Pero a pesar de este resultado exitoso, el futuro financiero del programa es incierto.

En los dos últimos años, el gobierno federal aportó unos $1,000 millones procedentes de las leyes American Rescue Plan y Bipartisan Safer Communities para poner en marcha la línea, concebida como una alternativa al 911 para aquellas personas que estén sufriendo una crisis de salud mental. Cuando se agote esa ayuda, los estados tendrán que cubrir el costo de los centros de llamadas.

“No sabemos cuánto dinero destinará el Congreso en el futuro”, dijo Danielle Bennett, portavoz de la Administración de Salud Mental y Abuso de Sustancias (SAMHSA), la agencia federal que está a cargo de la línea 988. “Pero la esperanza es que se mantenga un fuerte apoyo bipartidista para financiar el 988 adecuadamente y que los estados también establezcan sus propios mecanismos de financiación”.

Sólo ocho estados promulgaron leyes para sostener el 988 mediante tarifas telefónicas, según la Alianza Nacional de Enfermedades Mentales, que está haciendo seguimiento de los estados que financian el sistema. Otros presupuestaron financiación a corto plazo. Pero muchos estados, principalmente rurales, donde escasean los servicios de salud mental y las tasas de suicidio suelen ser más altas que en los estados más urbanos, no hay planes a largo plazo para proporcionar apoyo.

Según un de datos de la línea de Prevención del Suicidio y Crisis, desde el verano pasado el 988 recibió casi 5 millones de contactos, incluyendo llamadas, textos y mensajes de chat. Y los programas locales lograron responder a un alto porcentaje de las llamadas, en lugar de desviarlas a otros estados.

Para mantener a ese personal estatal que atiende los teléfonos, es fundamental asegurar la financiación a largo plazo de estos programas, afirman defensores de la salud mental y operadores estatales del 988.

En la versión anterior, “esencialmente, no se les pagaba a los centros de llamadas”, afirma Chuck Ingoglia, presidente y director ejecutivo del National Council for Mental Wellbeing, que aboga para que se invierta en el 988. “Cada vez más se reconoce que estamos facilitando el contacto con la gente y, por lo tanto, necesitamos más infraestructura”.

En Ohio, donde muestran que los operadores locales respondieron al 88% de llamadas, los legisladores admitieron recientemente que se necesita una financiación estable. En julio, el gobernador republicano Mike DeWine aprobó $46.5 millones para el 988 en el presupuesto del estado. Pero esa ayuda sólo alcanzará para dos años del programa.

“No es la financiación segura y sostenida que esperábamos”, dijo Brian Stroh, CEO y director médico de Netcare Access, un centro de llamadas que atiende a cuatro condados rurales en la frontera del este de Ohio.

SAMHSA, que distribuye los fondos para el 988, lo compara con el número de teléfono de emergencia 911, con la diferencia de que el 988 es estrictamente para crisis de salud mental. La ley de 2020, que estableció la creación del 988, permite a los estados cobrar recargos telefónicos para mantener el 988 indefinidamente. Esta estructura de financiación es similar a la del 911.

Stroh dijo que está “bastante satisfecho” con los resultados del primer año de 988 para Netcare Access. Pero agregó que con un sistema de financiación a corto plazo, es difícil asegurar la estabilidad laboral para los operadores de llamadas y competir con los salarios de otras industrias.

Kristin McCloud, directora ejecutiva de Pathways of Central Ohio, un centro de llamadas que también atiende a los condados rurales al este del estado, dijo que recibieron $573,056 en el primer año del 988. Esos fondos eran exactamente lo que necesitaban para formar al personal que atiende las llamadas de crisis y adquirir computadoras para que puedan trabajar a distancia.

Durante ese período, los operadores respondieron 2,316 llamadas, casi el doble de las atendidas el año anterior.

“Siento que por primera vez nos dieron el apoyo adecuado”, dijo McCloud, que lleva más de 35 años trabajando en servicios sociales.

Según la SAMHSA, antes de las subvenciones del 988, la mayoría de los centros de atención recibían fondos federales mínimos para responder a las llamadas de crisis, normalmente un estipendio de entre .

Al igual que Stroh, McCloud piensa que la reciente asignación de Ohio es un paso importante, pero le gustaría que el estado establezca un plan de financiación permanente. Un proyecto de ley pendiente en la legislatura agregaría un recargo a las facturas telefónicas para ayudar a financiar el 988, como .

Todos menos uno de los condados del este a los que Pathways of Central Ohio y Netcare Access prestan servicios han sido designados por la Oficina de Atención Primaria del Departamento de Salud del estado como zonas de escasez de profesionales de salud mental.

En North Dakota, donde casi todos los condados , un único centro de llamadas gestiona el programa 988 del estado.

Se trata del centro FirstLink, que ha visto un aumento considerable en el número de llamadas de crisis de salud mental desde la transición al 988. Comparando los primeros seis meses de 2023 con los primeros meses de 2022, las llamadas aumentaron un 55%, según Jeremy Brown, director de comunicaciones.

Esta demanda “nos ha ayudado a iniciar conversaciones con la legislatura estatal sobre financiación y apoyo”, dijo.

En mayo, el gobernador republicano Doug Burgum aprobó una asignación única de $1.86 millones para el 988 en el presupuesto de dos años de North Dakota.

Brown dijo que esta financiación ayudará a FirstLink a capacitar a sus empleados y a mantener las líneas telefónicas al día. También permitirá que los centros envíen unidades móviles de crisis cuando sea necesario.

FirstLink prefiere tratar de resolver las crisis por teléfono antes de enviar una de estas unidades, dijo Dallas Tufty, uno de los operadores de FirstLink.

“La única vez que llamamos para pedir un rescate o algo así es cuando la vida de la persona está en peligro inmediato e inminente”, dijo.

Tufty trabaja 40 horas a la semana en FirstLink, y al menos seis de ellas están dedicadas a responder llamadas y mensajes al 988. Operadores como Tufty también responden a la línea 211 de FirstLink, otro programa que proporciona información sobre asistencia de salud y servicios sociales. No es una línea de emergencia, pero a veces las personas en crisis llaman allí en lugar de hacerlo al 988.

Sin importar la línea a la que llaman, dijo Tufty, lo más difícil es no saber qué ocurre una vez que termina la llamada.

“En algunos casos no sabes si van a volver a llamar cuando lo necesiten,” dijo. “Aunque tengas un plan, no hay mucho que podamos hacer por teléfono para que la gente cumpla con ese plan”.

Aunque North Dakota y Ohio financian el 988 a través de presupuestos estatales, no todos los estados lo hacen. En Montana, el gobernador republicano Greg Gianforte recientemente destinó $300 millones a los sistemas de salud conductual y  discapacidades del desarrollo. Estos sistemas pueden financiar, entre otras cosas, “oportunidades para que los residentes de Montana reciban atención integrada de salud física y conductual”, según el . Pero el estado todavía no ha abordado la financiación del 988 en particular.

En 2021, los legisladores de Montana se negaron a promover un proyecto de ley para establecer una tarifa telefónica y cuenta de ingresos para financiar el 988, antes de su lanzamiento.

En este punto, “si se puede financiar con el actual presupuesto, sin nueva legislación, nos parece bien”, dijo Matt Kuntz, director ejecutivo de la sede de Montana de la Alianza Nacional de Enfermedades Mentales. “Sólo queremos asegurarnos de que se financie de forma sostenible, porque es un servicio importante”.

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Recovering Hope is one of only five providers in the state that offer family-based residential treatment, allowing women to enter the program while pregnant or to bring one of their children younger than 5 with them for the duration of their stay. Men can receive outpatient treatment but aren’t permitted in the residential program.

It’s the only such residential program located in a rural Minnesota county and is licensed for 108 beds. It has a waitlist that can span from two to six weeks, depending on whether a woman plans to enter treatment alone or with her child.

“If you don’t provide family services, the parents run the risk of losing their kids,” said Ashley Snyder, a licensed drug and alcohol counselor at Recovering Hope.

Family-based residential treatment has been recognized by behavioral health professionals as having better outcomes for women and their children. But such programs often struggle to stay afloat because of staffing shortages and volatile funding. And because of that complexity, families in rural areas are less likely to find such a residential treatment program in their communities.

Meanwhile, maternal opioid-related diagnoses have increased nationwide. From 2010 to 2017, the rates of women with those diagnoses at delivery and babies born with withdrawal symptoms increased by 82%, according to the Centers for Disease Control and Prevention. The increases disproportionately affected rural areas. At Recovering Hope, opioids are among the top substances, along with alcohol and meth, that lead women to seek treatment.

“There are too few programs,” said Margaret Ratcliff, an executive vice president at Volunteers of America, which co-published a national directory of family-based residential treatment programs with Wilder Research in 2019. At that time, the directory listed 362 family-based residential treatment programs nationwide, a number that experts, including Ratcliff, say is continually in flux.

Many of the programs offer some variation of the model in place at Recovering Hope, though the maximum age of children varies.

From its own affiliations with such programs, Ratcliff said, Volunteers of America has seen that “the problem is that Medicaid does not cover the cost of a comprehensive program, and grants come and go.”

Even at Recovering Hope, which has operated since 2016 and is expanding its outpatient treatment to include teenagers and building sober houses, smaller insurance reimbursements have affected care. Women in the center’s residential program previously spent up to an average of 40 days in high-intensity care at the beginning of their treatment, but that timespan is now closer to 30 days to contain costs due to those low reimbursement rates. Most of the women in the residential treatment program are covered by Medicaid.

High-intensity care accounts for a third of the center’s treatment plan. On average, women’s full residential treatment at Recovering Hope lasts 90 to 120 days. During that time, women can enroll their children in on-site day care and bring them along to programming. The kids receive regular visits from a Head Start educator and a psychologist.

Researchers say that family-based residential treatment by keeping them away from drug use during their pregnancy and strengthening their bond with their children. Experts also say the programs that women will complete treatment.

Beyond the financial hurdles involved in running family treatment programs, managers face logistical constraints. Providing schooling is one of the challenges that come with operating a family-based treatment center, Snyder said. For example, she said, part of the reason the facility allows only for children younger than 5 is to not affect local school enrollment.

“The school district kind of said, ‘Hey, if you put kids in our school district, and then take them out, that’s not great for us,’” she said. “‘We don’t have enough teachers. So, if you put three kids in the classroom that’s already at max, we would technically need to hire another teacher, but they’re only here for three months.’”

In addition to the age restriction, Recovering Hope limits the women to bringing one child each.

For Lisa Thompson, who was in residential treatment there from January to April, that limit led her to leave both of her kids with their grandmother rather than split them up.

“First getting there, it was really hard seeing women with their children and not having mine,” Thompson, 40, said. “But after being there, and becoming more comfortable, it was just nice being able to have that connection with other mothers there.”

For Gabriela Cajucom, Recovering Hope’s ability to accommodate one child helped her reunite with her oldest son one month into her inpatient program, which ran from November to February. Child Protective Services had originally placed him with his grandmother but allowed him to live with Cajucom as she completed her treatment.

“He even just ran up to one of the old day care ladies, like totally remembered her and gave her a hug,” said Cajucom, 26, who since has moved to outpatient treatment and is set to graduate in October. “It was a very good community feeling.”

CPS granted her custody of her son in May.

But despite success stories from Recovering Hope and other programs, some states have found it difficult to keep such facilities running.

In neighboring North Dakota, the state Department of Health and Human Services has been trying to establish a family-based residential treatment option like Recovering Hope since 2020. The state has been without one since April 2019, when its lone provider shut down.

The department has issued three requests for proposals seeking providers to offer a treatment model that allows children to live with a parent undergoing residential treatment but didn’t receive any responses.

“It was during covid, the height of covid, and programs were really trying to maintain what they had, or they were already decreasing some of their services due to capacity or changing their practices to go to telehealth,” said Lacresha Graham, the department’s manager of addiction treatment and recovery program and policy. “I guess that caused providers to not want to look at expanding.”

In requesting proposals, the state outlined requirements, such as: The provider must have the residential capacity to serve at least 10 women and their children at once and situate the facility in a community with a neonatal intensive care unit.

Though the expectation is that providers already have experience in adult addiction treatment, they also must change their care model to accommodate both the physical and health needs of mothers and children, Graham said.

In May, Republican Gov. Doug Burgum approved a one-time $1 million allocation in the state Health and Human Services 2023-25 budget to fund family-based residential treatment, which can be used to cover construction and renovation costs. As a result, the department is working to issue another request for proposals to find a provider that offers services like those at Recovering Hope.

“Ideally, there would be multiple across the state so there’d be better access to locations for women that would need it,” Graham said. “Our priority is getting one up and running and see where we can go from there.”

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But even with that early sign of success, the program’s financial future is shaky.

Over the past two years, the federal government has provided about $1 billion from the American Rescue Plan and Bipartisan Safer Communities acts to launch the number, designed as an alternative to 911 for those experiencing a mental health crisis. After that infusion runs out, it’s up to states to foot the bill for their call centers.

“We don’t know what Congress will allocate in the future,” said Danielle Bennett, a spokesperson for the federal Substance Abuse and Mental Health Services Administration, which oversees 988. “But the hope is that there will be continued strong bipartisan support for funding 988 at the level it needs to be funded at and that states will also create funding mechanisms that make sense for their states.”

Only eight states have enacted legislation to sustain 988 through phone fees, according to the National Alliance on Mental Illness, which is tracking state funding for the system. Others have budgeted short-term funding. But many predominantly rural states, where mental health services are in short supply and suicide rates are often higher than in more urban states, have not made long-term plans to provide support.

According to of Lifeline data, since last summer 988 has received almost 5 million contacts, including calls, texts, and chat messages. And state programs managed to answer a high percentage of 988 calls instead of routing them to call centers elsewhere.

Mental health advocates and state 988 operators say that to keep those in-state staffers answering phones, promises of long-term funding are critical.

In the earlier version of the National Suicide Prevention Lifeline, “call centers, basically, were not paid,” said Chuck Ingoglia, president and CEO of the National Council for Mental Wellbeing, which advocates for sustained investment in 988. “There is a growing recognition that we’re making it easier for people to contact and, therefore, we need to build more infrastructure.”

In Ohio, where shows local operators responded to 88% of calls, lawmakers recently acknowledged the need for stable funding. In July, Republican Gov. Mike DeWine approved $46.5 million for 988 in the state’s biennial budget. But that support will last only two years.

“It is still not the most secure form of funding that we would hope for,” said Brian Stroh, CEO and medical director of Netcare Access, a call center that serves four rural counties on Ohio’s eastern border. “What if we turned the tables a little bit and said we’re only going to fund 911 a little bit at a time? That’s a really hard proposition to work under.”

SAMHSA, which distributes 988 grant funding, likens the number to 911 except that it is strictly for mental health crises. The law that mandated 988’s creation, the , allows states to install phone surcharges to support 988 indefinitely, similar to the funding structure for 911.

Stroh said that, while he is “pretty pleased” with how the first year of 988 went for Netcare Access, with short-term funding it’s hard to reassure prospective call operators of job security or compete with rising wages in other industries.

For Kristin McCloud, executive director of Pathways of Central Ohio, a call center that also responds to rural counties in the eastern part of the state, the $573,056 her center received in 988’s first year was exactly what it needed. She had money for training staffers to answer crisis calls and supplying them with computers for remote work.

During that time, operators answered 2,316 calls — almost double the previous year’s volume.

“I really feel like, for once, we were given adequate funding,” said McCloud, who has worked in social services more than 35 years.

According to SAMHSA, before 988 grants, most call centers received minimal federal funding to answer Lifeline calls, typically .

Like Stroh, McCloud views Ohio’s recent allocation as positive but hopes the state installs a permanent funding plan. A bill pending in the legislature would add a surcharge to phone bills to help fund 988, as have done.

All but one of the eastern counties that Pathways of Central Ohio and Netcare Access serve are designated by the state’s Department of Health Primary Care Office as mental health professional shortage areas.

In North Dakota, where almost every county is , a single call center manages the state’s 988 program.

That center, FirstLink, has seen a significant increase in mental health crisis calls since the transition to 988. Comparing the first six months of 2023 to the first of 2022 alone, calls have increased 55%, according to Jeremy Brown, outreach director.

The demand has “helped us with sparking conversations with our state legislature about funding and support,” he said.

In May, Republican Gov. Doug Burgum approved a one-time $1.86 million appropriation to 988 in the state’s biennial budget.

Brown said the funding will not only allow FirstLink to train staff members and keep phone lines updated, but it will also help human service centers support mobile crisis units that can be dispatched to callers if necessary.

Though mobile crisis unit dispatch is an option, FirstLink prefers to deescalate crises over the phone, said Dallas Tufty, one of FirstLink’s operators.

“The only time that we’ll really call for rescue or something is if that person is in immediate, imminent danger of their life,” they said.

Tufty works 40 hours a week at FirstLink, at least six of those spent answering calls and messages to 988. Operators like Tufty also answer FirstLink’s 211 line, another program that provides health and social service assistance information to callers. It’s not an emergency line, but on occasion people in crisis call there instead of 988.

No matter which line a call comes through, Tufty said, the hard part is not knowing what happens once the call is over.

“There’s times where you don’t really know if they’re going to call back because they need to again,” they said. “Even if you make a plan, there’s only so much we can do on the phone to hold people to those plans.”

While North Dakota and Ohio fund 988 through their state budgets, not all states do. In Montana, Republican Gov. Greg Gianforte recently dedicated $300 million to the behavioral health and developmental disabilities systems that, among other uses, can fund “ opportunities for Montanans to receive integrated physical and behavioral health care,” according to authorizing the money. But the state has yet to address 988 funding specifically.

In 2021, Montana lawmakers declined to advance a bill that would have established a phone fee and corresponding revenue account to fund 988 ahead of its launch.

At this point, “if it is able to be funded in the budget, without new legislation, that’s just fine with us,” said Matt Kuntz, executive director of Montana’s chapter of the National Alliance on Mental Illness. “We just want to make sure that it’s sustainably funded, because it is an important service.”

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Weaver, 70, knew that after he emerged from surgery, he’d want privacy. But because he and his wife drove more than 150 miles from Bend, Oregon, to Oregon Health & Science University Hospital in Portland, immediately returning home was not an option.

So, the couple brought their Escape 19 camping trailer, a small but comfortable home on wheels, and parked it in one of the hospital’s 17 on-site RV parking spaces.

“Leaving that hospital with the bandage, the scar, and the rest of it, there’s no way I wanted to be in a hotel,” he said. “Being able to go down and stay in the trailer there, jeez, it was so huge.”

Weaver was fortunate. OHSU Hospital, one of two in the state, is one of several medical centers in the United States that maintain parking spaces specifically for RVs, electric hookups included. The hospital has offered the free amenity to patients since 2009.

Medical and RV industry professionals say hospitals that offer RV parking are easing access to health care for some patients who drive long distances for care, like many rural residents.

Monika Geraci, a spokesperson for the RV Industry Association, said she could understand the appeal to patients who travel with campers. “It’s your home away from home on wheels,” she said. “You’re able to bring all of your creature comforts. It’s your bed, it’s your sheets, it’s your bathroom, it’s your kitchen.”

Many patients drive eight to 10 hours to receive care at OHSU Hospital, said Brett Dodson, who oversees the facility’s parking and transportation services.

“They’ve seen the rural clinics and they need to come to that next level,” he said. “When they do, I think they’re more comfortable with an RV than they are trying to find a hotel.”

The average stay for a patient in the RV spaces is about seven days, and the limit is 30 days at a time. If a patient depends on the hospital for a recurring treatment like kidney dialysis, they’ll stay every few months. Recently, spots were occupied by transplant patients and a family with a baby in the intensive care unit, Dodson said.

The spots help patients keep close to their medical providers and avoid paying for hotels. If patients don’t have access to an RV or would rather stay in a hotel, Dodson’s team refers them to the that OHSU runs in partnership with the local chapter of Ronald McDonald House Charities or a nearby hotel that gives patients a discounted rate.

In addition to improving patient comfort, Dodson said, the RV spaces set the hospital up to provide better care. People who previously would have driven through the night to get to Portland for a morning surgery can now arrive the night before, he said. “They can get a good night’s sleep, they’d be ready for a surgery, and they’re there on time.”

Accommodations hospitals offer RV travelers vary widely and many aren’t part of an official policy. Among those that do offer overnight RV spaces, not all offer designated spaces or utility hookups like OHSU Hospital.

In Montana, patients have been parking their campers at Bozeman Health Deaconess Regional Medical Center for years. It started informally, when tourists got hurt while adventuring or sick while passing through the mountain city of 56,000 people. This spring, Bozeman Health created a short-term at the hospital, which so far has largely been used by Montana patients traveling for care they couldn’t receive closer to home.

Bozeman Health worked for years to turn itself into a medical hub in southwestern Montana, expanding into specialty services such as intensive care for infants and cancer treatment. Simultaneously, hotel prices in the destination town, one of the gateways to Yellowstone National Park, have skyrocketed, and competition to find a place to stay in peak tourist season is high.

“There are towns in Montana that just don’t have hospitals,” said Kallie Kujawa, the chief operating officer at Bozeman Health. “We had a couple who came who could not find anywhere to stay in town. This was the only place they could find to stay. And that was critical for them.”

Patients can reserve a space for free for up to two weeks. Like at the hospital in Oregon, they need to bring their own water and lug their trash out. Bozeman Health has only two RV spaces; though, Kujawa said, the system could expand if demand increases.

Since it isn’t always clear whether a hospital will allow someone to park an RV on its property, publications and forums for RV owners have offered advice on the issue. An article in Family RVing, the Family Motor Coach Association’s magazine, encouraged readers to call ahead and ask for permission. The association does not, however, have specific guidelines for its members about RV parking at hospitals, said Robbin Gould, the magazine’s editor. Still, “from what various FMCA members have reported, hospital officials have granted permission for them to park their RVs on hospital property,” she said.

And it isn’t always patients who are looking to sort out a hospital’s RV parking situation. Staff also have an interest in on-site RV amenities.

In Salida, Colorado, at Heart of the Rockies Regional Medical Center tends to get more use from hospital staff than from patients. Both patients and staff can stay at the six-spot, full-hookup lot for free.

One RV there recently was home to a new employee who was house hunting. Two nurses tend to use the lot while they work three straight days of 12-hour shifts, allowing them to avoid a commute over the mountains to their hometowns. A part-time general surgeon from Colorado Springs stays in the lot, too. A nurse comes down every week from Denver, a 2½-hour drive away.

“It’s been very popular, to say the least,” said the medical center’s CEO, Bob Morasko. “I just know that it works. And it helps us staff the hospital.”

ºÚÁϳԹÏÍø News Montana correspondent Katheryn Houghton and Colorado correspondent Rae Ellen Bichell contributed to this report.

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They couldn’t find a dentist near their home in Wilkin County, Minnesota, who accepted Medicaid. When a mobile clinic that would treat Medicaid patients drove nearly 200 miles from Minneapolis to the rural county on Minnesota’s western border, appointments that fit her family’s schedule were “hit-or-miss,” she said.

That all changed when Ehlert’s family found a clinic in neighboring Otter Tail County run by Apple Tree Dental, where dental therapists, who prioritize treating Medicaid recipients, provide much of the clinic’s care.

Now, “we actually go to the dentist like we’re scheduled to,” Ehlert said. “It really is indescribable how much of a difference it’s made.”

Dental therapists are licensed providers who offer basic care traditionally provided by dentists, including fillings and simple tooth extractions. Over a dozen states have turned to them to increase access to oral health care, and at least eight more are considering doing the same. Like Minnesota, some states have deployed therapists specifically to benefit underserved populations, such as rural residents, Medicaid recipients, and Native American tribes.

Still, dental therapists are not universally supported or available to most rural Americans, despite inadequate access to oral health services in many nonurban communities.

Karl Self, director of dental therapy at the University of Minnesota School of Dentistry, said that recruiting these midlevel providers is a cost-effective way to expand care in rural Minnesota.

Self has led the university’s program since the outset, after surveying schools in Canada, New Zealand, and the United Kingdom for examples of how to teach the new degree. Dental therapy has existed abroad since 1921 but was first practiced in the U.S. in 2004 within the Alaska Tribal Health System. Today, only five college programs offer dental therapy training.

Dental therapists deliver a slice of specialized care that helps fill gaps, Self said.

“Dental therapists are sort of the restorative experts,” he said. “They spend the vast majority of their time doing a very small segment of dentistry as a whole. But it’s a very high percentage of the primary care needs of patients.”

Under the supervision of a dentist, dental therapists can complete oral evaluations, fill cavities, and extract children’s baby teeth. In Minnesota, dental therapists with advanced training can treat patients without having a dentist on-site.

That flexibility enables those therapists to provide care in communities without full-time dentists.

Self said dental practices can deploy therapists to satellite offices, offering basic care multiple days per week and reserving more complicated procedures for occasional visits from a dentist.

When Katy Leiviska graduated from the University of Minnesota School of Dentistry as part of the school’s first class of dental therapists in 2011, she couldn’t find a job.

It was two years after Minnesota became the first state to license dental therapists. The new licensure came with strings attached, requiring the therapists to practice in areas that didn’t have enough dentists to serve the population, or to primarily treat low-income, uninsured, and underserved patients.

Leiviska called clinics almost daily looking for a job but found that most operators and owners didn’t know what dental therapy was.

“It took me almost a year to get in,” she said. In the meantime, “I was working at Applebee’s.”

Once she did join a clinic, Leiviska said, more than 90% of her patients were uninsured or on Medicaid. She has used her advanced dental therapy training to practice solely in urban areas since, but providers like her have become an integral part of Minnesota’s effort to fill dental care gaps in rural areas.

The same can’t be said for all states.

Across the border in Wisconsin, a bipartisan group of lawmakers introduced bills in 2017 and 2019 to create the license class. The Wisconsin Dental Association opposed the measures, arguing that the state should invest in its existing workforce rather than create another profession. Marquette University and the Academy of General Dentistry joined the association in its objection.

Since the first iteration of the bill required only that dental therapists attend a technical college for three years without prior training as a dental hygienist, the Wisconsin Dental Association was concerned that dental therapists could then extract teeth without dentist supervision, and that the bill didn’t require a dentist to examine a patient before a dental therapist worked on them. The association contended the bill should require candidates to attend a program certified by the Commission on Dental Accreditation.

During a 2021 attempt to pass a dental therapy bill, sponsors came to an agreement with the dental association that led it to a neutral position rather than opposition. The compromise would have made the Wisconsin law more closely resemble Minnesota’s approach. For example, dental therapists would be required to work in dental health professional shortage areas or have at least half their patients be from underserved communities.

The bill ultimately failed, but Democratic Gov. Tony Evers has reintroduced dental therapy in his proposed budget for 2023-25.

If a bill were to pass, said Matt Crespin, executive director of the Children’s Alliance of Wisconsin, it would be a “commonsense solution” to the state’s oral health crisis.

“In Wisconsin, it is very challenging if you are covered by Medicaid to get access to dental care — even privately insured or uninsured patients have a challenge in accessing providers, in particular in rural parts of the state,” he said. “Adding dental therapists to the dental team to work in collaboration with a dentist would increase access to care.”

Crespin, whose organization is part of a coalition that supports bringing dental therapy to Wisconsin, said one way he imagines increasing care options is by having dental therapists provide preventive care to students in public schools.

Access to care is a key issue in Wisconsin, where have shortages of dental professionals, according to the Rural Health Information Hub. In Minnesota, are listed as having such shortages.

Pinpointing dental care deserts takes only dentists into account; those numbers do not reflect whether counties in Minnesota have dental therapists.

According to Minnesota’s latest workforce report, as of 2018, the state had 92 dental therapists, including 25 working in rural areas. That same year, there were 5,683 hygienists and 4,140 dentists — most of them practicing in the Twin Cities area.

Neal Irion is one of those dental therapists. He treats patients at the nonprofit Apple Tree Dental clinic in Fergus Falls, a town of about 14,000 in western Minnesota.

“I’m delivering — like, me personally — close to $1 million a year of dental care,” he said. “That’s a lot of fillings; that’s a lot of exams.”

Over the years, Irion has watched as Apple Tree struggled to recruit dentists to serve the rural community. His clinic employs one part-time dentist, a full-time dentist, and two full-time dental therapists. And, like Irion, the other midlevel provider on staff, Alyssa Klugman, is an advanced dental therapist and licensed hygienist.

Klugman said her hourlong commute to work reminds her of patients’ having to travel sometimes hours for their appointments at the clinic. Those patients are often low-income and at high risk for dental disease.

“I see thousands of patients every year,” she said. “Being able to help that many people get out of pain or treat disease, it’s just incredible that I can have the opportunity to do that.”

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That effort pleased researchers and advocates for improving rural health because the dozen or so examinations of rural health data provided important details about the 46 million Americans who live away from the nation’s population centers. It began to fill a gap in the information used by those who study and address the issues that affect people in rural communities.

But those reports, the Morbidity and Mortality Weekly Report rural health series, began and ended in 2017. And though the CDC has addressed rural health in and data briefs, the agency hasn’t examined it in such depth since.

That’s one reason rural health advocates successfully pushed for the CDC to extend its rural health focus by creating an Office of Rural Health at the agency. The office is operational as of March 2023, and advocates hope the agency will commit to rural health research and provide analyses that lead to good public health policies for rural communities.

“What we’re seeing is rural continually getting left behind,” said Alan Morgan, CEO of the National Rural Health Association, which to fund the office. “They’re communities at risk, communities that may not be employing public health safety measures, and we are flying blind,” he said.

“What’s needed is an ongoing look at rural communities, their populations, to better direct both state and federal efforts to address health disparities,” he said.

The omnibus appropriations bill signed by President Joe Biden in December 2022 gave the CDC $5 million for the 2023 fiscal year to create the Office of Rural Health inside the agency, which has a $9.3 billion budget this year. to sharpen its focus on public health in rural areas with the new office, after covid-19 had an outsize impact on rural America.

Though the CDC is a data-driven public health agency, it’s unlikely the new office will solve preexisting rural data challenges. But CDC officials have said in-depth rural health initiatives that require collaborations across the CDC — like the Morbidity and Mortality Weekly Report rural health series — could become more common practice at the agency.

“Instead of comparing rural and non-rural, it was looking within rural,” said Diane Hall, acting director of the office, about the 2017 reports. “That MMWR sort of laid out some things that we can be thinking about doing more of so that within rural variation, [there’s] better understanding of how race and ethnicity play out in rural communities.”

In addition to ethnic disparities, the series examined illicit drug use, causes of death, and suicide trends, among other things. Those topics are already part of what the CDC tracks, but typically the agency compares rural data for those topics with urban data rather than creating a stand-alone analysis.

Hall said having an Office of Rural Health will also help the CDC continue collaborating with the Federal Office of Rural Health Policy, part of the Health Resources and Services Administration. That office has existed since 1987 and has been the primary federal office dedicated to rural health care. But its focus is on increasing access to health care rather than monitoring public health.

At the CDC’s Office of Rural Health, “we’re more likely to be focusing on prevention,” Hall said.

What the office is unlikely to do, she said, is create new surveys and collect data that the CDC does not already track. It would be a “pretty costly” undertaking, she said. “I think what would be more impactful is to work with the people that are already doing that and help them better understand that rural context.”

Rural data analysis poses challenges because of the smaller size of rural population centers compared with the larger populations of urban areas. For instance, small communities might not have adequate response rates to surveys, which can limit the conclusions researchers can make about the data.

Michael Meit, co-director of the Center for Rural Health Research at East Tennessee State University, said the 2017 series helped to mitigate the “small numbers” challenge, wherein samples aren’t large enough to be properly analyzed because rural areas have smaller populations.

Each of the series’ reports outlined data limitations such as small numbers and their effect on the analysis, which shows the CDC was “already pushing forward and trying to bring voice to these issues,” Meit said. “I think that by itself is huge.”

Hall, the acting director, said there isn’t a simple solution to challenges like small sample sizes but that the “CDC’s Office of Rural Health can work to highlight creative solutions being developed, such as our PLACES project.” PLACES, or Population Level Analysis and Community Estimates, is a collaboration among the CDC, Robert Wood Johnson Foundation, and CDC Foundation that releases data for smaller cities and rural areas. (ºÚÁϳԹÏÍø News receives funding support from the Robert Wood Johnson Foundation.)

Another challenge with rural health data is that small numbers can make it possible to identify who in a particular community is included in data. But the CDC has to prevent that from happening.

Sometimes, though, the agency does allow researchers to access files containing details like “race or ethnicity for small and highly visible groups” and “extreme values of income and age.”

Keith Mueller, director of the Rural Policy Research Institute, hopes the Office of Rural Health will make it easier for researchers to access that more detailed data.

“There would be somebody at the agency who can get at the data, who can help us answer the research question,” he said. “Collaborative work between people in the field and people in the agency who have the direct access to the data is far more readily available or likely to happen with this new office.”

Since the office is based in the CDC’s new Public Health Infrastructure Center, which launched in February, Hall said it’s well positioned to partner with researchers. The center manages the agency’s partnership grants, which are awarded to organizations that plan to improve public health services.

Hall said the office’s most immediate priorities, though, are to grow the staff beyond its current three members and to develop the CDC’s strategic plan for rural health.

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To do so, state officials reworked a system in place for more than 30 years — one that required low-income people seeking treatment to sometimes wait more than a month to receive state-funded care.

Policymakers’ solution, called Direct Access, was implemented last summer, promising to provide quick evaluations and care for people who ask for treatment.

But because of preexisting gaps in the state’s behavioral health care system — like those that limit options for care in other states — that promise of immediate treatment isn’t reaching some rural Minnesotans.

Providers say the shortcoming is a matter of life or death.

The need for behavioral health treatment in rural communities nationwide has been exacerbated by the ongoing flood of fentanyl into rural areas. Providers say the surge in need combined with rural workforce shortages have impeded the rollout of Minnesota’s new system because it hinges on the availability of licensed alcohol and drug counselors, who are in short supply in rural Minnesota.

Direct Access was Minnesota’s way of getting on board with what other states have done for some time: allowing treatment-seekers to choose their providers.

Previously, Minnesotans seeking publicly financed treatment had to wait for officials in their county to approve their request and refer them to a provider. But the change has also highlighted of treating substance use disorder in rural areas nationwide.

Across many states, rural areas are riddled with behavioral health provider shortages. Those deficits persist even though, compared with more densely populated places, rural areas have more people living in poverty and more people likely to be uninsured or underinsured — both risk factors for substance use disorders.

“We recognize that it’s probably not feasible for specialists to be everywhere,” said , a professor at Washington University in St. Louis and a member of the Rural Policy Research Institute Health Panel. “But if you don’t have that local provider, that is not good for the patient.”

Providers in Minnesota say the lack of local practitioners in rural regions means the systemic changes instituted months ago aren’t benefiting many patients.

At Riverwood, a treatment center overlooking the Mississippi River, nearly 50 inpatient beds are empty because the facility isn’t fully staffed. To fill those beds, the facility would need to hire at least 10 counselors, said , chief of behavioral health at NorthStar Regional, which operates Riverwood.

Of the 90 patients in Riverwood’s inpatient and residential outpatient care, Walsh said, about 90% are funded through Direct Access or Medicaid, and at least half of the program’s patients are from rural areas.

The staffing shortage has forced the facility to redirect people seeking treatment, but Walsh said the center has no way of knowing whether the people were admitted to another provider.

“If they’re not with us, we know that they’re at risk of death,” Walsh said. “That is what keeps us up at night.”

, a licensed alcohol and drug counselor in rural Kanabec County, about an hour’s drive north of Minneapolis, hates turning away prospective Direct Access patients. Her women’s treatment center, Recovering Hope, is one of only five providers in the state that offer family residential treatment. The facility has an on-site day care for children younger than 5.

Broekemeier, who is also Recovering Hope’s president, said the facility tries to avoid turning people away. “And we create beds for them.”

The facility is licensed for 108 beds but doesn’t typically use that many. It didn’t have any available on a recent Thursday afternoon when a mother arrived, seeking treatment with her child.

“But our team went and got some beds out of the shed,” Broekemeier said. “We weren’t going to send them away.”

Even so, women sometimes end up on the facility’s waitlist.

Before Direct Access, Minnesotans with low incomes were assessed by officials in the county where they lived to determine whether they were eligible for publicly funded addiction treatment. Under Direct Access, people can instead go directly to a provider to be assessed by a licensed counselor and receive care immediately, if they’re eligible.

or the federal Substance Abuse and Mental Health Services Administration’s .

Most of the state’s licensed counselors are in or near the Twin Cities, resulting in a population-to-counselor ratio three times as large in rural areas of the state as in urban areas. Ahead of the Direct Access launch, the Minnesota Association of Resources for Recovery and Chemical Health, MARRCH, a group of addiction treatment professionals, said the requirement that assessments be conducted by counselors, not other treatment workers, would worsen the disparity created by the counselor shortage in rural areas.

That wasn’t news to state officials who, in anticipation of challenges, instituted a nearly two-year transition period, during which Direct Access and the former county assessment process ran at the same time.

“Since this is a change from an almost 40-year process, we understood that people may need time to make the shift,” said , director of substance use disorder services at the Minnesota Department of Human Services. “We recognized with that transition that time would be needed to ensure that there were qualified individuals to do those documents.”

That transition period ran from October 2020 to June 2022.

Sather also said the state proceeded with Direct Access despite workforce shortages because it anticipated only an incremental increase in requests for assessment of patients’ behavioral health concerns.

But the rollout hasn’t been smooth, especially in places where counselor shortages are acute.

Thirty-six of Minnesota’s 87 counties have five or fewer counselors based in them. Twelve have no counselors licensed to them at all. Each of the 36 counties is rural.

Those counselor disparities especially hinder the Direct Access experience for people incarcerated in rural areas, said , CEO of Project Turnabout, which operates several treatment centers.

“They may have to wait five to 10 days to get an assessment because there’s not enough counselors to do them,” she said.

Recent expansions in telehealth have allowed counselors to conduct assessments virtually, but such outreach doesn’t eliminate “treatment deserts,” whose residents must drive hours to receive residential or outpatient care, said , president of MARRCH’s board of governors.

Telehealth has not been a “panacea of course-correcting some of the disparities,” she said.

The Range Mental Health Center in the Mesabi Iron Range has faced similar staffing challenges. Its director of substance use disorder services, , runs both inpatient and outpatient programs, with a staff of three counselors.

Archambault said Direct Access is a good idea but “doesn’t always work for us here, just due to staff. So if someone does walk in off the street, we might not have the staff to provide that service right away.”

The state implemented Direct Access in part to shorten wait times for treatment, which under the county-driven system were sometimes weeks. Back then, the state Department of Human Services mandated that counties complete an assessment within 20 days of a person’s request for an appointment and provide the results no more than 10 days later. Under Direct Access, providers are supposed to complete assessments within three days, to fulfill the policy’s promise that those in need have “access to care immediately.”

Archambault hired a fourth counselor earlier this year, so he predicts Direct Access intake will be quicker for the center from now on.

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MALMO, Minn. — Eight women, all 73 or older, paced the fellowship hall at Malmo Evangelical Free Church to a rendition of Daniel O’Donnell’s “Rivers of Babylon” as they warmed up for an hourlong fitness class.

The women, who live near or on the eastern shore of Mille Lacs Lake, had a variety of reasons for showing up despite fresh snow and slippery roads. One came to reduce the effects of osteoporosis; another, to maintain mobility after a stroke.

Most brought hand and ankle weights, which they would use in a later portion of the program focused on preventing falls, known as Stay Active and Independent for Life, or SAIL. The class meets twice a week in Malmo, a township of about 300 residents. It is run by Juniper, a statewide network of providers of health promotion classes.

A few years ago, older adults who were interested in taking an evidence-based class like SAIL — meaning a class proved by research to promote health — had only one option: attend in person, if one was offered nearby.

But then the covid-19 pandemic and physical distancing happened. Along with social isolation came the rapid introduction of remote access to everything from work to workouts.

After widespread lockdowns began in March 2020, agencies serving seniors across the U.S. reworked health classes to include virtual options. Isolation has long since ended, but virtual classes remain. For older adults in rural communities who have difficulty getting to exercise facilities, those virtual classes offer opportunities for supervised physical activity that were rare before the pandemic.

And advocates say online classes are here to stay.

“Virtually the whole field knows that offering in-person and remote programming — a full range of programming — is a great way to reach more older adults, to increase access and equity,” said Jennifer Tripken, associate director of the Center of Healthy Aging at the National Council on Aging. “This is where we need to move together.”

Since April 2020, the National Council on Aging has organized for service providers to discuss how to improve virtual programs or begin offering them.

“We found that remote programming, particularly for rural areas, expanded the reach of programs, offering opportunities for those who have traditionally not participated in in-person programs to now have the ability to tune in, to leverage technology to participate and receive the benefits,” Tripken said.

In 2022, at least 1,547 seniors participated in an online fitness program through Juniper, part of a Minnesota Area Agency on Aging initiative. More than half were from rural areas.

Because of grant funding, participants pay little or nothing.

Juniper’s virtual classes have become a regular activity both for people who live far from class locations and others who because of medical needs can’t attend. Carmen Nomann, 73, frequented in-person exercise classes near her home in Rochester before the pandemic. After suffering a rare allergic reaction to a covid vaccine, she’s had to forgo boosters and limit in-person socializing.

Virtual classes have been “really a great lifeline for keeping me in condition and having interaction,” she said.

Since 2020, Nomann has participated in online tai chi and SAIL, at one point logging on four days a week.

“Now, we would never go away from our online classes,” said Julie Roles, Juniper’s vice president of communications. “We’ve learned from so many people, particularly rural people, that that allows them to participate on a regular basis — and they don’t have to drive 50 miles to get to a class.”

When seniors drive a long way to attend a class with people from outside their communities, “it’s harder to build that sense of ‘I’m supported right here at home,’” she said.

Roles said both virtual and in-person exercise programs address social isolation, which older adults in rural areas are prone to.

Dr. Yvonne Hanley has been teaching an online SAIL class for Juniper since 2021 from her home near Fergus Falls. She had recently retired from dentistry and was looking for a way to help people build strength and maintain their health.

At first, Hanley was skeptical that students in her class would bond, but over time, they did. “I say ‘Good morning’ to each person as they check in,” she said. “And then during class, I try to make it fun.”

AgeOptions, an Illinois agency serving seniors, has seen similar benefits since introducing virtual fitness programs. Officials at the agency said last year that their operations “may have changed forever” in favor of a hybrid model of virtual and in-person classes.

That model allows AgeOptions to maintain exercise programs through Illinois’ brutal winters. Organizers previously limited winter activities to keep older adults from traveling in snow and ice, but now AgeOptions leans on remote classes instead.

“If the pandemic didn’t happen, and we didn’t pivot these programs to virtual, we wouldn’t be able to do that,” said Kathryn Zahm, a manager at AgeOptions. “We would just potentially spend months limiting our programming or limiting the types of programming that we offered. So now we can still continue to offer fall-prevention programs throughout the year because we can offer it in a safe way.”

But the new approach has challenges.

AgeOptions has identified increasing access to technology as a funding priority for the next few years, to ensure seniors can sign on.

The agency found that for many “folks in rural communities it was a challenge not only for them to have the device but to have the bandwidth to be able to do video conference calls,” Zahm said.

Tripken said providers and participants need guidance and support to facilitate access to virtual classes.

“For older adults in particular, that includes ensuring those with vision loss, those with hearing loss, those with low English proficiency” can participate in virtual classes, she said.

Some programs have created accommodations to ease the technology barrier.

Participants in Bingocize — a fall-prevention program licensed by Western Kentucky University that combines exercise and health education with bingo — can use a printed copy of the game card mailed to them by AgeOptions if they lack the proficiency to play on the game’s app. Either way, they’re required to participate on video.

The mail option emerged after Bingocize fielded requests from many senior service organizations trying to figure out how to offer it remotely, said Jason Crandall, the creator and international director of Bingocize.

Crandall designed Bingocize as a face-to-face program and later added the online application to use during in-person classes. Then covid hit.

“All of a sudden, all of these Area Agencies on Aging are scrambling, and they were scrambling trying to figure out, ‘How do we do these evidence-based programs remotely?’” Crandall said.

He said Bingocize was one of the few programs at the time that could quickly pivot to strictly remote programming, though it had never done so before.

“From when the pandemic began to now, we’ve come light-years on how that is done,” he said, “and everybody’s getting more comfortable with it.”

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For 65 years, residents of Nelsonville and the rolling hills of southeastern Ohio traveled to the hilltop hospital seeking care. Then, in 2014, the 15-bed hospital, which was often without patients, closed.

Later, the three-story brick building reopened as a hub for health services. With the help of several funding sources, Integrated Services for Behavioral Health, a nonprofit social service agency, transformed the building into a site for mental health treatment, primary and dental care, and food pantry access.

In June, the organization opened a 16-bed residential mental health treatment program on the former hospital’s top floor. The program serves children in rural southeastern Ohio and gives families an option besides sending their kids far away — sometimes out of state — for residential care.

“For a long time, we’ve been trying to figure out, ‘How do we support services being delivered more locally?’” said Samantha Shafer, CEO of Integrated Services for Behavioral Health. “Because when you have the programs here, the work you can do with families is more successful, health outcomes are better.”

Efforts to offer residential mental health services at Mary Hill Center, and in other rural Ohio towns, were boosted, in part, by a tiny share of Ohio’s $5.4 billion allotment from the American Rescue Plan Act, a federal covid relief law that was passed in 2021.

Congress gave $350 billion to state, local, and tribal governments as part of ARPA, allowing states to decide how they would use the funds. So far, dozens of states have allotted a relatively small portion to improving mental health resources. Ohio is one of a small group of states that further divided their allocation to spend a portion on children’s mental health care.

Experts said that using ARPA funds is just one way for states to support children’s behavioral health during what health professionals have called “,” which was worsened by the pandemic. In an effort led by the American Academy of Pediatrics, multiple organizations the Biden administration in October, urging it to declare a federal national emergency over children’s mental health.

“At the time that ARPA came out, we were really trying to figure out, as a country, how the mental health, behavioral health systems could be bolstered, because, in my opinion, the systems are really broken,” said Isha Weerasinghe, a senior policy analyst at the Center for Law and Social Policy, a national, nonpartisan group that advocates for policies that help people with low incomes. “And what ARPA was able to do was to provide some foundational dollars to help bolster the systems.”

The center has said that ARPA’s funding provisions are “” in mental health care. Nonetheless, Weerasinghe said an opportunity exists for the money to have a long-term impact on children’s mental health care if applied to organizations that have demonstrated a commitment to maintaining children’s well-being in their communities.

States have until 2024 to allocate their ARPA funding and until 2026 to use it. According to by the Center on Budget and Policy Priorities, a left-leaning think tank in Washington, D.C., most states have either completed or nearly completed their allocations. Among states, the median allocation to support mental health services is about 0.5%, based on the CBPP data. For states in the Midwest region, the median is about 3%.

The CBPP numbers showed that by August the mental health allocations varied widely in the mostly rural states where suicide rates repeatedly eclipse the national average by double or more. In some of those, including Montana, South Dakota, and Wyoming, officials allocated less than the nationwide median. Meanwhile, lawmakers in Colorado steered nearly 11% of the state’s money toward mental health.

Of the $84 million Ohio officials dedicated to pediatric behavioral health facilities, $10 million in the state’s southeast. That is less than half a percent of the state’s $5.4 billion ARPA allotment. But clinicians hope it will help address gaps in Appalachian Ohio’s mental health services for children.

In recent studies, the Public Children Services Association of Ohio, a nonprofit advocacy group, because of gaps in services, some children with behavioral health needs in Ohio were placed out of state or in a distant county for care. The association in 19 counties and found that for most of their cases in 2021, the agencies made many calls before finding a residential treatment facility placement for a child.

In April, Ohio Gov. Mike DeWine signed an executive order providing $4.5 million to youth residential treatment facilities to increase their capacity.

In Nelsonville and the rural, hilly country that surrounds it, ARPA money has played a minor role in expanding services.

The new residential treatment facility at Mary Hill Center, which serves 10- to 17-year-olds, was designed for 16 beds. But as of September, because of staffing shortages, the facility operated at limited capacity and had served a maximum of five children at once.

Shafer said non-ARPA money paid for most of the renovations needed to open the floor, but about $1 million from ARPA will help upgrade elevators and bathrooms.

Her organization will use an additional $7 million to build another residential treatment facility — its program modeled after Mary Hill Center’s — in Chillicothe, a city about 55 miles west of Nelsonville. That facility will have capacity for 30 beds, but it will start with a cap of 15. Construction is set to begin in January.

Services at the residential facility in Chillicothe will primarily be reimbursed under a new Medicaid program called OhioRISE, which will pay for behavioral health treatment at psychiatric facilities for young people. But the facility will also treat children who aren’t enrolled in Medicaid.

Before the rural Ohio projects were approved for ARPA funding, they were each reviewed by Randy Leite, executive director of the Appalachian Children Coalition, a nonprofit that advocates for children’s health. He decided which proposals for ARPA-funded projects from the Appalachian region were presented to Ohio’s Department of Mental Health and Addiction Services.

“I told people in Columbus I could give them $300 million of ideas to spend money on, but a lot of that wasn’t practical and doable,” Leite said. Instead, he focused on ideas that were “shovel-ready” — so they could be completed within the ARPA spending time frame — and sustainable.

“A lot of the sustainability is tied to services that are reimbursable,” he said.

Leite and the coalition presented Ohio officials with about $30 million in ARPA investment recommendations, including a project meant to expand telehealth capacity in schools. State officials approved only about a third of the total requested. The money went to the Integrated Services for Behavioral Health facilities and Hopewell Health Centers, a federally qualified health center that received about $1.5 million. That money will pay for renovations to its 16-bed child crisis stabilization unit in Gallia County, south of Nelsonville; an expansion of its day treatment program; and enhancements to its school-based mental health programs — including one in Nelsonville’s school district.

“For students to learn, they have to have good physical and mental health,” said Sherry Shamblin, chief strategy officer of Hopewell Health Centers. “Those supports are really needed for kids to be able to take good advantage of their education opportunities.”

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When he reaches Red Wing, a city of nearly 17,000 people, the 79-year-old retired engineer stops to pick up a senior whom he then delivers to an appointment, such as a dentist visit or an exercise class. When the appointment ends, Maybach is there to drive the person home.

It’s a route and routine he repeats a handful of times each month.

Maybach is unpaid, a volunteer among a cadre organized by Faith in Action in Red Wing, a nonprofit that relies on retirees to ferry residents to essential services.

The riders, mostly seniors, are people who don’t have immediate access to transportation, especially in rural areas where public transit options are either limited or nonexistent.

There are several such programs serving rural counties in Minnesota, but, as with other services across the country, their existence has become precarious because the number of volunteer drivers has steadily declined, according to transportation advocates. Volunteers either get to a point where, because of age, they can no longer drive, or the costs associated with their volunteerism are no longer sustainable. For decades, Congress has refused to increase the rate at which the drivers’ expenses can be reimbursed.

Experts say that with public transit in rural areas already insufficient and the long distances that residents in rural communities must travel to access health care, a decimated volunteer driver network would leave seniors with even fewer transportation options and could interrupt their health management. Already, social service organizations that rely on volunteers have begun to restrict their service options and deny ride requests when drivers aren’t available.

Recognizing the need for drivers in their community is often what got volunteers to sign up in the first place, but as car insurance and gas costs increase, the commitment is not “the attractive win-win that it once was,” said Frank Douma, director of state and local policy and outreach for the Institute for Urban and Regional Infrastructure Finance at the University of Minnesota’s Humphrey School of Public Affairs.

Volunteers, like Maybach, are eligible for a reimbursement of 14 cents per mile, which generally doesn’t come close to covering the cost of gas and wear and tear on a vehicle. And while the Internal Revenue Service increased the business rate from 58.5 cents per mile to 62.5 cents per mile , it did not raise the charitable rate because it is under Congress’ purview and must be set by statute. The charitable rate was last changed in 1997.

Despite the long-standing charitable rate, United Community Action Partnership, a nonprofit that runs a volunteer driving program in southwestern Minnesota, had for years been reimbursing drivers using the business rate. The program’s administrators didn’t realize the IRS could count volunteers’ reimbursements that exceed the charitable rate as income.

The organization experienced its “first major drop” in the number of volunteer drivers before the covid-19 pandemic, after it found out about the IRS rule and told volunteers about the tax implications of higher reimbursement rates, said Shelly Pflaum, the driving program’s administrator.

And although the nonprofit continued to reimburse at the business rate, the remaining drivers were frustrated that as gas prices spiked in the spring, the rate remained only 58.5 cents per mile, which did not cover the cost of gas or maintenance.

“When you’re paying nearly five dollars for gas, it is no longer helping,” Pflaum said. “So, there were some concerns: ‘With what I’m spending to drive my vehicle, this is no longer reasonable for me — I can’t afford to volunteer’ essentially is what it was coming down to.”

The IRS business rate bump in June was enough to convince most drivers to stay, but Pflaum said she lost a volunteer who had been driving for nearly 20 years.

The issue of unequal rates has gained bipartisan attention in Congress, with the introduction of — both sponsored by Minnesota representatives who propose increasing the charitable mileage reimbursement rate to the business rate. Similar proposals have been made in Congress before and failed.

According to by the Volunteer Driver Coalition, Minnesota had 1,900 volunteers that year who collectively served 77,000 riders.

One persistent hurdle that volunteers face is convincing their auto insurers that they are, in fact, volunteers and not drivers-for-hire like Lyft or Uber drivers. Otherwise, the insurers could require them to buy more expensive insurance meant for commercial ride-hailing drivers.

An that, as of September 2020, seven states had implemented laws barring insurance providers from denying or canceling insurance or increasing rates because the driver is a volunteer. Only two states had differentiated for-hire drivers from volunteers in insurance statutes at that time.

Last year, Minnesota passed legislation that distinguished volunteer drivers from drivers-for-hire. Legislators also reduced the drivers’ potential in-state tax liability.

In southeastern Minnesota, the driver shortage prompted a program at the nonprofit Semcac to cut back on the types of rides it offers. It limits users to two nonmedical trips per month.

“We would allow more if we had the drivers to do those, but we don’t want to take the drivers on nonmedical rides and then somebody doesn’t get to their doctor appointment,” said Jessica Schwering, operations manager at Semcac. “There’s way more of a need than what we can provide for, and it’s only getting worse.”

If Semcac cannot arrange a driver for a community member in need of a ride, the person must look for an alternative, such as a ride from a family member, or have their health insurance provider find one. Semcac has partnered with certain insurance providers to get their clients to medical and dental appointments. Not all volunteer driver programs have this structure.

Schwering manages 53 drivers spread across six rural counties. About half of them are in Winona County, a nearly 650-square-mile swath southeast of Minneapolis along the Mississippi River. She estimates that the average driver is 80 years old.

Schwering said volunteers who stop driving for her nonprofit most often cite medical reasons, such as not getting cleared by their doctor.

Douma, from the University of Minnesota, said the average age of volunteers is also a factor in the decline. “When the baby boomers were retiring, they were driving people from the Silent Generation and the Greatest Generation, who were less numerous than baby boomers, so you had more people available to do the driving for fewer people,” he said. “But now that the baby boomers are aging, those who may be most eligible to drive them are Gen X — and that’s a much smaller generation.”

Jim Maybach started driving for Faith in Action after retiring in 2011. Six years later, his wife, Judie, now 78, joined him after she retired from nursing. They have trouble imagining stopping anytime soon.

Still, their volunteer program has begun planning a new recruitment strategy to bring in a much younger base, stay-at-home parents.

“We were just trying to think, ‘Well, who else can we get?’” said Katherine Bonine, executive director of Faith in Action. “Because when we have our senior citizens, we’ve had some transfer from being a volunteer into a recipient as they grow older and their driving capabilities change.”

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