    [Senate Hearing 115-362]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 115-362

                          GRANDPARENTS TO THE RESCUE:
                      RAISING GRANDCHILDREN IN THE OPIOID
                               CRISIS AND BEYOND

    =======================================================================

                                    HEARING

                                   BEFORE THE

                           SPECIAL COMMITTEE ON AGING

                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 WASHINGTON, DC

                                   __________

                                 MARCH 21, 2017

                                   __________

                                Serial No. 115-2

             Printed for the use of the Special Committee on Aging

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                      ______

                             U.S. GOVERNMENT PUBLISHING OFFICE

    28-601 PDF                     WASHINGTON : 2018

                           SPECIAL COMMITTEE ON AGING

                       SUSAN M. COLLINS, Maine, Chairman

    ORRIN G. HATCH, Utah                 ROBERT P. CASEY, JR., Pennsylvania
    JEFF FLAKE, Arizona                  BILL NELSON, Florida
    TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
    THOM TILLIS, North Carolina          KIRSTEN E. GILLIBRAND, New York
    BOB CORKER, Tennessee                RICHARD BLUMENTHAL, Connecticut
    RICHARD BURR, North Carolina         JOE DONNELLY, Indiana
    MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
    DEB FISCHER, Nebraska                CATHERINE CORTEZ MASTO, Nevada
                                  ----------
                     Kevin Kelley, Majority Staff Director
                      Kate Mevis, Minority Staff Director

                                    CONTENTS

                                  ----------

                                                                       Page

    Opening Statement of Senator Susan M. Collins, Chairman..........     1
    Statement of Senator Robert P. Casey, Jr., Ranking Member........     2

                               PANEL OF WITNESSES

    Videotape Statement of Ann Sinsheimer and Marvin Sirbu,
      Grandparents, Pittsburgh, Pennsylvania; Linda James,
      Grandparent, Rochester, New York; and Belinda Howard,
      Grandparent, Fort Walton, Florida..............................     6
    Jaia Peterson Lent, Deputy Executive Director, Generations
      United, Washington, DC.........................................     7
    Megan L. Dolbin-MacNab, Ph.D., LMFT, Associate Professor,
      Department of Human Development, Director, Marriage and Family
      Therapy Doctoral Program, Faculty Affiliate, Center for
      Gerontology, Virginia Tech Faculty of Health Sciences, Virginia
      Tech, Blacksburg, Virginia.....................................     9
    Bette Hoxie, Executive Director, Adoptive and Foster Families of
      Maine and the Kinship Program, Orono, Maine....................    11
    Sharon McDaniel, MPA, Ed.D., President and Chief Executive
      Officer, A Second Chance, Inc., Pittsburgh, Pennsylvania.......    13

                                    APPENDIX
            Prepared Witness Statements and Questions for the Record

    Jaia Peterson Lent, Deputy Executive Director, Generations
      United, Washington, DC.........................................    34
        Jaia Peterson Lent Response to Questions for the Record......    38
    Megan L. Dolbin-MacNab, Ph.D., LMFT, Associate Professor,
      Department of Human Development, Director, Marriage and Family
      Therapy Doctoral Program, Faculty Affiliate, Center for
      Gerontology, Virginia Tech Faculty of Health Sciences, Virginia
      Tech, Blacksburg, Virginia.....................................    40
    Bette Hoxie, Executive Director, Adoptive and Foster Families of
      Maine and the Kinship Program, Orono, Maine....................    56
    Sharon McDaniel, MPA, Ed.D., President and Chief Executive
      Officer, A Second Chance, Inc., Pittsburgh, Pennsylvania.......    57
        Sharon McDaniel Response to Questions for the Record.........    59

                          GRANDPARENTS TO THE RESCUE:
                          RAISING GRANDCHILDREN IN THE
                            OPIOID CRISIS AND BEYOND

                                  ----------

                            TUESDAY, MARCH 21, 2017

                                           U.S. Senate,
                                    Special Committee on Aging,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:30 p.m., in
    Room SD-562, Dirksen Senate Office Building, Hon. Susan M.
    Collins (Chairman of the Committee) presiding.
        Present: Senators Collins, Fischer, Casey, Gillibrand,
    Donnelly, Warren, and Cortez Masto.

        OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN

        The Chairman. The Committee will come to order.
        Good afternoon and welcome. This hearing was originally
    scheduled for last week, as our witnesses know well, but winter
    does not always cooperate with our Senate schedules.
        I am particularly pleased to welcome today one of the new
    members of our Committee, Senator Fischer from Nebraska. I was
    absolutely delighted when I learned she would be joining our
    Committee, so thank you, Senator, for being here.
        This hearing focuses on an important topic, and I am very
    pleased that we have gathered here to discuss it today. Last
    year, nearly 1,000 babies in Maine--that is about 8 percent of
    all births--were born to women addicted to opioids and other
    drugs. This tragedy afflicts many other states as well as mine.
    In the United States, every 25 minutes a baby is born with an
    opioid addiction. In this crisis, as in past crises,
    grandparents are coming to the rescue. The Aging Committee is
    meeting today to recognize the grandparents raising grandkids
    and to explore what can be done to assist them as they take on
    this unanticipated challenge motivated by their love of their
    grandchildren.
        One in five grandparents provides child care regularly to
    their grandchildren. In fact, grandparents who help raise
    grandkids together with the child's parents can support healthy
    aging and be a positive experience for all concerned. Today,
    however, we are focusing on grandparents who are raising their
    grandchildren alone. These ``custodial grandparents'' are
    called on to help for a number of reasons, including alcohol
    and drug addiction, physical abuse, incarceration, divorce,
    financial difficulties, military deployment, and even death. In
    Maine, the number of children being raised solely by their
    grandparents increased by 24 percent between 2010 and 2015.
        At a time in life when most seniors are looking forward to
    enjoying more leisure time, these grandparents have found
    themselves as parents once again. They are waking up in the
    middle of the night to feed babies and planning afternoons
    around soccer practice, rather than playing golf or
    volunteering.
        Raising a second family also involves costs they had never
    anticipated as they budgeted for what was supposed to be their
    golden years. They are tapping into retirement savings, going
    back to work, or staying in the workforce longer just to make
    ends meet.
        In addition to the financial toll, raising children later
    in life presents social, emotional, legal, and other
    challenges. It can be socially difficult to become a full time
    caregiver as an older adult, often isolated from friends. It
    can be emotionally difficult to go from being a grandmother who
    spoils the kids to becoming the disciplinarian who makes sure
    that homework is finished.
        At the same time, it can often be emotionally difficult to
    navigate the relationship with the children's birth parents.
    The legal challenges are tough. The process of attaining
    custody is complex, lengthy, and costly. Without a proper legal
    arrangement, routine tasks such as enrolling kids in school or
    obtaining medical care can be difficult.
        Becoming a full-time caregiver can also take a toll on the
    health of the grandparent. The new caregiver role challenges
    both the physical, mental, and emotional health of grandparents
    resulting in higher rates of diabetes, heart disease, and
    depression.
        Despite all of these challenges, when asked if they regret
    taking on the caregiver role, a vast majority of these
    grandparents answer, ``No.'' They know that they are making a
    difference. They are providing love, stability, and a home to
    children who might otherwise have to live with strangers.
        WABI, the CBS television station in Bangor, Maine, recently
    featured stories of grandparents raising their grandchildren.
    What struck me the most in those stories was that the
    grandparents are not focused on the challenges; instead, they
    are focused on their love for their grandchild. As one put it,
    ``In the end, it is worth it to know that they are happy and
    safe.''
        Throughout history, grandparents have stepped in to provide
    safe and secure homes to their grandchildren, replacing
    traumatic pasts with loving and hopeful futures. The opioid
    crisis has called upon grandparents in epic numbers. We are
    here today to focus on what is being done to help those
    grandparents who have stepped up to help ensure a better life
    for their children's children.
        Senator Casey, it is delightful to have you here today, and
    I call upon you for your opening remarks.

      OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING
                                 MEMBER

        Senator Casey. Chairman Collins, thank you very much, and
    thanks for getting us started on this important issue.
        I want to thank the Chairman for calling this hearing, and
    as she just indicated, today's topic is indeed challenging, and
    that is an understatement. It is one that we both see back
    home, and I think that is true of every member of this
    Committee. And it is one that motivates us when we are here in
    Washington to try to focus on this issue and to tackle the
    problem.
        Grandparents Ann Sinsheimer and Marvin Sirbu joined me at a
    hearing recently, at a gathering in Pittsburgh, on the opioid
    problem in the city of Pittsburgh. And as you will hear from
    them shortly, they are raising their grandchildren because
    their daughter is struggling with an opioid addiction. Ann and
    Marvin are here with us today. Where are they? Oh, I did not
    see you coming in. I am sorry. Ann and Marvin are with us, and,
    Ann and Marvin, we want to first of all express our gratitude
    to you for being here again after having appeared in Pittsburgh
    and for giving a voice to grandparents across the country who
    are caring for their grandchildren under the hardest of
    circumstances.
        I also look forward to introducing Dr. Sharon McDaniel from
    Pittsburgh as part of our panel today. I will do that
    introduction a little later, but we are grateful that Dr.
    McDaniel is here.
        And like the State of Maine, the State of Pennsylvania has
    been hit hard by the opioid epidemic. More than 3,200
    Pennsylvanians died from drug overdoses just in 2015 alone.
    That is a 20-percent increase over the 2014 total.
        As the Centers for Disease Control and Prevention tell us,
    the majority of these drug overdoses are caused by opioids. The
    reality is that opioid addiction is devastating the lives of
    individuals with addiction. It is also putting a strain on our
    health care system, law enforcement, and communities across the
    country as well.
        It is also taking a toll on families. Too often, moms and
    dads are falling victim to the epidemic, and grandparents are
    stepping in to care for the children. That is one of the
    reasons why the number of children being raised by grandparents
    is on the rise. In Pennsylvania, 103,000 children--103,000
    children--are in the care of their grandparents or other
    relatives. Experts point to opioids as the major driver of that
    growth, and any parent will tell you that raising a child is
    rewarding indeed, and it is fulfilling. But it is also a major
    challenge.
        For grandparents, it can dramatically alter their life
    plans, as Senator Collins noted. They postpone retirement. They
    keep working longer to be able to afford clothes, child care,
    and food. Some deplete their nest eggs and retirement savings
    to finance these new costs. Many are isolated from their social
    networks.
        Raising children of a parent struggling with addiction
    presents additional challenges for grandparents. Often, they
    spend time in court struggling to sort out custody. Frequently,
    they need to learn the special education system to get their
    grandchildren the supports that they need.
        Children of addicted parents have often experienced trauma
    and have been exposed to violence and drug use, so grandparents
    must address a child's mental health needs. And they may need
    to help the child navigate their relationship with the parent
    who is still using opioids.
        All of this can be overwhelming when you expected the next
    phase of your life to be retirement, and it takes a tool on the
    grandparents' physical and mental health. These are all
    significant challenges for the grandparents, but, of course,
    most grandparents say that it is all worth it to have the peace
    of mind knowing that their grandchildren are safe. Grandparents
    stepping up to take on the role of primary caretaker of their
    grandchildren deserve our support. They should not feel
    isolated and unaware or unsure of where to turn for help.
        There are supports like the National Family Caregiver
    Support Program, which is under the Older Americans Act. This
    program helps ``grandfamilies''--a new term--by providing
    caregivers counseling and respite care. With grandfamilies on
    the rise, ensuring adequate federal funding is critical.
        There is also the modest child-only TANF funding that
    families can access, Temporary Assistance for Needy Families.
    But there is not a go-to place for older Americans facing this
    situation, and with more and more seniors taking on this role,
    we need to be thinking about how to better serve them.
        That is why I would like to work with Chairman Collins and
    others on legislation to create a one-stop shop for everyone
    trying to help grandparents raising their grandchildren to help
    make their job a little bit easier.
        We also need to continue to expand access to treatment. I
    am pleased, like we all are, that we provided $1 billion in
    funding to states over the next two years to combat the opioid
    epidemic as part of the 21st Century Cures bill at the end of
    the year. That is the good news.
        The bad news? This funding and other funding like it will
    be undermined if the Affordable Care Act is repealed. Just that
    repeal alone would remove at least $5.5 billion annually from
    the treatment of those with mental health and substance use
    disorders. So $5.5 billion could be gone even though the $1
    billion was added at the end of last year. We cannot allow that
    to happen.
        At the height of this epidemic, we cannot lose ground on
    health care coverage. It is too important to every generation--
    grandparent, parent, and child. So I am committed to fight to
    ensure that we maintain these vital programs that today help
    older Americans and grandparents who are raising their
    grandchildren.
        Today's hearing will help us learn from past experiences,
    including issues faced by grandparents affected by the crack
    cocaine epidemic in the 1980s and 1990s. We cannot arrest our
    way out of the opioid epidemic, and treatment matters, good
    treatment matters, so that grandparents can be grandparents,
    and grandchildren can once again be grandchildren.
        I look forward to hearing from our witnesses about how we
    can do that important task. Thanks very much.
        The Chairman. Thank you very much, Senator.
        Now we will turn to our witnesses. First, we will hear, by
    video, from grandparents who are raising their grandchildren.
    As Senator Casey has already previewed, two members of our
    audience today are featured also in the video. Drs. Ann
    Sinsheimer and Marvin Sirbu from Pittsburgh, Pennsylvania, will
    tell their story. Mrs. Linda James will share her story from
    Rochester, New York. And, last, we will hear from Mrs. Belinda
    Howard, who is from Fort Walton, Florida.
        Next we will hear from our panel that is right in front of
    us, and that includes Jaia Lent. Ms. Lent is the deputy
    executive director of Generations United. She leads work for
    the National Center on Grandfamilies. That was a new phrase for
    me also.
        We will then hear testimony from Dr. Megan Dolbin-MacNab,
    an associate professor of human development at Virginia Tech.
    She is also director of the Marriage and Family Therapy
    Doctoral Program.
        We will next, I am delighted to say, hear from one of my
    constituents, Bette Hoxie. Mrs. Hoxie is the executive director
    of Adoptive and Foster Families of Maine and the Kinship
    Program. Adoptive and Foster Families of Maine provides
    important services to grandparents, including kinship training,
    licensing and legal support, material support, and respite
    care. Mrs. Hoxie does tremendous work to support grandfamilies
    in Maine. I would note that I recognized her with the Angels in
    Adoption Award in 2004, and I am delighted that she has joined
    us today. She has personally raised some 19 children, which is
    truly extraordinary, and she is still at it.
        I will now turn to our Ranking Member to introduce our
    final witness on this panel, Dr. Sharon McDaniel.
        Senator Casey. Chairman Collins, thank you.
        Dr. Sharon McDaniel is the founder, president, and chief
    executive officer of A Second Chance in Pittsburgh,
    Pennsylvania. Dr. McDaniel is an alumna of foster care herself
    and was raised by relatives. She founded A Second Chance, which
    is a nonprofit that provides services to 800 families a day
    through kinship care in both Pittsburgh and Philadelphia, our
    two largest cities in the State. A Second Chance's mission is
    to provide a safe and nurturing environment to children who are
    being cared for by their relatives. It also works to prevent
    the cycle of drug and alcohol abuse and provide children in
    need with kinship placement. Dr. McDaniel is also a member of
    the Casey Family Programs Board of Trustees. No relation to me,
    but a great organization, great foundation.
        Clearly, Dr. McDaniel's work and that of A Second Chance is
    invaluable to the people of Pennsylvania, so I am glad she is
    here with us today, and I look forward to her testimony.
        I mentioned Ann and Marvin, as the Chairman did. They will
    be in the video. They will not be giving testimony, but they
    are here. So they are here in more ways than one, both in the
    video and in person. We are grateful they drove from Pittsburgh
    to be here. And as I mentioned, they have taken on this task of
    raising two granddaughters as a result of their mom's struggle
    with drug addiction. So they have made great sacrifices not
    only to be here but, of course, the larger sacrifice they have
    taken on. So thanks very much.
        The Chairman. Thank you, Senator.
        I would now direct your attention to the screens where we
    will hear the testimony of individual grandparents.

        VIDEOTAPE STATEMENT OF ANN SINSHEIMER AND MARVIN SIRBU,
         GRANDPARENTS, PITTSBURGH, PENNSYLVANIA; LINDA JAMES,
         GRANDPARENT, ROCHESTER, NEW YORK; AND BELINDA HOWARD,
                   GRANDPARENT, FORT WALTON, FLORIDA

        Ms. Sinsheimer. Hi. We are Ann and Marvin, and we are
    caring for our two granddaughters, ages 8 and 5.
        Mr. Sirbu. Well, I have a daughter who has been struggling
    with drug addiction for a dozen years. Well, I am 71. I had
    been thinking about when I would retire, but now I am thinking
    it is going to be later than I originally thought. I need
    health insurance for my oldest granddaughter, and I can get
    that through my employer if I continue working. And my
    expenditures are more than anticipated, and so it seems prudent
    to continue working a little longer.
        I have colleagues with young kids, but they are much
    younger than I am, and the people who I have associated with
    all my career are now themselves empty nesters. They are
    talking about their grandchildren, but only for occasional
    visits. And so it is a little awkward. The people I would
    normally socialize with do not want to talk about young kids
    anymore. And the people with young kids are in a different
    stage of life than we are. So it is a bit awkward.
        Ms. Sinsheimer. Yeah. It is hard to go out. It is hard to
    make plans to travel, like we were thinking about, and I guess
    sometimes I feel like it is a little lonely. I feel a little--I
    mean, I know I should not, but I feel a little ashamed about
    our situation. It is not like something you want to bring up at
    dinner when you are actually going out with your friends. So we
    are in such a different world from our peers.
        Ms. James. I am Linda James, and I have raised two of my
    grandchildren. I became a primary caregiver of my grandchildren
    in 1987 when my granddaughter was born in a crack house. Two
    years later, I went to Baltimore, Maryland, to pick up my
    grandson. Well, I started a support group because I felt that
    the kinship caregivers needed that emotional support. And they
    also needed tools to help them in raising their grandkids,
    tools such as how to navigate the special education system
    because a lot of children whose parents have been affected by
    drugs have some learning disabilities. So these grandparents
    need to know how to navigate their special education system.
        They also need to know how to take some of the old things
    that they have learned when they was growing up and applying
    some of the new things that we are now doing to really help
    their grandchild and to really understand their grandchild.
    Well, the skills that I found most helpful was really just good
    parenting skills and good common sense.
        Ms. Howard. Hi. My name is Belinda Howard, and I am from
    Fort Walton Beach, Florida, and I am raising our grandson,
    Logan. He is seven years old. So we rescue the children from
    foster care, and they have been in our home ever since.
        We are back in the public school system, and that is a big
    challenge. I thought I was done with that. So, financially, for
    my husband and me it is a challenge. You know, there is
    baseball equipment and basketball equipment and school lunches
    and just the time and, you know, not having that time frame
    where we feel like we were going to be empty nesters, and we
    are not. So that is a huge challenge.
        Being a part of an online support group through the
    Addict's Mom, called ``Grandparent to Grandparent,'' I want to
    say we are at 2,900 members strong, and it is good to have
    online support. But if we could have people-to-people support,
    you know, something on the ground, groups that we could go to,
    people that we could touch and help and, you know, encourage
    each other, that would be huge, you know, to just be able to
    know that there are other grandparents out there, you know, for
    whatever reason, struggling to take care of their grandkids.
        The most positive thing from this situation--because my
    husband and I have four children and three of them are addicts,
    we have eight grandchildren, and I want to say the most
    positive thing about everything is that our--our grandchildren
    think we're super heroes. They think that their Gammy and Pop-
    Pop can do everything.
        [End of videotape.]
        The Chairman. Well, I think the grandparents who are
    raising grandchildren are super heroes. I think she said it
    very, very well, and that is something all of us can admire.
        We are now going to start with testimony from our panel,
    and, Ms. Lent, we will begin with you.

      STATEMENT OF JAIA PETERSON LENT, DEPUTY EXECUTIVE DIRECTOR,
                   GENERATIONS UNITED, WASHINGTON, DC

        Ms. Lent. Thank you, Chairwoman Collins, Ranking Member
    Casey, and members of the Committee, for your leadership in
    holding this hearing on the important role of grandparents in
    providing safe and stable homes to children and the sharp
    increase in this trend attributed to the opioid crisis.
        For almost 20 years, Generations United's National Center
    on Grandfamilies has been a leading voice for issues affecting
    families headed by grandparents and other relatives.
        Today's grandparents provide a continuum of care from part-
    or full-time child care to raising a grandchild. My testimony
    will focus on grandparents and other relatives raising
    children, also known as ``grandfamilies.''
        According to the U.S. census, more than 2.6 million
    grandparents report they are responsible for their
    grandchildren. And there are many kinds of grandfamilies. Some
    grandparents are raising children inside the formal foster care
    system as licensed or unlicensed kinship foster parents. Others
    have no involvement or support from the child welfare system.
    And while the challenges these families face are varied and
    complex, they are united by one common factor: they believe
    beyond a shadow of a doubt in the importance of family. They
    believe that children fare better when they are raised in a
    family, not a system, and they are right. Yet we cannot ignore
    the fact that they often step in at great personal sacrifice,
    impacting their own health, family relationships, and financial
    well-being.
        My testimony focuses in four areas: the impact of the
    opioid epidemic on grandparents; the critical role
    grandfamilies play in helping the children thrive; the
    importance of supportive services to help grandfamilies
    succeed; and the valuable role that the National Family
    Caregiver Support Program can play in responding to the crisis.
        After years of decline, the overall numbers of children in
    foster care are on the rise. Child welfare systems are
    increasingly looking to grandparents and other relatives to
    care for children as they face shortages of foster parents to
    meet the growing need. And unlike parents or foster parents who
    plan for months or even years to care for a child, these
    grandparents usually step into their role unexpectedly. Some
    may have received a call in the middle of the night telling
    them to come and pick up their grandchildren or they will end
    up in foster care. Suddenly, they are forced to navigate
    complex systems to help meet the challenges of the children who
    come into their care, often after experiencing significant
    trauma.
        Taking on the unexpected expense of a child can be
    especially devastating to caregivers living on fixed incomes.
    Countless grandfamilies report spending down their retirement
    savings to address the health, mental health, food and clothing
    needs of the children, or to pay expenses from seeking legal
    custody of the children.
        And while grandparents have been called upon to raise
    children for many reasons over the years, the current opioid
    and heroin epidemic is overwhelming many families and child
    welfare systems.
        One grandparent shined a light on the impact when she said,
    ``For my 50th birthday, I got a two-year old. My story is not
    unique. The opioid epidemic has devastated communities all over
    the country. It does not discriminate against age, race, or
    gender. It affects all of us.''
        In 2014, more than a third of all children who were removed
    from their homes because of parental alcohol or drug use were
    placed with relatives. And although the child welfare system
    relies heavily on relatives, for every child being raised
    inside the foster care system with a relative, there are 20
    children being raised in grandfamilies outside of the foster
    care system. And those that raise children outside of the
    system usually struggle with even less support.
        Despite the challenges facing grandfamilies, children fare
    well in the care of relatives. Compared to children in non-
    relative care, they have more stability, are less likely to run
    away, are more likely to report feeling loved. When children
    cannot remain with their parents, research shows that placing
    children in grandfamilies reinforces stability, safety, well-
    being, and a child's sense of identity, reduces trauma, helps
    keep brothers and sisters together, honors family and cultural
    ties, and it increases the likelihood of having a permanent
    home.
        A young person may age out of a system, but they never age
    out of a family.
        Families face challenges that can be addressed through key
    supports such as information and referral services like Kinship
    Navigator Programs and support groups; physical and mental
    health care, including Medicaid; affordable legal services;
    lifespan respite care; financial supports such as Temporary
    Assistance for Needy Families and Social Security. And,
    finally, the National Family Caregiver Support Program can also
    play a valuable role in helping to respond to the crisis.
        Current law gives states the option to use up to 10 percent
    of their National Family Caregiver Support Program dollars to
    serve grandfamilies, yet only seven states use the full 10
    percent to serve the families; however, those who do, report a
    significant impact.
        A full list of Generations United's recommendations are
    included in my written testimony, including the importance of
    quality health and mental health care, financial, legal, and
    social supports, and child welfare reform.
        In closing, no matter the circumstances, every child
    deserves the roots and connection to the rich soil of family
    that nourish their growth and prosperity. Grandfamilies provide
    just that.
        The Chairman. Thank you very much for your testimony, Ms.
    Lent. I was struck by your line when you said that you can age
    out of foster care, but that you cannot age out of a family.
    That really sums up why this hearing is so important, so thank
    you for being here.
        Next we are going to hear from Dr. Dolbin-MacNab. Please
    proceed.

      STATEMENT OF MEGAN L. DOLBIN-MacNAB, PH.D., LMFT, ASSOCIATE
    PROFESSOR, DEPARTMENT OF HUMAN DEVELOPMENT, DIRECTOR, MARRIAGE
    AND FAMILY THERAPY DOCTORAL PROGRAM, FACULTY AFFILIATE, CENTER
      FOR GERONTOLOGY, VIRGINIA TECH FACULTY OF HEALTH SCIENCES,
                  VIRGINIA TECH, BLACKSBURG, VIRGINIA

        Dr. Dolbin-MacNab. Good afternoon, Chairman Collins,
    Ranking Member Casey, and distinguished members of the
    Committee. Thank you for the opportunity to testify before you
    today on this very important issue. I am Dr. Megan Dolbin-
    MacNab. I am an associate professor in the Department of Human
    Development and director of the Marriage and Family Therapy
    Doctoral Program at Virginia Tech. I have been researching
    grandfamilies for approximately 20 years. Today, I will provide
    testimony regarding the findings from scientific research on
    grandfamilies. The testimony I provide today reflects my
    professional views and experiences and not those of Virginia
    Tech.
        As Ms. Lent noted, in the United States, approximately 2.6
    million grandparents are primarily responsible for the care of
    their grandchildren. These grandparents play key roles in
    ensuring the safety and stability of 2.5 million or three
    percent of all U.S. children.
        The majority of grandparents raising their grandchildren
    are women, married, working, and younger than age 60. That
    said, census data suggest that grandparents raising
    grandchildren are disproportionately more likely to be divorced
    or widowed, less educated, and living in poverty. They are also
    disproportionately represented among racial and ethnic minority
    groups, though rates are increasing among white, non-Hispanic
    grandparents.
        Grandparents assume responsibility for their grandchildren
    in response to a variety of intersecting parental difficulties,
    including abuse and neglect, incarceration, physical and mental
    illness, and adolescent pregnancy. Of particular relevance to
    today's hearing, parental substance abuse has long been noted
    as one of the most common reasons that grandparents raise their
    grandchildren. Beyond parental difficulties, however,
    grandfamilies also develop in response to economic instability,
    cultural traditions of grandparent involvement, and familism.
        Raising a grandchild impacts all aspects of a grandparent's
    life. According to the research literature, commonly reported
    stressors include economic distress, legal difficulties,
    inadequate housing, strained family relationships, and social
    isolation. The demands of parenting may be particularly
    stressful for grandparents because their grandchildren often
    experience significant emotional, behavioral, and physical
    difficulties. These difficulties have been associated with
    grandchildren's histories of trauma and other adverse
    circumstances.
        Research has documented that the collective stressors
    experienced by grandparents raising grandchildren can
    negatively impact both their physical and mental health.
        In terms of mental health, studies consistently demonstrate
    that grandparents experience significant levels of depression,
    at rates that are higher than those within the general
    population.
        With regard to physical health, early research suggested
    that grandparents experience compromised physical health,
    dissatisfaction with their health, and functional limitations.
    More recent research, however, suggests that grandparents'
    adverse health outcomes may have less to do with raising their
    grandchildren, per se, and are more likely to be reflective of
    risk factors such as poverty or preexisting health conditions.
    Still, studies consistently find that grandparents raising
    grandchildren experience a variety of serious chronic health
    conditions and often engage in a variety of risky health
    behaviors. This is particularly concerning given evidence that
    grandparents often forgo preventative health care as a result
    of putting their grandchildren's needs ahead of their own.
        While the scientific research has illuminated the many
    stressors and adverse outcomes experienced by grandparents
    raising grandchildren, not all grandparents experience these
    negative outcomes, and many are resilient in the face of
    significant adversity. In fact, the experience of raising
    grandchildren is not entirely negative. The emotional
    connections that grandparents form with their grandchildren are
    highly rewarding, as is the chance to provide their
    grandchildren with better opportunities in life.
        In light of this information, researchers are increasingly
    examining grandparent resilience or the ability to positively
    adapt in the face of adversity. Studies have found that
    resilient grandparents have social support and demonstrate
    optimism, active coping, resourcefulness, and a sense of
    empowerment. Increasingly, researchers are developing and
    testing promising interventions that promote grandparent
    resilience and reduce adverse outcomes. Improving the quality
    of the larger environments in which grandparents are embedded
    is also important for promoting resilience.
        Support services play a critical role in reducing adverse
    outcomes and promoting resilience in grandparents raising
    grandchildren. Unfortunately, research findings suggest that
    grandparents underutilize these services due to ineligibility,
    difficulty navigating multiple agencies, and an inability to
    pay. Other barriers to accessing support include a lack of
    awareness of available services and even negative interactions
    with practitioners. Addressing these barriers requires a truly
    ecological approach to intervention that attends to individual
    level factors as well as macro level factors, including
    increased availability of services and more flexible
    eligibility guidelines.
        Grandparents raising grandchildren are important resources
    to their families and communities. Despite the challenges they
    experience, grandparents are highly resilient and deeply
    committed to giving their grandchildren the best lives
    possible. Supporting them means supporting some of our Nation's
    most vulnerable families.
        Thank you for the opportunity to appear before you today. I
    look forward to responding to your questions.
        The Chairman. Thank you so much for your excellent
    testimony.
        Ms. Hoxie.

      STATEMENT OF BETTE HOXIE, EXECUTIVE DIRECTOR, ADOPTIVE AND
     FOSTER FAMILIES OF MAINE AND THE KINSHIP PROGRAM, ORONO, MAINE

        Ms. Hoxie. Good afternoon, Chairman Collins, Ranking Member
    Casey, and members of the Special Committee on Aging. My name
    is Bette Hoxie, and I am honored to speak with you today
    regarding both my professional and personal experiences with
    this topic.
        I am first and foremost a mother, grandmother, and great-
    grandmother. I raised my grandson since his infancy, and he
    will soon be 18 years old and graduating from high school and
    on to study conservation law enforcement. I have to add, a few
    months ago he originally said, ``I think I will do social
    work,'' and I am thinking, ``Oh, please, no.'' But I did not
    say that.
        [Laughter.]
        Ms. Hoxie. I just said, ``Do whatever you want,'' and
    luckily he changed his mind.
        I am also the executive director of Adoptive and Foster
    Families of Maine and the Kinship Program. It is comparable to
    what others were talking about with regard to the Navigator
    Program, although we serve all three components, both foster,
    adoptive, and kinship. The aspects of kinship care or
    grandfamilies are closely replicated to the Navigator Program.
        Like so many other states, as you have already heard, Maine
    is severely affected by the opioid crisis that permeates our
    Nation and its vulnerable families. More and more infants are
    being born to mothers who are using opioids while pregnant.
    These births are taking a toll on a population of caring people
    who would, if they could, simply love their grandchildren,
    spoil them, and send them home to be raised and nurtured by
    their parents. However, obviously, for many families that is no
    longer an option. Instead, the grandparents are becoming the
    primary caretakers.
        The organization that I work for, Adoptive and Foster
    Families of Maine, works with an amazing team of professionals
    throughout the state to support these grandparents, who, in
    most cases, were never expecting to parent again, at least not
    in this way. They may not have a spare bed at home or clothing.
    They may need a crib. There are a number of different material
    goods that they will not have access to. So one of the things
    that our organization does on a very easy level is to collect
    new and gently used items, including the beds and furniture and
    clothing and make them accessible to the families. When we do
    not have them immediately at one of our offices, we put it on
    our list serve, and Maine's families are amazingly generous and
    kind, and they frequently fill that void within a few days.
        We also help the families as they are going through and
    navigating the licensing process to become foster parents for
    their grandchildren. And depending on where they are in time
    and space, we may also be helping them to work through the
    probate court system where some will get guardianship because
    the Department of Health and Human Services is not involved.
        For example, when they are going through the licensing
    process, as Senator Collins indicated, this is sometimes a very
    lengthy process, and it can be costly. Many of the homes in
    Maine are older homes and the windows are not egress,
    therefore, they will not pass the foster care licensing
    standard and that can be a barrier. One of the things our
    office has been able to do in some instances is to get
    donations of windows that are the right size or get volunteers
    who are willing to help install the windows, anything to try to
    bring some of these totally unexpected costs down.
        The organization provides specific support groups, and this
    is huge for the families. Being able to talk with others who
    are walking the walk and talking the talk just helps to make
    you feel like you are more a part of things. It diminishes some
    of the isolation that the other two presenters have talked
    about. And also at those meetings, we have the children come as
    well, so we provide child care, and that also helps them to
    feel like, ``Wow, I am not the only one being raised by my
    grandmother,'' or ``my grandfather,'' whatever the case is, and
    they feel less isolated themselves.
        Another benefit of those support groups is that although
    many people think of respite care as something that should last
    days or even weeks, for many of us--and I will include myself
    in this number--15 minutes to spend in the bathroom or go to
    the library to pick out a new book or even have time to read
    that book is huge. So at these support group meetings, for an
    hour and a half or two hours, they are engaging with other
    adults and feeling like that is a form of respite, and the
    children are in other rooms taking part in activities and
    sharing their own experiences.
        Something else that we are able to do is we rely on--you
    know, it is not a one-stop shop. Adoptive and Foster Families
    of Maine is a very small organization. Even though we have an
    office in Orono and one in Saco, we only have a staff of seven
    throughout the state, and two of them--three, actually, if I
    count myself--are what we consider kinship specialists, but the
    others have a variety of other designated positions. So we try
    really hard to provide those families with training, and we do
    a statewide training conference annually. And for the first 20
    families, kinship or grandparents, who are unlicensed, we
    provide them with the cost-free registration, and if they are
    traveling more than 60 or 70 miles, we may also pay for their
    overnight stay at the hotel because that is just so important
    for them to have those opportunities to both learn and to
    network.
        I mentioned earlier that I raised my grandson. Well, today
    I am raising a 19-month-old little boy. He is not biologically
    related to me, but he is still part of my family. When I agreed
    to raise my grandson nearly 18 years ago, I imagined, ``Will I
    still be walking upright and be able to march with him as he
    marches down the aisle?'' Just a few months away, I guess I
    will succeed in that. But now I am looking at being past 70 and
    at a little boy who is yet to be two years old, and my thinking
    is: Am I the right person? I love him, he loves me. We love his
    family. We are hoping for good things. But it is still a
    question. And, you know, his mom is struggling with this
    crisis, this world of the opioids, and, you know, I have no
    idea. I cannot see into the future what that will be for her. I
    know she loves her son, and that is huge. And I hope she loves
    herself enough to get the help she needs.
        But that is part of why I really want to talk with all of
    you today, is to think about the ways that we can help this
    whole dynamic. We cannot do anything in isolation. It cannot be
    just the child. It cannot be just the parents. It cannot be
    just the grandparents. It has to be an active networking to
    provide supports to all concerned and not the least of which is
    mental health care.
        Funds to meet the barriers for these families can be huge.
    Just traveling back and forth to the doctor with the children
    is an unexpected cost, never mind things like child care, which
    most of us need--clothing and diapers--all of these things are
    added to families who had expected to be retired by now.
        So I would just look to all of you because I think that it
    is great that the families can rely on organizations like
    Adoptive and Foster Families of Maine and individuals like all
    of us here who care. But as a Nation, we also need to step
    forward and say yes, you can rely on individual organizations,
    but you can also rely on your country because you are doing
    extraordinary work, keeping your family together as a family
    and, moreover, keeping those children safe.
        So I thank you for recognizing this important issue. I
    appreciate the opportunity to share just a little bit of what
    is happening in Maine, both in terms of what works--and there
    are some things that work--and what continues to be
    challenging. And I hope that I can respond to any questions and
    be useful as you work to support grandparents raising
    grandchildren who have been affected by the opioid crisis.
        Thank you.
        The Chairman. Thank you so much for your very compelling
    testimony. You truly are one of those super heroes that we have
    heard about.
        And last but certainly not least, we will hear from Dr.
    McDaniel. Thank you for being here.

     STATEMENT OF SHARON McDANIEL, MPA, ED.D., PRESIDENT AND CHIEF
         EXECUTIVE OFFICER, A SECOND CHANCE, INC., PITTSBURGH,
                              PENNSYLVANIA

        Ms. McDaniel. Thank you. Chairman Collins, Ranking Member
    Casey, and members of the Committee, good afternoon. I greet
    you by saying ``Kasserian Ingera.'' ``Kasserian Ingera.'' ``How
    are the children?'' The Masai Warriors of Africa go from
    village to village asking, ``How are the children?'' And so
    today you are asking, ``How are the grandfamilies and the
    children?'' And I thank you.
        I am Sharon McDaniel, President and CEO of A Second Chance,
    Incorporated, a leader in kinship foster care and support
    services in Pennsylvania. I am also on the Board of Trustees of
    Casey Family Programs, the largest national foundation
    dedicated to the safety, permanency, and well-being of children
    in the foster care system.
        Since 1994, A Second Chance has serviced over 21,000
    children throughout the two largest counties--Philadelphia and
    Allegheny County--in Pennsylvania.
        Each day the dedicated staff of A Second Chance services
    over 1,800 children. We have a mantra at A Second Chance that
    says, ``Every child touched by A Second Chance has a right to
    be safe and must thrive.'' We do not treat our children as if
    they are in foster care but, rather, simply with family.
        So who are the children? They range from newborns to 21
    years old. Fifty-six percent of the children in our
    Philadelphia office are under the age of five. This is an 11
    percent increase in two years due to the opioid crisis. Forty-
    eight percent of the children in our Pittsburgh office are
    under the age of five. They are all enrolled in CHIP. They
    receive Medicaid support. They are from urban and rural
    communities and 82 percent of our kids have entered care
    because of neglect which is often associated with parental
    substance abuse.
        Our caregivers, 65 percent of them are maternal
    grandparents. Forty percent of all of our caregivers are
    single, female heads of household. Sixty-seven percent are over
    the age of 55, and they are often low-income. Our parents are
    single moms (82 percent of them). They are low-income, and they
    have a GED.
        It is critically important to know that kinship families
    are resilient and do not lose value in crisis. I am profoundly
    humbled and appreciative to be able to share with you a couple
    of stories where grandfamilies have stepped up and stepped in,
    and I will start with my own. You see me.
        From the time that I was two years old, I was placed in the
    care of my fictive kin. They were not related by blood, but
    related by the heart. They were members of my father's village.
    Following the tragic death of my mother, my father sunk into a
    deep depression and attempted to drink his way out of the
    problem. And he realized that he did not want this life for his
    young children.
        I witnessed, and was central to, the personal sacrifices
    that my grandparents had to make for us. And in the book that I
    gave you all, I tell my entire story, so I hope you get a
    chance to read it.
        Today, I am reminded of a grandmother who I met a year ago.
    She was 62 years old, and she had a successful career at
    Verizon when she was suddenly asked to care for her five
    grandchildren due to her daughter-in-law's opioid addiction.
    The family made these arrangements outside of the child welfare
    system. Unfortunately, due to the lack of supports, this
    grandmother ended up losing her job, and she and her
    grandchildren had to rely on TANF child-only payments to
    support her financially. The provisions outlined in Families
    First could have helped this grandmom. Thankfully, her faith
    community stepped in. The grandmother said to me, ``Though I
    may not have much, I have my grandchildren. They are with me
    and not in the system, and we are going to be all right.''
        Grandfamilies inside and outside of the child welfare
    system need support. For those inside the system, they need to
    be seen as an asset and not a problem. Grandfamilies already
    deal with feelings of isolation and guilt, but they must be
    treated with the dignity and respect that they deserve.
        Grandfamilies outside the system need the same supports as
    those offered inside--navigator programs, support groups,
    financial support, and mental health counseling.
        As a Nation, where would we be without grandfamilies? They
    make unparalleled sacrifices because they value keeping their
    families together.
        In closing, my Grandma's Hands Support Group participants
    told me to tell you this: ``We do what we do because we love
    our grandchildren and our families. We need your help and
    cannot do what we do without your love, support, and suspended
    judgment of those we interact with each day. Treat us as if we
    were your own grandchildren.''
        Thank you for the opportunity to present to you today.
        The Chairman. Thank you so much for your terrific
    testimony.
        Ms. Hoxie, I am going to start with you, not surprisingly.
    You told me earlier when we were talking about your grandson
    whom you raised from when he was just an infant, and he is now
    18 and on the verge of graduating from high school, as you
    shared with us. And he is a handsome young man, too, I might
    add. You mentioned in your testimony that you are now
    approaching 70----
        Ms. Hoxie. I am past 70.
        The Chairman. Or past 70, and I know from our previous
    interactions that you have raised some 19 children over the
    years. Now you are taking on the role of mother once again of a
    toddler. Tell us what motivates you.
        Ms. Hoxie. Well, I think it is what we have all talked
    about. It is about keeping family together. He thinks of me as
    his grandmother, and our family is his family. And so, you
    know, I have a real passion for making sure that that family
    stays as intact as it is possible. And I cannot see the--I do
    not know what the future brings, but I know definitely that we
    are his family.
        The Chairman. Well, I think he is very lucky.
        Ms. Hoxie. Well, when he is not wrecking my house, I think
    I am pretty lucky, too.
        [Laughter.]
        The Chairman. You talked about the services that the
    organization for which you work which helps not only kinship,
    it provides programs for adoptive and foster and kinship
    families, and you mentioned the importance of support groups
    and respite care and how critical that is. Maine is a large
    rural state where people often live in very small communities.
    How do you cope with the barriers of providing services in a
    state as large and rural as ours is?
        Ms. Hoxie. For some things, you know, we have had a lot of
    support between different staff at the Department of Health and
    Human Services and other--you know, like where some of us from
    the staff is constantly on the road, so we have learned to
    rendezvous with folks who will say, ``Okay. We are going to be
    at the Clinton exit in 20 minutes. Can we stop by and drop off
    what you have requested?'' So sometimes it is as simple as
    that.
        With regard to support groups, we have 26 around the state,
    and for a small state, that is a lot.
        The Chairman. That is indeed.
        Ms. Hoxie. But it still does not come close to meeting all
    the needs, so we have developed a mentor program so people can
    be on the phone and responding and helping them work through
    whatever the issues are. Again, it is not 100 percent, but it
    is a lot better than it could be.
        The Chairman. And that must be particularly important when
    you are dealing with children who have special needs.
        Ms. Hoxie. Absolutely. And then, you know, a lot of my
    staff have professional expertise in that topic, but we also
    take advantage of a program called Maine Parent Federation,
    which is another statewide organization that really provides
    support to all families that may have a child with special
    educational needs. And as you know, because so many of these
    children have been prenatally exposed to drugs and alcohol, a
    lot of them have a lot of issues educationally. Some would
    happen perhaps just because of the climate, the atmosphere that
    they were originally raised in. But many of them are prenatally
    exposed, and their brains are really compromised,
    unfortunately.
        The Chairman. I really worry about those babies and what is
    going to happen to them later on as the effect of that prenatal
    exposure becomes evident, although I know we are doing a much
    better job and have developed expertise in helping those little
    children.
        Ms. Hoxie. Exactly.
        The Chairman. Ms. Lent, the Kinship Care Programs are a
    great example of what can happen when agencies collaborate
    effectively. When I considered the role of the Aging Network in
    helping grandparents, I was surprised to learn that some states
    are not expending the maximum allowable amount of their
    National Family Caregiver Support Program funds. In fact--and
    correct me if I am wrong--but I think you said only seven
    states were using the program fully. Why do you think that is?
        Ms. Lent. Sure. So the National Family Caregiver Support
    Program allows ten percent of the dollars from that program to
    be used to serve grandfamilies. The program is designed for all
    types of family caregivers, but up to ten percent can be used
    for these families. And what we find is that states need to
    learn from each other about this issue and effective programs
    to serve the families. So when the program was first enacted,
    we put together some information to do some resource and
    information sharing between states about effective uses of the
    funds. It is not a lot of money, but we have seen some really
    creative and effective use of these dollars from putting
    together legal guides to operating support groups, to
    information and referral services, to money for bunk beds when
    there is an emergency.
        So we really see a need to elevate those practices and
    share information about effective use of these funds so that
    the Area Agencies on Aging can understand the population
    better--it is not a population that they are traditionally
    thinking of serving--to educate them more on the special needs
    of the population and creative and effective ways to serve
    them.
        The Chairman. Thank you.
        Senator Casey?
        Senator Casey. Thank you very much, Madam Chair, and I want
    to, first of all, thank the panel for bringing your testimony
    here and your experience, your expertise, and even your
    passion. I will start with Dr. McDaniel.
        We know that--we have some sense, I should say, not all of
    us know for sure, but even someone who is not living through
    this challenge knows the burden that folks are carrying. And
    one of the issues is can that grandparent or grandparents, can
    they access resources or information to help them, especially
    initially when they know they have to take on a significant new
    assignment? And I guess I would ask you, what can we do to be
    helpful in providing more opportunities to create what I called
    earlier a ``one-stop shop'' or one place for people to go? Is
    that simply aggregating existing services or opportunities? Or
    is that something where we have to create a new model or a new
    paradigm?
        Ms. McDaniel. Thank you, Senator, for the question. I think
    Jaia talked earlier about how we can think differently about
    places like senior centers in a different way. There are many
    community resources, but it really is about the way in which
    communities operate are currently in categorical places, so
    senior funding does not cross over the child welfare funding.
    So how do we create an integrated approach where, if a grandma
    has a child that is inside the child welfare system or not,
    that if she shows up at a senior center that she is able to get
    all the supports that she needs for that young person. An
    integrated model is what's needed in every community in
    America. I think that would go a long way.
        We need to also normalize. We talk about grandfamilies
    living in isolation. Grandfamilies--and I am a grandmom--need
    to know they are not alone in this fight, in this crisis. We
    need to be able to think about public service announcements
    where families live, work, and play; about having flyers and
    information and letting them know that we are here with then.
        Senator Casey. One issue that has arisen is access to
    mental health services. Tell us about that, if you could, if
    there are any barriers. What do you know about that?
        Ms. McDaniel. The young people I serve are all eligible. In
    fact, we enroll them in CHIP and Medicaid. But for
    grandfamilies who are outside of the child welfare system, it
    can be extremely difficult. They go to a TANF office. They are
    asked a host of questions that they may not even understand or
    know, and the process becomes very cumbersome.
        We need to streamline the language and the process so that
    when grandfamilies show up at these offices, they know what
    they are being asked. I think if we do something like that will
    help grandfamilies know that there are supports available.
    There are kids who have had traumatic experiences. We need to
    address their trauma because, otherwise, we are going to
    continue to create another generation of young people who have
    gone untreated.
        Senator Casey. And I know that your work brings you in
    contact with the health care system on a regular basis, and I
    know that is not what you do most of your days making
    recommendations about how to improve health care. But do you
    have any suggestions that we should focus on, especially now
    where we have the attention of the Nation on the question of
    health care? Anything you would recommend there?
        Ms. McDaniel. Children need health care. I just want to
    share a story with you briefly. Two weeks ago, I had to work
    with a family to bury a two-year old child. That child was
    taken to the hospital, but did not receive appropriate
    treatment, and the child died of pneumonia.
        If she did not have health care, what would have happened?
    She showed up with Medicaid. We need to make sure that families
    have the health care that they need and also that our systems
    are responsive to our children.
        Senator Casey. I appreciate that. I will wait for the
    second round.
        The Chairman. Thank you.
        Senator Cortez Masto, nice to see you.
        Senator Cortez Masto. Thank you, Madam Chair, and thank you
    for having this panel on this important topic.
        I am the former Attorney General of Nevada and I bring that
    up because I spent eight years addressing this specific issue.
    I drafted legislation and worked to pass it through the
    legislature to form a substance abuse working group that I
    chaired. I additionally created a drug-endangered children's
    unit in my office to address this issue. Moreover, I have been
    very vocal about the opioid abuse occurring in the State of
    Nevada and across the country that we see has just taken
    control, unfortunately, of many of our lives.
        And so I have a number of questions for you because I think
    many of them are topics that we still need to address but we
    are too afraid sometimes to bring forward. So let me just give
    you an example.
        In the State of Nevada, to get substance abuse treatment,
    because there is very little of it, you have to commit a crime,
    and you get priority for that.
        Now, with that said, the Affordable Care Act has brought
    additional resources for treatment--mental health treatment,
    substance abuse treatment--and there is talk about repealing
    it. I have concerns about how that is going to impact our
    communities. Particularly, I am concerned about those who are,
    unfortunately, going down the path of substance abuse and those
    who must take care of their children.
        I am curious. Does anybody have any thoughts on the impact
    that taking away treatment, particularly for opioids, is going
    to have across this country on the individuals who need it,
    whether they are children or adults?
        Ms. Lent. I am happy to speak to that. What I can say is
    that health care is critically important to these families. In
    particular, Sharon spoke to the fact that she works with many
    families inside the system. We are also familiar with the needs
    of families that are operating outside of the child welfare
    system, so they have no one place to go for information and
    support. However, when they do access some information about
    what they can qualify for, usually the one thing that they can
    access is Medicaid for the children, and that is critically
    important.
        And you also have families that may be too proud to access
    any cash assistance or help, but they know that they cannot
    afford the medical care for children, so they find that
    critically important.
        Actually, there was just a comment--Washington Post
    commentator Michelle Singletary just did a story last week
    talking about Big Mama, who she pulls a lot of her financial
    advice from, and she specifically--she was raised by her
    grandmother, Big Mama, and she said, ``Big Mama was too proud
    to accept money, but she knew she did not make enough to get
    treatment and medicine that we all needed.'' So she learned
    from her. This is a person who is very savvy with dollars, but
    she needed the medical support, and it was critical to her
    family.
        So Medicaid in particular is a critical foundation for
    these families, and we would not want anything to tear away at
    that critical program.
        Senator Cortez Masto. And I appreciate that comment.
        The other piece I see missing, and that we typically do not
    fund, is education awareness. To me, that is the first step in
    prevention, and it never gets funded. I had to fight for $1
    million out of my legislature just to engage in an education
    awareness piece on the threat of methamphetamine abuse, and
    that was the only time that we had ever put money into
    education awareness. I am concerned that we are still going
    down that path with opioids, and, Dr. McDaniel, you talked
    about it. It is about the education piece. It is about talking
    about it. It is about making sure there are dollars going to
    communities to teach them about what is happening with this
    opioid crisis.
        I am interested also, Dr. McDaniel, on your thoughts on
    that, along with how we have an impact on our rural
    communities. In Nevada, we have rural communities that are
    challenged just to have resources or access to health care and
    mental health needs. I am curious about your thoughts on how we
    can work together to improve that at a federal level and
    provide the assistance that is necessary.
        Ms. McDaniel. Right. I would think about us going back to
    funding the Kinship Navigator Programs. Those programs work in
    rural and urban communities, so we have to make them available.
        And the other piece that I wanted to go back to is the
    education component. If we do not have the necessary treatment,
    we will also see children languishing in foster care because
    families will not be able to get the treatment to remediate the
    issues. We already have over 400,000 children in the foster
    care system. You will see that number go up if families do not
    receive treatment because they cannot go back home, they cannot
    be returned, if they have not addressed their drug and alcohol
    addiction.
        We need to make sure that the educational content addresses
    treatment as well as what could happen in child welfare.
        Senator Cortez Masto. Thank you. And I know my time is up.
    I just want to say, though, about what you are doing with
    respect to caregivers, that both the stress level and support
    out there are crucial to our communities in helping address
    this issue. And if there is a way that we can, Madam Chair,
    figure out how we can provide additional support to the
    caregivers as well, I am supportive of it, and I think it is
    something we should be looking to do. Thank you.
        The Chairman. Thank you very much.
        Senator Donnelly?
        Senator Donnelly. Thank you, Madam Chair.
        Before I begin my questioning, I want to first share the
    story of a woman from Indianapolis named Theresa Short. Theresa
    is a grandmother who is currently raising her grandson because
    her son suffers from an opioid addiction. She faces many of the
    same challenges that have been highlighted in this hearing here
    today.
        When describing the difficulties of raising a grandchild
    outside the formal foster system due to the opioid epidemic and
    the challenges of accessing necessary resources for her
    grandson, Theresa wrote, ``I could not get his medical records
    because I had no legal guardianship. I had to buy him new
    school supplies, new clothes and everything else a boy might
    need. As a grandparent, I had to do this alone with no support.
    The odds were stacked against my grandson and against me as a
    grandparent. Without having legal guardianship of my grandson,
    it made it difficult to reach out for help and to provide
    services to our family. My grandson is hurting, and many times
    he feels like he is already an adult. His childhood was taken.
    The things he has gone through are not easy, and trying to
    regain those relationships with his parents has been a process.
    Our grandchildren need to have access to counseling, and
    grandparents need to help change the cycle, and they need help
    to do that.''
        Theresa's story is shared by too many families in my home
    State of Indiana and across our country. I want to thank all of
    you for the work you do to address this issue and for taking
    the time to testify here today.
        Ms. Lent, I would like to ask you, as Theresa noted in her
    story, many children impacted by the opioid epidemic need
    access to counseling and mental health services. You mentioned
    in your testimony that Medicaid plays a critical role in
    providing health care to grandfamilies. In your view, how would
    grandfamilies be affected and impacted by the attempt to cut
    Medicaid spending by $880 billion in the American Health Care
    Act?
        Ms. Lent. Again, Medicaid is a critical source of support
    for these families. To some families, it is the only federal
    program or support that they do tap into, are aware of, and get
    access to. So it is important for the children. Children that
    are impacted by the opioid epidemic, if their parents are
    struggling with addiction and they have trauma in their
    history, they certainly need to get some support early on to
    make sure that they do not fall prey to a similar path. And
    having access to health care and stable support of a loving
    caregiver are two critical factors in ensuring that they,
    contribute and grow up to be healthy, thriving adults. And
    Medicaid in so many of these families is a critical part of
    that picture.
        Senator Donnelly. Thank you.
        Dr. McDaniel, you shared your organization immediately
    seeks to enroll children in CHIP in order to assess their
    medical needs. In your experience, are there sufficient
    counseling services available to children? And how essential is
    CHIP in connecting children to the counseling services that are
    available?
        Ms. McDaniel. Thank you for the questions, and let me
    answer the first one. In terms of the services available for
    children relative to trauma-informed care, absolutely no. There
    are not enough providers to address their needs because it is a
    specific way in which children need to be engaged when it is
    trauma-informed. There are not enough providers in that space.
        But in terms of CHIP, absolutely. Every child needs
    Medicaid. They need to be enrolled, even in the interim of
    finding that trauma-informed therapist or counselor. There
    needs to be someone who can support that young person. So,
    absolutely, CHIP is necessary.
        Senator Donnelly. Thank you.
        Thank you, Madam Chair.
        The Chairman. Thank you, Senator.
        Dr. Dolbin-MacNab, research findings suggest that being a
    custodial grandparent is particularly taxing on those
    grandparents who are raising children without the presence of
    any parent. I was interested and heartened to learn from you
    that some of the negative outcomes that you mentioned can be
    avoided or turned around by those grandparents who are more
    resilient. But my question to you is this: Is resilience an
    innate quality that people have? Or is it something that can be
    learned?
        Dr. Dolbin-MacNab. Thank you for that question. Your
    question underscores a significant point of discussion and
    debate among those who study resilience. What we think is that
    characteristics associated with resilience, including coping
    skills, benefit finding, and seeing the good things in a
    challenging situation--those are skills that can be trained and
    developed. I have a colleague at Case Western Reserve
    University, Dr. Carol Musil, who does wonderful work. Dr. Musil
    and her colleagues provide resourcefulness training to
    grandparents raising grandchildren, and this training has shown
    very promising results related to reducing grandparents'
    depression and stress, and improving their quality of life.
        There may be people who are more resilient than others, but
    many aspects of resilience are skills that can be taught. Also,
    we can improve grandparents' resilience by improving the
    quality of the environments in which grandparents are living.
    Providing grandparents with some of the supports that we have
    all been talking about today can help promote resilience as
    well.
        The Chairman. Thank you.
        Dr. McDaniel, we have also talked about the financial
    strain that many grandparents experience when they assume this
    unexpected role later in life. As you mentioned, these
    grandparents often spend their own money on housing and school
    supplies and food--expenses that they had no reason to include
    when they were doing their budgets for their older years.
        How often do you see grandparents drawing on their
    retirement savings or even returning back to work in order to
    have sufficient funds to care for their grandchildren?
        Ms. McDaniel. It happens every day for the 7.6 million
    children that we talked about, caregivers are caring for those
    young people outside of the child welfare system, and are doing
    whatever it takes to make it. As you heard earlier, we know
    that grandparents are often on limited incomes or poor. So what
    are they tapping into if they are already poor? So we see them
    going back into the workforce. We see them staying longer.
        So I think one of the recommendations that I would make, we
    need to do something in the industry in terms of looking at
    employers. What are employers doing when it comes to
    grandfamilies who are staying longer in the workforce? Are we
    being sympathetic? Are we ensuring that child care is
    available? The very same things we did when the Family and
    Medical Leave Act first took place. We need to think about how
    that is transferred and how that is translated to grandfamilies
    who are working longer.
        In the child welfare system, however, grandfamilies who go
    through the process of foster care, they receive the same
    dollars and support that a foster parent would receive. But,
    again, those families outside of the system need that same
    support.
        The Chairman. You anticipated my next question which I was
    going to ask Ms. Lent about. But, actually, I will ask all of
    you just to go across, and that is, it seems to me we have an
    unusual situation here. Obviously, it often is best for the
    child to be with the grandparent or be with another family
    member. And yet unless they go through the legal process, in
    most states they are not going to get the financial assistance
    they would receive if they were ``just foster parents.''
        Now, I know many foster parents in Maine, and they do an
    extraordinary job. They do get some assistance financially that
    many of these grandfamilies do not get. So is that correct? Is
    my understanding correct? And if so, do you have suggestions
    for what we might be able to do? Ms. Lent.
        Ms. Lent. Sure. So there is a continuum of arrangements
    that we see with grandparents raising grandchildren. On the one
    side, there would be those that go through the full licensing
    process, get the windows up to the exact requirements, have the
    right number of bedrooms, and go through that extensive
    process. And when they go through that process, the vast
    majority of those families would get the licensing rate that a
    traditional foster parent would be. But that is a small portion
    of all of the families.
        There are also those that can be in unlicensed foster care,
    so it is sort of an interim role where they may or may not get
    some amount of money, but it is not going to be the same amount
    as the fully licensed family.
        And then on the other end of the spectrum, there are those
    that just step in and keep the children from even making
    contact with the child welfare system. And by stepping in, in
    advance, and making sure that the child is safe and never even
    needs to make contact with the child welfare system, in a sense
    they are penalized, and they get almost no support. So that is
    the challenge that we have.
        Of course, we believe that we should be supporting families
    with what they need, not based on what circumstances ultimately
    brought the children into the relative's care. So we need to
    find a way that we present them with their full range of
    options, talk about the advantages and disadvantages of each,
    and make sure they get the support that they need.
        The Chairman. Thank you.
        Dr. Dolbin-MacNab. One of the things that I have heard is
    that many grandparents are afraid of the child welfare system.
    They are afraid that their grandchildren will be taken away
    from them. They are afraid that siblings will be separated.
    Whether or not that is the case, that is a fear that they have,
    and they often experience a sense of stigma related to being
    involved in the child welfare system. Some of the grandparents
    that I have worked with were involved with the child welfare
    system when they were parents with their own children.
        One of the things to consider is how can we raise awareness
    among child welfare professionals and educate grandparents so
    that these systems can better support grandparents and so that
    these systems are not perceived by grandparents as being an
    adversarial environment and experience.
        The Chairman. Ms. Hoxie?
        Ms. Hoxie. Well, I would like to share just a quick story.
    I have been working with a grandmother who has a very medically
    fragile baby that was placed with her because of her daughter's
    use of opioids, and she travels 240 miles twice a week to get
    the baby medical treatment, and at least once from Maine,
    Downeast Maine, to Boston once every 4 to 6 weeks.
        When she took the baby, it was with the fact that it was a
    safety plan. The Department of Health and Human Services had
    intervened, but they opted not to take the child into custody
    and left her with her grandmother. The grandmother was working.
    She had a reasonably good job. But because of the baby's
    incredible medical needs, she took family leave in the
    beginning. She went on to take leave without pay. During that
    time she really fell behind, and she was in danger of losing
    her vehicle.
        Now, imagine what it would be like to know that is the only
    way that you can get access to medical treatment for that
    child, and there she was about to lose it. We were able to get
    some help for her and get her payments caught up, and she has
    since gone back to work, and she is in the foster care
    licensing process now, and the Department has taken custody.
    So, eventually, until she is licensed, she will get $10 a day.
    But in the meantime, there is this huge gap. And, interestingly
    enough--and part of this is--what I am getting to is that part
    of it is creating that awareness throughout the state and
    within the systems, including the Department of Health and
    Human Services, of how important it is, if you are going to
    take custody, to do it quickly so that the family has just even
    that minimal support.
        In Maine--and I do not know if it is across the country,
    but in Maine, for babies that are medically fragile, that could
    actually succumb to these effects of that fragility, they
    actually--once they are licensed, they are eligible for $60 a
    day. But here 10 months have gone by without them getting
    anything just because of gaps in the system and people not
    being aware.
        So when we are educating people, we just need to do a
    better job of emphasizing the possibilities and to encourage
    that those safety plans, if you will, do not go longer than the
    designated 35 days, or whatever it is in whatever state,
    because that will make a huge difference for some families. I
    mean, obviously, there are many other issues, but that one
    comes to mind quickly because, you know, I felt so badly for
    this family.
        The Chairman. Thank you.
        Dr. McDaniel--I know I am way over my time--did you have
    anything you wanted to add?
        Ms. McDaniel. I just offer that if we would consider
    federal child welfare finance reform, that initiative would
    allow us to look at how we fund child welfare. In the current
    system, the child has to be abused or neglected in order to
    receive resources. That should not happen.
        The Chairman. Thank you.
        Senator Casey?
        Senator Casey. Thank you very much.
        Ms. Lent, I wanted to go back to your written testimony.
    Despite all the challenges that we have outlined or articulated
    here today, it is remarkable when you put on paper that list of
    positive outcomes that come from relative care, where you say
    on page 4 of your testimony, ``reinforces safety, stability and
    well-being, reduces trauma, reinforces child's sense of
    identity, helps keep brothers and sisters together, honors
    family and cultural ties, and increases the likelihood of
    having a permanent home.'' Really powerful outcomes for that
    child and that family.
        I guess that leads me to one question. You made reference
    to a foster care savings of about $4 billion. Can you tell us
    about that?
        Ms. Lent. Sure. We know that the vast majority of children
    being raised by grandparents are being raised outside of the
    foster care system, so I talked about those on this end of the
    continuum that step in and keep children out of foster care, so
    never entering the foster care system.
        Well, when you look at the savings from that foster care
    payment, it is conservatively $4.5 billion a year per year. So
    there are savings that come from that.
        But there are also long-term savings, I would also suggest,
    because the children fare so well, so much better in the care
    of relatives, the children have fewer behavioral and mental
    health issues in the long run, so they are more likely to end
    up being contributing to our communities and our economy in
    positive ways.
        Senator Casey. I appreciate that, and it is important for
    us to know that number.
        Dr. McDaniel, you had shared in your testimony the story of
    the grandmother who--let me get your exact words. You said that
    she was a 62-year-old grandmother who ``had a successful career
    at Verizon when she was suddenly asked to care for her five
    grandchildren due to her daughter-in-law's opioid addiction.''
    You go on to say that she had real trouble and her faith
    community saved her.
        Ms. McDaniel. Yes.
        Senator Casey. Tell me about that example and the reason
    you raise that example in your testimony. What is the point
    that we should take away from that?
        Ms. McDaniel. Right. I raise that because she was quite
    isolated. She did not know about the community resources that
    were available. She had gone to the child welfare system, and
    they told her, ``Well, because your family made those
    arrangements first, you are not eligible for any support from
    us.''
        So she went to the TANF office, and they said, ``We are
    going to give you TANF and Medicaid and pretty much that is
    about it''. If she was trying to get child care, she could not
    get child care, so she ended up losing her job. And what I did
    not add was that she was living in a one-bedroom apartment. If
    she was in the child welfare system, they would have said that
    was not adequate--``We need to move you to a larger place.''
    But she should not have had to go to a child welfare office to
    get that support for the children that come in care.
        So Navigator Programs, support programs, programs that are
    associated with senior centers are the kinds of resources she
    should have been able to go and get the support that she
    needed, not lose her job. She was almost retirement age, but
    she had to give up all those years because she did not have the
    adequate supports.
        Senator Casey. I appreciate that. Thank you.
        Ms. McDaniel. You are welcome.
        The Chairman. Senator Warren.
        Senator Warren. Thank you, Madam Chair, and thank you very
    much for holding this hearing, and thank you, Ranking Member.
        Last week, I was at the Manet Community Health Center in
    Quincy, Massachusetts, and the week before that, I was at Lynn
    Community Health in Lynn, Massachusetts, and talking to
    physicians and first responders and patients and local
    officials about how this public health care crisis has
    devastated communities and families across our Commonwealth.
        According to the Massachusetts Department of Public Health,
    an estimated 2,000 people in our state died for opiate
    overdoses just last year. And as the Chair and the Ranking
    Member have noted, thousands of children are affected, and many
    are left in the care of their grandparents. And I have seen the
    data on this that children whose parents struggle with
    substance abuse disorder are about twice as likely to develop
    the disorder themselves.
        So where I wanted to start this was a variation on the
    question that Senator Casey just asked Dr. McDaniel, and that
    is about resources and connections. But this one is about when
    you suspect a substance abuse problem.
        Ms. Lent, can I ask you, if grandparents become concerned
    about a grandchild's substance use, are there good options for
    them to access treatment or counseling in their own
    communities, maybe through a pediatrician, that grandparents
    are readily familiar with?
        Ms. Lent. So, again, those that are already connected to
    the child welfare system would probably turn to the social
    worker at the child welfare system for that information. But
    the vast majority do not have that resource available to them,
    so best-case scenario they live in a community that has a
    kinship navigator, where they would have a one-stop-shop answer
    to those questions. But those are also not available in most
    communities right now. We would like to see them.
        So I would say the vast majority of families in that case
    are going to look to the physician that they are connected
    with, probably their child's pediatrician, so it would be very
    important that the physician is familiar with issues of
    substance use and how it affects children when they are exposed
    and when their families are dealing with that crisis and to
    coordinate those services.
        Those that may not even be comfortable talking to their
    physician are going to look to their peer network, and that is
    why support groups and other types of services of some of the
    agencies represented here are really important because that
    peer-to-peer communication and where to go for support is
    really critical as well.
        Senator Warren. I understand that, and I think that is
    really important.
        Did you want to add to that?
        Dr. Dolbin-MacNab. Yes, thank you. Related to your
    question, there are some really exciting intervention models.
    One of those approaches is nicknamed SBIRT, which refers to
    Screening, Brief Intervention, and Referral to Treatment. This
    approach involves training a variety of practitioners, everyone
    from nurses to physicians, to screen people where they are and
    to make referrals in their communities for substance abuse
    treatment. I am in a rural community, and I think those types
    of resources are so important because people will go to their
    doctor to talk about what is going on, but they may not
    necessarily access a substance abuse treatment facility.
        Senator Warren. Right. And, you know, your point gives me a
    chance to talk about one in Boston, but it is the reminder, how
    many different kinds of services may be needed when it is time
    to intervene. The adolescent substance abuse program at Boston
    Children's Hospital brings together whole teams of
    pediatricians, social workers, child psychiatrists. They work
    on screening, they work on diagnosis, and they work on
    treatment for adolescents who have substance abuse disorder.
    And the idea is to do this hopefully at a time when they can
    keep children both at home and in school and try to work
    through these problems. And the program partners with pediatric
    practices throughout the region so that local doctors can get
    engaged in this.
        I take it from your comments, and from everyone nodding
    their heads about this, that this is an important thing for us
    to expand, that this is the kind of thing that we should try to
    make available throughout the country, so someone has got to
    weigh into this.
        I want to ask another part about this, and that is, when
    grandparents are trying to get substance use disorder diagnoses
    and treatment, both for their children and for their
    grandchildren, or for either, how important is health care
    coverage to providing access to preventive screening and to
    specialty care? Ms. Lent, could I ask you about that?
        Ms. Lent. Again, I would say it is critically important. I
    conveyed earlier that often when they do not have access to
    other services, they still have access to Medicaid for the
    children, and so that is a critical resource to them, again.
    But they need to be aware of it, so things like Kinship
    Navigator Programs and resources that can connect them to those
    services are important. But the health care is foundational.
        Senator Warren. Right. And if the cost of health care goes
    up or if Medicaid is sharply cut, what will be the impact? Ms.
    Hoxie, maybe would you like to speak to that?
        Ms. Hoxie. Well, I can certainly speak on a personal note.
        Senator Warren. Yes.
        Ms. Hoxie. If I did not have medical coverage for my
    children, I cannot even imagine, you know, what it would be
    like, and certainly for the families that I work with.
        I can give you one example of a family that lived in a
    rural area in Maine, and the grandmother was caring for her son
    who was addicted--his child--I do not know where the mother was
    in all of this--and her husband was ill. The son eventually
    overdosed and died, leaving grandmother with, ``Oh, my gosh,''
    you know, ``how do I meet the needs, the mental health needs
    now of this grieving child?''
        Two weeks later, her husband passed away, so she was, you
    know, looking everywhere to find grief counseling, and in the
    area that she lived in, there was not anything that was going
    to be available for 16 weeks.
        So I do not know if that answers your question, but going
    without it, you know, was devastating. And they did eventually
    find somebody that would work with them individually. She
    wanted someone that would work with them as a grieving family
    and with a child with some significant mental illness himself
    at this point.
        Senator Warren. I appreciate that, and I see you all
    nodding on this. You know, the Affordable Care Act made it
    possible for many families that are struggling with substance
    abuse to get access to the care that they need. And if the
    mental health and substance abuse disorder protections of the
    ACA are cut out, the estimate is that there would be $5 billion
    in resources taken out of this area, which would make it a lot
    harder for families to get their lives back on track.
        So this is something that I appreciate your talking about
    and a reminder of how much we need to do to make sure that we
    are trying to support families that are struggling with this
    terrible epidemic. Thank you.
        Thank you, Madam Chair.
        The Chairman. Thank you.
        I want to thank all of our witnesses for testifying today.
    Your testimony was so compelling and educational, not only to
    the members of this panel, but to those who are watching on C-
    SPAN and to others who will learn about this hearing.
        One of the motivations for holding this hearing was to
    raise public awareness about the growing prevalence of
    grandparents raising grandchildren, something that has always
    occurred in society, as Dr. McDaniel has made clear, but we are
    seeing a huge increase as a result of the terrible opioid
    epidemic that is devastating so many families in so many
    communities across our country.
        Through your programs, your advocacy, your research, your
    service, and your testimony today, you are truly making a
    difference, and I thank each and every one of you for that.
        I thought that I would conclude my comments, before turning
    to my colleague, by quoting on the plus side of what happens
    when a grandparent takes in a grandchild, and this was from an
    interview of a grandmother who was interviewed on Maine
    television recently. She put it best when she said, ``When your
    grandchild looks at you and says, `I love you more than 500
    peanut butter sandwiches,' then you think to yourself, in the
    end it is worth it to know they are happy and safe. You know,
    just normal little boys. Maybe a little overactive, but a
    normal little boy.'' And that really does sum it up, and that
    is the benefit of kinship care.
        Federal policies such as the National Family Caregiver
    Support Program continue to serve as a critical resource, but I
    agree with Ms. Lent in that a lot of states do not think of
    that program as a way to help grandparents that are raising
    grandchildren. There, again, I hope that we are raising the
    awareness of area Agencies on Aging, which do such fabulous
    work, that this is another possible use of the funding. We are
    going to continue to work together to look at what else we can
    do.
        In the meantime, I think we have an enormous debt of
    gratitude to those grandparents who are opening their homes and
    their hearts to their children's children.
        Senator Casey?
        Senator Casey. Madam Chair, thank you, and thank you for
    having this hearing and convening us. We hope we do not have to
    have future hearings on this topic, but I am afraid we may.
        I did want to reiterate what many of us have been thinking
    and I think some of us have tried to articulate one way or the
    other, and that is the heroic nature of what these individuals,
    these families are doing. We live in a society which, for not
    just recently but over, unfortunately, many generations, the
    people that we tend to point to as heroes really are not
    heroes. They are movie stars, athletes or people like that--
    really are not heroic. Soldiers are heroes, of course. People
    who protect us every day are heroes. And people who provide
    this kind of care and security for their family and in a sense
    our extended family are really heroic.
        To use an old expression, they lead quietly triumphant
    lives. Their names are not in the paper. They are not the
    subject of a claim of notoriety, but they get up every day and
    take on a more difficult task of raising children when they
    were looking forward to a tranquil and restful retirement.
        I do believe that we can come together and do more. I do
    not think the Federal Government is always the place to turn to
    for a new program or a new strategy to deal with the problem.
    But there has to be a way that the Federal Government can be a
    constructive partner in helping states and communities to
    aggregate services to come together. And we had some examples
    of that and some recommendations today.
        I think we have to make the right decisions the next couple
    of weeks and months on a range of policy matters, especially
    those relating to ACA and Medicaid especially, and I will be
    talking more about that. But we are grateful that you brought
    your own stories, your own expertise, and your own passion
    about these issues before us today.
        As a Pennsylvanian, I am especially grateful to Dr.
    McDaniel here, and also, Ann and Marvin, we are grateful that
    you made the trip to be with us today.
        But to all of our witnesses, I thank you for doing this,
    and thanks for bringing this information and heightening
    awareness of this challenge.
        The Chairman. Thank you, Senator Casey.
        Committee members will have until Friday, March 31st, to
    submit questions for the record. If we receive some, we will
    forward them on to you. Again, my thank you to all of you for
    your participation today.
        This hearing is now adjourned.
        [Whereupon, at 4:07 p.m., the Committee was adjourned.]

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                                    APPENDIX

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                   Prepared Witness Statements and Questions
                                 for the Record

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     Prepared Statement of Jaia Peterson Lent, Deputy Executive Director,
                       Generations United, Washington, DC
        Generations United is pleased to provide testimony to the Senate
    Special Committee on Aging. We applaud Chairwoman Collins, Ranking
    Member Casey, and members of the committee for your leadership in
    holding this hearing on the important role of grandparents and other
    relatives in providing safe and stable homes to children who cannot
    remain in the care of their parents, and the sharp increase in this
    trend attributed to the opioid crisis.
        Today's grandparents provide a continuum of care from part- or
    full-time child care to raising a grandchild due to the parent's death,
    disability, addiction or military deployment. This testimony will focus
    on grandparents and other relatives raising children, also known as
    grandfamilies.
        According to the U.S. Census, more than 2.6 million grandparents
    report they are responsible for their grandchildren.\1\ About 7.8
    million children live in households headed by kin--a grandparent,
    uncle, aunt or other relatives.\2\ About 2.5 million children are
    living with grandparents, relatives or close family friends without
    either of their parents in the home.\3\
    ---------------------------------------------------------------------------
        \1\ U.S. Census Bureau, 2015 American Community Survey.
        \2\ U.S. Census Bureau, 2010 Census.
        \3\ Annie E. Casey Foundation Kids Count Data Center. 2013-2015
    Current Population Survey Annual Social and Economic Supplement.
    ---------------------------------------------------------------------------
        There are many kinds of grandfamilies. In some grandparents are
    raising children inside the formal foster care system as licensed or
    unlicensed kinship foster parents. Some have legal custody but no
    connection or support from the child welfare system. Still others are
    raising the children informally without legal custody or guardianship.
    While the challenges these families face are varied and complex, they
    are united by one common factor: they believe beyond a shadow of a
    doubt in the importance of family. They believe children fare better
    when they are raised in a family, not a system, and they are right. Yet
    we cannot ignore the fact that they often step in at great personal
    sacrifice, impacting their own health, family relationships, retirement
    plans and financial well-being. These caregivers, and the children they
    are protecting and nurturing, deserve our respect and support.
        My testimony today will focus on four key points:

          One, the impact of the opioid epidemic on grandparents
    and other relatives;
          Two, the critical role of grandparents and other relative
    caregivers in helping children thrive when their parents are no longer
    able to care for them;
          Three, the importance of supportive services to help
    grandfamilies succeed; and
          Four, the valuable role that the National Family
    Caregiver Support Program and Area Agencies on Aging can play in
    helping respond to the crisis.

        First, a little about Generations United. Generations United is the
    only national membership organization focused solely on improving the
    lives of children, youth and older people through intergenerational
    strategies, programs and public policies. Since 1986, Generations
    United has been the catalyst for policies and practices stimulating
    cooperation and collaboration among generations. We believe that we can
    only be successful in the face of our complex future if generational
    diversity is regarded as a national asset and fully leveraged. For
    almost twenty years, Generations United's National Center on
    Grandfamilies has been a leading voice for issues affecting families
    headed by grandparents or other relatives and the need for evidence-
    based practices to support them.
    Impact of the Opioid Epidemic on Grandparents and Other Relatives
        Who are the grandparent caregivers? They are diverse in terms of
    race, culture, income and geography. Thirty-nine percent are over the
    age of 60 and approximately 58 percent are currently in the workforce.
    They are more likely to live below the poverty line than their peers--
    21 percent--and 26 percent have a disability. They face unique
    challenges that impact their well-being and their ability to fully
    support and parent their grandchildren.
        Unlike parents or foster parents who plan for months or years to
    care for a child, these grandparents or other relatives usually step
    into their role unexpectedly. Some may have received a call in the
    middle of the night telling them to come and pick up their
    grandchildren or they will end up in foster care. Suddenly, they are
    forced to navigate complex systems to help meet the physical and
    cognitive health challenges of the children who come into their care,
    often after experiencing significant trauma.
        Caregivers may struggle with their own mental health issues
    stemming from feelings of shame, loss or guilt about their adult
    child's inability to parent. They may suffer from social isolation and
    depression because they do not want their peers to know about their
    situation or because their peers are no longer parenting. Caregivers of
    children whose parents are using drugs may have their stress
    exacerbated by trying to maintain or navigate an ongoing relationship
    between the child and parent, often unaware if the parents are
    currently using drugs or alcohol and how their behavior will impact the
    child. Relative caregivers are often grieving a host of losses,
    including that of the treasured traditional grandparent role, control
    over their future, financial security or even the ability to go on
    vacation.
        Taking on the unexpected expense of a child can be especially
    devastating to caregivers living on fixed incomes. Countless
    grandfamilies report spending down their retirement savings to address
    the health, mental health, food and clothing needs of the children, or
    to pay legal expenses from seeking legal custody of the children.
    Others turn their retirement savings into college tuition payments.
    Many older caregivers live in one bedroom apartments or senior housing
    where children are not welcomed and need to move to larger, more
    expensive housing.
        While grandparents have been called upon to raise children for many
    reasons over the years, the current opioid and heroin epidemic is
    overwhelming many families and child welfare systems.
        Grandparent Pamela Livengood shined a light on impact when she
    said, ``For my 50th birthday, I got a two-year-old. My story isn't
    unique. The [opioid] epidemic has devastated communities all over the
    country. It doesn't discriminate against age, race or gender. It
    affects all of us.''
        After years of decline, the overall numbers of children in foster
    care are on the rise. From state to state, experts say the current
    opioid and heroin epidemic is the number one reason for this
    increase.\4\ Recent data show the percentage of children entering
    foster care due to parental drug and alcohol use rose from 22 percent
    to nearly 30 percent in just five years.\5\ This was the largest
    increase in any reason for removal. Some pockets of the country report
    as high as a 33 percent increase in the numbers of children in state
    custody.\6\
    ---------------------------------------------------------------------------
        \4\ Examining the Opioid Epidemic: Challenges and Opportunities:
    Hearing before the Committee on Finance, Senate, 114th Cong. (2016)
    (statement of Nancy Young, Ph.D., Director, Children and Family
    Futures, Inc., Lake Forest, CA). | Kamp, J. & Campo-Flores, A. (2016,
    January 11). Parents' drug abuse strains child-welfare agencies:
    Growing epidemic puts more children into foster care.
        \5\ National Data Archive on Child Abuse and Neglect. (2009-2015).
    Adoption and Foster Care Analysis and Reporting System, Foster Care
    Files 2008-2014. Retrieved from http://www.ndacan.cornell.edu/datasets/
    datasets-list-afcars.cfm.
        \6\ Quinton, S. (2015, October 9). How heroin is hitting the foster
    care system. Pew Charitable Trusts, Stateline. Retrieved from http://
    www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/10/09/
    how-heroin-is-hitting-the-foster-care-system.
    ---------------------------------------------------------------------------
        The current epidemic is hurting our country's families and
    stressing many state's child welfare systems. Child welfare systems are
    increasingly looking to grandparents and other relatives to care for
    the children as they face shortages of foster parents to meet the
    growing need. In 2014, more than a third of all children who were
    removed from their homes because of parental alcohol and drug use were
    placed with relatives.\7\
    ---------------------------------------------------------------------------
        \7\ Analysis conducted by Children and Family Futures (CFF) on the
    public use 2014 Adoption and Foster Care Analysis and Reporting System
    dataset. Estimates based on all children in out of home care at some
    point during Fiscal Year 2014.
    ---------------------------------------------------------------------------
        This is not just a child welfare system issue. As one grandmother
    said, ``Grandparents are doing whatever it takes to bring their
    grandchildren to safety.''
        Although the child welfare system relies heavily on relatives, the
    number of grandparents, uncles, aunts and others who step in to care
    for children and keep them out of foster care far exceeds those raising
    children inside the system. In fact, for every child being raised in
    foster care (often referred to as ``formal care'') with a relative,
    there are 20 children living with grandparents or other relatives
    outside of the foster care system, in ``informal care.'' Often thrown
    into this caregiving role with little or no warning, caregivers
    frequently do not know about supports and services for which they may
    be eligible. Those raising children outside the system usually struggle
    with even less support. They save our country's taxpayers more than $4
    billion a year by raising and keeping children out of foster care.
    These families deserve our respect and support.
    Impact of Grandparent and Other Relative Caregiving on Child Well-being
        Grandparents and other relative caregivers play a critical role in
    helping children thrive when their parents are no longer able to care
    for them.
        Despite the challenges facing grandparents and other relatives
    raising children, children fare well in the care of relatives. Compared
    to children in non-relative care, they have more stability, are less
    likely to run away and are more likely to report feeling loved. When
    children cannot remain with their parents, research shows placing
    children with grandparents or other relatives:

          Reinforces safety, stability and well-being
          Reduces trauma
          Reinforces child's sense of identity
          Helps keep brothers and sisters together
          Honors family and cultural ties
          Increases the likelihood of having a permanent home \8\
    ---------------------------------------------------------------------------
        \8\ Generations United. (2016). Children thrive in grandfamilies.

        When explaining why it was so important that he had been raised by
    his grandparents, Ray Krise, a member of the Skokomish Tribe near
    Shelton, Washington, said, ``If not for being raised by my
    grandparents, I would not have a cultural identity. I wouldn't know my
    family lineage and my son would not bear the name Tcha-LQad--a name
    that is 17 generations old . . . [They] helped me develop a real sense
    of pride and belonging.''
        Grandfamilies are also more likely to continue to provide a safe
    haven for a child long after they have turned 18 or transitioned out of
    the foster care system. A young person may age out of a system--they
    never age out of a family.
    Importance of Supportive Services to Help Grandfamilies Succeed
        While many strengths, challenges and needs are shared by these
    diverse families, the level, length and type of supports they need
    vary. Unfortunately, the degree to which these families receive
    supports and services from the child welfare system is often tied
    largely to the way in which they happen to come into their grandparent,
    aunt, uncle, or other relative's care, not the needs of the family.
        Grandparents who are able to step in to protect and care for their
    grandchildren and keep them out of the child welfare system are, in a
    sense, punished for this critical and loving act. While services are
    often still inadequate for caregivers who become licensed as foster
    parents, they are far more likely to receive crucial supports and
    benefits than those raising children outside foster care. Child welfare
    programs should do more to prioritize supports for caregivers who keep
    children out of foster care and address barriers to licensing relatives
    as foster parents when it is the best option for the family. Networks
    of aging services agencies and other community supports can play a
    critical role in helping these families by coordinating with child
    welfare agencies to provide seamless supportive services to families
    with older caregivers of children who are not getting the full range of
    supports and services they need from the child welfare system.
        Families commonly face challenges that can be addressed through the
    provision of key supports and services such as:

        Information and Referral Services such as kinship navigator
    programs that provide a single point of entry for learning about
    housing, household resources, physical and mental health services and
    financial and legal assistance.
        Physical and Mental Health Care and Services for older caregivers
    and children including Medicaid and Medicare, which have proven to be
    critical resources to grandfamilies. Quality counseling and trauma-
    informed mental health services have been shown to improve outcomes for
    the caregivers and children.
        Affordable Legal Services so grandfamilies impacted by parental
    substance use disorders, whether inside or outside the foster care
    system, can access a continuum of legal relationship options and
    understand the differences--both legal and practical--of adoption,
    guardianship and legal custody.
        Lifespan Respite provides coordinated, community-based respite for
    family caregivers caring for individuals with special needs of all
    ages.
        Financial Supports including access to Temporary Assistance for
    Needy Families (TANF)--one of the three primary purposes of which is to
    support children in the care of relatives, Social Security retirement,
    disability and survivor benefits for both the caregivers and for the
    children, and Supplemental Security Income for low-income caregivers
    and children who are disabled.
    Valuable Role That the National Family Caregiver Support Program and
            Area Agencies on Aging Can Play in Helping Respond to the
            Crisis
        When the National Family Caregiver Support Program (NFCSP) was
    signed into law as part of the Older Americans Act in 2000, Generations
    United successfully advocated that grandparents and other relatives
    raising children be included to support older Americans not only as
    those receiving care but also as those giving care. Current law gives
    states the option to use up to 10 percent of state NFCSP dollars to
    serve grandfamilies in which the caregiver is age 55 or older.
    According to the Administration for Community Living's Aging Integrated
    Database (AGID), only seven states use nearly the full 10 percent of
    funds to serve the families.
        Those who do use the funds to serve grandfamilies report
    significant impact. But they are stretching scarce resources elevating
    the urgency for additional investments to adequately meet the needs of
    grandfamilies. Examples of successful uses of funds range from
    information and referral services to support groups to legal guides and
    clinics. Families benefiting from services through the aging network
    report positive experiences and outcomes. They are often more receptive
    to services provided through the aging network, because they have a
    higher level of comfort with those agencies than the child welfare
    system, which many may fear or distrust.
    Policy Recommendations
          Protect the Social Services Block Grant (SSBG): SSBG
    provides critical support to states to serve children and older adults
    in communities, many of whom are in grandfamilies, through a range of
    community-based supportive services such as home-based meals, child
    care and child protective services. This flexible resource allows
    states to use the funds to meet local needs where they are greatest.
          Ensure Access to Quality Health and Medical Care: Ensure
    that health care reform efforts recognize the critical role that
    Medicaid plays in providing health care coverage to grandfamilies.
    Health care reform efforts should not prevent the children and
    caregivers in grandfamilies from having access to quality health and
    mental health care, or the ability of parents to access substance abuse
    treatment and prevention services.
          Promote Services to Grandfamilies Through the Network of
    Organizations Serving Older Americans: Urge states to maximize use of
    the National Family Caregiver Support Program (NFCSP) to serve
    grandfamilies. NFCSP funds may be used to provide supportive services
    to caregivers and children in grandfamilies regardless of whether they
    are involved with the child welfare system or have legal custody of the
    child. Although up to 10 percent of the program's funds can be used for
    grandfamilies, most states do not make full use of the program to help
    support these families. Policy should support national experts and
    other resources to help educate the aging network about grandfamilies
    and the most effective services to support them.
          Address Barriers to Licensing Grandparents and Other
    Relatives as Foster Parents: Adopt the Model Family Foster Home
    Licensing Standards, which Generations United developed in partnership
    with the National Association for Regulatory Administration and the
    American Bar Association Center on Children and the Law and with
    support from the Annie E. Casey Foundation, to eliminate unnecessary
    barriers that prevent suitable relatives and non-relatives from
    becoming licensed foster parents.
          Reform Federal Child Welfare Financing to Encourage a
    Continuum of Tailored Services and Supports for Children, Parents and
    Caregivers in Grandfamilies: Allow states to use federal child welfare
    funds for prevention services for caregivers, parents and children,
    such as kinship navigator programs, substance abuse treatment and
    prevention services, mental health services and in-home supports.
          Encourage Coordination of Services and Supports Among
    Temporary Assistance for Needy Families (TANF), Child Welfare and Aging
    Services Agencies: Through coordination, leveraging and braiding
    dollars among these agencies, more children and caregivers can be
    served.
          Ensure Grandfamilies Can Access Financial Resources to
    Help Them Meet the Children's Needs Such as TANF, Social Security, and
    Tax Relief: Access to TANF must be improved through a number of
    concrete policy and program steps including eliminating asset tests for
    caregivers over age 60 so that they can have savings for retirement;
    Social Security retirement, disability and survivor benefits and
    Supplemental Security Income must be protected and strengthened; and
    tax reform efforts should preserve the ability of grandfamilies to
    qualify for the Earned Income Tax Credit.
          Provide an Array of Legal Options to Grandfamilies:
    Ensure that grandfamilies have access to a continuum of legal
    relationship options and understand the differences--both legal and
    practical--of adoption, guardianship and legal custody. As part of this
    effort, grandfamilies' access to legal representation and assistance
    should be improved and expanded. Furthermore, all states should enact
    educational and health care consent laws so that children outside the
    foster care system and without a legal relationship to their caregivers
    can access education and health care services.
          Elevate and Promote Best Practices Through a National
    Technical Assistance Center on Grandfamilies: Create a National
    Technical Assistance Center on Grandfamilies that engages experienced
    experts to provide a clearinghouse of best or promising practices and
    programs for serving children, parents and caregivers in grandfamilies.
    This includes guidelines for states to encourage best practices to
    support grandfamilies impacted by parental substance use, including
    ways to help caregivers meet the children's needs and support birth
    parents' access, engagement and success in treatment. The Center can
    facilitate learning across states and provide technical assistance and
    resources to those who directly work with all three generations in
    grandfamilies.
    Conclusion
        Stacey Walker, who along with his sister was raised by his
    grandmother, said, ``My grandmother already lived in a government
    housing project, and although her salary was enough to keep her afloat,
    she now had all sorts of expenses . . . any young child's needs,
    multiplied by two.'' Stacey's grandmother sacrificed, scrounged and
    succeeded in raising her grandchildren. Stacey is what we at
    Generations United call a ``grand success.'' This past November, Stacey
    was elected the first African American supervisor of the Linn County
    Iowa Board of Supervisors. After his election, Stacey said, ``It's an
    honor to be an example of the value of being raised in an
    intergenerational home!''
        No matter the circumstances, every child deserves the roots and
    connection to the rich soil of family that nourish their growth and
    prosperity.
        Thank you for this opportunity to speak.
                                   __________
                               Jaia Peterson Lent
                      Response to Questions for the Record

    Sentor Elizabeth Warren
    Opioid Epidemic and Partial Fill Policies
        Older patients are frequently prescribed painkillers for chronic
    pain, or after surgery or other procedures.\1\ The Center for Medicare
    and Medicaid Services (CMS) reported that generic Vicodin was
    prescribed to more Medicare beneficiaries than any other drug in
    2013.\2\ In 2015, almost 30 percent of Medicare Part D enrollees used
    an opioid prescription.\3\ If older adults don't use their entire
    prescription, these pills can remain in the home--and the National
    Institute on Drug Abuse has estimated that over 70 percent of adults
    who misuse prescription opioids get the medication from friends or
    relative.\4\
    ---------------------------------------------------------------------------
        \1\ Ibid.
        \2\ Centers for Medicare & Medicaid Services, ``CMS Releases
    Prescriber-Level Medicare Data for First Time'' (April 30, 2016)
    (online at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-
    sheets/2015-Fact-sheets-items/2015-04-30.html).
        \3\ Paula Span, ``New Opioid Limits Challenge the Most Pain-
    Prone,'' New York Times (June 6, 2016) (online at: https://
    www.nytimes.com/2016/06/07/health/opioid-limits-older-patients-
    pain.html).
        \4\ National Institute on Drug Abuse fact sheet (online at: https:/
    /www.drugabuse.gov/sites/default/files/poppingpills-nida.pdf).
    ---------------------------------------------------------------------------
        As a consequence, efforts to reduce the amount of unused
    medications in the home can be a powerful tool to tackle prescription
    drug abuse.\5\ Grandparents raising grandchildren as a result of the
    opioid epidemic may want to keep unused medications out of reach of
    their adult children still struggling with substance use disorder, as
    well as their grandchildren, who are also at a higher risk of
    developing substance use disorder themselves.\6\ The Comprehensive
    Addiction and Recovery Act, passed in July 2016, empowers patients to
    talk to their physicians and pharmacists about partially filling their
    prescription medications in order to reduce the amount of unused
    opioids available for misuse.\7\ Instead of picking up their entire
    prescription all at once, patients would be able to take home a few
    days' worth of medicine at a time, without having to get a new
    prescription from their physician each time.
    ---------------------------------------------------------------------------
        \5\ National Institute on Drug Abuse fact sheet (online at: https:/
    /www.drugabuse.gov/sites/default/files/poppingpills-nida.pdf).
        \6\ ``Drugs, Brains, and Behavior: The Science of Addiction,''
    National Institute of Drug Abuse (July 2014) (online at: https://
    www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/
    drug-abuse-addiction).
        \7\ See S. 524: Comprehensive Addiction and Recovery Act of 2016
    (online at https://www.Congress.gov/bill/114th-congress/senate-bill/
    524/text).

    Question: Do the grandparents you work with express concern about
        having unused prescriptions in their home?
    Response:
        Anecdotally we find grandparents raising grandchildren are
    conservative in their own use of opioid and other pain killers. Most
    are well aware of the genetic and life experiences that their
    grandchildren face and are thoughtful about keeping their medications
    out of reach of children/youth in their care.
        However, some caregivers report they need to hide their
    prescriptions particularly when family members at risk of or struggling
    with substance use disorders are visiting. When the prescription is
    stolen by adult children, teenage grandchildren or neighbors, for
    example, they cannot get more of their needed medication until the next
    month which negatively impacts their own health and comfort.

    Question: Would empowering grandparents to work with their physicians
        and pharmacists to partially fill their prescriptions--while also
        ensuring patients needing pain medicine receive it--help
        grandparents keep unused medications out of the hands of those
        struggling with substance use disorder, or those at a high risk of
        developing it?
    Response:
        An option to partially fill prescriptions could be beneficial for
    grandparents raising grandchildren who have concerns that the
    medication may be stolen or taken by family members struggling with
    substance use disorders. Furthermore, in the event the medication was
    taken, caregivers would not have to wait a full month to refill their
    needed prescription. It could also help low-income grandparents who are
    unable to cover the cost of the entire medication at one time by
    breaking down the cost throughout the month.
        However, one of the major barriers to health care for grandparent
    caregivers is transportation. Securing transportation to the pharmacy
    once a month is often a hardship. Requiring them to go twice a month
    would be twice as difficult. Any partial fill policy should be optional
    and should include strategies to help address barriers related to
    transportation to secure the medication.

    Question: Are kinship navigator and support groups well-informed about
        new federal partial-fill policies?
    Response:
        Within our extended network of caregivers and those serving them,
    the majority reported that they were unfamiliar with partial-fill
    policies.

    Question: What sort of actions can be taken by states, physicians,
        pharmacists, and patient and kinship groups to increase awareness
        of the new federal partial-fill policy so that grandparents and
        other kinship caregivers can take advantage of these options?
    Response:
        Our network of support groups, caregivers and practitioners have
    expressed an interest and willingness to share information about
    partial-fill policies through their support groups, informational
    seminars, newsletters, community partner meetings, and through their
    health and wellness programs.

    Question: What other approaches do you think can be taken by states,
        physicians, pharmacists, and patient and kinship groups to reduce
        the amount of unused prescription medication in circulation?
    Response:
        Recommendations from our grandfamilies networks include:

          Making available and easily accessible drop off and
    disposal sites for unused medication.
          For new prescriptions, providing samples to make sure the
    caregiver can take the medicine without side effects or issues before
    even fully or even partially filling a prescription.
          Prescribing and including insurance coverage of
    alternative pain management approaches such as acupuncture.
          Providing education literature to support groups and
    service networks about the availability of partial-fill policies,
    alternative pain management approaches, and safe and accessible drop
    off and disposal options.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

      Prepared Statement of Bette Hoxie, Executive Director, Adoptive and
          Foster Families of Maine and the Kinship Program, Orono, ME
        Good afternoon Chairman Collins, Ranking Member Casey and members
    of the Special Senate Committee on Aging.
        I am honored to speak with you today regarding both my professional
    and personal experiences with this topic. My name is Bette Hoxie. I am
    first and foremost a mother, grandmother, and great grandmother. I
    raised my grandson since his infancy. Today he is 17 years old, and he
    will graduate from high school in June. He plans to go into
    conservation law enforcement after college.
        I am also the executive director of Adoptive and Foster Families of
    Maine Inc. and the Kinship Program.
        Like so many other states, Maine is severely affected by the opioid
    crisis that permeates our nation and its vulnerable families. More and
    more infants are being born to mothers who are using opioids while
    pregnant. These births are taking a toll on a population of caring
    people who would--if they could--simply love their grandchildren, spoil
    them, and send them home to be raised and nurtured by their parents.
    But for an all too growing number of families, this is no longer an
    option. Instead, the grandparents have become the primary caretakers.
        Adoptive and Foster Families of Maine and the Kinship Program have
    a great team of professionals working daily to support these
    grandparents--who, in most cases, were never expecting to parent again.
    They may not have a spare bed at home or clothing for the children. In
    these instances, we are there to help. We collect new and gently used
    items including beds, furniture, clothing, bedding and other material
    goods, and provide them free to grandparents. If we do not have what a
    grandparent needs in stock, we send out a request to the list serve,
    and usually receive it within a few days. This office works with over
    3,100 kinship families statewide--85 percent of the families are grand
    or great grandparents. One-third of the total is licensed as the foster
    parent to the child/children.
        We also provide licensing and legal education. We guide
    grandparents on how to work through Maine's Health and Human Services
    system or gain guardianship through the Probate Court system depending
    on where things are in time and space. We walk grandparents through the
    licensing process, which can be lengthy, complicated, and costly. To
    attain the license, grandparents must be mentally and physical fit to
    care for children. We guide grandparents to medical providers in their
    localities to attain physical and mental health assessments. In some
    situations we are able to use donated funds to support grandparents
    with the financial costs for filing paperwork and or finger printing if
    they cannot afford it. Their home must also be licensed. It must meet
    certain safety standards, including bedroom space and windows that meet
    fire codes. Many of the older homes in Maine have small windows and do
    not qualify. We try to work with the grandparents to come up with
    solutions.
        Our organization provides specific support groups so families can
    share their stories and get emotional support from others like them who
    are walking the walk and talking the talk! Childcare is provided for
    children during the meetings so, like their caretakers, they are less
    isolated and can learn that they are not the only child being raised by
    grandparents. These support groups also serve as a mini respite for the
    grandparents for that evening. In rural areas of Maine, where
    transportation is difficult and families are unable to attend the
    groups, mentors with similar life experiences are invited to assist the
    families by phone. Respite is still a much-needed requirement for the
    families served and it is very difficult to attain. Frequently at the
    support meetings, families will develop their own respite amongst other
    members.
        We also provide kinship training. The training explains how DHHS
    works and where to go for support. Relative caregivers participate and
    share what they needed the most when they first started. We provide
    referrals to appropriate legal guidance and mental health services, as
    well as other resources as needed. For instance, we find that many of
    the grandchildren have special needs, suffer from trauma, or may be
    living with the effects of pre-natal substance abuse. We connect the
    grandparents with resources to help, such as the Maine Autism Society
    or the Maine Drug Awareness Program.
        One of the most powerful sources of support for grandparents is to
    meet others who are also raising their grandchildren. We organize a
    statewide conference, which brings together grandparents all across the
    state for education, training, and networking. We provide complimentary
    registration to the first 20 new grandparents to participate and we
    cover hotel accommodations for those who are coming from far away. When
    the grandparents come together, they feel a sense of solidarity in
    knowing that they are not alone, and they leave with a new set of tools
    to support themselves and their grandchildren on their second parenting
    journeys.
        I mentioned earlier that I raised my grandson. Well, today--I am
    also raising a 19-month-old boy. He is the nephew of one of my adopted
    sons. The baby's biological mother is addicted to opioids. When I
    agreed to raise my grandson nearly 18 years ago, I wondered if I'd be
    able to walk down the aisle at his graduation. Now I find myself at 70
    plus years of age wondering, ``Am I the right person to take on this
    little boy?'' I am no stranger to caring for my children. I'm the
    parent to 19 children and 40 grandchildren and 2 great grandchildren.
        I work with families on a daily basis that resembles mine. Helping
    the families understand that our small office is here really helps--
    despite the fact that they know what they are struggling with includes
    a long tough road ahead. Grandparents need to know that this country
    supports them as well. Funds to meet the basic needs of families taking
    on a relative's child needs to be a priority. There are barriers in the
    foster care system but they are small compared to the needs in kinship/
    grandparent care!
        Many of the grandparents raising grandchildren had planned to be
    retired. Others are younger and still raising children of their own in
    addition to their grandchildren. Trying to make small or fixed-incomes
    cover the costs of such things as diapers and childcare are often
    insurmountable obstacles for the families who are giving their all to
    keep our nation's children within their families of origin and above
    all else safe!
        Thank you for recognizing this important issue. I appreciate the
    opportunity to share just a bit of what is happening in Maine both in
    terms of what works and what continues to be challenging. I hope I can
    respond to any questions and be useful as you work to support
    grandparents raising their grandchildren who have been affected by the
    opioid crisis.
                                   __________
    Prepared Statement of Sharon McDaniel, MPA, Ed.D., President and Chief
       Executive Officer, A Second Chance, Inc., Pittsburgh, Pennsylvania
        Chairman Collins, Ranking Member Casey, and Members of the
    Committee, good afternoon and thank you for holding this hearing on the
    effects of the opioid crisis on grandfamilies. As those who place the
    well-being of children first and foremost, I first say to you,
    ``Kasserian Ingera'', meaning ``and how are the children?'' It is the
    greeting of the Masai Warriors of Africa as they move from village to
    village asking about the children, as they know it's their
    responsibility to care for their young. I share in that same
    responsibility with all my heart.
        I am Sharon McDaniel, President and CEO of A Second Chance, Inc., a
    leader in the provision of kinship care and support services in
    Pennsylvania. I am also on the Board of Trustees of Casey Family
    Programs, the largest national foundation dedicated exclusively to the
    safety, permanency, and well-being of children in the child welfare
    system.
        Since 1994, A Second Chance has answered the call in meeting the
    needs of over 21,000 children throughout the two largest counties in
    Pennsylvania (i.e., Philadelphia and Allegheny). From time-to-time, we
    have also serviced a few of the smaller counties. Many of these
    children and youth were placed in the care of their maternal
    grandmothers. In fact, over 65 percent of our current children and
    youth are placed in the care of their maternal grandparents; where 40
    percent are single female heads of household.
        Each day, the dedicated staff of A Second Chance service over 1,800
    children, their caregivers, and their birth parents. This does not
    include the many uncounted grandfamilies who are outside of the system
    and receiving very few supports.
        My eyes have seen a lot throughout my 30-year career in child
    welfare. I worked alongside families through the heartbreak of the
    crack epidemic in the 90's. Today, the opioid epidemic is bringing
    children into the system at earlier ages. Through crisis and
    heartbreak, however, families can still triumph. Families do not lose
    value in crisis. Thus, I am profoundly humbled and appreciative to be
    able to share with you a couple of stories that elevate this
    conversation from the pages of my notes to the imprinted visuals in
    your heads about the importance of grandfamilies and the children that
    they care for on a daily basis.
        I will start with my own story . . . you see me! From the time that
    I was 2 years old, I was placed in the care of my fictive grandparents;
    they were not related by blood, but related by the heart. They were
    members of my father's village. Following the tragic death of my
    mother, my father sunk into a deep depression--which he attempted to
    drink his way out of, and realized that this was not the life that he
    wanted for his young children. Because the system had no real mechanism
    for kinship care back then, we were placed with my grandparents as
    foster children.
        I witnessed, and was central to, all of the personal sacrifices
    that my grandparents had to make for us, from child care to family
    support. When we were school age, my grandmother used her foster care
    payments to pay for those extra things that would support our
    educational, cultural and social needs. She only wanted the best for
    us.
        Like my grandparents then, many grandparents want the best for
    their grandchildren. Today, I am reminded of a grandmother I met last
    year. She was 62 years old and had a successful career at Verizon when
    she was suddenly asked to care for her five grandchildren due to her
    daughter-in-law's opioid addiction. The family made these arrangements
    outside of the child welfare system. Today, more than 2.5 million
    children are in a similar situation due to their parent's inability to
    care for them for a variety of reasons. Unfortunately, this grandmother
    ended up losing her job. She and her grandchildren lived in a one-
    bedroom apartment, had limited financial means and relied on TANF
    child-only payments. She was unaware of any support that could help
    with her overcrowded living conditions, including any support that the
    Department of Aging could offer her or her grandchildren. Thankfully,
    it was her faith community that stepped in and partnered with her to
    fill in the gaps when and where needed. The grandmother said to me,
    ``Though I may not have much, my grandchildren are with me and not in
    the system and we're gonna be all right!'' Her story is shared by many
    other grandmothers across the country.
        In Pennsylvania, I have seen a rise in the number of cases referred
    to us by the public child welfare agencies in Philadelphia and, to a
    lesser extent, Pittsburgh. In three years, the caseload in our
    Philadelphia office has grown from 180 youth to over 900 children, many
    under the age of five.
        In Philadelphia, from 2014 to 2016, there was an 11 percent
    increase in this age group. It is now at a staggering 56 percent. In
    Pittsburgh, the percentage of children under five has been steadier at
    around 48 percent. Because of the ages of these children and their
    unknown medical histories, we immediately enroll them in CHIP, as we
    must assess and follow up on their medical needs. It should be noted
    that over 90 percent of the children we service are eligible and
    receive Medicaid support.
        Why the difference between the two largest counties in
    Pennsylvania? Contributing to this difference is, in part, due to the
    size of each county. Philadelphia is larger and hovers borders with New
    York and New Jersey. There is a more diverse population as well. In
    Allegheny County, we see an older population. We do, however, know that
    trends traverse the state. We typically see what happens in the eastern
    part of the state, slowly creep to western Pennsylvania three or so
    years later, as we did with the crack and gang issues.
        Consistent with national trends, the majority of these cases
    involved parental neglect, which is often associated with drug
    dependency issues. The opioid epidemic is reflected in the national
    data on children in foster care. After years of declines, the number of
    children in care grew from 378,912 at the end of FFY 2012 to 412,647 at
    the end of FFY 2015. State and local child welfare officials attribute
    this increase to the opioid epidemic. Many of these children are being
    cared for by relatives. Of all children in foster care nationally, 29
    percent are living with relatives.
        In Allegheny County, 62 percent of children not living with
    relatives are placed in kinship care, and in Philadelphia County, 47
    percent are placed in kinship care.
        Grandfamilies, both within and outside the child welfare system,
    often lack the supports and services they need. Unlicensed relative
    foster parents are typically denied the financial support provided to
    licensed foster parents. Moreover, the vast majority of relative-headed
    households have no involvement with the child welfare system and are
    often unaware of the services and supports available to them.
        In many areas of the country, particularly rural areas hit hard by
    the opioid epidemic, those services are few and far between.
    Grandfamilies affected by the opioid epidemic will tell you that they
    need navigator programs which assist them with identifying and
    accessing available services including mental health services,
    financial assistance, counseling, support groups, legal assistance, and
    respite care--all of which are essential. Furthermore, these services
    must be available in urban, as well as, rural settings. Too often,
    transportation, access to services, and child care have been cited as
    barriers to grandfamilies.
        Despite the challenges faced by relative caregivers, research has
    shown that children experience better outcomes with kin than with non-
    relative caregivers. These outcomes include fewer placement changes,
    fewer school changes, increased likelihood of achieving permanency,
    better behavioral health outcomes, increased likelihood of placement
    with siblings and greater connections to community and culture.
        The best place to touch grandfamilies is where they are isolated.
    This isolation can come physically by way of their neighborhood or lack
    of transportation. It can also come in the form of financial burden.
    But perhaps the most critical isolation comes via the racial and
    cultural prejudice grandfamilies experience. It is in the ageism they
    face as caregivers. It is the unrecognized sacrifice they freely give
    because they value keeping their families together--the families that
    make up our Nation. What would we do as a Nation right now without
    grandfamilies? Where would those 2.5 million children go? We must not
    and cannot keep grandfamilies isolated any longer. What can be done to
    support grandparents raising children in the midst of this
    unprecedented crisis? Here are a few of my ideas:

        1.  Create a funding mechanism that blends federal child welfare
    and aging dollars to prevent the need for children to come into care.
    Let's get on the front end of this issue. Grandfamilies should not have
    had to lose their jobs to support their grandchildren.
        2.  Create more community support centers like the KARE Center in
    Arizona which is supported by Casey Family Programs in partnership with
    Arizona Children's Association. Additionally, create more holistic
    community-based kinship care programs like A Second Chance where
    families and their children can go for support services that are needed
    before removal of children becomes necessary.
        3.  Ensure that Senior Centers are equipped to support grandparents
    raising grandchildren with housing vouchers, support groups, counseling
    and in-home services, financial support and respite care.
        4.  Create more effective and readily available Drug Treatment
    Centers that treat the entire family. Grandfamilies need to understand
    how to negotiate the complexities associated with drug addiction and
    the impact on the children for whom they provide care for on a daily
    basis.
        5.  Re-examine the core tenets of the former Families First draft
    legislation. In order for grandfamilies and their grandchildren to
    receive services without the need to enter the child welfare system,
    flexible finance reform in child welfare is necessary and essential.

        As I was preparing my remarks for you today, I decided to consult
    the real experts and asked grandmothers who were attending a recent
    Grandma's Hands Support Group sessions at my organization what they
    would say to Members of Congress about what they needed. They told me
    this:
        ``We do what we do because we love our grandchildren and our
    families. We need your help and cannot do what we do without the love,
    support, and suspended judgment of those we interact with each day.
    Treat us as if we were caring for your own grandchildren.''
        Thank you Ms. Chairman and Members of the Committee for the
    opportunity to share my thoughts with you today.
                                   __________
                              Dr. Sharon McDaniel
                      Response to Questions for the Record

    Sentor Elizabeth Warren
    Opioid Epidemic and Partial Fill Policies
        Older patients are frequently prescribed painkillers for chronic
    pain, or after surgery or other procedures.\1\ The Center for Medicare
    and Medicaid Services (CMS) reported that generic Vicodin was
    prescribed to more Medicare beneficiaries than any other drug in
    2013.\2\ In 2015, almost 30 percent of Medicare Part D enrollees used
    an opioid prescription.\3\ If older adults don't use their entire
    prescription, these pills can remain in the home--and the National
    Institute on Drug Abuse has estimated that over 70 percent of adults
    who misuse prescription opioids get the medication from friends or
    relative.\4\
    ---------------------------------------------------------------------------
        \1\ Ibid.
        \2\ Centers for Medicare & Medicaid Services, ``CMS Releases
    Prescriber-Level Medicare Data for First Time'' (April 30, 2016)
    (online at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-
    sheets/2015-Fact-sheets-items/2015-04-30.html).
        \3\ Paula Span, ``New Opioid Limits Challenge the Most Pain-
    Prone,'' New York Times (June 6, 2016) (online at: https://
    www.nytimes.com/2016/06/07/health/opioid-limits-older-patients-
    pain.html).
        \4\ National Institute on Drug Abuse fact sheet (online at: https:/
    /www.drugabuse.gov/sites/default/files/poppingpills-nida.pdf).
    ---------------------------------------------------------------------------
        As a consequence, efforts to reduce the amount of unused
    medications in the home can be a powerful tool to tackle prescription
    drug abuse.\5\ Grandparents raising grandchildren as a result of the
    opioid epidemic may want to keep unused medications out of reach of
    their adult children still struggling with substance use disorder, as
    well as their grandchildren, who are also at a higher risk of
    developing substance use disorder themselves.\6\ The Comprehensive
    Addiction and Recovery Act, passed in July 2016, empowers patients to
    talk to their physicians and pharmacists about partially filling their
    prescription medications in order to reduce the amount of unused
    opioids available for misuse.\7\ Instead of picking up their entire
    prescription all at once, patients would be able to take home a few
    days' worth of medicine at a time, without having to get a new
    prescription from their physician each time.
    ---------------------------------------------------------------------------
        \5\ National Institute on Drug Abuse fact sheet (online at: https:/
    /www.drugabuse.gov/sites/default/files/poppingpills-nida.pdf).
        \6\ ``Drugs, Brains, and Behavior: The Science of Addiction,''
    National Institute of Drug Abuse (July 2014) (online at: https://
    www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/
    drug-abuse-addiction).
        \7\ See S. 524: Comprehensive Addiction and Recovery Act of 2016
    (online at https://www.Congress.gov/bill/114th-congress/senate-bill/
    524/text).

    Question: Do the grandparents you work with express concern about
    ---------------------------------------------------------------------------
        having unused prescriptions in their home?

    Response:
        At a Second Chance, Inc., we have not heard this directly from our
    grandparents, but I believe that they are so overwhelmed with other
    issues, that have not had time to consider this concern. Grandparents
    need to deal first with the basics including a safe and appropriate
    sleeping space, getting the child to their original school or
    registering them in a new school and dealing with the trauma of
    removal. Grandparents are also dealing with their own emotions.
        It would be good to have information available in the cases where
    it could be an issue in the household.

    Question: Would empowering grandparents to work with their physicians
        and pharmacists to partially fill their prescriptions--while also
        ensuring patients needing pain medicine receive it--help
        grandparents keep unused medications out of the hands of those
        struggling with substance use disorder, or those at a high risk of
        developing it?

    Response:
        This needs to be determined on a case by case basis. Among
    grandparents who are responsible for their grandchildren:

          58 percent are still in the workforce
          21 percent live below the poverty line
          26 percent of them are disabled

        Given these statistics, requiring grandparents to make multiple
    trips to a pharmacy could add an additional and unnecessary burden to
    the family route. It would depend on ease of access to transportation
    to the pharmacy, the hours of the pharmacy in relation to the
    grandparents work schedule and a range of factors. Advising
    grandparents of all their options and helping support their decisions
    would be the best approach.

    Question: Are kinship navigator and support groups well-informed about
        new federal partial-fill policies?

    Response:
        To my knowledge, kinship navigator programs are not focused on this
    option because of the wide range of unique issues that must be
    otherwise addressed.

    Question: What sort of actions can be taken by states, physicians,
        pharmacists, and patient and kinship groups to increase awareness
        of the new federal partial-fill policy so that grandparents and
        other kinship caregivers can take advantage of these options?

    Response:
        Public awareness campaigns and information provided by physicians
    and pharmacists could be an effective way to provide options for
    grandparents. Supporting and expanding kinship navigators to allow them
    to provide broader support would also help.

    Question: What other approaches do you think can be taken by states,
        physicians, pharmacists, and patient and kinship groups to reduce
        the amount of unused prescription medication in circulation?

    Response:
        Grandparents raising their grandchildren have enormous demands on
    their time and their energy, and 39 percent of them are over 60 years
    old. It is very important to have supports that are convenient and
    accessible. Transportation to pharmacies or other prescription drug
    drop off programs can be a challenge. Allowing grandparents to return
    unused prescription needs to be convenient and part of their existing
    routine to be the most effective.
        Another important approach is professional training. We know that
    research demonstrates the unconscious nature of bias against older
    caregivers. Given the current opioid epidemic and its impact on
    grandfamilies, we must consider implicit bias measures and training
    because they can illuminate hidden ageism with older care-givers. For
    instance, we cannot make assumptions that grandparents are not
    conscious of leaving drugs out in the open due to their age or that
    there is an automatic need for partial-refills regarding seniors.

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