Budget cuts in 2017 significantly impacted hyper-rural areas

Mental-health providers across Montana remember 2017 as the year the state's mental health-care system — careworn and fragile as Montanans' needs for services outstripped available resources — suffered a financial blow that devastated organizations in every corner of the state.

It's the year most state agencies big and small felt a monetary sting when more than $120 million was shaved from the state's general fund following the Montana Legislature's special session, in an effort avoid a budget deficit. And not least among those agencies was the state Department of Public Health and Human Services, which consumes a substantial portion of the state budget and therefore was dealt one of the most significant budgetary cuts, to the tune of nearly $50 million.

The $50 million slashing, enacted in November 2017, was the most substantial financial jab to the department that year, but was only the tip of the iceberg. Other cuts preceding those from the special session included a $12 million cut after the regular legislative session and about $18 million in cuts to Medicaid provider rates, case management workers and more.

By the time the dust from 2017 had settled, more than $95 million had been cut from the health department's budget — a depletion that would ripple through Montana's vulnerable mental health-care system in the years to follow.

Multiple clinics and nonprofits closed their doors or abated services, patients were displaced and forced to travel elsewhere for their mental-health needs, case managers were laid off and many organizations and private providers in rural areas saw a spike in caseloads.

Nearly three years later, providers are still picking up the pieces, working with other local mental-health professionals to meet the needs that existed prior to the cuts, but with fewer resources.

But to grasp the aftermath of such a financial hit, providers say one should travel to the more acute rural areas of Northwest Montana, where the issues surrounding mental health that are experienced in larger rural communities such as Kalispell, are magnified.

To better understand how the 2017 budget cuts impacted Northwest Montana's more isolated areas, the Daily Inter Lake traveled to Lake, Sanders and Lincoln counties, speaking with local residents, private behavioral health-care providers, community organizations, clinics and nonprofit entities regarding the past, present and future of mental health care in Montana's frontier.

According to the National Network of Libraries of Medicine, 45 of Montana's 56 counties are designated as “frontier counties,” which are described as being “the most remote and sparsely populated places along the rural-urban continuum.”

The federal government uses a code system known as FAR (frontier and remote) to determine how rural an area is, with level one being less rural and level four being hyper rural. Four levels are necessary because “rural areas experience degrees of remoteness at higher or lower population levels that affect access to different types of goods and services,” according to the United States Department of Agriculture Economic Research Service.

The most recent FAR data shows nearly 11% of Montana codes sit at a level four, which are described specifically as being a 15 minute drive or more from an urban area of 2,500 to 9,999 people, among other defining factors. That ranks the Big Sky state fifth for level four designations behind Alaska, North Dakota, South Dakota and Wyoming. On the opposite end of the scale, about 53% of the Montana population sits at a level one designation, the second-highest ranking behind Wyoming with about 57%. Based on FAR data, 100% of Montana has some level of rural designation, whereas other states, such as New Jersey and Maryland, have no areas that are designated by FAR as rural.

And often, Montana's frontier areas are also distinguished by poor social determinants of health, including low-paying jobs, more crime, high drug and alcohol abuse rates and lack of affordable housing. These challenge a community's ability to address its mental-health concerns and make it borderline impossible for any one entity to tackle the issue on its own.

AS DIRECTOR for Region 3 Western Montana Mental Health, it is Abby Harnett's duty to understand the unique personalities and mental-health needs in communities and the possible barriers to accommodating those needs in Sanders, Lake, Lincoln, Mineral and Flathead counties.

“If you want to know what rural mental health is, it's up here in our corner,” Harnett said. “We have a different and very unique set of challenges and we do live in some of those isolated areas of the state, there is no doubt about that.”

The counties Harnett oversees are among those that suffered the most from budget cuts after Western's executive leadership was forced to close down offices or make staffing and service cuts at others. The decision to close down offices all together, Harnett said, whether it be permanently or temporarily, was primarily spurred on by the hits to case management after provider reimbursement rates were reduced by about two-thirds.

Also referred to as social and human services assistants, case managers help patients navigate the medical system by connecting clients to different resources, building plans for treatment or recovery and working with other local entities. Case managers, which also deeply benefit organizations that focus on helping youth, older adults and people with disabilities, are especially important in frontier spaces where resources are already scant and collaboration between what agencies do exist is paramount.

When nickels and dimes could no longer stretch into dollars, Western closed down its Libby, Ronan, Livingston and Dillon locations. And in other parts of the state, the organization pulled back certain resources and altered services in places such as Butte in order to keep those areas afloat.

In Lincoln and Sanders counties alone, Harnett said 11 of Western's case managers were affected, all of whom looked after a large number of patients. Statewide, about 50 case manager positions with Western were eliminated.

“It was really difficult because we recognize and know that case management is such a vital part of the work we do, especially in community mental health,” Harnett said. “So we saw people fall through the cracks after that. It was heartbreaking, it was really, really difficult. Believe me, this decision was not an easy one.”

And the Western network, which for years has been the backbone for mental health and addiction counseling services in acute rural areas statewide, was only one of countless vital organizations impacted by the cuts.

In Kalispell, the Flathead Valley Chemical Dependency Clinic that served hundreds of valley residents at a time, dissolved after 40 years in operation. At the state capital, Helena Industries Inc. stopped providing services to hundreds with disabilities and laid off workers. Multiple public assistance offices, which are funded by the state health department and provide assistance to low-income individuals, closed as well. These are just a few among dozens of closings from financial pressure.

FOLLOWING THE many closures in frontier communities especially, Harnett explained that one of two things happened: either patients were left with no services at all in some of the smaller areas, or they went to other organizations for services.

In Libby, Western's closing displaced more than 200 patients. Some turned to the local Northwest Community Health Center, Cabinet Peaks Medical Center, Sunburst Mental Health Services, or private therapists for help. In Ronan, chemical-dependency and mental-health positions were eliminated and some employees were transferred to Polson. The clinic served clients from Elmo and Arlee to St. Ignatius and Pablo. After the shift, some clients found themselves at Sunburst in St. Ignatius and others transitioned to St. Luke's Community Healthcare in Ronan.

But such shifts presented immediate and obvious challenges in many communities.

The remaining licensed professionals — already with full patient lists of their own — began working longer hours. Hiring new qualified staff to work in such isolated areas at rates centers could afford became a waiting game. New clients inundated the offices of other providers, in some cases leading to wait lists 30 patients deep. And those experiencing a mental-health crisis who lacked a reliable vehicle or the funds to put gas in their tank to go elsewhere, sometimes found themselves waiting weeks to see someone.

“We have had to work early, work late, skip lunches, add days worked in a month,” said Sindy Filler, practice manager for the office of Randy Guinard LCSW, a Libby-based licensed therapy and counseling practice. “The people who do this kind of work, like Randy, are passionate about what they do and when someone calls and they are in crisis, it's really difficult to say no.”

Reporter Kianna Gardner may be reached at 758-4407 or kgardner@dailyinterlake.com