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Julie Large, a special education teacher at Hawthorne Elementary School, high fives fourth grader Dereck Green First in Trouble while practicing sight words on May 4, 2016, in Sioux Falls, S.D.
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How the health-care bill could sideswipe special education

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Less known to many Americans is the fact that Medicaid helps pay for special education in the nation's public schools. 

All Alicia Buono wants for her 10-year-old son, diagnosed with autism, she says, is for him to grow up to be independent. To prepare Connor for adulthood, the school district he attends – Contoocook Valley in southern New Hampshire – has him work with a speech pathologist, an occupational therapist, and a part-time paraprofessional.

But Ms. Buono worries her son and millions of other American children with special needs will be on the losing end of a Republican proposal to repeal key parts of the Affordable Care Act. Included in the bill, which squeaked by the House on Thursday, is an $880-billion cut in funding for Medicaid, $4 to $5 billion of which goes to elementary and secondary schools to pay for special education services and equipment.

“When there’s less money, who loses?” Buono, a member of ABLE NH, a New Hampshire-based advocacy group for people with disabilities, asks in a phone interview. “Ultimately, our goal is for [Connor] is for him to become independent as an adult.... The more we can invest in him being successful in school, the better his chances are of independence.”

Much of the backlash over the proposed health-care legislation has focused on the possibility of lost or reduced health coverage for millions of adult Americans and their families. Less known to many, however, is the degree to which Medicaid, the federal health program for the poor, also funds special education in elementary and secondary schools.

Since 1988, Medicaid has filled the gap in funding for special education, as Congress has never lived up to its pledge to pay for 40 percent of the average cost required to educate a child with disabilities. (Currently, Congress funds 16 percent of this per-student cost, according to the National Education Association). Since Medicaid funding began, the country’s special education system has shown improvement. The percentage of students with disabilities who have graduated from high school increased from 41 percent in 1993 to 65 percent in 2013, according to the National School Boards Association.

But school educators, school health professionals, and advocacy organizations warn that this progress could slip under the new health-care proposal, as these costs would be downshifted onto state and local governments. It’s hard to predict how widespread the damage would be, says Sasha Pudelski, assistant director of policy and advocacy for the School Superintendents Association (AASA), but that it could have “seriously negative impacts” on poorer and underfunded school systems that cannot afford to raise taxes or draw money from their general education funds.

“The districts that have the most to lose will have their education most impacted,” she says, noting that children living in poverty tend to need more special education services. “It would have absolutely devastating effects for students who, for example, need nursing care or who need individuals to monitor their health and medical needs throughout the school day.”

The nation's schools receive between $4 billion and $5 billion annually in Medicaid, much of which is used for special education, according to the Virginia-based AASA. School districts use two-thirds of this amount to pay for health professionals and other specialized personnel for students with disabilities, according to a 2017 survey of nearly 1,000 district officials in 42 states. While Connor is covered under his family's private insurance plan, his school district receives about $300,000 per year in Medicaid revenue. 

Sixty-eight percent of districts use these reimbursements to pay for the salary and benefits of staff specialists, including speech pathologists, physical and occupational therapists, and school nurses. Many districts also use Medicaid money to pay for student evaluations and equipment such as wheelchairs and assistive technology for the classroom. 

Many of these services are required under the federal Individuals with Disabilities Education Act, passed in 1975, which requires states to provide a “free and appropriate public education” to students with disabilities.

If Congress and President Trump were to approve the health-care bill as it stands now, school districts would still be required to comply with IDEA. But they would receive less money from Medicaid to pay for it. It also comes at a time when special education costs could be increasing, thanks to a unanimous Supreme Court verdict in March that found that special needs children “must be given an educational program reasonably calculated to enable a child to make progress.” That ruling already was widely expected to force school districts to spend more on special needs students.

The proposed legislation – on its way to the Senate, which has indicated it may write its own bill – would cut Medicaid by about $880 billion, or 25 percent, over a period of 10 years, shifting toward a per capita allotment and giving states greater responsibility.

Supporters of the bill say these changes are necessary to curtail national health-care costs they argue have spiraled out of control, Mark Trumbull reported for the Monitor. 

As Republicans look at a health-care system that’s imposing ever higher costs on both average Americans and on the federal budget, they argue that principles like free-market competition and consumer choice could prove vital to making health care more affordable and accessible. In tandem, other conservative values are being championed: limited government, turning power back to the states, and curbing federal deficits. 

But a coalition of school educators, health professionals, and advocacy groups including the AASA argue that doing so would further push the cost of educating children with disabilities onto state and local governments.

“Under this bill, the bulk of the mandated costs of providing health care coverage would be shifted to the states even though health needs and costs of care for children will remain the same or increase,” wrote the “Save Medicaid in the Schools Coalition” in a letter to top lawmakers last week.  

Ms. Pudelski at AASA is concerned that states would not pick up the costs. She mentions a 2016 study that found 31 states provided less state funding per student in the 2014 school year than in the 2008 school year, even though there are several million more students now than in 2008.

For now, though, Connor and his family say they are focused not on the debate in Washington, but on his education. 

"As a parent I think it's hard enough with a student with a diagnosis of autism to be able to be successful in school, socialize, and be a part of the school community," says Buono, his mother. "So with all of those interventions now, he's much better able to access curriculum, produce work, and I still hope become a member of his community."