Educaid: What if the US Systems of Education and Health Care Were More Alike?

Abstract

What if access to an education in the United States required insurance, leaving millions of children without a school? Would public insurance for education—Educaid—look like public insurance for medical care—Medicaid? This essay describes a fictional education system analogous to our current health care system as a means to highlight some of US health care’s failings. It incorporates real comments from parents whom we have interviewed about their experiences gaining access to health care services for their children. My purpose is to challenge each reader to consider the future for both the US education and health care systems, the urgent need for reform, and how major reforms might affect our children.

Amidst discussions about how to reform the US health care system, I often hear analogies made between health care and education. What if access to health care and access to education were more similar for our children?

Hypothetically, let’s imagine a future system of education transformed to include many of the parallels of health care today. While the scenario is fictional, the quotes are real comments from parents who have shared their time and thoughts to help us better understand the experience of families in the current health care system.^1–3 Most quotes have been altered slightly for relevance to the hypothetical education examples (eg, “clinic” has been changed to “school,” “doctor” has been changed to “teacher,” and “Medicaid” has been changed to “Educaid”). Fast forward into the future.

A Possible Future Scenario: Educaid 2030

While visiting communities across the country to hear from parents about their experiences with the newly privatized US education system, I learned about a recently implemented state insurance program for low-income children called Educaid. One mother expressed gratitude for the public assistance: “I was actually relieved when my husband lost his job because it made my son eligible for [Educaid] coverage.”

Obtaining continuous Educaid coverage, however, has been challenging for families. One father reported that he completed paperwork to enroll his 5-year-old child but then waited 6 weeks to receive an Educaid card in the mail. His son was not granted admittance to the local school until he had an Educaid card. Already several weeks behind, it was frustrating to discover that his Educaid card only allowed access to a few classrooms; most teachers were not accepting students with Educaid coverage. When his father went through the Educaid reenrollment process, he said “There was a huge hassle with that; I needed a bunch of documentation, I needed to come in, they put me in this big, huge ordeal…” only to find out that his son no longer qualified for Educaid because his (the father’s) earnings had increased by 39 cents per hour. He expressed concern about the perverse incentives inherent in this new system: “I feel it’s not right that a family trying to make it in life gets knocked back and down. My 10-year-old son lost his insurance because I got a 39-cent raise in pay.” He is grateful for the evening charity school that is open two evenings per week; however, it is usually overcrowded and must turn students away when all available rooms are full.

In response to this disgruntled father, one mother commented that he was lucky to have access to the charity school. According to her, “Absolutely no [schools] in our neighborhood would accept Educaid. We were referred to the local free [school] but weren’t accepted there because she had [Educaid]. The nearest [school] was 40 miles away. And, I had no means of transportation.”

Many parents had similar reports, and all worried that their children were falling behind. One mother waited 18 months to get her son into school and then was told that he would never catch up. She reported “When we came out of the [school], I was in tears, I just felt almost violated in a way because as a parent, you want to protect your child, and there wasn’t anything that I could do…there wasn’t any place for me to turn to complain, and it’s almost like they make you feel guilty—‘Well, you’re getting free services, so how can you complain?’”

Another parent had been receiving education insurance through her employer. While the insurance covered basic classes, she was borrowing money from her mother to meet a high deductible and to pay the copayments required for music and art classes. Last month, she lost her job and her daughter’s insurance. In her state, children are required to be uninsured for 6 months before they become eligible for public insurance. She is now halfway through the mandatory 6-month Educaid waiting period but still searching for a new school that will accept Educaid. She said, “It is impossible to find a [school] that will take [Educaid]. The only one I could find is 3 hours and at least two mountain passes away, making getting there impossible, especially in winter.” She plans to borrow more money from her parents to take an evening job training course in hopes of finding a better job so her daughter can have private insurance again. She said, “I am working toward being able to get a job where I would have [insurance coverage] forever, but in the meantime, you are always hoping something bad doesn’t happen, hoping you can come up with the money.” And for now, she is making hard choices: “We can’t afford to buy groceries; do we eat or do we go to [school]?”

After hearing that her daughter was currently out of school, someone recommended the federally qualified elementary school (FQES) in the next county. However, according to several other parents, this school has a long waiting list and limited capacity. The FQES can only grant admission to a few new students on the first day of each month. All other days, the school is closed to new uninsured children. According to one mother, if you are lucky enough to get in, “The quality is really good…I think there are people who decide that’s where they want to be, they know they’re serving a certain population, so I think they kind of take that seriously so you do get good quality.” For parents waiting to receive public insurance or admittance to a free school, a few resources exist through the local education department, which provides minimal tutoring and a lending library.

While talking with parents in an industrial community with several large factories, I heard more about some of the private plans available to children, mostly through their parents’ employers. There are now hundreds of employer-sponsored education insurance plans secured by union negotiations. However, employers change options frequently, and the insurance plans constantly revise contracts with schools. Some schools get dropped from a plan or removed from preferred formularies if they are unwilling to negotiate acceptable discounts. Thus, most parents must change their child’s school at least every year—sometimes almost monthly. One parent told me, “It’s hard enough to get private insurance, nobody can afford it, and if you have a private policy, then the [services] are just hit and miss around here.”

The plans are also limited in what they cover and how much they require parents to pay out of pocket. One distraught father told me that generic classes are usually covered with a minimal copayment. However, his 16-year-old daughter required specialized remedial coursework, and the costs exceeded the maximum allowed under their plan. In fact, few of the services that she needs are provided by schools in their network. He said, “There are certain [specialist courses] that are excluded. If you don’t have coverage, good luck getting into a specialist because you have to have a ton of money up front and specialists costs a lot.” When he tried to acquire a different insurance plan with expanded services, he was told that she had a preexisting condition and would not be eligible for coverage. So, his daughter had to drop out of school. She is now working a minimum wage job to earn enough money to pay for her schooling.

His 7-year-old daughter is gifted and needs to move into an accelerated learning classroom. This option, however, is also not adequately covered due to legal exceptions in his state, which allow insurance companies to pay disproportionate amounts for special education services. He has been contemplating moving to another state with parity insurance laws, but he is afraid to lose his current employer-sponsored coverage for his other two children.

For the wealthiest members of the community, the system is working well. Employers seeking to recruit the most skilled workers offer generous education insurance plans. These plans enable a child to receive a private education at a fraction of the cost they would have paid 20 years ago. And, since their parents are saving on private tuition and paying lower taxes as well, the small copayments and deductibles are usually not a problem. The competition in the education marketplace for children with these private plans ensures that they receive top-quality education, including small class sizes, personal tutoring, and their choice of the best teachers. Additional pay-for-performance measures, recently implemented across the system, have heightened the competition for students from wealthy families who traditionally perform better than their lower-earning counterparts. The better insurance plans are also accepted by almost everyone, so there is no need for students from these families to ever change teachers or schools.

Far-fetched or Close to Reality?

This hypothetical scenario could be considered far-fetched. Those of us who were educated in the American public school system cannot imagine children waiting months to receive Educaid and thus unable to attend a local school. Yet, nearly 9 million children in our country have no health insurance today, and millions more have significant coverage gaps.^4–6 Some wait months to obtain Medicaid or the State Children’s Health Insurance Program (SCHIP)^{7, 8} and even with coverage, many have difficulty gaining access to basic health care services.^1,9,10

The quotes in this essay from low-income parents illustrate the current reality for millions of American families unable to access adequate health care for their children.^1–3 These same quotes could also represent a future reality of inaccessible educational opportunities for children, if education begins to look more like health care. In fact, one can find numerous examples of current problems—unsafe schools, inequitable distribution of resources, low literacy rates, rising high school dropout rates among certain minority groups—that lend credence to an argument that the US educational system could already be in the midst of this transformation.¹¹

No Child Left Behind policies may be hastening this trend, and the survival of many public schools is further threatened by the severity of state funding shortages.^11,12 For example, despite a constitutional amendment requiring the Oregon legislature to provide adequate funds to meet minimum quality standards, our state Supreme Court recently ruled that schools have no legal recourse if state budgets fall short.¹³

Amidst reports of ailing school systems, privatization ideas resurface. School vouchers are a popular proposal. Advocates usually evade discussing plans for how vouchers will enable low-income students to obtain access to a private education if they cannot afford to make up the cost difference.^11,14 Fair enough, the current system of education in the United States is not perfect. However, proposed solutions to privatize our school systems deserve careful and thorough scrutiny in light of the current state of access to care and delivery of primary care services in our current health care system.⁹

When Health Care and Education Compete—Children Lose

Public education and health insurance (largely Medicaid and SCHIP) now fight for the top spot on most state budgets.¹⁵ Children’s advocates argue that both are woefully underfunded.^11,14,16 All children deserve access to both basic health care and a quality education. However, an incremental approach to expand public health insurance offerings could shrink resources for education as states earmark more funds for health care. Similarly, as rising private health insurance costs become a bigger portion of public schools’ budgets, children’s educational opportunities will suffer. Making a better future for our children will require moving beyond this impasse that pits health care against education.¹⁵

Children grow up fast, so we cannot keep borrowing time (and money!) from our children to prop up the current ailing systems with incremental solutions, hoping that we will be able to catch up on their educational and health care needs someday in the distant future—because by then they will already be grown up! NOW is the time for bold action, we cannot afford to wait any longer. Why not consider an approach that builds a primary health care system that looks analogous to the public education “ideal” with safe clinics for every neighborhood, community involvement, regional planning, and adequate funding for evidence-based services of uniform quality?