(transition whooshing) - [Anna] Coming up on "Impact," Missoula and Bozeman are expensive communities dealing with extensive homelessness.

- We realize that the demand is great and that the funding and the resources are little.

- [Anna] What options do these communities have to curb The problem?

(transition whooshing) And mismanagement of the nation's organ transplant system, where every second counts, hits rural patients harder.

- Living over here is problematic, one, because of the harvesting of the organs and the timing about that, so we have to get over there very quickly.

- [Anna] Now there's an overhaul in the works.

(transition whooshing) That's next on "Impact."

(gentle music) - [Narrator] Production of "Impact" is made possible with support from the Otto Bremer Trust, investing in people, places, and opportunities in our region, online at ottobremer.org, the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans, and viewers like you who are friends of Montana PBS.

Thank you.

(transition whooshing) - Welcome to "Impact," Montana PBS's News and Public Affairs series, examining issues important to you.

I'm Anna Rau.

The U.S. Department of Housing and Urban Development reports that homelessness in Montana grew by 45% last year.

That's the third largest increase in the nation.

In November, we brought you a story about the controversy over urban camping in ultra-expensive Bozeman.

Now we are expanding our coverage west of the divide to another pricey community, Missoula.

Montana PBS's Joe Lasar explores the options available to get people into homes as quickly as possible in two of the most expensive places in the state.

(transition whooshing) - [Steven] Yeah, well, we're we're still stumbling.

we're not in an apartment yet.

- [Joe] Steven and Belinda Ankney say it's been a tough winter living in their trailer on the streets of Bozeman.

Since we spoke with them last fall, Bozeman's urban camping ordinance has taken effect.

As part of the new rules, they've twice had to move their trailer, a process Steven says has been difficult.

Belinda's legal troubles are a barrier to them finding housing, and Steven's medical issues are a barrier to them affording it.

They've tried to go after housing resources available in town, but the system is strained, as the number of people experiencing homelessness in Bozeman has nearly doubled since 2019, according to HRDC President Heather Grenier.

- It's remarkably difficult because there's no pathway for us to help them.

There's no housing.

There's no rental assistance to help them get into a housing unit.

Even if there were a housing unit, there's no transitional housing.

- [Joe] To meet immediate needs, HRDC's warming shelters switched to year-round service in 2022.

And last year, local nonprofits, Haven and Family Promise, opened a new shelter facilities.

- And I think that will meet the emergency shelter needs for our community, certainly.

Now we've gotta focus on transitional housing and housing needs.

- [Joe] In the past year, rental prices have cooled off and vacancy rates have ticked up.

Those hopeful trends pair nicely with the nearly 1,800 housing units currently in various stages of development across the city.

According to the city of Bozeman, 411 of those units will be exclusively eligible to households making no more than the numbers on your screen.

The units will be federally subsidized so that residents pay no more than 30% of their monthly income.

(car whooshing) While that's welcome news, the Ankney take it with cautious optimism.

- I think Bozeman's actually really trying.

The commission, the city is just, this town is expensive.

- [Joe] While they wait to see if some housing assistance comes their way, they're doing what they can in between the struggles of their daily lives to find something on their own.

- One of the biggest misconceptions is that we wanna be here, that we're not trying to get out.

- [Joe] It could be easier for them somewhere else, but that would mean leaving their three daughters, who live with a relative in nearby Belgrade.

- And I don't want that to go away and I don't want that to stop.

I mean, I work too hard.

- That's our savior.

That's what's saving us.

That's what's keeping us going.

- [Joe] So for now, they're trying to get through the winter as best they can.

As communities work to address affordable housing shortages, what sort of assistance is there in the meantime?

For just under 16,000 Montanans, assistance comes from the U.S. Department of Housing and Urban Developments Housing Choice Voucher Program.

- The participant in the program, the family, the tenant, pays 30% of their adjusted monthly income toward the rent and the federal housing assistance payment covers the difference between that tenant's portion and up to a maximum voucher payment standard.

- [Joe] Vouchers are issued by public housing authorities, and they can be used wherever a landlord accepts them.

This gives voucher holders the flexibility to move without losing housing assistance.

They can be life-changing for those who get them, but the system is not without its shortcomings.

Cheryl Cohen oversees the statewide public housing authority that's run through the Montana Department of Commerce.

She says Getting a housing choice voucher through the state can take anywhere from a few months to a few years.

It's a 6 1/2 year wait in Missoula's region and 10 1/2 years in Bozeman's.

And as rents sharply rose over the past few years, the maximum amounts that vouchers will cover have struggled to keep up.

In some areas, they haven't even kept up with prices, at below market rent restricted properties.

- So if they can't keep up with a restricted rent, they're certainly not keeping up with private market rents.

And we don't berate landlords for making economic decisions.

Of course, they have to pay maintenance for their properties and property taxes.

- [Joe] A voucher holder has between 60 and 120 days to get into housing.

If they're not able to, they'll lose their voucher.

- [Cheryl] Super challenging to wait that long for a voucher and then not being able to use it.

(cars whooshing) - [Joe] For the state's second largest housing authority, navigating this gap between voucher payments and rent prices is uncharted territory.

- It was never a thing.

I mean, I didn't even track our success rate for years because it was just like, yeah, they succeed.

- [Joe] Jim McGrath is in charge of voucher programs at the Missoula Housing Authority.

He says during the pandemic, they saw about a 20% decrease in the number of vouchers that were successfully used.

- [Jim] Between high rents and low vacancy rates, those places were just so hard to find.

- [Joe] McGrath says that downward trend has leveled off, but that the mismatch between voucher payments and rent prices continues to be an issue.

But there is a way for housing authorities to try to work around it.

They're allowed to take a certain percentage of their vouchers and attach them to a specific property, ensuring that affordable units will be available.

They're called project-based vouchers.

- The advantage of that for the tenant nowadays is that you don't have to find a unit that you can afford.

So it deals with both affordability and availability.

- [Joe] 32 housing choice vouchers are attached to the recently opened Villagio Apartments.

The rest of the 200 units are federally subsidized for households making no more than the numbers on your screen.

The average three bedroom rental price in Missoula is $1,731 a month.

For a family of four at the top end of the income limit, a three bedroom rental at Villagio costs $1,220 a month.

(car whooshing) Last year was a big one for the Missoula community in terms of affordable housing.

In addition to Villagio, Trinity Apartments added another 202 rent-restricted units.

(bells chiming) Rental assistance might be all some people need to get back into housing, but for others, there are more barriers.

(car whooshing) About 1/3 of Missoula's homeless population are considered chronically homeless, on the streets a year or more or repeatedly and struggling with a disabling condition, like mental illness, a substance abuse disorder, or a physical disability.

Statewide, chronic homelessness has risen by 551% since 2007, the largest increase of any state in the U.S. Providing housing to those with the highest level of needs plus supportive services to help with their underlying issues is the idea behind permanent supportive housing.

- Again, with all the modern amenities you'd find in a market rate apartment, we have- - [Joe] Energy with partnership between local government and a number of nonprofits, 31 units of permanent supportive housing opened last September.

- The key to successful permanent supportive housing is having the necessary wraparound services on the property.

In other words, there is 24/7 staff here on site at Blue Heron Place to work with residents through a myriad of issues.

- [Joe] Residents pay 30% of their monthly income.

The wraparound services are voluntary.

In addition to improved housing stability and health outcomes for people, this model has been shown to be an effective way of mitigating costs associated with chronic homelessness.

- [Sam] Fewer trips by emergency services, fewer trips from the police, fewer negative interactions with community members and with businesses in town.

- [Joe] Because it is permanent supportive housing, turnover on these units can be years.

Folks who get in can stay as long as they want.

But for people whose needs aren't as intensive, Missoula's temporary safe outdoor space offers a similar supportive model, but on a quicker timeframe, - [April] Probably like 120 to 180 days like is the average stay here.

- [Joe] These 30 hard-sided trailers opened last January.

With the help of community partners, the site is staffed 24/7, and during the week by a social worker and peer support specialists that are there to connect people to services.

- Doing life skills and working with other businesses and seeing how we can get them plugged in.

We do work with like mental health and substance abuse.

They come on and we meet 'em where they're at, and then we work with them to try and move forward.

- [Joe] Missoula native, Michael Voss, was unhoused for five years before getting a spot here after completing a drug rehab program this fall.

He says having a place to himself has helped him stay focused on his sobriety.

- It's kept me off the streets, kept me away from my friends and stuff that would potentially pull me back into the addiction and make me lose my priorities and what's important.

- [Joe] Voss is working and saving money for a place of his own.

His criminal record makes that process complicated, but he says that in a few weeks, he'll have some extra support.

- Waiting for my girlfriend to get outta treatment so we can try to navigate that road together.

(car whooshing) - [Joe] These newly expanded housing options appear to be moving the needle on homelessness in Missoula.

According to numbers recently shared by the city, the homeless population is the smallest it's been since before the pandemic.

However, uncertainty looms over a key piece of the community's homeless response.

(car whooshing) The last of the city and county's COVID era American Rescue Plan money is currently being used to run the Johnson Street Emergency Shelter.

That money runs out in September.

(car whooshing) Missoula Mayor Andrea Davis says finding sustainable funding before then will remain a major priority for the city.

- You know, it's a big question and a big concern, actually, about where we will be able to find the money to be able to do this.

And it's important that we do it.

So we are talking internally.

We have, I think, some important conversations to have with the community.

There's a desire and a need to relocate the shelter eventually, and that work is also underway and needed.

- [Joe] The city is in the process of updating its growth policy and universal development code.

Davis says it's an opportunity to evaluate the recent housing successes and figure out how best to build on them.

- The more we can build at every single level, both rental and home ownership, in a way that still preserves the character and the enjoyment of our community, and that's not an easy task.

There is lots to debate in that space.

(car whooshing) - [Joe] The new universal development code is expected to be adopted late this year or early next year.

For "Impact," I'm Joe Lasar.

- Meanwhile, the battle over urban camping will reach a new venue.

The U.S. Supreme Court has agreed to review the landmark case that allows people to camp in public places if no shelter beds are available.

Oral arguments are scheduled to begin on April 22nd.

While receiving an organ transplant is a complicated and time-sensitive process with little margin for error, especially for those who live in rural states where specialized care is limited.

Montana PBS's AJ Williams talks to patients, practitioners, and politicians about what's being done to improve the system.

(transition whooshing) - [Yoga Instructor] Exhale, look, press with both hands.

- [AJ] Todd Ware takes a deep breath in during his morning yoga class, a simple act he doesn't take for granted.

- Yoga, I couldn't do it in the years before because even though it's a relaxing, it's still requires too much air.

And so now that I am breathing so much, I'm breathing at 134%, the yoga opens up my whole chest cavity.

- [AJ] Ware received a lung transplant at the end of 2020, 5 years after he was diagnosed with lung failure.

8 of 10 donated lungs aren't viable due to tissue damage, making every opportunity for transplant rare and invaluable.

Timing is everything when it comes to procuring donated organs, and a mishandling of them in the process means that patients like, Ware, can end up dying on the waiting list.

- When I learned that I had to have a transplant and I went on the list, I didn't know that I'd even survive till the transplant and organs were available for me.

I had had to take oxygen into the shower for the first time.

And I was in the shower with the tubes and I'm thinking, "This isn't gonna last for long and so this isn't gonna work."

- [AJ] A combination of Ware's critical condition and rare blood type put him toward the top of the list.

- Got the call that afternoon and it was wonderful and it is just a pleasant voice on the other side that said, "Todd, we have some wonderful lungs here that we think are gonna work for you and we'd like you to come over tonight."

- [AJ] When Ware received a call three months later on December 26th that there was an organ donation waiting for him, he had to get to the transplant center in Seattle as fast as possible.

Transporting a patient in critical condition is already a challenge.

Ware, himself a pilot, soon realized that winter weather may make travel on their critical timeline impossible.

- I checked though the aviation weather and we weren't flying.

Kalispell was not flying when I left for the airport.

And so by the time we had some thick fog in.

And by the time we got to the hospital and then they took me by ambulance to the airport, and we were clear to take off.

So the fog bank just left right before we did.

- [AJ] Ware made it to Seattle in time, as did his new set of lungs.

The donated organs arrived in a cooler to his operating room.

And 28 hours later, Ware woke up breathing better than he had in years.

Patients like ware traveling to receive care are only facing an additional hurdle in what some have called an already failing system.

The nation's organization for donating organs has received criticism over the years, and politicians are calling for change.

Historically, the network has been run on a federal contract through one private nonprofit called the United Network for Organ Sharing, known as UNOS.

According to a 2023 report written by a former officer of the Department of Health and Human Services, known as HHS, there are approximately 109,000 people waiting for organ donation, yet, 28,000 viable organs get wasted annually.

This means that patients getting the transplants they need, like Ware, are the exception.

- The network is 15 times more likely to lose, damage, or mishandle an organ in transit than a passenger airline losing its luggage.

- [AJ] Statistics like these have politicians calling for a federal reform, which Senator Grassley says he's been working on since 2005.

- More than a decade now, government watchdogs and the media have questioned the adequacy of the network's oversight.

That's because of multiple reports of fraud, waste, and abuse, criminality, deadly patient safety, and failure to recover organs.

More than 200,000 Americans have needlessly died on the transplant waiting list, disproportionately for people of color and people of rural America.

- [AJ] Critics of UNOS consider it a monopoly, and Senator Grassley helped lead the charge in creating the U.S.

Organ Procurement and Transplantation Network Act, which was unanimously passed by Congress in September of 2023.

The act aimed to break up the singular contract and open up the floor to competitive bidding.

In a statement to Montana PBS, Grassley says that he believes that the reform, quote, "will allow competent qualified contractors with advanced technologies and logistics capability to compete for the federal contract.

Patients should be served by the best contractors in the field and no longer have to settle for UNOS's status quo," unquote.

Grassley also stated that as far as rural transplant care, quote, "Under UNOS's maladministration, rural residents and people of color have historically struggled to receive consideration for an organ match, putting them at severe disadvantage that endangers their lives," unquote.

Additionally, HHS has the ability to revoke licenses for each organ procurement network.

And critics note that despite documented inefficiencies, as of 2023, HHS has never revoked a license.

Since passing the act, UNOS and HHS both have made formal statements in support of the changes.

However, Grassley pointed out in a recent congressional hearing that no changes have been implemented yet.

Dr. Erica Lease runs Ware's care team at UW Medicine in Seattle.

She sees that failure of rural patients firsthand as her team treats all patients from the inner mountain and Pacific Northwest as the lone center for lung transplants within the region.

- Even getting access to basic pulmonary care can be really difficult for people in rural areas or in areas like Montana where there really are very few pulmonologists who practice in the state of Montana.

They need to be able to get here for transplant.

And then, of course, they need to be able to follow up after transplant.

Specifically for lung transplant, it's important to follow up with a lung transplant center for the rest of somebody's life to make sure that that organ continues to function well.

- [AJ] In regards to Ware's 28-hour timeline of getting the call to getting new lungs, Lease says that that's a long turnaround time by organ transplant standards.

- 24 hours is actually pretty short, pretty long.

We used to say that people had to get here within three hours, which obviously then was really difficult for people who lived further distances.

And in the distant past, we actually required everybody to relocate to this area while waiting for transplant as well.

- [AJ] Rural patients, like Ware, will always have the additional hurdles of travel and weather to navigate on their end, but critics of UNOS believe that the patient's location should not be the determining factor for their consideration of getting lifesaving care.

Another part of the equation in reforming the system will be the procurement of the donated organs.

Lease says that the organ donation system requires immense coordination in the notification of availability, procurement, and delivery of the organs to the transplant centers like UWs.

- You know, in terms of what donors are available, that really comes down to local hospitals notifying their local organ procurement organization, which is the organization that manages donors and helps start the allocation process.

I don't know that I feel that the technology of how we allocate organs and how we transport organs and who transport plants or transports organs has really kept up at the rate that we are seeing the growth.

- [AJ] Transplant centers like UW receive the information as to which patient would be a match for the donation and set the transplant process in motion, like they did for Ware.

- This is what we use to ventilate or breathe for the patient.

- [AJ] Jack Lowney is an ICU nurse at Community Medical Center in Missoula, which is one of Montana's hospitals LifeCenter Northwest works with for organ donation.

Lowney assists the team in keeping patients who are brain dead and will pass away stable while they wait for the procurement team to arrive so the donated organs will have the best chance of longevity for their recipient.

- In Montana, it's a very vast state, so it can take quite a while to actually get a rep here to talk to the family to see if this is something that they would want.

You know, it's determined on both sides that this is a good candidate, and we have agreeance on both parties, then we move forward.

And you take one individual that's donated and two kidneys go to two different places, liver went to a different place, this organ went to a different place.

You know, one individual's life saves four to five other people, which is pretty cool.

- [AJ] As the organs get sent across the country to hopefully make it to the right transplant patient within time, rural transplant hopefuls, like Ware, await that life-changing call.

They're instructed to keep a packed bag and a charged phone and plan for every contingency they can.

(Todd breathes deeply) Ware considers his transplant something that's allowed him bonus time and an ability to live a better life.

Knowing how precious organ donation is, he believes that the mismanagement of the donor system is a problem that needs to change.

- Organs are so valuable, they need to be managed really well.

If there's anything that's lost, if there's even one organ that gets lost in process, then they really need to address that and fix the process.

My donor, just the amount of gratitude that I have for breathing with these lungs, I really want to thank his family mainly because they deal with a continued pain.

Just thankful that he was an organ donor.

- [AJ] There are currently 173 Montanans waiting for an organ transplant.

Ware hopes to keep connecting with other rural patients, helping them find access to transportation through a network of Angel pilots across the state.

Ware hopes to continue doing what he can to help his fellow Montanans navigate a system where success requires nothing short of a miracle.

For "Impact," I'm AJ Williams.

- Just this month the U.S. Government invited proposals to set up a competitive system for organ donation and transplantation.

That's all the time we have for this episode.

Thanks for joining us.

We'll see you on the next "Impact."

(gentle upbeat music) (gentle upbeat music continues) (gentle upbeat music continues) - [Narrator] Production of "Impact" is made possible with support from the Otto Bremer Trust, investing in people, places, and opportunities in our region, online at ottobremer.org, the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans, and viewers like you who are friends of Montana PBS.

Thank you.

(transition whooshing) (gentle music)