Limited access to health care a serious problem for Montana. (Kids Count).

High poverty rates and limited access to health care are two major threats to the well-being of Montana's children, more than 50,000 of whom live below the 2001 national poverty threshold of $16,535 for a family of four. Many of these same children are also among the 41,000 young Montanans who do not have any form of health insurance coverage.

And health care for Montana kids, particularly those in low-income families, will diminish even further if the state Legislature goes through with proposed cuts in public health programs--cuts that, while providing short-term savings, could actually lead to higher health care costs down the road.

Other important issues affecting Montana families and children in 2003 include low birth weight babies, substance and alcohol abuse, and early care and education for children. These are not short-term problems, but long-term needs deserving of statewide discussion and commitment.

The economic and overall well-being of Montana's children and their families is an important component of the state's economy. Montana KIDS COUNT, funded by the Annie E. Casey Foundation, is part of the Bureau of Business and Economic Research's commitment to provide policymakers and citizens with data that can inform community, state, and national discussions. Our need to track and monitor the well-being of kids is especially important in view of the health care, education, and economic challenges facing Montana families.

The Bureau recently published the 2002 KIDS COUNT in Montana Data Book. This article offers a summary of some of the report's major findings.

Demographics of Montana Kids and Families

More than one in four Montanans are under 18 years of age. School-age children and teenagers account for almost three-fourths of the youth population in Montana and almost one-fifth of the state's total population. Between 1990 and 2000, the number of kids in Montana under 18 years of age increased by about 8,000 (Table 1). This small increase is consistent with the overall aging trend of the state's population. The number of children under age 5 actually decreased between 1990 and 2000, a decline that will affect some school district enrollments in the coming years.

White children are the largest racial group in Montana, representing 85 percent of all children. American Indian children are the second-largest group and the largest non-white group, accounting for almost 10 percent of the 230,000 Montana kids 18 and younger. Nationally, American Indian kids represent 1 percent of U.S. youth. In Montana's rural areas, American Indians represent 18 percent of the youth population, compared to less than 4 percent of youth in urban areas of the state.

The American Indian population on tribal rolls and reservations is very young. Children account for 38 percent of the population on reservations, with the, majority 14 years old or younger. This youth demographic pattern has significant implications for these area's school systems and future workforce, and for economic development opportunities. Economic development leading to better employment opportunities and job growth is especially critical in the reservation economies. The higher dropout rates and lower graduation rates for American Indian high school students partly reflect the lack of adequate earning and employment incentives in the local job base.

The youthful orientation of American Indian populations will continue over the next decade, particularly in Montana's reservation counties. In many of these counties, including Glacier, Big Horn, and Roosevelt, American Indians make up the majority of the population. This demographic group has experienced high natural population growth, with an annual number of births above the number of deaths. In some of the reservation counties, the white population has actually decreased since the early 1960s because of a higher death rate and out-migration as compared to annual births. These patterns reinforce the importance of the American Indian population as the major demographic force in those counties.

The number of Montana children living in single-parent households increased dramatically during the past decade.

Eighteen percent of children under age 18 were living in single-parent households in 1990, a percentage that increased to just over 21 percent by Census 2000, representing 10,000 more Montana kids in single-parent households. Married-couple households continued to account for a majority of Montana kids' family structures in 2000.

The increased number of parents in the labor force is another major feature of youth demographic shifts over the last 10 years. The percentage of kids under age 18 with both parents in the labor force increased by more than 5 percentage points between 1990 and 2000. Looking at children under the age of 6, there was an almost 7 percentage-point increase--from 58.4 percent in 1990 to 64.9 percent in 2000. With more parents at work, the importance of childcare and early child education increases, whether those services are provided by private or public-funded sources.

Access to Health Care

While some indicators of physical health for Montana's children have moved in a positive direction, other indicators show that access to health care is a serious problem, especially for kids in low-income families where both parents work. Health care access problems and low coverage rates of private health insurance reflect the economic hardships among the state's working-poor families.

In our society, access to health care largely depends on private health insurance coverage. More than 41,000 Montana kids under age 18 had no form of health insurance, public or private, in 2000 (Figure 1). Children who are not covered by health insurance frequently do not have a family doctor and do not have access to standard types of care such as checkups and immunizations unless they were available through public health programs. Children without access to regular health care can develop health conditions that are not treated in a doctor's office through a routine visit, but instead escalate and result in emergency room visits and hospitalization.

National data show that uninsured kids are very young, with almost one-third of them 5 years of age and under. A high percentage of uninsured children, almost 84 percent, are in a family where at least one parent works full-time; 31 percent have both parents working. Nationally, 24 percent of children in low-income working families do not have health insurance. In Montana, 30 percent of children in low-income working families are without health insurance (Figure 2). National figures show that low-income children 6 to 11 years of age were more than three times as likely to be in fair or poor health than were higher-income children of the same age (6 percent vs. 2 percent).

The Medicaid health care program for low-income families is an important source of health care support for Montana kids. Twenty-two percent of Montana kids under age 18 relied on Medicaid or the Children Health Insurance Program (CHIP) in 2000, compared to 20 percent for the nation. Sixty percent of Montana kids were covered by private insurance plans provided by employers or purchased by individuals, compared to a national figure of 68 percent.

Almost one in every 10 kids in the state is either participating or eligible to participate in the Medicaid or CHIP programs. Potential cuts in state funding for the Children Health Insurance Program may result in the loss of funds from the federal government. These cuts mean reductions in program enrollment, despite the fact that more than 25,000 Montana kids currently are eligible but not enrolled.

Cutbacks in Medicaid, including provider reimbursements, are hampering efforts to recruit more health care providers into the Medicaid program. Increased controls on prescription drugs, cuts or freezes in provider payments, elimination of benefits, and increased cost sharing all work against increased coverage of health care through Medicaid and CHIP Medicaid, as one of the largest items in the state budget, faces increased program demands when the economy is depressed and incomes fall. As in other states, Montana's state tax revenue shortfall has resulted in program cutbacks that reduce health care access and increase the number of kids and families without insurance coverage.

Drug and alcohol use among Montana's youth is a major health problem. According to the Montana Youth Risk Behavior Survey, a survey of high school students conducted by the state Office of Public Instruction, Montana youth have the second highest rate of illicit drug use, the fourth highest rate of alcohol use, and the sixth highest rate of tobacco use in the nation. Loss of life, health problems, disruption of families and communities, violent behavior and crime, and the wasting of young lives are a few of the problems associated with childhood drug and alcohol abuse.

The oral health of Montana kids is another area in need of attention and resources. Montana has a shortage of dental professionals. Ten counties are without dentists and another 20 counties lack hygienists. In 1999, 21 percent of all Medicaid-eligible people and 25 percent of children in CHIP received dental care. With low Medicaid reimbursement of about 50 percent to 55 percent of usual charges for adults and around 72 percent for kids, there is a strong reliance on volunteer dental providers. Volunteer dentists and hygienists in Great Falls, Helena, Missoula, Billings, and Butte are diligently tending to low-income patients -- but waiting lists consistently show 500 to 1,300 patients and waits can be more than a year. Access to oral health care is not guaranteed even for the 60 percent of Montanans with private health insurance; only 20 percent of the plans include dental benefits.

One indicator of children's health that has shown improvement is the rate of immunizations. In 2000, the rate for kids 2 years old and younger was 94 percent. This reflects an increase of 5 percentage points over 1998 and demonstrates the hard work by public health agencies at the state and local levels throughout Montana. Montana's immunization rate is considerably higher than the national rate of 71 percent.

Another major success story has been the significant increase in screening rates of newborns for hearing impairment, a health problem that can lead to socialization and learning disabilities in early childhood. Increased efforts by state and local health agencies have resulted in a 78.3 percent screening rate for hearing impairment before discharge from Montana's hospitals in 2000. This compares to a 30 percent rate in 1998. The improvements in screening and immunization rates are testimony to the effective program delivery by Montana's public health network in a tight budget environment.

Health and Safety Indicators

Montana's infant and early childhood health indicators have shown strong improvement over the past decade. Infant mortality rates, child death rates, and births to teenagers have all changed in positive directions. However, the state has seen an increasing number of low birth weight babies -- those weighing less than 5.5 pounds at birth. In 2000, 6.2 percent of all live births in Montana were classified as low birth weight, compared with 5.9 percent in 1995.

Accidents, especially motor vehicle crashes, are the single most frequent cause of death for Montana children. Other violent causes, notably suicides and to a less degree homicides, become major specific causes of death for kids as they become older.

Alcohol and motor vehicle crashes are significant causes of injury and death to Montana teenagers. Of the 5,437 vehicle crashes involving teenagers in 2001, about 5 percent, or 271 accidents, involved teenage drivers who had been drinking. There were 17 fatal crashes that involved alcohol and teenage drivers.

The 2001 Montana Youth Risk Behavior Survey of high school students reported that 41 percent of the students surveyed had consumed five or more alcoholic drinks in a sitting at least once during the past 30 days. Drinking is directly related to traffic fatalities; about 37 percent of all traffic fatalities for all age groups in Montana are alcohol related. Many older Montanans classified as at-risk from acute drinking say they began drinking in high school.

Children in Montana are much more likely to drive when they have been drinking than the national average and are more likely to be in a vehicle driven by someone who has been drinking alcohol.

Along with riskprevention efforts, discussions are ongoing in the 2003 Legislature to modify Montana's drunken driving laws. According to Mothers Against Drunk Driving, Montana ranks at the bottom of all states in terms of drinking and driving, alcohol-related fatalities, prevention legislation, and DUI penalties. The Legislature is considering a variety of measures to enact tougher alcohol-related laws, including reducing the threshold at which drivers are deemed too drunk to drive from the current blood-alcohol limit of 0.1 to 0.08.

Social and Economic Opportunities

Poverty and lack of health care access are obviously affected by the performance of the Montana economy. And the economy did experience a slowdown in early 2001, mostly because of shutdowns and layoffs at several large industrial facilities. Post-Sept. 11 economic impacts on tourism, travel, and other industries, as well as slower job growth, have contributed to a lack of improvement in the economic indicators of family well-being into 2002. Montana's slow but steady employment growth, combined with lackluster growth in family income and earnings, represent lower wages and lower family incomes for many working parents in Montana.

Montana's consistently low standing in national rankings of job earnings and household incomes have not improved dramatically. Median household income of $32,045 in 2000 represented an annual average growth rate of 2 percent since 1997, hardly enough growth to pull the state up in the national rankings. Per-capita income grew just 2 percent between 1999 and 2000, making Montana workers among the lowest paid in the nation.

Reservation counties have some of the lowest income levels in the state despite strong population growth. Montana had eight counties (Figure 3) in 1998 where 60 percent or more of the population was at or below 200 percent of the federal poverty level, or below $33,060 for a family of two adults and two children. Four of those eight counties were American Indian reservation counties.

The 22 percent poverty rate of Montana kids is one of the highest in the nation. Fifty thousand Montana children live in families and households where annual income is below the U.S. poverty threshold as defined by the federal Office of Management and Budget.

Montana has a much higher proportion of children under age 18 in low-income working families, at 21 percent, compared to 15 percent nationally (Figure 4). Many of Montana's low-income working families are eligible for food stamps. Twenty-seven percent of Montana children in low-income working families received food stamps in 1999, compared to a national percentage of 24 percent (Figure 5).

Some of the social and economic challenges faced by Montana's low-income families and children spill over into play and school activities. National studies have shown that school engagement and involvement in a number of extracurricular activities, including sports and school clubs, are higher for kids from high-income families. Low-income working families need the opportunity, connections, and networks that are available to many middle- and upper-income families, and they need support services like job training, health insurance, child care, housing assistance, and saving incentives that will help them become economically independent.

Early care and education for children offer positive opportunities for overcoming the disadvantages of poverty, low earnings, and associated risk factors such as parents' lack of high school education, reliance upon welfare, and lack of health insurance. The policy challenge is to provide quality childcare and early education at a price that parents, especially families from low-income households, can afford. Lack of affordable and adequate child care can be a real dilemma for working-poor families, especially those where both mom and dad need to work to bring in an adequate family income, but they also need the availability and affordability of quality child care to make this happen.

There are long-run benefits to quality child care and early education programs, as research has shown that early care, access to health care, and early learning experiences significantly contribute to later positive outcomes--including success in school and eventually in the job market. The availability of such programs is especially important in Montana's rural counties.

Education and Schooling

The education picture for Montana kids has a number of very positive features. The statewide dropout rate is below the national rate. High school graduation rates are high in Montana, and basic test scores on reading and writing show Montana students performing above the national average.

Dropout rates in Montana schools were slightly below the national rate at 4.2 percent in 2000-2001, compared to an estimated national rate of 5 percent. The dropout rate for American Indian students was 10.4 percent, almost 3 times higher than the 3.5 percent rate for white students. About 2,295 students dropped out of Montana schools in 2000-2001. The 2000-01 dropout rate for Montana students in grades 7 and 8 was 0.5 percent; for Montana high schools, the rate was 4.2 percent. White students represent 87.2 percent of the total school enrollment and 70.6 percent of the dropouts, while minorities represent 12.8 percent of the total school enrollment and 29.4 percent of the dropouts. Graduation rates of Montana students were higher for whites--at 94 percent--compared to American Indian students at 84 percent.

There are a number of proactive ways to reduce the dropout rate:

* Strengthen school readiness by increasing family access to early education programs and access to health care including prenatal care;

* Strengthen parent and family understanding and involvement with teens' motivation and ability to stay in school by increasing parent participation in the planning of dropout programs; through staff development for teachers who work with at-risk youth; and through parent education and family support programs to negotiate conflicts or crises that can encourage children to leave school;

* Focus on risk factors and groups at highest risk of dropping out, including students with family incomes at or below the poverty line; those who lack health insurance; students with under-employed parents; and families who lack adequate child care; and

* Make it harder for students to drop out by strengthening school accountability for keeping young people on track; increasing students' understanding of the connection between education and job opportunities; designing dropout prevention programs to the age and profile of the student; strengthening GED programs and alternative schools.

Conclusion

The challenges of improving health care access and alleviating poverty for Montana kids are interrelated. Kids from low-income families face the greatest limitations on access to health care. They are also at highest risk of losing whatever access they may have, however limited, as cutbacks come to public health programs.

Montana's continued poor performance in national rankings of poverty and health care access is not intractable. There are private and public actions and policies which, combined with political commitment, can begin to address these problems. Policy actions for reducing the child-poverty rate include more education and job training for low-income parents; strengthening the safety net of income, health, nutrition, early care, and education programs; and increasing take-home earnings through a strengthened federal Earned Income Tax Credit and the creation of jobs with benefits for low-wage workers. The lack of year-round full-time employment and the high proportion of single parent families reflect obstacles to economic security as a component of stable families. Part-time jobs without benefits undermine economic security. Increasing the stability and overall well-being of families depends on effective economic development combined with wise family support policies for low-wage parents making the transition to g reater economic security.

Table 1

Selected Demographic Characteristics for Montana Children, 1990 and 2000

STATE SUMMARY STATISTICS FOR THE POPULATION UNDER AGE 18

                             1990                  2000

                              Number   Percent    Number   Percent

Total population             799,065             902,195
Population under age 18      222,104    100.0%   230,062    100.0%
 Males under age 18          114,288     51.5%   118,245     51.4%
 Females under age 18        107,816     48.5%   111,817     48.6%
 Children under age 5         59,257     26.7%    54,869     23.8%
 Children ages 5 to 17       162,847     73.3%   175,193     76.2%

LIVING ARRANGEMENTS

Population under age 18      222,104    100.0%   230,062    100.0%
 Children living in          219,987     99.0%   228,432     99.3%
  households
 Children living in            2,117      1.0%     1,630      0.7%
  group quarters
 Own children living in       39,430     17.8%    49,140     21.4%
  single-parent households
 Own children living in      168,497     75.9%   162,502     70.6%
  married-couple households
 Grandparents living with        N/A       N/A    11,098
  own grandchildren
 Grandparents responsible        N/A       N/A     6,053
  for own grandchildren

PARENTAL EMPLOYMENT

Own children underage 18     214,074    100.0%   218,232    100.0%
 All parents in labor force  141,760     66.2%   156,213     71.6%
 No parents in labor force    16,653      7.8%    13,871      6.4%
Own children under age 6      69,712    100.0%    63,486    100.0%
 All parents in labor force   40,740     58.4%    41,216     64.9%
 No parents in labor force     6,911      9.9%     4,770      7.5%

Source: U.S. Census Bureau, U.S. Department of Commerce, 2000.

Figure 1

Kids Under 18 without Private or Public Health Insurance


Montana   18%
U.S.      12%

Sources: U.S. Department of Health and Human Services and Montana
Department of Public Health and Human Services.

Note: Table made from bar graph

Figure 2

Children Living in Low-Income Working Families without Health Insurance,
1999


Montana  30%
U.S.     24%

Source: KIDS COUNT Data Book, Annie E. Casey Foundation, 2002.

Note: Table made from bar graph

Figure 4

Percent of Montana Children under Age 18 in Low-Income Working Families,
1999


Montana        21%
United States  15%

Source: KIDS COUNT Data Book, Annie E. Casey Foundation, 2002.

Note: Table made from bar graph

Figure 5

Montana Children in Low-income Working Families Receiving Food Stamps,
1999


Montana        27%
United States  24%

Source: KIDS COUNT Data Book, Annie E. Casey Foundation, 2002.

Note: Table made from bar graph

The KIDS COUNT in Montana 2002 Data Book is available online at www.bber.umt.edu/KidsCountMT.

Steve Seninger is the Bureau's director of economic analysis and Barbara Wainwright is the Bureau's marketing director.