Geography, Demographics, Economy, Income
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 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 services.
Montana is the fourth largest state in size, at 145,546 square miles. As of July 2019, Montana’s population was 1,068,778 – which averages to a population density of 7.34 people per square mile. The following map (Figure 1.) shows U.S. population density by county in 2017, with Montana outlined:
Figure 1.
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. 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.
A Montana Department of Labor and Industry report, 2020 Hindsight: A Summary of Montana’s Economic Changes in 2020, indicated that in April 2020, the unemployment rate tripled from 3.8% to 11.9%, as businesses, schools, and childcare providers closed to help slow the spread of COVID-19. It was also reported that for the first two quarters in 2020, the state was deemed to be in a recession. However, in the 2020 third and fourth quarters, the economy was on a rebound as reflected in an unemployment rate of 3.6% as of May 2021, getting closer to the pre COVID-19 unemployment rate of 4.2% in Montana and 3.5% nationally This report is accessible at: https://stats.bls.gov/eag/eag.mt.htm
Montana’s racial make-up is predominately white, with a 2019 census estimate at 88.1% of the population. American Indians make up the largest minority, at approximately 6.7% (see Table 1). The ethnic Hispanic or Latino population is 4.1%, compared to 18.3% nationwide.
Table 1: Annual Estimates of Resident Population by Race for Montana, 2019 |
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Race |
Population Count |
Population Percent |
White |
940,423 |
88.1% |
American Indian |
67,603 |
6.7% |
Asian |
8,927 |
0.9% |
Black |
7,787 |
0.6% |
Native Hawaiian / Pacific Islander |
224 |
0.1% |
Two or More Races |
36,517 |
2.8% |
American Indian Reservations
Montana is home to seven American Indian reservations and the Little Shell Chippewa, a federally recognized landless tribe. State law recognizes a unique government-to-government relationship between the state government and the eight tribal governments. According to the 2019 U.S. Census estimate, American Indians equal 6.7% of Montana’s population, or approximately 71,608 in number, of which 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 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, 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 includes an accommodation for the purchase of 200 acres. The site will include buildings for tribal government, a health clinic, and college-level and vocational instruction.
Table 2 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 2018 American Community Survey (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.
According to the Office of Public Instruction, the high school graduation rate in the 2018-2019 school year was 87%, compared to the 2017-2018 national average of 88%. The ACS reports the average percentage of high school dropouts for ages 16 – 24, for 2013-2017, was 6.6, which 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%.
The 2019 ACS 5-Year estimate indicates that 15.8% of MT’s children under age 18 are below the federal poverty level. According to the 2019 census, the rate of poverty varies greatly by county, from a high of 31% in Glacier to a low of 4.8% in Daniels. This is shown in detail on the following map (Figure 2.).
Figure 2.
Health Services Infrastructure
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%. There are currently no medical schools in the state. The following map (Figure 3.), updated in April 2020, illustrates the Health Professional Shortage Areas (HPSA) for Primary Care:
Figure 3.
In addition to the inherent challenges Montanans face when attempting to access a primary health care provider, Montana Law does not mandate school nurses. Many CPHD nurses spend time each week providing services in their local schools. The nurses’ work in the schools helps to bridge gaps in care, especially in counties with geographic HPSA designations.
In 2018, data indicated a school nurse to student ratio of 1 RN school nurse to 1,517 students. This was 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 (Figure 4.).
Figure 4.
Detailed characteristics of Montana’s maternal and child population groups, with health status, needs, and emerging issues are described in the 2020 Statewide 5-Year MCH Needs Assessment Summary and 2021 Needs Assessment Update. Factors impacting Title V services delivery are also noted. Seven priority areas were identified, listed here 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
State Health Agency Title V Service Delivery
Montana’s Title V 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. Needs covered by programs include social services, medical, physical, and behavioral/mental. It is also the agency that manages Medicaid in the state. Details on all services and programs can be found at: https://dphhs.mt.gov/.
Montana is considered a “decentralized” system when it comes to public health, and most services are provided at the local level through the County Public Health Departments (CPHDs). DPHHS has contracts with all 56 CPHDs, and much of its funding is passed through to support their work. Montana’s Title V 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 Title V MCHBG funds directly supported 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.
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 (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.
Financing of Health Services
Montana’s Title V MCHBG allocation to county health departments 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. 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 CPHDs have received 45% of the total funding.
In FFY 2020, the counties received $1,068,465 in Title V MCHBG funding to provide services to their county’s maternal and child population. The CSHS section expended $709,762 providing services to Children & Youth with Special Health Care Needs (CYSHCN), $167,097 was spent on state-level administrative costs, and the remaining $336,499 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, Developmental Services Division including Children’s Mental Health, and the Addictive and Mental Disorders 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; and is awaiting the final decision.
Montana Medicaid includes the following coverage groups that all have different eligibility requirements: Infants and Children including Newborn Coverage, Healthy Montana Kids Plus, Healthy Montana Kids (CHIP), Subsidized Adoptions, Subsidized Guardianship, and Foster Care; Pregnant Women; Low Income Adults with an 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 June 2021, 53,177 adult women were enrolled in Montana Medicaid Expansion, and 86,408 were enrolled in all other (traditional) Medicaid programs. As of April 2021, 1,907 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.
As of April 2021, there were 28,038 children enrolled in the Healthy Montana Kids (HMK) (CHIP) and the HMK Plus CHIP Expansion population, and there were 112,177 children ages 0-20 enrolled in all other Medicaid programs.
In addition to public insurance options, private insurance also covers much of the population. The ACA Federally Facilitated Marketplace enrollment for 2020 was 43,822, and for 2021 was 44,711. Table 3. outlines sources of health insurance for Montana, according to the U.S. Census American Community Survey estimates for 2018:
Table 3: 2019 Estimates of Resident Population by Insurance Coverage Type for Montana |
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Insurance Coverage Type |
Population Count |
Population Percent |
Employer-Based |
416,046 |
39.49% |
Direct-Purchase |
86,037 |
8.17% |
Medicare |
70,352 |
6.68% |
Medicaid |
161,659 |
15.34% |
TRICARE / Military |
11,879 |
1.13% |
VA Care |
4,918 |
0.47% |
Two or More Types of Health Insurance |
215,614 |
20.46% |
No Health Insurance Coverage |
87,141 |
8.27% |
Total |
1,053,646 |
100.00% |
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