WELFARE REFORM IMPACTS ON TRIBAL
SOCIAL SERVICES:
A NATIONAL FORUM
sponsored by the National Congress of American Indians

THURSDAY, APRIL 23,1998
DOUBLETREE HOTEL LLOYD CENTER
PORTLAND, OREGON

Transcription Highlights
C O N T E N T S
 

Introduction - Dr. Eddie Brown, Director, Kathryn M. Buder Center for American Indian Studies, Associate Dean for Community Affairs, George Warren Brown School of Social Work, Washington University, St. Louis, MO

Welcome - Ron Allen, President, National Congress of American Indians
 

Panel 1- Housing and Transportation

Daniel Goff, Director, North West Office of Native American Programs, Office of Housing and Urban Development

Leroy Bingham, President, Tribal Planning Services

D. Burnie, Coordinator, Welfare To Work, Federal Transit Administration. Robert McKay, Chairman, Cal/Trans Native American Advisory Committee, State of California Department of Transportation

Everet Waller, Chairman, Inter-Tribal Transportation Association
 

Panel 2 - Alcoholism and Substance Abuse

Marlene Echohawk, Director, Office of Alcohol and Substance Abuse
Anna Latimer, Executive Director, national Association for Native American Children of Alcoholics
 

Panel 3 - Emergency Assistance and Health Care Needs

John Bushman, Director, Division of Tribal Services, Office of Community Services, Administration for Children and Families (ADF/DHHS) Edie Adams, Child Welfare Specialist, Bureau of Indian Affairs, Department of Interior William Clark M.S., LPC, Deputy Executive Director of Human Services, Cherokee Nation

Bruce Greenstein /Sue Clain, Health Care Financing Administration, DHHS Mary Ann O'Neill, Chief, Mental Health and Social Services Programs, Indian Health Services/DHHS

Ed Fox, Health Policy Analyst, Northwest Portland Area Indian Health Board
 

Panel 4 - Child Support Services

Terry Cross, Executive Director, National Indian Child Welfare Association

Julie Quaid, Director, Early Childhood Education Department, Education Branch, Confederated Tribes of the Warm Springs Reservation

Sarah Sotomish, Economic Services Administration, Department of Social and Human Services, State of Washington

Jim Olsen, Office of Child Support Enforcement, Minnesota Department of Human Services
 

Panel 5 -Welfare of Elders

Dave Baldridge, Executive Director, National Indian Council on Aging Yvonne Jackson, Ph.D., Director, Office for American Indian, Alaskan Native and Native Hawaiian Programs, Administration on Aging, DHHS Rebecca Baca, Managed Care Consultant, National Indian Council on Aging

Deborah Corteora, Policy Analyst, Office of Medical Assistance Programs, State of Oregon

Bruce Greenstein, Health Care Financing Administration, DHHS
 
 
 

P R O C E E D I N G S
MODERATOR: Today we are going to be addressing the tribal support services necessary to move people from welfare to work. Ron, we thank you for your support through the National Congress of American Indians and we welcome you here to this meeting to give us a welcome.

MR. ALLEN: I think that if I was going to try to get a single concept across to you as we engage in the discussion today on the various topics of welfare reform, that is the concept of focus and perspective.

We talked about the need for development of our programs for our children and for our families. We talked about the need to strengthen and enhance the overall government-to-government capacities and relationships and cooperation between the tribes and the local governments and the state governments in implementing this program and making sure that the Federal Government is owning up to their responsibilities to Indian country who is often thought of, dealt with, I should say, as an afterthought policy with regard to Indian issues.

And last but not least, at our last forum we talked about the need for data, the need for data to understand exactly what's going on in our communities and a way to measure our needs, our progress, are we getting further behind, are we properly fighting the odds against the frustrating conditions imposed on our communities.

What are we going to talk about today? We've got housing and transportation, we have the need to deal with the alcohol and drug abuse problems in our communities, we have the need to be able to figure out how we are going to provide better services for our children in providing for their needs. We have the problems and needs of strengthening our communities and our relationship with our elders.

MODERATOR: We have to ask ourselves why is social services, family and children so important. You cannot have a strong tribe or a nation unless you have strong communities.

Federal Government has been at work taking a look at how they can coordinate and understand what resources are out there and how the communication and coordination can improve.

Transportation: How is that impacting welfare reform and moving people from welfare to work.

On tribal housing: We often hear that up to 25 percent of American Indians live in undeveloped housing with no running water, electricity, compared to 5 percent for the rest of the nation.

MR. GOFF: We have recently enacted new legislation known as NAHASDA, the Native American Housing Assistance and Self Determination Act, which provides much, much greater flexibility to tribal governments.

First of all, it gives control of the housing program on the reservations to the tribes rather than the housing authorities unless the tribe decides that they want to continue that relationship with the Housing Authority. But it does give the options to tribal leaders on how the money is to be spent.

Leaking roofs, running water, that sort of thing, those are all things that can be addressed using the NAHASDA grants. Previously it was always new construction, modernization on HUD constructed homes, and it was pretty limited.

Now, it's a much broader kind of an opportunity where existing housing can be renovated, improvements can be made. But these are decisions that the local governments have to make. They have to set the priorities as to where they think their housing dollars are best spent. NAHASDA is an entitlement grant. So essentially everybody who provides HUD with an Indian housing plan will be eligible for a grant that's put together on a formula basis.

There are other grants that are available through HUD, Indian Community Development block grants, that can very definitely be used in the area of economic development which is something I know that you are all very much interested in. There are Tribal Opportunity Program (TOPS) grants; there are drug elimination grants.

Recently we had a program called Family Self- Sufficiency . I think now under NAHASDA, with the flexibility you have, it might be something to definitely look at. The basis of that program was that the housing entity or the tribe entered into a contract with a family that said they would provide these services, they would provide these educational opportunities, and the family would agree that they would pay their rent, they would be responsible, they would do all of the things that they were expected to do to make this transition.

As a reward the rent that was paid by the family was put into escrow during this period. And if they successfully lived up to their contract at the end of that period, they were given the money as kind of a start-up to either get them a place of their own or get them started in business or whatever they needed the money for.

MR. BINGHAM: NAHASDA is a real earth-shaking event in Indian country. We can talk about it in the kind of clinical generic terms, we have this new act and it does these things, but it really is a fundamental change in terms of how Indian housing is part of the tools that we need to bring about change in our communities.

Leo Cummings and I have been leading the charge the last few years in consolidating our employment and training programs together and finding smarter ways to work. We are not getting anymore money in Indian country for the most part, so we have got to find better ways to use what we have.

We have been involved in 477 plans (Pub. L. 102-477) to help us make that happen on the employment and training side. Now tribal housing with NAHASDA finally gives us a program that, as Mr. Goff suggested, comes under tribal control. Indian housing has always been separate and apart from what the tribes were doing.

The HUD people, the housing people, the folks at the Indian Housing authorities, they worked with HUD almost exclusively, and it was a competitive environment. I would write a grant, this gentleman would write a grant, this gentleman would write a grant, and we would go compete against each other, and we would beat each other's brains out because only one of us was going to get money this year. Yet all three of our communities had these terrific housing needs as Dr. Brown pointed out.

We didn't come here to be grant managers. That's one of the things I realized after I got into the business. I was a CETA director and a JTPA director. And it occurred to me over a period of time that what we were doing was working out of these little boxes, and everybody was sort of doing their own thing, and we were never able to pull it together in terms of one comprehensive strategy.

NAHASDA finally allows us to do that. It gives the tribes the ability to take control and to finally bring housing under some sort of tribal direction. And it's a block grant now. That's a very critical piece. Every tribe that submits a plan is going to get money. All you have to do is fill out the forms and get in the documents. So now tribes can actually sit down with some certainty that year after year they are going to see Indian housing money.

We managed to do that with Indian child welfare a few years ago. Now we are doing it with Indian housing. There are $600 million in Indian housing this year. That's up $150 million from the year before. And the tribes have control. They can either run the programs themselves or they can authorize their existing housing authorities to do it.

But by taking those housing programs and talking amongst people like yourselves, the social workers, the people in employment and training, housing and the folks that are out there working in the communities, these programs can finally become an integral part of what the tribal strategy is for resolving the issues for these families on welfare.

So NAHASDA really does give us a tremendous opportunity if you use it. There are a alot of ways that you can take those HUD dollars and integrate it with the other things that you are doing and really help develop a successful strategy in dealing with welfare reform.

MODERATOR: A lot of the support services that we have been talking about, whether it's child care, housing or whatever, almost seems to pit the working poor against the people on welfare.

The question I have in housing is: if you are committed to move people from welfare to work, and you have people who are qualified and are able to be on TANF, what is the commitment to make sure or to prioritize those individuals for housing to help them move? Is that a flexibility that the tribe has to set that prioritization?

MR. BINGHAM: It's absolutely a tribal decision now. Tribes now have the ability to create their own policies and procedures. So, for example, if it's a tribal decision to move all of the TANF families or welfare families to the top of the list, or move all the elders to the top of the list, they have that ability now to create that policy.

MODERATOR: So with the creativity that we are talking about, we know we still don't have enough money and the tribe is expected to be very, very creative so that greater pressure is put at the tribal level, the tribal council and tribal leadership of how do we take what money we have and put it to work in the most creative way of providing quality shelter for Indian people. But clearly it goes back to the tribal government.

Some of our researchers said that transportation was mentioned as one of the main barriers to putting TANF recipients back to work. There is no public transportation.

People in remote areas are isolated. They need assistance to get to the state office. The tribe owns a bus but there is nothing to help people get to work. Their available transportation is not adequate for maintaining employment.

MR. BURNIE: At the Department of Transportation we agree for the last year and a half to two years we have been working very hard to make sure that as welfare reform moves forward transportation isn't a forgotten issue.

According to the Administration for Children and Family, they have been saying that only about 6 percent of welfare recipients own automobiles, and that the automobiles that they own are worth between $600 and $700. So that means they are not all that reliable.

So we are going to have to depend on public transportation and some kind of specialized transportation to get people to support services and to jobs if we are going to be successful with welfare reform.

At the beginning of welfare reform, transportation wasn't very high on the agenda.The States did not anticipate that transportation would be a problem. And of the TANF plans that have been submitted, very few of them mentioned transportation. But we know we are not going to be able to succeed if we can't get people to jobs.

Now, what we have said the basic problems were in terms of transportation is where the jobs are and where people are. This is both true in the inner city and in the rural areas. Most of the jobs in this country are growing in the suburbs and yet it has some of the poorest connections vis-a-vis public transportation.

Also, the jobs tend to take place, entry level jobs, not necessarily during the nine to five work hours. They are often during shift work. So that means they are going to be late at night or on weekends. And guess what happens to the public transportation we have late at night and on the weekends.

Now, this is a very difficult problem and it's easy to get discouraged about it. But one of the things we have been trying to do is get that on the agenda both with the TANF programs and the Department of Labor with their $3 billion dollar welfare-to-work program. Because typically people on the human services side, the way they tend to think about the problem is, here is a subsidy, here is money for the transportation. But it does you no good to have a subsidy if the transportation isn't there in the first place.

So we work very hard with DOL and DHHS to make sure that those TANF dollars and those welfare-to-work dollars, the $16 billion a year for TANF and the $3 billion over the next two years for welfare-to-work can be used not only to support individuals' transportation but actually to create transportation.

In addition to that many of you may have heard that the highway and mass transit programs are being reauthorized right now. It's called ISTEA. The Congress is looking at those programs right now and re-authorizing them. As part of that, the administration has proposed a program to put additional dollars out there to help make those connections to connect low income people as well as welfare recipients to jobs and support services. And the Senate has passed that bill, and the House has passed that bill. And each of them have reserved $150 million annually for that.

MR. McKAY: What I will be addressing today mainly would be dealing specifically with California and the problems that CALTRAN sees in California.

Within the State of California we have an MPO and RPTAs. Metropolitan Planning Organization and Rural Training -- Rural Planning -- anyway, RPTAs. The RPTAs and the MPOs are the ones that control 75 percent of transportation monies that comes into California.

All the tribal governments within the State of California, if they have a plan or they want to get some type of input on how transportation is going to affect their people getting from point A to point B, point A being where they live, point B being where they want to go to work with this welfare reform, they basically have to get a hold of the MPOs or the RPTAs, whichever one is in their district.

And one of the best ways to do is to find out what district you are in, CALTRAN's district, and who is the administrator of that district, the district director, and find out what MPO do I fall into to go apply for the type of changes and let the MPO know the needs that we are experiencing here in California. And you have to be put on a list.

CALTRAN itself is just now in the process of developing a proposal to submit to Department of Labor and probably to Department of Transportation when it comes into reality if they do get any part of that glass of $150 million. We will probably be writing a proposal on how we want to do this. So what we need also is from the tribes in California to put input into their district directors and into the deputy director.

MODERATOR: Right now our major way of getting transportation money or something is working through the state unless we were to approach the ISTEA situation and begin to talk about direct funding.

MR. McKAY: ISTEA, I don't know how it works in the rest of the states, but in California ISTEA has a certain amount that is line item for the Bureau of Indian Affairs. And then they have the rest of that gone to the Department of Transportation which 75 percent of the monies that come into California through gas taxes or the Department of Transportation goes out to the MPOs and RPTAs. And they control what is going to be used towards -- the department itself only has 25 percent, and that's to run all the state workers, CALTRAN's workers, and different type of programs that they want funded.

The RPTAs and the MPOs do have access to submitting proposals for a portion of that 25 percent that CALTRAN has.

MODERATOR: Now, will the ISTEA legislation change that, or is that still going to continue to work that way?

MR. McKAY: As was said earlier, under ISTEA most of the money goes out either to the states or the metropolitan areas. If it's a metropolitan area it goes to a planning organization that represents the area decision maker. I don't see any apparent reason that a tribe couldn't be part of that area decision making.

That metropolitan planning agency takes those dollars and then allocates the dollars either for highway projects or for mass transit projects. That is still the basic way in which the program will work under the reauthorization as well.

MR. BURNIE: Let me answer a little bit more on that one. The man from Department of Transportation is talking about the money going out to the tribes or out to the MPOs and the MPOs represent the tribes. Nowhere in the United States, that we know of, maybe it does exist, that an Indian tribal government sits on an MPO. And the MPOs are the ones that allocate where the dollars go.

MS. HILL: Is there a specific requirement that the Federal Government can put to the MPOs that they have consultation with Indian tribes or Native Americans.

MR. BURNIE: When ISTEA first passed -- and by the way, ISTEA stands for the Intermodel Transportation Efficiency Act of 1991 -- it had very, very strong -- it took the public involvement process and it stepped it up a notch.

The idea is that there should be no plan, transportation plan, without full community involvement, including Native Americans. The enforcement of that has probably been very uneven. I mean, as every MPO has striven to develop a public participation process, in developing that process they are to be going out within their communities, including the Indian members of that community, and developing that public participation process.

It isn't something they are supposed to do on their own but to do collectively. And periodically they are to revisit that process and try to improve upon that process. So that's one opportunity.

If you find in your area that that's not taking place, that you are not having the kind of input that you should have in developing your transportation plan, then I think the proper step is to come to our organization, the federal organization, the Federal Transit Administration.

And of course we have got regional offices all over the country, including in San Francisco and California, and try to make that case that we can be supportive of you in trying to make sure that public participation provides for that kind of consultation because ISTEA went to a more participatory process.

MR. YAZA: My question is, those tribes that do have current transportation programs, such as we do, we have a Navajo Transit System in existence, a public transportation system, these programs that already are in existence, would they be able to apply immediately for these funds and access these dollars so that we can provide transportation services for our clients in the TANF programs?

MR. BURNIE: Yes. The new access to jobs program is not to support the services that are already there because those connections are already being made. The intent of the access to jobs program, and of course it's not -- the reauthorization of ISTEA isn't complete yet, and then the appropriations will have to take place, so we will have to find out how much money actually ends up in that pot.

But in terms of those dollars, as I said, they are meant for new services. But existing transportation systems are probably in a very good position to put a plan together and come in for those dollars. Probably in a much better position for those that don't have any kind of plan.

What we have to do is really figure out how this program is going to work. So I am saying we are at a very good juncture now. We know that the dollars are going to be out there because it's both in the House and the Senate. We can be meeting with you and getting your input and figuring out how this program ought to be administered so it takes into account the concerns that you have.

MODERATOR: Gentlemen, 30 seconds for a wrap-up statement and then we are going to move on.

MR. McKAY: California is a 209 state and it says that no preferential treatment, they voted that in last year. So that eliminates a lot of the different types of programs that we can go for as even American Indians, even though we do have a special relationship with the Federal Government. Thank you.

MR. BINGHAM: We have to look past the obvious. And I think one of the things we need to do is quit looking for somebody to bring money to help us. And I think more than anything else we need to find those creative solutions ourselves. It is part of our tradition. Creativity is part of our tradition.

MR. GOFF: Continuing on the same theme. The ball is in your court now. You guys, you know what you need. You have the expertise on your reservations to do it. Now you have the flexibility through NAHASDA to use those monies in a way that's going to be more effective for your people.

MR. BURNIE: On the theme of do it now and not wait, your TANF dollars and those welfare to work dollars can be used for transportation. And there will be guidance coming out to that effect probably within the next couple of weeks. So you can start to use those dollars.

And when the access to jobs program comes down the line those TANF dollars and those welfare to work dollars can be matched with our dollars so that you can have 100 percent federal funding for those transportation services that you need. And the automobile can be part of that. You can use your TANF and welfare to work dollars to do those things with the automobile as well.
 
 

PANEL 2

MODERATOR: One of the things we are finding that's so critical is that many of our TANF clients come to the TANF office, whether it's state or tribal, and come with multiple problems, and one of those is alcoholism and substance abuse.

DR. ECHOHAWK: Alcohol and substance abuse, as we are all aware, have been defined as the No. 1 problem within Native American communities. And given that fact, we know that we face a big challenge related to the high correlation of alcohol abuse with violence in our communities. And just to name a few of those behaviors we are talking about child abuse, domestic violence, suicide, homicide, gangs, assaults, et cetera.

Many of our households, as we heard earlier, are single parents with children who are on welfare. Who cares for the children while the mothers are to receive training or to get into the job market? What is the quality of that care?

What alcohol treatment programs are available for families seeking help? What is the quality of the programs? If the mother has no transportation, how does she get to a training resource center and/or a job?

How do we answer these questions in a manner worthy of us as Native Americans and worthy of our children?

So I didn't time myself on that. Those are questions I have posed for our own programs. We have over 400 programs that are 638. You are all aware of that in this area. All of our alcohol programs are 638.

We have ten youth regional treatment centers. And, again, we heard concerns of funding earlier for other programs that we have. Within the alcohol programs it has been estimated we are funded at 40 percent of our needs. So that means 60 percent of the needs that we have to address a serious problem, that we have called our most serious problem. We need to have that extra funding to be able to provide for those services.

MS. LADAMER: It's good to be here to talk about the impact of welfare reform on our women and our children. It's absolutely imperative that we integrate and look at substance abuse treatment and especially prevention when we are looking at welfare reform.

In looking at welfare reform there is an overall failure to address the impact of substance abuse on poverty and lack of education and the individual's ability to become self-sufficient. And I want us to look at the words that we use in terms of helping our families because even on welfare we are very self-sufficient.

The requirements, in terms of when we are working with the families, need to be therapeutic, they need to be compassionate and not punitive in nature.

It is absolutely imperative, necessary, must happen that we support a public policy that will not penalize the women who suffer from addiction and have had little or no real opportunities in the past to empower themselves through education, through work, or other resources including child care, transportation, housing, that we have been talking about in our haste to overhaul the system that has many flaws, and they are obvious.

We should avoid replacing it with a system that's going to reinforce and continue to perpetuate a financial and psychological demoralization, to bring those feelings down about who we are as women and mothers and life givers; that we don't perpetuate that, make it worse on our women and children who are affected by alcohol and drug dependents and domestic violence.

MODERATOR: You know, Anna and Marlene, I don't think any of us would argue with what you have said. It's very clear. But the reality is how do we make that work? How do we recognize individuals coming to TANF, or coming into the state program or tribal program, who may be at risk, or who may have alcohol and substance abuse, if we don't ask, or if we don't have some type of family assessment in place when the individuals come in and we assume people are going to work and we have no understanding the kind of family problems they are having, the kind of individual problems they are having, et cetera? What do you do? How do you get them? Let's say that they do. Are you set up or organized that there is a good strong coordination between what you are trying to do and what the alcoholism program in the community is trying to do?

A PARTICIPANT: Yes, we do. We have a very good working relationship both with our tribal health organization, Klamath Tribal Health and Family Services, and with the organization that does the drug and alcohol treatment for Klamath tribal members. That's Klamath Alcohol and Drug Abuse or KADA. We will then make a written referral to them for treatment services.

We also, on occasion, do pre-drug testing as well. If we feel like the family's issues are such that they are using, and that is one of the main barriers, we do drug screening. We refer them over to a local agency for urinalysis. The first time they get a urinalysis we don't sanction them. That's our baseline if they come back positive for whatever substance they have been using.

And then at that point in time we do testing after that. Actually, the program that does our drug and alcohol treatment does it for us, and they will do random testing. It is a requirement for them to be in the program to do random testing.

MS. HILL: The Southern California Tribal Chairman's Association require substance abuse testing as part of the application process. And if they are found to be positive the plan also requires them to go into treatment or counseling.

And what we are finding out is that there is no funding available for this. The TANF program can pay for the testing but not for the counseling, not for the treatment. And so we have this plan. And the tribal chairs, the tribal leaders that are part of our consortium plan are very supportive of this because this is the first time that we have ever had any leverage in the community to require them to get counseling or treatment.

DR. ECHOHAWK: You are talking about in California specifically.

MS. HILL: No. I am talking on behalf of all the tribes because if they run the TANF programs and the individual is having problems with substance abuse then they are going to be asking you for additional funding.

DR. ECHOHAWK: Okay. The way it is set up now with funding, all the monies go out to the tribes. We have very, very little discretionary funds to speak of at all. So the money is out there. And, again, this is where we are talking about networking. Possibly the states can -- you will have resources there. But, again, what are the priorities with --
 

PANEL 3

MODERATOR: We are going to be talking first on emergency assistance. And we have with us in that regard Mr. John Bushman who is the director of the Division of Tribal Services of the Office of Community Services in the ACF/DHHS.

We also have Ms. Edie Adams, Child Welfare Specialist with the Bureau of Indian Affairs, Department of Interior; Mr. Bill Clark, who is the deputy executive director of Human Services for the Cherokee Nation. Will be talking on Medicaid in just a bit.

I think it's important to understand -- emergency assistance. We talked this morning about the tremendous need, particularly when we are talking about single parent mothers with children and the kind of situations and the needs that are out there.

MR. BUSHMAN: Welfare reform legislation it has given us the opportunity, us in Indian country, to run TANF programs in lieu of the state and design and develop our own kinds of programs which can include a new form of emergency assistance.

Briefly, let me tell you now that 22 states in the country do have now under the guise of TANF something akin to emergency assistance. They call it diversion payments. And what those diversion payments are intended to do, if a family comes in and seeks assistance and they are in danger of going on TANF, but all they need is a helping hand, maybe they need their car repaired, or maybe a mother needs some child care, or she needs some clothes to go for job interviews, these states will provide diversion payments to this family and allow them to get the kinds of services that would divert them away from TANF.

One of the problems with emergency assistance over the long term is under the new TANF rules -- again, states are defining it differently so there is no one set definition. And that goes for tribes as well. But the basic premise is that it's a continual ongoing form of payment.

Then time limits and work participation requirements kick in. So in order to avoid that states are providing this one-time diversion payment, and that way the time limits and the work requirements don't kick in on the families seeking this assistance, and they can move on.

We can develop emergency assistance programs. We can bring in housing programs, transportation programs.

Those tribes that are running TANF can take their TANF dollars and use it for transportation. They can use it for housing. They can bring in all these other programs under this TANF umbrella. What it's going to necessitate, and I leave you with nothing else than this, is to be creative, to think outside of your normal realm because any rule that we have ever known about how public assistance was delivered in the past, there are no rules.

Tribes, like the states, are given the opportunity, the flexibility to design programs that work for their particular communities and their particular service populations. We will work with them to get their plans approved. We have been very successful. We now have five plans pending which will represent about 150 tribes in the country probably by July 1 will be running TANF.

MS. ADAMS: We don't have emergency assistance in the Bureau of Indian Affairs under social services. We do have a line item miscellaneous assistance. And when that breaks down it means a burial assistance that is to follow county guidelines.

The Bureau of Indian Affairs is in the process of revising the general assistance regulations. They have been in draft for about eight months.

So I guess the heads up to all the tribes is you need to be aware and keep in touch of when those regulations are coming out because we had worked to make some major changes in them. We are trying to work with the new welfare reform.

MODERATOR: If I am on TANF and I get sanctioned, state TANF, can I be expected to be covered by the tribal social services program?

MS. ADAMS: The way we have written it when we left was that it will be depending on why you were terminated. Also it depends on the tribes because in our new regulations the tribes have the opportunity to revise their program.

They can take over social services, and they can determine their own eligibility, their own dollar amount. And the bottom line of that, which I will warn you of, is that there will be no money increase.
 

MODERATOR: Has the Cherokee Nation applied to run TANF.

MR. CLARK: No, sir.

MODERATOR: Why not? I am surprised because you seem to have had a long term organization to provide social services. One would think the Cherokee Nation would be at the forefront in applying to run their own TANF program.

MR. CLARKE: One of the things that the state could not do, they could not give me the numbers of people that they had served during that period that we were allowed to use. So it just didn't seem financially worthwhile to us to go into that.

MODERATOR: You know, it's interesting. John Bushman said, hey, guys, that money that you received on TANF, if you negotiated you can use that. That doesn't necessarily have to be spent on monthly stipend or a monthly allowance. It could be used for transportation, it could be used for a number of things.

However, that sounds good except when you start, if you don't necessarily have the state match, or even if you have the state match, if you take money from that you are taking money from already at a loss or a negative. Maybe 477 is the answer. Maybe how you begin to organize and put your money together.

MR. BUSHMAN: Change also needs to occur at the federal level. The thing about TANF is that -- this is one of the reasons why TANF was passed. I mean, we had experts saying that the welfare system was broken, and then we had states saying let us fix it ourselves without the mandates of the federal government. You are telling us what to do all the time. So Congress passed the law and the president signed it.

The TANF legislation, the federal government has virtually no say-so in how the states design their programs. For the tribes the legislation requires the Secretary of Health and Human Services to negotiate some of the statutory specifics of TANF with each tribe that comes in.

But our position, and the 12 that plans have been approved thus far, as long as the tribes propose and keep -- propose a plan in keeping with the statute, the tribes can design programs any way they want to do them and they will be approved.

Now, in answer to your last question about where are the regulations. The regulations have been approved by the Department of Interior. They are now at the Office of Management and Budget for review. They have 90 days -- they can take up to 90 days to review them. I fully expect when I get back to Washington next week that I will begin talking with OMB. And I hope that that process is merely an education process.

MR. BUSHMAN: I just want to quickly touch on this funding issue. I do want to say that tribes have only been authorized to operate this program since last July. So the fact that we only have 12 plans approved thus far is not indicative of the interest out there.

My recommendation to any tribe would be to not run TANF without state funding. And it's certainly in the state's interest to provide that funding. In fairness to the states a lot of these legislatures are bi-annual legislatures, and they are only now having to deal with the issues of state match for tribal governments.

The states have been struggling mightily to implement their own TANF programs let alone start thinking about, well, what are we going to do about the tribes. But there are certainly many arguments that can and are being made to the states for the tribes as to why they should give that money to the tribes.

The 12 tribal TANF plans that have been approved thus far are all different from one another. Like I have said, we leave it to the tribes to define their work activities so there is innovation there.

The kinds of services that each of the 12 plans are going to approve are all different, so there is a lot of innovation there. It's hard to generalize about any one plan because it's up to each tribe to determine what their unique circumstances and needs are and then develop and design programs that will meet those needs.

MODERATOR: Let's move on now to the impacts of Medicaid.

MR. GREENSTEIN: Medicaid is a state federal partnership that's operated by each state. So the Medicaid program is something that is going to vary across state lines. They determine who is eligible, the scope and amount of services that are offered. The state gets generally about 60 percent back on the dollar from the Federal Government which varies across states, differing by the income level in each state.

Medicaid basically covers people from low income families, dependent children, the aged, blind, the disabled receiving SSI, pregnant women and children up to age six, and low income children and families that came in the program after 1983.

During the 1980s there were a lot of new changes made to Medicaid eligibility which complicated matters. And then welfare reform came around and complicated matters much further for Medicaid. Basically what welfare reform did was de-link the two programs.

Previously if you were eligible for cash assistance you were definitely eligible for Medicaid. That's now not the case. States were also given discretion to reduce the income ceilings consequently making it more difficult for people to qualify for Medicaid. And they also increased the amount that the states could look back on resources for individuals therefore making it more difficult to qualify for Medicaid.

But the case has been that states haven't been moving in that direction. In fact in the most recent study roughly half of the states are continuing to use the same application for cash assistance and Medicaid. None of the states have made it more difficult to get on Medicaid.

My only concerns here are that while so far the wrath of welfare reform hasn't affected Medicaid as drastically as some analysts had originally suspected, things to look out for will be an economic downturn, ineffective outreach efforts. Because there are now people that would be otherwise qualified for Medicaid, but since there is not a link with cash benefits a lot of times they don't know. There is roughly three and a half million kids out there now qualified but are not enrolled.

MS. CLAIN: What I do, is I focus on Indian health issues in Medicaid and Medicare legislation and in the Children's Health Insurance Program (CHIP).

First of all you will recall that Congress tried to turn the Medicaid program into a block grant, to limit the amount of federal money, to do away with the entitlement for individuals to Medicaid. Congress did not succeed in that. But what they did not succeed in doing to the Medicaid program they did succeed in doing in creating the Children's Health Insurance Program.

Unlike Medicaid, CHIP is a block grant. The entitlement goes to the states. States are entitled to receive federal funds if they submit a plan that meets the requirements in the law. There is no individual entitlement to Children's Health Insurance.

The funding is a higher federal match for states than was the case under Medicaid, but there is a limit on the total amount of federal dollars. Under Medicaid there is no limit to how much money a state can draw down as long as they come up with their state match for covered services for covered individuals. There is an absolute limit on the number of federal dollars that will go to the CHIP program.

There is even more flexibility for states in the CHIP program than there is under Medicaid. There is a corresponding lack or reduction in the amount of federal leverage we have in telling them how to operate their programs.

Another thing that's different between CHIP and Medicaid that you should look out for is that the legislation permits a state to vary the services within the state by geographic area. As soon as I saw that in the legislation I started to worry that some states, which shall remain nameless, might come in and try and write out the reservation areas or provide lesser services in reservation areas.

So far we have not seen that happen. We have not seen any state plan come in, yet, that varies by geographic area. But that is possible, and it's something you need to be watching for closely.

Another one of the limitations in CHIP is that only the 50 states, the District of Columbia and the Territories can submit a plan, receive federal funding and operate a CHIP program. Tribes did try, as the legislation was going through, for a tribal set-aside. That was not successful.

There is perhaps the need to have Commerce Committee staff, OMB, White House staff and others make some visits to Indian country, learn first- hand what your needs are, what your issues are, and the capability that tribes have in operating a number of complex programs.

Those of us in the administration saw direct results from that. As the president was developing his Medicaid reform proposal there were provisions that were put in there at the department level, that were attempts to benefit Indian country, that would not have stayed in previous OMB eras. And there were things that OMB itself put in even beyond what the department did, to benefit Indian people. It made a difference.

I can't highlight the importance of educating enough. Policy Makers need to be educated about the unique cultures of American Indians.

Quickly, the CHIP program has a couple of other opportunities and limits you need to be aware of. States have the choice between setting up a separate insurance program and Medicaid expansion or some combination of the two. Important for Indian country, if they choose the Medicaid expansion route, there is no cost sharing for services to the children.

Two other things. The state plan for CHIP must include a description of procedures to be used to ensure the provision of Child Health assistance to targeted low income kids who are Indians. This does not require consultation, per se, but it makes good sense for a state to consult.

And that's why partly in response to NIHB and NCAI resolutions, and partly in response to that legislative provision, the department sent out a letter in February requesting states to consult with tribes, tribal organizations, urban Indian organizations, IHS units and others on their development of the CHIP plan. That's available on our HCFA web site and includes a list of HCFA regional office, American Indian and Alaskan native contacts, and CHIP regional office contacts.

MS. O'NEILL: Originally some of the concerns from the welfare reform and its impact was primarily due to the de-linking of Medicaid from TANF that Bruce spoke to earlier. Some of these concerns were around the question of whether individuals were going to be following up on their Medicaid eligibility. Even if they were eligible, once their cash assistance to them had been severed through the loss of AFDC or SSI payments.

The other concern was the disproportionate risk that was being faced by children because their health needs are primarily preventive in nature. And because of that there was the thought that there would be less likelihood that Medicaid enrollment would be sought out for them.

The third was that there was a concern that the reductions in the welfare enrollment throughout the U.S. under the Act would produce migration of Indian families between reservation and city environments depending upon job opportunities, medical crisis, travel resources and welfare benefit options by state.

Now, hopefully, Ed can speak to some of that, Ed Fox. At our level we have not been able to really see the extent to which any of these concerns have been realized, and it still needs to be determined.

Very briefly, I will go over five significant roles that Medicaid plays for Native American health care. The first is that the Medicaid program acts as an insurance program covering physician, hospital, and other basic health care services for eligible Native Americans, especially families with children.

Second, Medicaid acts as a source, a revenue for IHS and tribally operated clinics and hospitals.

Third, it acts as a purchaser of managed care products. And in this manner Medicaid is reshaping the health care delivery system for many Native Americans and other under-served low income populations.

Fourth, Medicaid also assists low income elderly and disabled Indians who are eligible for Medicaid in meeting their premium and cost sharing obligations.

And finally, Medicaid offers coverage for nursing home and other long term care services needed by frail, elderly and disabled Native Americans.

I would like to stress the role that Medicaid plays as a source of revenue for Native American health facilities. In Fiscal Year '97 IHS and tribally operated facilities received about $187 million in Medicaid reimbursement which is about 10 percent of the 1.8 billion which is appropriated for IHS and tribally operated health services. The Medicaid reimbursements for '96 was 154 million, and for '95 it was 108 million. So that clearly you can see how important the revenue from Medicaid is for the Indian health care delivery system.

The amounts from the last three fiscal years are the result of collections from about 25 percent of the IHS user population which is enrolled in the Medicaid program. This percent of the Medicaid population within the IHS user population has remained relatively the same within those last three years.

The increased amounts of Medicaid reimbursements during the same period is largely due to the change in the method of computing reimbursement rates and the improvement in the IHS and tribal billing for Medicaid services.

MS. O'NEILL: One of the things to remember is IHS, as an appropriated program, is not an entitlement program, but Medicaid is. When the funding for a given year is consumed the provisional purchase of service must be postponed until the next fiscal year when new appropriations become available. This is partly evident in the case of contract health services for which waiting lists for non-emergency services are not uncommon in the areas as many of you already know.

In contrast, though, Medicaid is an entitlement program. This creates some uneven levels of appropriations from the two sources of funding for health care, IHS, and for Medicaid. And the tribes in IHS really need to be more aware of that.

Also, under the Balanced Budget Act the growth and spending and appropriated programs such as IHS has become tightly constrained and will be for the next five years due to the across the board caps that IHS and the other domestic programs have been subjugated to.

IHS funding is not likely to grow nearly as fast as federal spending on an entitlement program like Medicaid which is projected to grow around 7 percent per years. The result is that the revenue for Medicaid is likely to become increasingly important to many IHS tribal and urban programs to help relieve the appropriated funding limitations over the next few years.

Lastly, I would like to emphasize that we all need better data in order to help us with our planning, and I would like to recommend that tribes consider in the context -- I will go ahead and make the recommendations even though Sue was very careful about that from her speech.

MR. FOX: One of the keys to moving from welfare to work is to have health care services. There isn't a group in the United States that should be more well positioned to move from welfare to work, in terms of having health care, than American Indians. Our board works hard to get a fair appropriation for the Indian Health Service budget. All Indian people should have what they need in terms of health care, that key element of moving from welfare to work.

Unfortunately, the appropriation isn't there. We need Medicaid resources. In the northwest it's not just 10 percent, it's probably 20 percent of our budgets for Indian health programs. It's important for us to monitor what happens to Medicaid, and we have done that, and we have done it in each of our quarterly meetings. And in Washington we talk about it at almost every meeting of the Indian Health Commission.

And we have acted to tell state Medicaid directors that we don't want to have a negative impact. We want them to train their work force properly so they let people know that they are probably still eligible for Medicaid even if they are no longer eligible for welfare services.

The evidence that there are fewer eligibles is again anecdotal. Northwest Tribal Social Service and Health Programs staff have reported that there are aspects of TANF programs in our three states that appear to have reduced the number of people.

Well, how would this happen? We heard the story at a meeting at the Health Commission in January where someone said they heard that when a person is told by letter that they are no longer eligible for welfare services, that they are automatically disenrolled for Medicaid.

The state Medicaid people at the meeting thought that could be true. They didn't know. And we still haven't had a final determination to actually think that is true. Well, they need to stop doing that. They need to stop automatically disenrolling people from Medicaid when they are no longer eligible for welfare services.

And they promised us a letter and some training of their staff so that people know that you may still be eligible for Medicaid even though you are no longer eligible for welfare services. That will be more important two years into Idaho's TANF plan when everyone is off welfare unless the tribes run their own programs, and in five years in the other two states.

Another reason people may be disenrolled, imagine you are in Idaho. The grant is $276. There is a two-year time limit. You have to sign an individual responsibility contract. You don't have transportation to get to the jobs anyway, and you are sitting there thinking should I even apply for this, is it worth the effort.

Unfortunately, a decision to not sign up for welfare may mean also not signing up for Medicaid. Our Indian health programs will not get the money that we need to maintain our programs because of that. So that's the two ways I think that we may be seeing an impact of welfare reform on Medicaid.

We have people that are being told they are no longer eligible for welfare services and perhaps being automatically disenrolled for Medicaid and not told you need to reapply for Medicaid.

And we also have people sitting there in an office in a not very nice environment being told that we have all these conditions for you to get welfare services, and they are getting up and walking out the door. And they are not signing up for Medicaid. So we are going lose people that way.

PARTICIPANT: The Medicaid eligibility can be dependent on only what's in the law which is income and assets. So these extraneous tests, if it were dedicated to job or something related to the family then that wouldn't be allowed to be counted in the eligibility determination. the programs and we wanted to continue to do it. And then we were able to do the TANF the way we wanted to do it.

So that is the question. That does work well for us because we do still send up our own people for MA and for our TANF at the same time so they don't get lost. And we do it not only for our own people, but we do it for all the people in our two townships that we have.

The other thing that we are doing working with the state is they are now looking at having our Medicaid benefits specialist to work in our different clinics. IHS and the different directors in our state have gotten together and asked the state if we can have that specialist in our clinic. And we have applied for that now. So we will be able to do that hopefully.

A PARTICIPANT: Helen Spencer, Legal Services. I am real concerned about the EPSDT, the Early Periodic Screening Detection whatever. I know the rate in Washington State. And Washington State usually takes every Medicaid option -- very, very good about waivers and options and things. But it's fourth from the bottom in the states on EPSDT enrollment. There is just a lot of children that are eligible under that program, and a lot of them have to be Indian kids that aren't getting enrolled.

And my other issue is I really worry that the managed care programs that have Indian children in their managed care aren't doing the periodic testing and aren't doing the good screening and aren't being really held to the fire to really fully give those children all of the health care benefits that they are entitled to.
 
 

PANEL 4

JULIE QUAID: The problem in Oregon is when we started off with the 4E contract the state did not volunteer, nor did Warm Springs offer, on the match issue. And as we all know, matching 4E is an expensive proposition.

Warm Springs has about 50 kids in care at any one time in substitute care, and you multiply that on just an average of $100 a kid per month times 50 times 12, and we have come up with a lot of money.

I can say that I have been working on that particular issue for almost a year and a half now, and as of last month the Oregon legislative assembly has approved the matched fund for the Warm Springs Tribe. So we have moved in that direction.

We have always made a match for Grande Ronde. We had a cap on it of 10 children because when we originally struck that deal that was their need. The Grande Ronde people will tell you their needs expanded to about 60 kids now, so it is time to revisit that to look at match for Grande Ronde.

The offer is on the table for every tribe in Oregon to enter into a four-year agreement with us if they choose to.

MODERATOR: Okay. As Terry is coming up to the mike it's interesting to note we looked at research in Arizona, Terry, and we see that GA over the last few years has decreased. But almost in direct comparison to that, child neglect and abuse cases have increased. Perhaps, maybe, you could mention some response to that.

TERRY CROSS: Right. Ed, that's consistent with what's happened in welfare reform in those states that had it before this act was passed. In those states that had welfare reform, prior to welfare reform at the federal level, the child abuse neglect rates went up as the welfare rates went down. So we know that there is a problem in that. Partly that's due to the pressure on single parent families and families living in poverty. Those are the families who are often most likely to neglect.

And in Indian country it is primarily an issue of neglect rather than abuse though abuse still is a problem in our communities. The highest percentage of the people who get into trouble with the system are those where the factors are neglect.

And the research also shows that the neglect of children seems to have little to do with parenting knowledge. It has everything to do with poverty and substance abuse so that when people are overwhelmed and -- it's the depth of poverty, not just income that gets our families in trouble.

It's when you don't have housing or transportation or furniture or your plumbing doesn't work. And all of those things add up so that people aren't able to meet the needs of their kids.

We don't know yet in so many areas what the long-range impact of welfare reform is going to be for the well-being of our kids. And this is an area I want to emphasize. We are talking about child abuse, child neglect, child sexual abuse, abandonment, adoption, foster care, all of those things that have to do with the dependent needs of children.

The Child Welfare League of America estimates that there will be a million new children in the foster care system as a result of both welfare reform and the Adoption and Safe Families Act.

If you take the numbers, as we have done at our association -- I am with the National Indian Child Welfare Association and we try to watch what these things mean in a larger picture. We are about 1 percent of the population but we are about 3½ percent of the foster care population nationwide.

A million new children in care translates into about 35,000 new Indian children in care. And we know that just over half of those are in urban areas. So at the tribal level we are talking about 15,000 new kids in care. I don't see on the horizon new dollars coming in any of the budgets to respond to that need if it in fact develops or is developing out there. And it's one of the things we need to be able to do is to track those numbers.

You can imagine what that's going to do at the state level and tribal level with not only 15,000 new kids in care at the tribal level, but another 15,000 EQUI (phonetic) notices coming to your tribes that you need to respond to and determine whether kids are members of your tribe and whether you are going to intervene in those cases.

I think the most recent evidence of that is the Adoption and Safe Families Act that is showing us that families -- it's a much more punitive kind of system. What the Adoption and Safe Families Act is saying that child protection, child safety and permanency is paramount above the family reunification and family preservation.

We are basically seeing termination plans started at the moment a child comes into care, so parental rights termination is going to happen much earlier in the process.

We really encourage people to read that Adoption and Safe Families Act and look at it pretty carefully as to how it is going to impact tribes. And while there is no specific language in that act about tribes, other than the extension of the family preservation funding, it will impact any tribe that has 4B funding, Part 1 or Part 2, the child welfare funding or the family preservation funding, or anyone who has a 4E agreement will be impacted by the Adoption and Safe Families Act.

Specifically one of the things we are concerned about with welfare reform is the stress on relative care givers and grandparents and how those cases are counted, and if grandparents are taking care of kids and receiving welfare. If the unit that's counted as only the child, we understand that it's not as great an impact. But if the unit is the family, then grandparents may have to go to work under the rules of TANF. So we are going to watch that.

Kinship homes. Especially workers will have greater task and case management in order to make sure that eligible children are receiving the benefits and their families are receiving the benefits under TANF.

There is going to be struggle and pressure between parenting versus work. We estimate that 11 percent of Indian children out there have some form of serious emotional disturbance or serious disability. Those children, we are concerned about the pressure of whether or not you take care of your kids, who needs extra attention, or whether you go to work.

The high percentage of teen parents in our communities is a concern. Teen parents are required to live under adult supervision. Many of those teen parents are also victims of sexual abuse and may be forced into the foster care system if they are going to get any benefit because they can't reside at home.

SSI was cut back for many children. Parents may have to relinquish custody of their children just to get services for their children.

The last issue is child support and whether or not the involvement of parents, especially abusive parents, how we are going to get them to participate in the child support enforcement, and whether or not that's going to raise issues and problems around visitation, access to children, and how well protected that information is about where children and families reside.

MODERATOR: Terry, I am kind of interested because I do agree. If the kind of stress we are talking about is going to be placed on those TANF mothers, the chances of child abuse or neglect are dramatically going to increase.

And statistics have shown that through the Indian Child Welfare Act 4E and a number of the other agreements on foster care and developing of foster care, we have been very efficient in the Indian community of removing children and putting them in foster care and haven't spent too much time about how do we preserve the family, how do we keep the family together.

So in some ways we have actually done more placement in foster care, even though it's been with other Indian homes, than when the state was doing it. The question is what's going to happen in the Indian community to keep families together rather than to support foster care or adoption.

TERRY CROSS: I think it's a legitimate concern. On the one hand you could expect the number of placements to go up as tribes take on responsibility for protecting our own children and we begin to own the problems of child abuse and neglect.

The good side of that is that we are recognizing that there are problems and we are intervening. The negative side of that is that we haven't had the resources to keep families together and to intervene at a time and at a level to prevent those problems rather than having them erupt into more serious problems or we haven't been able to get kids back home quickly enough.

Nationwide, family preservation and family support services are under attack. I don't know if you have read the Adoption and Safe Families Act, but there no longer is a federal statute covering family preservation and family support. That language was done away with under the Adoption and Safe Families Act.

Even though the program of 4B, Part 2, was extended for three additional years, it is no longer called family preservation, family support. It's got another -- services to safe families or something like that. and it added three programs. It added support for adoptive parents, it added family reunification as a service. And there was one more. I think it's pre-adoption services.

So what they are doing is saying that the money that had been set aside before for family preservation, family support, you can now use it for adoption and permanency things, and we are not even going to call this piece of legislation family support and family preservation anymore. We are going to reduce the extension to three years instead of five. And my guess is in the year 2001, unless there are significant changes in our legislative process we will not have family preservation dollars.

The larger mentality, I think, is an anti-family mentality. The Personal Responsibility Act is aimed at that same mentality.

I would like to share also the concerns that we already have. Many families are refusing to be on TANF because they have been sanctioned already. They are not able to meet those needs because of the barriers, the mental health issues. Either it's alcohol and drug issues that they are not able to deal with, not able to get proper treatment and follow-up afterwards. So reunification is very difficult for these 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, their homes are already overcrowded and taking on more responsibility as a parent when they are a grandparent or an uncle

We have grandparents refusing to go for TANF assistance or No Parent In The Home grants because they have to go to work, they have to get training, and they are already disabled, and they can't deal with that. And they are not able to force the kids to stay in school. Now, if you can't keep your kids in school then you are sanctioned also and you are taken off of the program.

So we have many barriers we are dealing with, just to get the people on TANF and keep them on TANF. Without the assistance of dealing with the barriers it's going to be impossible for us to make sure we are successful in making them self-sufficient.

MODERATOR: Thank you, Terry. Appreciate that very much.

Let's move on to the area of child support enforcement. Child support enforcement is something that the tribes have not been heavily involved in in the past as we all see here in the future. Basically child support enforcement is the fact that if you have individuals living on the reservation, single parent mothers or single parent spouse with children whose spouse is capable of paying child support, the question is you have got to know who that person is and how do you track them down to enforce the payment of child support. And in order to do that you have got to have a very rigorous state system to track individuals.

So part of the 4D program was added to the welfare reform which basically said if you are going to receive TANF services you must declare who the parent or the father of your children -- in most cases it's the father -- so that that person can be tracked down to make sure or to ensure that they are paying child support.

The question then came on some reservations that are non-280 of the jurisdictional issue of people going on to enforce American Indian people to pay child support. So under the law, as it stands now, welfare reform law states that realizing that the child support enforcement is a rigorous kind of system to be put in place, they have indicated that tribes are able to develop their own. But as an interim step that they might want to sign an agreement with the state that would allow that collection of child support enforcement on reservation.

This is again a relatively new program. But as people are beginning to look at it, particularly as tribes take over TANF program, they can begin to see the possible savings that might be to them in getting child support enforcement payments. However, it's kind of hard -- what do they say, squeezing blood from a turnip or whatever? Most of our people in poverty it's going to be very difficult for them to pay child support.

So there is a lot of issues out there. But a lot of tribes now are beginning to look at how do we get involved in that, how do we make sure that we work, if not in coordination with the state, then how do we begin to develop our own.

MS. SOTOMISH: Okay. For me that's going to be an awful big challenge, so I am going to give it a shot. We do have handouts at the back and there is a page in there that addresses the tribal child support provisions in the new legislation and also in the Balance Budget Act.

And there is also an action transmittal that's in draft form that addresses cooperative arrangements or cooperative agreements with states and tribes. And there is a couple of other documents there that are helpful in taking a look at child support enforcement in Indian country.

It was very interesting to sit through a lot of the other presentations today because I saw such a trend in a linkage with child support kind of just tying into some of the other programs. And I think that tribes really need to think about this and think about it very seriously.

Child support is tying into TANF, child support is tying into tribal jobs, child support is tying into Medicaid and Indian Health Service.

And it was interesting to see the similarities between child support and Medicaid. There is the state federal partnership. Child support is still an entitlement under the new legislation. The state has to have a state plan. There is a requirement for a state match in order to pull down federal funds, and the federal funds are uncapped. I just found that was really interesting.

In 1976 child support was mandated by the Federal Government to all tribes in the United States. In order to qualify for public assistance monies, AFDC, every state had to have a child support program.

And since then, and that's been quite a few years, there has been a lot of legislation that's provided the states with incentive monies, technical assistance monies, monies for computers, and along with that a lot of rules and regulations and requirements about what we do, how we do it, when we do it, why we do it. And so there has just been a development of some very, very comprehensive child support laws that relate to the state and the Federal Government.

Tribes were, up until recently, practically and for all purposes ignored in the legislation. And so it's been difficult to figure out how the tribes fit into this process.

With this legislation I can see that there is kind of a glimmer of hope, a glimmer, that there is going to be some opportunities for tribes. I am going to just say one thing. Right now it's going to be critical for tribes to think about how they want to do child support. They need to get up to speed on how it's done now so that they can tell the Federal Government how not to do it.

And we need tribal leaders, we need judges and attorneys, and we need everyone here, social services people, to think about it and take some time to prepare some testimony and get involved in some tribal consultation that's going on. Actually there is one session going on right now in Albuquerque.

Some of our basic functions are locate, paternity, support obligations, establishing support obligations, support amounts, enforcement and interstate. The state has been involved in the arena because the tribes, I think there is a void there.

And I am hoping that tribes can involve themselves in this process and kind of take over control, establish their own programs, their own schedules, and do their own thing. I think there are some benefits to that.

I am going to let Jim fill in the rest of the blanks in terms of a little bit more information on the legislation and also the tribal consultation.

MODERATOR: Sara, let me ask you a question before you leave. If the tribe didn't take over TANF, and the state was administering TANF, what is the payoff, or what would be a reason that the tribe would want to have a child support enforcement program of their own? What's the benefit to the tribe, if any?

MS. SOTOMISH: So your question is, the state has a TANF program --

MODERATOR: State operated.

MS. SOTOMISH: - and the tribe doesn't?

MODERATOR: And the tribe doesn't. What would be the incentive for the tribe to get into child support enforcement?

MS. SOTOMISH: One of the issues that we have seen is that the state does do the child support. They do paternity, they do setting the obligation and the amount, and they attempt to enforce especially those assets that are off the reservation.

The concerns that tribes have is that the state doesn't understand tribal economies. They are setting unreasonable child support orders. I think the tribes, the ones that we have got within in Washington, are saying we can do it better, and we can have our own schedule, we can have our own laws, we can do it according to the way we want to do it.

We don't have to set the amount according to what the state schedule is, and we can use our tribal custom, in-kind support, so we don't have to just set money value to the child support amount. There is a lot more flexibility for the tribes to get involved to take over.

MODERATOR: If they collect that child support enforcement do they have to pay it back to the state to supplant the TANF, or can they keep it as part of their own?

MS. SOTOMISH: If they have a tribal TANF program -- actually there isn't a good answer to that right now. It's been very controversial especially in Oregon. Some of the Klamath members here are laughing.

That's another good reason to come to the tribal consultation and to tell the Federal Government how you think money ought to be distributed because right now if a tribe has a TANF program the state is collecting, the assignments to the state, there is a lot of variables in here.

It's very likely that the states are going to be required to collect and send the Federal Government its fair share.

Right now there is kind of a whole harmless process going on where the tribes and the states have made agreements already, there is no regulations, there is no rules, and the Federal Government is holding the state harmless.

But if you look at the history of child support the Federal Government really implemented child support to kind of recoup expenses. We talk about requiring parents to be responsible. But the other half is that the Federal Government was spending a lot of money on AFDC. And child support is a very good way of bringing money back into the treasury when they required the assignment for child support and for the states to collect it.

MODERATOR: Okay, Mr. Jim Olsen is going to tell us how it works in Minnesota.

MR. Olsen: Actually just to expand what Sara Colleen just said because I disagree with her on remitting the monies back to the feds on tribal TANF program. So I think it's unclear all the way around on how distribution will occur under a tribal TANF program. And it will be interesting to see how it plays out.

I am just going to briefly talk about two provisions within the law that as Sara Colleen talked about, do address tribes and child support. One provision in 42 U.S.C. 654-33, which provides for the ability for states and tribes to enter into government to government agreements for purposes of child support enforcement, which could mean either the state collecting child support on behalf of the tribal TANF program or the tribe collecting on behalf of the state program or any which way you want to look at it.

It's interesting because Sara Colleen and tribes within the State of Washington have been going down this road for quite some time. But it will be interesting to see how the feds come out, how flexible they are going to be in that area.

The other provision which is in 402 U.S.C. 655(F), which allows the Secretary of DHHS to contract directly what tribes provide child support services, bypassing the state, that is where the consultations are occurring right now. There is one going on in Albuquerque right now. There is one in Portland, what, in May?

A PARTICIPANT: May 22nd.

MR. Olsen: May 22nd. And then there is one at a future date in Nashville, Tennessee.

That relationship in the child support arena, as I read law, cannot occur until the Secretary does publish and finalize regulations. So it's a wide open game right now. As Sara Colleen said, it's vitally important to get input because nothing is going to happen until those regulations are out in that area,

As Dr. Brown kind of alluded, there is a whole lot of variables. This is totally separate from tribal TANF programs as far as tribes running or not running child support programs. But you can get into a whole bunch of mishmash if the tribe is running the TANF program, not running the child support program, or the state is running the child support program and the TANF program.

I think this is all going to be playing out for quite some time. And as I have said, some people are kind of making a lot of this up as we go along because we have not had a whole lot of directions from the feds at this point.

But I did want to just quickly say as of about three days ago Minnesota at least now does have the legislative authority to financially participate with tribes located in Minnesota in the TANF program. We needed legislation to do that. So as I hear, some states were choosing not to participate for whatever very strange reason.

MODERATOR: Jim, let me ask you the question before you sit down. If I were a TANF administered tribal program, what are the benefits if I would want to have a child support program in place in agreement with the state? What's the payoff for the tribe who wants to run their own TANF?

MR. Olsen: Under these provisions there is good and bad about, in my mind I guess, under each provision. There may be more flexibility on a tribe that may go directly to the Federal Government to start a child support program. That's unclear to me at this point.

On the other hand they may lose opportunities. Again, Minnesota, part of our legislation allows the Department of Human Services to share access to all its statewide computer systems to put in child support or TANF system. Or tribes may want to utilize parts or all of those systems. That may be lost if a tribe creates a direct relationship with the Federal Government.

I think until they deal with some of the distribution issues, I don't know that I can fully answer your question. In other words, where child support collections go and who is going to fund -- again, which is another important part, by the way -- the consultation. If a tribe enters into an agreement with the state, the states get 66 percent federal participation to run those programs. The rest of the money is paid for by the states.

You have got that issue to deal with, if a tribe enters into an agreement with the state who is going to cover the non-federal share of administering the program. I think it's unclear and there is opinions all over the place on what will happen when the Secretary issues regulations on the direct relationship.

I don't think they are bound by that 66 percent FP that states are in their relationship with the feds. So I think that's still an open question to be dealt with. Theoretically in my mind it could be 100 percent federal funding of the administration of the child support program going down that road.

MODERATOR: Who are you looking for? Aren't you Klamath? Tell us just a little bit how it's working there because it would be interesting. Klamath runs their own TANF program, and you also run a child support with an agreement with the State of Oregon? Or how do you do it?

A PARTICIPANT: Okay. We are developing an agreement, the State of Oregon. Right here is the Oregon child support contact for us. I want to embarrass her while I have the chance.

We do child support enforcement for our TANF program, and they could do the collections for us. I think that, Celeste (phonetic), is the same type of arrangement. We refer the cases. We have the clients fill out the necessary paperwork that we developed to collect information, questionnaires on child support, and refer them over to the State of Oregon to do our child support enforcement collection for us. And they in turn pass 100 percent of the monies collected back to us.

There is no federal match because that whole harmless thing they were talking about earlier. At this point in time the Federal Government has backed off on doing it. Although there was a glitch at the beginning of the year which has been since worked out to some extent.

That's essentially it in a nutshell is that we collect the information, we turn it over to the state, the state collects for us, sends the checks back to us, and we use that then to pay down the amount of money we have been actually paying out in benefits.

It creates revenue for the program and it's kind of been the lifesaver for us because we have had to spend so much money out in expenditures just for our TANF clients. Our case loads, when we took it on, jumped way above what we were expecting them to and what the state identified in 1994. So without that money coming in we would have been really hard-pressed to continue the program.

MR. BUSHMAN: I have a question for the gentleman from Minnesota. I didn't hear your comment because I was buried back here in the back. But I think I heard you say that the State of Minnesota is now going to contribute to tribal TANF state funds?

MR. Olsen: We have the legislative authority now to do it and we have authority to do that. About three days ago the governor signed the legislation.

MR. McKAY; My name is Bob McKay. I am from California. Just a little brief background. California, actually the majority of the tribes live off of their reservations. When we are talking about this TANF are we talking about tribal members that live on the federally recognized land? Because in California at least 50 to 60 percent of the tribal members live off of their reservation.

MR. BUSHMAN: You define your service area in your plan. You don't have to stick to the reservation. You can define your service area and where you are going to serve. For example, Celeste, you serve what, 11 counties? Klamath serves one county, one big county, one of the biggest in the State of Oregon.

And, again, the law says -- if you go back to Section 412 it says the tribes define the service area, and it's not having to do with anything having to do with the --

MR. BUSHMAN: Oh, yeah, they also define their service population as well. Thank you, yes. So you can serve all Native Americans in that area or just tribal members.

And the other thing the law does is when you go to the state and identify Native Americans in your service area, it just doesn't have to be tribal members in your tribe. It has to be all Native Americans. That's what the law says.

MR. BUSHMAN: The thing I want to point out is that child support enforcement is important 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 can follow them. You already have a child support order and everything already established, and it can follow them. And that's real important for self-sufficiency.
 
 

PANEL 5

MODERATOR: Welfare of the elders. You have heard several times today people talking about welfare reform and elders who are tending their children. What is interesting in some places we are finding that some of the welfare mothers who have small children, single parent mothers, concerned about themselves finding work, have started to leave their home communities and go into the more urban areas to look for work. And in the process they have left many of their children at home to be cared for either by extended family or grandparents.

MR. BALDRIDGE: In order to understand Indian countries' ability to deal with elder abuse we need to also talk about some pressures on the Indian criminal justice system. A recent Department of Justice report to the attorney general points out that law enforcement in Indian country fails to meet even our basic public safety needs.

In contrast to national trends violent crime is rising sharply in Indian country. A '96 IHS report says the homicide rate for Indian males is almost three times higher than for white males. A reported crime in Indian country is twice as likely to be violent than elsewhere in the U.S.

Between '92 and '96 violent crime in the U.S. dropped by 17 percent while it skyrockets on our reservations. In '95 the murder rate on Fort Peck Reservation was more than twice that of New Orleans. In '96 the Navajo Nation, our largest reservation, had 46 homicides which would place it in this nation's top 20 most violent cities. That same year Laguna Pueblo's nine officers were assaulted 34 times mostly by juveniles. At Salt River (inaudible) drive-by shootings rose from one in 1992 to 55 in '94.

We need resources. The report says we need 4,000 new Indian police officers just to come up to the par with rural America. So it doesn't take a lot of imagination to figure out how well this system is going to serve Indian elders, the victims of silent crimes of abuse.

The few studies suggest that our elders are most frequently suffering from abuse of neglect or financial abuse. Neither is violent, neither results in calls to the police. We don't even like, as Indian people, to talk about it. It's interesting that honoring our elders is a value that we all share regardless of our tribe. And it's a proven vote-getter at election time, that's for sure.

But I think we had better not ever kid ourselves that our current criminal justice system will be able to take care of abuse because it's being overwhelmed by a wave of far more visible violent crime.

We need day-care centers on our reservations. We need tribal support for Title 7 of the Older Americans Act which has the potential to put five million dollars in the pockets of tribes to help with elder protective activities. And we need, I think, to better utilize the resources we do have, such as our Title 6 sites, as vehicles to educate elders about abuse, give them a safe place to talk.

We thought that elders would probably share our concerns about welfare reform. So we asked our 13 elder board members two weeks ago to distribute a questionnaire form to some elders. They responded with more than 200 of them.

I will stop and not talk to you about these, but these are very interesting questions. As soon as we get them quantified we will supply the results to you because our elders have some very real fears. Eighty percent of them are afraid of abuse. As we get this published we will distribute it to you. Thank you.

MS. JACKSON: Indian elders are like elders of the general population. All of our life experiences live with us. So when we get a certain age we start developing the chronic diseases, arthritis, many of the conditions that don't allow us to continue functioning the way we did as younger people. That means we often need somebody to help take care of us. And I see this as one of the really big unplanned consequences of welfare reform.

Ninety-five percent of care of elders in our Indian communities is done by family members. All of that, probably 99.9 percent of that, is unpaid for. So if family members are having to move off the reservation to get a job that leaves the elder without care. If the family member has to get a job to work, even if it's close by the reservation, that still leaves the elder without someone to care for them.

Unlike child abuse, most states do not require reporting of elder abuse, so we can't say what elder abuse is today and what the difference has been in two or three years.

MODERATOR: Yvonne, let me ask. What about the whole question, are grandparents tending for their children? Are they going to be held to the same time requirements and work requirements as other individuals?

MS. JACKSON: It's my understanding a lot is age dependent. If you are age 65 and older then you won't be required to work. If you are under age 65 then potentially you will be required to work.

MODERATOR: Yet many of our grandparents who have teenagers who have children, who have left them with their children, are in that under 60 age group --

MS. JACKSON: Right.

MODERATOR: -that may never have worked before, and have raised their children, and are now raising their grandchildren. Is there any movement to change that or any direction or discussion going on currently?

MS. JACKSON: I have not heard any of it.

MODERATOR: Has anybody in the audience?

A PARTICIPANT: I think our state is looking at that. I have heard DSHS people in Washington State say this is something that they want to look to fix at the state level. I don't know how far that's gotten.

MODERATOR: You know that if you are in a TANF tribe you can set the qualifications however you would like it. But that is a concern and it does raise a number of issues. Okay, thank you.

MS. BACA: Good afternoon. I am glad you are still awake.

Through an initiative funded by the W.K. Kellogg Foundation, a voice for Indian elders, the National Indian Council on Aging is conducting a project to help Indian elders understand and influence managed care and health related policy.

The interface between today's health care policies and the Indian health care delivery system has enormous implications for how health care is funded and delivered in Indian communities.

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 percent of Indian age 65 and older who reside in rural areas have no vehicle available to them, 34 percent have no telephone in their living quarters, 24 percent speak English poorly.

In coping with the complications and confusion created by health and welfare policy, change is difficult for elders at best. However, despite the barriers that elders face, Indian elders have overwhelmingly responded to NICOA's initiatives to focus on solution oriented activity to address their most pressing concerns regarding health care.

For example, in New Mexico when we asked Indian elders if they would like to attend a forum to discuss their health care concerns we had 300 people who were primarily Indian elders attend a conference three weeks later.

By conducting forums with Indian elders health care providers and key national state and legislative leadership we hope to identify pressing access and health related issues affecting Indian elders, determine how we can access and target good health care for Indian elders, identify viable solutions to health issues and concerns, and encourage and support collaborative solution oriented activity that will enhance and improve health care for Indian elders.

At these forums elders discuss their most pressing concerns and fears regarding their access to appropriate and adequate health care. In addition health care professionals, who are committed to providing health care to Indian elders, participate and express that they find it difficult to provide quality health care when they are faced with inadequate funding and limited staff who are often insufficiently trained.

Indian elders basically say that they want comprehensive health care delivery that is sensitive to their cultural needs, they want adequate funding sources to obtain comprehensive health care services including preventive health care and long-term care, and they need educational training resources so that they and their families can understand how to obtain these health care services that they need.

Existing programs which could provide funding and resources for access to comprehensive health care services do not often reach Indian elders. Resources from programs such as supplemental security income, Medicaid, Medicare, and other social and medical related programs could make significant difference in the ability for elders to obtain comprehensive health care and get needed items such as dentures, eyeglasses, durable medical equipment, home and community base care for frail elders, long-term care.

Elders tell us that they want to play a role in creating viable solutions to their health concerns. And with the help of AARP, NICOA is currently developing an educational program to help elders help them understand their options. However, without collaborative and cooperative support from federal and state agencies who provide needed funding for health care and education training programs we will be unable to meet those needs.

Welfare reform will place added pressure on elders whose resources are already limited. Indian elders must be able to access health programs and funding resources if we are to limit further negative impacts to the already growing needs of a rapidly expanding Indian elder population.

MODERATOR: Cortora. Okay, Debra Cortora who is the policy analyst at the Office of Medical Assistance Programs, the State of Oregon. We are happy to have you.

MS. CORTORA: Thank you for letting me come and speak to you today. I am the policy analyst for the Medicaid program for American Indians and Alaska Natives.

In our state we do use the quarterly tribal meetings to talk about health issues that face the tribes not only for elders but for all the members of the group. This is an opportunity to move issues forward to the state's attention and for us to take a look and remove barriers and implement change.

When the MOA, the Memorandum of Agreement, was I guess finalized, this was an important forum for us to be able to communicate with each other on how the services would be reimbursed and how that would look. One of the things during that process that I discovered was that there were many services that were covered for people that the tribes felt that they couldn't bill for. And so what we really started doing in this process was taking a look at the services that could actually be reimbursed for.

For example, maternity case management. It took a while to determine that there were two different issues really happening. They were talking about home services being provided, medical, and then maternity case management which is a social support program for the pregnant woman.

Out of that process we were able to define how that could be billed for. And then, also, CHRs would be able to be reimbursed for when they provided the social support through the maternity case management.

We plan on using the same process on looking at potential health barriers for the elders and taking a look at what -- whether there are things that they just think we can't bill for, or if there is actual barriers that are preventing care for the elders.

I guess the biggest message that I want to give with this is that what we discovered was that there were many things that were just misunderstood. And so we took the time to take a look at things and make changes and not be content on just leaving things the way they were.

MR. GREENSTEIN: For those that are still left awake, we will see if I could change that.

I am going to talk briefly about the interplay between Medicare and Medicaid and particularly about some changes that were made through the Balanced Budget Act last year.

The new programs that were added that allow Medicaid to buy premiums and pay for some of the services associated with Medicare are limited to those who are qualified for Medicare to begin with. And in order to qualify for Medicare you have to have what is called 40 quarters of credit with Medicare which means you have worked for 10 years with an employer or self-employed that pays into the Medicare system.

So having said that, there are two new categories in Medicaid eligibility which allow for your Medicaid to pay for some of the Medicare expenses such as the premiums, co-pays and deductibles.

There is two groups. One is called the QI group. And for those with incomes between 100 percent and 135 percent of the federal poverty level, these people will be, once enrolled, have Medicaid pay for the Medicare expenses. And if I get too technical here just stop me for a question.

But what this means, oftentimes these individuals are not involved in the Medicaid program previously. So this is really a challenge for states, and in this case tribes, to do outreach for these individuals.

Oftentimes the cost of obtaining health care, even through Medicare, can become prohibitive. And this is a way to allow Medicaid to pay for it, and it also reduces any burden that may be placed on IHS facilities and budgets as well.

The other category is the second called QI, Qualified Individuals 2, for those with incomes between 135, which is the end of the first group, up to 175 percent. Now, this group was a product of Congress' insistence that nobody should establish an increase in their Medicare premium rate because home health was switched from one budget to another.

So the consequence is this benefit pays out $1.07 every month. So far only one state has implemented it. It's Oregon actually. And so individuals get a check for $1.07 at the end of the month to pay the difference in their premium.

But nevertheless this is -- and it's working though. But this is an example, though, that there may not be a great incentive, particularly in the second category, to push for outreach and enrollment. But clearly in the first category there is.

It's important for tribal members, social service organizations, people that have contact in kind of the non-traditional welfare stream where food stamps and cash assistance will be handed out, and people know this information there, but elsewhere to encourage older people that are seeking health care in this manner to get it at least paid for in the way that Congress had designed it to be paid for such as through Medicare and Medicaid. I'll stop there.

A PARTICIPANT: What I was going to ask people on the panel or anybody else that wants to answer to it, like on the NAHASDA Committee, we drew the line at 55 to be considered an elder, and above that would be older elders.

On TANF I don't exactly know where you draw the line there and what you are going to make for qualifications to qualify for TANF applications. If you are going to make them work, if they take children in, and this and that all down the line.

I just want to know what kind of flexibilities, all the programs, IHS, TANF, as well as our housing, how we can all work together to get safe and sanitary homes and atmosphere for the elders as well as the children. Would they all be willing to work together?

Okay. Let's say we have a couple that are, let's say, 55, and we have some children that need a place, and these are grandparents, how much flexibility would be allowed for these grandparents to take these children in without requiring them to go to work, and on down the line like that.

What kind of protocol process would we have our people follow. Where could we draw the line for our people to get into homes, decent homes, along with the children. How would they all coordinate together, I guess is what I am asking.

MR. BALDRIDGE: My only experience is with federal programs. We find we are very much at the mercy of those. The Department of Labor, for example, with an employment program, states 55. Title 6 in the Older Americans Act has its own, to us, large and arbitrary limit. I would guess that this might be negotiable with states on an individual basis. Maybe somebody in the audience can help us out, Sue or Helen. I truly can't answer your question. I don't know that.

A PARTICIPANT: I think he really touched on a key issue here. I think, really, what we are finding in talking with Indian elders is there are already some existing programs, in addition to TANF, that are not being accessed. And I think it has everything to do with outreach, it has everything to do with having the information and understanding it.

Indian elders need this information but it's got to be simple, it's got to be understandable, and there's got to be a support network out there in communities to help them understand. So basically we have to educate the community, not just elders, about these resources and how we tie them together..

A PARTICIPANT: Just a question on the QI and the QI-2. I mean, this is an extension of QMB and SLMB in effect. Do you -- again, it's sort of like the EPSDT. It seems like -- the numbers I recall is like the participation already in QMB is only like 50 percent of all the people eligible or enrolled now.

Do you get involved in trying to educate people or getting more information, getting better participation? That's the same population that's addressed by the new legislation that already isn't applying, signing up for QMB or SLMB.

A PARTICIPANT: The answer is I don't have any direct participation, but I know that states have pretty wide variation in the enrollment rates. And they are all, in my estimation, kind of abysmally low.

This is a group that's really difficult to get out and contact because there is not a typical pass-through area like there would be for families, for instance. When Medicaid would be the secondary source of health care payment to Medicare, and Medicare doesn't have central pass-through as well, you lose that ability to a nexus. They would find people naturally.

The other issue is on the QI-1 and 2 they are capped allotments to the states so the states have a little bit of forecasting to do so they don't end up with too many enrollees such that they lose their match by the end of the year because they have too many people in their program, their money runs out and then they have to pay all out of their own pocket.

I don't think that's going to be the case, though. But nevertheless this is another outreach issue, that if states tend to focus on this population and also do a better job at catering to specific groups in, say, different methods of communication and languages, then they may have a better shot at --

A PARTICIPANT: Every reason to get involved earlier and try and locate these elders quicker because the money might not be there if you delay too long.

MR. FOX: (Inaudible) Ms. Cortaro if she could tell us how this principle that looks like we are going to establish for maternity case management or maternity use of CHRs to provide services, how that might apply to home and community base care for our elders. How might that go and how might it be a little bit different.

MS. CORTORA: Well, the reimbursement would probably be somewhat different. We would probably have to use like what we call a targeted case management methodology. Targeted case management is when you look at a specific population where you need to provide some social supports in order to achieve a health outcome. And I would suspect that this would in part be something we could take a look at.

The other piece of it really is you talk about the outreach. One of the things that does work for maternity case management is that Title 10, which is a family planning program, many of the Title 10 clinics actually initiate maternity case management on a positive pregnancy result. So at that time they encourage the person that is pregnant to apply for Medicaid to see if they are eligible, and they try and get them into maternity case management.