NATIONAL CONGRESS OF AMERICAN INDIANS

Welfare Reform Impacts on Tribal Social Services:
a National Forum
 

Executive Summary

Thursday, April 23, 1998
Doubletree Hotel Lloyd Center, Portland, OR
 

On Thursday, April 23, 1998, the National Congress of American Indians (NCAI) hosted the second in a series of national forums to discuss the impacts, options and concerns surrounding the implementation of welfare reform in Indian country.

Dr. Eddie Brown, the Director of the Kathryn M. Buder Center for American Indian Studies and the Associate Dean for Community Affairs at the George Warren Brown School of Social Work, a component of Washington University in St. Louis, served as moderator for the five panel discussions. Dr. Brown presented Raymond T. Burke (Wish Lau Tu La'tin), of the Confederated Tribes of the Umatilla Indian Reservation, who provided the invocation. Afterwards, Dr. Brown introduced NCAI President and Jamestown S'Klallam Chairman W. Ron Allen, who welcomed the forum attendees.

President Allen spoke about the overwhelming number of issues that Indian tribal communities must face on a daily basis- threats to tribal sovereignty; threats to natural resources; threats to religious, cultural, and tribal traditions; and threats to the health and well-being of Indian people. All of these issues are priorities for Indian tribes. Tribes are challenged to focus on and gain perspectives on each of these issues. In the arena of welfare reform, tribal communities are faced with a variety of complex and interactive issues which must methodically be examined for viable solutions. Framing a dialogue about welfare reform options, concerns, and impacts ultimately serves to strengthen tribal governments, tribal nations, and tribal families.

Panel 1: Housing and Transportation

The first panel addressed housing and transportation issues. Descent housing is crucial for individuals, particularly single mothers with children, who are attempting to transition from welfare to work. Daniel Goff, Director of Housing for the North West Office of Native American Programs within the U.S. Department of Housing and Urban Development (HUD) addressed tribal opportunities to meet housing needs on reservations through newly enacted legislation, the Native American Self Determination and Housing Assistance Act (NAHASDA). NAHASDA gives tribal governments, rather than tribal housing authorities, control of their housing program. Under NAHASDA, tribal governments are eligible to receive an entitlement grant that offers them broad discretion over how housing dollars are best spent.

HUD also offers other grants which may be useful to tribes in meeting their housing needs; these include: Indian Community Development Block Grants, Tribal Opportunity Program (TOPS) grants, and drug elimination grants. Tribes are also eligible to administer Family Self-Sufficiency Programs, whereby the tribe contracts with individual families to provide needed support services. Families that fulfill the obligations of their contract by paying rent in a timely manner, making use of support services, etc. receive financial assistance in transitioning into a new house, starting a new business, or other investments they may be interested in making.

Leroy Bingham, President of Tribal Planning Services, highlighted the fundamental change in Indian housing policy that is encoded in NAHASDA. Prior to NAHASDA, housing grants were awarded on a competitive basis. Housing programs were distinct from other social and support services that were provided in a more integrated fashion. Because of the previous funding mechanism, tribes could not count on consistent funding; they could not formulate comprehensive strategies. NAHASDA offers tribes guaranteed funding- year after year- as long as they submit a housing plan and all of the necessary documentation.

NAHASDA authorized $600 million in Indian housing for FY 1998, an increase of $150 million from FY 1997. Due to the consistency of funding, tribal housing programs can finally become an integral part of the tribal strategy for resolving issues of families on welfare. Because of the options that NAHASDA offers, tribes can utilize HUD dollars more effectively by integrating programs and providing more comprehensive services. Tribal governments can set their own priorities, policies, and procedures; they can devise a program that is significantly different from anything else they have ever done. They can think outside of the box. Of course, far greater funding levels are needed in order to meet tribal housing needs, so tribal governments are still required to be extremely creative in designing and customizing their housing programs.

Doug Burnie, Welfare to Work Coordinator for the Federal Transit Authority, noted that according to DHHS' Administration for Children and Families, only 6% of welfare recipients own automobiles. The estimated worth of these automobiles, between $600 and $700, indicates that they are not very reliable. In short, most welfare recipients are dependent on public transportation. Unfortunately, transportation was not initially recognized as a significant barrier in moving welfare recipients into the workforce. Both in rural and urban areas, the basic problem is the mismatch between where the people are and where the jobs are. The majority of job growth is occurring in the suburbs, which severely lacks adequate public transportation. Furthermore, entry level jobs which welfare recipients may be able to obtain, often occur in shifts. Workers who are employed late at night or on weekends will also face a lack of transportation.

Unfortunately, most agencies tend to think that a transportation subsidy will solve the problem. A subsidy is useless if there is no transportation system available in the first place. DHHS and DOL have ensured that both the annual $16 billion for TANF programs and the $3 billion over the next two years for Welfare to Work programs can be used not only to support and individuals' transportation needs but also, to actually create transportation service systems. The reauthorization of highway and mass transit programs (called " The Intermodal Transportation Efficiency Act of 1991," or ISTEA) is attempting to add dollars to assist low income individuals and welfare recipients in receiving transportation to access jobs and support services. These funds will be awarded through a competitive grant process, once an appropriation is made. Both the House and the Senate have reserved $150 million annually for these block grants.

Robert McKay, Chairman of the Cal/Trans Native American Advisory Committee for the State of California Department of Transportation, spoke specifically to the transportation situation in California. The State of California has instituted Metropolitan Planning Organizations (MPOs) and Rural Planning Transportation Agencies (RPTAs), which control approximately 75% of the transportation monies in California (the remaining 25% of funds are in state control). Tribes in California that have transportation concerns should determine which MPO/RPTA they fall into and apply to that MPO/ RPTA with their needs and suggested changes. All of the requests are compiled and each MPO/RPTA decides how their monies will best be spent. Unfortunately, Indian tribes are not represented on any of the California MPOs/RPTAs. ISTEA, which was enacted in 1991, attempted to make transportation planning a more participatory process. In this spirit, every MPO/RPTA should have developed a public participation process to formulate a community transportation plan. Community involvement in MPO/RPTA transportation plans has not always been enforced. If tribes have been left out of their regional transportation planning process, they may contact the Federal Transit Administration for assistance.

Mr. Evert Waller, Chairman of the Intertribal Transportation Association, lamented that the $150 million set aside for ISTEA will never be enough. He estimated that $450 million would be a good initial funding block. The Intertribal Transportation Association assists tribes in uniting and getting organized to get their share of transportation monies. Tribes need to start identifying their needs to advocate for funding necessary to meet those needs.

Panel 2: Addictions, Dependencies and Violence

The second panel discussion focused on the issue of Alcoholism and Substance Abuse. Dr. Marlene Echohawk, Director of the Office of Alcohol and Substance Abuse Programs within the DHHS' Indian Health Service, acknowledged that families dependent on welfare are often multi-problem families. Often alcohol and substance abuse are critical issues to be addressed before other issues and barriers can even be identified. All of the 400+ alcohol programs that IHS funds are tribally contracted. These alcohol programs and the ten regional youth treatment centers funded by IHS are estimated to be operating at a funding level of about 40% of need. More than half of the alcohol and substance abuse treatment need in Indian country is unfunded.

Anna Latimer, Executive Director of the National Association for Native American Children of Alcoholics, emphasized the necessity of integrating substance abuse treatment and prevention into supportive services provided to welfare recipients transitioning to work. Substance abuse treatment should be therapeutic and compassionate, rather than punitive in nature. There is great concern over the hasty overhaul of a welfare system that currently has many flaws. In attempt to rectify these obvious problems, however, there should be deliberate and well-planned attempts to avoid replacing the faulty system with a new system that continues to reinforce and perpetuate the financial and psychological demoralization of welfare recipients, who are primarily single mothers with children.

Some tribes, like Klamath, have well-established relationships between social service providers and alcohol and substance abuse treatment centers. Both the Klamath Tribe and the Southern California Tribal Chairman's Association have Tribal TANF programs that require substance abuse screening and/or testing as part of the application process. Although identifying substance abuse is a crucial step, the lack of funding for subsequent treatment poses a large barrier. TANF funds can be used to pay for drug testing, but not for counseling or treatment. Because IHS alcohol programs are tribally contracted, IHS has very few discretionary funds. Tribes may have to work with their state or network with other organizations to try and meet funding needs for alcohol and substance abuse programs.

Panel 3: Emergency Family Assistance and Health Care Needs

The third panel emphasized Emergency Assistance and Health Care Needs. John Bushman, Director of the DHHS' Division of Tribal Services, stated that under welfare reform, tribes are given an opportunity to run TANF programs and develop programs which can include a new form of emergency assistance. Twenty-two state TANF programs offer emergency assistance in the form of diversion payments, which are one-time payments to families in danger of going on TANF. Diversion payments can be used to get a car repaired, pay for child care, purchase clothes for a job interview, etc. These diversion payments, or emergency assistance, may vary from state to state. Tribes that administer a Tribal TANF program can integrate many services, such as housing, transportation, and emergency assistance, all under the umbrella of a TANF program; TANF funds may be expended on all of these support service needs.

Tribes need to be creative about putting together a program that will meet their needs. Welfare reform gives tribes the flexibility to design creative programs, and the Division of Tribal Services will work with tribes to get their TANF plans approved. The legislation (Pub. L. 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996) requires the Secretary of Health and Human Services to negotiate some of the statutory specifics of TANF with each tribal plan that is submitted. Because five tribes currently have pending TANF plans, it is estimated that by July 1^st, 150 tribes will be served by a Tribal TANF program. Although tribes do have some clear incentives to operate a Tribal TANF program, lack of sufficient funding is a strong disincentive. Mr. Bushman recommended that any tribe without a state match should not consider administering a Tribal TANF program.

Edie Adams, Child Welfare Specialist for the Bureau of Indian Affairs (BIA), told participants that the BIA does not have an emergency assistance program. She stated that a line item called "Miscellaneous Assistance" under the Welfare Assistance program is used to cover burials and natural disasters, but that there is no emergency assistance provided. The BIA is in the process of revising the regulations for their General Assistance Program. Tribes were asked to keep an eye out for them and to be sure to provide the BIA with comments, because the regulations do contain substantial revisions in attempting to work within welfare reform.

William Clark, Deputy Executive Director of Human Services for the Cherokee Nation, stated that the Cherokee Nation has not applied to administer its own TANF program because the State of Oklahoma could not provide the tribe with data that it needed for planning purposes; the tribe had no idea how many TANF recipients it would need to serve and no way to estimate what it would cost the tribe. It did not seem financially worthwhile for the tribe to administer a tribal TANF program. However, the Cherokee Nation has been running an integrated service program since 1996. With the involvement of church groups and corporate businesses, Cherokee Nation has been able to provide supplies and services to tribal families in need, who are ineligible for all other programs. They serve an estimated 400 people.

Bruce Greenstein, from the Health Care Financing Administration (HCFA), gave an overview of and explained recent changes to the Medicaid program. Medicaid provides health insurance for low income families, dependent children, the aged, blind, and disabled receiving SSI, pregnant women and children up to age 6, and low income children and families that came to the program after 1983. Because Medicaid is a state/federal partnership that is operated by the state, the program varies from state-to-state. Many changes to eligibility criteria for Medicaid were made in the 1980s. Welfare reform has compounded problems with enrolling eligible families and children by de-linking welfare assistance and health insurance.

Prior to welfare reform, families and children that were eligible for welfare were automatically eligible for Medicaid. Eligibility for welfare assistance no longer guarantees eligibility for Medicaid. States were also given discretion to reduce the income ceilings, making it more difficult for people to qualify for Medicaid; fortunately, none of the states have elected to do so. Welfare reform has not yet affected Medicaid as harshly as some analysts had originally thought, but in an economic downturn or, if outreach efforts continue to be ineffective, Medicaid programs could be dramatically affected. Currently, there are about three and a half million children who are qualified for Medicaid, but who are not enrolled in the program.

Sue Clain, Policy Analyst for HCFA, reminded the group that Congress failed in block granting the Medicaid program, but has recently initiated the new Children's Health Insurance Program (CHIP), which is block granted to states. There is a higher matching rate of federal dollars than there is for the Medicaid program, but there is a limit on the total amount of federal dollars a state can receive. The CHIP program offers states increased flexibility in the development and implementation of their program; states can (1) expand Medicaid, (2) develop a separate Children's Health Insurance Program (CHIP) or (3) use some combination of the two.

Tribes are not authorized to administer the CHIP program, but should be aware of their state CHIP plan for a number of reasons. First, according to the authorizing legislation (Pub. L. 105-33, the spending provisions of the Balanced Budget Act of 1997), states can vary the services within the state by geographic area. So far, states have not elected to vary the services they will provide. Second, state CHIP plans must specifically describe how they intend to ensure the provision of Child Health assistance to low-income Indian children. Third, in February 1998, DHHS sent a letter to all states requesting that they consult with tribes. A copy of this consultation request, in addition to a list of HCFA regional offices and HCFA American Indian and Alaska Native contacts are all on their website at: http://www.hcfa.gov. It is important for tribes to educate their state and federal policymakers about the unique status and culture of Indian communities. Commerce Committee, OMB, and White House staff need to visit Indian country to see first-hand what the needs and issues are and to see the capability that tribes have in currently operating a number of complex programs.

Mary Ann O'Neal, Chief of Mental Health and Social Service Programs with IHS, summarized some concerns about the impact of welfare reform on health care services. Originally concerns about access to health care centered around the de-linking of Medicaid from TANF; there was a question about whether individuals would follow up on their Medicaid eligibility. Another concern was the disproportionate risk that children face because their health care needs are largely preventative, and the reduced likelihood that Medicaid enrollment would be sought out for children, if such health benefits were not directly linked to financial assistance payments. The third concern was that reductions in welfare enrollment throughout the U.S. would produce a migration of Indian people to and from reservations and urban areas depending on job opportunities, medical needs, travel resources, and welfare benefit options.

Medicaid plays five significant roles in Indian health care: (1) Medicaid acts as an insurance program covering the cost of health care, (2) Medicaid acts as a source of revenue for IHS and tribally operated clinics and hospitals, (3) Medicaid acts as a purchaser of managed care products, thus reshaping the health care delivery system, (4) Medicaid assists low income elderly and disabled Indians in meeting premium and cost sharing obligations, and (5) Medicaid offers nursing home coverage and other long-term care services needed by frail, elderly, and disabled Indian people. Medicaid is a major source of revenue for Indian health facilities; in FY 1997, IHS and tribally operated facilities received about $187 million in Medicaid reimbursements, which is about 10% of the 1.8 billion appropriated for IHS and tribally operated health care services. Currently, about 25% of the IHS user population is enrolled in the Medicaid program. Medicaid enrollment and reimbursement is critical to Indian communities because, while IHS consists of appropriated programs (with capped expenditures), Medicaid remains an entitlement program, serving all who are eligible.

Dr. Edward Fox, Health Policy Analyst from the Northwest Portland Area Indian Health Board, reminded the group that it is impossible to move from welfare to work without good health and access to health care services, including preventative health care. In the Northwest, Medicaid reimbursement represents close to 20% of the health care services budget; it is crucial for tribes to monitor what is happening to Medicaid. In the northwest, tribes have worked with states to ensure that Indian families and individuals are not unfairly disenrolled from the Medicaid program that they rely on. The state of Washington promised the tribes that they would create a letter for recipients that explained that once recipients are no longer eligible for welfare, they may still be eligible for Medicaid. The state also promised to train their staff to ensure that persons ineligible for welfare would be made aware that they could still be Medicaid eligible. In states that have very stringent TANF programs, eligible persons may decide that its not even worth the effort to apply for and receive welfare. In this case, when people decide not to apply for welfare, they may also decide not to apply for Medicaid. Indian health programs suffer severe budget constraints and will receive lower reimbursements as eligible persons decide not to apply for Medicaid. It may be beneficial to tribes to get together and advocate that their state assign a Medicaid benefit specialist to their office.

Panel 4: Welfare of Children

The fourth panel addressed the issue of child support services. Julie Quaid, Director of the Early Childhood Education Department within the Education Branch of the Confederated Tribes of the Warm Springs Reservation, discussed the difficulty that they have had in funding their substitute care placements. When Warm Springs administered the Title IV-E program under a contract with the state of Oregon, the state did not offer, nor did the tribe volunteer, to match the federal dollars. After a year and a half of negotiations, the state has agreed to provide the match for the approximately 50 children per month that Warm Springs has in substitute care. The Grande Ronde tribe received a state match for federal IV-E dollars since they initially contracted with the state. They do have a capped matching amount that is equivalent to the funding required by substitute care of ten children, because originally the tribal need was only for ten kids. Since then, their substitute care placements have risen to about 60 kids; it's time to revisit the state match for Grande Ronde. The state of Oregon is offering to enter into a IV-E agreement with any tribe in state who chooses to run a IV-E program.

Terry Cross, Executive Director of the National Indian Child Welfare Association, pointed out the relationship between welfare reform and child abuse and neglect cases. In states that instituted welfare reform before it was federally mandated, child abuse and neglect rates went up as welfare rates went down. Incidents are predominantly neglect, although abuse does occur. Child neglect is often attributed to the pressure on single parent families and families living in poverty. Child neglect is also highly related to substance abuse. The Child Welfare League of America estimates that an extra 1 million children will enter the foster care system as a result of both welfare reform and the Adoption and Safe Families Act (ASFA). This estimate translates to about 35,000 new Indian children in foster care. Because a little over half the children are in urban areas, about 15,000 Indian kids in foster care will be in the tribal system.

Both ASFA and welfare reform are more punitive kinds of systems- with a strong anti-family mentality. Relative caregivers and grandparents, teen parents, and parents with children formerly receiving SSI will all be heavily impacted. Although we are recognizing the problems, we do not yet have the resources to intervene and keep families together. Because of mental health issues, drug and alcohol issues, and housing issues, reunification will be very difficult for a number of families. Families are already looking at how they are going to break up their family and plans on how they are going to place their children with other relatives. For the other relatives with already overcrowded homes, they are taking on more responsibility as a parent when they are already a grandparent or an uncle.

In introducing members of panel four who would speak to the issue of Child Support Enforcement, Dr. Brown, discussed the mandate for welfare recipients to establish the paternity of their children and to allow the state to seek child support on their behalf. In non-280 states (Pub. L. 280, 67 Stat. 588, 18 U.S.C. § 1161-62, 25 U.S.C. § 1321-22, 28 U.S.C. § 1360 (1953), the issue of enforcement of child support payments on reservations has just arisen. Tribes may administer their own Tribal Child Support Enforcement Program; they may choose to sign an agreement with their state to be served by the state program while they develop such a program of their own. Particularly as tribes take over TANF programs, they begin to see the savings to their program that might be possible by instituting Child Support Enforcement program. Because so many of our people are in poverty, however, it may be like squeezing blood from a turnip.

Sarah Coleen Sotomish, from the Economic Services Administration under the Department of Social and Human Services for the State of Washington, was impressed by the similarities between the Child Support Enforcement (CSE) program and the Medicaid program discussed in a previous panel. Both CSE and Medicaid are state/federal partnership programs that are jointly funded and administered by the states. The collection of child support has been mandated in the U.S. since 1976. Legislation, infrastructure funding, and technical assistance have been directed to states, while tribes have been largely ignored. States have been involved in basic CSE functions: establishment of paternity, location of non-custodial parents, establishing support obligations, establishing support amounts, enforcement of child support orders, and negotiating inter-state agreements.

Tribes need to become familiar with CSE programs so that they can affect legislation and direct the federal government in how CSE should be implemented on reservations. Tribal leaders, judges, attorneys, and social service staff need to be involved in the CSE consultations. In a state where tribes are served by a state TANF program, it may be to their advantage to operate a tribal CSE program because of the states' lack of understanding of tribal economies. States may set unrealistic child support orders. Tribes have the option to set their own schedules and regulations; they can use tribal customs and in-kind support. There is a great amount of controversy now of the reimbursement of child support funds to/from the state and to/from the tribe. Depending on who is running the TANF program and who is running the CSE program, there are questions about how the money ought to be distributed. Right now, because there are no regulations governing the distribution of child support funds, tribes and states are entering into individually negotiated agreements.

Jim Olsen, from the Office of Child Support Enforcement for the Minnesota Department of Human Services, emphasized two major provisions dealing with CSE. 42 U.S.C. 654-33 provides statutory authority for states and tribes to enter into government-to-government agreements for the purposes of CSE. 402 U.S.C. 655(F) allows the Secretary of DHHS to contract directly with tribes to provide child support services, bypassing the state; this is what the current consultations are addressing. DHHS must publish and finalize regulations governing the contracting of a tribe with the federal government to provide CSE. This CSE program is distinct from the TANF program; a tribe can administer either one or both programs. Contracting directly with the federal government may provide a tribe with increased flexibility, beyond that which the state is willing to give them. On the other hand, because some state/tribal agreements entail tribal access to state computer systems and data sharing, tribes may lose some opportunities by contracting with the federal government. Ultimately, these effects will not become clear until the distribution issues are settled. One of the most pressing issues is that of financial feasibility. States receive a 66% federal contribution; they match only 34% . In the case of tribal programs in which the state has contracted with the tribe, it is unclear who will cover the non-federal share of administration costs.

Klamath operates a tribal TANF program and has an agreement with the state of Oregon regarding CSE. In the TANF application process, the tribe collects all of the information necessary to determine the suitability of a child support order. The tribe refers the recipient to the Oregon state CSE program, where the state is responsible for establishing the order and collecting the monies. The state remits the collected child support orders to the tribe, who utilizes the collected dollars to continue to operate their TANF program and pay out cash assistance.

John Bushman pointed out that CSE is paramount for Indian families in that once a family transitions from being on TANF to being self-sufficient or having a job and being employed, the child support order continues to be in effect. This source of income, support from the non-custodial parent, is very important in helping a family become self-sufficient.

Panel 5: Welfare of Elders

The fifth panel focused on the Welfare of Elders. Dr. Brown contextualized the welfare of elders panel by reminding the group that as single parent mothers go into urban areas to look for work, many leave their young children at home to be cared for by extended family or grandparents.

Dave Baldridge, Executive Director of the National Indian Council on Aging (NICOA), was particularly concerned about the rates of elder abuse (which are largely unknown) and the inability of the criminal justice system to deal with elder abuse. A recent DOJ report emphasized that law enforcement in Indian country fails to meet even the most basic public safety needs. The report states that we need 4,000 new Indian police officers just to keep pace with rural America. Obviously, such an overburdened system is not capable of effectively serving Indian elders who are victims of silent abuse. Elder abuse is frequently financial abuse or neglect rather than physical abuse; because this abuse is not violent, it is overwhelmed by far more visible violent crime issues. Eighty percent of elders are afraid of abuse. Day-care centers on the reservations might help to reduce elder abuse. Tribal programs under Title VII of the Older Americans Act have the potential to direct $5 million to tribes to help with elder protective activities. Also, Title VI sites could be better utilized as vehicles to educate elders about abuse and give them a safe place to talk.

Dr. Yvonne Jackson, Director of the Office of American Indian, Alaskan Native, and Native Hawaiian Programs under the Administration on Aging at DHHS, talked about the unplanned consequence of welfare reform- that as young people leave the reservation to find jobs, elders will be left without caregivers. Ninety-five percent of elder care in Indian communities is done by family members; ninety-nine point five percent of that care is unpaid. The migration of younger Indian individuals will leave elders with the added stress of parenting young children (grandchildren and relatives) while leaving them without caregivers. Most likely, grandparents over the age of 65 will not be subject to welfare work requirements and time limits. Grandparents and children under the age of 65, however, will potentially be subject to these requirements. Many of our relative caregivers in Indian country do fall into this category of being less than 65 years old. Tribes who operate their own TANF program have the option to exempt grandparents and relative caregivers from these requirements; other tribes must negotiate these issues with their states.

Rebecca Baca, Managed Care Consultant from NICOA, mentioned the work that NICOA has done with funding from the W.K. Kellogg Foundation to help Indian elders understand and influence managed care and health related policy. Problems with nutrition, transportation, housing, education, unemployment and health make improving access to quality health care difficult for Indian elders. The 1990 Census shows that 30% of Indian elders who reside in rural areas have no vehicle available to them; 34% have no telephone in their residence; and 24% speak English poorly. Health and welfare policies changes create a great deal of complication and confusion for elders.

NICOA is focusing on solution-oriented activities to address the concerns of elders. At conferences and forums, Indian elders, health care providers and key national state and legislative leadership are identifying pressing access and health related issues, determining how we can access and target good health care for Indian elders, identifying viable solutions to health issues and concerns, and encouraging and supporting collaborative solutions. Elders want comprehensive health care delivery that is sensitive to their cultural needs; adequate funding sources to obtain comprehensive services, including preventive and long-term care; educational training resources so they and their families can understand how to obtain the health care services that they need; and a role in creating the solutions to their health concerns. Existing programs (i.e., Medicaid, Medicare, Supplemental Security Income) often do not reach the Indian elders that need them. Welfare reform is placing added pressure on elders who resources are already limited.

Deborah Coteora, Policy Analyst with the Office of Medicaid Assistance Programs for the State of Oregon, uses quarterly tribal meetings to talk about tribal health care issues and concerns. One of the problems that has emerged through these meetings, is that tribes were confused about what health care services could be billed for and reimbursed. In short, there were many services that were covered by Medicaid that tribes felt they couldn't bill for. Now a process is being instituted whereby Medicaid Assistance Program staff are defining services that can be reimbursed. They will continue to use the same process to assist tribes in looking at other health care barriers to determine whether there are things that they just think they can't bill for or whether there are actual barriers that are preventing care.

Bruce Greenstein, from HCFA, discussed the interplay between Medicare and Medicaid in light of some changes made through the Balanced Budget Act of 1997. Some new programs were added that allow Medicaid to buy premiums and pay for some services associated with Medicare that are limited to those who have qualified with Medicare to begin with. Two new categories in Medicaid eligibility which allow Medicaid to pay for some Medicare expenses (i.e., premiums, co-pays, deductibles) are called Qualified Individual-1 (QI-1) and Qualified Individual-2 (QI-2). QI-1 covers individuals with incomes between 100% and 135% of the federal poverty level; once individuals are enrolled in QI-1, Medicaid will pay for the Medicare expenses. QI-2, for individuals with incomes between 135% and 175% of the poverty line, pays out a benefit of $1.07 a month, and is a result of Congress' insistence that no one should establish an increase in their Medicare premium rate because home health was switched from one budget to another. So far, only the state of Oregon has implemented QI-2. It is important that tribal social service organizations, tribal members, and people who have contact with the in-kind, non-traditional welfare stream encourage Indian elders to seek health care in the manner that it has been designed to be paid for- through Medicaid and Medicare.

Outreach to needy Indian individuals and families is critical. Outreach is only effective if accurate and timely information is provided. Information must be simple and understandable. The community, as well as the elders, must be educated to ensure that a support network is formed. Although Medicaid and Medicare enrollment rates vary widely by state, all states share abysmally low enrollment rates. Elders are a particularly hard group to reach because there is no typical pass-through area or program , like there is for families, and there is no natural way to catch individuals that may be eligible for these programs. Also, because QI-1 and QI-2 are capped allotments, it is important to get Indian elders enrolled which funds are still available.

Mary Ann O'Neal suggested an idea that is being considered in New Mexico. In order to provide appropriate care for elders as well as meet work participation rates under TANF, tribes are working with the state to develop a working relationship with community colleges or other nearby universities to get training for care providers and consider their caregiving activities as meeting work requirements. This serves to maintain family cohesiveness and to meet work requirements under TANF. Another forum participant commented that the state of Oregon has Senior Disabled Services, through which the caregiver can receive an orientation, be trained, be certified by the state as a care provider, and receive some money to care for their relative. John Bushman mentioned that another way to avoid evoking work requirements on grandparents caring for children is to create a child-only case, in which only the child receives cash assistance under TANF. Child-only cases, however, are considered counterproductive to the intent of the statute. Another participant in the forum stated that Oregon does case management and enforces work participation rates on a case-by-case basis. In each case, they consider what is feasible for that family. If work is not feasible, then the parent in the case is not asked to work. The family is only required to cooperate with the TANF program; the state may only require that the parent ensure that their child(ren) go to school. If the parent makes sure that the child(ren) are in school, they are cooperating with TANF and they will not be sanctioned.

In closing, Dr. Brown reminded the group of the resources that our Indian communities can draw upon. We have been running a variety of programs in the past- social service programs, child care programs, alcohol treatment programs; we run effective programs. Undeniably, we may not have adequate funding to administer an ideal program or even to meet our people's needs.

A researcher by the name of Fred Polack studied all of the great nations in the world throughout history in order to determine what made those nations great. He found that it wasn't nations with the most people or resources; he found the deciding factor that made a nation great was the idea of vision. He concluded by saying, "Nations with visions are powerfully enabled. Nations without vision are at risk." We can say the same about our own communities. Welfare reform clearly presents a formidable challenge. No one knows exactly how we will tackle that challenge. We must begin to build on the strengths in our communities and understand that if the solution is to come, it's going to come from within the communities.
 
 

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