Evans said she lost Medicaid coverage in September because she hadn’t received paperwork after moving from Great Falls, Montana. She has had to forgo the blood pressure medication she can no longer pay for since losing coverage. She has also had to put off needed dental work.

“The teeth broke off. My gums hurt. There’s some times where I’m not feeling good, I don’t want to eat,” she said.

Evans is one of about who have lost Medicaid coverage as the state reevaluates everyone’s eligibility following a pause in disenrollments during the covid-19 pandemic. About two-thirds of those who were kicked off state Medicaid rolls lost coverage for technical reasons, such as incorrectly filling out paperwork. That’s one of the in the nation, according to a ËØÈËÉ«ÇéƬanalysis.

Even unsheltered people like Evans are losing their coverage, despite state officials saying they would automatically renew people who should still qualify by using Social Security and disability data.

As other guests filtered out of the shelter that February morning, Evans sat down in a spare office with an application counselor from , which serves much of the homeless population here, and recounted her struggle to reenroll.

She said that she had asked for help at the state public assistance office, but that the staff didn’t have time to answer her questions about which forms she needed to fill out or to walk her through the paperwork. She tried the state’s help line, but couldn’t get through.

“You just get to the point where you’re like, ‘I’m frustrated right now. I just have other things that are more important, and let’s not deal with it,’” she said.

Evans has a job and spends her free time finding a place to sleep since she doesn’t have housing. Waiting on the phone most of the day isn’t feasible.

There’s no public data on how many unhoused people in Montana or nationwide have lost Medicaid, but homeless service providers and experts say it’s a big problem.

Those assisting unsheltered people who have lost coverage say they spend much of their time helping people contact the Montana Medicaid office. Sorting through paperwork mistakes is also a headache, said , a case manager at HRDC, a homeless shelter in Bozeman.

“We’re getting mail that’s like, ‘Oh, this needs to be turned in by this date,’ and that’s already two weeks past. So, now we have to start the process all over again,” she said. “Now, they have to wait two to three months without insurance.”

Montana health officials told NPR and ËØÈËÉ«ÇéƬHealth News in a statement that they provided training to help homeless service agencies prepare their clients for redetermination.

and some other conservative states against disenrolling high rates of people for technicalities, also known as procedural disenrollment. They also warned states about unreasonable barriers to accessing help, such as long hold times on help lines. The Centers for Medicare & Medicaid Services said if states don’t reduce the rate of procedural disenrollments, the agency could force them to halt their redetermination process altogether. So far, CMS hasn’t taken that step.

Charlie Brereton, the director of the Montana health department, resisted calls from Democratic state lawmakers . Redetermination ended in January, four months ahead of the federal deadline.

“I’m confident in our redetermination process,” Brereton told lawmakers in December. “I do believe that many of the Medicaid members who’ve been disenrolled were disenrolled correctly.

Health industry observers say that both liberal-leaning and conservative-leaning states are kicking homeless people off their rolls and that the redetermination process has been chaotic everywhere. Because of the barriers that unsheltered people face, it’s easy for them to fall through the cracks.

, a physician and a homeless researcher at the University of California-San Francisco, said it may not seem like a big deal to fill out paperwork. But, she said, “put yourself in the position of an elder experiencing homelessness,” especially those without access to a computer, phone, or car.

If they still qualify, people can usually get their Medicaid coverage renewed — eventually — and it may reimburse patients retroactively for care received while they were unenrolled.

Kushel said being without Medicaid for any period can be particularly dangerous for people who are homeless. This population tends to have .

“Being out of your asthma medicine for three days can be life-threatening. If you have high blood pressure and you suddenly stop your medicine, your blood pressure shoots up, and your risk of having a heart attack goes way up,” she said.

When people don’t understand why they’re losing coverage or how to get it back, that erodes their trust in the medical system, Kushel said.

Evans, the homeless woman, was able to get help with her application and is likely to regain coverage.

Agencies that serve unhoused people said it could take years to get everyone who lost coverage back on Medicaid. They worry that those who go without coverage will resort to using the emergency room rather than managing their health conditions proactively.

Baker, the case manager at the Bozeman shelter, set up several callbacks from the state Medicaid office for one client. The state needed to interview him to make sure he still qualified, but the state never called.

“He waited all day long. By the fifth time, it was so stressful for him, he just gave up,” she said.

That client ended up leaving the Bozeman area before Baker could convince him it was worth trying to regain Medicaid.

Baker worries his poor health will catch up with him before he decides to try again.

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But earlier this year, MacDonald said, her 8-year-old son started to become aggressive. At first the family thought it was ADHD. Her son was indeed eventually diagnosed with attention-deficit/hyperactivity disorder — as well as disruptive mood dysregulation disorder, which makes it difficult for her son to control his emotions, particularly anger.

“He was hurting me. He was threatening to kill his brother. One of the last straws was they had four people at school holding him down for almost an hour trying to calm him down,” she said.

The American International School of Jeddah told her that her son couldn’t come back. His behavior was so severe that MacDonald started to look for residential treatment back in the U.S.

She found in Montana. Children in the Intermountain program learn to build healthy relationships through intense behavioral therapy over the course of up to 18 months.

Intermountain Residential is one of the only facilities in the U.S. that serves young children with emotional dysregulation, like her son.

MacDonald remembers crying hysterically when she dropped him off in June, but tears gave way to hope as his violent outbursts decreased over the weeks and months afterward.

“Now when we have our weekly calls, it’s very normal. It’s like talking to your child again. It’s wonderful,” she said.

Intermountain is one of about a dozen programs in the nation that provide long-term behavioral health treatment for kids under 10, according to the . It’s one of the only options for kids as young as 4.

Intermountain is tucked away in a quiet neighborhood in Helena and has been treating children for over 100 years. The children Intermountain treats have emotional disorders, behavioral issues stemming from mental illness or trauma, and other issues. They struggle with self-harm, severe depression, or violent outbursts that can lead to attacking other people or animals. Most families that come to Intermountain have tried medication, outpatient therapy, or even short-term residential treatment, all without success.

Long-term treatment programs like the one Intermountain offers are often a last resort for families.

It can take months before kids with severe mental and behavioral health issues feel safe enough to open up to Intermountain staff, said , who manages the residential program. Some kids have been traumatized or abused while adults were supposed to be caring for them, she said. Living through that can leave them deeply scared of or resistant to adult interaction, even once they’re living in a safe environment. Bryce said that Intermountain staff have to gain a patient’s trust before working to figure out the root cause of the child’s behavior. It takes time before they can make an effective long-term treatment plan based on intensive behavioral therapy and building healthy relationships.

Intermountain parents and staff were shocked when the facility that it would close its doors this fall, blaming staffing shortages.

Some parents threatened to sue. A law firm representing them argued in a to Intermountain’s board that it has a contractual responsibility to finish treating children who remain at its residential facility.

Intermountain then reversed course, saying it would downsize in an attempt to keep the program open. But spokesperson said it’s no guarantee Intermountain can keep its doors open long-term. Intermountain plans to decrease its capacity from 32 beds to eight.

, until recently executive director of NATSAP, thinks staffing shortages are not the full story of Intermountain’s troubles.

“We are seeing a lot of long-term facilities moving to what they call the short-term, intensive outpatient. You’re able to get insurance money easier,” she explained. Stokes said she knows of 11 long-term programs for kids 14 and younger that have shifted to offering only shorter stays, of 30 to 90 days.

Short-term programs are cheaper and insurance companies will pay for them more quickly, Stokes said. Over the course of a year, short-term programs can treat more patients than long-term residential facilities. That can make them more lucrative to run.

But those programs aren’t likely to help kids who might have to leave Intermountain. In fact, short-term programs could cause them harm.

“The problem is if that kid bombs out of that shorter-term stay, or they do well and maybe six months down the road they don’t have the tools in their toolkit to continue that, and now you’re labeled as treatment-resistant, when that kid wasn’t treatment-resistant,” Stokes said.

Kids labeled treatment-resistant can then be rejected from other short-term programs.

For now, parents of kids at Intermountain are looking for other treatment options because of the uncertainty over whether Intermountain will remain open. Parents told NPR and ËØÈËÉ«ÇéƬHealth News they’ve had to sign up for waitlists that can take a year or longer to clear for the few programs that take kids 10 and younger. That’s if they can find facilities that would accept their kids at all.

Stacy Ballard hasn’t been able to find a facility willing to treat her 10-year-old adoptive son with reactive attachment disorder who is currently at Intermountain. The condition can make it hard for kids to form an attachment with their family. Ballard said her son can be extremely violent.

“He was walking around our house at night thinking about killing all of us, and he said it was almost nightly that he was doing that,” Ballard explained.

Facilities that treat children his age generally won’t treat kids with a reactive attachment disorder diagnosis, which often is associated with severe emotional and behavioral problems.

MacDonald also can’t find another facility that could be a backup option for her son. He was supposed to complete 14 more months of treatment at Intermountain.

She said she can’t gamble on keeping her son at Intermountain because of the uncertainty over whether it will remain open.

So, she’s getting ready to leave Jeddah and fly back to the U.S., taking a leave of absence from her job.

“I’ll take him to my family’s place in South Carolina until I can find another place for him,” she said.

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HELENA, Mont. — Mike Hossfeld unlocked a heavy black steel door to his home’s gun safe, unveiling both modern and antique firearms, some dating from the early 1900s.

“Most of this is mine. There are a few weapons in here that belong to other folks,” he said.

Hossfeld regularly stores firearms for others who are going through a mental health crisis or a rough period. That puts time and space between them and their guns, which can significantly reduce suicide risk.

Hossfeld first stored a firearm, for his National Guard commander, in the 1980s, after the commander talked about suicide.

“We carried our sidearms in a shoulder holster. So I just walked over and took the strap off and said I was going to store his weapon for him in my toolbox,” Hossfeld recalled.

His commander recovered and was very happy to get his weapon back, Hossfeld said. And that’s the whole premise, Hossfeld said, of a Montana law passed earlier this year: to make it easier to help a friend get through a mental health crisis and alleviate the immediate risk of suicide until they get better.

The law for others from legal liability if someone self-harms after picking up their gun.

Public health officials hope that will encourage more people like Hossfeld to store firearms for family and friends. They also want to encourage gun shops and shooting ranges to offer storage for the public.

Montana public health officials are creating a map of locations that store firearms, similar to other states’ so-called safe storage maps.

Montana has the across the country, after Wyoming, according to the Centers for Disease Control and Prevention. About 85% of Montana’s gun deaths are suicides, . That’s much higher than the national average of 60%.

Tough Conversations

At a local gun show this spring, Lewis and Clark County Suicide Prevention Coordinator set up a booth amid a sea of camo and pro-gun T-shirts.

“I have, like, little guns on my earrings. I’m cool, I’m friendly. I’m not here to waggle my finger at you,” she said.

Instead, Hegstrom talks to people about how to bring up a tough topic like suicide, and safe storage of firearms for anyone at risk, with friends and family.

Sometimes her message is well received, but in other cases people shy away, which Hegstrom said is a sign there’s still a lot of work to do to normalize conversations about firearms and suicide.

Hegstrom is working on a local “safe storage map” identifying gun shops and other locations willing to store guns for the public. She hopes it will become a statewide resource and a tool for suicide hotline operators.

Colorado, Washington, Louisiana, and other states have implemented some version of a safe firearm storage map or public messaging campaign encouraging people to store firearms outside the home while at increased risk for suicide.

Legal Barriers

Background check requirements and variation in state and federal gun laws give some gun shop owners pause when it comes to storing firearms for at-risk people or having their stores on a public safe storage map.

“I’m not really sure that firearms dealers doing hold agreements is really the best idea,” said Ed Beal, owner of in Helena.

Hegstrom asked Beal to participate in the safe storage map for Lewis and Clark County, but Beal said he has a lot of questions about what is legally required under federal law when it comes to storing firearms temporarily, particularly about what background checks his shop would have to do to return a person’s gun to them after they participate in the safe storage program.

Some gun shop owners participating in safe storage programs in other states say federal background check laws can also deter people from using the storage program in the first place.

Hammer Down Firearms, a gun shop outside Denver, is on the safe storage map for Colorado.

The idea of storing guns for the public is fine in theory, said co-owner Chris Jandro. However, he said, only two people have used the shop’s service.

Many customers back out once they hear that they’ll need to pass a background check when they come back to get their gun, Jandro said.

That background check includes

Having gotten treatment doesn’t necessarily disqualify someone from getting a gun back, but the questions can be confusing, especially for someone in crisis.

NPR and ËØÈËÉ«ÇéƬHealth News requested an interview with the Bureau of Alcohol, Tobacco, Firearms and Explosives, which regulates gun shops, but did not receive a response.

Federal law doesn’t prohibit a person from storing guns for another person.

But in some places, like New York and Massachusetts, state laws can make doing so legally almost impossible, according to Harvard public health researcher .

“In New York state, you might be a licensed gun owner, but you’re still not supposed to hold onto somebody’s guns, because you’re supposed to register each individual gun,” she explained.

The only workaround is to formally transfer ownership of a weapon at a gun shop. Ownership would have to be transferred again before the gun could be returned, Barber said.

In New York, that includes filing paperwork with the state for each gun.

Other states allow immediate family members to hold on to a relative’s guns without transfer paperwork, but they prohibit extended family members or friends from doing so.

These legal hurdles just take too long to navigate during a crisis, said emergency room physician and University of Colorado professor , who helped set up .

Betz suggested that gun transfer and background check laws include exceptions for suicide prevention. “It would make it easier to give your gun to your cousin, for example,” she said.

That’s what lawmakers did in Washington state. A recent law change friends and extended family members, rather than just immediate family, to store a gun — if suicide is a risk.

Support From Public Health Officials and Gun Enthusiasts

It will take time to address the legal barriers and patchwork regulatory landscape, but that shouldn’t deter health officials in the face of a growing crisis, said Betz. The number of suicides involving firearms pushed the national suicide rate to an all-time high in 2022, according to a of preliminary mortality data.

Betz said there is still a place for red flag or extreme risk laws that allow courts to legally seize firearms from someone who poses a risk to themselves or others.

But that should be a last resort, she said.

Gun rights advocates are coming around to the idea of voluntary safe storage. was chairman of the board of Prickly Pear Sportsmen’s Association for 13 years. The association operates a shooting range in Helena.

Swant said he overcame his initial reluctance and started working with Lewis and Clark County health officials after hearing the stories of people who lent their guns or held someone else’s guns to avert a crisis. “That made a difference,” he said.

There isn’t a lot of data on how often people use public safe storage options or ask friends or family to hold on to their guns to reduce suicide risk.

According to a survey of Colorado and Washington state gun owners, a little over a quarter of respondents a firearm away from home in the last five years. However, they could have been storing guns for reasons beyond suicide risk, like during a long vacation or visit from grandchildren.

Researchers in Colorado are planning a study to gather more information on how often people store guns outside their homes to prevent suicide.

Making It Normal to Ask for Help

It’s going to take repeated and widespread messaging campaigns to truly change people’s behavior, said Barber, the Harvard researcher.

“You need the kind of message saturation that we’ve got with designated drivers and ‘friends don’t let friends drive drunk,’ where you’re seeing it in TV shows, on movies, you’re seeing it in PSAs,” she said.

Some gun enthusiasts want to help.

, a North Carolina-based custom gun case designer, said he has periodically gone into crisis over the years. When that happens, his friends take his firearms and change the code for the safe at his shop.

He started talking about his experiences on various gun-oriented podcasts to promote the idea of safe storage. He has a list of people to call “when things start going dark.” He also keeps a note to himself in his gun safe in case he needs to be pulled back from the brink.

“Time to reach out, things will get better, you’re not weak. You’re doing the right thing. Make the phone call. Signed, Future Pete,” the note reads.

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“She’s been here almost a year, just laying on her bed,” she said.

Inside the cell, dimly lit by a single window, a woman was curled up under a fleece blanket, only her bright-pink fingernails sticking out.

This woman was charged with burglary in September 2022, Root said. An evaluation after her arrest determined that mental illness prevented her from standing trial and that she required treatment at the Montana State Hospital, the state-run inpatient psychiatric hospital.

Like many inmates deemed unfit for trial due to a mental health condition, she has been stuck on a waiting list for the Montana State Hospital’s 54-bed forensic unit, which stabilizes inmates through medication and treatment so they are competent to stand trial. The woman in the Kalispell jail was No. 2 on the unit’s waiting list of 70 people as of June 30. Meanwhile, the northwestern Montana jail where she’s waiting isn’t equipped to treat mental illness, and the jail staff can’t force her to take medication.

“So, they just deteriorate within our facility,” Root said of her and other inmates with mental health conditions.

Before their legal case can proceed, people charged with crimes in Montana must understand the charges they face and participate in their own defense. But because of bottlenecks in services across the country, people in jail with serious mental illness are waiting months to receive the care needed to “restore” their competency to stand trial.

The Montana State Hospital for years has struggled to keep up with the number of people who are criminally committed to the facility, but Root said the number of such people at the Flathead County jail has grown since the pandemic and as Montana’s recent population boom has pushed up housing costs.

This year, state lawmakers began to address the woes of the troubled state hospital, which lost its federal funding and accreditation in 2022 amid a rash of patient deaths, by creating a $300 million fund to improve behavioral health care in the state and passing bills to increase transparency.

Now, state health officials are asking lawmakers to change criminal commitment laws so the Montana Department of Public Health and Human Services has a say before a judge orders a patient committed to the Montana State Hospital or another state-run facility.

“That is something we would like to address with you,” Chad Parker, an attorney for the health department, told the Children, Families, Health, and Human Services Interim Committee in July. “That is something we’d like to look at to try and change, to give the department some more control, to at least give us a place at the table.”

But Republican , a member of the interim committee, said that there is nowhere else to send patients facing criminal charges for evaluation and treatment, and that the health department should focus on improving patient care instead of denying patients access.

Parker said judges rarely order patients to be committed at community care facilities as an alternative to the state hospital system, though he acknowledged that community service options have dwindled, in part due to low Medicaid reimbursement rates. Lawmakers raised those rates by about 20% this year, but it will take time to determine whether that increase is enough to rebuild mental health services that have shuttered.

In the meantime, patients are funneled to the state hospital as it’s the only option for many inmates who need mental health care.

“When there are no available patient beds or they are not available for some time, the department can be held in contempt or receive another sanction,” Parker told the legislative committee. “And we need to address that, as well.”

In an emailed statement, health department spokesperson Jon Ebelt said that state law doesn’t require courts to consider wait times before committing inmates to the state hospital for mental health care. Neither Ebelt nor Parker pointed to specific community services or other mental health facilities that could treat inmates in the criminal justice system to become fit to stand criminal trial.

Interim legislative committees study issues during the Montana Legislature’s off years (it is in session only in odd-numbered years), and can draft bills for the next session, scheduled to start in January 2025. During their July meeting, lawmakers on the Children, Families, Health, and Human Services Interim Committee decided to explore what community mental health services are available but did not commit to drafting the legislation sought by the health department. The committee next meets .

In an interview with ËØÈËÉ«ÇéƬHealth News and Montana Public Radio, Kalispell District Court Judge Amy Eddy did not address the health department’s proposal to give the state a say on involuntary commitments. But she noted that the state hospital is currently the only facility in the state that can take patients charged with crimes and involuntarily medicate them.

Involuntarily medicating inmates found to be mentally unfit is often the only way to stabilize them so they can stand trial and then be transferred to community services to help them maintain the mental stability that the medications can provide, according to experts in Montana’s judicial and mental health systems.

“It’s not realistic to change the commitment laws and keep people out of Montana State Hospital” unless other tools are developed, said executive director Matt Kuntz, who has worked in the past with lawmakers on changes to commitment laws.

However, Republican said Montana’s commitment laws do need to be reexamined if the state is to rebuild its struggling behavioral health treatment system and reduce wait times for services in the state hospital.

Keenan requested that another committee, the Law and Justice Interim Committee, also study the commitment laws. But Keenan did not request any specific changes, and that committee had not responded to his letter as of Aug. 30.

“Montana has strictness when it comes to forced medication in mental health situations,” Keenan said. “That is something that needs to be looked at.”

Montana guarantees the right to a court hearing before people can be forced to take medication. That could be a hurdle to expanding the types of mental health facilities that can involuntarily medicate patients, particularly among those that can hold patients for only a few days, said Keenan.

The $300 million state lawmakers appropriated this year aims to fund both community-based mental health services and regional mental health facilities that could take on patients who need a lower level of care than what’s offered at the state hospital. But it will take years for any of those initiatives to come to fruition.

While additional mental health services are needed, the state also needs to work on improving care at the state hospital for the patients it does serve, said Eddy, the Kalispell judge.

Eddy said once inmates make it to the state hospital for treatment, they’re typically there for two weeks, instead of the allotted 90 days, before being sent back to the county jails. That makes it difficult to truly stabilize them, she said.

Many inmates refuse to take medication once they return to jail to await their legal proceedings, then they mentally deteriorate, according to Eddy and Root, the jail official. The jails also might be unaware of an inmate’s diagnosis or whether they’re on medication, Eddy said.

“That makes it very difficult, having gone through all this effort to restore this person’s fitness, to then keep them fit to proceed in the criminal stuff,” she said.

Some inmates are left waiting once again in jail only to go back through the process to get treatment at the state hospital.

“Then sometimes they’ve been here for so long, I think nobody knows what to do, and then they get released,” said Root.

With limited community mental health resources, those who are released typically end up back in jail, only to repeat the cycle.

“Probably my biggest frustration with our system is the mentally ill and having people in here that should not be criminally charged,” Root said. “Yes, they’re not safe to be out in the public, but being in jail is not the answer either.”

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“This morning, Missoula, Montana, learned that there is no place in America that is safe from hateful, misguided groups,” the crowd of reporters and onlookers.

The 1993 fire at Blue Mountain Clinic was part of a particularly violent period of anti-abortion attacks in the U.S. that continued through the 1990s and 2000s, when clinics were . Now, less than a year after the U.S. Supreme Court overturned Roe v. Wade, rhetorical and physical attacks have increased against clinics that still provide abortions in conservative-led states.

The U.S. Justice Department formed a after last year’s Supreme Court decision, in part to bring more attention to anti-abortion violence and threats. Since 2011, the DOJ has of criminal and civil cases over obstructing access to, threatening, or damaging abortion clinics. It charged 26 people in 2022 — more than in the previous three years combined. The FBI is also , primarily in states that have maintained or bolstered abortion access since the June 24 Dobbs v. Jackson Women’s Health Organization decision overturning Roe.

The increase in violence has led abortion rights advocates to worry that more violence could be coming if the fringes of a fragmented anti-abortion movement become impatient with judicial and political efforts to ban and restrict abortion. Meanwhile, anti-abortion activists worry that vandalism committed at pregnancy resource centers over the past year is an indication that abortion rights advocates could escalate into violence if states further tighten abortion access.

Violence against abortion providers was already on the rise before the Supreme Court’s decision to end federal protections for abortions, according to the National Abortion Federation. Nationally, from 2020 to 2021, reports of stalking rose 600%, clinic invasions 129%, and assaults 128%, . The organization is still aggregating its 2022 figures, which include data from after Roe was overturned, but it expects the upward trends to continue, according to Chief Program Officer Melissa Fowler.

“When a clinic closes, the protesters don’t just pack up and go home,” Fowler said. “A lot of times, they will travel or even move to other communities and states and target the clinics that remain open there.”

There have also been attacks on anti-abortion pregnancy resource centers, which have been vandalized in several states since last year. Police in Minnesota were looking for the vandals responsible for smashing windows and spray-painting in red, “If abortion isn’t safe, neither are you,” at Abria Pregnancy Resources in St. Paul last summer, .

The clinic’s director, Angela Franey, had previously voiced support for the Supreme Court’s Dobbs decision.

Last May in Wyoming, after a draft opinion of the decision was leaked to the press, a new abortion clinic in Casper was set on fire before it could open. Owner Julie Burkhart blamed the incendiary rhetoric of anti-abortion groups.

“They are highly skilled in getting these lone wolves to come in and do their dirty work so that their hands can remain clean,” Burkhart said.

Federal officials recently charged a woman with arson in that case. According to an affidavit, 22-year-old Lorna Green at the Wellspring Health Access clinic in her hometown of Casper because “she did not like abortion.”

The clinic plans to open this spring, but its future is uncertain. A state law bans nearly all abortions in Wyoming, though on March 22 a judge temporarily blocked the law while a legal challenge against it is pending.

In Montana, the most recent attack against an abortion clinic happened in 2014 in Kalispell, about 120 miles north of Missoula by car, where the son of an anti-abortion activist broke into and vandalized All Families Healthcare. He was sentenced to 20 years in prison with 15 years suspended.

All Families Healthcare owner Susan Cahill said she wanted to continue working after the break-in. But her family, fearing for her safety, persuaded her to retire.

“I was quite depressed for a couple of years after the office was destroyed,” Cahill said.

The clinic’s closure created an abortion care desert for four years before another provider took over the practice.

Montana continues to allow access to abortion services because of protections in its state constitution, but clinics that perform abortions are few. Blue Mountain reopened after its 1993 fire, and Planned Parenthood of Montana also provides abortion services in multiple Montana cities. All Families reopened under new owner Helen Weems, in Whitefish, just north of Kalispell in northwestern Montana’s Flathead Valley.

Montana’s Republican governor and Republican-led legislature are now seeking to restrict abortion access. Gov. Greg Gianforte and state Attorney General Austin Knudsen are asking the state Supreme Court to overturn its 1999 decision in the case Armstrong v. State, in which it held that abortion access is protected under the Montana Constitution’s right to privacy.

“It’s time for the Montana Supreme Court to take up the Armstrong case, take another look at it, and reverse it,” Montana Attorney General Austin Knudsen said at a January anti-abortion rally in the Montana Capitol. “It is garbage law and it needs to go.”

Meanwhile, state lawmakers are that seeks to decouple abortion access from the constitutional right to privacy, along with other measures that would restrict abortion. Gianforte’s administration and conservative lawmakers are also for Medicaid patients to obtain medically necessary abortions.

However, most Montanans support abortion access, and voters rejected a 2022 ballot initiative that would have created criminal penalties for health officials who do not work to save the life of an infant born after an attempted abortion or birth, even if the infant has no chance of long-term survival.

A from the Public Religion Research Institute found a greater percentage of Montanans than of people in any bordering state think abortion should be legal in most or all cases.

The message sent by voters in Montana — and those who passed 2022 ballot measures in support of reproductive rights in California, Kansas, Kentucky, Michigan, and Vermont — has left Republican lawmakers with unexpected challenges, said , a law professor at the University of California-Davis who studies the anti-abortion movement.

Those politicians want to avoid upsetting voters, but they also want to pacify the more extreme anti-abortion groups by promising progress through legal means, said Ziegler. With the movement fragmented after Roe was overturned, those in the mainstream anti-abortion movement worry about what the more radical elements might do if their cause isn’t advanced in the courts and statehouses, she said.

“Quite literally the last thing you want is PR where your movement is being associated with violence,” Ziegler said.

Health care providers in Montana said the post-Roe era has been an uneasy time as they defend themselves against legal and political attacks while trying to keep their doors open for patients from Montana and neighboring states where abortion is banned.

“Our patients show up every day because they are desperate to get this care,” said Nicole Smith, the current executive director of Blue Mountain Clinic. “We have to be there and hold the line for them.”

Weems, of All Families Healthcare, said having to constantly fend off legal attacks on abortion care has changed how she thinks of herself.

“It’s felt like there’s been a change in my role from strictly a medical provider to more of a political activist,” she said.

Abortion rights advocates are working to support medical providers in managing the mental toll these legal attacks take. The newly created Montana Sexual & Reproductive Health Collective is partnering with licensed therapists to provide free emotional and psychological support for providers.

“We don’t want to have to be doing triage on our abortion providers or our abortion rights community,” said Hillary-Anne Crosby, the group’s leader. “We want to be there every step of the way so it does not get to that crisis point.”

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BUTTE, Mont. — Jennifer Mitchell remembered getting a call nearly two years ago that her 69-year-old husband, Bill, had crashed his car and had been committed to the Montana State Hospital, the state-run psychiatric hospital for adults about 20 miles from their home in Butte.

Physicians thought Bill Mitchell had dementia and could be a danger to himself or others, according to medical records. But once he was admitted, his wife really began to worry. She couldn’t visit him because of covid-19 restrictions, and she couldn’t get details about the care or the medicine he was receiving.

“I tried to get an idea of what he was taking, not taking. I could not get answers,” Jennifer said.

When Bill was discharged after 60 days, Jennifer discovered he had been taken off some of his congestive heart failure medications. A month later, he went into cardiac arrest and was moved to hospice care. He died on Aug. 4, 2021, six days after his 70th birthday.

The psychiatric hospital in southwestern Montana has been under scrutiny since the federal Centers for Medicare & Medicaid Services in April 2022 following Federal officials found in the investigations that the hospital had failed to meet Medicare’s “basic health and safety requirements.”

Mitchell said that she was infuriated by the lack of transparency around her husband’s care and that she hoped decertification would force a change for the better. But it’s had the opposite effect. When federal oversight and funding of the Montana State Hospital was removed, so too was the ability of the public to learn details surrounding patient deaths and injuries.

Between April’s decertification and the end of December, five Montana State Hospital patients have experienced severe injuries requiring immediate medical care or hospitalization, and there have been eight substantiated abuse and neglect reports, Montana Department of Public Health and Human Services spokesperson Jon Ebelt said.

Six patients died in that period, though Ebelt declined to say how many deaths were investigated or if any deaths were deemed preventable.

The circumstances surrounding all those incidents are not publicly known. That’s because, unlike federal investigations, state-level investigations are not public record.

The state health department denied a public records request for all investigations into Montana State Hospital patient deaths, injuries, and assaults since losing federal certification. Ebelt cited that says any records about providing treatment to the seriously mentally ill are confidential and privileged.

States vary widely in what information about abuse and neglect at state-run medical facilities is made public, said David Hutt, deputy executive director for legal services for the National Disability Rights Network.

Hutt noted that the lack of transparency at the Montana State Hospital is unique because it lost federal certification and oversight, which is extremely rare.

State-hired contractors have produced highlighting improvements at the Montana State Hospital, such as a reduction in falls among geriatric patients. But those reports don’t disclose information related to patient deaths, severe injuries, or substantiated abuse and neglect cases, which had led to decertification in the first place.

The lack of information frustrates some lawmakers as they consider state health officials’ and Republican Gov. Greg Gianforte’s request for a $300 million appropriation to overhaul the state’s mental health system and a nearly $20 million request for capital improvements and CMS recertification efforts at the state hospital.

“We’ve stabilized MSH since that decertification with a change in leadership and with no significant increase in deaths, serious injuries, or substantiated abuse or neglect allegations,” state health department Director Charlie Brereton told state senators during his recent confirmation hearing.

Brereton, who declined to be interviewed for this article, did not mention at his hearing whether there had been more recent patient injuries and deaths, or substantiated reports of abuse and neglect.

State Democratic Rep. Mary Caferro, who serves on committees considering funding requests and other legislation to reform the state hospital, likened the current level of oversight at the state hospital to the fox watching the henhouse.

“The legislature, when we have good information, thorough information, we make better policy that’s in the best interest of the people we represent,” Caferro said.

Mental health experts agree with Caferro.

“We should know the answers to whether people in the hospital are safe,” said Ben Miller, a clinical psychologist and former president of Well Being Trust, a national foundation focused on mental health care.

through the Montana Senate and is before the House would automatically send all abuse and neglect reports at the state hospital to Disability Rights Montana within five days of an incident. The nonprofit is the federally designated advocacy and watchdog organization for people with disabilities in the state. It recently released a report detailing how

Bernie Franks-Ongoy, the organization’s executive director, said that Disability Rights Montana hopes to be able to share general information from the reports with lawmakers and the public, but noted that state law significantly limits what can be made public. Caferro said she’ll seek to amend the bill to make redacted versions of the reports available to lawmakers and the public.

The Montana Mental Disabilities Board of Visitors also has regular access to the facility and patient records, but its and the next inspection isn’t expected until next year.

Some lawmakers call the oversight adequate.

“I don’t worry so much about the administration at the hospital hiding anything because they really do have the light shown on them constantly with DRM and the Board of Visitors,” said Republican Rep. Bob Keenan, who chairs the committee considering funding requests for the state hospital and the state’s mental health system.

Keenan and Gianforte blame the current conditions at the facility and loss of CMS certification at the state hospital on prior Democratic administrations. Federal officials noted at the Montana State Hospital in 2017, but federal officials later deemed those issues resolved.

If lawmakers approve the mental health funding requests, the administration plans to open two lower-level mental health facilities in the coming years to reduce demand at the state hospital. However, the hospital would remain a key fixture of Montana’s mental health system, according to state health officials. Mental health advocates and many lawmakers agree the state hospital should be saved.

Jennifer Mitchell, the woman whose husband died shortly after his discharge from the state hospital, thinks the hospital is beyond repair and worries more patients will die at the facility. She reflected on how hospital officials frequently changed her husband’s medication in response to his depression and refusal to eat, and said she believes her husband would still be alive today if he hadn’t been committed there.

“There were just so many little mistakes or little things that could have been different, and it would have been a totally different outcome,” she said.

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Hilton, who was recovering from a broken leg, watched from his recliner as friends and family sorted through old hunting gear, jewelry, furniture, and clothes. “The only thing that’s not for sale is the house — everything else has to go,” Hilton, 68, said as he checked his blood sugar.

Hilton has Type 2 diabetes, heart disease, and other health issues that have left him disabled and unable to work for years. For income, he relies on federal disability benefits. Because of a shoulder injury and fibromyalgia, 64-year-old Beaty — Hilton’s partner of seven years — does, too. Combined, their income is roughly $1,500 a month.

That’s no longer enough, though. Investors bought their house this year and raised the rent from $1,000, including utilities, to $1,800, plus the cost of utilities.

“They’re not evicting me — on a fixed income, I can’t do it,” Beaty said as she sorted through her belongings.

They have nowhere else to go. And they were not just losing their home: The stress of the ordeal caused them to end their relationship. Beaty planned to move into her daughter’s one-bedroom apartment.

Despite his poor health and still relying on leg braces to prevent another broken leg, Hilton, who is on Medicare, planned to live out of his truck while he waited for a spot to open up at one of the few assisted living facilities in Flathead County, which is mostly rural. The wait could last days, or months.

Beaty and Hilton are part of a recent surge of homelessness among people older than 60. The housing affordability crisis, driven in part by the covid-19 pandemic, and high inflation are chipping away at their fixed incomes. Although data is limited, advocates for seniors and people who are homeless say greater numbers of adults are showing up at shelters across the country.

The problem is particularly acute in Montana, where the snow has started to fly as the long Rocky Mountain winter sets in.

Rents in Montana have skyrocketed since the pandemic started. Since 2019, Lewis and Clark County, for example, has seen rental costs jump 37%, one of the largest spikes in the U.S., according to published by The Washington Post. Nationally, rents rose 11% on average in 2021.

The fast-paced growth in Montana and elsewhere in the Mountain West has been driven in part by an influx of highly paid remote workers, drawn to wide-open spaces and abundant recreation opportunities in communities that were plagued by housing shortages even before the pandemic. Kalispell, the largest city in Flathead County, is the fastest-growing city among those in the U.S. with fewer than 50,000 people, .

Inflation and rising rents are leaving many older Americans on the brink of ruin. The poverty rate for people 65 and older rose from 8.9% in 2020 to 10.3% in 2021, according to Ramsey Alwin, president and CEO of the National Council on Aging.

Alwin said people who rely on traditional retirement income, such as Social Security, are having trouble affording the basic necessities. “You’ll find that individuals are often coming up short by about $1,000 a month in order to meet their true needs,” she said.

As a result, many older people must make hard choices about whether to pay for daily needs such as food and medication or rent. Others simply can’t stretch their money and must leave their homes. An upcoming 8.7% cost-of-living increase in Social Security benefits will help offset the effects of inflation, which for the 12 months that ended in September. But Alwin said that won’t be enough to stem the tide of seniors who are losing housing because of rising rental prices.

Montana is home to in the country. According to a of older adults in the state, about 44% struggled with housing during the previous year, and only 10% considered housing affordable.

Emergency homeless shelters in Montana, and across the country, are reporting that more seniors have been showing up at their doors over the past year, many of whom could no longer make rent or couldn’t find a new place to live after their homes were sold out from under them, said Steve Berg, vice president for programs and policy at the National Alliance to End Homelessness.

Berg said it’s impossible to say how many seniors are winding up homeless for the first time because don’t break down the number of people 25 and older into smaller age groups and other data isn’t granular enough to differentiate people losing housing for the first time from older people who are chronically homeless.

Community organizers working directly with homeless people have a deep understanding of how the trend is playing out in their areas.

At the Poverello Center in Missoula, Montana, people in their 60s have become the second-largest age group served by the shelter, said Programs Director Lisa Sirois. She said that she has seen people in their 80s and 90s with no place to go and that the shelter has had to turn away some of them because it wasn’t designed for their needs.

People in wheelchairs have difficulty navigating the narrow hallways, she said, and the shelter’s elevator often breaks down, forcing people to use the stairs to access its dorms. The dorms are lined with bunk beds, which also present challenges.

“Any senior clients or folks with disabilities usually can’t do a top bunk,” Sirois said.

Brian Guyer, housing department director for the Human Resource Development Council Bozeman, said that when his shelter can’t serve a senior, it also must ask the person to leave. A memory that still haunts him, he said, is of an older man who froze to death three days after being denied a spot in the Bozeman shelter because he was incontinent and had mobility problems. “He actually was found outside of a Lowe’s store here in Bozeman,” Guyer said.

And with the older homeless population growing, his staff, already overworked and underpaid, cannot take care of them all, he said.

To prevent the worst outcomes, state and national groups are proposing a slew of changes.

The Montana Coalition to Solve Homelessness, a new organization that plans to lobby on behalf of shelter providers during the legislative session that starts in January, wants the state to modify its Medicaid program to make shelters eligible for funding. They would use the money to provide Medicaid services that could assist seniors living in a shelter or pay for case management services to help seniors navigate benefit programs that offer food assistance and subsidized housing or find assisted living and nursing home facilities.

But the number of available spots in those facilities is shrinking. Nationally, nursing home closures have . In Montana, eight nursing homes either have closed this year or are slated to close by the end of December, according to Montana health officials. Rose Hughes, executive director of the Montana Health Care Association, said other facilities are having difficulty keeping their doors open because Medicaid reimbursement rates are often lower than their operating costs.

Other advocacy organizations want to focus on economic stabilization initiatives that would help older people stay in their homes. One idea is to change how Social Security payments are calculated by pegging them to the , an online calculator that estimates living expenses by location. But that would require congressional approval.

“Your current housing is your best chance for keeping housing for this population,” said Mark Hinderlie, CEO of Hearth, which focuses on homelessness among seniors nationally.

Then there is increasing the housing supply, which most people agree is a long-term solution. In Montana, Republican Gov. Greg Gianforte that would create incentives to encourage the building of more market-rate apartments. But critics say developers are unlikely to create enough subsidized housing on their own.

For Hilton, any sort of open housing unit can’t come soon enough. As he leaned against his truck in the driveway of his now former home, he hugged Beaty as she sobbed into his shoulder before they parted ways.

He drove away in search of a place to camp out, waiting for a call from a local assisted living facility with an opening. He hoped that call would come before winter temperatures settled in.

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Vikings head coach Jim Benn was running his team through drills in the pristine fall weather, without much interruption. Just a couple of weeks earlier, though, players needed frequent water breaks as they sweated through temperatures in the low to mid-90s, about 15 degrees higher than average for the time of year.

Although temperatures have started to drop now that autumn is underway, Montana and many other states in the northern U.S. are getting hotter — and staying hot for longer. August is when many high school sports ramp up, and this year’s was either the hottest on record or close to it for many communities across Montana, according to the National Weather Service and other meteorologists. The heat wave stretched into September, and at least six Montana cities broke the 100-degree mark during the first half of the month.

This August was the hottest on record for the nearby states of Idaho, Washington, and Oregon. Nationwide, this summer was the third-hottest on record,

Health experts and researchers say states — especially the states in the northern U.S., such as Idaho, Maine, Montana, and North Dakota — aren’t adapting fast enough to keep high school athletes safe. Students and their families have to protect athletes. Many states that have taken action did so only after an athlete died.

“Between high school and college, we’re losing roughly six athletes each year to exertional heatstroke, and the majority of those are high school athletes,” said Rebecca Stearns, chief operating officer at the University of Connecticut’s , which is named after a Minnesota Vikings player who died from heatstroke in 2001. The institute studies and tries to prevent the condition.

The true number of heat-related deaths could be higher, she said, because death certificates aren’t always accurately filled out. Exertional heat illness is the second-leading cause of death for high school and college athletes, behind cardiac arrest, she said.

In Bigfork, Benn said he hadn’t seen one of his athletes experience an exertional heat illness — such as heat exhaustion or heatstroke, which can cause fainting, vomiting, and even death — during his nearly 30-year coaching career in Montana until last year. An athlete became overheated at an early summer football camp during the .

“We immediately got water on him, got him cooled down,” he said.

The player recovered after he was sprayed with a hose. Benn said he didn’t have an immersion tub filled with ice water on hand, which is what Stearns said is the recommended treatment.

“It is exactly why we need standard policies that have medical best practices incorporated,” Stearns said.

The Korey Stringer Institute and Washington, D.C., based on how well they follow best practices for preventing and responding to exertional heat illness among high school athletes, as well as other health risks such as cardiac arrest. Montana is 48th on the list, followed by Minnesota, Maine, and California.

California is last, according to the institute’s report, because it’s the only state that doesn’t regulate high school athletic trainers, which are generally responsible for the health and safety of athletes. Stearns said the institute is working with California sports officials who are pushing for laws that require licensing of athletic trainers.

States in the northern U.S. dominate the bottom third of the institute’s rankings. Stearns said many states the institute has approached about improving heat safety think it isn’t an issue or resist some policies because implementing them could come with a hefty price tag.

But some of the efforts don’t cost a penny, she said. At Bigfork High School, for example, Benn has implemented a three-day acclimatization period, without football pads, when his players return to the field in early August. “That’s really low-hanging fruit, in my perspective,” Stearns said.

Stearns added that most heat-related illnesses occur during the first days of practice, which are typically the hottest and when athletes are not accustomed to exerting themselves in the heat. But she said the state’s high school sports association should mandate acclimatization periods.

Montana and many other states also don’t have a system dictating when practices need to be modified — for example, by removing pads or reducing the length and the number of workouts — or canceled altogether, said Stearns. Policies that require an emergency plan for responding to an exertional heat illness are lacking in many northern states, as well.

Stearns and other researchers, such as at the University of Georgia, said states should use what’s known as the “wet bulb globe temperature” — which accounts for air temperature, humidity, and radiant heat from surfaces such as turf that absorb sunlight — to make those determinations, rather than the heat index. The heat index doesn’t account for radiant heat, which increases the risk of developing heat illness. The foundation of the National Federation of State High School Associations said in February that it was sending to high schools across the country.

Stearns said that research suggests acclimatization periods reduce the number of exertional heat illnesses by as much as 55% and that states that have used the wet bulb globe temperature to mandate changes to practice have seen an 80% reduction.

In Georgia, Cooper’s work documenting heat-related deaths among high school athletes in 2012. Since the policy shift, Georgia has gone from being the state with the highest number of heat-related deaths among high school football players to having no deaths.

Researchers such as Cooper have begun to provide regional policy guidelines based on the local average wet bulb globe temperatures to help states understand the risks for high school athletes and give them a starting point for making policy changes.

New Jersey was among the early adopters of the wet bulb system among states in the northern U.S. when it in 2020 requiring school districts to buy the thermometers. The state also requires hundreds of schools to put cold immersion tubs on-site when temperatures reach a certain level. The state is now second in the institute’s rankings of sports safety policies, behind Florida and ahead of Georgia.

In the Pacific Northwest, Oregon and Washington have policies that mandate changes to school sports practices based on the heat index, not the wet bulb globe temperature. Heat and sports safety researchers say that’s better than nothing.

The , which regulates high school athletics, has implemented heat guidance that allows referees to call for extra breaks during football or soccer games, said executive director Brian Michelotti. The association also asks other sports, such as cross-country running, to schedule meets early in the day.

While Montana health officials say the state has never documented a death related to heat illness among the state’s high school athletes, the historic heat waves over the past two summers have athletic officials considering additional precautions. “It really has triggered us to have more discussions about that and really come back and revisit with some sport science committees,” Michelotti said.

He said any policy changes would have to be approved by the association’s seven-member board and wouldn’t happen until at least next year.

Heat and sports safety experts such as Stearns at the Korey Stringer Institute said adding statewide policies and mandates saves lives by ensuring that all coaches and schools are following best practices before a death happens.

“One life is too much a price for all of the games in a season,” she said.

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The small group kicked off the “sterilization shower” for the 25-year-old by laying out chalk-written signs that said “See Ya Later Ovulater” and “I got 99 problems but tubes ain’t one.” And they munched on cookies that had abortion-rights slogans, such as “My Body, My Choice,” written on them in frosting.

“Cheers to Dani and her choice to get sterilized,” Kristina McGee-Kompel said.

Marietti is a full-time graduate student in Helena working toward becoming a therapist. She doesn’t want kids to get in the way of her career, she said. She had considered permanent sterilization before, but the possibility that the Supreme Court would overturn Roe v. Wade pushed her to seek out an OB-GYN who would help her with a permanent method of contraception.

“‘I want to do this as soon as possible,’” she recalled telling the doctor.

“I always knew I didn’t want children, and of course when you say that as a younger person, everyone is like, ‘Oh, you’ll change your mind,’ or, ‘Just wait until you find the one,’” she said. “I always kind of ignored that.”

Abortion is still legal in Montana, but whether it will remain so is unclear. State Attorney General Austin Knudsen, a Republican, to overturn its 1999 decision that said the state constitution’s right to privacy includes the right to end a pregnancy.

The uncertainty around abortion access in Montana and other states where abortion is now or could become illegal, plus the fear of future legal fights over long-term contraception, has seemingly spurred a rise in the number of people seeking surgical sterilization, according to reports from doctors. That includes Marietti, who is having a salpingectomy, a procedure in which the fallopian tubes are removed instead of tied, as in tubal ligation, which can be reversible.

How many people sought permanent sterilization after the fall of Roe won’t become clear until next year, said Megan Kavanaugh, a researcher for the Guttmacher Institute, which gathers data related to reproductive health care across the U.S. and supports abortion rights.

But anecdotal reports indicate that more people have been undergoing permanent birth control procedures since the Supreme Court’s June 24 decision in Dobbs v. Jackson Women’s Health Organization, which struck down Roe. Dr. , who chairs the American College of Obstetricians and Gynecologists’ ethics committee, said providers across the country are beginning to see an influx of patients into their operating rooms.

The North Carolina OB-GYN recounted what one of her patients said just before a recent surgery. “She wanted to have autonomous control over her body, and this was her way of ensuring she was the person who got to make the decisions,” Arora said.

In Montana, Dr. Marilee Simons, an OB-GYN at Bozeman Health Deaconess Hospital, said more adults in their 20s and 30s without children have come to the hospital for sterilization consultations. Many are women who already practice birth control, she said. “They are still worried about an unintended pregnancy and what that might mean in the future,” she said.

Most are asking to have their tubes removed to permanently prevent pregnancy. A smaller number of people are asking for hysterectomies, which surgically remove part or all of the uterus. To meet demand, Bozeman Deaconess has dedicated at least one provider to work with these patients multiple days a week.

Planned Parenthood of Montana President and CEO Martha Fuller said clinics statewide have seen an “unprecedented” increase in patients asking to be sterilized, including requests for vasectomies.

But some people seeking sterilization procedures across the U.S. are being turned away. Arora said some patients who don’t have children and are in their childbearing years are reporting difficulties finding providers willing to sterilize them.

Those providers’ reluctance may stem from studies and data that suggest the for patients who are sterilized at age 30 or younger is high. had mixed results and found that some women feel less regret over time, Arora said.

Arora said she makes sure her patients understand the implications of any sterilization procedure, especially irreversible options. She also asks whether patients are being pressured into asking for the procedure. “I honestly believe my job is not to be a gatekeeper, but to empower and uplift those goals and wishes, especially after good, shared decision-making and informed consent,” she said.

Some patients who have been denied sterilizations have turned to therapists like Barbara DeBree, who has a private practice in Helena and writes letters to providers attesting that the patients have thought through their decisions. Other mental health care providers say they’re also fielding requests for letters of support, DeBree said.

“This is not a quick decision for them,” she said, referring to the patients asking for letters.

Providers’ ethical worries about future regrets aren’t the only barriers that patients seeking sterilization procedures may face. Cost and insurance coverage can also be issues.

Helena resident Alex Wright, 23, doesn’t plan to have children and wants to be sterilized. She plans to schedule a consultation to see whether her provider will perform the procedure. She said that if her regular provider won’t do it, she will seek out someone from online lists of providers willing to perform the procedure on younger people.

“That’s only helpful if I can get the financial assistance to get it taken care of through those people,” she said, referring to her insurance coverage.

Wright said her insurance company estimates she’ll pay about $4,000 out-of-pocket if she goes with an in-network provider. Using an out-of-network doctor could cost substantially more.

Although some people are seeking permanent procedures in reaction to the Dobbs decision, others are doing so because they believe the Supreme Court will continue upending reproductive health norms. Kavanaugh, the researcher at Guttmacher, said Justice Clarence Thomas opened that door by suggesting in his concurring opinion in Dobbs that other precedents should be revisited, including the 1965 Griswold v. Connecticut decision that says banning contraceptives violates a married couple’s right to privacy.

“I think we are anticipating that there’s going to be some attacks on contraception,” Kavanaugh said.

That’s what worries Shandel Buckalew, of Billings, Montana, who wants a full hysterectomy. The 31-year-old said her doctor thinks she has endometriosis, a painful condition in which tissue that normally grows inside the uterus grows on other parts of the reproductive organs. Buckalew hasn’t undergone the because she doesn’t have health insurance and can’t afford it.

“Even though I have an IUD, the amount of cramps and the pain I go through — oh, I get so sick,” she said.

She hopes a hysterectomy would alleviate that pain, in addition to providing permanent birth control because she doesn’t want kids. But her lack of health insurance makes the procedure unaffordable.

She’s trying to get health insurance before her intrauterine device expires in two years because she fears the reproductive health care landscape could shift dramatically. She described feeling terrified and angry.

“It feels like my life doesn’t matter,” she said.

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Cook pensaba utilizar el cerebro del cerdo para una práctica conocida como “curtido de cerebro”, que ha sido utilizada por los indígenas durante miles de años.

Los sesos se machacan en agua y se introducen en pieles de ciervo y alce para fabricar cuero. Cook explica que los ácidos grasos del cerebro ablandan la piel y le dan un bonito color blanco antes de ahumarla para impermeabilizarla.

“El seso te dará el cuero más fuerte y duradero. Por eso la gente lo prefiere”, dijo.

Cook utiliza las pieles que curte para fabricar tambores, mocasines y vestimenta tribal. Tradicionalmente, los indígenas como Cook utilizan los sesos de animales que capturan para curtir su piel. Pero Cook ha cambiado a los sesos de cerdo para todo su curtido, en parte debido a la caquexia crónica, que infecta a ciervos, alces y renos.

La caquexia crónica (CWD) es causada por unas proteínas mal plegadas llamadas priones en el cerebro, que deterioran las funciones corporales de los animales infectados hasta que mueren en un par de años tras la infección.

La enfermedad de Norteamérica desde que se descubrió por primera vez en animales salvajes, hace más de 40 años, en Colorado.Ìý

(CDC) indican que no se debe consumir carne de animales positivos, aunque no hay pruebas de que la enfermedad pueda transmitirse a los humanos. El investigador de los Laboratorios Rocky Mountain, Brent Race, dijo que no se ha descartado esa posibilidad. Señaló que la materia cerebral sería especialmente peligrosa de manipular, ya que contiene la mayor concentración de proteínas que causan CWD.

“No hay pruebas de transmisión, pero tampoco hay mucha gente que manipule el tejido de mayor riesgo, trabajando con él con las manos en cantidades tan elevadas”, explicó. “Definitivamente es un riesgo alto”.

La caquexia crónica sólo hasta ahora en la reserva de los Pies Negros, pero una vez que está presente, es imposible de erradicar, según los responsables de la fauna salvaje.Ìý La enfermedad ya está obligando a los miembros de la tribu a cambiar sus prácticas tradicionales, como el curtido de cerebros, o a abandonarlas por completo, según el investigador de los Pies Negros Souta Calling Last.

A Calling Last también le preocupa que la propagación de la caquexia crónica impida a los miembros de la tribu comer carne de caza. Algunas familias dependen de la carne de los ciervos, alces y renos que pueden capturar durante varios meses del año.

Ahí es donde entran los perros. Calling Last recibió una subvención federal de $75,000 para llevar a cabo un estudio, de un año de duración, cuyo objetivo es adiestrar a perros para que puedan olfatear la caquexia crónica y los residuos tóxicos que podrían afectar a las personas que cosechan y consumen plantas tradicionales.

El proyecto pretende proteger la salud de los miembros de la tribu haciéndoles saber dónde se ha detectado la enfermedad y dónde se han encontrado residuos tóxicos, y preservar así espacios seguros para la realización de prácticas tradicionales.

De pie, junto a un humedal lleno de espadañas, Calling Last explicó que los perros detectarán la caquexia crónica en los excrementos de ciervos y alces en lugares como éstos, que sirven de abrevaderos para las manadas. La idea es ayudar a alertar a los gestores de la fauna salvaje de la presencia de la enfermedad lo antes posible.

Los perros también serán adiestrados para olfatear sustancias químicas, metales pesados y otros contaminantes en los excrementos de visón y nutria, de modo que puedan analizarse para detectar sustancias químicas y contaminantes en vertederos ilegales llenos de coches viejos, muebles y electrodomésticos.

Poder detectar la presencia de esas toxinas ayudará a proteger a los miembros de la tribu que utilizan plantas como la menta para el té o los sauces que se queman en las cabañas-sauna, dijo Calling Last.

“Para mantenernos sanos y fuertes, para ser personas con buen espíritu y buena mente, se supone que debemos comer estos alimentos”, añadió.

Algunos perros ya han salido por la reserva para olfatear los excrementos de visón y nutria y comprobar si hay residuos tóxicos. Michelle Vásquez, de la organización Working Dogs for Conservation, dijo que todavía está recogiendo excrementos de ciervos y alces que dan positivo en CWD para empezar a adiestrar perros este verano.

Calling Last enviará muestras de excrementos, suelo y agua para su análisis desde los lugares en los que los perros alerten a sus cuidadores para confirmar que efectivamente han detectado la enfermedad.Ìý Si el proyecto de Calling Last demuestra que los perros pueden llevar a cabo esta labor de forma eficaz, Vásquez afirma que Working Dogs espera ampliar esta iniciativa a todo el país.

Los investigadores de la facultad de veterinaria de la han estudiado si los perros son capaces de detectar la caquexia crónica en el laboratorio, pero el proyecto de la reserva de los Pies Negros es el primer intento de hacerlo sobre el terreno, según Vásquez.

El adiestramiento se llevó a cabo en unas instalaciones especiales a las afueras de Missoula.Ìý En las instalaciones, Vásquez, hizo que su labrador negro Charlie, de 4 años, detectara el olor de la nutria de patas negras escondido en uno de los varios recipientes hechos con tubos de PVC. Es uno de los muchos olores que el excitable labrador está entrenado para detectar.

“Cada uno de ellos tiene algo diferente. Así que tendremos distractores”, señaló. Esos distractores pueden ser comida y olores de otros animales que los perros encontrarán en el campo.

Joe Hagberg, del Servicio de Pesca y Caza de los Pies Negros, dijo que espera que los perros puedan detectar si la caquexia crónica sigue presente en la zona donde se detectó la enfermedad por primera vez, en la parte oriental de la reserva.

“Nos ayudará enormemente”, comentó junto al arroyo donde se abatió al animal que dio positivo. Tras la detección de 2020, Hagberg mató varios ciervos de aspecto enfermizo para conocer la prevalencia de la enfermedad.

“Recogimos 54 ciervos en toda la zona, en un perímetro de 10 millas. Todos ellos dieron negativo en las pruebas”, señaló.

Hagberg está contento con estos resultados, pero añadió que cuenta con recursos limitados para buscar la enfermedad en otras zonas de una reserva de 2,300 millas cuadradas.

Calling Last espera que el proyecto ayude a funcionarios como Hagberg a contener la enfermedad, que puede propagarse sin ser detectada durante años antes de acabar con un rebaño. Tiene previsto publicar un estudio sobre su trabajo y espera conseguir financiación adicional para reproducirlo en otras naciones tribales de Montana y Wyoming, muchas de las cuales se encuentran en zonas con mayor presencia de la caquexia crónica.

Calling Last contó que la tribu Blood, una de las tribus hermanas de los Pies Negros en Canadá, ya ha obtenido financiación para un proyecto similar.

“Creo que el mero hecho de poder vigilarlo, registrarlo y saber definitivamente que se están cosechando alimentos que no contienen el prión sería una gran victoria para cualquier nación”, concluyó Calling Last.

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