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INTRODUCTION The many different functions of the DC Department of Human Services had consumed on average 34% of DC's budget over the 11 years from FY87 to FY97, and some 18% of its total funded personnel. Its share of the budget has grown substantially from 29% in FY87 to 38% in FY97, 40% in FY00, and a projection to 42% by FY04. Its approved personnel levels for FY 97 were about 5400 "FTE's" and to over 5850 in FY00. Some of these costs are state functions, but costs may well vary for urban and suburban areas. Comparisons are given with 20 states at the state level, but inner cities certainly exceed state averages. Virtually all of these costs are incurred by the 150,000 or so DC residents below the poverty level. Federal acceptance of a larger share of the Medicaid payments has reduced DC's share of this budgetary requirement significantly ($136M in FY98, rising to $185M in FY01), but will not impact on personnel levels. In fact, federal dollars now account for 55% of all DC spending for health and human services, and pay the salaries of 47% of DC's government workers in these areas. The local DC hospitals that care for the large number of "medically indigent" remain a major drain on DC resources, and generate health statistics which contribute substantially to the reputation of our nation's capital as one of America's unhealthiest cities. There are serious management problems in each of the major areas covered here, and three of them have been taken out from under city control into the hands of receivers. Despite the rampant problems in this functional area, the maze of agencies and administrations performing different tasks has made it difficult for NARPAC, Inc. to get its arms around many of the specific issues. Nonetheless, this chapter provides the following:
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Even in the area of hospital care, the DC appears statistically to be no match for other states (including Maryland and Virginia). Despite the fact that DC hospitals provide 79% more beds per capita and have 16% higher than average occupancy, and are 120% larger (beds/hospital) than in the 20-state average, and even though their rate of surgery per occupant, and outpatient/inpatient ratios are right on the norm, they are staffed with 30% more personnel per bed, and charge on average 62% more for an average day's hospital room (see comparative community hospital costs . The DC General Hospital staff cuts announced in late 1995 were a tiny step in the required direction. The city's health system appears to be providing excessive subsidies not only for its "patients", but also for its staff. How much of this is caused by an urban vs regional socioeconomic environment, and how much is caused by blatant inefficiency cannot be divined from these numerics. However, the fact that the infant mortality rate is almost 90% higher in our nation's capital than in other MSAs (19.3 v 10.5) is not encouraging. Nor are the recent expose's indicating misuse of the DC's fire personnel and its emergency services to provide taxi services for those needing routine medical care (Washington Post, April 30, 1995). More analysis is needed to confirm or deny the anecdotal evidence that the DC government is wasteful and negligent in all its operations, and that such non-professional performance is "expected" by the majority of its residents--and higher level officials. The annual DC audit by the Greater Washington Society of CPAs for FY97 continues to identify the DC General Hospital as a major drain on DC budgetary resources. As a helath provider of last resort in an inner city with many poor people, it is not expected to "break-even" as other enterprise funds might. However, it is serving fewer and fewer patients (total inpatient days have dropped from 125,400 in '91 to 68,400 in '97), as well as less emergency room treatment, and less outpatient care. The 500-bed facilty is now operating at less than 50% capacity, and its equipment is suffering from inadequate maintenance. It has operated at a deficit of between $40M and $50 M for the past three years. Some new--possibly regional--solution to DC's hospital requirements is sorely needed. (See below). In yet another embarrassment to the nation's capital, the Washington Hospital Center has been identified (in May, 1998) as liable for fines for the mishandling of radioactive waste masterials by the Nuclear Regulatory Commission. And in another example of DC's inability to govern itself, it has come to light that those responsible for managing the Public Fund for Drug Prevention and Children at Risk have failed completely to account for either the income to the fund (from a check-off box on DC tax returns), the grants provided to local charitable organizations, or even for the expenses of the haphazzard six-year opeation. The recent Washington Post article (5/7/98) asserts that this is a "reflection of the entity's bizarre bookkeeping history and the chaos of the Tax and Revenue Office". The Greater Southeast Community Hospital Financial problems in DC's public hospitals, serving primarily those without Medicare/caid coverage, had become well known by the spring of 1999. DC was obliged to provide a bail-out in April so that the Greater Southeast Hospital-- essentially the only hospital for the poorest Ward (8) of the District--could continue to operate. The 320-bed hospital, 2200 employee hospital has been serving about 40,000 emergency cases, and 11,000 inpatients annually, and was reported to have piled up $68M in debt. A local bank claimed that $2.6M in Medicaid checks had been cashed to meet payrolls and tried to foreclose on its $10.6M debt. The courts decided that patient needs outweighed the bank's losses, and the Mayor provided an emergency $8.5M line of credit. GSE filed for bankruptcy, and a new task force was formed to come up with a long-range solution. There was general agreement that there were too many employees and/or too few patients. The drop in inpatient load was the direct result of the arrival of the HMOs--the norm of 670 hospital-days per 1000 recipients in 1996 had dropped 50% to 334 in 1998--with no commensurate reduction in staffing. Some 72,600 of DC's 125,000 Medicaid recipients are now covered by HMO's. It was also clear that GSE could not survive on the going rates for federal medical reimbursements. Discussions began of consolidation between the three DC hospitals at risk: GSE, DC General, and Howard University. By October, a judge made clear than GSE was still "hemorrhaging money" with 3.5 employees per (largely unused) hospital bed. An Arizona hospital management firm offered GSE a $24M bailout package, but hospital officials resisted the thought of a take-over that could jeopardize their jobs. The Mayor announced that no further bailouts would be forthcoming from DC;'s taxpayers, advising GSE to accept the offer. Creditors began to demand payment, and a series of extensions carried on into November, when the buyer temporarily backs out due to questionable equipment inventories, and federal suits to reclaim $3.6 million in Medicaid overpayments. Creditors demanded liquidation, but the buyer offered a new, lower ($22M) purchase price, leaving the creditors to 'eat' $48 million in losses. The judge OK'd the sale, and all sides worked until December 31st to finalize the details and improve a deal the creditors asserted was "riddled with loopholes.". The long-term future of the hospital and its staff is far from assured, even though the newly appointed administrator vows to break even in her first year. Following the privatization of the Greater Southeast Community Hospital (above) at the end of 1999, public attention finally turned to the appalling mismanagement of DC General (DCGH)--the City's largest publicly-supported hospital--whose major function is the care of DC's exceptionally large population of disadvantaged and uninsured. Management was placed under a relatively independent and apparently "untouchable" Public Benefits Corporation (PBC) by former Mayor Barry in 1995. Since then the hospital, with declining patient load, oversized facilities, no capital investment, and huge overstaffing has sunk further into debt, covered by faulty bookkeeping and questionable (still unexplained) "loans" from the DC Government. Doing something about DCGH and PBC did not make the final 2000 scorecard for either the Deputy Mayor for Children, Youth, or Families, or the City's new Director of the Department of Health, but it has been high on NARPAC's own list for action based on their non-competitive productivity statistics, and eminent suitability for regional solutions. Newspaper articles began to focus on DCGH in early 2000. Health care hearings by the DC Council focused on evident problems, but a health care commission refused to touch the issue. A staff director was fired for not seeing enough patients (!); The Washington Post pointed out that while the patient load decreased 24%, the staff had increased 13%, and the PBC had increased its own salaries by 50%. Staff-to-patient ratios had reached almost twice the national average, Medicaid records were poor, and claims of owed payments inflated. "Loans" from the DC Government were unauthorized, and deficits continued to grow, making PBC virtually bankrupt. Surprise inspections found the hospital liable for loss of accreditation, and several PBC local clinics remained unlicensed after 30 months of operations. By May, DCGH workers were staging protests for raises, and better patient care (!), PBC's CEO Fairman was finally coming under attack for not reducing the hospital's bloated staff, and Congress threatened hearings over the CEO's illegal slush fund, which was finally shut down by DC's CFO. In June it was discovered that DCGH was handing out jobs to friends and relatives of DC Council members and local union officials. A 'consultant's report' pointed out that the PBC oversight was superficial, and top-heavy with inexperienced managers. DoH Director Walks feigned outrage, and Mayor Williams finally acted to replace some PBC board members with responsible, knowledgeable people. In July, Fairman was put on 'administrative leave' with the obvious intent to dismiss. In return, Fairman then soughtone million dollars in severance pay, demonstrating that he had a severance clause assuring payment even if dismissed for malfeasance--approved by the PBC Board. The Control Board (unusually diffident to this issue) claimed never to have seen or approved it. A House subcommittee rebuked the DC Government for unauthorized--but never questioned--payments to DCGH. The suddenly reinvigorated PBC Board then fired 18 senior members of the DCGH staff, a very unusual step in DC. Consultants reported that it would take $112M to renovate DCGH, suggesting that it should probably be replaced instead. By the end of July, the PBC Board had produced a plan to cut more that 300 of the 1000 DCGH jobs; reduce their 2001 budget by $39M (highly unlikely); and scale back their facilities. It also suggested a severance package of $66 thousand for departing CEO Fairman rather than the ridiculous $1 million sought. As of August, 2000, this story was still incomplete. The ultimate disposition of DCGH is still in question, and as yet there is no indication of anyone being blamed or censured for years of gross and flagrant abuse of position and authority. NARPAC believed it is high time for the current DC Government--both executive and legislative--to face squarely the root causes of such clear and embarrassing mismanagement. Hopefully, the media will do it if elected officials do not. By the spring of 2001, major actions were underway, and by the summer of 2002, none of the predicted calamities had transpired.
This lengthy discussion of the problems with DC General is still valid, but now overtaken by events. It represents a major instance of a tough decision well made and carried out. This item has been 'archived'
In early 1998, there is still little indication that many of the worst problems with DC's health services are being addressed. Difficulties in the hospitals still abound, and welfare problems remain almost insoluble. So far, there is only one glimmer of hope: Turning Around the DC Morgue The DC Morgue has, over the past two years become the source of some of the city's worst problems, with failures in air conditioning, an enormous backlog of unexamined and unrefrigerated corpes, and conditions rivalling those in the lesser Third World Countries. All of this is now beginning to change. The facilities have been upgraded, and, with the help of the US military, the backlog has been eliminated. But more important, management changes are now underway. In January, 1998, the DC Appleseed Center testified before the DC Council, and in March, 1998 released a report recommending reforms to DC's Officer of the Chief Medical Examiner (OCME). OCME has two important responsibilities; supporting criminal justice agencies by providing accurate certification of the cuases of violent, suspicious and sudden unexpected deaths, and supporting public health agencies by determining the causes of employment- and disease related deaths that might constitute a threat to public health. Over the past several years, serious problems at the OCME have reverberated throughout the DC criminal justice and public health systems. In recent months, reports have indicated that an average of three people die in the District each month whose cause of death is never fully determined by the OCME--by far the highest rate in the nation; forensic pathologists employed by the OCME were found to be conducting autopsies after their medical licenses had expired, possibly imperiling prosecutions; and at least one violent offender remained at large- -and committed a second violent offense--following a questionable finding by the OCME that prevented his prosecution for an earlier crime. DC Appleseed has analyzed the OCME's problems, compares its funding and staffing to that of medical examiners of other jurisdictions, and concludes that their persistent problems suggest a beakdown in leadership and oversight(!). In February, the Control Board took important steps towards resolving OCME's immediate problems, including the appointment of a new Chief Medical Examiner who is a highly qualified forensic pathologist (from New York), and his staff is to be increased in the near future. DC Appleseed has also suggested that OCME be removed from the Department of Health, and governed by a department in the criminal justice area--such as the Police Department itself. Appleseed has also recommended oversight by a commission of members of both the public health and justice realms, as has been done successfully in many other jurisdictions. NARPAC, Inc. would further suggest that this commission include experts from neighboring jurisdictions to assure that DC avails itself of the best regional expertise. The residual problems of DC's morgue continue to embarrass the city. In late September, 1998, some 114 unidentified bodies that have been "warehoused" in the DC Morgue for months--if not years--were finally put to final rest through cremation or burial. At the same time, however, it has come to light that DC's death rates for children under 5 is several times the national average, and that the number of these deaths officially registered as resulting from "unidentified causes" is also way above the national average. This has lead to suspicions that child abuse is going largely unpunished in DC as a result of poor work in the OCME. The District's professional new medical examiner is actively pursuing this issue. Oddly enough, the only neighboring jurisdiction with similarly disturbing statistics is Prince George's County. By September of 1999, however, progress at the morgue appeared to be running into trouble, as conflict surfaces between the outspoken new Medical Examiner, Jonathan Arden, and his staff, which has grown from fewer than 30 last year to 44 at present. They are conducting about 1200 autopsies a year. [This compares to the Maryland State Medical Examiner's Office in Baltimore which handles just over 3000 autopsies per year with a total staff of 70--i.e., almost 60% higher productivity.] The DC morgue does have a $2.5M renovation plan ready to implement, but current working conditions still fall way short of acceptable standards. Much of the staff remains under-qualified, although Arden claims the "incompetent and marginally competent" are gone. Arden's "imperious style" has added to the level of discontent in which some employees claim they are "scared to say anything"...for fear of becoming "the next one who's going to be fired". Arden, in his own defense, claims that he was obliged to shake things up to impose adequate accountability, and get rid of "inappropriate and unacceptable work practices". He asserts that the morgue has employees "who were actively insubordinate, intransigent, and subverting the process". In words that echo those of the new DCPS Superintendent Ackerman and the new Police Chief Ramsey, he expected challenges, but that the obstacles have been greater than expected. In a series of interviews with the Washington Post Staff, he attacked what he calls the "frustrating and mystifying culture of dysfunction". Coming in from the outside, he claims to "have no ties to the prior history and culture of the DC government and regime" but that "being a no-nonsense guy, he is sick and tired of the nonsense...." Arden appears to still have the support of the Mayor and his immediate staff. NARPAC is resisting the temptation to consider this situation typical of the entire DC government (considering the unique nature of the work), but similar rumblings are heard elsewhere, and the overall issue of DC government employee productivity remains in question. Furthermore, time is beginning to run out for the Mayor to exercise "heroic measures". Let's hope the Case of the DC Morgue does not result in the perpetuation of the status quo. Foster Care System Problems in foster care were noted as early as April, 1999. Changes in federal rules was bringing a surge in adoptions nationwide--including a 53% increase in DC. A separate report indicated that alcohol or drug abuse was involved in 75% of all DC foster care cases, and that the total cost to the city annually resulting from all the ramifications of drug abuse had reached $1.2 billion. In July, 1999 it was reported that DC does not conform to the new 1997 federal adoption criteria, and was in danger of losing funding for some 3225 kids--emergency action by the DC Council averted loss of federal funding. In September, the health care at the Oak Hill Facility was found to be in violation of a court order. In October, 100 foster care parents threatened to give up their charges if not paid more promptly, a problem claimed to have been caused by faulty computers. In November, an independent audit finds more serious difficulties--with some providers being paid two or three times for the same work. Treatment of the Retarded Problems in the group homes contracted to take care of DC's mentally retarded began to surface in the Spring of 1999 when the Chief of MRDDA was sacked because of reports of 350 cases of abuse and neglect. In December, 1999, the Washington Post ran a startling expose' of 116 suspicious deaths of seriously retarded patients in group homes, presenting evidence of improper or destroyed death records, resulting in the suspension of one Health Services official. A complete overhaul of MRDDA appears inevitable, when a newly appointed oversight panel presents its findings. . DC Reports on 'Caring for the Vulnerable' Sporadic problems and horror stories concerning the retarded have continued to appear since that seminal Post report, with more and more attention coming from both Congress and the DC Council. Finally, in November, 2000, DC's Deputy Mayor for Children, Youth and Families wrote to the Washington Post describing what the city had done since the Post exposed the city's problems caring for the mentally retarded in March of 1999. Excerpts from her letter follow:
The District still is not where it needs to be to provide consistently high-quality care to our most vulnerable citizens, but it has made substantial progress. Early this year, I ordered an examination of the entire system with a focus on accountability. There were several studies commissioned. What have we done with the resulting information?NARPAC Commentary: 20 months and counting. The Metropolitan Washington Public Health Assessment Center at the George Washington University School of Public Health and Health Services prepares an annual report comparing 27 different indicators for each of the metro area jurisdictions, the region as a whole, and compares them to the averages for the entire US. Examples of these indicators are shown in the left hand chart below, using the regional value as "1"and displaying values for the US, the region, and DC.. In 19 of the total of 27 indicators, the Washington does better than the national average. But in only two areas (suicide rates and mental health problems) does DC rank better than its surrounding suburbs. In most cases, DC is 1.5x to 4.8x worse than the suburbs. The more complete report, available through the MW Council of Governments, rates were "better than the national average for 17 of the 19 indicators analyzed by race, and better for blacks in only 5 of the 19 areas". Not surprisingly, the report avers that "the data available for 10 indicators confirm that people with more education and higher household incomes tend to have healthier behaviors". In a separate but related effort, the Washington Post reported that DC now has some 60,000 persons addicted to drugs or alcohol, and that that 10% of the population is responsible for: o 40% of all visits to the city's Emergency Rooms; o 27% of all AIDs cases; o 85% of all foster care placements; and o 50% of all automobile accidents. In 1996, the total number of recipients of some form of social welfare per thousand capita for DC was 14% higher than for the average state; the amount per recipient was about 11% higher; and thus the amount per capita about 26% higher. Consequently, and perhaps most critical, the social welfare costs per non-recipient were 68% higher (assuming that the non-recipients pay for the recipients). Comparing costs to this 20-state per-capita average, DC recipients received 45% more in medicare; 40% more in medicaid; 13% lesss for social security; 12% more for supplemental income; the same amount per dependent child; 49% more for food stamps; 91% more for school lunches; 20% more for unemployment insurance; 34% more for workman's compensation, and 170% more for vocational training. In many other areas, the DC disadvantaged got more than their share of primarily federal largesse. Federal grants for housing were over 5x the average, to public schools more than 3x and to colleges more than 8x as high. Despite these high payments, services have often been totally inadequate. Court-appointed receivers have taken over both DC public housing and the child welfare system within the past two months. In 1995 Congressional testimony, Mayor Barry stated his "calling to serve 'the last, the lost, and the least'", with the result that now:
"We are out of step with our neighbors in terms of eligibility and benefits. We not only pay out more than we should, we attract many from other areas who should not be our responsibility."
Under pressures from the Financial Control Board, the DC has begun to respond to the need to revamp their welfare programs. Having initially sought a total waiver from the new federal welfare standards, the Mayor has now agreed to develop a more realistic plan. He has also recently agreed to bring DC's welfare payments more closely in line with those of the neighboring states of Maryland and Virgina. Good news is unfolding concerning welfare reform, both nationally and locally. A September, 1998 press report indicates that the national 'surplus' in welfare reform funds has reached $4.7B over the past two years. According to a recent GAO report, the states are finding creative uses for these surpluses--which the law allows them to keep and redirect. Some like DC, are improving the welfare services for those remaining, or providing better job training, employment search, and even transportation and child care. Others are reallocating a portion of their savings outside the welfare system, or simply holding their windfall in the federal treasury for future contingencies, such as a sharp decline in the economy. DC is showing similar good news, with a $38M surplus in FY98. The number of DC households receiving welfare is down 4400 to 20,700 and the individuals in those households down 13,600 to 55,700--still well over 10% of DC's population. part of the surplus is being used to upgrade the deplorable welfare facilities in several parts of the city. This reduction reflects national trends starting four years ago, but greatly accelerated by Congress's passage of the 1996 Personal Responsibility and Work Opportunity Act. Nationwide, since 1994, America's welfare rolls have dropped an astonishing 37% from 14.4 million to 9 million according to Neal Peirce in the Washington Post. Furthermore, in many states, many fewer of those applying for welfare are accepted--down from 80% acceptance to 25%. Unfortunately, according to Peirce, the rising tide of welfare reform is not lifting all boats equally. He reports that "an ominous racial divide may be opening: in 1997, 25% of white families on welfare left the rolls, compared to only 17% of black and 9% of Hispanic families." NARPAC, Inc. does not know if these biases apply in DC as well. Welfare Case Load Nationally, the changes in federal welfare rules have produced a remarkable reduction in total individuals on welfare. According to a spring, 1999, study, 65- 85%of those dropped are now working, with an average annual income just under $10,000 for 32 hours of work. Maryland reported that its welfare roles had declined 61% from 172,840 in 1996 to 68,750 two years later. With a population well over 20 million, Maryland has about half of DC's welfare cases in a population of just over 500 thousand. But in DC, a federally-funded $52 million welfare-to- work contract program was revoked after becoming snarled in a dispute with a non-performing contractor. Only some 25% of the 6000 recipients dropped from DC's roles so far have found work--and a total of 18,000 will be at risk by 2002. Medicaid Progress At the same time, significant changes are being made to streamline the management of Medicaid payments in the District. Three major improvements have been effected to date: the Federal Government matching rate has been raised from 50% to 70% (in fact, it probably should go even higher); more than 20,000 ineligible recipients have been screened from the rolls (so far!); and as NARPAC has reported (below), inpatient hospital rates have been reduced by some 25% (leaving oversized facilities in their wake). Together, the resulting savings are substantial. Given federal approval, those savings will be applied to providing guaranteed health insurance to all low- and moderate-income families with children. According to the DC Dept of Health's chief Medicaid officer, this can have a major downstream impact on those health indicators that make DC one of the most unhealthy cities in the United States. NARPAC, Inc. heartily congratulates these new management accomplishments, with particular emphasis on the clever proposal to invest these savings in the better health of the city's most at-risk population.
Reports of fraud involving tens of millions of DC Medicaid payments also surfaced in early 1999, with several Councilmembers calling for the ouster of its Director Offner. By mid-year, Offner was gone, but still claiming that he had substantially reduced questionable Medicare payments for three straight years. Meanwhile, national statistics continue to show that despite Medicaid, DC's prenatal is the worst among 50 US cities, with 64% of all births to unwed mothers, 16% of whom are teenagers, delivering babies 18% of whom are premature, and 13% underweight at birth. DC Food Stamp Program In a related move, as of September, 1998, DC's 40,000 food stamp recipients are now being paid through "Electronic Benefits Transfer" (EBT) cards. Department of Agriculture officials hope that these cards can eliminate as much as $84 million in fraudulent trading in the stamps. DC DRAGS ITS FEET ON WELFARE REFORM The Brookings Institution's Center on Urban and Metropolitan Policy has just recently released its third annual report on the national goal of "ending welfare as it has been known", "The State of Welfare Caseloads". Triggered by passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996, Brookings has set out to monitor the reduction in welfare caseloads nationwide. It is indeed an encouraging story, with a 52% reduction in active welfare cases from their historic high of 5.2 million cases in 1994. In a shorter paper, Brookings is calling attention to the fact that caseloads have been slower to drop in urban areas than in suburban and rural areas. This is somewhat peculiarly billed (for hyperbole?) as an "increase" in the share of urban welfare, and somehow "adding" to the urban burden. In fact, of course, most welfare costs are paid by the federal government, not local jurisdictions or states, and even the urban reductions have been quite astounding. In fact, the urban caseload has dropped almost 41%, while the national caseload has dropped almost 52% since their 1994 peaks. Brookings has selected the 100 largest US cities, which are located within 89 "urban counties" and draws some interesting conclusions. These cities with almost 33% of the country's population have seen their welfare caseload "grow" from 47.5% of the national load to 58.1%. More important--though unsaid--is that the average reduction in urban caseload has been on the order of 35%--about 612,500 cases altogether! Of the remaining cases nationwide, 70% are in the ten largest states (v 43% in '94) with 53% of the US population. Similarly, 10 urban counties are now home to 32.7% of welfare cases (v 24%) which contain only 12% of the US population. As the welfare high tide subsides, the deepest pools remain around a few large urban areas--where the poor always tend to congregate. Of possibly greater interest is the racial composition of the welfare caseload. Blacks continue to comprise a steady 45% of all caseloads (in the 25 largest city/counties) has risen from under 34% to over 36%. More troublesome is that in the 20 largest cities (different data base): Blacks, with 16% of the population, account for 48% of
the caseload; And, as is discussed elsewhere relative to subsidized housing and kids in poverty, a large majority of those black welfare cases involve young single moms struggling to raise one or more kids under difficult, if not deplorable, housing conditions. NARPAC Commentary What the Brookings report does not focus on (although the data points are provided) is that the District of Columbia has the distinction of having one of the nation's highest number of welfare cases per resident (as a city), and one of the lowest caseload reduction rates (as a city or a state). Only ten major cities and three states have a lower success rate than DC's 29.3% reduction over the past four years. And perhaps even more surprising, DC is home to more welfare cases than 25 (half) of the fifty US states (19,000+). If the DC government is looking for a benchmark for Welfare, it need look no further than these available data. At the beginning of 2001, the Urban Institute released an extensive new study entitled The Status of TANF Leavers in the District of Columbia". This report indicates that some progress is being made in reducing the number of families receiving "temporary aid". The transition from AFDC (Aid to Families with Dependent Children) to TANF (Temporary Aid to Needy Families) promises to be one of the major changes in US socioeconomic policy. It is as yet by no means clear that the "hard core" welfare recipients will be able to make the desired "welfare-to-work" adjustment. What does appear clear is that the progress in DC still lags that of the US altogether. As is indicated on the top right graph below, the total number of TANF cases in the US has declined from a maximum of about 5,000,000 in 1994 to about 2,400,000 by the end of 1999. In that same time period, the caseload in DC has fallen from a peak of about 27,200 to a level of about 18,000. As a result, DC's share of the total national caseload has risen from under half a percent, to almost 0.8% at the end of '99, as indicated on the bottom right graph. Within two years, it is quite likely that DC will grow to greater than one percent of the total national caseload. The problem will be exacerbated as thousands more reach their five-year welfare limit-- two-thirds of whom cannot read at a 6th grade level. Perhaps more worrisome is the fact that less than a third of those that have exited the DC TANF program left due to improved financial status. As shown on the table to the left above, the rest left for other reasons that leave their future in doubt. It is informative to note the characteristics of those leaving the TANF program, The predominance of young, single moms with more than one young child clearly makes the problem more difficult. NARPAC notes this same problem in trying to take advantage of the theoretical Section 8 Housing mobility feature. (The section which follows provides more up-to-date information indicating that DC's TANF caseload has in fact begun to decline significantly.) Although there is no recognized correlation, there are indications that the number of DC homeless is on the rise. After falling for four years straight, the number of families applying for emergency shelter rose 33% to almost 1300 families in 2000. In 1999, DC had a higher fraction of its population homeless at some point during the year than such cities as New York and Philadelphia. The official record for that year was almost 7500 people seeking space in shelters. If other housing arrangements are included as well, some experts believe that as many as 12,700 were homeless at sometime during the year--amounting to some 2.2% of DC's total population. And the numbers for 2000 are likely to be worse. The plight of DC's poorest does not appear to be improving. This update was provided by the D.C. Department of Human Services' Income Maintenance Administration for The Nonprofit Agenda, the newsletter of the Washington Council of Agencies. WCA, in turn, has authorized NARPAC to reproduce an abbreviated version here (TANF stands for Temporary Assistance to Needy Families): DC has made significant strides in helping parents move from welfare to work. Its caseload has declined to its lowest level in the last twenty-five years and thousands of families now receive a paycheck instead of a welfare check. The district's success has led to several significant financial awards and national recognition: o $41.7M in bonuses for program performance in the last two years alone; o a $20 million award in each of the last two years for its success in reducing out-of-wedlock births. Only two other states have received this award in. consecutive years. It should be noted that these reductions in live births to single moms will eventually have a direct impact on reducing DCPS enrollment and shrinking the number of school facilities needed in DC; o a High Performance Bonus for improvement in keeping working welfare recipients employed and helping them to earn higher wages. Besides DC, only three states this year received both a High Performance Bonus and a Bonus for Reduction in out-of-wedlock births. DHS has referred almost 5,000 recipients for job placement assistance in the last 6 months and virtually all non-exempt adults have been referred to an employment program at some point. Based on a study by the Urban Institute, DHS believes that approximately 5,200 families left TANF for work since DC (somewhat belatedly) implemented welfare reform. According to this study, the typical person who left welfare worked 40 hours a week and earned over $8 an hour. In fact, DC has achieved the federal government's overall work participation rates every year since welfare reform was enacted. These results were achieved through a welfare reform strategy that focused intensive resources in helping families find jobs and in supporting families while they participated in training and looked for employment. Specifically, the District funded programs that provided employment assistance, literacy education, childcare, free health insurance, food assistance, and a tax credit for working low-income families. These efforts have led to significant caseload decline, as indicated below: Between March 1997 (when DC welfare reform was implemented) and February 2001, the total number of families receiving TANF fell 33% from 24,266 to 16,151. The decline among "non-exempt" TANF cases -- i.e., cases in which an adult is expected to either work or participate in work activities -- has been even steeper, falling 38% to 10,819. DC's caseload declined without many of the penalty-focused policies (such as full-family sanctions and shortened time limits) used in other states Hence DC's decline is truly the result of successes in transitioning families from welfare-to-work and not the result of punitive actions. Despite Real Achievements, Much More Remains to be Done Under federal law, a family that includes an adult cannot generally receive federally-funded TANF benefits for more than 60 months. Beginning in March 1997, months in which families receive federal TANF cash assistance count against this 60-month time limit unless the parent or caretaker is excluded from the grant, as is the case in so-called "child-only" cases. While much attention has been focused on March 2002 as the month in which time limits will begin to take effect, about 75 percent of the current TANF caseload has notreceived TANF continuously since March 1997 and will not reach the 60-month time limit in March 2002. In fact, the caseload that has received TANF continuously since March 1997 has declined 44% percent from 4,688 in January 2000 to 2,652 in January 2001. But time is running out for those remaining. DHS is taking action to help those who have been on welfare the longest move from welfare to work by implementing the following intensive plan: o Together with DoES, developing a subsidized employment program for 2000 recipients focusing on their long-range barriers to employment, requiring recipients to participate in education and/or training activities, and placing those not ready to enter unsubsidized employment in subsidized jobs that will allow them to learn ski1ls and appropriate behaviors; o Visiting the home of each recipient who has been on welfare continuously since March of 1997 before they reach the time limit to encourage program participation and determine the reason for past noncompliance, to ensure that the customers understand the work requirements and consequences of failing to comply with program requirements, and assisting them with their assigned work program; and, if appropriate, assisting the customer in applying for an exemption; o Ensuring that every customer that has received welfare for 48 months or longer is referred to an employment provider, giving priority to recipients who have been on welfare the longest. These programs have helped several thousand individuals move from welfare to work and significantly reduced the number of recipients in danger of reaching the time limit in 2002. o Implementing the following administrative changes designed to support
and facilitate the transition to work:
Unless exempt from participation, every recipient who "hits the time limit" must be engaged in a work activity or face sanctions. DHS does not want to penalize a recipient who is making a concerted effort to improve her life. Similarly, DHS does not advocate cutting an individual's benefits if a doctor has certified that a short-term medical condition temporarily prevents working. Paying for benefits with local dollars would allow DC to continue to provide assistance to recipients who are trying to help themselves while penalizing those who refuse to follow program requirements. Currently, there are sufficient financial resources to pay for TANF benefits with MOE funds without any additional cost to DC. DC has made important strides in developing a welfare-to-work strategy that will assist all TANF recipients to prepare for, find, and retain employment. Many parents have already found work. Taken together, efforts to expand employment providers, increase adult education programs, provide technical assistance to participants and employers, and make home visits are improving DC's success in assisting parents (most of whom want to work) to find and keep jobs and thereby strengthen their families' independence.
Whether park maintenance is appropriately a human services function rather than a public works function is certainly problematic, but with the National Park Service taking care of most of DC's federally owned public lands, DC is free to concentrate on the needs of its needier local residents. Nevertheless, it is one more area where the DC government had failed to take care of its own--a problem Mayor Williams is now working hard to fix. According to the FY00 DC Budget, the DCDRP has set itself four goals: a) to improve customer service with greater citizen participation; b) to enhance financial strength by encouraging more public/private initiatives; c) to reform business practices and work more closely with both the federal agencies and the DC public school system to "maximize resources"; and d) to invest in its workforce with better recognition of employee and volunteer services and better job training. Integrating the School System with Neighborhood Parks In November of 1999, NARPAC took advantage of a chance meeting with DC's new Director of Recreation and Parks (only appointed in July, '99) to write and question him about cooperation between DCDRP and DCPS. His response is repeated below:
This is in response to your correspondence in reference to a closer working relationship between District of Columbia childcare providers. NARPAC was impressed by the thoughtfulness and thoroughness of this reply. If this is representative of closer working relationships between all DC childcare providers, then it will surely redound eventually to the advantage of the city's residents--of all ages, to the productivity of the city's government, and to the image projected by the city. Consistent with this aim, DCDRP announced in late December, 1999, that 73 of its local recreation centers would be open and staffed to provide activities for school kids on holiday. Nevertheless, it seems highly unlikely that the DCDRP will be able to maintain its facilities with only 24 maintenance employees.
Each month brings additional headlines in the local papers about problems in all aspects of the city's provision of human services. Click here to bring up a chronological listing of Washington Post stories about DC's hospitals, foster care, welfare abuses, etc. for the past year.
This item has been 'archived'
URBAN INSTITUTE STUDIES: "Long Term Care for the Elderly" and "The Impact of Welfare Reform on Child Welfare Financing" A recent (1997) study by the Urban Institute analyzes problems in long-term care for the elderly and related state health policy. Some 33 million Americans are now over age 65, and 21% of these are disabled, of which 75% live at home with upaid care from relatives. But 40% will spend some time in a nursing home before they die. As in so many other areas, DC defies the norms for Medicaid expenditures for elderly beneficiaries. In 1995, DC spent $19,406 per elderly beneficiary compared to the national norm of $7,800 -- 30% higher than any other state, and $2,356 per elderly resident, compared to the US average of $967 -- 30% higher than any other state except New York. By comparison, Maryland and Virginia (combined) are 6% below the national norm per beneficiary, and 29% below per resident. DC spending for mental health for the elderly is 4.5 times as high as the national average. Furthermore, DC's average Medicaid rates for nursing facility reimbursement are the 4th highest in the US, and 85% higher than the national average ($157 v $85 per diem). Maryland and Virginia combined are 17% below that national average. Such disparities within the metro area are difficult if not impossible to rationalize, and must contribute to the demographic imbalances which plague the District's socioeconomic well-being. At the other end of the spectrum, a second new Urban Institute report, this one discussing the effects of welfare reform on child welfare, tabulates the per-child AFDC grants and monthly foster care payments for FY95. DC's AFDC payment rate is 28% above the national average, though by no means the highest among all the states (ranking 13th). In foster care payments, DC payments are 23% over the national norm, this time ranking 8th highest. By comparison, Maryland and Virginia average 32% below the national norm in per child AFDC grants, and 17% above in foster care payments. Again, these imbalances between neighboring metro jurisdictions will tend to sort the disadvantaged population and concentrate both the young and old needy in the inner city.
The pitiful plight of many of DC's mentally retarded citizens was also brought to light in a series of Washington Post articles in March of 1999. Although the infamously inadequate Forest Haven facility has been closed for some time, it is now clear that "contracting out" the problems and then not monitoring the results can be equally bad. There have been some 350 reported cases of serious neglect and abuse of patients, including overdrugging or neglected medical treatment, physical abuse, and--of course--fraud, by 'scurrilous' overseers. These patients are farmed out to about 150 local contractors--many of them private families willing to take on one or more retarded persons for various menial tasks--in return for substantial DC government payments. The current 1100 beneficiaries of this program each cost the District about $100,000 per year.
According to the annual report of the White House's DC Task Force for 1996, considerable federal assistance is flowing to DC agencies:
May 1998 Update of Federal DC Task Force Federal assistance from the Department of Health and Human Services (HHS) and other relevant agencies to the District has continued across the gamut of health and human services problems. According to the 1998 update: o Child care initiatives: HHS has undertaken a major effort to improve the administration and provision of child care services--and the inspection of child care facilities--within DC. Virtually every aspect is receiving technical assistance to bring capabilities up to federal standards, and to achieve obligation and drawdown of federal funds available from prior years back to FY95. Starting in early 1998, even the Defense Department has been brought in to help upgrade the licensing and monitoring of child care facilities. HHS is also providing technical assistance in developing rates and criteria for combining Head Start and city child care efforts.
The table below presents NARPAC, Inc.'s updated listing of functions and aims within this general category, offering simple goals and approaches for achieving them, and noting the progress (if any) to date. The tabulations and entries are clearly preliminary, but are intended to indicate the full range of steps needed to assure long-range solutions to the District's systemic problems.
Revised Version -- January, 2002 -- changes from original in green
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This long-closed
hospital between New Hampshire and Vermont Avenues is 13 blocks north
of the White House.
(1) TANF cases in which children are not living with their parents
but are being cared for by a relative who does not receive TANF benefits
for him/herself, as well as cases in which the youngest child is less
than one year of age, are "exempt" from work requirements.
