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 2021, Montana’s population was 1,104,271 – which averages to a population density of 7.59 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 2020 census 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.

 

 

American Indian Reservations

 

Montana’s seven American Indian reservations and the Little Shell Chippewa, a federally recognized landless tribe, are 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 2020 U.S. Census estimate, American Indians equal 6.2% of Montana’s population, or approximately 67,222 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 includes 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.  The median age for the whole state in 2020 was 40.1 years.

 

 

The 2020 American Community Survey (ACS) 5-year estimated average median household income in Montana was $56,539 compared to the U.S. total average of $64,994.  Under the same survey, Montana’s per capita income was $32,463, compared to the U.S. average of $35,384.

 

According to the Office of Public Instruction, the high school graduation rate in the 2020-2021 school year was 86.13%, compared to 85.9 the previous year.  Montana’s Office of Public Instruction reports the overall dropout rate in the 2020-2021 school year, for grades 9-12, was 3.75%. However, the rate for the American Indian population over the same timeframe was 5.87%.  The ACS 5-year average (2016-2020) for ages 25-plus for Montana with a bachelor’s degree or higher was 33.1%, compared to the U.S. rate in 2021 of 37.9%.

 

In 2020 , 15.2% of MT’s children under age 18 were living below the federal poverty level.  The same year, 17% of children under the age of 5 were living below 100% of the federal poverty level.  Poverty rates vary 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 2020 Montana BRFSS Annual Report, the prevalence of no personal health care provider among Montanans 18 and older was 27.3%, compared to the U.S. percentage of 22.4%. There are currently no medical schools in the state. However, there are plans for: a non-profit school in Great Falls, anchored by the Touro College and University System; and a satellite campus of the for-profit Rocky Vista University College of Osteopathic Medicine in Billings.  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 about 50% of the counties have 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. Of Montana’s 56 counties, the number of HPSAs for these three disciplines are: 45 for Primary Care; 50 for Mental Health; and 38 for Dental Health, which means residents in these counties have limited access to healthcare.  

 

Healthcare specialties may be in more populous areas of the state, or out-of-state travel may be required to access appropriate care.  Consider a child living in Plentywood Montana (the star on the following map). If they have an asthma attack and require specialized medical attention, they are 353 road miles and 220 aeronautical miles from the closest providers in Billings and the location of the closest level IV NICU.  The closest FQHC is in Glendive, which is 137 miles away. Even in more populated settings, it is not guaranteed there will be a specialist within a reasonable vicinity to care for a particular need. The numbers represent counties with less than 2,000 residents; from 496 in Petroleum (#1) to 1,959 in Liberty (#12).

 

 

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; the level of community and support services; the system of care for their CYSHCN; Availability of telehealth services; is internet and cell phone coverage adequate; and, how will built environment, which looks quite different in rural towns, impact their family?

 

Montanans have several options for accessing affordable healthcare services, which include Federally Qualified Health Centers and their Satellite Clinics; Seasonal and Migrant Clinics; Indian Health Services; and Tribal Health Departments. However, the map on the next page shows the maldistribution of these services, and lack of options in the eastern third of the state:

 

Montana Law does not mandate school nurses.  The most recent data, from 2018, indicated the school nurse to student ratio of 1 nurse to 1,517 students.   Many CPHD nurses also provide services in their local schools, which helps to bridge gaps in care, especially in counties with geographic HPSA designations.  These same nurses, also provide services such as immunizations and family planning to their community members. County Health Departments’ are also gap fillers for providing referrals to social services.

 

 

 

Detailed characteristics of Montana’s maternal and child population groups, with health status, needs, and emerging issues and factors impacting service delivery are described in the 2020 Statewide 5-Year MCH Needs Assessment Summary and 2022 Needs Assessment Update. 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 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 when it comes to public health (https://www.cdc.gov/publichealthgateway/sitesgovernance/index.html), 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 support CPHDs in 49 counties in FFY 2021 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 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 2021, Montana received a total of $2,281,008.

 

Historically, based on the funding formula, the CPHDs have received 45% of the state’s total.  In FFY 2021, the counties received $1,055,830 in Title V MCHBG funding to provide services to their county’s maternal and child population.   Other expenditure categories were as follows: the CSHS section expended $753,164 providing services to Children & Youth with Special Health Care Needs (CYSHCN); $228,100 was spent on state-level administrative costs; and $243,914 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; which was denied in 2021.

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 April 2022, 60,060 adult women were enrolled in Montana Medicaid Expansion, and 37,280 adult women were enrolled in all other (traditional) Medicaid programs. Additionally, 1,647 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 2022, there were 28,617 children enrolled in the Healthy Montana Kids (HMK) (CHIP) and the HMK Plus CHIP Expansion population, and there were 107,493 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 2021 was 44,711.  Table 3. outlines sources of health insurance for Montana, as reported by the Montana Healthcare Foundation:

 

Table 3: 2019 Estimates of Resident Population by Insurance Coverage Type for Montana
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%