Beginning in May 2020, Alaska enhanced Medicaid coverage through the 1115 Waiver for three target populations.  Population 1 is children and adolescents (0-21) and the parents or caregivers, with, or at risk, of mental health or substance use disorders.  Population 2 is transitional age youth and adults (18+) with acute mental health needs.  Population 3 is adolescents and adults with substance use disorders.  The Medicaid 1115 expansions related to child welfare will provide funding for community-based outpatient services to include intensive case management services, mental health day treatment, home-based family treatment services, and acute intensive services.  These acute intensive services will include mobile outreach and crisis response, 23-hour crisis stabilization, residential treatment, and therapeutic foster care.

The Family First Prevention Service Act (FFPSA) (H.R. 253) made Title IV-E funding available for child welfare prevention services including substance use disorder treatment, in-home family services, and mental health treatment.  The Administration for Children and Families has determined that Title IV-E should be the payer of last resort.  This means that if other funding streams (like Medicaid or private insurance) can pay for allowable services that would generally qualify under Title IV-E prevention services, those funders will have the responsibility for paying before the Title IV-E agency pays. 

Because FFPSA requires 50% of State child welfare prevention spending to be on supported and well-supported evidence-based practices, this will require states to implement services meeting this criterion that are not already eligible for Medicaid funding.

Until preventions begin to reduce the number of children in care, OCS will have a limited budget for funding new services.  Community investment and public/private grant funding will most likely be the initial seed for new community-based preventions.  As communities launch their chosen preventions, their investments of time and financial resources should leverage public and private investors, including OCS.  It is reasonable to expect that by utilizing centralized administration and shared systems, the overall cost of establishing services in multiple communities will decrease.

Of the 574 Federally recognized American Indian and Alaska Native (AI/AN) tribes and villages, roughly 40% (229) are in Alaska.  This creates a unique authority dynamic because, in addition to a traditional Federal and state governance, there are 229 uniquely sovereign tribal nations.

When it comes to the relationship between U.S. governmental entities, the Federal government has been tasked with protecting “tribal self-governance, tribal lands, assets, resources, and treaty rights, and to carry out the directions of Federal statutes and court cases (2020, p. 23).”  This self-governance is the crux of the issue related to child welfare decisions.  In the U.S. Federalism model, each state is responsible for the welfare of its citizens; this includes child protective services.  Since the beginning of statehood, Alaska’s Office of Children’s Services has been responsible for protecting Alaska’s children.  However, historically, this issue has blurred the lines on how decisions are made for Native children.  In 2020, 65% of all Alaskan children in foster care are Alaska Native despite only 16% of the overall population in the state being American Indian or Alaska Native (Alaska Department of Health and Social Services, 2021).

Within child welfare systems in Alaska, the problems have been the disproportionate number of Native children in foster care compared to non-Native children, the separation and resulting trauma from Native children being removed from their culture and communities, the low family reunification rates, and the adoption of Native children into non-Native homes.  The Tribal State Collaboration Group was started 25 years ago as a collaboration between state and Tribal representatives to address these problems.  This group still exists today and has been the breeding ground for what became the Alaska Tribal Welfare Compact.

The Alaska Tribal Welfare Compact was a first-of-its-kind legal agreement made in 2017 between the State of Alaska and participating Alaska Native Tribes and Tribal Organizations to address the problem.  The Compact recognizes tribes as sovereign over their citizen’s child welfare, and for tribes that want to manage all or part of their child welfare, it provides the funding and operational structure to delegate the oversight and management to them.

There are currently 15 AI/AN or Tribal organizations as co-signers of the Alaska Tribal Child Welfare Compact.  These entities include Aleut Community of St. Paul Island, Aleutian Pribilof Islands Association, Association of Village Council Presidents, Bristol Bay Native Association, Central Council Tlingit & Haida Indian Tribes of Alaska, Chugachmiut, Cook Inlet Tribal Council, Copper River Native Association, Kawarek, Inc., Kenaitze Indian Tribe, Maniilaq Association, Native Village of Eyak, Nome Eskimo Community, Sun’aq Tribe of Kodiak, and Tanana Chiefs Conference.

The Compact has defined the work of Tribal child welfare into five scopes of service.  These scopes of work are prevention, initial diligent and ongoing placement searches, family contact, safety evaluations, and licensing assist.  Each Co-Signer is at a different stage of capacity building or implementation.  The Tribal-State Compact implementation teams are working hard to move toward a remarkable and historic Tribal-led child welfare system.  The importance of the Compact cannot be over-stated. 

Now is the time for Alaska’s stakeholders to come alongside Tribal child program leaders and provide the resources they may need to stand up their child welfare programs. 

Alaska is diverse in ways that most states do not experience.  The most prominent racial categories of Alaskans are 65% white, 16% American Indian or Alaska Native, 8% two or more races, and 7% Hispanic or Latino (United States Census Bureau, 2021). More notable is that Alaska is home to one of the most diverse school systems, with over 100 languages spoken.  The work of the AIA promotes accessibility for all and equity in design and delivery of wellbeing services.

Alaska Native citizens have suffered the tragic effects of colonialism and racism since the 1700s.  They were displaced, oppressed and have suffered the loss and erosion of their wholistic and beautiful cultures.  We acknowledge that we live and work on their land and that we have been a part of the systemic racism that has deteriorated family structures, spiritual practices, education, and community wellbeing.  It is our desire at the AIA to promote unity and collaboration.  Our heart is to provide a space for listening and healing while moving toward effective work on decreasing disproportionality in our child welfare systems.  While we strive toward implementing of evidence-based and promising practices, we recognize that the most successful and important practices are ones that are designed by those that use them and are built on cultural norms and community cohesion.  Unfortunately, these organic family preservation systems are often not studied or evaluated by governing bodies, making them ineligible for certain funding streams. As a group, we will strive to support, promote, and prioritize locally designed and culturally appropriate programming in Alaska’s communities.

The lack of workforce within the disciplines needed for child welfare prevention programs continues to be a significant barrier for program implementation. Finding certified behavioral and mental health clinicians to administer or oversee programs related to family and child wellbeing has been difficult for most agencies, particularly those who bill Medicaid for services. This causes a problem because most evidence-based practice models require clinician- level practitioners and oversight. 

Recruiting practitioners to rural communities is an even greater hurdle as lack of housing and amenities reduce the appeal to those that may consider working in Alaska’s smaller communities. Alaska’s land and population diversity are two of its greatest strengths, but these strengths create complexities in serving Alaska’s children and families.  Child welfare prevention programs in Alaska must operate well in small communities, with strategic on-site delivery and internet demands, and be created with inclusive cultural practices. Prevention programs will need to rely heavily on the labor force available within communities without a burdensome demand for clinical-level practitioners.