FINANCING (There will never be enough money!) Stephanie B. C. Bailey, MD, MS Director of Health Nashville, Tennessee February 8, 2006

Our Stories: …from our neighborhoods …from the practice …from the greater perspective

Mary B. 53 years old Grandmother with custody Food stamps, small government check and children on TennCare Has not seen a doctor in years “better not to know” “too many other things to think about”

Raphael, age 10, 4 th Grade Mother incarcerated “waited all day to talk to mentor, wanting only to tell her about seeing his sister being shot the night before” Expelled at end of school year because someone said something about his mother

Renaldo, age 11, 6 th grade Mother killed at age 6 Father lives in East Tennessee 3 cousins in household

Amanda, age 8 Mother on disability Old brother, age 17, in jail Older sister, age 15, pregnant All three children have separate dad

Christopher, age 12, 5 th grade 1 of 6 children Father on disability Suspended 2 x week, in school, for anger All brothers expelled from school 2 older/2 younger

Kenny, age 12, 4 th grade 1 of 6 children Father incarcerated

Thomas, kindergarten Crack baby Kicked out of school for attacking teacher

Courtney, age 5, kindergarten Mother incarcerated Aunt raising 7 children, none are hers

Keisha, age 6, 1 st grade Dad incarcerated 5 siblings, older teenage sister has a baby

JARVIS Age six, first grade Two older brothers, ages 16 and 17 Lives with aunt because both parents incarcerated on drug charges October 2005, placed back in first grade……………

Jackie, age 12, 4 th grade Family has been put out of MDHA Was in room when uncle was shot Has been raped WHEN SHE GROWS UP…. ……………she wants to be a doctor

Incarceration Handicaps Violence, truancy, suspensions Mixed families Failure (academic) Needing and/or wanting attention Lack of tools Adult indifference Low self-esteem

Ms. Sadie “My daughter was not sending them to school and their father didn’t want custody. She was on drugs. I took them in my home and I got legal guardianship because they needed to be in school. I was hoping she would be able to take them back when she came out of rehab. I was told she had a terminal illness caused by HIV. She died almost 4 yrs ago.”

Between 1990 and 1998, the number of grandchildren being raised solely by grandparents and with no parent living in the home increased to more than 1.3 million – an increase of 53%.

Relative Caregivers Substance Abuse, by a birth parent (38%) Incarceration, (17%) Abandonment, (17%) Removal by child protective services because of neglect/abuse, (11 %) Teen pregnancy Emotional Problems/Mental Health, (11%) Parental Death, (6%)

The majority in one study, simply assumed care giving informally out of a strong sense of familial obligation and love – the grandparent being a constant and stable presence in a child’s life....but in most studies, grandparents were in a crisis situation when they assumed the care and had no prior plans to raise their grandchildren

Summary Characteristics the “WHO” Typically female Black Unmarried Unemployed Living at or below poverty level Undereducated Additionally, “they fear being unable to raise their grandchildren to adulthood”

One grandmother said…. “ If they don’t take me out of here in an ambulance, I’ll care for them. I’ve had to almost crawl to the kitchen sometimes but they’ve never gone without a meal”

One 63 years old Grandmother: “when I had a son I started him on cereal when he was 4 weeks old, fruits and vegetables when he was 6 weeks, and meats 2 weeks after that…..for my granddaughter I was told to give no rice cereal until she was 5 months old” “I use to give half an aspirin for fever if my son had a reaction to immunizations, but I was told not to do that now”

CAREGIVERS’ HEALTH = SAFETY NET For RAPHEAL, KEISHA, JACKIE, KENNY, CHRISTOPHER …. and the rest….

Streams of Funding Categorical Each with its own set of forms Does it address the wholeness? Does it create the impact? Does it prohibit working together? An answer; but is it the answer?

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow (HCFA)

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow (HRSA)

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow (CDC)

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow (SAMHSA)

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow (OPHS)

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow (STATE FUNDS)

CMS Pregnant Wife, Drug Addicted Husband Children State Funds Substance Abuse Agency Department of Health MEDICAID Mental Health Agency Family Planning Community Organizations Clinics Department of Health CHC Substance Abuse CDCSAMHSAOPHS State Family Planning Agency HRSA Resource Flow

Pedro Garcia, PhD Superintendent of Schools “he will never use ‘not having enough money’ as an excuse for not achieving…..money makes it easier and without it is just more challenging!”

“He who has a why to live can bear with almost any how.” Nietzsche

W. McDermott “Medicine in Modern Society” Public Health System Constituency Type System Healthy ‘watchdog’ Balance is critical Aiding developing individuals in their continuous interaction with the environment

REALITY SYMBOL EXTRAORDINAIRE THERE WILL NEVER BE ENOUGH MONEY!