(graphics whooshing) - [Hannah] Changes to healthcare policy at the federal level is set to reshape what rural healthcare looks like in Montana.

- Volatility, ambiguity, complexity, and uncertainty, that's the reality of healthcare in Montana right now.

(graphics whooshing) - [Hannah] Plus, meet the Billings residents welcoming refugees into their lives.

- We believe, as an organization, that relationships have the power of transformation.

(graphics whooshing) - From the campuses of Montana State University, Bozeman, and the University of Montana, Missoula, you're watching "IMPACT" from "Montana PBS Reports."

And those stories are straight ahead.

Stay with us.

(graphics whooshing) - [Stan] Major funding for "IMPACT" comes from the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans.

Funding also comes from viewers like you, who are friends of Montana PBS.

Thank you.

"IMPACT" is an editorially independent production of "Montana PBS Reports."

Coverage decisions are made by our team of Montana-based journalists.

For feedback, questions, or ideas, email us, impact@montanapbs.org.

(dramatic music) (graphics whooshing) - Welcome to "IMPACT."

I'm Hannah Kearse.

Healthcare policy has been dominating state and federal agendas.

And in Montana, the 2025 legislature continued its popular Medicaid expansion program, but the federal level, things largely went the other way.

Montana PBS's Sam Wilson has been exploring how these changes are impacting healthcare in rural communities.

- Hi, Hannah.

Yeah, rural healthcare is a tough business on a good day, and it's really important to remember that these remote hospitals are essential, and not just for people living in small towns.

- Yeah, Montana is a big state, and we spend a lot of time behind the wheel.

It's really not hard to imagine getting into an accident somewhere far away from home.

- For sure.

In these small hospitals in rural communities, they might be the only option for hours, and they provide lifesaving care, whether or not a person has insurance to pay for it.

So as the federal government drastically reduces funding for insurance programs, many rural providers are concerned for the future.

- I know right now, I can just start going through my head the number of patients who I've seen here, who all of them would've been dead, or had serious, serious long-term problems, had they not had this facility here.

And I'm just one person.

- [Sam] Across the country, rural clinics and hospitals have been forced to close due to the soaring costs of healthcare.

Montana providers have thus far avoided this fate.

Though it's not out of the question.

The Garfield County Health Center in Jordan has managed to stay afloat with a series of mill levies.

- And we just don't wanna be beat up next one on the block.

We're trying to keep open and save lives, and show compassion to the community that we can do this.

- [Sam] Is it safe to say then that the Garfield County Health Center was in danger of having to close the whole facility?

- Yes.

Yes.

- [Sam] The challenges facing Krista Wright and other rural hospital administrators are many, geographic isolation, difficulties recruiting staff, and low patient volume.

And changes to health insurance policy at the federal level are likely going to make things harder.

President Trump's H.R.1, known as the Big Beautiful Bill, is estimated to cut $911 billion out of Medicaid over 10 years nationwide.

That could be $5.4 billion less for Medicaid in Montana, with 31,000 people potentially losing their coverage.

- You know, what we know is that rural hospitals, rural health clinics, federally qualified health centers that serve rural Montana are operating on extremely narrow margins.

So many of them are actually operating in the red or close to it.

We would expect, if there's a big increase in uninsured patients, that that's gonna be hard on hospitals.

- [Sam] These Medicaid reductions will mostly be the result of new work requirements and more frequent eligibility checks.

The state says it'll take 40 to 50 new full-time employees to tackle the oncoming deluge of paperwork.

- So there's now a very complicated process that states will have to go through for every patient who's enrolled to verify that they are either working or volunteering, or exempt under one of the many exemptions that Congress included from that.

It takes a lot of state capacity to do that analysis well.

And so part of the projection is, a lot of people who actually remain eligible and are either working or exempt are gonna lose coverage just because of that sort of increase in bureaucratic red tape.

- And so, unfortunately, what we find is that when people don't have health insurance, costs for everybody go up, because uninsured patients will eventually seek out care, and then it gets provided to them in the most expensive setting.

And if they don't have insurance to cover that, those costs get spread around to everybody else who does have insurance through incrementally higher premiums.

And so it's the most inefficient system, and it leads to, unfortunately, the worst outcomes.

- Knock-knock.

- Hi, how are you?

- I'm doing pretty well.

How are you?

- [Sam] The One Health network of community health centers stretches across Eastern Montana and Wyoming, and is based in Bighorn County, - In Montana in general, and certainly in Bighorn County, we have a lot of folks who have behavioral health needs, mental health, substance use disorder.

Unfortunately, we see the demand, the need for those services, increasing everywhere across the state.

So in a community where there's a lot of folks who are struggling with addiction or with mental health challenges, and then we have to do all the paperwork to maintain eligibility for Medicaid, it becomes even more challenging, for sure.

- [Sam] At One Health's H.O.P.E Clinic in Hardin, staff members offer support for the folks Mark is talking about, including Kenard Black Eagle, who should easily qualify for Medicaid.

For one, he's a tribal member, a clear exemption left in H.R.1.

- I had Medicaid when I was a kid, but I haven't really gotten into that in a bit long time.

- [Sam] And why is that?

- It's really hard out here, you know, like to get a ride to go get my Social Security, and like some Natives like me are like illiterate, you know, like, we don't really know anything about ourselves, really.

- [Sam] Without insurance, Black Eagle is unable to get into a treatment facility.

Instead, he goes to the emergency room at the Big Horn Hospital.

- I at least go like once a month, you know, for withdrawals or anything like that.

Like they help out, but like you said, it's really expensive.

I think I owe like a lot of money, and I think it's stacking up, stacking up, and sometimes people don't wanna go, you know, because they keep going so much, and they owe so much to the hospitals.

- [Sam] When Medicaid expansion first passed in Montana in 2015, it presented an opportunity to study the question, what happens to a healthcare system when more people can get insurance?

- A lot of our analysis is focused on Medicaid claims.

So we've seen, for example, that when people gain coverage in Medicaid over the first few years of enrollment, their use of emergency services and inpatient services decreases, and their use of preventive services tends to increase.

The other thing that we really saw was that this helped the healthcare system provide better for the needs of Montana communities.

So we saw, for example, in a survey of about half the critical access hospitals, or the rural hospitals in the state, that almost every one of them added new services after Medicaid expanded.

And this was because they have a revenue source to reliably pay for those services.

- [Sam] While Medicaid expansion reduced the number of people without insurance, it also led government healthcare spending in the US to double to 14% of GDP, far more than any other country.

For their troubles, Americans can expect to live three years less than incomparable nations.

- Right now, we finance healthcare by paying for widgets, basically.

So the more surgeries that you do, if you're sick, our healthcare (laughs) industry makes money off of you being sick.

We do surgeries, we do interventions.

They're quite costly.

Sadly, we make money off of people being sick.

Until we can start aligning paying for health, and instead of paying for sickness, we're going to continue on this pathway.

- [Sam] Representative Gillette voted against continuing Medicaid expansion in the 2025 session.

- ACA has not been a friend to rural health, unfortunately.

- [Sam] How much of a friend H.R.1 will be to rural health is still up in the air.

To get the bill across the finish line, Congress included a five-year $50 billion grant to H.R.1 called the Rural Health Transformation Program, and directed states to use the money to make one-time transformative investments.

$1.2 billion is headed to Montana.

- And the hope is that collectively, we'll be able to invest those dollars in ways that yield a lasting benefit.

Now, you know, when we're considering decreasing a pretty stable revenue source in health insurance and Medicaid to one-time infusion of dollars that hopefully will yield some sustainable changes, I think we all collectively have to be pretty creative.

- Oh, I can't think of one item that we could invest in that is truly one time only and doesn't have to be sustained.

Whether it's loan repayment for nurses or behavioral health professionals, like, okay, we do that for the five years, and then what happens after that five years?

Organizations are gonna come to the legislature and say, "We'd like to continue this program."

But I think we can recognize that our healthcare system, we need the little Jordan Montanas to exist.

We absolutely have to.

At what level?

We can have a conversation about, but it means that we need to push more funding towards them.

(chimes clanging) - [Sam] The Rural Health Transformation Program isn't the only way to push funding to smaller hospitals.

The Garfield County Health Center has decided to convert to a rural emergency hospital, which means they'll cut expensive inpatient services in return for higher reimbursement rates and a $280,000 monthly payment from the federal government.

On top of just keeping the lights on That money will allow Krista Wright to bring Robert Gneiting on as a second full-time nurse practitioner.

He had been visiting as a travel nurse.

- With our provider that's coming on board, we're able to offer a few more services, with his training being able to take care of pregnant women.

- [Sam] And she's got a list of services she thinks the Rural Health Transformation Program money could help with as well, CT scans, dialysis, physical therapy, - Mental health is a big one.

We would really like to get a doctor in that can do mental health to take the burden off some of the stress from these people.

And there's a lot of it out there.

- [Sam] But having those services doesn't count for much if people can't get health insurance.

For Kenard Black Eagle, the alternative isn't pretty.

- Me, I lost all my family, you know, to addiction.

There's a lot of people lost just like me.

So all you gotta do is just be right beside them.

That's it.

You know, someone needs to know that I'm there with you, you know?

And that helps a lot.

- [Sam] After talking with Black Eagle, I learned his Medicaid application was denied due to issues with documentation.

Back in Jordan, Robert Gneiting has his own struggles with insurance, even as he helps others.

- I wrestle so much with it, 'cause people need help, but it's like ever since the Affordable Care came out, like for me, what they did is, they've passed that on all to middle class.

And so I spend out of pocket 14,000, and I just got found I'm gonna get a 20% increase in my premium.

- [Sam] Though the business of healthcare has only become more convoluted, the basics of providing effective care hasn't changed much.

- Yes.

- That's why I like, in the world of health, we ask the questions, we go through this stuff, what can I tell you or teach you that you can do now- - [Sam] As we wrapped up our conversation, a nurse knocked on the door.

- If they're ready and, you know, motivated to do something.

- [Sam] Was that knocking on the door?

- It was.

- [Sam] Okay, we can- - [Nurse] Sorry, we got a kid that's come in and cut his finger with band saw at school.

Probably stitches.

- Okay.

I gotta run.

Thank you.

- [Sam] Once again, Robert Gneiting and the Garfield County Health Center to the rescue.

For "IMPACT," I'm Sam Wilson.

- Officials at the health centers we spoke with said there probably won't be any hospitals closing in Montana soon, but as things get tighter, more might follow Garfield County's lead and convert to a rural emergency hospital.

This year, the United States has capped its refugee admissions at an all-time low.

This comes at a time when the United Nations counts more people forcibly displaced by persecution, violence, or human rights violations than ever before.

Montana PBS's Stan Parker talked to those in the refugee resettlement community in Billings to learn more about resettlement and how they're navigating the changes.

(graphics whooshing) - [Stan] When Nancy Van Maren comes to the Billings Airport to welcome an arriving traveler, sometimes it's to greet someone she's meeting in person for the very first time.

That's because for the past few years, she's been an active part of the refugee resettlement community in Billings, a network of professionals and volunteers that want to make sure newcomers thrive in their new home.

She leads a nonprofit called Nations to Neighbors.

- Approximately 40% of the world's refugees are children.

Our mission is to promote the successful integration of refugees into the Billings community.

And we do that by coming alongside them in lots of practical ways, but also, always with a relational element.

The US Refugee Admissions Program is highly focused on early economic self-sufficiency, highly focused on getting everybody to work who can work.

As a result of that, what happens to the kids?

So we began with a focus on youth, and it's maintained, really.

It's the biggest part of what we do.

We provide educational and academic social support for youth and youth mentorship, and then also we promote English acquisition for adults, also in a relational way.

And then just generally, community integration for refugees and a few other immigrants in the Billings community.

- [Stan] Nations to Neighbors got its start by resettling Afghans who came to the US after the fall of Kabul in 2021.

(attendees laughing) Since then, it has evolved to play a supporting role in resettlement because Billings received an official resettlement agency in 2024, Lutheran Family Services Rocky Mountains.

Resettlement in Billings had happened sporadically over the decades, but the opening of this office made Billings an official destination for refugees and those known as Special Immigrant Visa holders, Afghans endangered by their work for the US government.

- So we welcome them at the airport.

We make sure temporary housing and culturally appropriate hot meal is ready for them.

And then once they're here, my office is responsible for helping to find housing, for helping to find jobs.

We offer cultural orientation, so that our clients understand the ins and outs of what it means to live on the day-to-day in the US, as they slowly become American themselves.

- [Stan] By the end of 2025, the agency had handled 20 resettlement cases.

Since cases can be whole families, that comes out to 54 individuals from Afghanistan, Iraq, South Africa, Syria, and Venezuela.

- Well, when you're talking about a population that's a refugee or an asylee, the entire grounds of being granted that status means that they have experienced persecution or a well-founded fear of persecution as a result of their nationality, race or ethnicity, their religion, their political opinion, their membership in a social group.

Those five grounds are a part of what determines whether or not someone is even eligible to be a refugee or is eligible to apply for asylum.

- [Stan] I interviewed a Venezuelan refugee for this story, but decided not to use the recording out of concern for the safety of her remaining family back home.

Instead, I asked Van Maren to read for you an English translation of what she told me about her time after she fled Venezuela before arriving here, - "I had to start from scratch with everything.

And what destroys a human being the most is losing the security of what they have or who they are, because you lose your identity, because you lose your ability to move forward.

And that's what my government does.

It shatters your security, your mental stability.

They break you into pieces, so you're not able to stand up to them.

I tried to be strong and told myself I couldn't cry, because my family depended emotionally on my composure.

They needed me to be calm, so they could be calm too.

And for a long time, I adopted a facade of strength that was breaking me inside.

And there were days when I felt I couldn't go on, I couldn't take it anymore, I couldn't bear it any longer, but I had to be strong."

The woman who spoke these words is one of the strongest individuals I know.

- [Stan] 2025 was a year of whiplash and uncertainty for the resettlement community.

Once President Trump took office for a second term, he put the brakes on refugee resettlement.

- On January 20th, the US Refugee Admissions Program was essentially shut down.

So that meant that the number of refugees coming into our community was going to be very small, if not zero, for the foreseeable future.

- A refugee on average goes through 36 months of background checks, medical checks, and security screenings.

Those run through eight different agencies within the US.

So there's a lot of vetting and a lot of time that happens before they even travel.

So with that executive order halted all of the processing, domestic and internationally, stopped some of them mid-travel, and those individuals had to turn around.

It halted all admissions into the US.

So for Billings, we had five cases, that's 25 persons, who had their travel canceled as a result of that.

- [Stan] Amos's office also saw their funding reduced, and had to reduce staff from five to two.

- It also stopped all of the direct client assistance.

So in Billings, we had our newest family, six individuals, directly impacted by this.

They lost the very small amount of federal funds that are used primarily to help secure housing, because housing is the trickiest part of resettlement.

- [Stan] Later in 2025, President Trump reshaped the refugee admissions program for the new fiscal year, setting the admissions ceiling to 7,500, a historic low.

He also made the decision to prioritize the white South African population for resettlement, which has been a controversial choice in the wider resettlement community.

New developments have only kept adding uncertainty for refugees and their advocates, including bans on admissions from some countries, and also scrutinizing the status of refugees who are already here.

On January 13th, Minnesota refugee advocates told "The New York Times" that of refugees in Minnesota had been arrested by federal agents and sent to Texas.

This development happened after my conversation with Van Maren, but is related to an unease that's set in over the past year.

- There's been a change, right, in this work, in what we face each day.

But really what keeps me going, I think it comes down to three things.

One is knowing with great certainty that I'm doing the right thing.

Second is prayer.

And third is knowing the breadth of support in this community.

Here's the country you're from.

We know that there are hundreds of people who want the best for our new neighbors.

- [Stan] For her, creating lasting bonds among new neighbors is what it's all about.

- [Stan] Something she calls the long welcome.

- The long welcome really is about relationships.

We believe, as an organization, that relationships have the power of transformation.

If you are truly going to be integrated, and you're gonna thrive, it's probably because of a relationship, or two or three or six, that you've developed in the community.

- [Stan] Van Maren has now dedicated her life to this work, and it all started with a revelation she had during an experience on a US military base, where she helped processed Afghans who fled their country after the US withdrew.

- It's really when it became just abundantly clear to me that as a person of faith, as a Christian, it's not optional for me, I am to welcome the stranger, it's just non-negotiable.

And then the whole New Testament concept of the greatest commandment, one of the greatest commandments being to love our neighbor as ourselves.

So who is my neighbor?

And I think that that has been answered in scripture, and that's why I'm involved.

Yeah.

There's no asterisks to Genesis 1:26 that says that we're made in the image of God.

There's no little asterisk as to everybody, but.

Nope, no asterisk - [Stan] For "IMPACT," I'm Stan Parker.

- Van Maren says Nations to Neighbors plans to expand its services to include immigrant legal services.

She hopes to have that running by the middle of 2026.

That's all we have for this episode of "IMPACT."

You can find all our previous shows on our website or on the PBS app for your phone or smart TV.

If you have feedback, questions, or story ideas, send us an email at impact@montanapbs.org.

I'm Hannah Kearse.

And from all of us here at Montana PBS, thanks for watching.

(dramatic music) (dramatic music continues) (dramatic music continues) - [Stan] Major funding for "IMPACT" comes from the Greater Montana Foundation, encouraging communication on issues, trends, and values of importance to Montanans.

Funding also comes from viewers like you, who are friends of Montana PBS.

Thank you.

(graphics whooshing) (cheerful music)