On Thursday, Sept. 22, students, faculty and staff gathered over lunch in the Barus Building Dewey Conference Room for the first of the Department of Education’s four-part fall semester speaker series. Georgetown University McCourt School of Public Policy Associate Professor Nora Gordon kicked off the series with her dynamic presentation, “Medicaid, Special Education, and Children’s Access to Health Services.”
Dr. Gordon, a research associate of the National Bureau of Education Research and an expert on Title I of the Elementary and Secondary Education Act, has been studying school-based Medicaid billing for special education and trends in how states use categorical versus general aid for education. Looking around the room at various student teachers, she shared her excitement at talking about the project with people who have spent more time in schools than she has, then jokingly answered a query on how she balances teaching, research, advisory panels, and raising three kids (the secret to her success: an 8:30 p.m. bedtime). Then she briefed the audience on how in 1988 Congress authorized Medicaid to reimburse for Individuals with Disabilities Education Act (IDEA)-related services for children with special education needs. She had been surprised to learn just how large the Medicaid program is for school-aged children.
In exploring children’s access to health services, Gordon looked at how the different goals and players interact and how researchers can formulate questions, gaining insight on the ins and outs of a policy goal designed to improve outcomes for students with disabilities. The system is incredibly complex, Gordon revealed; Medicaid only funds children’s medical services under IEPs, covering speech, physical, and occupational therapy but not learning disabilities. IDEA covers 16% of the cost, distributing federal special education funds through state and discretionary grant programs, but the content and fidelity to the goals written into students’ IEPs are highly variable, Gordon found – as is cross-state participation in special education programs. Some states, such as Texas, are attempting to reclassify special education, moving students into plans requiring fewer services and saving more money. The percentage of children identified as having special education needs ranges from state to state; for example, 9% in Texas have needs compared to 18% in Massachusetts (one audience member pointed out that Rhode Island has been reported to have the highest percentage, around 20%). IDEA adjusts numbers based on poverty because of a correlation between poverty and disability, while dollar amounts are based on predicted, rather than actual, students with special education needs. School districts are attempting to match numbers to finances set by states while Medicaid amounts vary. One goal, Gordon reported, is to look beyond education financial incentives such as funding formulas and instead focus on measures of effectiveness such as how many students have an IEP, how many students need an IEP, and whether the IEPs are appropriate and well-implemented. One must question, Gordon told the audience, whether special education needs are the same across all states and all populations or whether some students are being underserved. Districts are required by law to service students with needs, but states are struggling with funding constraints.
Billing for Medicaid is complex; private vendors are hired for billing and receive a commission on reimbursements. The National Association of Medicaid Directors conferences feature “big billing” (Gordon compared them to “big pharma”) vendors persuading school administrators to sign on with them. Billing is often layered so that teachers and therapists cannot see students’ Medicaid statuses, and pull-down menu options can have unclear options for entering information such as dosages. There is no comprehensive data source, Gordon revealed; the National Alliance for Medicaid and Medication tracks only 26 reporting states. There are 51 different policies and programs across our country, and coverages vary greatly.
Dr. Gordon listed some questions to inform Medicaid under the IDEA policy:
- Do incentives to bill affect access (both for medical services and other special education services), general education resources, and child outcomes (health, education, and long-term)?
- How do observable aspects of state reimbursement policies correlate with observations?
She also reported that 26 states choose to charge administration fees, which vary from 1% in Kansas to 88% in Nebraska. 34 states and the District of Columbia have no fee. This leads to questions about whether access was in or out of school and whether the fees relate directly to the number of students with access, but her questions were limited by available data. Gordon’s findings support the claim that therapists want to help students and address their needs, but varying incentives and billing practices and state policies make it difficult to track needs addressed and goals met.
Gordon fielded questions from audience members, some of which she was unable to answer because she can only measure what’s across all states – giving students and faculty a glimpse into the frustrations of those who depend on good data to adequately track program effectiveness. She confirmed that IDEA and Medicaid amounts shouldn’t interact because they are formula-driven and not district or state comparisons. IDEA funds don’t have to be medical, she informed the crowd, so those funds are more flexible. She also referred the audience to research by MIT Ph.D. candidate Elizabeth Setren, who has closely studied the charter school system in Boston and discovered that when the charter schools removed IEPs for special education students and English Language Learner students, the students’ scores have gone up. This led her to question what it means to have an IEP and whether a good general education could replace IEPs. Gordon left the crowd with this food for thought.
The Brown Education Department Speaker Series will include three more events this fall:
Tuesday, Oct. 18, 4 p.m.: Jason Okonofua, assistant professor in Psychology at Stanford University, discussing “When Bias and Threat Persistently Interact: A Holistic Approach to Understand the Lingering Effects of Stereotypes”
Wednesday, Oct. 26, 5 p.m.: Clint Smith, writer, teacher, 2014 National Poetry Slam champion, and Ph.D. candidate at Harvard University, discussing The Danger of Silence, How to Raise a Black Son in America, and his recently-published collection of poems, Counting Descent
Thursday, Nov. 3, 12 p.m.: Hilary Levey Friedman, visiting assistant professor in American studies at Brown University, discussing “Playing to Win: Raising Children in a Competitive Culture”