Kate Clyatt is one of those seasonal workers. She’s 28 and works as a ranch hand in the unincorporated community of Helmville, Mont., where there’s a saloon, rodeo grounds, two churches, a K-8 public school and a post office. In the sweeping ranchland surrounded by mountains, there are also a lot of cows.

On a typical morning, Clyatt is moving cattle — coiling up an electric fence on a spool and whistling to encourage the herd to move along.

She wears a snap-collared flannel shirt tucked into bluejeans, and a sweat-stained cap that keeps the sun from her eyes. She also wears a brace on her right wrist — support for an injury she got when she rolled a four-wheeler a couple weeks earlier.

Clyatt explains that she stayed on her parents’ health care plan until she was 26, as allowed by the Affordable Care Act. Then, when she aged out, she signed up for Montana’s expanded Medicaid program.

“Ranching is just not a job with a lot of money in it,” Clyatt said. “I don’t know at what point I’m going to be able to get off of Medicaid.” To qualify for Montana Medicaid, a program jointly funded by the state and the federal government, individual adults must make no more than around $17,000 dollars a year.

Herding cattle is a hard way to make a living, Clyatt says. But, like a lot of Montanans, she loves working outside.

“There’s a lot of seasonal work in our parks,” Clyatt said, “in our forest systems, guiding — bringing income into this state. I mean, there is just a lot of seasonality to a lot of the quintessentially Montana jobs.” Such work and income may ebb and flow, but the need for medical coverage doesn’t.

Clyatt doesn’t keep track of her work hours; she gets paid by the month. And she’s unclear how that might fit into Montana’s new law that says certain Medicaid enrollees need to prove they work or do other “community engagement activities” for at least 80 hours a month to receive care.

Those required “community engagement activities” can also include vocational education, substance use disorder treatment and community service, among other options.

A part of Montana’s new law does attempt to carve out exemptions for workers in seasonal jobs, but the state health department is still developing what that will look like.

Those who don’t meet the exemptions will have to report their compliance with the requirements. For rural workers like Clyatt, that constant reporting could be difficult — she only gets cell service at the stop sign on the edge of town.

When work and reporting requirements went into place in Arkansas last year, 18,000 people lost health coverage. Arkansas, Kentucky and  all have seen their “work requirement laws” blocked this year, as a federal judge raised questions about what the policy could mean in terms of a potential loss of health care coverage.

Backers of the work requirements in Montana say a legal fight may also challenge the policy, which narrowly passed in the state’s 2019 legislative session. But until that happens, or the Supreme Court takes up one of the other state’s cases, Montana will keep rolling out its plan.

, with the Montana Budget and Policy Center, an organization that advocates for social services for people who have low incomes, says health coverage losses like those experienced in Arkansas are expected in Montana too.

“There are going to be a number of enrollees that will be subject to these requirements,” O’Loughlin said. “And what we’ve seen in other states — Arkansas in particular — is that the vast majority of those that are subject to the requirements … often have challenges in reporting their hours.”

After Montana state health department officials watched around 17,000 people in New Hampshire fail to comply with that state’s policy, Montana increased its estimate of how many residents it expects its own new law to impact.

State officials now project 4-12% of current Medicaid enrollees will be affected: They will either fail to meet the work requirements in the law, or won’t comply with the monthly reporting process regarding their work hours and status. That means up to 12,000 people could lose health coverage in Montana. (Like most adults on Medicaid across the U.S., the majority of enrollees in Montana are already working.)

The work-requirements policy passed the Montana legislature with unanimous support from Democrats and in May was signed by Gov. Steve Bullock — also a Democrat, who is now running for president on his track record of political wins in a state that leans conservative.

The policy was a political compromise.  in Montana was due to expire this summer, and Republicans refused to renew it without a work requirement. Even now, conservative leaders in the statehouse say the bill that passed didn’t go far enough and the work requirements are weak.

But Republican state Rep. Ed Buttrey, who helped push the “work requirements” bill into law, disagrees. He expects some people will lose health coverage, but said the requirements are not meant to be punitive.

“We never set a number of people to try to purposely disenroll,” Buttrey said. “We wanted to find out how many people are truly able-bodied and not working — who should be doing more to benefit themselves and their family, but weren’t.”

The Trump administration, which encourages states to add work requirements to Medicaid, claims such policies could improve health outcomes and get people out of poverty.

Montana submitted its workforce requirement proposal to the federal government at the end of August. According to the program’s timeline, the requirements would start in January 2020, if approved by the Trump administration.

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On a recent night, three Montana residents, who call themselves pain refugees, boarded an airplane from Missoula to Los Angeles. They say that finding doctors willing to treat chronic pain in Montana is almost impossible, and the only way they can get relief is to fly out of state.

Before Gary Snook dropped into his seat, he paused in the aisle, pressing his fingertips into his upper thigh. He bent his knees slightly and moved his hips side to side. He was getting in one final stretch before takeoff.

“My pain, it’s all from my waist down,” he said. “It’s like being boiled in oil 24 hours a day.” Snook has been taking opioids since he had spine surgery for a ruptured disk 14 years ago. After the operation, he says he was in so much pain he couldn’t work. He’s tried all kinds of things to get better.

“I got a surgery, epidural steroid injections, acupuncture, anti-inflammatories, physical therapy, pool exercises,” he said. “I’ve tried anything that anyone has ever suggested me to try. Unfortunately what I do right now is the only thing that works.”

Executive Officer Ian Marquand said his organization doesn’t play favorites. “The board does not encourage particular kinds of doctors, it does not discourage particular kinds of doctors. The door is open in Montana for any qualified, competent physician to come in and practice.”

But acknowledged that there’s fear around prescription painkillers in Montana’s medical community. He chairs the Montana Medical Association’s  on prescription drug abuse, and he said he does hear of doctors being more wary.

Mentel, who started practicing medicine in the 1990s, said that when he was training, medical education didn’t include treating long-term pain.

“The perfect tool, the perfect medicine that would take away a person’s pain and allow them to function normally does not yet exist,” he said. “So we are trying to use any tool, any means we can to help lessen the severity of their pain.”

Mentel said opioids do help some patients, but he hopes his generation of doctors will learn more about pain and understand ways to treat it beyond opioids.

In March, the Centers for Disease Control and Prevention published long-awaited  that said opioids should be the treatment of last resort for pain, and if used, should be combined with other treatments such as exercise therapy.

“Patients are in pain,” Mentel said. “We don’t have great tools for them and we need to recognize that this is going to be a chronic-disease state. They may be in pain for the rest of their lives. So … how do we treat them without actually harming them?” he said.

The California Solution

For Snook, relief is found at a small strip-mall clinic in suburban Los Angeles run by Dr. Forest Tennant, a former Army physician who says he has consulted for the National Institute on Drug Abuse, the National Football League and NASCAR.

He has about 150 patients, half of them from out of state.

Tennant says there are legitimate reasons to be concerned about opioids, and that’s why doctors need to specialize in pain management.

To an untrained physician, said, addicts and pain patients can look similar. “Doctors can get conned,” he said. “I think that it is true that we’ve had a lot of opioids that get out on the street, and people get them … whether it is heroin or a prescription opioid.”

But opioids can also help people, Tennant said. Because of that, he said, the drugs shouldn’t be stigmatized, but used responsibly.

“They are the last resort, when there is no other option. You don’t use them until everything else has failed,” he said.

Tennant is lobbying for a to guarantee more access to opioids for pain patients, so people like Snook don’t need to travel so far for a prescription.

“Had I stayed in Montana, I would have killed myself,” said Snook. “I just want humanitarian care, and I get that in California.”

This story is part of a reporting partnership with NPR, Montana Public Radio and Kaiser Health News, an editorially independent program of the .

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People in Butte who experience serious trauma or need specialty care rely on flights — air ambulances — to get them the help they need.

There were close to 3,000 air ambulance flights in Montana last year. And Amy Thomson of Butte was on one of them.

Last year, she was curled up among the medical bags in the back of a fixed-wing plane. Her 2-month-old daughter, Isla, had a failing heart, and the hospital that could help her was 600 miles away.

Thomson watched as Isla was placed in a small box strapped to a gurney inside the air ambulance.

Some air ambulance companies offer membership programs as protection from big bills. For an annual fee of about $60 to $100, patients face no cost beyond what their health insurance pays if they use that company’s services.

But, Laslovich said that doesn’t always work because a patient can’t always know who is going to pick them up.

There is a lack of understanding about the actual costs of running an air ambulance business, said Rick Sherlock, the president of the . The costs include specialized labor, training, equipment and fuel.

“So those cost drivers are there and [it’s necessary] to maintain readiness to respond 24 hours a day, seven days a week, 365 days a year,” Sherlock said.

He says some air ambulance companies remain out of insurance networks because they can’t always reach in-network deals that allow them to stay profitable.

“I think what you also have to look at is that negotiations between [air ambulance] companies and insurance companies take place when there’s good negotiations on both sides,” Sherlock said. “In situations where there may be only one or two insurance options in an area, it’s harder and harder to negotiate on a level playing field.”

For Laslovich, it comes down to one thing:  “You want to know what my personal opinion is about what the problem is? It’s money.”

There are three health insurance companies operating in Montana, and at least 14 air ambulance providers. At the time of Isla Thomson’s trip to Seattle Children’s Hospital, the Thomsons’ insurer, PacificSource, had no in-network agreements with any air ambulance company in the Thomsons’ area. ( did not return calls seeking comment.)

For people with insurance who think they’re protected against crippling health care bills, the cost of an air ambulance ride can be a shock.

Amy Thomson ended up not having to pay, but it took repeated appeals. According to Thomson, on the same day her family was arranging to meet with a lawyer, she was notified by her insurance company that it would pay an additional amount of about $30,000, on top of the $13,000 out-of-network fee, to the air ambulance company, and the air ambulance would waive the rest of the fee.

Isla Thomson turned 2 in November. She’s a healthy child with big blue eyes, but at times her mom still worries.

“Nobody takes a lifeflight for a joy ride. You’re not going on kayak.com and booking a lifeflight,” she said.

Thomson didn’t think the flight should be free, yet the huge bill felt wrong, too: “I ethically believe this is a part of healthcare. This is not some separate entity. There is something ethically wrong that these companies are profiteering off of people’s worst moments in their lives.”

A Montana interim legislative committee is investigating air ambulance companies’ wide range in pricing within the state. The state of Maryland has undertaken a .

In North Dakota, an air ambulance  for adding on the industry.

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“But that had an arson fire, and then we rebuilt that,” says Cahill, who performed abortions as a physician assistant for 38 years. “Then we had the anti-choice people try to arrest me for doing abortions when I wasn’t a doctor.”

The biggest blow occurred in March 2014. in a recent trial that Klundt took a hammer to the photos in Cahill’s office, poured iodine on the floor and tossed files from cabinets. Klundt damaged the building’s heating and plumbing and discharged a fire extinguisher. He said he broke into the clinic looking for prescription drugs.

Everything was destroyed in Cahill’s clinic.

“I’ve worked since I was 17,” she says. “Everything I’ve had, I’ve worked for.”

The clinic was in Kalispell, population 20,000. It’s the hub of the Flathead Valley, and the largest employer is Kalispell Regional Medical Center. In a town full of health care professionals, Cahill was the only one providing abortions.

“Because I was the only one, I got targeted,” she says.

Cahill’s clinic was a general family practice; her patients have had to find other health care. For abortion care, the options are more limited.

“Anytime a provider stops providing services, the need doesn’t go away,” Barcroft says. “Patients still need that care.”

The loss of Cahill’s clinic has been frustrating, Barcroft says.

“I know from talking with our providers that we have seen a definite increase of patients from the Flathead area,” she says.

Cahill says she worries most about poor women, or those from the town of Browning, on the Blackfeet Indian reservation.

“The disadvantaged are always the ones that lose,” Cahill says. “Now you’ve got people who are on Medicaid, or who are from Browning, and are teenagers.” It can be much harder for them to get to Missoula, she says. “I used to give gas money for people to go home. Now … it is just a harder struggle for them.”

Cahill says plenty of local physicians can perform abortions, but they’re afraid.

Samantha Avery trained under Cahill at All Families Healthcare. At the time, Avery thought about going to medical school to pursue a career like Cahill’s.

“I know that she wanted me to be the one to take over her clinic,” Avery says. “End even before all of this, I told her, ‘I just don’t know if I could do that to my family — my future family. I can’t be the Susan Cahill. I’m not that brave of a person.’ ”

Avery decided instead to work for the Public Health Department in Flathead County. She says it was hard for her to watch Cahill lose everything so quickly. The weight of the community’s opposition to abortion is difficult to counter, she says — citing Zachary Klundt, who was convicted in the attack against the clinic, as just one example.

Klundt’s mother was on the board of , which advocates for alternatives to abortion. She resigned after the attack.

Michelle Reimer, the executive director of Hope Pregnancy Ministries, says that what happened to Cahill and her clinic was terrible, and totally against her group’s mission.

“There is not a place for it in a Christian organization,” Reimer says. “There is always going to be the outlier, the one who represents us poorly, or who says the wrong thing, or — as we all would with a very volatile topic like abortion — expresses [himself or herself] passionately rather than logically. And I think we see that on both sides.”

Reimer says at the core of her faith is compassion — and telling a woman that regardless of what she chooses, she is loved.

In June, Klundt was sentenced to 20 years, with 15 years of that suspended. He was also ordered to pay restitution. In the courtroom, Klundt read Cahill an apology.

“I cannot even believe I did that to another soul,” he says. “But I did that to you. I know what it’s like to live with fear, and for me to do that to you is awful. And I am truly so sorry.”

He said his actions do not represent his faith.

For women in the Flathead Valley, Susan Cahill says, getting reproductive care is not any easier now that Klundt is sentenced. Her clinic is still gone.

This story is part of KHN’s reporting partnership with and .

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

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