessary was one of the policies I highlighted. There are still large parts of Missouri without reliable broadband internet access, and not everyone has a phone or computer capable of transmitting video. Further, not every medical treatment requires a visual examination (for example, mental health services). Given our state’s well-documented shortage of healthcare providers, any effort to improve healthcare access without sacrificing safety or quality of care is welcome.

It’s easy to forget that back during the COVID-19 pandemic, Missouri ranked among the national leaders in telemedicine access. Various laws and regulations were waived for emergency response purposes, allowing patients to access their providers virtually with more ease than ever before. In turn, telemedicine grew tremendously in both functionality and popularity, among patients and providers alike—until the emergency ended and many of the unnecessary regulatory burdens telemedicine previously faced were allowed to return.

After several years of telemedicine reform nearly reaching but failing to cross the finish line, SB 79’s passage feels like a long time coming. As states across the country continue improving their licensing laws to expand healthcare supply and account for changing technology, Missouri could no longer afford to keep reform on hold. And while the bill doesn’t address all of the areas in which I think Missouri’s telemedicine laws could be improved, it does represent a small, important step in the right direction.

Going into next year, there is still plenty of work to be done to improve Missourian’s access to care. Hopefully, SB 79 is a signal that our lawmakers are dialing up more expansive healthcare reforms for 2026.

The post Missouri Finally Dials in Telemedicine Reform appeared first on Show-Me Institute.

This has, not surprisingly, led to a lot of citizen concern and pushback. In response to this, city government has gone in exactly the wrong direction and scaled back public comments at its council meetings. This is not how local government is supposed to operate.

I worked at the St. Louis County Council from 2001 through 2006. Most of the time, very few people showed up to give public comment. There were exceptions. Over the past few decades, several things have happened to change how local governments in Missouri (and probably everywhere) handle public comments in meetings. First, security concerns have increased for obvious reasons. Second, adding video and streaming to local meetings has encouraged some people to attend and play to the crowd while speaking. Finally, COVID really brought local government front and center to a lot of people (and not in a good way).

So some local governments have changed speaking policies after some public comment sessions got out of hand, like this one. Sedalia, however, has in my opinion gone too far (and I say that as someone who speaks before a lot of local councils).

Sedalia has limited all public comments to items on the agenda unless you have requested permission 48 hours beforehand to speak about something else. I don’t oppose a similar version of this idea, which St. Louis County and a few others have implemented, which is to place public comment on agenda items early in the meeting (where it should be, before officials vote on the issue) and save non-agenda items for the end (where officials can leave if they have to as their voting is over). I also don’t disagree with time limits on comments, though those limits should be flexible based on the number of speakers. (Sedalia’s three-minute time limit is not flexible.)

Being forced by Sedalia city government to beg permission to speak on other items of concern 48 hours ahead of time is deeply troubling. Here is a recent video of people being aggressively gaveled down at the end of a meeting for simply wanting to make public comment. (I know at least one of these people stated they requested permission more than 48 hours ahead of time, but apparently that request was “lost.”)

Local governments have a right to impose some limits on public comments at their meetings to manage an orderly process. Sedalia is going too far, however. Requiring 48-hour notice and pre-approval for speakers who simply want to address city issues that might not be on that night’s agenda is not good local government practice. Sedalia should change its rules.

The post Shutting Down Dissent in Sedalia appeared first on Show-Me Institute.

Missouri lawmakers are considering a change to the performance levels the state uses to categorize students based on end-of-year test scores. Currently, Missouri categorizes students into one of four performance levels. From lowest to highest, these are: (1) below basic, (2) basic, (3) proficient, and (4) advanced. I believe the meaning of these categories is self-evident, as it should be.

A proposed change in House Bill 607 would add a fifth performance level, called “grade level,” which would fall below the “proficient” category and above the “basic” category.

Wait, what? What does testing at a “proficient” level mean, if not testing at “grade level?” And how can a student test at grade level but not be proficient? Digging a little deeper, the bill defines a student as “proficient” if the student can: “Demonstrate mastery over all appropriate grade-level standards and has introductory-level knowledge for the next grade or level of education.” When I think of what the word “proficient” is intended to communicate, this sounds about right.

But what, then, does the new “grade level” category mean? According to the bill, it also means that the student: “Demonstrates mastery over appropriate grade-level subject matter.” However, it goes onto indicate that a grade level student: “May be ready, with appropriate reinforcement, for the next grade or level of education.” This means that a student could be classified as testing at grade level on end-of-year assessments, even if he or she is not fully ready for the next grade. This does not sound like “grade level” performance to me, and I suspect many Missourians would agree.

This matters for two reasons. First, in case you haven’t been paying attention to national education headlines recently, student learning has been declining for about a decade now, and the decline has accelerated since the COVID pandemic. Missouri is no exception to the national trend. In the face of disappointing academic outcomes, it is important to maintain clear and rigorous standards. We should continue to demand the best from Missouri children. This watered-down version of “grade level” performance seems like a step in the wrong direction, like an implicit acceptance of the fact that our children are learning less in school than their counterparts from a decade ago.

Second, consider when schools and districts report out to the public on student performance. With this new category, they’ll be able to report on the share of students who are performing at “grade level” or higher, but this will not mean what most people will think it means. If I hadn’t read the language of the bill myself, I certainly would not understand it. The definition of “grade level” in the bill, as quoted above, is more appropriately communicated by the term “basic,” which is already a performance category. I want our schools to report on student performance in a transparent manner, rather than obfuscating it.

At first glance, how the state chooses to report out on student test performance may not seem like a big deal. But the more I think about it, the more this bothers me. I cannot think of a single positive rationale for doing this. It is certainly not aspirational. I don’t think it is a stretch to call it dishonest.

I hope the lawmakers in Jefferson City reject this change in the interest of maintaining high standards for our children, and promoting transparency in Missouri government.

The post Legislating Lower Standards for Missouri’s Children? appeared first on Show-Me Institute.

In 2020, Kansas City became the first major U.S. city to eliminate bus fares entirely. At the time, city leaders leaned on a slapdash four-page “mini report” that promised an $11 million local GDP boost. To put it mildly, it was wrong.

Since then, ridership dropped, assaults on drivers went up, and the Kansas City Area Transportation Authority (KCATA) is now staring down a $10 million budget gap. The COVID money that kept KCATA afloat runs out next year. KCATA’s new leadership is asking to study whether fares should return. That’s where we are now: back at the beginning, but with less credibility and fewer resources.

The New York proposal has the same weaknesses. The author estimates a 23% increase in ridership, a 12% increase in speed and billions in economic gains—all for the low, low cost of $600 million in forgone fare revenue. But his math is speculative, his benefits are theoretical, and like in Kansas City, the costs are very real.

The problem isn’t just financial. Prices matter. Fares aren’t only about revenue—they’re also a tool to manage demand, discourage misuse, and incentivize better service. Eliminate them and you get overuse, fewer behavioral constraints, and more wear on already stretched systems. You also change the customer’s relationship with the service. When it’s free, expectations fall—for riders and for the agency.

Proponents talk about fairness. But there’s nothing fair about asking everyone to pay for a system that primarily serves a few. The better solution is targeted subsidies for those who need the help, which would preserve incentives, protect the system, and respect taxpayers.

Kansas City tried fare-free transit. It failed. New York doesn’t have to make the same mistake.

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In part two of this series, I briefly mentioned that in Missouri’s recent period of overwhelming Medicaid growth, the only eligibility category that had a reduction in enrollment is people with disabilities. Today, there are approximately 125,000 disabled Missourians enrolled in the Medicaid program, which is down 50,000 since its peak in 2023, down 25,000 since 2019, and is actually lower than at any point in the past 20 years (which is as far back as the data goes).

What could possibly explain this sudden shift? One explanation, as I referenced in part one, is that Missouri is still catching up on processing thousands of program eligibility redeterminations that were paused for several years during COVID-19. But the problem with that theory is that you wouldn’t expect many people with disabilities to lose Medicaid coverage once they qualify. They, unlike several other populations such as healthy adults or pregnant women, are less likely to only need coverage temporarily or just until they can get back to work. This is why I think it’s likely that disabled individuals are simply receiving their coverage through different means.

One way this could happen is through what I’ve called “PTD shifting,” which is something that I’ve been warning about since early 2020. PTD (permanent total disability) shifting was a key component of Medicaid expansion supporters’ claims that adopting the proposal would be costless for Missouri taxpayers. PTD shifting occurs when states exploit the way Medicaid is financed to shift a significant portion of disabled enrollees’ costs to the federal government. Given that people with disabilities often have a variety of complex medical issues, providing them health coverage can be very expensive, which in turn means that shifting these high costs to the federal government could save states a lot of money. The problem is that the federal government has explicitly stated numerous times that this practice is not allowed.

To be clear, I don’t have any definitive proof that Missouri’s Medicaid agency is doing anything wrong, but the latest program enrollment data should be raising some eyebrows. If my fears are confirmed, and Missouri is practicing PTD shifting, state taxpayers might soon be on the hook for an enormous Medicaid bill. This is because once the federal government discovers a state has been wrongfully receiving extra federal funds to support its Medicaid program, the feds could require state taxpayers to pay them back, which in this case could amount to hundreds of millions of dollars.

Needless to say, Missouri’s Medicaid program deserves a closer look from our state’s elected officials as soon as possible. The longer it takes to get to the bottom of what’s going on, the more difficult and expensive the fix is likely to be.

The post Medicaid’s Checkup: Part 3 appeared first on Show-Me Institute.

Once again, several bills have been filed that would drastically improve Missouri’s telemedicine laws. As I’ve written before, Missouri was one of the best places in the country for telemedicine a few short years ago. Patients and providers were given a plethora of options for how they communicated, which greatly expanded access to health services across Missouri. But after the emergency declaration for COVID-19 ended, Missouri reinstated a variety of measures that needlessly restrict telemedicine access.

According to a report from the Cicero Institute, Missouri’s telemedicine laws are lacking in three key areas. First, our state is not what Cicero calls “modality neutral.” What this means is that Missouri’s telemedicine laws don’t allow for several modes of communication that have shown to be successful in other states. At least one bill filed this year attempts to move our laws closer to modality neutral by allowing telemedicine services to be provided via audio-only (not video) technologies. This is something mental health providers are very interested in.

Second, Missouri restricts telemedicine access across state lines. If you’re in St. Louis and need a doctor, why shouldn’t you be able to see a provider over telemedicine who practices in Illinois? With so many Missourians struggling to find the healthcare they need, expanding telemedicine access to any licensed provider who’s willing to treat Missourians seems like it should be a no-brainer.

Finally, Missouri makes it unnecessarily difficult for providers to write prescriptions for their patients, especially if they’ve only ever seen them over telemedicine. The process is even more cumbersome if the provider is an advanced practice registered nurse (ARPN). Clarifying the prescribing process and making it easier for APRNs to treat patients via telemedicine should be a benefit to both patients and providers. Fortunately, there are several bills filed this year that tackle these issues.

It’s time for Missouri’s elected officials to recognize that it’s not 2019 anymore. Telemedicine has come an incredibly long way in recent years, yet Missouri’s laws still treat the service as if things are the same as they were pre-COVID-19. Hopefully, this is the year Missouri’s policymakers take notice and take the actions necessary to expand telemedicine access.

The post On Hold for Telemedicine appeared first on Show-Me Institute.

The 2024 results indicate that 4 in 10 Missouri 4th graders scored below the Basic level on the assessment. What does that mean? According to a researcher from the University of Virginia, “students performing below NAEP Basic level have less vocabulary knowledge and less world knowledge, which would limit their inferencing and comprehension capability.” Another researcher describes it thusly: “Below Basic on the NAEP means that a student is performing below the minimum expected level of academic achievement for their grade, indicating a lack of foundational skills and inability to demonstrate even basic mastery of the subject matter being assessed.”  The 42 percent of Missouri 4th graders who scored at below Basic last year are most likely now in the 5th grade trying to figure out what the heck their textbooks in any subject are trying to teach them.

Here is how the performance of Missouri 4th graders has changed over time.

This graph shows scale scores (NAEP is on a scale from 0 to 500). While Missouri was hovering just above the national average until 2017, we then began a steep slide that is barely leveling out.

But scores everywhere have declined because of COVID, right? Not so. In 2024, we outperformed just five states—Oregon, Alaska, New Mexico, Oklahoma and West Virginia. Here is the same chart for Mississippi.

Twenty six years ago, we outperformed Mississippi by 16 scale score points. Now, it’s ahead of us by seven.

What will Missouri look like in 15 years, when almost half of 25-year-olds are barely literate? We have a new governor and a new commissioner of education. Perhaps these questions should be put to them.

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