The Montana Gap
Livingston is one of the Montana towns that had to shift mental health services in response to state budget cuts.
The Montana Gap is a series of articles produced by several newspapers across the state in collaboration with the Solutions Journalism Network. The series reports on solutions to the mental health challenges facing rural Montana communities.
Previously: The story of a mentally ill Livingston woman, "Sarah," underscored the challenges Montana's mental health system faces as community-level providers are rocked by political battles over public spending. Now: How two of Montana's most recent budget fights have swung the state toward more health spending - and away from it again.
A pair of sweeping changes have rocked Montana's healthcare system, including mental health services, over the past two-and-a-half years - first state-level Medicaid expansion in 2016 and then a round of major budget cuts that have come into effect in 2018.
The Medicaid expansion came first, boosting spending. As part of the 2010 Affordable Care Act, or Obamacare, states were given the option of expanding their Medicaid programs, accepting more federal money to provide more residents with coverage. Despite vocal opposition from fiscal conservatives, Montana lawmakers voted in 2015 to adopt expansion through the Montana HELP Act.
Health advocates and state officials point to the expansion - facing a renewal fight in the next year - as a seminal moment for the state's healthcare system, including programs aimed at treating addiction and mental illness. Officials say the federal dollars that expansion injects into the system make it possible for thousands of lower-income Montanans to afford services like counseling or treatment for substance use disorder.
Crucially, said Zoe Barnard, the state's top mental health administrator, the expansion gave the state mental health division breathing room to direct more money to preventative programs. She said prevention had been neglected in the past in favor of must-fund crisis services like providing severely mentally ill people with medication.
For example, the Medicaid expansion funneled $7.7 million into chemical dependency programs for people with drug or alcohol addictions in 2017, funding care for almost 3,000 patients, according to figures provided by DPHHS. It also provided $3.5 million to help 5,300 Montanans receive counseling - something Barnard said makes it easier for people to get help for mental illness before their condition gets so severe they end up in an emergency room.
"That should pay dividends for the state into the future, not on a biennial kind of schedule but on a generational kind of scale," Barnard said.
Over the last year, health advocates' efforts to tout the benefits of expansion ran headlong into another set of headlines: providers and patients protesting what they called crippling budget cuts to community care. Those reduction came as tax collections fell below projections and an expensive 2017 fire season drew down the state's reserves.
Implementing cuts ordered by the Legislature, the health officials lowered the reimbursement rates providers get through Medicaid, cutting compensation for most services provided through mental health centers like Western Montana Mental Health by three percent. The hourly rate for case management work, which legislators singled out, was reduced from $72.88 to $32.76.
Barnard said the state health department can't estimate how much those cuts will reduce state mental health spending because it's tricky to predict how lowering rates will shift the services independent providers bill for. In any case, newer revenue projections raise the prospect that the state may actually bring in the money to reverse some of its cuts.
What is clear, though, is that the cuts have rocked the Medicaid-dependent system. Western Montana Mental Health, for example, closed offices in Libby and Dillon and also shut down its Livingston Mental Health Center, where Sarah was getting care, at the end of April. The system's Bozeman branch Gallatin Mental Health worked with local organizations to transfer patients losing services.
"At the end of the day, we cannot continue at the rates provided to us and make it work," Gallatin Mental Health director Michael Foust said as he announced Western Montana's Livingston location would close.
Up next: Part 3: 'What is the strategy?'
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