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 MCHBG services.

Montana is the fourth largest state in size, at 145,546 square miles.  As of July 2022, Montana’s population was 1,122,867 – which averages to a population density of 7.7 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 the first two quarters in 2020, the state was deemed to be in a recession due to the effects of COVID-19.  However, by March of 2022 the unemployment rate fell to a low of 2.3%.

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 6.2% (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 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 competent 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.

Table 2 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 2020-2021 school year was 86.13%, and the overall dropout rate 3.75%. However, the dropout rate for the American Indian population over the same timeframe was 8%.  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, now there are two medical schools opening in the state: a satellite campus of the for-profit Rocky Vista University College of Osteopathic Medicine in Billings will accept its first class of students in July 2023; and a non-profit school in Great Falls, anchored by the Touro College and University System opening in the Fall.

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 location of the University of Washington-School of Dentistry (UWSOD) 4th year students to complete their dental rotation. During FFYs 2018-2022, the UWSOD blended their HRSA Grants to States to Support Oral Health Workforce Activities funding to support 51 student rotations in 17 HPSA sites. These students reported 2,607 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 only 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).