And with the State Budget Offices' prediction of a $1 billion shortfall for next fiscal year, things don't look like they are going to get any better.
But they could get worse.
Cates described the Missouri Department of Health and Senior Services as a "silent service" because when his department is doing well, nobody notices.
"If you woke up today and had safe water, safe food and did not get a communicable disease, thank the Department of Health," Cates said during his visit Monday in New Madrid.
DHSS does not serve a group of constituents, according to Cates, but is accountable for all the citizens in Missouri "from preconception to post-death."
Cates said the Department of Health and Senior Services is charged by law with a list of duties including safeguarding the health of Missouri's people; monitoring adverse health effects of the environment and reporting on them to elected officials; developing comprehensive disease prevention plans; licensing and certifying hospitals and other health care providers; implementing higher education through student loan programs; keeping vital statistics and other records; assisting children with special health needs; and assisting the elderly and low-income adults with disabilities secure and maintain economic independence and dignity among others.
Additionally, his department is faced with costs such as responding to imminent health threats such as anthrax, SARS and monkey pox. "We're already, every day, doing this," he said.
Over the last couple of years, however, funding for public health has dropped while funding for senior citizens is flat. "Nobody's going to cut a senior program," Cates said, explaining senior citizens lobby heavily for their issues while public health "had no local advocacy...It appeared to be an easy target to make these reductions."
Cates said 70.4 percent of the DHSS's money is federal dollars earmarked for specific purposes.
Along with a budget-trimming retirement bill limiting replacements, general revenue cuts by the state have resulted in 239 DHSS positions being eliminated.
Services eliminated or reduced to balance the budget have resulted in 50,000 fewer patients treated at regional health centers and 10 fewer dental loan students each year in a state already short on dentists.
DHSS actions taken to meet the budget challenge include outsourcing programs and eliminating services such as issuing marriage records and collecting hospital survey data as well as a reduction in the number of the department's divisions, centers and offices by consolidating functions.
Middle management positions have been eliminated, and the department has cut back on everyday expenses and even eliminated training for staff.
While training was cut to preserve front line services, Cates said staying current through training is important because "what was good 20 years ago is not good now."
While funding shrinks, his department's concerns are growing.
"We have a major problem in Missouri with sexually transmitted diseases," Cates said.
Another concern for the department is health care access in medical manpower shortage areas because facilities do not necessarily mean equal access. "We're deeply concerned about local public health entities," he said.
Cates said the department is also concerned about its ability to protect Missouri citizens from threats such as SARS, Monkey Pox, West Nile Virus and influenza as well as diseases most people think are just history now.
Tuberculosis "came back as a major, major health problem," Cates said, and health care professionals are now seeing drug-resistant strains of TB.
With modern travel, a disease anywhere in the world is only 24 hours away. "Everything moves, everything travels," Cates said.
People with concern about program cuts should contact their legislators who must make the tough funding decisions. "It's not in our authority to put it in or take it out," Cates said of department personnel.