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Can a 28-year-old from D.C. fix Montana’s mental health system?

Posted at 10:38 AM, Sep 19, 2023

Soon after 26-year-old Charlie Brereton started working at the Montana Department of Public Health and Human Services in December 2021, a few long-time state employees began referring to him by an irreverent nickname: “the Intern.”

But Brereton, now 28, was never an intern at the state’s largest department, which wrangles a staff of nearly 3,000 and a biennial budget of roughly $7 billion. Equipped with an undergraduate political science degree, three years as a D.C. policy staffer and no professional health care experience, he came to the agency in the newly created position of chief of staff. Today, he’s the department’s director, reports Montana Free Press.

Over six feet tall with a measured, baritone voice, Brereton is in the driver’s seat for a key part of the Gianforte administration’s agenda: remaking much of Montana’s disjointed system for mental health care, addiction treatment and developmental disabilities into something functional, even harmonious, with help from an unprecedented $300 million allocated by the 2023 Legislature.

The administration’s specific end goals for this systemic restructuring are far from clear. But it’s hard to find anyone who works in the behavioral health and disabilities services field in Montana who says major and concerted change isn’t necessary. Those parts of the state’s health care “system,” policy experts say, are cracking under the strain of rising expenses, a small workforce stretched across a rural state and perpetual budget shortfalls. Group homes for people with developmental disabilities and short-term mental health crisis beds have shuttered in recent years, leaving vulnerable people with fewer services and their families and caretakers frantic and overburdened. It’s not uncommon for Montanans in the throes of a mental health episode to spend hours in the back of a sheriff’s car en route to the state psychiatric hospital in Warm Springs. And even after losing federal accreditation last year due to unsafe conditions, Montana State Hospital continues accepting psychiatric patients who have nowhere else to go.

It’s an overwhelming system that can become dizzying the closer you look. Fixing it, one lawmaker observed, is a project akin to “putting someone on the moon.”

The Gianforte administration rarely misses an opportunity to place blame for the dysfunctional system on the state’s former Democratic leaders. But the current occupants of the governor’s office have also pledged to pursue real, systemic change. With interest from key legislators and an ample state budget surplus, the Republican administration says Montana appears ready for reform. And some observers see Brereton as a compelling reason for optimism: The state, they say, has landed a policy wunderkind with a dogged work ethic and the political chops to overcome some of its deeply entrenched health care problems.

“I’m all for people who put their shoulder to the wheel and go to work,” said Sen. John Esp, R-Big Timber, one of the architects and members of the newly formed Behavioral Health System for Future Generations Commission. The group, vice-chaired by Brereton, is charged with making recommendations for the best uses of the $300 million, a sum providers and advocates see as a historic windfall for a long underfunded system. “And he’s one of those guys.”

Brereton also has his skeptics. Some doubt that a young administrator by way of the nation’s capital can successfully address the legal and operational problems that run throughout Montana’s dysfunctional system. Others say they’ve struggled to get a good read on Brereton’s character, motivations and policy agendas.

“He’s either one of the most intelligent human beings I’ve ever met [and] on track to be a rock star, or he’s an expert-level politico-salesman kind of guy,” said one well-connected Republican legislative staffer who observed Brereton during the 2023 session and requested anonymity to preserve relationships with the executive branch. “He’s a smart guy who knows health policy. And sometimes I think he thinks he’s already figured out the best way to do it.”

Charlie Brereton, center, director of the Montana Department of Public Health and Human Services, speaks with Rep. Bob Keenan, R-Bigfork, left, in the director’s Helena office on Sept. 8, 2023. 

The director has tried to dispel the know-it-all narrative for months. During the legislative session, Brereton maintained that the Gianforte administration does not have a pre-determined formula for overhauling Montana’s mental health and disabilities systems. With the work of the Behavioral Health Systems for Future Generations Commission now underway, the director denies that he alone is pulling the levers of a statewide, multi-branch reform effort.

Brereton originally declined interview requests for that reason, saying in a written statement a personal profile would “detract from what hardworking agency staff, legislators, constructive stakeholders, and the governor are also doing” to remake Montana’s health care landscape. But the director eventually changed his mind and agreed to an interview in early September.

Sitting in his corner office on the third floor of the health department’s headquarters in Helena, across the table from Gianforte director of strategic communications Travis Hall, Brereton reiterated that he didn’t want to be at the center of the story.

“I can’t stress this enough, that this is a collaborative effort. This isn’t about me,” Breterton said. “It’s a team effort, and I just want you to know that, and just wanted you to hear that from me.”

Even so, lawmakers and longtime behavioral health advocates say Brereton’s leadership and ambition loom large. The bookshelf in his office holds telling titles: “Grit: The Power of Passion and Perseverance” and “Execution: The Discipline of Getting Things Done,” alongside binders of records from the last two legislative cycles. When it comes to fixing Montana’s systems for mental health, developmental disabilities and addiction, the director acknowledged that setting the state on the right track for years to come is an enormous responsibility. But it’s one he said the administration is willing to undertake.

“I think we’re willing to blow the lid off of issues and talk about them very openly and in a manner that, frankly, could put this administration in a vulnerable position. But unless we do that, unless we’re willing to have the frank, honest, open conversations about what’s not working, we will not see change,” Brereton said. “We cannot sweep these things under the rug.”

Accounts of what it’s like to work with the new director depend on who’s telling the story. During his two years at the health department, some critics who’ve worked with Brereton say the director has been difficult to challenge and costly to cross. Public disagreements or perceived snubs have earned lawmakers, health care providers and lobbyists confrontational conversations with Brereton and, sometimes, stone-cold silence from the department. When the door is closed, some observers say, Brereton doesn’t shy away from leveraging a with-me-or-against-me attitude.

Others counter that it’s precisely that formidable persona — a display of “hubris,” or simply being “articulate,” depending on the account — that could help Brereton and the Gianforte administration achieve change in a long-stuck system.

“Some people can say he’s temperamental. Well guess what, when you’re a CEO sometimes you have to be a little temperamental,” said Carter Anderson, the former interim administrator at Montana State Hospital who retired from the state health department in March. “If you don’t have the one right guy there, it’s not going to happen. You’ve got to have somebody at the top pushing all the agendas.”

Brereton didn’t grow up in a family of government employees or professional politicians. But the family’s endeavors hint toward an ambitious streak: His father built a career in private school administration, moving the family from Ohio to Georgia before eventually landing in North Carolina. Brereton’s two older siblings pursued tech sector careers and business ventures. His twin sister, Emma, became a professional artist with a flair for the political, serving for a time as the art director of the Republican National Committee and recently launching her own consulting business.

Speaking to MTFP in September, Brereton said his family was “very politically involved” and he remembers being interested in government and health care from a young age. He eagerly tracked the debate over the Affordable Care Act as a teenager in 2010. In college, he shadowed his uncle’s work as an emergency room physician and briefly considered a career in medicine. But a pull toward policymaking won out, and he said health and human services has always been his preferred arena.

“To me, health care policy, it blended my interest in health care with my interest in government and policy, and in politics,” Brereton said. Another element, he said, was a desire to serve.

“If you don’t have your health, you have almost nothing,” he said. “And so what a fantastic subject to invest in for your career. Helping people become healthy and stay healthy.”

Brereton chose to start building that career in the nation’s political core. He studied political science as an undergraduate at George Washington University in Washington, D.C., while stacking his resumé with early work experience, including internships with then-Republican Speaker of the U.S. House of Representatives John Boehner, North Carolina Republican Gov. Pat McCrory, and U.S. Sen. Richard Burr, also a Republican from North Carolina. By the time he graduated in 2017 at the age of 22, Brereton was climbing the ladder at the D.C. lobbying firm Squire Patton Boggs LLC, eventually, he has said, becoming one of the firm’s youngest-ever public policy advisers. He returned to Congress after nearly two years in that job to work for the U.S. Senate Health, Education, Labor and Pensions Committee chaired by then-Sen. Lamar Alexander, a Republican from Tennessee.

Brereton said he began looking for new jobs near the end of 2020 as the Senate and White House shifted to Democratic control. Though he was invited to stay on as a committee staffer for another ranking Republican, Brereton said, he was ready for something new. A colleague connected Brereton with Christine Heggem, Gianforte’s chief of staff, who recruited him to join the incoming governor’s administration as a health policy adviser. The rest, Brereton said, “is history.”

He has suggested that the jump from D.C. to Montana is not as random as it may appear. The new position was a fresh opportunity to move his policy work “closer to the ground.” He’d worked as an intern in a governor’s office before and liked it. And he’d had a longstanding interest in “moving West,” Brereton said, a desire perhaps shaped by childhood visits to Montana to see cousins and an aunt and uncle who lived in the state.

“Moving to Montana, moving to a rural and frontier state in the West, was something that I frankly had always planned on doing. I didn’t know when that would happen or how that would happen. And the opportunity presented itself,” Brereton said.

Less than a year after reporting for work as Gianforte’s health policy adviser, having navigated much of the pandemic and the 2021 Legislature, Brereton was promoted. He took the newly created position of chief of staff at the health department, a position he has since referred to as “second in command” of the state’s largest agency, behind Gianforte’s first appointee, Adam Meier. At the time, health department spokesperson Jon Ebelt told Montana Free Press that Brereton had taken the job, effective December 2021, after a competitive hiring process.

In his new role, health department employees got to see Brereton’s working style and influence up close. He was polished, with crisp suits and attentively sculpted hair, and was a forthright communicator about the department’s large and small priorities. One employee noticed that his parking spot, originally located near some of the agency’s branch managers, eventually moved closer to the director’s and the building entrance. In meetings and interviews, Brereton and Meier sometimes angled for the last word, underscoring their respective takeaways.

Former health department staff also described Brereton as having a hand in seemingly every policy area the agency touches. He edited the work of supervisors, overseeing the projects of their direct reports, making corrections others had missed. No matter the subject, he always seemed to show up to meetings prepared.

Charlie Brereton, left, director of the Montana Department of Public Health and Human Services, walks to a meeting in Helena with Rep. Bob Keenan, R-Bigfork, center, on Sept. 8, 2023. 

“He’s got great attention to detail. Tremendous attention to detail,” Meier said in an August interview with MTFP. He recalled Brereton learning a granular piece of information and later referencing it with ease. “All of sudden, two weeks later, he brings up this key detail that’s completely relevant to the conversation you’re having.”

That astuteness rubbed some state employees the wrong way. Brereton’s precision could feel like micromanagement, they said — an indication that he didn’t trust some of the agency’s most experienced employees. Most of the 10 former state health department employees who spoke to MTFP declined to be quoted for this article, citing fear of damaging their relationships with the health department.

“He runs a tight ship in terms of controlling people,” one former employee said. Brereton seemed to have “no humility” or respect for the expertise of those who worked under him, the person said. “He had to see and approve everything.”

In the eyes of the Gianforte administration, Brereton was excelling. After eight months on the job, he was promoted yet again, this time without having to compete against other applicants. Meier, citing family health issues, left his position as agency director and the state. Instead of conducting a nationwide search, as the administration had done before, Gianforte chose Brereton.

Months later, when 28-year-old Brereton stood before the Senate Public Health, Welfare and Safety Committee for his confirmation hearing, he made his pitch for what the department could become in his hands: innovative, efficient and, ultimately, a model of limited and effective government.

“My team often hears me discuss the importance of increasing the self-sufficiency of our clients and knowing which investments, which programs and which interventions will truly motivate and help them to become self-reliant and independent,” he continued. “I believe that all human beings want to live this way.”

Brereton is conscious about his rapid trajectory through college, D.C. and Montana. His professional experiences, he said, have been “relatively unusual,” but make sense in light of his personality.

“An intense work ethic, the seizure of opportunities at every turn to develop subject and policy matter expertise,” Brereton said of himself during his confirmation hearing. “And ultimately, an aptitude for leadership.”

He was confirmed along party lines, with all but one Republican senator voting in favor and all Democrats opposed.

In the midst of a chaotic Legislature featuring a nearly $3 billion budget surplus, Brereton and his allies dedicated themselves to steering a foundational piece of the administration’s behavioral health reform through the legislative thicket: an eye-catching bill with a hefty price tag.

House Bill 872 created a $300 million fund for investments in behavioral health and disabilities services and a commission to recommend how to use the money. The commission, through its composition and authority, gives the executive branch of government — Gianforte and the health department — a larger role in directing the spending of state dollars, a job typically within the purview of the Legislature.

Convincing the Legislature to hand over such a large sum for the execution of largely undefined projects proved challenging. Fortunately for Brereton, the bill was shepherded through the Legislature’s political obstacle course by two lawmakers passionate about mental health reform: Esp, the Republican from Big Timber, and Rep. Bob Keenan, R-Bigfork, the bill’s sponsor.

A seemingly tireless legislative veteran, Keenan sold HB 872 to fellow lawmakers as a rare opportunity to make sweeping, structural changes to a beleaguered system. The surplus allowed the Legislature to lean into large-scale reforms, he said: buying or building new facilities, investing in community-based services to help prevent inefficient hospitalizations, improving patient care in state facilities and avoiding negligence lawsuits in the process.

Keenan compared it to the type of system-wide rebuild that happened in the early 2000s, after Montana’s failed stint with an out-of-state company hired to manage its mental health system. For the first time in years, he said, the Legislature and the governor’s office were mutually invested in systemic reform.

“This bill and the opportunity that we have right now to do something that the whole United States will look at is an incredible opportunity,” Keenan said in March at the bill’s first budget hearing.

Regardless of Keenan’s pitch, HB 872 faced strong headwinds. Some lawmakers derided its $300 million allocation as a “slush fund.” Others warned that the governor’s office was grabbing the Legislature’s purse strings and would eventually outsource major reforms to expensive consulting firms, as the health department has done at the Montana State Hospital. Despite Brereton’s repeated commitments to be transparent and collaborate with lawmakers, critics alleged that the bill was basically a blank check for unknown investments, including purchasing or constructing new treatment facilities.

“Just to clarify: Did I hear that you guys don’t know what you’re building?” said Rep. Jonathan Windy Boy, D-Box Elder, during the bill’s March hearing in the House Appropriations Committee.

“Not at this point in time,” Brereton replied. The governor’s proposed budget included construction estimates for two 50-bed residential facilities for mental health treatment and another residential campus for people with intellectual disabilities, Brereton said, but the department had not decided whether to move forward with those investments.

“Could the [health] department have rushed a plan and a proposal forward and presented it to you all? We absolutely could have. But we’ve elected to hit pause to do this in a thoughtful, data-informed, rational manner alongside the Legislature and providers and stakeholders,” Brereton said.

Charlie Brereton, left, director of the Montana Department of Public Health and Human Services, speaks with Rep. Michele Binkley, R-Hamilton, right, at a meeting in the State Capitol Building in Helena on Sept. 8, 2023. 

“Director, it kind of sounds like to me that we’re kind of putting the cart before the horse on this thing here,” Windy Boy replied. “And you’re sitting here, I’m sitting here across the table here, and you’re wanting me to give you $300 million, but you don’t know what the heck you’re gonna do with it. Am I correct in that assumption?”

“I don’t think so. I think we have a vision,” Brereton said. “The intent of the proposal is to establish an advisory commission, given the magnitude of the reforms that we’re proposing, and work with the Legislature to do it in partnership.”

After heavy scrutiny from lawmakers, an amended version of the bill passed out of the committee with only one dissenting vote. Windy Boy and other supporters signaled that, given the degraded condition of the state’s mental health system, a bold if vague investment seemed better than nothing at all.

The bill weathered additional debate in the following weeks, receiving a mix of Republican support and Democratic skepticism in the House. By the time it advanced to the Senate, Esp, Keenan and Brereton had rallied even stronger endorsements from members of both parties, including from some typically hawkish fiscal conservatives.

“They came to us with a blank slate, and if they’d come to us with a plan all laid out, we wouldn’t have liked that either,” said Sen. Carl Glimm, R-Kila, before an April vote on the bill by the Senate budget committee. Glimm also pointed out that the onus was on the Legislature to stay engaged in the commission’s work in the months ahead. “We’re going to have to pay attention to this.”

At the bill’s second-to-last vote, one of the Legislature’s most experienced health and human services advocates made a final plea to revise the Gianforte administration’s plan. Rep. Mary Caferro, D-Helena, said lawmakers should not cede control over such a significant investment that could end up going toward inpatient institutions similar to the state hospital. The money would be better spent, she said, rebuilding the network of community health providers that have struggled to keep their doors open after budget cuts in 2017 and the tumultuous years of the pandemic.

“This is taking us backwards. We should be taking this $300 million — $300 million — and be investing it in community services, not in the highest level of care. Not without accountability,” Caferro said. “To me, it seems like the plan is clear. Continue to spend more money on consultants, more money on contracts from out-of-state companies that don’t know Montana.”

The bill passed its final vote 56-40, with 12 Republicans and 28 Democrats opposed.

‘CALLED TO THE PRINCIPAL’S OFFICE’Throughout the journey of HB 872 and several other policy battles last session, lawmakers and lobbyists regularly crossed paths with Brereton. Some found the director and his staff to be responsive and open to feedback on bills, but not all. Rep. John Fitzpatrick, R-Anaconda, was one lawmaker who routinely criticized Brereton’s presentations before appropriations committees. He cast doubt on the department’s estimates for infrastructure fixes at state facilities — roofs, parking lots, wells — and asked for a cost-benefit analysis of pursuing recertification from federal health inspectors at the Montana State Hospital. Fitzpatrick said he never got that analysis, or other information he requested.

“The department was completely uncooperative,” Fitzpatrick said in a September interview. At some points, the lawmaker became so frustrated he took to referring to the director by another nickname that circulated among legislators and staff: Prince Charlie.

“That’s where that started,” Fitzpatrick said. “Because first of all, he’s a dashing, good-looking guy so he looks like a Prince Charming. And he’s just got a kind of style that he seems aloof and in charge, and he just didn’t seem that terribly interested in my policy ideas.”

Other lawmakers said they struggled to work with the director through policy disagreements. At a budget meeting in mid-January, Republican and Democratic lawmakers questioned Brereton about the governor’s proposal for Medicaid provider rates. The administration wanted to increase “base” reimbursements for certain providers but also asked for an additional $25 million in the first year of the budget cycle to distribute at the department’s discretion.

“… he’s just got a kind of style that he seems aloof and in charge, and he just didn’t seem that terribly interested in my policy ideas.”REP. JOHN FITZPATRICK, R-ANACONDACaferro, vice chair of the health department’s budget subcommittee who was then serving her 10th term in the Legislature, expressed confusion at the idea. Why not use that $25 million, she asked, to boost base rates even higher? And why not present lawmakers with a candid, detailed plan for how the $25 million would be spent? In a more terse than usual response, Brereton referenced the department’s earlier presentations on the Medicaid rate plan and pushed back against the suggestion that the strategy was not transparent.

“Transparency is the name of the game here,” Brereton said. “I think you’ve seen from our roughly two weeks together thus far that we are striving for transparency. There is nothing happening here to — I’ll stop there. But what we’re going to do is take this back, figure out how we can best present, re-represent our plan to you … and report back.”

Montana Department of Public Health and Human Services director Charlie Brereton, center, appears with staff members before lawmakers on Thursday, Jan. 5, 2023.

After that hearing, according to Caferro and two other Democratic caucus members, Caferro was asked to meet with Brereton and Gianforte’s budget director, Ryan Osmundson, in Osmundson’s office. After she arrived, Caferro said, she felt that the conversation quickly turned into a confrontation. The director referenced her questions during budget hearings and said she had appeared increasingly agitated during the recent meeting, Caferro recalled. In a recent interview, Caferro said Brereton seemed to not understand her role as a legislator.

“His actions indicated to me that he took my questions, my comments, personally,” Caferro said. “It seemed as though I got called to the principal’s office to indirectly get chewed out for asking too many questions.”

Asked about his exchange with Caferro, Brereton said that the budget director called the meeting, not him, and that he wasn’t sure of Osmundson’s intent in asking Caferro to attend. Brereton said he did not recall “the tone of the meeting” as reprimanding. He said the department did later change the presentation of its Medicaid rate plan in an attempt to clear up communication with lawmakers.

“We really do our best to respond to legislator concerns and repackage information for them, discuss topics in different ways,” Brereton said. “But in this role, you can’t make everyone happy.”

Other clashes between lawmakers, lobbyists and health advocates emerged during and after the legislative session. In May, the governor vetoed two bipartisan reforms for the state hospital, including Senate Bill 4, which required the health department to share the hospital’s abuse and neglect reports with the federally appointed watchdog group Disability Rights Montana. In a statement to MTFP at the time, DRM Director Bernadette Franks-Ongoy said the veto made her believe Brereton “never meant” his pledges of transparency during the session.

The health department pushed back against Franks-Ongoy’s characterization in a lengthy email to MTFP after the article was published. In that response, every instance of the word “transparency” was typed in bold font.

“Inaccurate, inflammatory statements from stakeholders are not constructive and suggest a lack of commitment to partnering with the department to reform [Montana State Hospital] and a state-run health care facilities system that has been neglected for decades,” the May email said, in part. “Such statements and misinformation work against the department’s reform efforts — which stakeholders should be celebrating, as many have observed the system crumble for years under past administrations — and consequently put our patients last.”

In an August interview, Franks-Ongoy said she was never contacted by the health department directly about her statement but described feeling generally cut off from the department’s corrective work at the state hospital. Though the Legislature later overrode Gianforte’s veto of both reform bills, Franks-Ongoy said her organization has not since received a single abuse or neglect report — as required by SB 4 — from the hospital during Brereton’s tenure, an outcome she finds remarkable for the size and patient population.

“The amount of energy that went into vetoing SB 4 — tell me that that’s about transparency and collaboration. That’s baloney. And if I was a person who swore, I would use stronger language,” Franks-Ongoy said. “The best thing the department can do is open their doors to us and say, ‘Look, we have a problem here. We’ve hired consultants to come in and help us. We welcome your input.’” Instead, she said, “they put up every possible roadblock.”

Since the Legislature adjourned in May, the behavioral health commission’s work has picked up speed. The governor in July appointed three members to the group — Brereton, a disabilities services professional and a mental health researcher — while Keenan, the commission chair, tapped an assortment of five lawmakers with experience on different committees. Caferro, Fitzatrick and other lawmakers who have publicly sparred over HB 872 are not among them. Together, the commission is obligated to recommend to the governor how to spend the $300 million, only a portion of which can be used before 2025.

The health department did not confirm Brereton’s position on the commission before Gianforte’s announcement and downplayed the agency’s role in setting priorities for the group’s work in statements to MTFP. But in the spring and summer months leading up to the first commission meeting, Brereton continued to be in regular contact with Keenan and Esp about HB 872, according to a copy of Brereton’s professional calendar received through a public records request. In June, Brereton and top health department staff spent hours in preparation, coordinating weekly “steering committee” meetings with other Gianforte administration staff.

At the group’s first meeting, in July, Keenan and Brereton sat side by side at the head of a square configuration of tables as chair and vice chair of the commission. The two steered the proceedings almost equally. At the meeting’s outset, seemingly looking around the room for a staff member, Keenan consulted Brereton.

“Who does roll call? Do I do roll call?” he asked, receiving some laughs from the crowd.

“Mr. Chair, for today I suggest you do roll call,” Brereton replied.

By the fourth hour of the meeting — after introductions and presentations and public comment — Brereton and Keenan had taken off their jackets and tugged up their shirt sleeves. Brereton, slated to give a presentation, began to explain the many layers of his agency’s ongoing reform efforts. He said the department had been “extremely busy behind the scenes” in preparation for the commission meeting, even before the bill was signed and the Legislature adjourned.

“We started putting our heads together, started thinking about the resources that would be required to ensure this is a successful commission,” he said, looking across the tables at other members. “And, again, that we emerge with some meaningful, impactful initiatives, tangible policy and programmatic reforms.”

Brereton said the department had decided that the commission’s work would be overseen and guided by a private contractor hired to identify problems in Montana’s behavioral health and developmental disabilities services system, find gaps between state and local planning efforts, and ultimately create strategic plans for both mental health and disabilities services reform. Each of those plans would be paired with a “multi-biennia implementation plan,” Brereton said.

“So these are documents or plans that the department will use, hopefully use, over the course of many years, regardless of what happens with this commission,” Brereton said.

In mid-August, the state announced its plan to award the contract to Alvarez & Marsal Public Sector Services LLC, a New York-based consulting firm that also holds the state contract to oversee operations and reforms at the Montana State Hospital and other state-run facilities.

According to copies of the new agreement and application materials obtained by MTFP in September through a public records request, Alvarez & Marsal was the highest-scoring applicant out of three bidders. The selection committee remarked that the company “demonstrated extensive experience” in the areas of reform and was “well-versed in other initiatives that are ongoing in Montana.” Alvarez & Marsal was also the most expensive applicant, proposing a top hourly rate more than twice that of the contender with the next-highest score, the Public Consulting Group LLC. The state agreed to pay Alvarez & Marsal the price it requested: $632.50 per hour for the contractor’s senior staff working on the project, $517.50 per hour for junior professionals, and $460 per hour for support staff. The contract is slated to expire in December 2025, with the opportunity for one-year extensions after that.

In earlier statements to MTFP and other news outlets, Ebelt, the health department spokesperson, said the range approved for the new contract is between $5 and $10 million. Payments, he said, will be funded by the $300 million allocated for system reforms.

Keenan did not balk at the rate of pay when asked about the contract by MTFP. Instead, he doubled down on the importance of investing in long-term reform, even if it involves up-front costs, in a September text message.

“It’ll be a bargain if we fix this problem,” Keenan said.

‘OUR LIST OF TO-DOS IS EXTREMELY LONG’In conversations with MTFP, lawmakers and many longtime health and human services experts oscillate between hope and pessimism about the potential of the “Future Generations” commission, the hiring of expensive contractors and Brereton’s leadership. Some question how the Gianforte administration can promise to build a strong future for mental health care and developmental disabilities as the health department is culling state Medicaid rolls in the nationwide redetermination process. Others are still bitter about the department’s proposed budget for paying Medicaid providers, a strategy occasionally described during the session by Caferro and others as a “10-foot rope for a 20-foot hole.”

Some health care groups and service providers agree with those points but ultimately describe the commission’s $300 million fund for future investments as the beginning of a much-needed chapter of change.

“I think Charlie has the best grasp on the behavioral health system that we’ve seen in a long time, and Adam [Meier] before him as well,” said Mary Windecker, director of the provider advocacy group Behavioral Health Alliance of Montana. “He gets it that there has to be a continuum. He understands what the problems are. Now, whether he, in his position, can fix all that? I don’t know.”

Other lobbyists, providers and lawmakers, some with much longer resumes than Brereton, are cynical. They remember glossy reports and strategic plans of decades past examining the shortcomings of Montana’s behavioral health system. They say those documents, also written by high-end consultants, have failed to materialize into real change.

Fitzpatrick, the Republican lawmaker from Anaconda, doubts that the commission itself will produce meaningful reform ideas, despite the best intentions of its members. He believes the final proposals sent to the governor’s office will be those conceived by Alvarez & Marsal and supported by Brereton.

“Alvarez & Marsal is driving this train,” Fitzpatrick said. “I don’t have much personal criticism in the way of Mr. Brereton. I think he’s a very smart guy, he’s a very polished guy. But I don’t think he has the management experience and the life experience to handle this thing without significant help. And that help is not coming from inside Montana.”

Speaking to MTFP in September, Brereton denied that any hired consultants are “telling us what to do.” He also pushed back against the critique that the health department has “pre-baked” recommendations for how to spend the money earmarked for reform.

“Nothing could be further from the truth,” he said. The commission’s role, he continued, is an integral part of sussing out the right investments.

“We will take commission feedback under serious consideration, and when we agree with the feedback that’s provided, the initiatives and the recommendations that go to the governor will reflect the commission’s input,” Brereton said. “It’s collaborative in nature. Our department could not do this without the commission. I mean, it’s an all-hands-on-deck exercise.”

Despite the strong disagreements that arose during the 2023 Legislature, Brereton said he does not foresee a fork in the road where commission members disagree about how to spend funds or pursue new policies. If a schism develops, he said, the department will “work aggressively to find a middle ground and come to a consensus.”

Some health care providers, advocacy groups and lawmakers point out that the proposals delivered to the governor’s desk will be an early mile marker in a much longer process toward change. Buildings and programs can take years to construct, they say, and even longer to determine whether any particular part of an expansive and interlocking system is working the way it should.

“That’s where the rubber meets the road. It’s not what you conceptually design in a committee. It’s when you actually start to implement it that it gets really hard,” Fitzpatrick said. He and many other observers park their forward-looking musings at the same place. “The question is, will Mr. Brereton still be around to see how this thing goes, or will he go off and apply for a job in another state?”

The department director has at least a partial answer.

“I don’t know where I’ll be in 10 years. I hope to still be in Montana,” Brereton said. For now, he said, he remains “laser-focused” on the department, managing his team and the work ahead. “Our list of to-dos is extremely long.”

When it comes to the future of Montana’s behavioral health care and developmental disabilities systems, Brereton’s vision of success sounds simultaneously simple and impossibly grand.

“In 10 years, I hope that they are robust,” Brereton said. “That Montanans who need access to services can access the appropriate services where they need it and when they need it.”