When budget cuts led Western Montana Mental Health Center to start curtailing its services five years ago, rural communities primarily felt the effect. But as the decline of one of the state鈥檚 largest mental health providers has continued, it鈥檚 left a vacuum in behavioral health care.
It started in places like Livingston, a town of 8,300 where, in 2018, Western closed an outpatient treatment clinic and 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鈥檚 fastest-growing cities.
The private nonprofit鈥檚 initial closures were attributed to made in 2017. Since then, Western鈥檚 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鈥檚 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.
鈥淲e鈥檝e become the face of the failure of the system because we鈥檙e the only organization providing these services,鈥 said Levi Anderson, Western鈥檚 CEO.
The decline illustrates a national problem: a U.S. health care system that doesn鈥檛 adequately pay for mental health care. Clinics nationwide have shuttered programs they can鈥檛 afford and left beds empty that they can鈥檛 staff.
鈥淭hose are the kinds of stories that I hear every week from every part of the country,鈥 said Chuck Ingoglia, CEO of the National Council for Mental Wellbeing. 鈥淢ore people are experiencing depression and anxiety and are in need of care, and we have this corresponding reduction in capacity. It鈥檚 a perfect storm.鈥
Cracks in Montana鈥檚 system have shown up elsewhere. Community clinics can鈥檛 compete for staff. Private practice therapists have months-long waitlists. The Montana State Hospital 鈥 a public psychiatric hospital and the fallback when local services aren鈥檛 enough 鈥 lost federal funding after staffing shortages and mismanagement led to .
Policymakers 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鈥檚 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.
鈥淥f all of the crisis houses in the state, every one of them was started and operated by Western,鈥 said Tom Peluso, a longtime mental health advocate and former board director for Western. 鈥淣obody else was willing to make the investment.鈥
Still, almost every community in Montana lacked crisis stabilization services, according to a released last year. Emergency rooms and the state hospital became ill-equipped alternatives.
Most of Western鈥檚 patients rely on Medicaid, a federal-state health coverage program for people with low incomes or disabilities. Health professionals have long said Medicaid鈥檚 state-set payments don鈥檛 cover the cost of care, which a
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鈥檚 reimbursement for case management. By 2019, 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, 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 and struggled to staff its remaining crisis centers.
As services faltered, so did people鈥檚 trust in Western. That included Peluso, who left the company鈥檚 board last year after roughly two decades. In his resignation letter, Peluso wrote that selling assets 鈥渋s not a business plan.鈥
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鈥檚 longtime CEO retired.
鈥淚t was the first time it felt like, 鈥業f you don鈥檛 like it, leave,鈥欌 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鈥檚 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鈥 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.
鈥淲e started running into problems with them saying, 鈥榃ell we don鈥檛 have anybody who can come out now, we鈥檒l send out somebody in the morning,鈥欌 said County Attorney Ben Krakowka. 鈥淭hat doesn鈥檛 work when somebody鈥檚 in crisis now.鈥
In late 2019, it would end its contract with Western to provide services in its detention center. County officials said they鈥檇 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鈥檚 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 with Western in 2022, plan to open crisis facilities with different providers at the helm. Anderson said new vendors alone can鈥檛 fix Montana鈥檚 problems.
鈥淥ur current state is not a result of Western not knowing how we could provide good care,鈥 Anderson said. 鈥淭he current state is a result of the state not funding good care.鈥
Lawmakers are that would spend $300 million over several years toward behavioral health care system. They鈥檙e also considering a constitutional amendment . 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 by how much. Mental health workers have said adjusted Medicaid rates are only a stopgap, and crisis services can鈥檛 rely on those payments alone.
Montana state officials a statewide program to fund specially designated clinics that offer local mental health and substance abuse services 鈥 paying for the value of the care instead of each service independently.
鈥淲e鈥檝e got to change the system,鈥 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鈥檚 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鈥檛 plan to return to its former level of crisis services.
鈥淭he need is there,鈥 he said. 鈥淲e just can鈥檛 continue to subsidize the program.鈥
Western鈥檚 two remaining crisis centers are in Missoula and Ravalli counties 鈥 just 47 miles from each other in the vast state.