Rep. Kimberly Dudik has earned a reputation as a defender of children. She prosecuted abuse cases, worked to reduce sex trafficking as a legislator, and is part of a group analyzing the growing number of kids removed from their families to be placed in foster care.
But the Missoula legislator said she focused so intently on the children that she never thought to ask: Does Montana do enough to help pregnant women get into treatment for drug use and provide the services mothers need to stabilize their families?
“I had never thought about it in that way,” she said.
Dudik is not an outlier. More than two dozen state leaders interviewed for this story had not considered the unique needs of mothers and mothers-to-be who use drugs. Only a few had ideas about what Montana can do better.
That blind spot leaves gaps in state policy that become craters for women seeking help. It means that as the state spends significant time and money to reinvent its justice system and develop strategic plans to combat drug use, pregnant women are mentioned only in passing as one of many target groups, if they are mentioned at all.
Unless something changes in the way elected leaders and doctors respond to drug use by women with families, experts said Montana could continue to rank among states with the fewest treatment services for pregnant women as well having one of the nation’s highest rates of drug-exposed births and removals by Child and Family Services.
From 2008 to 2015, the percentage of Montana babies who experienced opioid withdrawal shortly after birth grew fourfold. The series of symptoms known as neonatal abstinence syndrome is now diagnosed in almost nine of every 1,000 births, according to discharge data analyzed by the state.
More than half of those infants’ bills were paid by Montana Medicaid, and their complications tripled the state's expenses compared to an average birth, according to an analysis by Cody Custis, a state epidemiologist.
Among the Montana leaders interviewed, most assumed that if a pregnant woman sought drug treatment, she would receive it. The Missoulian found that few of them knew:
- that most people confront months-long waiting lists.
- about medication-assisted treatment, even though doctors say it can more than triple the likelihood of success for getting off drugs, is significantly cheaper than inpatient programs and is the safest way to treat pregnant patients and their unborn children.
- that Montana has fewer providers per capita of buprenorphine — the drug that can eliminate drug cravings — than nearly every other state. After factoring for Montana’s size, only Alaskans must travel farther to access the care.
- that many pregnant women delay prenatal care, if they go to the hospital at all, often fearing they might be reported to police or that they will lose their children. The result is that their babies may be born in worse health.
Asked what Montana could do to expand access to drug treatment for pregnant women, many legislators worried what it would cost the state, particularly after a recent drop in revenues triggered several rounds of budget cuts this year. Right now, nearly all drug treatment funding comes from federal sources, except for the state’s growing share of Medicaid costs.
Rep. Shane Morigeau, a Missoula Democrat, worked as a prosecutor for the Confederated Salish and Kootenai Tribes. At first, he said his instinct was to take a tough stance on drug use, but his view was changed by the stories of relatives and close friends who sometimes became addicted after being prescribed painkillers.
“It’s a very complicated issue,” he said. “We should focus on more access to treatment and funding support programs. If we had the resources to address the addiction problem up front, we’d save money on the back end.''
Sen. Cynthia Wolken, D-Missoula, agreed.
“Why do addicts have to commit a felony to even get on a wait list for treatment?” asked the attorney who has served on numerous state committees related to drug use or child abuse. “We are addressing things in the most expensive way, in the criminal justice system and the court system.”
Judiciary Chairman Rep. Alan Doane agreed Montana might need to improve access to drug treatment, but said it would be a tough sell to use state funds to do it.
“I’m against taking money away from people who make good choices and using it for people who make poor choices,” the Bloomfield Republican said.
House Majority Leader Ron Ehli, R-Hamilton, said the stakes are too high not to find a better way to help women who use drugs during pregnancy, particularly because of how it affects unborn children.
“There’s nothing more important,” he said. “Doing something now is going to reap huge benefits down the road.”
Sen. Mary Caferro, D-Helena, argued legislators have already decided that the kinds of programs these women need most are not a priority. She pointed to the slew of budget cuts earlier this year to health and social service budgets.
“We’re going the wrong direction on all of these things,” she said.
Treatment center leaders interviewed by the Missoulian said they would like to expand services, but their programs currently lose money on the majority of patients.
Medicaid rates are lower than the actual costs of the care, they said, and treatment programs cannot bill at all for some critical services because of the way the state wrote reimbursement rules. It will soon get a little more difficult.
Initially, legislators objected to a proposal by the Department of Public Health and Human Services to cut Medicaid rates 3.47 percent and shrink the list of services it would fund. On Dec. 28, they dropped a formal objection, allowing the department to move ahead with a 2.99 percent cut instead.
Legislators waffled on whether they might support rate increases in the future, citing larger budget issues or skepticism about whether non-medical care such as case management actually improves outcomes.
Conrad Republican Rep. Rob Cook, an expert on the health program's budget, said he does not think increasing rates for particular services will solve the problem. Rather, he wishes state, but especially federal, leaders would get more serious about controlling health care costs.
“The reason we can’t treat anybody and it costs so freaking much for medicine in this country is we’ve never addressed the actual prices these guys charge,” he said.
State Sen. Bob Keenan, a veteran Republican from Bigfork, wondered if raising Medicaid reimbursement rates could encourage more programs to follow national best practices that would save the state money in the long run. He noted that drug treatment “has become a business,” so changing the terms of state contracts would be a logical strategy to improve the quality of programs.
Keenan said it is the responsibility of the Department of Public Health and Human Services, and ultimately Gov. Steve Bullock, to find such efficiencies and demand best practices when signing contracts.
Zoe Barnard, Montana's Addictive and Mental Disorders Division director, said they have little control over decisions that private providers make about care strategies.
“We can say this is the standard of care for this type of work, for example, but we don’t say you have to provide X, Y or Z services,” she said. “They can choose to provide some or all of the services.”
Starting in November, the Missoulian repeatedly asked to speak with Bullock about drug use during pregnancy and his overall strategy for addressing opioids and methamphetamine. Spokeswoman Ronja Abel instead emailed a statement from an earlier press release about a bill the Democrat approved that expanded access to Naloxone, which can reverse the effects of opioid overdose.
“I am committed to ensuring Montanans can continue to get coverage through Medicaid expansion, our most powerful vehicle available to combat this epidemic, as well as integrating behavioral and physical health, reducing costs and improving care, and making sure communities have the tools they need to confront this growing problem,” the statement read.
Abel also attached a copy of a draft strategic plan for combating drug use that was released by the state health department earlier this year. The 34-page report only includes one use of the word “women,” encouraging more stigma-free access to prenatal care. A request for all state health department records related to drug use during pregnancy yielded three reports, totaling five pages, about the Medicaid costs of treating infant withdrawals.
Some states formed departmental task forces or legislative committees to identify best strategies of caring for women who use drugs during pregnancy. When asked why Montana has not done similar work to create specific solutions, Barnard said, “I have other people I’m equally concerned about, like veterans.”
Attorney General Tim Fox, a Republican, said he hopes to find collaborative solutions with Aid Montana, his initiative to address drug use in the state.
Asked whether pregnant women, in particular, had been part of those discussions, he said, “We certainly thought about their needs.
“We want to make sure babies are born healthy and that they’re in a healthy home. Unfortunately, there’s all too much of the opposite because of substance abuse disorders in the state. I don’t recall if it’s in our report, but I did see stats on neonatal abstinence syndrome,” he said.
The 87-page report issued in September includes one passing mention of pregnant women and does not include any reference to infant withdrawals, although a related, two-page handout does. A November summit hosted by Fox in partnership with the Montana Healthcare Foundation included one brief comment about drug use during pregnancy as a presenter cited a Medicaid report commissioned by the foundation.
Fox deferred detailed questions to the Department of Public Health and Human Services, saying it is their “area of expertise.” He said his knowledge of the challenges women face when seeking treatment was “only general,” but said his agency would do more to work with health officials on solutions.
“If there are barriers that prevent pregnant women from getting treatment, we need to look at those and remove the appropriate ones,” he said.
There are small signs Montana could be on the verge of making systemic improvements to help pregnant women who use drugs. But most did not start with elected leaders.
The Montana Healthcare Foundation has funded several pilot projects to test strategies for reducing the number of babies born with neonatal abstinence syndrome and to help more of their mothers so the family can stay together. A handful have had impressive early results, but it remains unclear how several of the projects will be funded long-term.
Montana also recently secured a $4 million grant from the federal Substance Abuse and Mental Health Services Administration to address the lack of medication-assisted treatment in the state. The pilot project is funded through April 2019.
And Child and Family Services hopes to soon provide more support for parents who use drugs, partnering them with specialized case managers to keep them on track with recovery and other agreements made as part of plans to reunite their families.
After interviews with the Missoulian, a few state leaders said they would add mothers who use drugs to their list of priorities for the 2019 Legislature.
“We need to do something,” Dudik said.
Earlier this month, she said she had talked to state health officials about how to expand the strategies successfully piloted with support from the Healthcare Foundation. She also is interested in increasing the length of time Child and Family Services can work with parents who use drugs before finalizing a child’s removal.
She and Keenan, among others, suggested Montana could create a “safe harbor” law that would guarantee pregnant women would not face criminal charges if they sought medical help or drug treatment, similar to provisions that protect people who call 911 about a drug overdose.
Some lawmakers, mostly Republicans, said they might support "fetal harm" laws like those enacted in other states that make it a crime to use drugs during pregnancy. Others said making drug use more illegal would not solve the problem and runs counter to the state's efforts to put fewer nonviolent offenders in prison, offering them increased support services instead.
Rep. Jimmy Patelis, a Billings Republican who joined the Legislature after retiring as a U.S. chief probation officer for the Montana district, supports criminal justice reinvestment and penalizing women who use drugs while pregnant.
"I'm 100 percent behind that because there's another life involved and if you're jeopardizing that life through harm and using substances, you should be held accountable for that — in addition to getting help," he said.
Wolken said the state should lean heavily on the Montana Healthcare Foundation for advice as it develops solutions. She did not want the issue to become delayed by “another commission” when good ideas already exist.
“These conversations are happening,” she said. “But there needs to be a catalyst.”