Geography, Demographics, Economy, Income

 

The context for delivery of health care services in Montana is first formed by understanding its vast size, and second by its small population. These factors are inverse to the realities of providing health care in most of the nation.  The population's racial composition is another characteristic that very few states share, with American Indians being the principal minority.  This overview starts with basic information on these elements and then provides additional details on factors impacting Title V MCHBG services.

 

Montana is the fourth largest state in size, at 145,546 square miles.  As of July 2023, Montana’s population was 1,132,812 – which averages to a population density of 7.8 people per square mile.  Figure 1. shows U.S. population density by county in 2020, with Montana outlined:

 

      Figure 1.

 

Thirty-three percent of Montana’s population lives in rural or frontier areas, characterized, in part, by limited access to health care in local communities.  The remainder are concentrated in only ten of the fifty-six counties (U.S. Census 2020).  Agriculture, tourism, logging, and natural resource extraction are major industries.  Economic growth is increasing in the high-tech sector; manufacturing; pulse crops such as chickpeas and lentils; and small business startups. The healthcare industry is Montana’s largest economic sector by employment. The growth in health care has been steady over the past decade and is expected to experience rapid job growth as Montana’s aging population requires more healthcare services. In 2023, the unemployment rate was 2.5%.

 

Montana’s racial make-up is predominately white, with a U.S. Census American Community Survey 2017-2021 estimate at 84.5% of the population.  American Indians make up the largest minority, at approximately 6.6% (see Table 1).  The ethnic Hispanic or Latino population is 4.2%, compared to 18.7% nationwide.

 

 

Montana’s seven American Indian reservations and the Little Shell Chippewa, a federally recognized landless tribe, are each unique in their demographics and cultures. The seven reservations are as follows:  Blackfeet, Crow, Flathead (Confederated Salish, Pend d’Oreille and Kootenai), Fort Belknap (Gros Ventre and Assiniboine), Fort Peck (Assiniboine and Sioux), Northern Cheyenne, and Rocky Boy’s (Chippewa and Cree).  For more information, see http://tribalnations.mt.gov.

 

State law recognizes a unique government-to-government relationship between the state government and the eight tribal governments.  According to the U.S. Census American Community Survey 2017-2021 estimate, American Indians equal 6.6% of Montana’s population, or approximately 67,612 in number, of which 59.5% live on tribal lands.  Information on culturally responsive delivery of maternal and child services is detailed in the Needs Assessment Summary.

 

The Little Shell Chippewa Tribe, which received federal recognition in December 2019, is without a reservation or land base. With approximately 5,400 members, there are population concentrations in numerous cities and towns across Montana and in other states. Many changes are expected during the next decade as federal recognition is implemented.  The legislation included an accommodation for the purchase of 200 acres.  The site currently hosts a tribal health clinic, which opened in April 2022. In the future, the site will include buildings for tribal government, and college-level and vocational instruction.

 

The following table compares some of the MCHBG demographic profile information for the geographic area of each reservation, using 2021 American Community Survey (ACS) 5-year estimates.  The median age for the whole state in 2021 was 40 years.

 

 

 

 

 

 

The 2021 ACS 5-year estimated average median household income in Montana was $60,560 compared to the U.S. total average of $69,021.  Under the same survey: Montana’s per capita income was $34,423, compared to the U.S. average of $37,638; 15.2% of MT’s children under age 18 were living below the federal poverty level compared to the US rate of 17%, and 17.7% of MT’s children under the age of 5, compared to the US rate of 18.5%.  Poverty rates vary greatly by county, from a high of 25.7% in Big Horn to a low of 7.5% in Jefferson.  This is shown in detail on the following map.

 

 

According to Montana’s Office of Public Instruction, the high school graduation rate in the 2022-2023 school year was 85.6%, and the overall dropout rate 2.65%. However, the graduation rate for the American Indian population over the same timeframe was 66%.  The ACS 2021 5-year estimate for ages 25-plus in Montana with a bachelor’s degree or higher was 35.7%, very similar to the U.S. rate of 35.4%.

 

Health Services Infrastructure

All of Montana’s counties are designated as medically underserved in at least one of the three disciplines: Primary Care, Mental Health, and Dental Health.  According to the 2021 Montana Behavioral Risk Factor Surveillance System (BRFSS) Annual Report, the prevalence of no personal health care provider among Montanans ages 18 and older was 19.1%, compared to the U.S. percentage of 16.0%.

 

Up until 2023, there were no medical schools in Montana.  However, there are now two medical schools in the state: a satellite campus of the for-profit Rocky Vista University College of Osteopathic Medicine in Billings accepted its first class of students in July 2023; and a non-profit school in Great Falls, anchored by the Touro College and University System opened in September.

 

Since 1971, Montana has been a part of a cooperative program between the University of Washington School of Medicine and the Montana University System. Known as the WWAMI Medical Education Program, it makes it possible for thirty Montana students per year to enter the University of Washington School of Medicine. The Montana students who are admitted to this program complete the first one and a half years of medical school at Montana State University and the final two and a half years at the University of Washington in Seattle, Washington. During their third and fourth years students work in hospitals and clinics rather than classrooms. Students in the WWAMI Program can take third and fourth year courses not only in the Seattle area but also in a number of other sites in the states of Washington, Wyoming, Alaska, Montana, and Idaho.

 

Montana’s Graduate Medical Education Council is currently sponsoring the following residency programs in the state:

Of Montana’s 56 counties, there are twelve with less than 2,000 residents and twenty-two with less than 5,000 residents. A county’s population is one variable for determining its Health Professional Shortage Area (HPSA) designation score for access to primary care, mental health, and dental health services. The Primary Care Office (PCO) annually reviews the 56 counties’ HPSA scores.  Currently, 51 are a mental health HPSA, 49 are a primary care HPSA, and 38 are a dental health HPSA, which indicates that the county experience challenges to access healthcare. 

 

Since 2013, the Oral Health Program has used Dental HPSA scores to determine the locations where University of Washington-School of Dentistry (UWSOD) students go to complete their dental rotations. During FFYs 2018-2023, the UWSOD blended their HRSA Grants to States to Support Oral Health Workforce Activities funding to support 61 student rotations in 17 HPSA sites. These students reported serving 2,844 patients, who received one or several of the 4,846 preventive oral health procedures.

 

Healthcare specialties may be available in more populous areas of the state, or out-of-state travel may be required to access appropriate care.  For example: a child living in Plentywood (the star on the following map) has an asthma attack and requires specialized medical attention. Their access options are to either drive 353 road miles or fly 220 aeronautical miles to the closest provider and level IV NICU in Billings.  The nearest FQHC is in Glendive, 137 miles away. The numbers on the map represent counties with less than 2,000 residents: from 496 in Petroleum (#1) to 1,959 in Liberty (#12).

 

 

Montana’s shortage of providers extends beyond rural areas into more populated settings, with no guarantee there will be a specialist to care for more complex needs. The Primary Care Office (PCO) reviews Conrad 30 J-1 visa waiver requests for foreign medical graduates willing to work in Health Professional Shortage Areas (HPSAs). In 2023,  the PCO recommended seven visa waivers for specialists. So far in 2024, the PCO has recommended four specialists practicing in endocrinology, obstetrics and gynecology, oncology, and neurology as well as three primary care providers practicing in internal medicine. All providers are serving in urban HPSAs in Great Falls and Billings.

 

Families in rural areas have many healthcare challenges, including distance to the closest medical care of any kind; specialist and healthcare facility locations; location of supplemental services; and, access to critical care.  They also have secondary considerations such as: are there any school-based services; what is the level of community and support services; is there any system of care for Children & Youth with Special Health Care Needs; what is the availability of telehealth services; is internet and cell phone coverage adequate; and, how built environment, which looks quite different in rural towns, impacts their family?

 

The following map shows the 2021 percentage of residents who have internet access by county for the state.  It ranges from a high of 87.6% in Gallatin, to a low of 63.7% in Meagher.

 

 

While Montana’s larger rural communities are served by hospitals, most of rural Montana is served by Critical Access Hospitals (CAH). According to the 2021 Montana Rural Health Plan, there are 66 licensed hospitals, of which 49 are designated as Critical Access Hospitals (CAH) which have a 25-bed limit, and even among those communities with CAHs there is great disparity in the services offered, and the depth of the medical delivery system.

 

Montanans can also access services at one of the 61 rural health clinics; four Short Term/Prospective Payment System (PPS) hospitals; one of the 15 Federally Qualified Health Centers and their Satellites, Seasonal and Migrant Clinics; American Indians are able to access care at their Reservation’s Indian Health Services and Tribal Health Departments, and at Urban Indian Health Centers located in Billings, Butte, Missoula, Helena, and Great Falls.

 

However, the following map shows the maldistribution of these services, and lack of options in the eastern third of the state:

 

 

School nurses are not mandated by Montana Law.  Montana has one of the highest school nurse to student ratios in the country: 1 school nurse to nearly 2,000 students.  Twenty-six of 56 counties have no school nurse at all, and 98% of Montana students have no registered professional school nurse or too few school nurses in their county.  Many school nurses serve more than one school and spend precious time travelling between campuses.

 

Montana is also subject to geographic disparities in the provision of ambulance services, with fewer than three ambulances covering every 1,000 square miles of land area.  According to the Montana Ambulance Association, the industry is experiencing funding gaps and workforce shortages, leading to ambulance service closures across the state.  Ambulance deserts are defined as places and people that are more than 25 minutes from an ambulance station.  This may be due to terrain and road conditions, as well as distance.  The following map shows the extent of the problem, with ambulance deserts showing in yellow (Federal Office of Rural Health Policy, 2023):

 

 

In FFY 2023, eighteen County Public Health Departments (CPHDs) that selected SPM 1 implemented activities for services that their nurses provided in local schools.  These helped to bridge gaps in care, such as: administering medication; vaccinations; hearing and vision screening; disease surveillance; and health education.  CPHDs also provide services such as immunizations, and family planning to county residents, as well as providing education and referrals to social services.

 

Detailed characteristics of Montana’s maternal and child population groups are described in the 2020 Statewide 5-Year MCH Needs Assessment Summary and 2024 Needs Assessment Update. This includes: health status; needs; and emerging issues and factors impacting service delivery. Seven priority areas were identified, listed here by population domain:

• Perinatal & Infant: Infant Mortality
• Children: Oral Health
• Adolescent: Bullying Prevention
• Women & Maternal: Annual Preventive Healthcare Visit
• Children and Youth with Special Health Care Needs: Medical Home
• Cross-Cutting & Systems Building: Access to Public Health Services
• Cross-Cutting & Systems Building: Family Support Services and Health Education

 

State Health Agency: Title V Maternal & Child Health Block Grant (MCHBG) Service Delivery

 

Montana’s MCHBG program is housed in the Department of Public Health & Human Services (DPHHS), the largest state agency in Montana.  DPHHS seeks to promote and protect the health, well-being, and self-sufficiency of all Montanans by offering programs to address Montanans’ needs for social services, medical, physical, and behavioral/mental health care.  Details on all services and programs can be found at: https://dphhs.mt.gov/. 

 

Montana is considered a “decentralized” system for providing public health services (https://www.cdc.gov/publichealthgateway/sitesgovernance/index.html), which are provided at the local level through the CPHDs.  DPHHS has contracts with all 56 CPHDs, and much of its funding is passed through to support their work.  Montana’s MCHBG Program provides leadership and direction to state, local, and non-governmental programs; and partners for issues affecting the health of the maternal and child population.  For example, by connecting state and national performance measure strategies with local efforts. 

 

In addition to the priority maternal and child health needs, several overarching issues pose unique challenges to health care delivery: the aging population; geographic disparities; and access to health care.  Some CPHDs are the sole source of certain maternal and child health care services, such as immunizations, for the surrounding population.  Montana’s MCHBG funding is directly supporting CPHDs in 51 counties in FFY 2024 and is critical to meeting the public health needs of the maternal and child population across the state.

 

Statutory authority for maternal and child health services is found in the Montana Code Annotated (MCA) Title 50, Health and Safety. General powers and duties of the state include administration of federal health programs delegated to the states; rule development for programs protecting the health of mothers and children; acceptance and expenditure of federal funds available for public health services; and use of local health department personnel to assist in the administration of laws relating to public health.  Montana's Initiative for the Abatement of Mortality in Infants (MIAMI) is authorized in MCA 50-19-401, and Fetal, Infant, Child and Maternal Mortality Review (FICMMR) is authorized in MCA 50-19-301.

 

Financing of Health Services

 

Montana’s MCHBG allocation to CPHDs is based on: the total numbers of women of childbearing age (15 to 44 years); infants and children ages 0 through 18; and the number of those individuals living in poverty.  The funds are allocated as required by Section 501 to 510 [42 U.S.C. 701 to 710]; and ARM 37.57.1001 governing the MCHBG. In FFY 2023, Montana received a total of $2,363,404.

 

Historically, based on the funding formula, the CPHDs have received 44% of the state’s total.  In FFY 2023, the counties received $996,000 in MCHBG funding to provide services to their county’s maternal and child population. Other expenditure categories were as follows: the CSHS section expended $776,628 providing services to Children & Youth with Special Health Care Needs (CYSHCN); $183,628 was spent on state-level administrative costs; and $410,214 was spent on state-level MCH programs.

 

DPHHS administers the Montana Medicaid Program (MMP) through several divisions including but not limited to: Human and Community Services Division for eligibility determination; Health Resources Division; and, Behavioral Health and Developmental Disabilities Division, authorized under 53-6-101, Montana Code Annotated (MCA), and Article XII, Section XII of the Montana Constitution.  The MMP complies with its state plan and waiver authorities, thus meeting the unique healthcare needs of Montanans. With multiple divisions focused on Medicaid services, DPHHS partners with various providers and stakeholders to address social determinants of health on many levels.

 

In 2015, MT’s biennial legislative body passed Senate Bill (SB) 405, Montana Health and Economic Livelihood Plan, which expanded Medicaid effective January 1, 2016. House Bill (HB) 658, the Medicaid Reform and Integrity Act, passed by the 2019 Legislature, continued SB 405 through June 2025. HB 658 included a work requirement, an 80-hour monthly work or community engagement requirement for the enrollee, which was planned to be effective January 2020.  The state submitted an 1115 waiver to CMS in August 2019; which was denied in 2021.

 

On March 31, 2023, the Medicaid waivers ended which were put into place during the COVID-19 pandemic to make sure people had Medicaid or CHIP coverage. States then began determining current eligibility for coverage. Beginning in April 2023, DPHHS is evaluated Medicaid and HMK members’ eligibility for continued coverage and renewed or terminated coverage as appropriate.

 

Montana Medicaid includes the following coverage groups that all have different eligibility requirements: Infants and Children including Newborn Coverage, Healthy Montana Kids Plus (Children’s Medicaid), Healthy Montana Kids (Children’s Health Insurance Program), Subsidized Adoptions, Subsidized Guardianship and Foster Care; Pregnant Women; Low Income Adults with a Severe Disabling Mental Illness (SDMI); Aged, Blind/Disabled and/or receiving Supplemental Security Income; Breast and Cervical Cancer Treatment; Medically Needy or Categorically Needy;  Low Income Montanans Including Medicaid and Medicaid Expansion and Montana Medicaid for Workers with Disabilities. 

 

As of February 2024, 31,775 adult women were enrolled in traditional Medicaid programs, and 43,552 in Medicaid Expansion. Additionally, 1,520 women were enrolled in Pregnant Women Medicaid. The number of pregnant women covered by other types of Medicaid cannot be pulled accurately because Medicaid is not aware of most other pregnancies until receiving the global pregnancy bill after the baby is delivered.

 

The 2023 Montana Legislature voted for a state budget that contained $6.2 million in state and federal funds over the next two years to extend continuous postpartum eligibility from 60 days to 12 months after pregnancy. That ensured coverage for between 1,000 and 2,000 additional parents in the state each year, according to federal and state estimates.

 

As of February 2024, there were 15,357 children enrolled in the Healthy Montana Kids (HMK) Children’s Health Insurance Program (CHIP), 85,862 children ages 0-20 enrolled in traditional Children’s Medicaid (HMK Plus), and 6,418 children ages 0-20 in HMK Plus Expansion.

 

In addition to public insurance options, private insurance also covers much of the population.  The ACA Federally Facilitated Marketplace enrollment for 2023 was 53,860.  Table 3. outlines sources of health insurance for Montana, as reported by the Montana Healthcare Foundation: