United States General Accounting Ofllce /f o Ls Testimony Ill1110 ll 140656 For Release Ackquacy of Nutrition Programs on Indian Delivery Ekpectedat Reservations 9:00 a.m. EST Tuesday February 20, 1990 Statementof Flora H. Milans, Associate Director Resources, -unity, andEconomic Development Division Before the Cutxnittee on Agriculture, Nutrition and Forestry and Select mttee on IndianAffairs United States Senate Messrs. Chairmen and Members of the Committees: We appreciate this opportunity to discuss our findings on the U.S. Department of Agriculture's (USDA) food assistance programs on Indian reservations. This work was done at your request as well as several other members of the Senate. Our testimony today is, in part, based on our September 1989 report,1 which addresses the availability of food assistance and the nutritional adequacy of the Food Distribution Program on Indian Reservations: (Indian commodity program) and the Food Stamp Program. In addition, we will discuss our ongoing follow-on work in which Indian recipients of these programs, and community representatives, including social service providers, health care professionals, program officials, and leaders within the reservations, told us their views on how hunger and nutritional concerns were being addressed by federal food assistance. Our work was confined to four reservations: Fort Berthold in North Dakota; Pine Ridge in South Dakota: White Earth in Minnesota: and Navajo in Arizona, New Mexico and Utah. SUMMARY OF FINDINGS The Food Stamp Program along with commodity foods have contributed to the improved diet of Indian households on the reservations. However, there are indications that some hunger-- more common among food stamp participants and nonparticipants in both federal programs-- exists on all four reservations we visited. According to recipients and community representatives, the major causes of hunger are (1) obstacles in applying and qualifying for food stamps, (2) the h eavy reliance on the federal programs that are not intended to provide a full diet for most households, (3) procedural requirements of the Food Stamp Program that influence the size and delivery of benefits, and (4) high food prices that erode the purchasing power of food stamp benefits. lFood Assistance Programs: Nutritional Adequacy of Primary Food Prcjrams on Four Indi- n Reservations (GAO/RCED-89-177, September 24, 1989). Of greater concern to those we spoke to on each of these reservations is the prevalence of diet-related problems, such as obesity, diabetes, heart disease, and hypertension, and how federal food assistance and the lack of adequate nutrition education may have an impact on those diseases. In particular, while the limited variety and poor quality of some commodity foods are concerns for even healthy individuals, these foods can present serious problems for participants with diseases that require special diets. Based on a consensus of people that we talked to, it appears that providing better access to food assistance, an adequate and nutritious diet, and proper education that addresses the nutritional needs of the general reservation population, as well as those with diet-related diseases, could improve the quality of life. BACKGROUND Our September 1989 report identifies various federal and nonfederal food assistance programs and nutrition education available on the four reservations and addresses the adequacy of the nutritional design of the Food Stamp Program and Indian commodity program. It also presents program and tribal officials' views on whether these programs are meeting the nutritional needs of Indian participants. Our follow-on work builds on our earlier report. It provides, for the first time, the recipient perspective on how well the programs are meeting their needs and whether nutrition education is adequate. We obtained this perspective through the use of focus groups8 which are small homogeneous groups assembled to candidly discuss a topic under the guidance of a moderator. We also discussed the nutritional impact of the Food Stamp Program and Indiah commodity program with panels of health care and social 2 service providers, and program officials from the reservation communities. We focused on the two primary programs--the Food Stamp Program and the Indian commodity program--that provide food assistance to recipients on the four reservations. The Food Stamp Program increases the food purchasing power of low-income households, enabling them to buy a more nutritious diet. It is funded by USDA and administered through a cooperative federal-state effort. Benefits are provided to eligible households in the form of food coupons that are exchanged for food at participating stores. The dollar value of the food stamps that a family receives varies, based on an assessment of household size and countable income,2 and is intended to provide a nutritionally adequate, low- cost diet when combined with a portion (about 30 percent) of the recipient's income. If a household has no countable income, food stamps provide for their total monthly diet. 1JSDA's Food Distribution Program on Indian Reservations was created primarily to help meet the nutritional needs of Indian households located on or near Indian reservations. The Indian commodity program provides participants with a monthly food package comprised of a variety of surplus and purchased commodities. The package is intended to be consistent with national dietary guidelines, and the size of the food package does not vary with income. USDA considers the Indian commodity program to be a supplemental food program, which is not intended to be the sole source of food for recipient households for the complete month. Reservation households that are eligible to participate in both the Indian commodity program and the Food Stamp Program may choose to participate in either but not in both programs simultaneously. 2Not "all of a household's income is actually counted. Some exclusions and deductions are allowed .when determining its food stamp benefits. 3 HUNGER IDENTIFIED AS A PROBLEM PRIMARILY FOR NONPARTICIPANTS AND FOOD STAMP HOUSEHOLDS Federal food programs have helped to alleviate hunger on the reservations by providing Indian households the opportunity to obtain a more adequate diet. However, at all four reservations, some of the food stamp and commodity recipients told us that they often did not have enough food to eat and had to borrow food or skip meals to make it through the month. Health and social service providers from these communities had also witnessed hunger--among families who needed food assistance but could not get it: among children, for whom the one meal of the day was the school lunch: among the elderly who gave some of their food to other needy family members: and finally, among food stamp participants who ran out of benefits before the end of the month or who had to wait weeks for their food stamps. Recipients and community representatives identified various factors to help explain the causes of hunger on the reservations. Some factors, such as the Food Stamp Program's lengthy application process and stringent eligibility criteria, illiteracy, language barriers, and poor physical accesq t,s food stamp offices, are perceived as obstacles to participation in federal food assistance. Other factors relate to high unemployment that leaves households that participate in the programs with little resources beyond their food assistance with which to buy food, and the procedural or administrative requirements of the Food Stamp Program. The lengthy application form, which combines application to several assistance programs, and the need for receipts, pay stubs, and other documentary evidence to verify statements on the application form deter some households from applying to the program, according to either recipients or community representatives at all locations. Further, according to one Food Bank ifficial , the time it takes some households to meet the verification requirements could delay receipt of food stamps by up 4 to 3 or 4 weeks. While the Food Stamp Program can expedite benefits for applicants with little income, this official did not indicate whether households that were experiencing delays were eligible for expedited benefits. It should be noted, however, in an earlier study3 of other states' practices, we found indications that eligible households were not always offered expedited benefits. In addition, illiteracy, language barriers, and poor physical access to the food stamp office further hinder participation for many Indian households. For example, participants may have to travel anywhere from 30 to 165 miles one way to get to the main food stamp office on the Pine Ridge and Navajo Reservations, which can limit their ability to comply in a timely manner with the procedural requirements of the program. According to both recipients and community representatives, the limited number of offices serving remote areas of the reservations and the absence of reliable transportation make the program inaccessible for many. Food stamp offices at some of the reservations offer alternative services where applicants can be interviewed at a satellite location in lieu of the main office. However, operation of these satellite offices may be limited to 1 to 4 days a month, and for a limited number of hours each day. Furthermore, the lack of adequate transportation can make even the satellite offices inaccessible. According to community representatives at some reservations, many households must rely on neighbors or others for transportation to the food stamp office. At all four reservations, recipients and community representatives agreed that a principal obstacle to participation in the Food Stamp Program is the asset limitation as applied to 3Fooi Stamp Proqram: Administrative Hindrances to Participation (GAO/RCED-89-4, October 21, 1988). 5 automobiles. Recause only $4,500 of a vehicle's value--an amount set in 1978-- is excluded from consideration when applying the $2,000 asset limitation for eligibility, families with cars that are less than 3 years old, in all likelihood, will not qualify for benefits. Some commodity recipients at three reservations told us that they could not qualify for food stamps because they had cars that exceeded Food Stamp Program limits, while others indicated that they had sold their cars in order to qualify for the program. Furthermore, community representatives told us that households do not understand the eligibility and administrative differences between the two food assistance programs and wrongly assume that ineligibility for one program automatically disqualifies them from participation in the other. Recipients and community representatives told us that they also had concerns about the monthly reporting requirement of the Food Stamp Program and the administrative burden it places upon recipients. Households with earned income that are subject to this requirement must report income, expenses, and other information that determines benefit levels and to provide supporting documentation. Failure to submit a complete and timely monthly report can delay benefits or cause participants to be terminated from the program. In an earlier report4 that looked at the reasons for food stamp participants being temporarily terminated from the program, we found that states may adopt a monthly reinstatement option. This option permits states to accept a monthly report in the month after it is due and provides the recipient, if still eligible, a full month's benefits, rather than reduced benefits prorated from the time the report was correctly submitted. We noted that 13 states had not adopted this option, including Minnesota, which 4Fooud Stamp Program: Participants Temporarily Terminated for Procedural Noncompliance (GAO/RCED-89-81, June 22, 1989). 6 contains the White Earth Reservation: North Dakota, which contains the Fort Berthold Reservation: and New Mexico and Utah, which contain portions of the Navajo Reservation. Recipients that we talked to at the Fort Berthold and Navajo reservations have had their benefits terminated for untimely reporting and have had to reapply for benefits. Others at Fort Berthold, Navajo, and Pine Ridge have experienced delays of anywhere from 10 days to 1 month in receiving benefits because they did not complete or made errors in their monthly reports. Because information from the monthly reports is used to establish benefit levels in subsequent months, the food stamps received may not be sufficient to meet current food needs. Although the program is designed to provide a means of obtaining minimum food requirements through a combination of food stamps and income, in practice this does not happen when recipients have fluctuating incomes and expenses. For example, a household's prior month's income could be high, resulting in a small benefit, when the household may need a larger benefit in the current month due to a loss of income or higher shelter costs. According to some recipients at three of the reservations, this type of mismatch creates hardships for many. High reservation food prices and costs to travel off the reservation to buy lower-priced food contribute to hunger among food stamp participants, according to recipients. They pointed out that because the food stamp benefit is based on the cost of purchasing the Thrifty Food Plan5 at current average national food prices, it does not take into account the high food costs on the reservations. 5USDA's lowest cost diet plan that specifies quantities and types of foods providing a nutritious diet. 7 Additionally, recipients at some reservations told us that since food stamps are issued to everyone on the same day of the month, grocers can and do increase food prices during the week of issuance. Although food stamp regulations allow states to stagger issuance of stamps, we noted that only the states serving the Navajo Reservation use a staggered issuance schedule. Recipients also told us that to get better value from their food stamps, they had to travel 50 to 75 miles off the reservation to purchase food at lower prices. Recipients we talked to who did not have cars or whose cars were unreliable had to incur the expense of finding alternative ways to travel. NUTRITIONAL CONCERNS At all four reservations the most prevalent diet-related concerns are obesity, diabetes --which is near epidemic proportions at Fort Berthold and Pine Ridge--heart disease, and hypertension. According to health care providers, diets low in fat and salt and high in nutritional variety can prevent or minimize these diet- related diseases at the four reservations. Recipients and community representatives we talked to believe that the Indian commodity program cannot accommodate the special diets required to treat these problems unless changes are made to the food package. Also, many recipients we talked to had limited resources beyond their food assistance, particularly at Fort Berthold, and had to rely on the commodity foods for most or all of their diet. Recipients and community representatives told us that the commodity package lacks the nutritional variety needed for a healthy diet because many commodities are consistently unavailable, servings of vegetables and fruits are inadequate, and some other foods are inedible and cannot be used. At three reservations, approkimately half of the 60 plus items offered in the program are available at any given time for recipient selection. As a result 8 of the poor variety, some recipients told us that they often eat the same foods throughout the month and often for many months at a time. For example, often the only meat is luncheon meat, the only vegetable is canned green beans, and the only fruit is canned pineapple. While we did not examine the reasons for the lack of variety in the program, we were told that many factors affect the availability of commodities. According to USDA, market conditions, tribal food preferences and ordering practices, price fluctuations, and storage limitations at the state and reservation level limit the variety of food available at specific reservations for specific months. Community representatives noted that the package, as presently designed, does not provide adequate servings of fruits and vegetables for healthy individuals. According to USDA, the commodity package provides only 73 percent of the servings of fruit and 28 percent of the servings of vegetables recommended by the American Red Cross and USDA. Because diabetics need more of these items than do healthy individuals, according to Indian Health Service officials, the commodity package can significantly aggravate this problem. Recipients in each of the focus groups told us that the poor quality and inedibility of some of the commodity foods further limited variety. Spoiled milk, moldy cheese, flour infested with bugs, and canned foods with foreign objects could not be eaten by these households and had to be discarded. Although the program provides for replacement of damaqed or inedible foods, recipients at some reservations told us that program officials did not replace inedible items or that recipients could not afford to drive back to the warehouse to return items. To help overcome some of these problems, recipients suggested that USDA place expiration dates on all commodities. 9 In 1985, USDA reviewed the nutrient profile of the commodity package and concluded that the package provided a nutritionally adequate, supplemental diet for healthy individuals and made further improvements in the program to reduce the fat and salt in the package. However, USDA's conclusion assumed that the maximum variety of foods is consistently available to recipients, which recipients' experiences indicate may be unrealistic. Some recipients and health care providers at all four reservations believe that some commodities still contain too much fat and salt and that additional changes to the package are needed. In December 1989, USDA proposed further changes to the commodity package to make it more consistent with dietary guidelines and to be more responsive to the special needs of its participants. These changes would increase the quantity of fruits and vegetables and further reduce the fat and salt content of the package. NUTRITION EDUCATION Since many of the health problems on the four reservations appear to be diet-related, community representatives told us that providing proper education through the federal food assistance programs is necessary to the prevention and treatment of these problems. Commodity participants, in particular, could benefit from nutrition education as they may not get an adequate variety of foods or be able to control the fat and salt content of their diets. According to recipients, some nutrition education is available on the four reservations, but efforts by the commodity program are limited, and little, if any, assistance is provided to food stamp participants. 'Nutrition education is a component of both the Food Stamp Program and the Indian commodity program. The Secretary of 10 Agriculture has discretion in setting the form and content of nutrition education programs for food stamp participants and the state agencies administering the Indian commodity program determine the form, content, and amount of program funds allocated to nutrition education activities. We found that nutrition education activities of local food stamp offices serving the four reservations consisted primarily of having nutrition brochures and other literature available for food stamp recipients. However, because most recipients receive food stamps at their residence, they are not exposed to this literature except when applying or reapplying for benefits. Food stamp recipients we interviewed at the four reservations were neither aware of nor had they received any nutrition literature from their local food stamp office. We also found that nutrition education provided by the commodity program was limited and varied by reservation. The Navajo commodity program provided the most nutrition education activities of all four reservations, although not all recipients participated in the educational program. At the White Earth, Fort Berthold, and Pine Ridge reservations we found that other federal agencies or programs were providing nutrition education--primarily the Indian Health Service, USDA's Special Supplemental Food Program for Women, Infants, and Children, and USDA's home extension service. Commodity recipients we talked to were aware of some of these efforts, but told us that these activities may not be available to all food assistance participants because they require an agency referral. Health care providers at all four reservations told us that for nutrition education to have the greatest impact it should be provided along with federal food assistance. Also, to guarantee a certain level of activity, Navajo representatives recommended that 11 the Food Stamp Program and commodity program earmark funds for nutrition education instead of leaving it to the discretion of local administrators of the programs. Community representatives from the Navajo and Fort Berthold reservations also suggested that the federal health, welfare, and food assistance programs be allowed to consolidate program funds to sponsor mass media campaigns and education programs that would promote understanding of good health and nutrition and to allow the agencies to use outside experts to effectively design these programs. Community representatives noted that nutrition education provided through the federal programs needs to be tailored to the behavior and knowledge of recipients and that one-on-one counseling with a nutritionist is the most effective way. White Earth, Fort Berthold, and,Navajo representatives also thought that nutrition education should address cultural foods and their effects on health as well as different ways to prepare commodities in times of limited nutritional variety. In addition to providing nutrition education through the food programs, community representatives at all four reservations thought that more nutrition information should be provided through the public school curricula to address dietary habits at an early age. They believe there is a need for extra training for teachers, particularly in elementary schools, and for parents so that learning can be reinforced outside the classroom as well as inside. GAO OBSERVATIONS Many factors affect the nutritional status of Indians: the availability of an adequate food supply, accessibility to food, undeistanding how to select and prepare nutritious foods, and individual health problems, which may impair a person's access to 12 an adequate diet. Based on a consensus of people that we talked to, many of these factors cannot be fully addressed by existing federal programs. However, improving the adequacy and availability of food assistance and proper education may allow broader participation in the federal food programs and help reservation households attain better nutrition. Based on our current and past work,6 the application process and asset limitations can be obstacles to participation in the food stamp program. Illiteracy, language barriers, poor physical access, and a lack of understanding about program eligibility and benefits are additional factors that can make the administrative requirements obstacles for Indian applicants. Some of these obstacles can be minimized through better implementation of existing services authorized by food stamp legislation and regulations. For example, funding for outreach services, which has been reinstated by the Hunger Prevention Act of 1988, is available to states to promote informational activities regarding program eligibility, benefits, and the application process. Further, current program regulations require states to provide assistance to applicants who have difficulty in obtaining the required documentary evidence to support information on their application. This service could make the application process less burdensome for those households who are experiencing problems. People that we talked to told us that one change that could make the Food Stamp Program more accessible to Indian households involves the $4,500 automobile exclusion in applying the $2,000 asset limitation. They believe the $4,500 exclusion, which has not been updated since 1978, limits participation in the program, can deny rural participants the reliable transportation needed to 6Fool; Stamp Program: Administrative Hindrances to Participation (GAO/RCED-89-4, October 21, 1988). 13 comply with procedural requirements of the program, and does not account for inflation. Additionally, recognition of how some food stamp procedural requirements and administrative practices can impact food stamp benefits is important to addressing hunger on the four reservations. Delays or interruptions in food stamp benefits resulting from noncompliance with monthly reporting requirements, as we previously reported,7 can be partially addressed by adopting the reinstatement option that allow states to accept reports up to one month late with no interruption in benefits. It should also be noted that the Hunger Prevention Act of 1988 makes monthly reporting an option of the state agencies. In addition, recipients and community representatives believe that staggering the issuance of stamps throughout the month, instead of issuing them to all participants concurrently, might help discourage grocers from raising their prices when food stamps are issued. Reducing the prevalence of obesity, diabetes, heart disease, and hypertension depends on Indians having food available that is low in fat and on changing certain aspects of their lifestyles, such as choosing food low in fat and salt, preparing these foods in a nutritious manner, and increasing exercise. Since many Indian households rely heavily on food assistance for their diet, providing quality food and proper education through the federal programs is important to the prevention and treatment of these diet-related diseases. Ensuring that adequate nutritional variety is consistently available, the fat and salt content of the package are within moderate levels, expiration 7Fooi Stamp Proqram: Participants Temporarily Terminated For Procedural Noncompliance (GAO/RCED-89-81, June 22, 1989). 14 dates are placed on commodities, and inedible commodities are replaced can improve the quality of diet provided commodity recipients. Improving the quality of diet for food stamp and commodity households depends on proper nutrition education to convince the Indian population with diet-related health problems to adopt the food preparation and consumption patterns that will benefit them. Proper nutrition education can better assure that program recipients are getting the maximum value from their food assistance benefits. This concludes my prepared statement. We will be pleased to respond to any questions. 15
Adequacy of Nutrition Programs on Indian Reservations
Published by the Government Accountability Office on 1990-02-20.
Below is a raw (and likely hideous) rendition of the original report. (PDF)