Después de este brote relacionado con el restaurante Dave’s Sushi en Bozeman a finales de marzo y abril, la Administración de Alimentos y Medicamentos (FDA) realizó (llamadas Morel mushrooms en inglés). Encontró que estos hongos crudos o poco cocinados fueron los posibles culpables, y llevó a la agencia a emitir sus primeras pautas sobre cómo prepararlos.

Todavia “no se comprenden completamente las toxinas de las colmenillas que pueden causar enfermedades; sin embargo, utilizar procedimientos de preparación adecuados, como cocinarlos, puede ayudar a reducir los niveles de toxinas”, según la guía de la FDA.

Pero, Incluso entonces, sigue existiendo un riesgo, según la FDA: “Preparar y cocinar adecuadamente las colmenillas puede reducir el riesgo de enfermedad; sin embargo, no hay garantía de seguridad incluso si se los cocina antes del consumo”.

Jon Ebelt, vocero del Departamento de Salud de Montana, dijo que hay información de salud pública o literatura médica limitada sobre las setas colmenillas. Y las muestras tomadas de Dave’s Sushi no detectaron toxinas, patógenos, pesticidas o compuestos orgánicos volátiles o no volátiles específicos en los hongos.

Aaron Parker, propietario de Dave’s Sushi, dijo que las colmenillas son un “artículo de boutique”. En temporada, generalmente durante la primavera y el otoño, pueden costar $40 la libra, mientras que las compradas fuera de temporada cuestan cerca de $80 la misma cantidad, explicó.

Muchos prestigiosos libros de recetas describen cómo saltar las colmenillas para conservar el codiciado sabor a tierra. Parker dijo que en Dave’s, se vertía un salsa, a veces hirviendo, sobre los hongos crudos antes de servirlos. Después de su propia investigación, agregó que descubrió que hervirlos entre 10 y 30 minutos es la forma más segura de prepararlos.

Parker dijo que contactó a chefs de todo el país y descubrió que muchos, como él, se sorprendieron al enterarse de la toxicidad de las setas colmenillas.

“No tenían idea de que las colmenillas tenían este tipo de factor de riesgo inherente, independientemente de la preparación”, dijo Parker.

​Según el Código Alimentario de la FDA, la gran mayoría de las más de 5,000 especies de hongos carnosos que crecen naturalmente en América del Norte no han sido sometidas a pruebas de toxicidad. De las que se hicieron pruebas, 15 especies son mortales, 60 son tóxicas ya sea crudas o cocidas (incluidas las “falsas” morillas, que parecen morillas comestibles esponjosas) y al menos 40 son venenosas si se comen crudas, pero son más seguras cuando se cocinan.

La , una organización nacional sin fines de lucro cuyos miembros son expertos en hongos, registró 1,641 casos de intoxicaciones por hongos y 17 muertes entre 1985 y 2006. Ciento veintinueve de esos envenenamientos se atribuyeron a setas colmenillas, pero no se informó ninguna muerte.

Marian Maxwell, presidenta de divulgación de la Puget Sound Mycological Society, con sede en Seattle, dijo que cocinarlos descompone la quitina de los hongos, el mismo compuesto que se encuentra en los exoesqueletos de los mariscos, y ayuda a destruir las toxinas. agregó que las colmenillas pueden contener naturalmente un tipo de hidracina, una sustancia química que se usa a menudo en pesticidas o combustible para cohetes y que , afectando a las personas de distinta manera. La hidracina se elimina al cocinar, dijo, “pero algunas personas todavía sufren reacciones a pesar de que está cocida y la mayor parte de la hidracina se ha eliminado”.

Heather Hallen-Adams, presidenta del comité de toxicología de la North America Mycological Association, dijo que se ha demostrado que la hidracina existe en las colmenillas falsas, pero no es tan “clara” en las verdaderas, que fueron los hongos utilizados en Dave’s Sushi.

Las intoxicaciones alimentarias causadas por hongos en restaurantes son raras (se cree que el brote de Montana es uno de los primeros en el país relacionado con este hongo), y han ocurrido con poca frecuencia en el extranjero. En 2019, un brote de intoxicación alimentaria por colmenillas en un restaurante con estrella Michelin en España enfermó a unos 30 clientes. Una mujer que comió los hongos murió, pero luego se determinó que . En 2019 se sirvieron colmenillas crudas en una ensalada de pasta en Vancouver, Columbia Británica, que envenenaron a 77 consumidores, aunque ninguno murió.

Antes de que se emitieran las nuevas directrices, la guía de la FDA para los estados era únicamente que servir hongos silvestres debía ser aprobado por una “autoridad reguladora”.

El prohíbe la venta de hongos silvestres en restaurantes u otros establecimientos de alimentos a menos que haya recibido la aprobación para venderlos, aunque los hongos silvestres cultivados pueden venderse si las operaciones de cultivo son supervisadas por una agencia reguladora, como fue el caso de las colmenillas en Dave’s Sushi.

Las regulaciones estatales varían, según realizado por el Departamento de Salud Pública de Georgia e incluido en las pautas regulatorias de la Association of Food and Drug Officials. Por ejemplo, Montana y media docena de otros estados permiten que los restaurantes vendan setas silvestres si provienen de un vendedor autorizado, según el estudio. Otros 17 estados permiten la venta de hongos silvestres que hayan sido identificados por un experto acreditado por el estado.

El estudio encontró que los diversos recursos que utilizan los estados para identificar hongos silvestres seguros (incluidas las asociaciones que reúnen a expertos, académicos y la industria de servicios alimentarios) pueden sugerir la necesidad de una mejor comunicación.

El estudio reconoció un “documento de orientación” como el “paso adelante más importante” dada la variedad de regulaciones y la demanda de hongos silvestres.

Hallen-Adams dijo que la “gente que sabe de hongos” sabe que las colmenillas crudas son venenosas, pero eso no es de conocimiento común entre los chefs.

En el caso de Dave’s Sushi, dijo Hallen-Adams, era obvio que la información de seguridad no llegó a las personas que la necesitaban. “Y esto podría ser algo que podría abordarse mediante el etiquetado”, afirmó.

Agregó que no se ha puesto mucho énfasis en garantizar que los consumidores sepan cómo preparar adecuadamente los hongos, “y eso es algo que debemos empezar a hacer”.

Hallen-Adams, que capacita a personas en Nebraska sobre la identificación de hongos, dijo que la North America Mycological Association planeaba actualizar su sitio web e incluir información más destacada sobre la necesidad de cocinar los hongos, con una mención específica a las setas colmenillas.

El Departamento de Salud de Montana tiene la intención de publicar directrices sobre la seguridad de las colmenillas en la primavera, cuando se acerca la temporada de hongos.

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The FDA conducted an after the severe illness outbreak linked to Dave’s Sushi in Bozeman in late March and April. The investigation found that undercooked or raw morels were the likely culprit, and it led the agency to issue its first guidelines on preparing morels.

“The toxins in morel mushrooms that may cause illness are not fully understood; however, using proper preparation procedures, such as cooking, can help to reduce toxin levels,” according to the FDA guidance.

Even then, a risk remains, according to the FDA: “Properly preparing and cooking morel mushrooms can reduce risk of illness, however there is no guarantee of safety even if cooking steps are taken prior to consumption.”

Jon Ebelt, spokesperson for Montana’s health department, said there is limited public health information or medical literature on morels. And samples of the morels taken from Dave’s Sushi detected no specific toxin, pathogen, pesticide, or volatile or nonvolatile organic compound in the mushrooms.

Aaron Parker, the owner of Dave’s Sushi, said morels are a “boutique item.” In season, generally during the spring and fall, morels can cost him $40 per pound, while morels purchased out of season are close to $80 per pound, he said.

Many highly regarded recipe books describe sauteing morels to preserve the sought-after, earthy flavor. At Dave’s, a marinade, sometimes boiling, was poured over the raw mushrooms before they were served, Parker said. After his own investigation, Parker said he found boiling them between 10 and 30 minutes is the safest way to prepare morel mushrooms.

Parker said he reached out to chefs across the country and found that many, like him, were surprised to learn about the toxicity of morels.

“They had no idea that morel mushrooms had this sort of inherent risk factor regardless of preparation,” Parker said.

According to the FDA’s Food Code, the vast majority of the more than 5,000 fleshy mushroom species that grow naturally in North America have not been tested for toxicity. Of those that have, 15 species are deadly, 60 are toxic whether raw or cooked — including “false” morels, which look like spongy edible morels — and at least 40 are poisonous if eaten raw, but safer when cooked.

The , a national nonprofit whose members are mushroom experts, recorded 1,641 cases of mushroom poisonings and 17 deaths from 1985 to 2006. One hundred and twenty-nine of those poisonings were attributed to morels, but no deaths were reported.

Marian Maxwell, the outreach chairperson for the Puget Sound Mycological Society, based in Seattle, said cooking breaks down the chitin in mushrooms, the same compound found in the exoskeletons of shellfish, and helps destroy toxins. Maxwell said morels may naturally contain a type of hydrazine — a chemical often used in pesticides or rocket fuel that — which can affect people differently. Cooking does boil off the hydrazine, she said, “but some people still have reactions even though it’s cooked and most of that hydrazine is gone.”

Heather Hallen-Adams, chair of the toxicology committee of the North American Mycological Association, said hydrazine has been shown to exist in false morels, but it’s not as “clear-cut” in true morels, which were the mushrooms used at Dave’s Sushi.

Mushroom-caused food poisonings in restaurant settings are rare — the Montana outbreak is believed to be one of the first in the U.S. related to morels — but they have happened infrequently abroad. In 2019, a morel food poisoning outbreak at a Michelin-star-rated restaurant in Spain sickened about 30 customers. One woman who ate the morels died, but her death was . Raw morels were served on a pasta salad in Vancouver, British Columbia, in 2019 and poisoned 77 consumers, though none died.

Before the new guidelines were issued, the FDA’s to states was only that serving wild mushrooms must be approved by a “regulatory authority.”

The FDA’s Food Code bans the sale of wild-picked mushrooms in a restaurant or other food establishment unless it’s been approved to do so, though cultivated wild mushrooms can be sold if the cultivation operations are overseen by a regulatory agency, as was the case with the morels at Dave’s Sushi. States’ regulations vary, according to by the Georgia Department of Public Health and included in the Association of Food and Drug Officials’ regulatory guidelines. For example, Montana and a half-dozen other states allow restaurants to sell wild mushrooms if they come from a licensed seller, according to the study. Seventeen other states allow the sale of wild mushrooms that have been identified by a state-credentialed expert.

The study found that the varied resources states use to identify safe wild mushrooms — including mycological associations, academics, and the food service industry — may suggest a need for better communication.

The study recognized a “guidance document” as the “single most important step forward” given the variety in regulations and the demand for wild mushrooms.

Hallen-Adams said raw morels are known to be poisonous by “mushroom people,” but that’s not common knowledge among chefs.

In the Dave’s Sushi case, Hallen-Adams said, it was obvious that safety information didn’t get to the people who needed it. “And this could be something that could be addressed by labeling,” she said.

There hasn’t been much emphasis placed on making sure consumers know how to properly prepare the mushrooms, Hallen-Adams said, “and that’s something we need to start doing.”

Hallen-Adams, who trains people in Nebraska on mushroom identification, said the North American Mycological Association planned to update its website and include more prominent information about the need to cook mushrooms, with a specific mention of morels.

Montana’s health department intends to publish guidelines on morel safety in the spring, when morel season is approaching.

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But even with these two new pools of money intended to last two years, the state’s schools may struggle to remove all but the most dangerous sources of lead, considering about half the schools that tested their water between July 2020 and February 2022 found high lead levels. Medical experts say of lead is safe to ingest.

“When you start replacing faucets and drinking fountains in the hundreds of schools that we have in Montana, that gets eaten up pretty quickly,” said Democratic state Rep. , who added the state funding to an passed this spring.

If the total were divided evenly among the approximately 590 schools that need to meet the state’s new lead testing rules, each school would receive less than $8,000 from the state to test and upgrade its faucets, pipes, and water fountains. The state already knows that 110 schools have had at least one water fixture with lead levels of 15 parts per billion or higher, three times the level that requires action under Montana rules.

Most schools with lead levels over the state limit could address their “exceedances” with the state money, according to state Department of Environmental Quality spokesperson Moira Davin. “Our plan is to address as many schools as possible with this funding,” she said.

But part of the challenge for Montana is that it doesn’t yet know how extensive a problem its schools have. More than a fifth of the state’s schools facing the new rules — 129 facilities — hadn’t completed any sampling as of Aug. 3, said Greg Montgomery, director of the department’s program. And replacing a single school’s pipes can cost hundreds of thousands of dollars.

, an environmental health instructor at the Harvard T.H. Chan School of Public Health, said that the money Montana has in hand is not a lot when it comes to fixing pipes but that it could be enough to get filters on all the faucets.

“We are not talking about solving the whole problem here,” said Levin, who worked on lead exposure during her nearly 40 years at the U.S. Environmental Protection Agency.

Lead is particularly and can lead to brain and nervous system damage and slowed development and growth. It typically gets into drinking water in schools through piping or fixtures. A 2020 requires schools to test water supplies every three years. If lead concentrations surpass 5 parts per billion, fixtures must be addressed — and shut off if higher than 15 ppb.

, an economics professor at Amherst College, said prioritizing fountains or pipes with high lead levels after a “first draw” test could help a lot. The test measures lead in water the first time a faucet is turned on for the day, after the water’s been sitting in a pipe all night. That sample provides the best data to pinpoint the greatest risks, she said.

Running all faucets for a few minutes before kids get to school is quite protective for kids, Reyes added, because the quantity of lead diminishes as the water runs. But Reyes often imagines a kindergartner getting to school early for free breakfast and drinking from a water fountain before anyone in the building clears the pipes.

“Everything kids need to grow — lead is the opposite of those,” Reyes said.

Montana officials will decide how to distribute the money from the legislature, reimbursing schools for costs such as installing new faucets, water filters, plumbing, and water bottle filling stations. The federal grant, meanwhile, will be used for covering costs related to testing, Montgomery said.

Schools will have to participate in the state’s Lead in Schools program by sampling their drinking water to get any of the state funding, he said, and they won’t be able to use the money on projects completed before the state bill was signed into law.

Montgomery said the amount available to schools would depend on whether they have any fixtures over the “action level,” or fixtures with lead concentrations over 5 ppb. Funding will be prioritized on a first-come, first-served basis, he said.

Even if a school doesn’t have high samples of lead in its test results, Montgomery said, it could seek money to install water bottle filling stations with filters. Schools could also use the money for larger projects such as replacing piping, but, Montgomery said, the state will set a limit on how much each school can get. And, he said, it’s unlikely the money will be able to cover something like a $100,000 pipe replacement project.

The goal is to make money available to all schools, regardless of size, and ensure a couple of schools aren’t “gobbling” the entire amount, Montgomery said. That means schools with extensive issues will likely need to pick which areas to fix.

“We want to make sure the small schools have equal footing as the large schools,” Montgomery said.

Many Montana schools have already launched remediation projects after receiving high lead results.

One sink at Skyview High School in Billings had one of the highest levels of lead detected in schools across the state. Scott Reiter, the executive director of facilities for Billings Public Schools, said the sink was in a control room in the auditorium and people rarely used it. After the results came in, the fixture was removed to make the sink unusable.

On a larger scale, he said, all cold-water piping for drinking and sinks was replaced at Rimrock Learning Center in Billings last summer. Reiter said the school had been remodeled and all fixtures replaced about five years ago, so when lead was detected all over the school, it was clear it wasn’t just one fixture.

“We knew that it had to be in the lines,” Reiter said.

Reiter said the school district used leftover money from a 2013 elementary school district bond to replace Rimrock’s pipes, which he estimated cost $100,000.

While Reiter said he was disappointed costs from the Rimrock pipe replacements and other projects that have already happened couldn’t be reimbursed retroactively, he welcomed the state’s additional funding. “Any help to the schools for something like this is great,” he said.

The Great Falls Public Schools district also exemplifies how extensive and expensive such work can be. The district used $19,511 from an earlier $40,000 state allocation for drinking fountains, water bottle fillers, and filters across schools in the district, said Brian Patrick, its director of business services and operations. He said the district also got 783 tests covered by the state, each costing $25.

His district used a bond passed in 2017 to fund a pipe replacement at Lewis and Clark Elementary School, where 23 tests came in at 5 ppb or higher. The pipes were replaced last summer, Patrick said, costing $411,252.

“It doesn’t get fixed in one fell swoop,” Patrick said.

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Jones, who is 31 and lives in Belgrade, Montana, said she had “zero control over what was going on” during her hospital birth. Jones wanted a midwife to help deliver her third child, and after finding one she clicked with, she decided to go with a home birth.

“I felt like I was in control of everything and she was there to listen to what I needed from her,” Jones said.

The only downside, from Jones’ perspective, was that her insurance didn’t cover home births attended by a midwife as an in-network service. Jones paid about $5,500 out-of-pocket.

Home births . In Montana, they accounted for 2.85% of all births in 2021, behind Idaho’s nation-leading 3.56% but still the sixth-highest rate in the country. Women who choose home births say they can provide a more familiar setting and a more natural experience than a hospital birth, along with the greater control cited by Jones. Doctors say hospital births are generally safer but that home births can also be a safe choice for many low-risk pregnancies.

Montana’s Republican-dominated legislature this year moved to support home births with a measure requiring they be covered by Medicaid and another that expands the types of drugs midwives can administer. Republican Gov. Greg Gianforte signed the bills into law in April.

Montana Republicans touted the moves as evidence of their commitment to women and families at a time when they were passing strict abortion limits. Since the legislative session ended in May, Gianforte has signed into law bills limiting abortion access, including a after 15 weeks. The governor also for new mothers on Medicaid to 12 months in the state budget, and approved an .

“Advancing his pro-life, pro-child, pro-family agenda, the governor supported extending Medicaid coverage for mothers to 12 months postpartum, and proudly introduced an adoption tax credit and a child tax credit in his Budget for Montana Families,” Gianforte spokesperson Kaitlin Price said via email.

The child tax credit has not been signed into law.

Kelly Baden, vice president for public policy at the Guttmacher Institute, a national research and policy organization that studies reproductive rights, said the new home-birth laws and postpartum care expansion are among the supports reproductive safety professionals have been pushing for decades.

“Anything a state can do that helps improve the economic or health care coverage of people is important,” Baden said, adding that those things don’t need to be done as political cover for abortion restrictions.

The new laws would not have helped Jones: Whether insurance covers home births in Montana varies by policy, and Jones’ insurance declined to cover her home birth because it was out of network.

But the passage of , which adds most home births to Medicaid-covered services, is a boost for women enrolled in the federal-state health coverage program for low-income residents. The average in a hospital in Montana is $11,938.

Lindsey Erin Ellis, co-founder of the Montana Birth Collective, is a doula, or someone who provides emotional support during pregnancy rather than the medical care of a midwife. She said while the cost of giving birth outside a hospital is less, the out-of-pocket expense for a patient can be more if they lack insurance coverage.

“Having Medicaid is huge because those midwives can then accept those clients and be paid for their work,” Ellis said.

The legislation on the medications midwives can administer brings Montana into alignment with the nearby states of Idaho, Colorado, and Washington, and enhances patient safety, said Amanda Osborne, vice president of the board of the Montana Midwifery Association.

That measure, , allows midwives to administer IVs, antibiotics to prevent infections in babies, oxygen, and prescription drugs that help stop hemorrhaging, all of which Osborne described as the “standard of care for pregnant women” and which midwives have the training to administer. The bill does not address pain medications.

Prior to the 2023 law, Osborne said, midwifery laws in Montana were last updated in the 1990s and midwives were not able to administer basic, lifesaving medications.

“I think women and babies deserve safe care no matter where they decide to give birth,” Osborne said.

Home births are a safe option for low-risk pregnancies and healthy babies, Osborne said. If a pregnancy becomes higher-risk, the patient is transferred to a physician’s care. High-risk indicators include high blood pressure, gestational diabetes, and carrying twins, Osborne said.

Recent trends suggest home births will continue to tick up. And while some practitioners praised the new laws, issues of cost and access aren’t going away.

Averee Chifamba, who has a midwifery practice in Bozeman called Saddlepeak Birth, was the midwife for Jones’ home birth. Of the roughly three dozen licensed midwives in Montana, there are eight — soon to be nine — in Bozeman, Chifamba said, and most of the home-birth practices there are full.

Chifamba said HB 392 increases midwives’ drug prescribing privileges to the standard of care for other health care professionals. But HB 655 is a “hard one” for her because the Medicaid reimbursement rate is so low, Chifamba said.

“We love the idea that it opens up the availability, that if we want to serve Medicaid families as a small business, we can now; it’s just whether that’s going to be worth the hit the midwife is going to take financially,” Chifamba said.

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The session likely will be remembered for GOP leaders , one of two transgender representatives in the Capitol, from House floor debates. That the ban has distracted from approvals of unprecedented increases in Medicaid mental health and provider reimbursement rates is unfortunate, said Mary Windecker, executive director of the Behavioral Health Alliance of Montana.

“We’ve never talked about these kinds of numbers before,” Windecker said.

Lawmakers also passed major bills related to abortion, behavioral health, transgender rights, workforce issues, and insurance requirements. Some, like the Medicaid reimbursement hikes, were greeted with cheers. Others, with threats of legal challenges.

Medicaid Reimbursement

Windecker said several factors provided momentum for Medicaid provider rate increases, including the covid-19 pandemic and pressure from providers and facilities after the legislature cut rates to the bone in 2017 amid a budget shortfall.

Back then, lawmakers cut nearly $50 million from the Department of Public Health and Human Services budget, a devastating blow for providers, with long-term ramifications. Last year, 11 nursing homes in Montana closed their doors, citing low provider rates as a chief cause.

By contrast, lawmakers went into this session with a $2.5 billion surplus in the state budget, which lawmakers and providers said should be used to rebuild the state’s health care system.

The legislature commissioned after the last session to look at Medicaid provider reimbursement rates in areas like behavioral health, long-term care, and developmental disability services. Throughout the session, lawmakers heard hours of testimony from providers and patients asking lawmakers to fully fund the provider rates the study identified as covering the average cost of services.

During the last discussion on the state budget, on May 2, Republican Rep. Llew Jones — chair of the House Appropriations Committee — lauded the two-year budget for exceeding the 100% benchmark for provider rates.

Democratic Rep. Mary Caferro made a distinction between the next two fiscal years. She said the funding falls short of the benchmark in the first year of the budget — by about $10 million.

“But you know what, it’s nothing to shake a stick at,” Caferro said. “I’m very, very happy that we got this far.”

Still, it will be important to watch how the boosted provider rates help the supply of services, what that means for caseloads, and whether the health department can start getting people off waitlists, said Montana Budget and Policy Center Executive Director Heather O’Loughlin.

According to Rose Hughes, executive director of the Montana Health Care Association, which advocates for nursing homes, the provider rates for nursing homes increased from $209 per patient per day to $262 the first year of the next biennium, and $278.75 the next.

“They’ve done a lot and the problem is that the challenges are also huge, and the workforce issues are huge, and it’s going to take time to see,” Hughes said. “I hope it works. I hope what they’ve done works.”

Abortion

Lawmakers passed 10 bills restricting abortion, five of which Republican Gov. Greg Gianforte signed in a ceremony on May 3.

Since the Supreme Court overturned Roe v. Wade in June 2022, Montana has been one of 20 states and the District of Columbia to . Abortion access is protected through the of the state’s constitution. Bills championed by the Republican supermajority chipped away at that protection and are expected to be challenged in court.

Among the new laws, takes the right to an abortion out of the constitutional privacy clause in an attempt to remove the legal justification for allowing continued abortion access. At the bill signing, Gianforte said this was one of the most important bills of the session.

is a version of a ballot measure, called the “born alive” referendum, that Montanans. HB 625 requires health care providers to give care to an infant born alive after an attempted abortion or face a fine and up to five years in prison.

, by the state health department, requires prior authorization and additional documentation for abortions to be covered by Medicaid or the Children’s Health Insurance Program. The health department adopted an administrative rule that would have the same effect, but a state judge amid a legal challenge.

prohibits the abortion of a “viable” fetus. Viability in the bill is presumed at 24 weeks and defined as the ability of a fetus to live outside the womb, including with artificial aid.

Another dilation and evacuation procedures, one of the most common ways of ending a pregnancy after 15 weeks.

Transgender Rights

, which prohibits certain surgical and medical treatments for youth with gender dysphoria, is the bill that sparked Zephyr to tell lawmakers that if they voted for it, and Gianforte’s amendments to it, they would have “blood on [their] hands,” referring to elevated among trans youth.

Gianforte signed SB 99 into law, as well as , which allows a student to call another student by a name or refer to them with pronouns they don’t use without legal disciplinary action. Opponents refer to it as a “deadnaming” bill.

Lawmakers also passed a and restricting where they can be held that was ultimately amended to replace “drag” with the descriptor “adult-oriented.” Another bill headed to Gianforte’s desk in a way that opponents say erases transgender, nonbinary, and two-spirit people from Montana code. The sponsor, Republican Sen. Carl Glimm, said the point is to distinguish sex from gender. That bill was to be transmitted to the governor.

Behavioral Health Investment

Gianforte and lawmakers from both parties started the session promising investment in behavioral health, including building community-based services and upgrading the beleaguered Montana State Hospital, which the governor outlined as .

Republican Rep. Jennifer Carlson’s , which would stop involuntary commitment of most patients with Alzheimer’s, traumatic brain injuries, or dementia to the Montana State Hospital, is awaiting a decision from the governor.

Gianforte also announced a $2.1 million grant to fund free, optional mental health and substance abuse screenings for schools statewide. The grant will also support same-day services for students assessed as being at high risk for suicide.

Another bill, which passed in the final hours of the session, would create a for behavioral health and set up a commission to oversee the funding allocation.

There was also some tug of war over Gianforte’s Healing and Ending Addiction through Recovery and Treatment, or , fund.

, sponsored by Caferro, makes it so youth suicide prevention programs can benefit from HEART funds. Carlson sponsored , which requires reporting on how HEART money is used. Both bills passed by wide margins and were signed into law.

Access and Workforce

Another one of the lawmakers’ goals at the beginning of the session was expanding patient access to health care.

The governor signed into law, allowing physician assistants to practice independently. Gianforte said in a statement that it will reduce patients’ barriers to health care, particularly in rural areas.

, also signed by the governor, expands pharmacists’ ability to prescribe certain drugs and devices that do not require a new diagnosis or are “minor and generally self-limiting.”

Lawmakers passed , which would allow behavioral health providers licensed in another state to practice in Montana.

Insurance Requirements

A handful of new insurance requirements are also on track to become law.

One bill waiting on the governor’s signature would copayments at $35 for a month’s supply.

Another diabetes-related bill would require coverage of 20 visits of in the first year of a patient’s diagnosis and 12 subsequent follow-ups. Meanwhile, a bill that would have of continuous glucose monitors died in the Senate.

Two bills signed by the governor and to be covered by insurance.

that would require insurance to cover 12 months of birth control is awaiting transmittal to the governor’s office, as is one that would require insurance coverage of fertility preservation for cancer patients.

Keely Larson is the Â鶹ŮÓÅ Health News fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Â鶹ŮÓÅ Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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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Twenty-three days after her cancer diagnosis, the 36-year-old Helena resident said, she had put $7,579 on three credit cards to pay for her out-of-pocket fertility preservation costs.

Her insurance didn’t cover it. In Montana, fertility preservation for newly diagnosed cancer patients whose pending treatment could cause infertility isn’t required to be covered by insurance.

On March 15, 2023, Beall finished her chemotherapy and began to lobby Montana’s legislature to change that.

Beall has taken the helm in advocating for that would require insurance to cover the initial costs of fertility preservation for people diagnosed with cancer. That includes requiring coverage of appointments with a reproductive endocrinologist and the retrieval of sperm, eggs, or embryos, but not their storage or procedures like in vitro fertilization.

Amid a to Montana’s legislative session, the bill, which has already been approved by the state Senate, is close to passing its final hurdle. The legislature is scheduled to end its 90-day session on May 5, which means the bill has just a few days before the House of Representatives will need to give it final approval before it heads to the governor’s desk.

The bill has bipartisan support, but Beall is worried about how lawmakers will respond to what she says is an inaccurate estimate of what it will cost. Beall said the bill’s prepared by state agencies contains a handful of errors. For example, Beall said, it assumes men’s and women’s fertility preservation costs the same. But the cost for sperm banking is around $700, while women can pay between $7,000 and $11,000, according to an estimate by Billings Clinic. The fiscal note also includes the cost of eight years of storage, which is not included in the bill, and budgets for 2.1 female fertility cycles.

According to Stacy Shomento, one of two reproductive endocrinologists in Montana, who practices at Billings Clinic, there has not been a cancer patient in their program who has undergone two rounds of fertility medication before starting cancer treatment since 2011.

Estimates from Blue Cross and Blue Shield of Montana place a $75,000-a-year price on the bill for the insurance company. Spokesperson John Doran said the company didn’t include costs for men in its estimation since they were “negligible,” and estimated that seven to 10 of their female members would use the coverage annually.

The bill would cost BCBS members about 12 cents extra a month, Doran said. Montana’s Department of Public Health and Human Services estimated a similar increase for Medicaid members.

The that a total of between 18 and 39 men and women each year would participate if the bill passes.

Insurance covers fertility preservation in .

When Beall started researching legislation, she called Democratic state Sen. Pat Flowers to ask if he thought a bill could succeed this session, and he said: “Let’s do it.”

Flowers’ wife was diagnosed with breast cancer when their two children were young. At an emotional hearing on April 14, Flowers said they were considering a third child but fertility preservation wasn’t much of a discussion, and, if it had been, it wouldn’t have been a financial option for a young family living paycheck to paycheck.

“I know we could not have afforded to spend $7,500 to make that happen,” Flowers said.

Cancer takes a lot from you, Beall said. But what fertility preservation offered was a sense of hope that she still had control over her future.

Beall and her boyfriend want to have kids. She was able to finance the out-of-pocket expenses for fertility preservation but acknowledged that not all young cancer patients can afford to do so, especially within such a short time frame.

Once a patient is diagnosed, oncologists want to start chemotherapy right away, and fertility preservation must happen as quickly as possible. Missing one payment can leave a patient’s timeline “screwed up,” Beall said, and there’s generally no payment plan.

“If you can’t finance this out-of-pocket, it’s too late for you, and you’ll have to go into whatever your next treatment is,” Beall said. “You’re going to know you’re going to be infertile and there was an option but you just couldn’t finance it, so your idea of a biological family is done.”

It was at one of the bill’s legislative hearings that Beall, for the first time, met another woman who had gone through the same thing she had.

Carley VonHeeder was diagnosed with Hodgkin lymphoma when she was 24. VonHeeder, now 25, said she was so “dissociated” through the process of starting cancer treatment and fertility preservation that she wasn’t processing it.

Meeting Beall was the first time she felt someone could appreciate all she’d gone through, VonHeeder said, and it made her feel more empowered each time she returned to the Capitol to testify.

“It filled a hole I didn’t even know I had,” VonHeeder said.

Aimee Grmoljez, a lobbyist for Billings Clinic, said in a hearing on the bill that fertility preservation is within the standard of care — doctors are required to tell patients about the option — yet it’s not covered by insurance.

Grmoljez said she couldn’t think of another procedure that falls along the same lines.

Shomento, Beall’s reproductive endocrinologist, said patients can see a specialist in Bozeman — where Shomento is — or in Billings, where the state’s only other specialist practices.

Shomento said most of her job is helping patients with general infertility, something she said about 1 in 6 or 8 couples deal with.

“It’s not going to affect an everyday person very much,” Shomento said. “But it’s going to affect the cancer person in a huge way.”

Becky Franks, CEO of Cancer Support Community Montana, said people generally think of cancer as an “old person’s disease.”

Franks said that 20 or 30 years ago the focus of cancer treatment was how to keep the patient alive. Now, Franks said, that has shifted to getting the patient “to truly live, and not just keep breathing.”

Blake Underriner was diagnosed with cancer at 14, which is also when he learned the treatment would make him infertile. His mom took him to an appointment to bank his sperm while he came to grips with starting chemotherapy.

Underriner, who lives in Billings, said he preserved the decision to have kids later in life when he preserved his sperm. Underriner married his wife in 2020 and now, at age 37, he has an 8-month-old daughter, Kennedy.

“She’s just so fun,” Underriner said. “She’s turning over in her crib when it’s naptime instead of taking a nap. She’s almost crawling. She’s just a bundle of joy.”

Keely Larson is the Â鶹ŮÓÅ Health News fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Â鶹ŮÓÅ Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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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“The thing that keeps me up at night is, am I doing a good job for my community?” Zephyr said.

Five days later, the anger bubbled over as Zephyr spoke against amendments from Republican Gov. Greg Gianforte to , which would prohibit minors with gender dysphoria from receiving certain medical and surgical treatments. Zephyr said the lawmakers who voted for the measure should be ashamed.

That prompted Republican Majority Leader Sue Vinton to speak. “We will not be shamed by anyone in this chamber,” Vinton said.

“Then the only thing I will say is: If you vote yes on this bill, and yes on these amendments, I hope the next time there’s an invocation, when you bow your heads in prayer, you see the blood on your hands,” Zephyr said in response.

Later that day, the Montana Freedom Caucus, a conservative group of lawmakers, released a statement calling for Zephyr’s censure for using “inappropriate and uncalled-for language.” The release and a Freedom Caucus used male pronouns to refer to Zephyr, leading to fresh outrage by LGBTQ+ supporters accusing Republicans of deliberately misgendering her.

Two days later, Republican House Speaker Matt Regier would not allow Zephyr to speak during a debate on another bill. Regier said it was because she had committed a breach of decorum.

With two weeks to go in the legislative session, Republican lawmakers, who are in the majority, are sponsoring anti-LGBTQ+ bills. There are at least four related measures, including the bill to ban gender-affirming care for minors.

Many similar bills are being heard in conservative-led statehouses across the U.S. The American Civil Liberties Union has tracked so far in 2023 legislative sessions.

Back in the Capitol on April 13, Zephyr stopped at a storytelling event presented by drag performers on the second floor. Parents, children, and supporters sat in folding chairs and on the floor while drag performers read stories.

Zephyr was visibly emotional. A short time later, former Democratic lawmaker Moffie Funk, who also attended the storytelling event, approached Zephyr to thank her for her work.

“I have just been so impressed to see the way Rep. Zephyr has handled questions on the floor, just keeps her calm, stays cool, and is so powerful in her words and so powerful in the way she represents her community and Montana,” Funk said.

Before the session, Zephyr said she had a goal of changing at least on LGBTQ+ issues.

One lawmaker who typically votes in favor of anti-transgender bills told Zephyr about having read something about her in a far-right blog and said, “That doesn’t sound like Zooey; she wouldn’t do that.” The lawmaker, whom Zephyr didn’t name, subsequently stopped reading the blog.

Proponents of measures like SB 99 and , a bill that would have banned minors from drag shows and would have banned events like drag storytelling in public schools or libraries, frame the legislation as necessary to protect children.

In a small victory for LGBTQ+ supporters, HB 359 was amended to remove references to drag performers and now would prohibit minors from attending “adult-oriented” shows.

Democratic Rep. SJ Howell, who is transgender and nonbinary and uses the pronouns “they” and “their,” has been working at the Capitol for a decade, first as a lobbyist and now as a lawmaker representing Missoula. In all their work, Howell said, it’s very clear that relationships matter. Progress is a long game, and it may take years to pass legislation that promotes the rights and recognition of transgender and nonbinary people, Howell said.

One thing that could hinder that progress is the national debate over anti-LGBTQ+ policy proposals.

Erin Reed, who describes herself as a queer writer and content creator, has been tracking the LGBTQ+ bills nationwide and is also Zephyr’s partner of almost a year.

Four years ago, the debate playing out in statehouses was over transgender rights in sports, Reed said, but that’s shifted. Now, a third of the bills target health care — like gender-affirming hormone therapy, mostly related to minors — and the rest focus on banning drag shows or the use of preferred pronouns and bathrooms, or targeting the rights of transgender people in insurance coverage and workplace protections.

But beyond the flood of anti-LGBTQ+ bills, at least have passed LBGTQ+ protections, Reed estimated.

Howell said it’s challenging being a state representative trying to focus on Montana when so much focus has been on this national issue.

Personally, Howell said, they came to the legislature to build relationships and make good policy, and they see many of their colleagues as friends.

“When the mutual respect isn’t present, it can be deeply frustrating and harmful, and we can do better as a body,” Howell said.

Republican Rep. Neil Duram sits between Zephyr and Howell on the House Judiciary Committee, which has heard all the LGBTQ+ bills this session. He said having both in the legislature better represents Montana.

“If it was just me, and 99 other people like me on the House floor, we may not set the best policy for the people of Montana,” Duram said.

Duram spoke during a House floor session discussing , which would allow classmates to refer to a transgender student by their birth name or gender assigned at birth, unless it crossed into bullying. He said he’s enjoyed getting to know Judiciary seatmate Zephyr and that he’ll make sure people aren’t “inflicting bullying behavior.”

Duram voted for HB 361. He said his decision was encouraged by his community.

“And, ultimately, that’s where my conscience is going to sit,” he said.

On the morning of April 13, Howell and Zephyr were hearing testimony before the House Judiciary Committee on a bill that would define sex in Montana law, . The vibe in the room felt heavy.

Sen. Carl Glimm, sponsor of SB 458, said the bill seeks to define the terms “sex,” “male,” and “female” in state law. Glimm said the bill was necessary because people conflate sex and gender and maintained the bill wasn’t about gender fluidity or expression.

“Gender is obviously something different than biological sex. Biological sex is immutable and that means you can’t change it, and there’s only two biological sexes,” Glimm said. “You may claim to be able to change your gender or express your gender in a different way, but you can never change your biological sex.”

LGBTQ+ advocates, like the Montana Human Rights Network, say that by defining people as simply male and female, the bill would legislate “transgender, nonbinary, and intersex people out of existence.” The Montana Human Rights Network said the definitions used in SB 458 were based “on an unscientific and archaic understanding of basic biology.”

About an hour after the hearing, people gathered outside the Capitol in an April snowstorm for a drag show.

Performers lip-synced for a crowd ranging from kids to college students to retired folks who were waving rainbow-colored flags and carrying umbrellas.

As “Rise Up” by Andra Day played in the background, Katie Fire Thunder said she came to the drag show from Bozeman to show her allyship with the LGBTQ+ community.

Fire Thunder called this session’s anti-LGBTQ+ bills “disgusting,” and said they don’t represent Montana or what young people care about. But having both Zephyr and Howell serving in the Capitol has made a major difference, Fire Thunder said.

“When things are really hard and there’s all these hateful people, they’re a little glimmer of hope,” Fire Thunder said.

Kole Burdick, 20, also of Bozeman, said it’s important to “uplift queer people and show moments of queer joy,” and commended Zephyr and Howell for their work.

“I think they’ve been working really hard to protect our community and keep our community safe, and I really appreciate them for that,” Burdick said.

Keely Larson is the Â鶹ŮÓÅ Health News fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Â鶹ŮÓÅ Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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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Prashar, now 14, did a finger stick, saw her blood sugar was 127, and went back to the mat. For most people with diabetes, the target range is , and up to 180 two hours after meals.

Prashar doesn’t have to check her blood sugar often. She wears a continuous glucose monitor, or CGM, that gives her blood glucose readings on her phone every five minutes. When she’s feeling differently than her CGM is showing, as on that March day at the gym, she checks her level by doing a finger stick.

But most of the time, she simply glances at her phone to see whether her numbers are trending low or high, which beats repeatedly pricking her finger, she said.

“I would hate it so much,” Prashar said. “It’s such a pain and it’s harder to see trends.”

Montana lawmakers are considering a bill that would for people with Type 1 and Type 2 diabetes. and experts back up the effectiveness of the devices, showing better blood test results, fewer long-term complications, and a reduction in health care costs.

Studies show CGMs can greatly benefit people with Type 1 diabetes. There are also promising results for people with Type 2 diabetes, the more prevalent of the two types, but the compared with that on Type 1.

House Bill 758 has broad support from lawmakers, but it faces opposition from insurance companies and some providers. That opposition focuses on the cost, whether a CGM is medically necessary at all stages of diabetes, and the possibility that CGM manufacturers will raise their prices if there is an insurance mandate.

CGMs can be worn on the legs, stomach, or arms, and they stay in place with an adhesive patch. A thin tube goes under the skin and measures blood glucose levels from tissue fluid. The data is transmitted via Bluetooth to a phone or similar device. Instead of a finger prick, which provides a reading for a single point in time, a CGM gives the wearer a continuous stream of data.

According to GoodRx Health, CGMs can each year out-of-pocket.

Blue Cross and Blue Shield of Montana, the state’s largest insurer, estimates the bill, if passed, would cost the organization nearly $5 million a year, spokesperson John Doran said.

CGMs aren’t medically necessary in all circumstances, Doran said, and medical necessity should be determined through a partnership between provider and payer. But Doran said that he understands there are instances in which a CGM may be necessary and that Blue Cross already covers CGMs in those cases.

“These things are a convenience,” Doran said. “They provide you real-time information and there is some benefit to a person’s lifestyle to these monitors.”

Lawmakers in several states are to regulate coverage of CGMs, and Illinois’ governor into law last year.

A study published in the Journal of Diabetes Science and Technology in 2022 , a condition in which a person’s body can’t make enough insulin (as in Type 1) or use it effectively (as in Type 2). By 2030, the study estimated, 55 million people in the U.S. will have diabetes, with total medical and societal costs of more than $622 billion — a 53% increase from 2015. According to the American Diabetes Association, have been diagnosed with diabetes.

Various studies, diabetes educators, and health care providers say that CGMs can help people with diabetes reduce their A1C levels, a common measure of blood sugar levels used in diabetes management. Proper management can reduce complications from diabetes — like retinopathy, heart attack, and nerve damage — that lead to higher costs in the health care system through emergency room visits and hospitalizations.

Dr. Brian Robinson, an endocrinologist at St. Peter’s Health in Helena, said supplies for people with Type 1 diabetes are generally covered by insurance. When he considers recommending a glucose monitor for a patient, he said, the decision is driven by insurance rules that are informed by the .

“My patients are better because of CGMs, there’s no doubt about that,” Robinson said. But he noted the science doesn’t yet support his opinion that CGMs should be given to everyone with diabetes, no matter what.

Not all physicians, especially in endocrinology, agree that a person with Type 2 diabetes needs a continuous glucose monitor, Robinson said. But if a person needs a shot each day to manage diabetes, he said, that patient should have access to a CGM.

Lisa Ranes, manager of the diabetes, endocrinology, and metabolism center at Billings Clinic, said the benefits of a CGM are the same for people with Type 1 and Type 2 diabetes.

Many studies have shown that for patients on lower quantities of insulin, like some people with Type 2 diabetes, as for people with Type 1 diabetes, who rely on insulin throughout the day.

“It gives patients that complete picture to help them make the decisions on what they need to do to keep their blood sugar safe,” Ranes said, giving examples like upping the frequency or dose of insulin, having some food, or exercising.

For people with Type 2 diabetes, Ranes said, CGMs could be helpful in early diagnosis. Type 2 diabetes is progressive, Ranes said, so the sooner it is under control, the better.

When Cass Mitchell, 76, was diagnosed with Type 2 diabetes over 30 years ago, her doctor told her that people with Type 2 diabetes don’t live long because they have a hard time managing their care.

Mitchell, who lives in Helena, warmed to finger pricks. But test strips were expensive, about $1 each at the time, she said.

About 10 years ago, she got a CGM. Mitchell went from testing maybe twice a day to looking at her blood sugar on an app 20 to 25 times each day. She said she’s more in tune with her diabetes and uses her device’s time-in-range reports — showing how often blood glucose stays within a set range — to make lifestyle changes.

Mitchell has lowered her A1C from around 11% to 7%. According to the ADA, the target for most adults with diabetes is .

Mitchell’s device is covered under Medicare and supplemental insurance and would remain so with the passage of HB 758. She said if she had to pay out-of-pocket she wouldn’t be able to afford her CGM and that she was excited about the potential of the bill to give more people access to CGMs.

Dr. Hayley Miller, medical director of Mountain States Diabetes in Missoula, initially thought HB 758 sounded good, but now she isn’t so sure. She thinks the biggest risk of the bill passing is that prices for CGMs go up.

“It seems like I’m against it, but it really is, when insurance gets involved everything gets tricky,” Miller said.

Emma Peterson, a former diabetes educator for St. Vincent Healthcare in Billings and Providence Endocrinology in Missoula, said most people working in diabetes care think everyone diagnosed should just have a continuous glucose monitor.

“At the end of the day, both forms of diabetes and all the other many forms of diabetes have the same complications and still face the same struggles of trying to keep blood sugars in range,” Peterson said.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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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As an employee of Family Outreach in Helena, Montana — an organization that assists developmentally disabled people — part of his workday involves driving around, picking up clients, and taking them to work or to run errands.

“What’s up, gangsta?” Johnson said as a client got in the car one day in March.

The pair fist-bumped and Johnson asked what type of music the client liked.

“Gangsta stuff,” came the response. Rap, mainly.

Snoop Dogg played in the background as Johnson and his client drove to McDonald’s, where Johnson helps his client work. The duo washed dishes for two hours in the back of the fast-food restaurant, where it smelled like maple syrup and sulfur.

About two weeks earlier, Johnson testified at a hearing at the Montana Capitol that seeks to raise health providers’ Medicaid reimbursement rates to levels aligned with the average cost of the care they provide. The bill is informed by a 2022 study that recommended benchmark rates after its authors found that Montana Medicaid providers like Family Outreach were being significantly underpaid.

“The provider rates need to be funded so people that work in this field or that work in adjacent fields can have solid ground, a place where you can build a career,” said Johnson, who makes $16.24 per hour in his position as an individual living specialist.

Republican Gov. Greg Gianforte and legislators agree that Medicaid rates need to rise; where they disagree is by how much. The proposals range from the bill Johnson testified for — Democratic Rep. Mary Caferro’s bill to raise rates to the study’s benchmarks — to Gianforte’s plan to fund 91% of that benchmark in 2024 and 86% in 2025.

Meanwhile, the Republicans leading the House Appropriations Committee, a key budget panel, are proposing an average increase of 92% for fiscal year 2024 and 97% in 2025.

Providers and leaders who work in behavioral health, developmental disability, long-term care, and family support services have attended the multiple hearings on rate adjustments, saying thanks for the proposed increases but asking for more. Many providers said the benchmark rates in the study are already outdated.

Providers across the United States say they haven’t seen significant reimbursement increases in more than a decade, according to , president of the National Association for Behavioral Healthcare. Behavioral health can be an afterthought for policymakers, resulting in lower rates than for medical or surgical reimbursement, he said

, associate professor of health policy and management at the Harvard T.H. Chan School of Public Health, said the supply of staff is inadequate to meet demand for behavioral health care across the U.S.

“And it’s not clear we’re going to meet any of that without paying people more,” Barnett said.

Some health providers have raised wages but still struggled to draw workers and keep the ones they’ve got. Family Outreach raised the wages of some direct care workers from $11 per hour to $12.20 per hour this year, and by more in places where the cost of living is higher, such as Bozeman. But even starting wages of $16 or $18 an hour aren’t attracting enough people to work there, Family Outreach Program Manager Tyler Tobol said.

“It’s a field that not a lot of people want to get into, so those that we can find, I think being able to pay a higher wage, a living wage, I think that would be the best benefit we get out of the rate increase,” Tobol said.

The organization went from 153 employees in 2020 to 128 today. The staffing shortage means employees now focus mainly on making sure clients have the basics — medications and meals — instead of providing additional community integration and activity support services.

At Florence Crittenton in Helena, where moms 18 to 35 with substance use disorders can live with their young kids while undergoing treatment, a mom entered the kitchen where women are taught life skills like learning to cook dinner. The woman told a staff member she was making juice for her child.

“This is where life happens,” said , Florence Crittenton’s clinical and residential services director.

Executive Director said the organization’s two main sources of revenue are Medicaid reimbursements and fundraising. Fundraising, which used to account for 30% of revenue, now makes up between 60% and 70% of the money coming in.

“It’s the reason we’re still open,” Krepps said.

At any given time, an average of 15 to 18 of Florence Crittenton’s 50 staff positions are vacant. If Medicaid rates don’t increase, she said, the organization will have to consider if it can continue operating the recovery home at its current capacity.

“The full rates would just barely cover where we are today,” Krepps said of raising Medicaid reimbursement rates to benchmark levels.

In 2021, Florence Crittenton closed a youth maternity home for pregnant youths and young moms ages 12 to 15, the only home in the state that took teens under 16. Krepps said Florence Crittenton didn’t take Medicaid fees there because the rates were too low.

“It’s heartbreaking,” Champer said. “It’s like clockwork on Monday morning. I come in and see the inquiries and referrals about moms who need treatment and we can’t function at full capacity because we don’t have staff.”

, the CEO of Youth Dynamics, which provides home support, case management, and community-based psychiatric rehabilitation across the state, said his organization is paying its staff more than it can afford. Even with the rate increase, he said, they’d only break even.

In the past three years, Youth Dynamics has lost 56 full-time employees. The covid-19 pandemic made people realize they could find other jobs that paid more and even allowed them to stay home, Sulser said.

Two years ago, the entry-level pay for Youth Dynamics was $10.70 per hour, and it now averages $13.70. Still, staffing shortages led to the closure of a group home in Boulder and one in Billings, shrinking the organization’s capacity from 80 to 64 beds statewide.

Ashley Santos, program manager for the organization’s three remaining group homes in Boulder, said she is trying to figure out how to attract enough staff to reopen the closed home there. An increase in pay supported by the provider rate increase could give her flexibility to provide extra incentives, she said.

But it’s hard to attract workers when Hardee’s has a starting wage of $18 per hour compared with Youth Dynamics’ $16, she said. And fast-food jobs don’t come with the emotional toll of working with kids who have a severe emotional disturbance diagnosis like PTSD or depression.

Back in Helena, Johnson made his last stop of the day for Family Outreach. He sat next to a client on the couch at the house where the client lives with his mom. Johnson called the number on the back of his client’s debit card to see how much money was left on it before they went out to run errands.

Johnson and the client then headed to a local supermarket. Trips like these give his client a chance to interact with other people, while his mom gets some time to herself.

“You look nice,” Johnson said to the client as they got into the car, the folksy music of Dougie Poole, the choice of Johnson’s previous client, playing in the background.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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 .

USE OUR CONTENT

This story can be republished for free (details).

Horning, 51, was diagnosed in 2014 with acute myeloid leukemia, an aggressive cancer — the five-year survival rate for those . Horning had been through chemotherapy and a stem cell transplant, which severely weakened her immune system. Because the MMR vaccine contains live virus, she couldn’t get the vaccine herself and had to temporarily avoid her vaccinated daughter.

Now, Horning is worried about Montana legislation that could further compromise her and other immunocompromised people by making it easier for more people to opt out of routine vaccinations.

“If they do allow this, and a significant amount of people don’t vaccinate their kids, then there could be community spread,” Horning said. “And then I’m really in danger, the same as a newborn is in danger.”

In 2021, Montana passed — — which prohibited discrimination based on vaccine status in settings like employment, education, and health care. In effect, it banned private businesses and local governments from requiring employees to be vaccinated, not just against covid-19 but any disease. A federal judge in health care settings in a lawsuit filed by hospitals, medical providers, and nurses. Two other lawsuits challenging HB 702, one by are pending.

This year, lawmakers have introduced proposals to expand vaccine exemptions in schools and change criteria in the workplace and the legal system.

Proponents of the school-related measures include mothers advocating for their parental rights over whether to vaccinate their children; a nurse who maintained that medical choices should be private; and a day care instructor concerned about the connection between vaccines and autism, a .

Some experts say those bills, like HB 702 from two years ago, are an overreaction to the fear and anger surrounding the covid pandemic.

Those who promote vaccine exemptions on the grounds of parental rights and individual freedom should be honest about the consequences, said Cason Schmit, an assistant professor at Texas A&M University School of Public Health. Those consequences could include more people sick and dead from preventable diseases, he said.

“We know what the outcomes of these types of laws are,” Schmit said.

According to a nonmedical vaccine exemptions have increased over the past two decades in the U.S.

Medical exemptions for vaccines are granted for conditions that could result in adverse reactions to a vaccine, such as a cancer patient undergoing chemotherapy. The nonmedical type comprise religious — based on a sincerely held religious belief — and conscience exemptions — based on personal or moral beliefs.

According to Lauren Wilson, president of the Montana Chapter of the American Academy of Pediatrics, no state in the last 20 years has implemented a conscience exemption for childhood vaccines. The reports philosophical exemptions in 15 states.

Currently, Montana allows exemptions based on religion but not conscience for K-12 school vaccinations, and the religious exemption must be provided on a notarized affidavit. A medical exemption must be signed by a licensed health care provider.

That would change under , sponsored by Republican Sen. Daniel Emrich, which would require schools, employers, health care providers, state agencies, and other entities to accept “without question or malice” religious or conscience exemptions pertaining to certain medications, including vaccines. Any entity that doesn’t comply would lose state funding.

Religious or conscience exemptions could be used for any of the immunizations required in the : varicella, diphtheria, pertussis, tetanus, poliomyelitis, rubella, mumps, and measles for attendance in primary schools, and influenza B before starting preschool.

SB 450 also would remove the requirement that an exemption be given on a notarized affidavit and allows that a signed letter or statement is sufficient.

Supporters say SB 450 would preserve parental rights as well as the right to choose what goes into one’s body, and provide a justification to refuse vaccination if someone is not particularly religious.

Opponents, including Montana Families for Vaccines, the Montana Medical Association, and Wilson, said states with conscience exemptions have the lowest vaccination rates.

“I think part of the problem is that vaccines have been victims of their own success,” Wilson said. “There have been many childhood illnesses that have been eliminated for more than a generation, and people don’t remember.”

Another measure, , would require schools to inform parents which exemptions are available through whatever communication they already provide to students about vaccines. It initially added a conscience exemption for schools, too, but that was taken out of the bill.

Republican Rep. Jennifer Carlson, the sponsor of both HB 715 and 2021’s HB 702, cast doubt on whether HB 715 would significantly affect vaccination rates. She said during a legislative hearing on Feb. 27 that the state has a 95%-97% vaccination rate despite its existing medical and religious exemptions.

In the , 96% of Montana’s kindergartners were vaccinated against measles, mumps, and rubella, while 3% were excused under religious exemptions, according to the state’s public health department. According to the, the share dropped to nearly 93% of Montana kindergartners in the 2020-21 school year.

Nationally, about receive two recommended doses of MMR vaccine and 2% remain unvaccinated because of nonmedical exemptions.

Carlson emphasized that HB 715 wasn’t about covid, and that she isn’t opposed to vaccinations, saying at the hearing that she and her five children have all had their childhood vaccines.

“This bill is not a debate about the efficacy of vaccines,” Carlson said.

Dr. Marian Kummer, a retired pediatrician and Montana Families for Vaccines board member, said she worries that if HB 715 and SB 450 become law, it will leave the state vulnerable.

“The fear is what’s going to happen if they pass the personal exemption — the exemption rate will go up and that is going to put more communities at risk for outbreaks of these diseases,” Kummer said.

To maintain immunity against measles, needs to be fully vaccinated — having both MMR shots — against the disease. Kummer said if there are more exemptions, the state could fall below that threshold.

The 2021 legislature that eliminated the requirement that vaccine rates be reported to Montana’s Department of Public Health and Human Services and local health departments.

Democratic Rep. Ed Stafman has that would boost vaccine and exemption reporting. Stafman said that at some point there will be an increase in outbreaks because of increasing exemptions, and data will be crucial.

“When that outbreak happens here, we’re going to be in deep trouble,” Stafman said.

In the workplace, would require workers’ compensation insurance to cover adverse reactions to employer-mandated vaccines.

And in the courthouse, would prohibit the use of vaccination status as evidence or grounds for decisions in guardianship or custody cases. It also would make it so vaccination status can’t be used as a factor in determining criteria for adoption.

That bill’s sponsor, Republican Rep. Caleb Hinkle, said including vaccination status in evidence could lead to biased decisions because of how politicized vaccinations have become.

But Schmit of Texas A&M said the measure could handicap judges’ ability to rule what is in the best interests of a child.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

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