'Everything under the sun'

There is an empty space in Diana Burd's life where her son used to be. She sees him in the plants he gave her, the movies they watched, the trips they had yet to take.

She couldn't understand how he was feeling until he was gone.

Looking back, Burd said the signs were there. Her son told his brother to leave his stuff alone. But, he also told his brother that when he was gone, everything he owned would be his.

"I remember, I was like, 'Oh, Wyatt,'" Diana said. "And he said, 'No, Mom, everything that I own is Thunder's."

Wyatt Madplume took his own life in July of last year, 12 hours before he was scheduled for a behavioral health intake in Great Falls that could have sent him to a residential treatment program, Burd said.

Burd said Madplume, 27, was often compared to Robin Williams, always cracking jokes and worrying about others more than himself. He wasn't a person you'd expect to be going through what he was going through, she said, but he was brought to the edge by losing 12 people close to him in the span of three years, including the death of his long-time girlfriend.

Burd and Madplume had been trying "everything under the sun" for two years before his death, seeking local treatment at their Indian Health Service facility for his mental health and substance abuse disorders, Burd said. Madplume had been in and out of the emergency room in Browning many times, and attempted suicide three times before he killed himself in July.

Burd, who appeared before the Joint Appropriations Subcommittee for Health and Human Services at the Montana Legislature last week to testify in support of continuing Medicaid expansion, said they couldn't find resources at their local IHS to sustain Madplume's recovery. The cycle of crisis to crisis left Madplume with waning faith in the system's ability to help him, so they turned to help from Medicaid and found him a place in Great Falls that could give him consistent care for long-term recovery.

It was a last ditch effort, Burd said. But Madplume had struggled for too long, and on the final night before his intake it became too much for him.

Stories like Madplume's are common in Montana, with data from the Department of Public Health and Human Services showing that Montanans have the third-highest rate in the nation for suicide.

Many of the behavioral health advocates who lined up to testify last week for continuing Montana's 10-year-old Medicaid expansion law cited that statistic. They argued expansion is crucial to provide the behavioral health services that Montanans need in tribal and rural communities in Montana, while opponents argue it is an expensive state program that does not solve the problems with Montana's behavioral health programs.

Medicaid expansion is a program to extend Medicaid eligibility to Montana residents who make up to 133% of the federal poverty line. The program, implemented in Montana by the 2015 HELP Act, is up for re-examination this legislative session.

Rep. Ed Buttrey, R-Great Falls, is sponsoring House Bill 245, which would extend the Medicaid expansion program for another two years. And Rep. Mary Caferro, D-Helena, is carrying House Bill 230, to refine the Medicaid expansion program to offer continuous coverage and reopen some Offices of Public Assistance that closed during state budget cuts several years ago. Both bills drew hours-long testimony in support of expansion in the House Human Services Committee on Wednesday, Jan. 22. The committee did not immediately take action on the bills.

Meanwhile, Sen. Carl Glimm, R-Kila, is proposing Senate Bill 62, which would phase out Medicaid expansion later this year. Glimm's bill passed the Senate Public Health, Welfare and Safety Committee on Friday, Jan. 24 and now moves to the full Senate for debate.

Buttrey, who has led Medicaid expansion legislation since 2015, said the state has seen a substantial increase in the availability of behavioral health and substance abuse services since its implementation.

For the community in Fort Belknap, Medicaid expansion made all the difference by allowing lower income residents to get access to the behavioral healthcare they need, Dr. Jennifer Show, the chief medical officer for the Fort Belknap reservation, said.

Show said prior to the HELP Act's passage in 2015, the reservation declared a medical emergency on the reservation because of the rising number of suicides. Since the implementation of Medicaid expansion, Show said the crisis center went from receiving over a hundred phone calls a month to an average of one phone call per month, and they were able to lift the state of emergency in 2022.

The biggest reason for this change is more community members having access to their healthcare services, and the ability to hire more providers, Show said. With the resources from Medicaid expansion, they were able to implement a 24/7 model for provider access, meaning their community members can call at any time and talk to a provider.

Fort Belknap also modeled their behavioral health treatments around integrative care, meaning that the treatment of behavioral health is treated alongside coexisting substance abuse disorders. Show said a vast majority of people who struggle with substance abuse have coexisting mental health issues which cause them to self medicate.

Burd said these treatment options could have helped Madplume in a way that their local facility could not.

"Integrated care was what my son needed, because he had a mental illness and an addiction," Burd said.

Fort Belknap's community mirrors the effect of Medicaid expansion on rural and tribal communities all over Montana, said the Montana Healthcare Foundation's CEO Aaron Wernham. The foundation surveyed tribal hospitals and rural hospitals across the state this past year, and found a massive increase in the availability of behavioral health and substance abuse treatment.

"Eighty percent of the hospitals we talked to had added behavioral health services," Wernham said. "And over, you know, over the course of Medicaid expansion, we've actually seen a doubling in the number of state approved substance abuse treatment providers."

Both sides of the argument have economic concerns as a main tenet of their argument, with proponents arguing expansion, especially the access to behavioral health care, promotes a healthy and productive workforce and opponents of expansion saying it is a risk for the state and discourages people from working.

Glimm, the sponsor of the bill that would sunset expansion, said the program relies on federal funding at a time when the federal government is deep in debt.

"So what is a really easy way to cut some of that spending is to roll Medicaid expansion back to traditional Medicaid," Glimm said. "I mean, that's, you're talking hundreds of millions of dollars, right? That would be a big deal. And if you want to talk about risk, that's a huge risk for the state."

Glimm also argued that the economic growth from more people in the workforce will more than alleviate the economic issues from the sunset of Medicaid expansion.

"Ultimately, the goal is to put those people to work, so that they're productive members of society. And everybody's better off for it. They're going to be better off for it. The system is going to be better off for it. Taxpayers are going to be better off for it, right? Everybody's in better shape," Glimm said.

But data that Buttrey provided in his testimony provides a contrary perspective – he said since 2015, Medicaid expansion has actually generated more revenue than it takes to keep the program going. Buttrey said this is because more people are healthy and able to participate in the workforce, more jobs are available as the healthcare industry expands, and Montanans' personal taxable income increases.

"When you add these things up, the program actually provides a budget savings of $27 million if you look at the last biennium," Buttrey said.

Matt Kuntz, the executive director of the National Alliance on Mental Illness, said before expansion he talked with many traditional Medicaid patients who had to choose between working and seeking treatment, because if they worked they would cross the income threshold and lose their Medicaid coverage.

"They ended up in the spot where they were struggling and they needed – they needed care," Kuntz said. "The only way to get care was to not work."

When asked about the potential effects on behavioral health treatment, Glimm said a bill passed last session, House Bill 872, also known as Behavioral Health for Future Generations, tackles the issue from a different angle. The bill has a series of proposals aimed at revamping the systems of behavioral health in Montana and incentivizing providers to go into behavioral health.

"The 872 stuff is going to be probably providing more valuable stuff for behavioral health and mental health than what Medicaid expansion does," Glimm said. " I mean, Medicaid expansion is paying for portions of some of it, but we still have problems with the system."

But Wernham said since HB 872 is a one-time fund, the new programs will not be able to stay afloat without the help of Medicaid expansion.

"A one-time injection of funds from the behavioral health system for Future Generations Bill may help get things off the ground, but to really sustain them and build them and run as a business, the healthcare providers need a reliable source of ongoing reimbursement for providing services," Wernham said.

Burd worries deeply about the effects of a sunset of Medicaid expansion for the mental health of her Blackfeet tribal community, because of the lack of economic resources.

"We need ... the resources for suicide, not only for Native kids, but for everybody to be able to be understand that suicide can be prevented, there should be resources in place," Burd said, "but also the Medicaid, the way to pay for it."

Burd experienced suicidal urges for the first time in her life after Madplume's death. She said her support system helped her find resources, which saved her from possibly succumbing to the same fate.

"When you find out somebody loved had taken their life, you are stuck in a trauma state. And ... unless you get help, you are stuck there," Burd said.

Burd is learning to live without Madplume, without his kindness and his humor. She said a therapist in one of the grief groups she attended likened it to learning to live without an arm, without the presence of something that's always been there.

"You're living in this world where you were used to having this person every day," Burd said. "Now you have to create a life without them. And every second, every day, you're going to remember they're – it's not there no more."

Emma White is a reporter with the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Broadcasters Association, the Montana Newspaper Association and the Greater Montana Foundation. White can be reached at [email protected].