The money is part of the approximately $50 billion that states and local governments will receive nationwide in opioid settlement funds over nearly two decades. The payments come from more than a dozen companies that made, distributed, or sold prescription opioid painkillers that were sued for their role in fueling the overdose epidemic.

Many places have begun deciding where that money will go and making payments to schools, public health departments, and local governments. South Carolina, for example, has awarded more than $7 million to 21 grantees. Wisconsin has posted two years’ worth of spending plans that total nearly $40 million.

Montana, West Virginia, and Hawaii are among the states moving slower.

Montana began receiving its first settlement payments in January, and, by fall, payments totaled roughly $13 million. As of early December, the Montana Opioid Abatement Trust — a private nonprofit created to oversee 70% of the state’s share — had met once to agree to its rules of operation, and its money remained locked behind an inactive grant portal. The remainder, divided among the state and local governments, either hadn’t been spent or wasn’t publicly recorded.

Those charged with distributing the money say they’re building a framework to spend it in ways that last. Meanwhile, some addiction treatment providers are eager to use the funds to plug gaps in services.

The tension in Montana reflects a nationwide push-pull. Those handling settlement dollars say governments should take their time planning how to use the enormous windfall. Others argue for urgency as the drug supply has become increasingly deadly. More than 100,000 Americans died of overdoses in 2022, surpassing the previous year’s record-setting death toll.

Nearly 200 Montanans died of a drug overdose in 2021, the latest year state data is available. That number, likely an undercount, is roughly 40 more deaths than the year before. Emergency medical responders have continued to record an increasing number of opioid-related emergencies this year.

In Billings, the Rimrock Foundation, one of the state’s largest behavioral health providers, has seen its number of clients with opioid use dependency more than triple since 2021. Like other treatment facilities, Rimrock has a waitlist, and addiction treatment providers worry about the limited community resources that exist for patients once they are discharged. “The result of not addressing this is a lot of deaths,” said Jennifer Verhasselt, Rimrock Foundation’s chief clinical officer.

Debbie Knutson, Rimrock’s medical unit and nursing supervisor, said there is widespread confusion about how and when the state’s settlement dollars can be used.

“It’s very concerning if we have money available that we could use to help people that is just kind of sitting, waiting for somebody to decide where it should go,” Knutson said.

Rusty Gackle, the Montana Opioid Abatement Trust executive director, said a lot of work has happened behind the scenes to get local governments ready to accept their initial payments and for regional leaders to form systems to request money from the trust. That included hosting a series of town hall-style meetings to share information about the process. He said many of those local regions are still finalizing their governance structures.

“I would love to progress a little bit faster,” Gackle said. “But I’d rather do it right so that we’re not having to go backwards.”

Montana officials got a late start too, he added. Some states began receiving settlement dollars last year, but Montana was toward the tail end of the line.

Montana is dividing its money three ways: 15% to the state, 15% to local governments, and the rest to the Montana Opioid Abatement Trust, with some money set aside for attorneys’ fees.

As of late November, the state hadn’t begun spending the $2.4 million it had in hand for state agencies. Officials also aren’t tracking how and when local governments spend their direct payments.

Similarly, West Virginia and Hawaii hadn’t — by late November — begun spending the largest shares of their funding. In West Virginia, the makeup of the foundation board that will oversee roughly 70% of the state’s settlement dollars was announced only in August, six weeks after the state’s deadline, and the board is now sitting on more than $217 million.

Nationwide, state and local governments have received more than $4.3 billion as of Nov. 9. How much of that has been used remains uncertain due to states’ lack of public reporting. But from what is known, it varies.

Colorado, whose spending plan is similar to Montana’s but received its settlement money earlier, has allocated millions toward school and community-based programs, recovery housing services, and expanded treatment services.

Sara Whaley, a Johns Hopkins researcher who tracks states’ uses of opioid settlement funds, said a slower start isn’t inherently wrong. She prefers governments take time to spend the money well rather than fund outdated or untested practices. In some cases, governments are building entirely new systems to dole out the money. Several waited until the courts finalized the settlement amounts and details.

“There are definitely states that were like, ‘We are going to get money at some point. We don’t know how much or when, but let’s start setting up our system,’” Whaley said. “Other folks were like, ‘We have a lot going on already. We’ll just wait until we get it and then we’ll know what the settlement terms are.’”

Even once committees start meeting, it can take months for the money to reach front-line organizations.

Connecticut’s opioid settlement advisory committee made its first allocation in November, eight months after it was formed. Maine’s recovery council, which controls half the state’s settlement funds, has been meeting since November 2022, but just recently voted on priorities for the more than $14 million it has on hand and still needs to establish a grant application process.

Tennessee’s Opioid Abatement Council accepted grant applications this fall. Stephen Loyd, council chair, said the process — from picking awardees to processing payments — will take roughly six months. Within that time, he said, 2,808 Tennesseans are likely to die of drug overdoses.

As an interim step, Loyd proposed at an October meeting to award $7.5 million to an emergency six-month initiative to flood the state with naloxone, a medication that reverses opioid overdoses.

But his proposal was met with protests from council members, who pushed back on what they saw as a circumvention of the grant process they had spent months establishing. The council didn’t vote on the emergency initiative but instead created an expedited review process to consider fast-tracking future applications.

Gackle said he doesn’t think Montana is far behind others. Now that spending systems are almost in place, he said, things should move faster.

Lewis and Clark County, home to the state capital, Helena, has a yearlong plan and budget for opioid settlement funds. A cohort of 17 counties in rural eastern Montana defined its regional settlement decision-makers in November and, by early December, had yet to begin official talks about where the money should go.

Brenda Kneeland, CEO of Eastern Montana Community Mental Health Center and an advisory committee member for the Montana Opioid Abatement Trust, said eastern Montana has one inpatient treatment center for substance use disorders and zero detox facilities, so emergency rooms end up serving as a fallback resource.

Kneeland said local officials want to ensure they understand the rules to avoid trouble later and to stretch the funding.

“You don’t get an opportunity to try to correct such a wrong very often,” Kneeland said. “It’s just a huge job at a county level. I’ve never seen an undertaking like this in my career.”

The Montana Opioid Abatement Trust advisory committee will meet quarterly, meaning its next chance to review any submitted grants will be next spring.

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En dos ocasiones, intentó usar la línea de ayuda de Montana para completar una entrevista requerida para recertificar sus beneficios del Programa de Asistencia Nutricional Suplementaria (SNAP, conocido antes como Food Stamps o estampillas de alimentos). Cada vez, la llamada se cortó después de más de una hora en espera.

“Estaba lista para llorar”, dijo Brost, parada en la larga fila, esperando que la oficina abriera en una mañana reciente de noviembre. “Tengo a un niño de 13 años que está hambriento”.

Las familias de bajos ingresos que necesitan servicios como ayuda alimentaria y dinero en efectivo, se han convertido en daños colaterales en la carrera burocrática para determinar si decenas de millones de personas aún califican para Medicaid. Esto después que finalizara en la primavera el período de gracia durante la pandemia, en el que se prohibió anular inscripciones.

Estas son personas cuyas solicitudes y formularios de renovación se han retrasado o perdido, o que, como Brost, no pueden comunicarse con los abrumados trabajadores del centro de llamadas del gobierno.

El impacto para las familias de bajos ingresos es una consecuencia que el proceso para expulsar a beneficiarios de Medicaid pasó por alto. Desde abril, millones han perdido la cobertura, y millones más están en camino de perderla.

“Este desmantelamiento de Medicaid ha creado enormes problemas para el personal administrativo”, dijo Leighton Ku, director del Centro de Investigación de Políticas de Salud en la Escuela de Salud Pública Milken de la Universidad George Washington.

La mayoría de los estados dependen de los mismos trabajadores y sistemas informáticos para analizar la elegibilidad para Medicaid y SNAP, según el Centro de Prioridades y Políticas Presupuestarias.

La dificultad para inscribirse en otros beneficios de asistencia públicos varía, dependiendo de cómo cada estado configure sus programas y cuán bien estén dotadas las agencias para manejar el trabajo adicional causado por las recalificaciones de Medicaid.

Históricamente, las personas que buscan ayuda pública han enfrentado largos períodos de espera en los centros de llamadas y opciones limitadas de apoyo en persona. Estos problemas de larga data se han agravado a medida que un número récord de beneficiarios de Medicaid buscan asistencia con la inscripción.

Por ejemplo, abogados y organizaciones que ayudan a los que solicitan beneficios de alimentos en Montana, Missouri y Virginia, dijeron que las solicitudes han desaparecido sin respuesta, y a menudo los trabajadores que determinan la elegibilidad no responden.

“Nuestros clientes ya están viviendo al límite, y esto simplemente los puede terminar de demoler”, dijo Megan Dishong, directora adjunta de la Asociación de Servicios Legales de Montana.

La inscripción en el programa SNAP es aproximadamente la mitad que la de Medicaid. En abril, casi 42 millones de estadounidenses recibieron asistencia alimentaria, en comparación con los 87.4 millones inscritos en el programa de salud.

SNAP en sí ha experimentado cambios importantes este año; una norma que aumentó los beneficios durante la pandemia expiró y se reinstauraron los requisitos de trabajo. Según los datos federales más recientes, la inscripción disminuyó en 1 millón de enero a agosto, mucho menos que la disminución en la inscripción de Medicaid que comenzó en abril.

Sin embargo, las fuentes oficiales de datos no capturan los retrasos y otras dificultades que enfrentan las personas para obtener beneficios.

En Virginia, donde las oficinas locales del Departamento de Servicios Sociales del estado manejan las solicitudes de Medicaid y SNAP, “he tenido varios clientes que han presentado solicitudes y simplemente se han perdido”, dijo Majesta-Doré Legnini, de Equal Justice Works en el Legal Aid Justice Center que trabaja en temas de SNAP.

Un cliente que solicitó ayuda por primera vez no recibió noticias durante tres meses y tuvo que volver a presentar la solicitud. Otro obtuvo beneficios después de dos meses y medio, luego de haber sufrido retrasos en el procesamiento de la solicitud, una carta de denegación y una apelación.

Una familia con estatus migratorio mixto, donde los niños calificaban para recibir beneficios, no los obtuvo por ocho meses, después que fueran expulsados erróneamente del programa y experimentaran retrasos después de volver a presentar la solicitud.

Virginia debería procesar cada solicitud en un plazo de 30 días. “La mayoría de mis clientes tienen niños menores de 15 años”, dijo Legnini, “y muchos dicen que tienen problemas para conseguir suficiente comida para alimentar a sus hijos”.

En Missouri, una demanda federal presentada antes que comenzara el proceso de expulsiones de Medicaid alega que un sistema disfuncional impide que los residentes de bajos ingresos obtengan ayuda alimentaria. A más de la mitad de los solicitantes del estado se les denegó ayuda en julio porque no pudieron completar una entrevista, no porque no fueran elegibles, según un documento presentado en el caso.

Ahora, con Missouri reevaluando la inscripción de Medicaid de más de 1 millón de beneficiarios, defensores dicen que esas fallas sistémicas se han convertido en una grave crisis para los más vulnerables.

Por su parte, oficiales de Montana han dicho que el proceso de revisar la elegibilidad se suma a un sistema ya problemático.

En septiembre, Charlie Brereton, director del Departamento de Salud Pública y Servicios Humanos de Montana, informó a los legisladores que el estado estaba trabajando para mejorar su línea de ayuda de asistencia pública, “que, francamente, ha estado plagada de algunos desafíos y problemas durante muchos, muchos años”.

Brereton dijo que se aumentaron los salarios de los coordinadores de clientes para cubrir trabajos en persona. El estado contrató a unos 50 trabajadores de agencias nacionales para fortalecer el personal del centro de llamadas, y creó una espera separada en su línea para las personas que solicitan ayuda temporal para alimentos o dinero en efectivo.

Jon Ebelt, vocero del Departamento de Salud de Montana, no respondió directamente sobre cuánto es la espera en línea para SNAP y asistencia de dinero en efectivo, pero dijo que las solicitudes “se están procesando de manera oportuna”.

Las personas que intentan utilizar el sistema del estado dijeron que las esperas largas persistían en noviembre.

Desde abril, casi 5,000 habitantes de Montana están recibiendo menos beneficios de SNAP. Pero eso no necesariamente significa que menos personas califiquen, dijo Lorianne Burhop, directora de política del Montana Food Bank Network.

Los clientes sin acceso a Internet, con minutos de teléfono limitados o sin la capacidad de viajar a una oficina de asistencia pública pueden no poder sortear los obstáculos para mantener sus beneficios.

“Hemos visto números consistentemente altos en los bancos de alimentos, mientras que con SNAP, hemos visto una disminución gradual”, dijo Burhop. “Creo que hay que considerar el acceso como un factor que impulsa esa baja”.

En Missoula, DeAnna Marchand estaba en espera en la línea de ayuda de Montana cuando se acercaba una fecha límite en noviembre. Enfrentaba múltiples cortes: uno para recertificar la asistencia alimentaria para ella y su nieto, otro para demostrar que aún calificaba para el programa de Medicaid que paga por su cuidador en el hogar, y un tercero para mantener el Medicaid de su nieto.

“No sé lo que quieren”, dijo Marchand. “¿Cómo se supone que debo obtener todo eso si no puedo hablar con alguien?”.

Después de media hora, siguió las indicaciones para programar una devolución de llamada. Pero una voz automatizada dijo que los espacios estaban llenos y transfirió la llamada de nuevo a espera. Una hora después, la llamada se cortó.

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Twice, she’d tried to use Montana’s public assistance help line to complete an interview required to recertify her Supplemental Nutrition Assistance Program, or SNAP, benefits. Each time, the call dropped after more than an hour on hold.

“I was ready to cry,” Brost said as she stood in line with about a dozen other people waiting for the office to open on a recent November morning. “I’ve got a hungry 13-year-old kid.”

Low-income families that need safety-net services, such as food and cash assistance, have become collateral damage in the bureaucratic scramble to determine whether tens of millions of people still qualify for Medicaid after a pandemic-era freeze on disenrollment ended this spring. These are people whose applications and renewal forms have been delayed or lost, or who, like Brost, can’t reach overwhelmed government call center workers.

The impact on services for low-income families is an overlooked consequence of the Medicaid “unwinding,” which has led to coverage being terminated for millions of people since April, with millions more expected to lose coverage in the coming months.

“The Medicaid unwinding has created huge problems for administrative staff,” said Leighton Ku, director of the Center for Health Policy Research at George Washington University’s Milken Institute School of Public Health.

Most states rely on the same workers and computer systems to sort eligibility for Medicaid and SNAP, according to the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C. The difficulty of signing up for other public assistance benefits varies, depending on how each state sets up its programs and how well agencies are staffed to handle extra work caused by Medicaid redeterminations.

People seeking public aid have historically encountered long call center wait times and limited options for in-person help. Those long-standing problems have worsened as record numbers of Medicaid recipients seek help with enrollment.

Attorneys and organizations assisting applicants for food benefits in Montana, Missouri, and Virginia, for example, said applications have vanished without a response and phone calls to workers determining eligibility frequently go unanswered.

“Our clients are already living on a razor’s edge, and this can just knock them off,” said Megan Dishong, deputy director of the Montana Legal Services Association.

SNAP enrollment is about half that of Medicaid. In April, nearly 42 million Americans received food assistance, compared with 87.4 million enrolled in the health coverage program.  

SNAP itself has undergone major changes this year — a policy that increased benefits during the pandemic expired, and work requirements have been reinstated. According to the most recent federal data, SNAP enrollment dropped by 1 million from January to August, much less than the decline in Medicaid enrollment that started in April.

Still, official data sources don’t capture delays and other difficulties people face in getting benefits.

In Virginia, where local offices of the state Department of Social Services handle Medicaid and SNAP applications, “I’ve had several clients who have submitted applications and they’ve just gone into the ether,” said Majesta-Doré Legnini, an Equal Justice Works fellow at the Legal Aid Justice Center who works on SNAP issues.

A client applying for assistance for the first time didn’t hear anything for three months and had to refile. Another got benefits after 2½ months, after having endured application processing delays, a denial letter, and an appeal. A family with mixed immigration status — the children qualified for benefits — didn’t have benefits for eight months after being erroneously cut off and then experienced delays after reapplying.

Virginia is supposed to process each application within 30 days. “Most of my clients have kids that are under 15,” Legnini said, and many tell her “they’re having trouble getting enough food to feed their kids.” The Virginia Department of Social Services did not answer questions from KFF Health News.

In Missouri, a federal lawsuit filed before the unwinding began alleges that a dysfunctional system prevents low-income residents from getting food aid. More than half of Missouri applicants were denied aid in July because they couldn’t complete an interview — not because they were ineligible, according to a document filed in the case.

The application of Mary Holmes, a 57-year-old St. Louis woman with throat cancer and other chronic conditions, was denied in February 2022 because she couldn’t reach a call center to complete her interview. Holmes repeatedly phoned the call center but waited for hours on hold, often with hundreds of people ahead of her. Her benefits were reinstated after the judge admonished the state for the long waits during a March 2022 hearing. The lawsuit remains open.

Now, with Missouri reassessing the Medicaid enrollment of more than 1 million recipients, advocates said those systemic flaws have escalated into a crisis for the most vulnerable.

“It’s a major firestorm with both these things going on at once,” said Joel Ferber, director of advocacy for Legal Services of Eastern Missouri, which represents Holmes and the other plaintiffs.

State officials said they had “made significant strides to make interviews more widely available,” according to a recent case filing, such as by hiring “outside vendors to handle Medicaid calls to free up more state employees to handle SNAP interviews.”

Montana officials said the Medicaid redetermination process similarly collided with an already troubled system in that state.

In September, Charlie Brereton, director of the Montana Department of Public Health and Human Services, told lawmakers the state was working to improve its public assistance help line, “which, frankly, has been plagued with some challenges and issues for many, many years.”

Brereton said the agency increased the wages of client coordinators to fill in-person jobs. The state contracted about 50 workers from national agencies to supplement the call center’s staff and created a separate queue on its help line for people applying for food or temporary cash assistance.

Jon Ebelt, a Montana health department spokesperson, didn’t directly answer how long SNAP and cash assistance callers are waiting on hold on average, but said applications “are being processed in a timely fashion.”

People trying to use the state’s system said the long waits persisted in November.

Since April, nearly 5,000 fewer Montanans are receiving SNAP benefits. But that doesn’t necessarily mean fewer people qualify, said Lorianne Burhop, chief policy officer for the Montana Food Bank Network. Clients without internet access, unlimited cellphone minutes, or the ability to travel to a public assistance office may not be able to jump through the hoops to keep their benefits.

“We’ve seen consistently high numbers at food banks, whereas SNAP, we’ve seen trickling down,” Burhop said. “I think you have to consider access as a factor that’s driving that decline.”

In Missoula, DeAnna Marchand waited on hold on Montana’s help line as a November deadline approached. She fell into a category of people facing multiple cutoffs: one to recertify food assistance for her and her grandson, another to prove she still qualifies for the Medicaid program that pays for her in-home caregiver, and a third to keep her grandson’s Medicaid.

“I don’t know what they want,” Marchand said. “How am I supposed to get that if I can’t talk with somebody?”

After half an hour, she followed prompts to schedule a callback. But an automated voice announced slots were full and instructed her to wait on hold again. An hour later, the call dropped.

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En Missouri y Florida, beneficiarios que decidieron llamar por teléfono a las líneas directas para renovar su cobertura, reportaron haber estado en espera por más de dos horas.

El verano pasado, los padres de un hombre discapacitado en Tennessee, que había estado en Medicaid durante tres décadas, lucharon contra el estado para mantenerlo inscrito mientras agonizaba de neumonía en un hospital.

Siete meses después de lo que se predijo sería el mayor terremoto en los 58 años de historia del programa gubernamental de seguro médico para personas con bajos ingresos y con ciertas discapacidades, los estados han revisado la elegibilidad de más de 28 millones de personas y han cancelado la cobertura de más de 10 millones de ellas.

Y se espera que millones más pierdan Medicaid en los próximos meses.

La caída sin precedentes en la inscripción se produce después que esta primavera terminaran las protecciones federales que habían prohibido a los estados sacar a las personas de Medicaid durante los tres años de la pandemia.

Desde marzo de 2020, la inscripción en Medicaid y el Programa de Seguro de Salud Infantil (CHIP) había aumentado en más de 22 millones hasta alcanzar la cifra récord de 94 millones de beneficiarios.

El proceso de revisión de la elegibilidad de todos los inscriptos en Medicaid no ha sido nada sencillo para muchos afiliados. Algunos están perdiendo cobertura sin entender por qué. Otros están luchando por demostrar que todavía son elegibles.

Tanto beneficiarios como defensores de pacientes dicen que los funcionarios de Medicaid enviaron formularios de renovación obligatoria a direcciones viejas, calcularon mal los niveles de ingresos e hicieron malas traducciones de los documentos.

Intentar procesar los casos de decenas de millones de personas al mismo tiempo también ha exacerbado las fragilidades de larga data en el sistema burocrático. Algunos hasta sospechan que ciertos estados han aprovechado el confuso sistema para desalentar la inscripción.

"No sólo es malo, es peor de lo que la gente puede imaginar", dijo Camille Richoux, directora de políticas de salud de la organización sin fines de lucro Arkansas Advocates for Children and Families. "Esta reducción no se ha tratado de determinar quién es elegible por todos los medios posibles, sino de cómo podemos expulsar a la gente por todos los medios posibles".

Sin duda, algunos de los beneficiarios de Medicaid que se inscribieron en el programa cuando la tasa de desempleo en Estados Unidos se disparó, en medio de los aislamientos por covid-19, han obtenido desde entonces seguro médico a través de nuevos empleos, a medida que el desempleo volvió a caer a los mínimos previos a la pandemia.

Y algunos de los que se dieron de baja se están inscribiendo en planes de los mercados de seguros establecidos por la Ley de Cuidado de Salud a Bajo Precio (ACA).

Por ejemplo, Sarah London, directora ejecutiva de Centene, dijo a los inversionistas el 24 de octubre que el gigante de la atención médica esperaba que hasta 2,4 millones de sus 15 millones de miembros de atención administrada de Medicaid perderían la cobertura debido a cancelaciones, pero más de 1 millón habían adquirido sus planes del mercado desde octubre la misma época el año pasado.

Aún así, nadie sabe cuántos ex beneficiarios de Medicaid siguen sin seguro. Los estados no hacen un seguimiento de lo que les sucede a todos luego que son expulsados del programa. Y las cifras finales probablemente no se conocerán hasta 2025, después que el proceso finalice el próximo verano y los funcionarios federales investiguen el estatus de seguro de los estadounidenses.

Sin Medicaid, los pacientes no van a sus citas

Trish Chastain, de 35 años, de Springfield, Missouri, dijo que su cobertura de Medicaid expirará a fines de año. Aunque sus hijos todavía están cubiertos, ella ya no califica porque sus ingresos son demasiado altos: $22 la hora. El empleador de Chastain, un centro de rehabilitación, ofrece seguro médico, pero su parte de la prima sería de $260 al mes. "No puedo permitirme eso con mi presupuesto mensual", dijo.

Dijo que no sabía que podría ser elegible para un plan de más bajo costo en los mercados de seguros de ACA. Sin embargo, eso todavía significaría nuevos costos.

Las brechas en la cobertura pueden poner en peligro el acceso de las personas a los servicios de salud o su seguridad financiera si reciben facturas médicas por atención que no pueden posponer.

"Cualquier tipo de atención que se posponga —ya sea asma, autismo o algo tan simple como un dolor de oído— puede empeorar si se espera", dijo Pam Shaw, pediatra de Kansas City, Kansas, que preside el Comité de asuntos gubernamentales estatales de la Academia Americana de Pediatría.

Médicos y representantes de centros de salud comunitarios de todo el país dijeron que han visto un aumento en las cancelaciones y faltas entre los pacientes sin cobertura, incluidos los niños. A nivel nacional, los estados ya han dado de baja a cerca de 1,8 millones de niños en los 20 estados que proporcionan datos por edad.

Los niños suelen calificar más fácilmente que los adultos, por lo que sus defensores creen que a muchos se los expulsa injustamente porque se considera que sus padres ya no son elegibles. Mientras tanto, la inscripción en CHIP, que tiene niveles de elegibilidad de ingresos más altos que Medicaid, ha mostrado sólo un pequeño aumento.

Los niños representaron porcentajes variables de las personas dadas de baja en cada estado, desde el 68% en Texas hasta el 16% en Massachusetts, según KFF.

En septiembre, la administración Biden dijo que la mayoría de los estados estaban realizando controles de elegibilidad de manera incorrecta y cancelando de manera inapropiada la inscripción de niños o miembros del hogar elegibles. Ordenó a los estados restablecer la cobertura para unas 500,000 personas.

Horarios variables, tasas de bajas variables

Idaho, uno de los pocos estados que completó la reducción en seis meses, dijo que canceló de la inscripción de 121,000 personas, de las 153,000 que revisó en septiembre porque sospechaba que ya no eran elegibles con el fin de la emergencia de salud pública. De los expulsados, alrededor de 13,600 se inscribieron para cobertura privada de ACA, dijo Pat Kelly, director ejecutivo de Your Health Idaho, el mercado de seguros de salud estatal. Los funcionarios estatales dicen que no saben qué pasó con el resto.

California, por el contrario, comenzó a remover beneficiarios recién este verano y está transfiriendo automáticamente la cobertura de Medicaid a los planes del mercado para aquellos elegibles.

Hasta ahora, las tasas de bajas de Medicaid de las personas analizadas varían dramáticamente según el estado, en gran medida a lo largo de una división política azul-roja, desde un mínimo del 10% en Illinois hasta un máximo del 65% en Texas.

“Siento que Illinois está haciendo todo lo que está a su alcance para garantizar que la menor cantidad posible de personas pierdan la cobertura”, dijo Paula Campbell de la Asociación de Atención Primaria de Salud de Illinois, que representa a docenas de centros de salud comunitarios.

A nivel nacional, alrededor del 71% de los afiliados a Medicaid que perdieron la cobertura fue debido a problemas de procedimiento, como no responder a las solicitudes de información para verificar su elegibilidad. No está claro cuántos siguen siendo elegibles.

Funcionarios estatales y locales de Medicaid dicen que han intentado comunicarse con los beneficiarios de muchas maneras, a través de cartas, llamadas telefónicas, correos electrónicos y mensajes de texto, para verificar la elegibilidad. Sin embargo, algunos beneficiarios no tienen un correo electrónico o servicios de Internet consistentes, no hablan inglés o están haciendo malabarismos con necesidades más urgentes.

"El esfuerzo de desmantelamiento sigue siendo un gran desafío y un impulso significativo para todos los estados", dijo Kate McEvoy, directora ejecutiva de la Asociación Nacional de Directores de Medicaid.

La gente no entiende lo que está pasando

En muchos estados, eso ha significado que los afiliados hayan tenido que enfrentar largas esperas para obtener ayuda con las renovaciones.

Las peores esperas telefónicas se produjeron en Missouri, según una revisión de KFF Health News de las cartas que los Centros de Servicios de Medicare y Medicaid (CMS) enviaron a los estados en agosto. En la carta al programa de Medicaid de Missouri, los CMS dijeron que preocupaba que el tiempo de espera promedio de 48 minutos y la tasa del 44% de habitantes de Missouri que abandonaron esas llamadas en mayo estuvieran "impidiendo el acceso equitativo" a la asistencia y la capacidad de los pacientes para mantener la cobertura.

Algunas personas quedan en espera más de tres horas, dijo Sunni Johnson, trabajadora de inscripción en Affinia Healthcare, que administra centros de salud comunitarios en el área de St. Louis. Se trata de un obstáculo importante para una población en la que muchos tienen minutos limitados en sus celulares.

En Florida, que ha eliminado a más de 730,000 personas del programa desde abril, los inscritos a principios de este año estuvieron esperando casi dos horas y media en un centro de llamadas en español, según un informe de UnidosUS, un grupo de defensa de los derechos civiles. Las versiones en español de la solicitud de Medicaid, el sitio web de renovación y otras comunicaciones también son confusas, aseguró Jared Nordlund, director de UnidosUS en Florida.

“Apenas pueden hacer bien las traducciones al español”, dijo.

Miguel Nevarez, secretario de prensa del Departamento de Niños y Familias de Florida, que gestiona el proceso de redeterminación de Medicaid, criticó las quejas sobre malas traducciones y largas esperas para acceder al centro de llamadas en español como una “narrativa falsa”. Dijo: "Los datos muestran claramente que Florida ha ejecutado un plan justo y eficaz para las redeterminaciones".

En California, líneas telefónicas congestionadas, oficinas de los condados abarrotadas y con poco personal, y problemas para descargar las solicitudes de renovación electrónicamente están "agravando la dificultad de las personas para renovar su Medicaid”, dijo Skyler Rosellini, abogado principal de la oficina de Los Ángeles del National Health Law Program. "Sabemos, según los casos que recibimos, que la gente no logra salir adelante".

Jasmine McClain, asistente médica de 31 años, dijo que intentó todo antes de que Montana terminara la cobertura de Medicaid para sus hijos, de 3 y 5 años, a principios de octubre. Envió la documentación en línea y por fax para demostrar que aún calificaban. Pasó horas en espera en la línea directa estatal. Después que terminó la cobertura de sus hijos, fue a una oficina estatal de asistencia pública en Missoula pero no pudo conseguir una cita. Un día a mediados de octubre, aproximadamente 30 personas hicieron fila afuera de la oficina desde las 6:40 am, antes de que abriera.

Después de tres semanas de pedir ayuda mientras sus hijos no tenían seguro, el estado restableció la cobertura de sus hijos. Dijo que un supervisor le dijo que la documentación de la familia presentada en línea no había sido procesada inicialmente.

“El sistema de llamadas telefónicas era un desastre. Las devoluciones de llamada tardaron una semana”, dijo McClain. “Tuve que superar muchos obstáculos”.

Los voceros de los programas de Medicaid de Montana, Florida y Missouri dijeron que sus estados habían reducido los tiempos de espera de las llamadas.

Algunos beneficiarios de Medicaid buscan ayuda a través de los tribunales. En una demanda colectiva de 2020 contra Tennessee que busca ponerle una pausa a la revisión de elegibilidad para Medicaid, los padres de los beneficiarios describen pasar horas al teléfono o en línea con el programa, tratando de garantizar que no se pierda la cobertura de sus hijos.

Uno de esos padres, Donna Guyton, dijo en un expediente judicial que el programa Medicaid de Tennessee, llamado TennCare, envió una carta en junio revocando la cobertura de su hijo Patrick, de 37 años, quien había sido elegible para Medicaid debido a discapacidades desde que tenía 6 años. Mientras Guyton hacía llamadas y presentaba apelaciones para proteger el seguro de su hijo, fue hospitalizado con neumonía, y estuvo internado semanas hasta que murió a finales de julio.

“Mientras Patrick luchaba por su vida, TennCare amenazaba con quitarle la cobertura de su seguro médico y los servicios en los que dependía”, dijo en un expediente judicial. “Aunque deberíamos haber podido centrarnos en la atención de Patrick, nuestra familia tuvo que navegar por un sistema que seguía negando su elegibilidad y poniendo en riesgo su cobertura médica”.

TennCare dijo en un expediente judicial que la cobertura de Medicaid de Patrick Guyton nunca fue revocada: la carta de terminación fue enviada a su familia debido a un “error”.

Phil Galewitz en Washington, D.C., escribió este artículo. Daniel Chang en Hollywood, Florida; Katheryn Houghton en Missoula, Montana; Brett Kelman en Nashville, Tennessee; Samantha Liss y Bram Sable-Smith en St. Louis; y Bernard J. Wolfson en Los Ángeles contribuyeron con la historia.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Callers in Missouri and Florida reported waiting on hold for more than two hours on hotlines to renew their Medicaid coverage.

The parents of a disabled man in Tennessee who had been on Medicaid for three decades fought with the state this summer to keep him enrolled as he lay dying from pneumonia in a hospital.

Seven months into what was predicted to be the biggest upheaval in the 58-year history of the government health insurance program for people with low incomes and disabilities, states have reviewed the eligibility of more than 28 million people and terminated coverage for over 10 million of them. Millions more are expected to lose Medicaid in the coming months.

The unprecedented enrollment drop comes after federal protections ended this spring that had prohibited states from removing people from Medicaid during the three pandemic years. Since March 2020, enrollment in Medicaid and the related Children’s Health Insurance Program had surged by more than 22 million to reach 94 million people.

The process of reviewing all recipients’ eligibility has been anything but smooth for many Medicaid enrollees. Some are losing coverage without understanding why. Some are struggling to prove they’re still eligible. Recipients and patient advocates say Medicaid officials sent mandatory renewal forms to outdated addresses, miscalculated income levels, and offered clumsy translations of the documents. Attempting to process the cases of tens of millions of people at the same time also has exacerbated long-standing weaknesses in the bureaucratic system. Some suspect particular states have used the confusing system to discourage enrollment.

“It’s not just bad, but worse than people can imagine,” said Camille Richoux, health policy director for the nonprofit Arkansas Advocates for Children and Families. “This unwinding has not been about determining who is eligible by all possible means, but how we can kick people off by all possible means.”

To be sure, some of the Medicaid recipients who signed on to the program when the U.S. unemployment rate soared amid covid-19 lockdowns have since gotten health insurance through new jobs as unemployment dropped back to pre-pandemic lows.

And some of the disenrolled are signing up for Affordable Care Act marketplace plans. Centene CEO Sarah London, for example, told investors on Oct. 24 that the health care giant expected as many as 2.4 million of its 15 million Medicaid managed care members to lose coverage from the unwinding, but more than 1 million customers had joined its exchange plans since the same time last year.

Still, it’s anyone’s guess how many former Medicaid beneficiaries remain uninsured. States don’t track what happens to everyone after they’re disenrolled. And the final tallies likely won’t be known until 2025, after the unwinding finishes by next summer and federal officials survey Americans’ insurance status.

Without Medicaid, Patients Miss Appointments

Trish Chastain, 35, of Springfield, Missouri, said her Medicaid coverage is scheduled to expire at the end of the year. Though her children are still covered, she no longer qualifies because her income is too high at $22 an hour. Chastain’s employer, a rehab center, offers health insurance but her share of the premium would be $260 a month. “I can’t afford that with my monthly budget,” she said.

She said she did not know she might be eligible for a lower-cost plan on the Affordable Care Act marketplace. That still would mean new costs for her, though.

Gaps in coverage can jeopardize people’s access to health services or their financial security if they get medical bills for care they cannot postpone.

“Any type of care that's put off — whether it's asthma, whether it's autism, whether it's something as simple as an earache — can just get worse if you wait,” said Pam Shaw, a pediatrician in Kansas City, Kansas, who chairs the American Academy of Pediatrics’ state government affairs committee.

Doctors and representatives of community health centers around the country said they have seen an uptick in cancellations and no-shows among patients without coverage — including children. Nationwide, states have already disenrolled at least 1.8 million children in the 20 states that provide the data by age. Children typically qualify more easily than adults, so child advocates believe many kids are being wrongly terminated based on their parents’ being deemed no longer eligible. Meanwhile, enrollment in CHIP, which has higher income eligibility levels than Medicaid, has shown only a tiny increase.

Kids accounted for varying shares of those disenrolled in each state, ranging from 68% in Texas to 16% in Massachusetts, according to KFF. In September, President Joe Biden’s administration said most states were conducting eligibility checks incorrectly and inappropriately disenrolling eligible children or household members. It ordered states to reinstate coverage for some 500,000 people.

Varying Timetables, Varying Rates of Disenrollment

Idaho, one of a few states that completed the unwind in six months, said it disenrolled 121,000 people of the 153,000 recipients it reviewed as of September because it suspected they were no longer eligible with the end of the public health emergency. Of those kicked off, about 13,600 signed up for private coverage on the state’s ACA marketplace, said Pat Kelly, executive director of Your Health Idaho, the state’s exchange. What happened to the rest, state officials say they don’t know.

California, by contrast, started terminating recipients only this summer and is automatically transferring coverage from Medicaid to marketplace plans for those eligible.

The Medicaid disenrollment rates of people reviewed so far vary dramatically by state, largely along a blue-red political divide, from a low of 10% in Illinois to a high of 65% in Texas.

“I feel like Illinois is doing everything in their power to ensure that as few people lose coverage as possible,” said Paula Campbell of the Illinois Primary Health Care Association, which represents dozens of community health centers.

Nationwide, about 71% of Medicaid enrollees terminated during the unwinding have been cut because of procedural issues, such as not responding to requests for information to verify their eligibility. It’s unclear how many are actually still eligible.

State and local Medicaid officials say they have tried contacting enrollees in multiple ways — including through letters, phone calls, emails, and texts — to check their eligibility. Yet some Medicaid recipients lack consistent addresses or internet service, do not speak English, or are juggling more pressing needs.

“The unwinding effort continues to be very challenging and a significant lift for all states,” said Kate McEvoy, executive director of the National Association of Medicaid Directors.

‘People Are Not Getting Through’

In many states, that has meant enrollees have faced long waits to get help with renewals. The worst phone waits were in Missouri, according to a KFF Health News review of letters the Centers for Medicare & Medicaid Services sent to states in August. In the letter to Missouri’s Medicaid program, CMS said it was concerned that the average wait time of 48 minutes and the 44% rate of Missourians abandoning those calls in May was “impeding equitable access” to assistance and patients’ ability to maintain coverage.

Some people are waiting on hold more than three hours, said Sunni Johnson, an enrollment worker at Affinia Healthcare, which runs community health centers in the St. Louis area. That’s a significant hurdle for a population in which many have limited cellphone minutes.

In Florida, which has removed over 730,000 people from the program since April, enrollees earlier this year were waiting almost 2½ hours on a Spanish-language call center, according to a report from UnidosUS, a civil rights advocacy group. The Spanish versions of the Medicaid application, renewal website, and other communications are also confusing, said Jared Nordlund, the Florida director for UnidosUS.

“They can barely get the Spanish translations right,” he said.

Miguel Nevarez, press secretary for Florida’s Department of Children and Families, which is managing the state’s Medicaid redetermination process, criticized complaints about poor translations and long waits for the Spanish-language call center as a “false narrative.” He said, “The data clearly shows Florida has executed a fair and effective plan for redeterminations.”

In California, similarly jammed phone lines, crowded and understaffed county offices, and trouble downloading renewal applications electronically are all “compounding people’s difficulty to renew” their Medicaid, said Skyler Rosellini, a senior attorney in the Los Angeles office of the National Health Law Program. “We do know, based on the cases we’re getting, that people are not getting through.”

Jasmine McClain, a 31-year-old medical assistant, said she tried everything before Montana ended Medicaid coverage for her kids, ages 3 and 5, in early October. She tried submitting paperwork online and over fax to prove they still qualified. She spent hours on hold with the state hotline. After her kids’ coverage ended, she went to a state public assistance office in Missoula but couldn’t get an appointment. One day in mid-October, roughly 30 people lined up outside the office starting as early as 6:40 a.m., before its doors opened.

After three weeks of her pleading for help while her kids were uninsured, the state restored her kids’ coverage. She said a supervisor told her the family’s paperwork submitted online wasn’t processed initially.

“The phone call system was a mess. Callbacks were a week out to even talk to somebody,” McClain said. “It just was just a lot of hurdles that I had to get through.”

Spokespeople for the Montana, Florida, and Missouri Medicaid programs all said their states had reduced call wait times.

Some Medicaid recipients are seeking help through the courts. In a 2020 class-action lawsuit against Tennessee that seeks to pause the Medicaid eligibility review, parents of recipients describe spending hours on the phone or online with the state Medicaid program, trying to ensure their children’s insurance coverage is not lost.

One of those parents, Donna Guyton, said in a court filing that Tennessee’s Medicaid program, called TennCare, sent a June letter revoking the coverage of her 37-year-old son, Patrick, who had been eligible for Medicaid because of disabilities since he was 6. As Guyton made calls and filed appeals to protect her son’s insurance, he was hospitalized with pneumonia, then spent weeks there before dying in late July.

“While Patrick was fighting for his life, TennCare was threatening to take away his health insurance coverage and the services he relied on,” she said in a court filing. “Though we should have been able to focus on Patrick’s care, our family was required to navigate a system that kept denying his eligibility and putting his health coverage at risk.”

TennCare said in a court filing Patrick Guyton’s Medicaid coverage was never actually revoked — the termination letter was sent to his family because of an “error.”

Phil Galewitz in Washington, D.C., wrote this article. Daniel Chang in Hollywood, Florida; Katheryn Houghton in Missoula, Montana; Brett Kelman in Nashville, Tennessee; Samantha Liss and Bram Sable-Smith in St. Louis; and Bernard J. Wolfson in Los Angeles contributed to this report.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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She recalled vividly one baby who stayed in the NICU for 90 days with neonatal abstinence syndrome, a form of withdrawal, because his mother had used substances while pregnant.

The mother came in every day, Peterson said. She took three buses to get to the hospital to see her baby. Peterson watched her sing to him some days and read to him on others.

“I saw in the NICU the love that she had for that baby,” Peterson said. “When it came down to it, she lost custody.”

At the time, Peterson said, she felt more could be done to help people like that mother. That’s why, in 2018, she founded Empowered, a program that provides services for pregnant and postpartum women who have a history of opioid or stimulant use or are currently using drugs.

The program helps about 100 women at any given time, Peterson said. Pregnancy often motivates people to seek treatment for substance use, she said. Yet significant barriers stand in the way of those who want care, even as national rates of fatal drug overdoses during and shortly after pregnancy continue to rise. In addition to the risk of overdose, substance use during pregnancy can result in premature birth, low birth weight, and sudden infant death syndrome.

A federal initiative seeking to combat those overdoses is distributing millions of dollars to states to help fund and expand programs like Empowered. Six states will receive grant funding from the Substance Abuse and Mental Health Services Administration to increase access to treatment during and after pregnancy. The Nevada Health and Human Services Department is distributing the state’s portion of that funding, about $900,000 annually for up to three years, to help the Empowered program expand into northern Nevada, including by establishing an office in Reno and sending mobile staff into nearby rural communities.

Other states are trying to spread the federal funds to maximize reach. State officials in Montana have awarded their state’s latest $900,000 grant to a handful of organizations since first receiving a pool of funding in 2020. Connecticut, Iowa, Maryland, and South Carolina will also receive $900,000 each.

Officials hope the financial boosts will help tamp down the rise in overdoses.

Deaths from drug overdoses hit record highs in 2021, according to the Centers for Disease Control and Prevention. More recent preliminary data shows that the rates of fatal drug overdoses have continued to rise since.

Deaths in pregnant and postpartum people have also increased. Homicides, suicides, and drug overdoses are the leading causes of pregnancy-related death.

Fatal overdoses among pregnant and postpartum people increased by approximately 81% from 2017 to 2020, according to a 2022 study. Of 7,642 reported deaths related to pregnancy during those years, 1,249 were overdoses. Rates of pregnancy-related opioid overdose deaths had already more than doubled from 2007 to 2016.

Meanwhile, mothers and mothers-to-be in rural parts of the country, some of the hardest hit by the opioid crisis, face greater barriers to care because of fewer treatment facilities specializing in pregnant and postpartum people in their communities and fewer providers who can prescribe buprenorphine, a medication used to treat opioid addiction.

Data distinguishing the rates of overdose mortality among pregnant and postpartum people in urban and rural areas is hard to come by, but studies have found higher rates of neonatal opioid withdrawal syndrome in rural parts of the country. Women in rural areas also died at higher rates from drug overdoses in 2020 compared with women in urban areas, while the overall rate and the rate among men were greater in urban areas.

In Nevada, a 2022 maternal mortality and severe maternal morbidity report found that most of the state’s pregnancy-related deaths, 78%, happened in Clark County, home to Las Vegas and two-thirds of the state’s population. However, the state’s rural counties had the highest pregnancy-related death rate — 179.5 per 100,000 live births — while Clark County’s was 123 per 100,000 live births.

During a recent event hosted by Empowered, four mothers recounted their struggles with addiction while pregnant. “It was never my intention to actually have a drug addiction,” said a mother named Amani. “I’ve always wanted to get out of the cycle of relapsing and drug usage.”

Amani, who asked to be identified only by her first name for fear of stigma associated with using drugs while pregnant or after giving birth, said she found the support she needed to treat her addiction in 2021. That’s when she began seeking help at Empowered.

Substance use while pregnant or postpartum is “incredibly stigmatizing,” said Emilie Bruzelius, a postdoctoral fellow in the Department of Epidemiology at Columbia University’s Mailman School of Public Health and author of a study of trends in drug overdose mortality during and after pregnancy. The stigma and fear of interacting with child welfare or law enforcement agencies prevents people from seeking help, she said.

A Rand Corp. study found that states with punitive policies toward mothers with substance use disorders have more cases of neonatal abstinence syndrome. Nevada was among them.

Researchers have found that, in addition to facing fear of punishment, many women don’t have access to treatment during and after pregnancy because few outpatient centers specialize in treating mothers.

Both Nevada and Montana had fewer than one treatment facility with specialized programs for pregnant and postpartum women per 1,000 reproductive-age women with substance use disorders, with Montana ranking in the lowest quintile.

One Health, a community health center covering Montana’s sprawling southeastern plains, is using the newly awarded federal money to train peer support specialists as doulas, professionals specialized in childbirth who can provide support throughout pregnancy and after.

Megkian Doyle, who directs the center’s community-based work, said in one case a survivor of sex trafficking who was drugged by her abusers worked with a recovery doula to prepare for the potential triggers of being exposed to medical workers or needing an IV. In another, a mom in stable recovery from addiction was able to keep her baby when hospital staffers called child protective services because she already had a safety plan with her doula and the agency.

After birth, recovery doulas visit families daily for two weeks, “the window when overdose, relapse, and suicide is happening,” Doyle said. The workers, in their peer support role, can continue helping clients for years.

While doula care, rarely covered by insurance, is unaffordable for many, Medicaid typically covers peer support care. As of late September, 37 states and Washington, D.C., had extended Medicaid benefits to cover care for 12 months postpartum. Montana and Nevada have approved plans to do so. Health centers in similarly rural states have taken note. The program’s latest cohort of recovery doulas includes five peer support specialists from Utah.

With its trauma-informed approach, the Nevada-based Empowered program takes a different tack.

The program focuses on meeting its participants’ most pressing need, which varies depending on the person. Some people need help getting government-issued identification so they can access other social services, including aid from food pantries, said Peterson, the founder and executive director. Others may need safe housing above all.

Empowered is not abstinence-based, meaning its participants do not lose access to services if they relapse or use substances while seeking help. Because some participants may be actively using drugs, the Empowered office is also a distribution site for the overdose reversal medication naloxone and test strips that detect fentanyl, a powerful synthetic opioid that has contributed to jumps in fatal overdose rates in recent years. The program’s staff also provide education about the effects drugs have on an unborn baby during pregnancy.

Being able to be honest with Empowered staff made a difference for Amani.

“I can’t tell you how many times I’ve tripped and fallen but tried to get back up and fallen again,” she said.

The goal is not only to stabilize participants’ lives but to make them resilient — whatever that may look like for each individual. For many, that includes having stable housing, food security, job security, and custody of their children.

To her, Amani said, the Empowered program means love, support, and not being alone.

“I wouldn’t be here, literally, without them,” she said.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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La casa no parecía un refugio para víctimas de violencia doméstica; estaba escondida a simple vista. Young no podía darle la dirección a nadie. La clandestinidad le daba una sensación de seguridad. Pero para su compañera de cuarto, una madre joven, era difícil cuidar a su bebé sin su familia allí para ayudarla.

Algunas residentes no podían ir a trabajar porque no tenían auto. Varias intentaban escaparse a la noche para alejarse por un momento de los toques de queda, las ventanas cerradas y los sistemas de seguridad.

“Estábamos ahí porque necesitábamos estar protegidas”, dijo Young. “Para mí, era un lugar cómodo. Para otras, era como estar en una prisión”.

Por mucho tiempo, el estándar para este tipo de refugios, también llamados casas de acogida, ha sido alojar a las víctimas de violencia doméstica en casas ocultas con direcciones secretas.

Este modelo surge de la idea de que la clandestinidad protege a las sobrevivientes de sus abusadores. Pero los directores de estos refugios han dicho que cada vez es más difícil mantener ocultas las ubicaciones, y que esta estrategia puede aislar a las víctimas.

Ahora, algunos refugios están transicionando a un modelo abierto. Esta primavera, Haven, una organización sin fines de lucro de Bozeman, terminó la construcción de un campus que reemplazó a la casa verde, ubicado a minutos de una carretera principal que conduce a la ciudad. El nombre de la organización está escrito en letras llamativas al costado del nuevo edificio.

Hay espacio para un jardín comunitario, clases de yoga y un lugar para que las residentes reciban a sus amigos. Está a poca distancia a pie de supermercados y una escuela primaria, y bordea un parque urbano que es ideal para pasear perros o pescar.

Erica Coyle, directora ejecutiva de Haven, dijo que por muchos años el antiguo refugio de la organización fue un secreto no tan secreto en la ciudad de más de 54,000 personas.

“Nuestro trabajo no es rescatar a un sobreviviente y mantenerlo escondido”, dijo Coyle. “Lo que debemos estar haciendo, como comunidades y como movimiento social, es escuchar a los sobrevivientes cuando nos dicen: ‘El aislamiento de los refugios es un gran obstáculo para mí’”.

Estos cambios en el modelo de los refugios para víctimas de violencia doméstica se están expandiendo por todo el país. En los últimos años, organizaciones en Utah y Colorado construyeron refugios públicos que proveen recursos in situ, como servicios legales.

Una organización de asistencia a víctimas en la ciudad de Nueva York ha pasado años sentando las bases para crear refugios que permitan a los residentes invitar a amigos y familiares.

Los estados rurales, como Montana, parecen estar adoptando el modelo de los refugios abiertos más rápido que las zonas urbanas. Kelsen Young, directora ejecutiva de la organización Montana Coalition Against Domestic and Sexual Violence, explicó que es mucho más difícil mantener un lugar secreto en pequeños pueblos donde todos se conocen.

Los refugios de Missoula y Helena adoptaron el modelo abierto hace años y, según Young, ya están en marcha planes para hacer lo mismo en otras ciudades.

Gina Boesdorfer, directora ejecutiva del Friendship Center en Helena, dijo que los refugios ocultos obligan a las sobrevivientes a permanecer escondidas en vez de apoyarlos en sus propias comunidades y permitir que sigan sus rutinas cotidianas.

“Demuestra claramente la falta de sistemas de apoyo y recursos en las comunidades”, dijo Boesdorfer. “[Los refugios ocultos] siguen colocando la carga en las víctimas y no en los abusadores”.

No hay un registro de cuántos refugios han adoptado el modelo abierto. Lisa Goodman, psicóloga y profesora del Boston College que estudia cómo mejorar los sistemas de apoyo para sobrevivientes de violencia, dijo que la definición de “abierto” en referencia a los refugios varía.

Algunos simplemente dejaron de tratar de ocultar sus direcciones, permitiendo a los residentes obtener transporte para ir a trabajar mientras otros espacios están fuera de los límites. Otros refugios permiten a los residentes recibir visitas u ofrecen espacios comunitarios para reuniones.

“Tal como solía ser el movimiento contra la violencia doméstica, [estos cambios] están empezando desde abajo”, dijo Goodman.

Los primeros refugios fueron establecidos por mujeres que acogían a otras mujeres en sus casas. A partir de la década de 1970, se empezaron a construir refugios bajo el supuesto de que los lugares secretos eran más seguros.

Pero a medida que fueron creciendo para alojar a más personas, los refugios ocultos se volvieron cada vez menos prácticos, ya que muchas sobrevivientes trabajan y tienen hijos que van a la escuela. Por no mencionar el desafío que presentan los avances tecnológicos que permiten rastrear la ubicación de un teléfono celular por GPS, por ejemplo.Goodman dijo que no existe un registro nacional de refugios que estén considerando el modelo abierto. Cada refugio debe tomar en cuenta preguntas importantes, incluyendo cómo evaluar a las visitas para asegurarse de que no sean una amenaza; cómo proteger a una sobreviviente cuyo abusador todavía anda suelto, y cómo mantener un equilibrio entre la independencia y la privacidad de las que quieren mantenerla.

Pero después de décadas de valorar la clandestinidad, salir a la luz pública no siempre es fácil.

En 2021, un refugio anteriormente escondido en el valle de Vail de Colorado — un grupo de pueblos rurales ocultos entre las mejores estaciones de esquí del mundo — abrió una nueva sede. La propiedad comprende pequeños apartamentos y servicios que ofrecen recursos para la salud mental, asistencia legal y ayuda con asuntos de vivienda, para residentes y no residentes. 

Sheri Mintz, directora ejecutiva de Bright Future Foundation, propietaria del refugio, dijo que tomó tiempo lograr que la gente aceptara el nuevo modelo. Algunos activistas en contra de la violencia doméstica temían que la transición pusiera en riesgo la seguridad de las sobrevivientes.

Respondiendo a estas preocupaciones, la organización actualizó el sistema de seguridad del nuevo refugio. Se hicieron recorridos de las instalaciones con policías para verificar que el lugar fuera seguro y crear planes de respuesta en caso de cualquier problemas de seguridad.

“Hasta ahora, no hemos tenido ningún incidente grave”, dijo Mintz. “Siempre hemos tenido clientes que pueden ser víctimas de acoso. No veo que eso haya aumentado o cambiado de alguna manera desde que estamos en este refugio público”.

En la ciudad de Nueva York, Olga Rodríguez-Vidal, vicepresidenta de refugios para víctimas de violencia doméstica de Safe Horizon, dijo que su organización todavía está trabajando para que sus patrocinadores apoyen el modelo abierto.

Los directores de Safe Horizon quieren tener una combinación de viviendas de emergencia privadas para las personas que están saliendo de una crisis y otras opciones para los que estén en alojamientos provisionales y quieran recibir visitas.

“Esto es muy nuevo e innovador y tal vez nos da un poco de miedo”, dijo Rodríguez-Vidal.

En Bozeman, Haven tiene dos edificios en su nuevo campus. El primero es un centro de recursos con oficinas para empleados, servicios para clientes y espacio para eventos comunitarios. Hay cámaras conectadas a un sistema de seguridad que pueden identificar las placas de abusadores conocidos, y hay controles de seguridad con cada visitante.

El nuevo sitio permite tener sistemas de seguridad mucho más avanzados que los que se podían usar cuando la organización estaba tratando de “camuflarse” en el vecindario, dijo Coyle.

Por dentro, el edificio está diseñado para que las personas que han experimentado traumas se sientan seguras. Cada ventana tiene una vista de lo que serán los jardines de la propiedad. Una parte del edificio incluye salas de terapia para adultos. Una de ellas tiene una vista a la sala de juegos para niños, así los padres pueden recibir ayuda sabiendo que sus hijos están a salvo.

La vivienda de Haven, a poca distancia a pie del centro principal, está fuera del alcance de personas que no trabajan o residen allí, lo cual permite mantener la privacidad de los residentes. Las sobrevivientes eligen cuándo y si quieren participar en eventos organizados en el edificio de al lado. El sendero de entrada a la vivienda de las residentes está cercado y es privado.

Sara Young es una de las sobrevivientes que opinó sobre el diseño del nuevo refugio de Haven y dijo que en general está contenta con los cambios. Le alegra que los residentes tendrán más espacio que el que ella tenía en su refugio, y que habrá más acceso a los distintos servicios que ofrece la organización.

Pero a Young no termina de convencerle la idea de un refugio público. En el refugio que la acogió,  se sentía segura sabiendo que la dirección no era pública y que su ex no la conseguiría. Le gustaba que los vecinos del refugio no sabían por qué estaba allí; no quería sentirse juzgada por haber estado en una relación abusiva. 

Pero Young reconoce que el hecho de tener una dirección pública no la habría disuadido de alojarse en el refugio.

“Estaba desesperada, estoy segura de que habría ido igual”, dijo Young, y agregó que no tendría la estabilidad que siente hoy en día sin el apoyo y la ayuda que recibió en el refugio. “Pero no quería que nadie lo supiera”.

Por otra parte, dijo Young, tal vez el modelo del refugio público contribuya a reducir el estigma que ella temía y ayude a que más personas entiendan que cualquier persona puede encontrarse en una relación abusiva, y qué hacer en esos casos. 

Young estará pendiente de cómo el modelo sigue desarrollándose.

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Nothing about the house identified it as a domestic violence shelter — it was hidden in plain sight. Young wasn’t allowed to give anyone the address. The secrecy made her feel safe. But her roommate, a young mom, struggled to care for her baby without her family there to help. Some residents couldn’t get to work because they didn’t have a car. Several housemates tried to sneak out at night for a break from curfews, locked windows, and alarm systems.

“We were there because we needed to be kept safe,” Young said. “For me, it was comfortable. For them, it felt like being in prison.”

The long-held standard for domestic violence shelters has been to keep residents in hiding at undisclosed addresses. That model stems from the belief that secrecy keeps survivors safe from their abusers. But domestic violence shelter directors have said keeping their locations secret has gotten more complicated, and the practice can isolate residents.

Now, some shelters are moving into the open. This spring, the Bozeman nonprofit Haven finished construction of a campus minutes off a main road leading into town that replaced the green house. Sun-catching letters display the nonprofit’s name on the side of the nonprofit’s new building.

There’s space for a community garden, yoga classes, and a place for residents to host friends. It’s within walking distance of grocery stores and an elementary school, and it borders a city park that’s a go-to spot for people to take their dogs or to fish.

Erica Coyle, executive director of Haven, said the nonprofit’s old shelter had been a not-so-well-kept secret for years in the city of more than 54,000 people. “Our job isn’t to rescue a survivor and keep them hidden away,” Coyle said. “What we need to be doing overall, as communities and as a movement, is listening to survivors and when they say, ‘The isolation of staying in a shelter is a big barrier for me.’”

Similar changes are percolating across the nation. In recent years, organizations in Utah and Colorado built public-facing shelters that connect clients to resources on-site such as legal services. A victim assistance organization in New York City has spent years laying the groundwork to create shelters that allow residents to invite friends and family over.

Rural states like Montana seem to be making the shift to open shelters ahead of urban areas. Kelsen Young, executive director of Montana Coalition Against Domestic and Sexual Violence, said that’s likely because it’s harder to keep a location secret in towns where everyone knows everybody. Shelters in Missoula and Helena made the shift years ago, and she said plans are in the works elsewhere.

Gina Boesdorfer, executive director of the Friendship Center in Helena, said hidden sites force survivors into hiding instead of supporting people in their communities and regular routines.

“It really highlights a lack of other supports and resources in a community,” Boesdorfer said. “That still places the burden on the victim rather than placing the burden on the offender.”

No one is tracking how many shelters have shifted to an open model. Lisa Goodman, a psychologist and professor at Boston College who studies how to improve systems for survivors of violence, said shelters’ definition of “open” varies.

Some open shelters simply stopped trying to hide their address, allowing residents to get rides to work while buildings remain off-limits. Others allow residents to have visitors in their quarters or offer community spaces for gatherings.

“As the domestic violence movement used to be, it’s sort of bubbling up from the bottom,” Goodman said.

The earliest havens arose when women took other women into their homes. Starting in the 1970s, shelters were built on the assumption that secrecy is safest. But as shelters grew to serve more people, staying hidden became less practical as more survivors work and have kids who attend school. Not to mention the challenge of technological advances like phone GPS tracking.

Goodman said there is no national guide for shelters considering an open model. Each needs to weigh big questions, such as: How do shelters screen visitors to make sure they’re not a threat? How do they protect a survivor whose abuser is still loose and dangerous? And how do they balance residents’ independence with confidentiality for those who want it?

Moving into the open isn’t always an easy sell after decades of emphasizing secrecy.

In 2021, a once-hidden shelter in Colorado’s Vail Valley, a cluster of rural towns tucked amid world-class ski resorts, opened a new facility. The property comprises small apartments alongside services such as behavioral health, housing, and legal aid for residents and nonresidents alike.

Sheri Mintz, CEO of the Bright Future Foundation, which owns the shelter, said it took time to build buy-in. Some advocates against domestic violence worried the transition would risk survivors’ safety.

In response, the organization upgraded the shelter’s security system well beyond its former site. Police officers toured the facility to check for safety and create response plans for security breaches.

“So far, we haven’t had any serious incidents,” Mintz said. “We have always had a situation where there are clients that might be victims of stalking. I don’t see that that has increased or changed in any way since we’re in this public-facing shelter.”

In New York City, Olga Rodriguez-Vidal, vice president of domestic violence shelters for Safe Horizon, said the victim assistance organization is still working to get funders on board with an open model.

There, the leadership hopes to create a mix of confidential emergency housing for people leaving a crisis, while allowing tenants in more transitional housing to decide whether they want visitors.

“This is very new and innovative and maybe a little scary,” Rodriguez-Vidal said.

In Bozeman, Haven has two buildings on its new campus. The first is a resource hub with employee offices, services for clients, and space for community events. Cameras attached to a security system can flag license plates registered to known abusers, and every visitor is screened before being buzzed in.

The new site allows for much more advanced security systems compared with what the nonprofit could use when trying to blend in with the neighborhood, Coyle said.

Inside, the building is designed to feel like a safe space for people who have experienced trauma. Each window has a view of what will be the property’s gardens. One side of the building includes therapy rooms for adults. One of those rooms has a view of a kids’ playroom so parents can get help while knowing their children are safe.

Haven’s housing, a short walk from the main hub, is still off-limits to anyone but staff members and residents to keep that space private. Survivors choose when and if they want to interact through events hosted next door. The driveway to residents’ housing is gated and private.

Sara Young was among the survivors who weighed in on the design of Haven’s new shelter and, overall, she’s excited about the changes. She’s happy there will be more space for residents compared with the house that was her refuge and that there’s easier access to services.

But Young is a little unsure about the idea of a public-facing shelter. She felt safe knowing the address wasn’t public for her ex to see. She liked that shelter neighbors didn’t necessarily know why she was there; she didn’t want to feel judged for having been in an unsafe relationship. But a public address wouldn’t have kept Young from showing up.

“I was desperate, I’m sure I would have gone,” Young said, adding that she wouldn’t have the stability she feels today without that help. “But I didn’t want anyone to know.”

Then again, Young said, maybe having the shelter out in the open will help whittle the judgment she feared, and help more people understand that anyone can find themselves trapped in unsafe relationships, and what to do when that happens.

She plans to watch how it plays out.

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Towarnicki’s breath caught, a familiar feeling after four years of working night shifts as a sexual assault nurse examiner in this northwestern Montana city.

“You almost want to curse,” Towarnicki, 38, said. “You’re like, ‘Oh, no, it’s happening.’”

These nights on duty are Towarnicki’s second job. She’s on call once a week and a weekend a month. A survivor may need protection against sexually transmitted infections, medicine to avoid getting pregnant, or evidence collected to prosecute their attacker. Or all the above.

When her phone rings, it’s typically in the middle of the night. Towarnicki tiptoes down the stairs of her home to avoid waking her young son, as her half-asleep husband whispers encouragement into the dark.

Her breath is steady by the time she changes into the clothes she laid out close to her back door before going to bed. She grabs her nurse’s badge and drives to First Step Resource Center, a clinic that offers round-the-clock care for people who have been assaulted.

She wants her patients to know they’re out of danger.

“You meet people in some of their most horrifying, darkest, terrifying times,” Towarnicki said. “Being with them and then seeing who they are when they leave, you don’t get that doing any other job in health care.”

A former travel nurse who lived out of a van for years, Towarnicki is OK with the uncertainty that comes with being a sexual assault nurse examiner.

Most examiners work on-call shifts in addition to full-time jobs. They often work alone and at odd hours. They can collect evidence that could be used in court, are trained to recognize and respond to trauma, and provide care to protect their patients’ bodies from lasting effects of sexual assault.

But their numbers are few.

As many as 80% of U.S. hospitals don’t have sexual assault nurse examiners, often because they either can’t find them or can’t afford them. Nurses struggle to find time for shifts, especially when staffing shortages mean covering long hours. Sexual assault survivors may have to leave their town or even their state to see an examiner.

Gaps in sexual assault care can span hundreds of miles in rural areas. A program in Glendive, Montana — a town of nearly 5,000 residents 35 miles from the North Dakota border — stopped taking patients for examinations this spring. It didn’t have enough nurses to respond to cases.

“These are the same nurses working in the ER, where a heart attack patient could come in,” said Teresea Olson, 56, who is the town’s part-time mayor and also picked up on-call shifts. “The staff was exhausted.”

The next closest option is 75 miles away in Miles City, adding at least an hour to the travel time for patients, some of whom already had to travel hours to reach Glendive.

Nationwide, policymakers have been slow to offer training, funding, and support for the work. Some states and health facilities are trying to expand access to sexual assault response programs.

Oklahoma lawmakers are considering a bill to hire a statewide sexual assault coordinator tasked with expanding training and recruiting workers. A Montana law that takes effect July 1 will create a sexual assault response network within the Montana Department of Justice. The new program aims to set standards for that care, provide in-state training, and connect examiners statewide. It will also look at telehealth to fill in gaps, following the example of hospitals in South Dakota and Colorado.

There’s no national tally of where nurses have been trained to respond to sexual assaults, meaning a survivor may not know they have to travel for treatment until they’re sitting in an emergency room or police department.

Sarah Wangerin, a nursing instructor with Montana State University and former examiner, said patients reeling from an attack may instead just go home. For some, leaving town isn’t an option.

This spring, Wangerin called county hospitals and sheriff’s offices to map where sexual assault nurse examiners operate in Montana. She found only 55. More than half of the 45 counties that responded didn’t have any examiners. Just seven counties reported they had nurses trained to respond to cases that involve children.

“We’re failing people,” Wangerin said. “We’re re-traumatizing them by not knowing what to do.”

First Step, in Missoula, is one of the few full-time sexual assault response programs in the state. It’s operated by Providence St. Patrick Hospital but is separate from the main building.

The clinic’s walls are adorned with drawings by kids and mountain landscapes. The staff doesn’t turn on the harsh overhead fluorescent lights, choosing instead to light the space with softer lamps. The lobby includes couches and a rocking chair. There are always heated blankets and snacks on hand.

First Step stands out for having nurses who stay. Kate Harrison waited roughly a year to join the clinic and is still there three years later, in part because of the staff support.

The specially trained team works together so no one carries too heavy a load. While being on night shift means opening the clinic alone, staffers can debrief tough cases together. They attend group therapy for secondhand trauma.

Harrison is a cardiac hospital nurse during the day, a job that sometimes feels a little too stuck to a clock.

At First Step, she can shift into whatever role her patient needs for as long as they need. Once, that meant sitting for hours on a floor in the lobby of the clinic as a patient cried and talked. Another time, Harrison doubled as a DJ for a nervous patient during an exam, picking music off her cellphone.

“It’s in the middle of the night, she just had this sexual assault happen, and we were just laughing and singing to Shaggy,” Harrison said. “You have this freedom and grace to do that.”

When the solo work is overwhelming or she’s had back-to-back cases and needs a break, she knows a co-worker would be willing to help.

“This work can take you to the undercurrents and the underbelly of society sometimes,” Harrison said. “It takes a team.”

That includes co-workers like Towarnicki, who dropped her work hours at her day job after having her son to keep working as a sexual assault nurse examiner. That meant adding three years to her student loan repayment schedule. Now, pregnant with her second child, the work still feels worth it, she said.

On a recent night, Towarnicki was alone in the clinic, clicking through photos she took of her last patient. The patient opted against filing a police report but asked Towarnicki to log all the evidence just in case.

Towarnicki quietly counted out loud the number of bruises, their sizes and locations, as she took notes. She tells patients who have gaps in their memories that she can’t speculate how each mark got there or give them all the answers they deserve.

But as she sat in the blue light of her computer screen long after her patient left, it was hard to keep from ruminating.

“Totally looks like a hand mark,” Towarnicki said, suddenly loud, as she shook her head.

All the evidence and her patient’s story were sealed and locked away, just feet from a wall of thank-you cards from patients and sticky notes of encouragement among nurses.

On the harder evenings, Towarnicki takes a moment to unwind with a pudding cup from the clinic’s snacks. Most often, she can let go of her patient’s story as she closes the clinic. Part of her healing is “seeing the light returned to people’s eyes, seeing them be able to breathe deeper,” which she said happens 19 out of 20 times.

“There is that one out of 20 where I go home and I am spinning,” Towarnicki said. In those cases, it takes hearing her son’s voice, and time to process, to pull her back. “I feel like if it’s not hard sometimes, maybe you shouldn’t be doing this work.”

It was a little after 11 p.m. as Towarnicki headed home, an early night. She knew her phone could go off again.

Eight more hours on call.

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It started in places like Livingston, a town of 8,300 where, in 2018, Western closed an outpatient treatment clinic and told more than 100 patients to travel 30 miles over a mountain pass to Bozeman for stabilizing mental health care. This spring, Western closed that clinic too, a crisis center in one of Montana’s fastest-growing cities.

The private nonprofit’s initial closures were attributed to state Medicaid cuts made in 2017. Since then, Western’s financial troubles have spiraled. It cut jobs or retrenched services every year since 2019. In February, Western closed three mental health crisis centers, leaving just two others to serve the rural 147,000-square-mile state.

Western’s money problems have built slowly and are due largely to low reimbursement rates from Medicaid, staffing strains, and rising costs. Former Western board members and employees say poor management has also played a role. The company has said it is losing money by subsidizing crisis services for the state.

“We’ve become the face of the failure of the system because we’re the only organization providing these services,” said Levi Anderson, Western’s CEO.

The decline illustrates a national problem: a U.S. health care system that doesn’t adequately pay for mental health care. Clinics nationwide have shuttered programs they can’t afford and left beds empty that they can’t staff.

“Those are the kinds of stories that I hear every week from every part of the country,” said Chuck Ingoglia, CEO of the National Council for Mental Wellbeing. “More people are experiencing depression and anxiety and are in need of care, and we have this corresponding reduction in capacity. It’s a perfect storm.”

Cracks in Montana’s system have shown up elsewhere. Community clinics can’t compete for staff. Private practice therapists have months-long waitlists. The Montana State Hospital — a public psychiatric hospital and the fallback when local services aren’t enough — lost federal funding after staffing shortages and mismanagement led to patient deaths and assaults.

Policymakers have promised to boost funding for behavioral health care statewide through bills and budget measures. Health professionals, while hopeful, are skeptical that an influx of cash is enough to create lasting changes.

Community crisis centers are a safety net when someone’s mental health spirals, leading to suicidal thoughts or disconnection from reality. They provide services to stabilize patients and prevent recurring crises.

Western opened such centers in Butte, Bozeman, Helena, Kalispell, Polson, Missoula, and Hamilton starting in 2010.

“Of all of the crisis houses in the state, every one of them was started and operated by Western,” said Tom Peluso, a longtime mental health advocate and former board director for Western. “Nobody else was willing to make the investment.”

Still, almost every community in Montana lacked crisis stabilization services, according to a state-funded report released last year. Emergency rooms and the state hospital became ill-equipped alternatives.

Most of Western’s patients rely on Medicaid, a federal-state health coverage program for people with low incomes or disabilities. Health professionals have long said Medicaid’s state-set payments don’t cover the cost of care, which a state-commissioned study confirmed.

Anderson said crisis services never made money. Until recently, Western could rely on other programs to make up the difference, such as case management, which links patients to ongoing care.

In 2017, the state roughly halved Medicaid’s reimbursement for case management. By 2019, Western spent $3.4 million more than it earned.

Then came the covid-19 pandemic, which disrupted school-based mental health services, another Western revenue source, as learning went remote. Simultaneously, competition for health workers spiked, meaning Western had to increase pay or ratchet back services with fewer employees.

In 2020, the company whittled its school-based programs, laid off dozens of mental health workers, and closed at least two sites. In 2021, it emptied a group home in Hamilton and listed two large affordable housing units for sale. Last year, Western closed a crisis facility in Kalispell and struggled to staff its remaining crisis centers.

As services faltered, so did people’s trust in Western. That included Peluso, who left the company’s board last year after roughly two decades. In his resignation letter, Peluso wrote that selling assets “is not a business plan.”

Kathy Dunks, a Western employee for 29 years in Butte, felt a shift around 2018, when Anderson and other new leaders arrived soon after the company’s longtime CEO retired.

“It was the first time it felt like, ‘If you don’t like it, leave,’” Dunks said.

She was laid off in 2019, when Western replaced regional leaders with managers to oversee company-wide programs. Dunks turned down a new role with Western, saying she no longer trusted the company.

Anderson said the goal was to standardize treatment among sites and save money. Around the same time, some of the company’s highest-paid employees got raises, which Anderson said likely happened to retain top-trained staffers at the time.

Anderson said that the company is balancing services clients need with remaining viable and that it tries to incorporate employees’ feedback. He said management restructuring led to some turnover, but the pandemic and low funding exacerbated long-standing pressures.

At its peak, 17 counties paid Western to provide local services. As the company struggled, the participating counties dropped off to just one as of this year.

In 2020, Anaconda-Deer Lodge County ended its contract with Western, which helped it provide crisis response and psychiatric evaluations.

“We started running into problems with them saying, ‘Well we don’t have anybody who can come out now, we’ll send out somebody in the morning,’” said County Attorney Ben Krakowka. “That doesn’t work when somebody’s in crisis now.”

In late 2019, Lewis and Clark County announced it would end its contract with Western to provide services in its detention center. County officials said they’d hire their own staff for better access to data and more control. The county also announced it would seek applicants for its crisis response team, a service Western provided.

Western cut ties with the county altogether, including closing the area’s sole crisis facility. Anderson said the company had been clear: Western needed to provide a continuum of care to do its job well.

While Lewis and Clark County has filled some gaps since, its crisis house remains closed. The one company that applied for the job determined reimbursement rates would cover only half the costs.

Some jurisdictions, like Gallatin County, which ended its contract with Western in 2022, plan to open crisis facilities with different providers at the helm. Anderson said new vendors alone can’t fix Montana’s problems.

“Our current state is not a result of Western not knowing how we could provide good care,” Anderson said. “The current state is a result of the state not funding good care.”

Lawmakers are considering a bill that would spend $300 million over several years toward fixing the state’s behavioral health care system. They’re also considering a constitutional amendment to establish a mental health trust fund. That would be in addition to a fund Republican Gov. Greg Gianforte created to fill gaps in mental health care, though some details remain undecided and competition for those dollars will be high.

State representatives also proposed to raise Medicaid reimbursement rates but haven’t agreed by how much. Mental health workers have said adjusted Medicaid rates are only a stopgap, and crisis services can’t rely on those payments alone.

Montana state officials are exploring a statewide program to fund specially designated clinics that offer local mental health and substance abuse services — paying for the value of the care instead of each service independently.

“We’ve got to change the system,” said Mary Windecker, executive director of Behavioral Health Alliance of Montana.

The Montana Department of Public Health and Human Services received a federal grant to begin making plans to adopt that system. But if that change comes, it’s years out.

Meanwhile, mental health clinics are struggling to keep existing programs from further unraveling.

As for Western, Anderson said the center is still committed to serving clients. Western is using former crisis beds to expand group home programs and began accepting new residents in March.

For now, the company doesn’t plan to return to its former level of crisis services.

“The need is there,” he said. “We just can’t continue to subsidize the program.”

Western’s two remaining crisis centers are in Missoula and Ravalli counties — just 47 miles from each other in the vast state.

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