[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




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                         U.S. GOVERNMENT PUBLISHING OFFICE 

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                       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
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                 Kevin Kelley, Majority Staff Director
                  Kate Mevis, Minority Staff Director
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                                CONTENTS

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                                                                   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.
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    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.
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    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\
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    \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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