(NOTE: This report was originally written in 2015.  Updated information and statistics have been added according to availability, and/or significance of change.)

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 2017 census estimate at 89% of the population.  American Indians make up the largest minority, at approximately 6.5%.  The ethnic Hispanic or Latino population is only 3.6%, compared to 17.3% 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 2019, illustrates the Health Professional Shortage Areas for Primary Care:

The 2017 American Community Survey (ACS) 1-Year Estimate indicates that 17.5% of MT’s children under age 18 are below the federal poverty level.  The same ACS also shows the average poverty rate for all Montana families at 14.4%.  According to the 2010 census, the rate 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 2013 – 2017 ACS 5-year estimated average median household income in Montana was $50,801, compared to the U.S. total average of $57,652.  Under the same survey, Montana’s per capita income was $28,706, compared to the U.S. average of $31,177.  A positive economic indicator is an unemployment rate of 3.6% for April 2019, which is the same as the national rate.

According to the Office of Public Instruction’s Statewide Dropout and Graduate Report, the status of education in the state shows a high school graduation rate in 2015 of 86%, compared to the national average of 82%.  The overall high school dropout rate has improved from 4.3% in 2011 to 3.4% in 2015.  However, disparities exist in the American Indian population, with a 2015 high school graduation rate of 66.6% and dropout rate of 9.5%.  For bachelor’s degrees, the Census & Economic Information Center reports that Montana is about equal to the national average, at 29.3% for people 25 and older.

School nurses are not mandated by Montana Law, which contributes to one of the most negative school-nurse to student ratios in the country: 1 school nurse to 1,728 students.  Twenty-eight of 56 counties have no school nurse at all, and only 6% of students live in a school district that meets the national standard of 1 nurse to 750 students.  Many school nurses serve more than one school and spend precious time travelling between campuses. (Montana Association of School Nurses’ - The State of School Nursing in Montana, 2015.)

Due to a long history of natural resource extraction, Montana has 25 Superfund Sites on the National Priorities List (NPL).  A Superfund Site is any land that has been contaminated by hazardous waste and identified by the Environmental Protection Agency as a candidate for cleanup, because it poses a risk to either human health or the environment.

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).

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 following table compares some of the MCH 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 MCH 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 Montana Legislature passed a Medicaid expansion bill which was signed into law in April 2015, and extended in May 2019 with a work requirement.  Coverage began after federal approval and a contractor was secured to assist the state in administering the program. The state received federal approval of waivers needed for the unique provisions to help with job training and placement in October 2015. The law extends health care coverage, through Medicaid, to adults between the ages of 19-64 who earn incomes less than about $16,000/year for an individual and $28,000/year for a family of three. Initial adult enrollment by January of 2016 was 37,928.  Adult enrollment as of April 2019 was 95,246, or 9.2% of the state’s population.

Children in households below 250% of the Federal Poverty Level have had access to health care coverage through the Healthy Montana Kids program since 2008.  Behind the scenes it is still two programs, CHIP and Children’s Medicaid. However, families only have to complete one application. In October 2018, Montana had 129,478 children enrolled in coverage. This was an increase of 4,458 over the previous October. Separate enrollment figures are as follows: Children’s Medicaid at 105,773, and CHIP at 23,705.

The ACA Federally-Facilitated Marketplace enrollment for 2017 was 52,473, and for 2019 that number decreased to 45,374.  The table below outlines sources of health insurance for Montana, according to the U.S. Census American Community Survey estimates for 2008-2017:

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 2018, the counties expended $1,031,168 to provide services to their county’s maternal and child population.  The CSHS section expended $740,679 (31.18%) providing services to CYSHCN;  $132,414 (5.8%) was spent on administrative costs; and, the remaining was spent on state-level MCH programs.

The 2015 MCH Needs Assessment resulted in the establishment of ten priority areas.  The aging population, geographic realities, and access to care issues all pose unique challenges to health care delivery.  Some County Public Health Departments are the sole source of certain MCH health care services, such as immunizations, for the surrounding population.  Montana’s Title V funds will directly support County Public Health Departments (CPHDs) in 52 counties in FFY 2020, and are critical to meeting the public health needs of the MCH population across the state.