Overview of the State

The context for delivery of health care services in Montana is first formed by understanding its vast size, and secondly by its small population. These factors are inverse to the realities of providing health care in most of the nation.  The racial composition of the population is another characteristic which 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 services.

Montana is the fourth largest state in size, at 145,546 square miles.  It is larger than Germany, and the ten smallest-sized states combined do not have as much area.  Conversely, the city of Dallas, Texas has a significantly higher population.

Western Montana is mountainous and heavily forested, while the eastern two-thirds are semi-arid rolling plains.  More than half of the population lives in rural or frontier areas, characterized, in part, by limited access to health care in local communities.  Agriculture, tourism, logging and natural resource extraction are major industries.

The definition of a Level 1 Frontier and Remote Area is that residents must have to travel at least 60 minutes to reach an urban area of 50,000 or more people. Although 52 percent of the land area of the United States is in these areas, only 4 percent of Americans live there. The map below shows the nationwide context of these areas by zip code:

Montana’s racial make-up is predominately white, with a 2019 census estimate at 89% of the population.  American Indians make up the largest minority, at approximately 6.6%.  The ethnic Hispanic or Latino population is only 4%, compared to 18.3% nationwide.

All of Montana’s counties are designated as medically underserved in some way.  According to the 2016 Montana BRFSS Annual Report, the prevalence of no personal health care provider was 26.4%, compared to the U.S. percentage of 21.9%. The following map, updated in April 2020, illustrates the Health Professional Shortage Areas for Primary Care:

The 2018 American Community Survey (ACS) 5-Year Estimate indicates that 16.4% of MT’s children under age 18 are below the federal poverty level.  The same ACS also shows the average poverty rate for householders with related children under the age of 5 is 19.1%.  According to the 2010 census, the rate of poverty varies greatly by county, from a high of 25.9% in Big Horn to a low of 9.5% in Fallon.  This is shown in detail on the following map:

The 2018 ACS 5-year estimated average median household income in Montana was $52,559 compared to the U.S. total average of $60,293.  Under the same survey, Montana’s per capita income was $29,765, compared to the U.S. average of $32,621. The pre-COVID-19 unemployment rate was 4.2% in February 2020, while the U.S. rate was 3.5%.

According to the Office of Public Instruction, the high school graduation rate in 2018-2019 school year was 87%, compared to the 2017-2018 national average of 88%.  The American Community Survey reports the average percent of high school dropouts for ages 16 – 24, for 2013-2017, was 6.6%.  This was close to the U.S. average of 6%. However, significant disparities existed for the American Indian population, at 18.5%.  For bachelor’s degrees, the U.S. Census reports the 2014-2018 5-year average for ages 25-plus for Montana was 31.2%, which is very close to the U.S. average of 31.5.

School nurses are not mandated by Montana Law. In 2018, data indicates a school nurse to student ratio of 1 RN school nurse to 1,517 students. This is an improvement from 2015, when the ratio in Montana was 1 RN school nurse to 1,728 students. Unfortunately, at this time, 45% of Montana’s 56 counties have no school nursing services thus, 96% of Montana students have no RN school nurse or have too few school nurses in their county and 29% of Montana students have no school nurse in their entire school district.

Due to a long history of natural resource extraction, Montana has 25 Superfund Sites on the National Priorities List (NPL).  The Montana Department of Environmental Quality oversees the remediation work.  Details are available at:  https://deq.mt.gov/Land/fedsuperfund.

In 2014, the Bakken Oil Field boom continued to place a major strain on infrastructure systems in eastern Montana.  Especially hard hit were towns within the impact area, as they received very little tax money from oil production.  The pace of explosive growth has now slowed, leaving government services to struggle with the typical effects of a “boom and bust” cycle. 

The level of activity is tied to the price of oil, which went from $105.79 per barrel in June 2014, to $30.32 per barrel in February 2016, to a May 2019 price of $68.94 (U.S. Energy Information Administration Data).  County revenue collections, which support schools, were down 57% in 2016 (MT Legislative Fiscal Division).  As of June 2020, that price is down to $35.49.

Montana is home to seven American Indian reservations, and one state recognized landless tribe, (Little Shell Chippewa.)  State law recognizes that there is a unique government-to-government relationship between state government and the eight tribal governments in Montana.  According to the 2013 – 2017 ACS, American Indians equal 6.5% of Montana’s population, or approximately 66,865 in number.  Of those, 59.5% live on tribal lands.  Information on culturally competent delivery of maternal and child services is detailed in the Needs Assessment Summary.

Each reservation is unique in demographics, and in the cultures of each tribe.  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.

The Little Shell Chippewa Tribe is without a reservation or land base. The tribe only recently received federal recognition, in December 2019.  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 includes an accommodation for the purchase of 200 acres.  The site will likely include buildings for tribal government, a health clinic, and college-level and vocational instruction.

The following table compares some of the MCHBG demographic profile information for the geographic area of each reservation.  The median age for the whole state is 39.8 years.

The principal characteristics of Montana’s maternal and child population groups, with health status, needs and emerging issues, are detailed in the Needs Assessment Summary.  Priorities are also specified, as well as the competing factors impacting Title V services delivery.

The 2015 legislature passed the Montana Health and Economic Livelihood Plan (HELP),which expanded Medicaid to adults up to age 64 earning up to 138% of the federal poverty level (FPL).  Coverage was effective January 2016 and was scheduled to end on June 30, 2019.  The 2019 Legislature passed HB 658, the Medicaid Reform and Integrity Act, that continued Montana's Medicaid expansion program for another six years, as long as federal funding continues. 

HB 658 adds an 80-hour monthly work or community engagement requirement for enrollees.  As of February 2020, 81,864 adults were enrolled – which is 7.8% of the state population. 

The plan is open to individuals who earn less than $16,000 a year (the amount, however, adjusts based on household size, i.e., $33,000 for a family of four), most of whom work in businesses that traditionally do not offer heath care coverage. It includes premiums and co-pays (not to be more than 5% of an individual’s income total), personal asset limits, increases Medicaid claim reimbursements; and includes a $2.5 million workforce development component. 

Since 2009, children up to age 19, living below 250% of the federal poverty level, have been eligible for Healthy Montana Kids (Children’s Medicaid and CHIP).  As of December 2019, enrollment was 119,030.

The ACA Federally-Facilitated Marketplace enrollment for 2019 was 45,374, and for 2020 that number decreased to 43,822.  The table below outlines sources of health insurance for Montana, according to the U.S. Census American Community Survey estimates for 2018:

Statutory authority for maternal and child health services are 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 (including programs for nutrition, family planning services, improved pregnancy outcomes, Title X, and Title V); 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.

Montana’s Title V Program provides leadership and direction to state and local programs and partners for issues affecting the health of the MCH population.  Montana’s Title V/MCHBG allocation to county health departments is based on the total numbers of women of child bearing age (15 to 44 years); infants and children ages 0 through 18; and individuals aged 0 to 44 living in poverty. 

Montana’s Title V/MCHBG 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. Historically, based on this funding formula, the County Public Health Departments have received 45% of the total funding.  In FFY 2019, the counties expended $1,032,464 to provide services to their county’s maternal and child population.   The CSHS section expended $691,995 (30.09%) providing services to CYSHCN;  $123,933 (5.39%) was spent on administrative costs; and, the remaining was spent on state-level MCH programs.

The 2020 Statewide 5-Year MCH Needs Assessment has identified seven priority areas, by population domain:

• Perinatal & Infant: Infant Mortality
• Children: Oral Health
• Adolescent: Bullying
• Women & Maternal: Annual Preventive Healthcare Visit
• Children 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

In addition to the priority maternal and child health needs, there are several overarching issues which pose unique challenges to health care delivery: the aging population; geographic realities; and, access to health care.  Some County Public Health Departments are the sole source of certain maternal and child health care services, such as immunizations, for the surrounding population.  Montana’s Title V funds are directly supporting County Public Health Departments (CPHDs) in 52 counties in FFY 2020, and are critical to meeting the public health needs of the maternal and child population across the state.