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Tuesday, November 12, 2019

Cuts for Disabilities, Contracts for Consultants

In The Politics of Autism, I discuss the issue's role in campaign politics.   In the 2016 campaign, a number of posts discussed Trump's bad record on disability issues more generally.   As his actions as president indicate, he has little use for Americans with disabilities.

This past spring, the Trump administration proposed big cuts for Medicaid and other programs that benefit people with autism and other disabilities.

Meanwhile, however, agency that runs Medicaid blew millions on PR consultants. Dan Diamond and Adam Cancryn at Politico:
At least eight former White House, presidential transition and campaign officials for President Donald Trump were hired as outside contractors to the federal health department at the cost of hundreds of thousands of dollars per year, according to documents newly obtained by POLITICO.
They were among at least 40 consultants who worked on a one-year, $2.25 million contract directed by Centers for Medicare and Medicaid Services Administrator Seema Verma. The contractors were hired to burnish Verma’s personal brand and provide “strategic communications” support. They charged up to $380 per hour for work traditionally handled by dozens of career civil servants in CMS's communications department.

Monday, November 11, 2019

Pennsylvania Penalizes United Healthcare


A November 4 release from the Pennsylvania Insurance Department:
Insurance Commissioner Jessica Altman today released a market conduct examination report on the practices and procedures of UnitedHealthcare Insurance Company. Based on violations of the Mental Health Parity and Addiction Equity Act (MHPAEA) and other violations contained in the report, UnitedHealthcare has agreed to develop an $800,000 public outreach campaign to educate consumers about their mental health and substance use disorder benefits. The company has also agreed to pay restitution to consumers from claims wrongly denied, overpaid out-of-pocket expenses, and interest on delayed claims. The department levied a $1,000,000 civil penalty for violations found during the examination.

The report, which covers the period from January 2015 through March 2016, found extensive noncompliance with mental health parity and prompt pay laws, as well as concerns with the company's coverage for services relating to autism spectrum disorders and substance use disorders. The examination also covered company operations, handling of consumer complaints, and policyholder services.

"Market conduct examinations provide the department with an opportunity to review a company's practices and procedures, including its compliance with laws requiring parity of coverage for substance use disorders and mental health," Altman said. "The violations within this area were very disappointing as they negatively affected some of our most vulnerable populations."

The department is conducting similar comprehensive market conduct examinations, emphasizing mental health and substance use disorder parity, on all of Pennsylvania's major health insurers, to ensure all Pennsylvania health insurers are in compliance with state and federal law. Previous examination reports were issued to Blue Cross of Northeast Pennsylvania in early 2018 and Aetna in early 2019.

In addition to the mental health and substance use disorder parity violations, the Insurance Department noted the following, among others:
  • Inaccurate calculation of consumers' total out-of-pocket costs for autism claims.
  • Delayed payment and improper handling of claims. The law requires all uncontested claims and uncontested portions of contested claims be paid within 45 days of receipt.
  • Delayed responses to consumer complaints.

UnitedHealthcare has been ordered to address many of the violations through changes in company practices and procedures, and the Insurance Department will be verifying that these corrective actions have taken place through a reexamination process. The department also acknowledges the company has been cooperative in its response to the violations.

"As a result of this report, UnitedHealthcare will improve its procedures to help consumers make better informed decisions about their coverage and their care," Altman said. "The results of this examination will also help the department in its ongoing oversight of the company and ensure that consumers are receiving the benefits they are entitled to under law."

The Mental Health Parity and Addiction Equity Act of 2008 requires health insurance plans to contain equivalent levels of coverage for mental health and substance use disorder care as for medical or surgical care. This coverage includes quantitative limitations (copays, deductibles, and limits on inpatient or outpatient visits that are covered) and non-quantitative limitations (pre-authorizations, providers available through a plan's network, and what a plan deems "medically necessary"). The federal law was incorporated into Pennsylvania law in 2010 through Act 14.

Currently, parity for mental health and substance use disorder coverage is required for individuals with the following health plans:
  • Individual and small group health plans, as required by the Affordable Care Act;
  • Large group health insurance plans which offer substance use disorder and mental health coverage. Fully insured plans are required to offer this coverage under Pennsylvania Act 106;
  • Children's Health Insurance Program (CHIP) and Medicaid Managed Care.
The Insurance Department reviews all individual, small group, and large group policies to ensure those policies contain all state and federal policy requirements, including mental health and substance use disorder parity. However, the Insurance Department has found even in policies containing language meeting all requirements a lack of appropriate administrative oversight or other operational problems have led to mishandling of these important consumer protections.

Consumers who believe their health plans are not in compliance with parity requirements for mental health and substance use disorder coverage, or who have questions about the benefits to which they are entitled, are urged to contact the Insurance Department's Bureau of Consumer Services.

Find more information on substance use disorder and mental health coverage here. More information and videos on parity can be found here.

Sunday, November 10, 2019

Study of Bullying

In The Politics of Autism, I discuss challenges facing autistic adults and children One is bullying.

Danequa L. Forrest, Rhiannon A. Kroeger, and Samuel Stroope have an article at the Journal of Autism and Developmental Disorders titled "Autism Spectrum Disorder Symptoms and Bullying Victimization Among Children with Autism in the United States."

The abstract:
Children with autism spectrum disorder (ASD) experience more frequent bullying victimization compared to their neurotypical peers. This study used the 2011 Survey of Pathways to Diagnosis and Services to examine associations between six Children’s Social Behavior Questionnaire (CSBQ) subscales and bullying victimization among 1057 children with ASD. Bivariate results showed significant correlations between each CSBQ subscale and more frequent bullying victimization. Yet results from multinomial logistic regression models indicated that after adjusting for all CSBQ subscales and covariates, two of the CSBQ subscales remained significantly associated with greater risk of bullying victimization: not being optimally tuned to the social situation, and resistance to changes. Implications for future research and efforts toward reducing bullying victimization among children with ASD are discussed.

From the article:
Interventions for school bullying may be especially effective to reduce and prevent bullying victimization. In addition to the safety, health, and academic impacts of bullying on children who may already face significant life challenges, school districts receive funding based on student attendance, which can be low in schools where bullying is common due to children feeling unsafe in their environment. For example, California school districts lose roughly $276 million a year due to students not feeling safe and staying home (Baams et al. 2017). Schools have an economic responsibility to address bullying. Research has found that parents and teachers generally support the idea of bullying prevention programs, and they are more likely to approve such programs if they have witnessed a child being bullied (Gradinger et al. 2017). The effectiveness of anti-bullying programs on reducing victimization is directly related to teacher involvement (Li et al. 2017), suggesting that reducing bullying goes beyond initiating programs and extends to supporting teachers as they implement programs. Interventions on average decrease bullying by 20–23% and victimization by 17–20% (Ttof and Farrington 2011). If effective, interventions could ultimately help decrease violent offending and drug use in perpetrators of bullying (Farrington and Ttof 2011) and prevent health problems such as depression associated with bullying victimization (Farrington et al. 2011), with implications for individual, school, and community well-being

Saturday, November 9, 2019

Person-First or Identity-First?

From the preface to The Politics of Autism.
A major theme of this book is that just about everything concerning autism is subject to argument. There is not even any consensus on what one should call people who have autism and other disabilities. “In the autism community, many self-advocates and their allies prefer terms such as `Autistic,’ `Autistic person,’ or `Autistic individual’ because we understand autism as an inherent part of an individual’s identity,” writes blogger Lydia Brown.[i] Other writers prefer “people-first” language (e.g., “persons with autism”) since it puts the persons ahead of the disability and describes what they have, not who they are.[ii] For the sake of stylistic variety, this book uses both kinds of language, even though this approach will satisfy neither side. I can only say that I mean no offense.
Giacomo Vivanti has an essay at The Journal of Autism and Developmental Disorders titled "Ask the Editor: What is the Most Appropriate Way to Talk About Individuals with a Diagnosis of Autism?"
Although person-first and identity-first language reflect a common intent to de-pathologize autism and inspire respect, they do so through the lens of two different agendas—the first one prioritizing the principle that the individual is more than the diagnosis, and the second one advancing the idea that the diagnosis itself should be reason for pride and respect. This latter agenda is being increasingly endorsed by many segments of the autism community as a revolutionary change in our understanding of autism (Baron-Cohen 2017; Pellicano et al. 2018), although concerns have been raised about its relevance to some individuals and groups touched by autism, including those in the more impaired end of the spectrum (Jaarsma and Welin 2012; Mitchell 2019; Ortega 2009). In contrast, there has been less attention to the “centrality of the person” agenda that person-first language aspires to promote, i.e., the acknowledgement that beyond the autism diagnosis— and its negative as well as positive associations—there is a unique person whose human rights should be respected. The human rights violations that individuals with autism and other disabilities continue to experience suggest that recognizing the humanity and individuality of each person in the spectrum continues to be a priority (e.g., Drew et al. 2011; United Nations Committee on the Rights of Persons with Disabilities 2017). This is particularly important for those in the most impaired end of the spectrum, such as minimally verbal individuals, who are less equipped to advocate for their rights and more at risk to be treated as “less than people”. Although the two perspectives are not mutually exclusive, the challenges experienced by these groups might relate more to the “we are people first” priority conveyed by person-first language than to the “autistic pride” narrative conveyed by identity-first language. In addition to the focus on humanity, the emphasis on individuality expressed by person-first language appears to still be relevant to many in the autism community. For example, when reviewers urge authors to use identity-first language in their manuscript because it “reflects the preferences of the autism community” they are failing to acknowledge that the views expressed by the self-selected responders in the Kenny et al. surveys might not reflect the experience of other individuals or groups in the autism community who had not been engaged in the study (e.g., minimally verbal adults). Arguably, this is the kind of phenomenon that person-first language had the purpose to counteract.
Against this background, a complete shift away from person-first language appears premature. Rather, we support the judicious use of person-first and identity-first language in our journal as appropriate for the context, taking into account the preferences of participants described in each study and, when these preferences are unknown, considering how different linguistic formulations relate to different historical agendas, priorities and experiences of different groups and individuals within the autism community

Friday, November 8, 2019

Disability Groups Oppose Weakening of Fair Housing Protections

In The Politics of Autism, I discuss the day-to-day challenges facing autistic people and their families.  Housing is a big one for autistic adults.

The Autism Society of America and the Autistic Self Advocacy Network have signed a letter to HUD from the Consortium for Citizens with Disabilities (CCD).  The topic is a proposed rule that would make it harder for people with disabilities to file complaints under the Fair Housing Act.
The proposed rule, if finalized as written, risks permitting covert discriminatory practices to proliferate without the appropriate and necessary enforcement tool of disparate impact liability. The proposed rule miscalculates the balance of interests by weighting the process unfairly against individuals alleging discrimination, obstructing accountability, making it prohibitively difficult for people facing discrimination to access an appropriate and timely remedy, and dismantling a key tool for addressing systemic discrimination under the FHA. The proposed disparate impact rule would effectively preclude individuals with disabilities from using disparate impact claims to address situations such as the following:
  • a city that accuses a non-profit of violating a zoning ordinance by operating a “group home” in a single-family residential neighborhood though the house was purchased for use by a man with intellectual and physical disabilities, who is the only resident of the property and receives services from the non-profit on a round the clock basis when he’s home;
  • a housing provider who operates a separate office that deals with applicants who will be using a housing subsidy program to pay their rent, and requires burdensome documentation attesting to future payment in order to consider rental applications from people with disabilities; a town that prohibits several unrelated people with addiction histories from living together in a house in a “single-family” zoning district, an ordinance that treats them less favorably than a similarly-sized family related by blood or marriage; or
  • a government agency refuses to issue a permit to an AIDS public interest group to open and run a hospice for clients with AIDS, claiming that the land is zoned exclusively for agricultural purposes
The proposed revisions in §100.500 will drastically increase the burden of bringing a case to address prohibited discrimination for the plaintiff. In the proposed rule, the current burden shifting standard is replaced with a five-part component set of tests, placing nearly all of the burden on the people who are intended to be protected from discrimination under the Fair Housing Act. For example, people experiencing discrimination may be asked to essentially identify the justifications the defendant will raise and address them. A plaintiff may be required to prove by the preponderance of evidence that “a less discriminatory policy or practice would serve the interest in an equally effective manner without imposing materially greater costs on, or creating other material burdens for, the defendant.” The proposed rule not only sets a much higher bar for a person experiencing discrimination to meet, but one based on information that
only the entity with the discriminatory policy may have.

Thursday, November 7, 2019

Underimmunization Global Crisis

In The Politics of Autism, I look at the discredited notion that vaccines cause autismTwitterFacebook, and other social media platforms have helped spread this dangerous myth.   Measles can kill.

Lawrence O. Gostin and colleagues have an article at The Lancet Infectious Diseases titled "The Public Health Crisis of Underimmunisation: a Global Plan of Action."

The summary:
Vaccination is one of public health's greatest achievements, responsible for saving billions of lives. Yet, 20% of children worldwide are not fully protected, leading to 1·5 million child deaths annually from vaccine-preventable diseases. Millions more people have severe disabling illnesses, cancers, and disabilities stemming from underimmunisation. Reasons for falling vaccination rates globally include low public trust in vaccines, constraints on affordability or access, and insufficient governmental vaccine investments. Consequently, an emerging crisis in vaccine hesitancy ranges from hyperlocal to national and worldwide. Outbreaks often originate in small, insular communities with low immunisation rates. Local outbreaks can spread rapidly, however, transcending borders. Following an assessment of underlying determinants of low vaccination rates, we offer an action based on scientific evidence, ethics, and human rights that spans multiple governments, organisations, disciplines, and sectors.
From the article:
Even a casual search of the internet and social media shows ubiquitous misinformation about vaccines. Robocalls and automated bots amplify false and misleading messages. Anti-vaccine messages often purport to come from reliable scientific sources or genuine anecdotes of children harmed. Internet searches fail to distinguish between authoritative sources and messages intended to mislead. Social media platforms (eg, Twitter, Facebook, and YouTube) can rapidly spread false or misleading information, ranging from disproven beliefs that vaccines cause autism to unfounded fears about spacing multiple vaccines during infancy. Organised, funded entities and celebrity anti-vaxxers can be especially influential among adolescents and worried parents trying to navigate divergent messaging.16 Although over a dozen high-quality studies17,18 have found no link between measles, mumps, and rubella (MMR), thimerosal, and autism, public misperceptions stubbornly persist following the 1998 publication of the discredited Wakefield study.19 Almost any vaccine can be the target of false information campaigns. In 2013, social media messaging featured young Japanese girls reportedly harmed by the human papillomavirus vaccine.20 False messaging dampens public acceptance despite the evidence concluding that universal human papillomavirus vaccination could almost eliminate cervical cancers.

 The government’s highest ethical duty is to safeguard the public’s health through evidence-based policies. Yet, government officials can sometimes discourage or undermine public trust in immunisations. In 2011, the US Central Intelligence Agency orchestrated a fake vaccination campaign in Pakistan to obtain DNA from the family of Al-Qaeda fugitive Osama bin Laden, leading to popular conspiracy theories that place vaccine workers at risk. In France, Marine Le Pen’s National Rally Party voiced concerns regarding vaccine safety. In April 2018, Pakistani politicians tweeted false information to discredit polio vaccines. US President Donald Trump hassent mixed messages regarding vaccine policies. He intimated, in 2016, that childhood vaccines cause autism, but later encouraged Americans to secure measles vaccinations to prevent outbreaks. His administration’s policy to deny influenza vaccines to people unlawfully crossing US borders threatens the health of migrants and US residents alike.22

Wednesday, November 6, 2019

Reimbursement Rates in Nevada

The Politics of Autism includes an extensive discussion of insurance and explains the limits of insurance mandates.

Mark Hernandez at The Nevada Independent:
Changes in Anthem Blue Cross reimbursement rates could put intensive treatment out of reach for scores of Nevada children.
Starting in 2020, reimbursement rates that Anthem would pay to medical providers for autism-related services were supposed to be lowered to the same rate as Medicaid, which is less than the national average and which advocates have long said is woefully low. Anthem changed course a few weeks later, saying the first rates were a mistake, yet some medical providers are already looking towards other insurance companies to do business with.

“Since 2015, Anthem has continually reduced their rates by approximately 60 percent which has become cost-prohibitive for us to remain in-network with them,” said Jon Paul Saunders, clinic director of the Las Vegas-based Lovaas Center, which focuses on autism treatment. “In Anthem’s attempts to align with Medicaid rates, they have lost us as a participating provider.”
As one of the major medical insurance providers in Nevada, the dispute over Anthem Blue Cross and Blue Shield’s rates could limit which doctors are available for autism-related services. There are currently 60 children who are covered by the insurer that receive treatment from the Lovaas Center, and they may have to pay out of pocket to continue with the provider or seek help elsewhere.
A spokesperson for Anthem Blue Cross responded to a request for comment from The Nevada Independent by saying that the latest rates are the same or higher than existing levels.

Monday, November 4, 2019

Mental Health Services for Autistic Adults -- "Punting"

The Politics of Autism discusses health care, and explains that autism services can be complicated, creating difficulties for autistic people and their families. 
No government agency has exclusive jurisdiction over all of these areas. The federal government takes the lead with some, while states and localities may be the main arenas for others. At each level, different bureaucracies deal with different aspects of autism. Courts and private organizations also play important roles in autism policymaking. Each place on the autism policy map has its own jargon and rules, hence the “alphabet soup” that bedevils parents.
At Autism, Brenna B. Maddox and colleagues have an article titled "“I wouldn’t know where to start”: Perspectives from clinicians, agency leaders, and autistic adults on improving community mental health services for autistic adults."

The abstract:
Most autistic adults struggle with mental health problems, and traditional mental health services generally do not meet their needs. This study used qualitative methods to identify ways to improve community mental health services for autistic adults for treatment of their co-occurring psychiatric conditions. We conducted semistructured, open-ended interviews with 22 autistic adults with mental healthcare experience, 44 community mental health clinicians, and 11 community mental health agency leaders in the United States. The participants identified clinician-, client-, and systems-level barriers and facilitators to providing quality mental healthcare to autistic adults. Across all three stakeholder groups, most of the reported barriers involved clinicians’ limited knowledge, lack of experience, poor competence, and low confidence working with autistic adults. All three groups also discussed the disconnect between the community mental health and developmental disabilities systems, which can result in autistic adults being turned away from services when they contact the mental health division and disclose their autism diagnosis during the intake process. Further efforts are needed to train clinicians to work more effectively with autistic adults and to increase coordination between the mental health and developmental disabilities systems.
From the article:
At the systems level, a major barrier is the disconnect between the developmental disabilities and the mental health systems. All three stakeholder groups described the problems that occur because the developmental disabilities and mental health systems have very little integration. These problems begin as early as when an autistic adult decides to seek help for a mental health problem, but is turned away due to his or her autism diagnosis and is instead referred to the developmental disabilities system. Although developmental disabilities services may be helpful for a range of concerns, they typically do not focus on mental health conditions. Thus, when an autistic adult contacts a developmental disabilities clinic and expresses a desire for mental health treatment, he or she may be referred back to the mental health division. This  phenomenon of autistic adults being “punted” between the developmental disabilities and mental health systems in the United States has been described in previous work (Maddox & Gaus, 2019), and parents of young adults on the spectrum find the task of navigating different service systems intimidating and time-consuming (Anderson and Butt, 2018).
  • Anderson, C., & Butt, C. (2018). Young adults on the autism spectrum: The struggle for appropriate services. Journal of Autism and Developmental Disorders, 48, 3912–3925. doi:10.1007/s10803-018-3673-z
  • Maddox, B. B., & Gaus, V. L. (2019). Community mental health services for autistic adults: Good news and bad news. Autism in Adulthood, 1, 13–17. doi:10.1089/aut.2018.0006

Sunday, November 3, 2019

Charter Home School Loophole in CA Vax Requirement

In The Politics of Autism, I analyze the discredited notion that vaccines cause autism. This bogus idea can hurt people by allowing disease to spread

Mackenzie Mays at Politico:
Nearly all California students must get vaccinated after state leaders tightened laws following the 2014 Disneyland measles scare, but at least one loophole remains: new hybrid programs known as charter home schools.

Across the country, state leaders and health advocates have aggressively pushed for new vaccination requirements, especially after the U.S. this year experienced its highest number of measles cases since 1992. California has been at the forefront, enacting a law last month that cracks down on doctors known for approving scores of waivers so unvaccinated children can attend school.

But there remain ways to get around the law and still receive a taxpayer-funded education, even in California. Though many home-based charters bring students together for regular classroom instruction or activities, the state doesn't uniformly enforce vaccination laws for such programs.

...

The state's strict vaccination laws, both written by State Sen. Richard Pan (D-Sacramento), a pediatrician, apply to all schools except for “home-based private schools and students enrolled in an independent study program." Charter schools are public. But for the increasing number of programs that blend home instruction and class time, the rules blur.

California doesn't have a clear interpretation of whether home-based charter schools qualify for the exemption, and some charter programs have relied on that ambiguity to skirt vaccination requirements.
...
 A POLITICO analysis of state data shows kindergarten classes at 41 percent of charter schools do not have “herd immunity,” because fewer than 95 percent of these students are up-to-date on their vaccinations. This is compared with 20 percent of similar public non-charter schools for which data is available.

Saturday, November 2, 2019

Special Education and Inequality in NYC

In The Politics of Autism, I write about the experiences of different economicethnic and racial groups.   Inequality is a big part of the story. Affluent states and school districts have more resources than poor ones.  Educated professionals are better able to protect their children's interests than poor people who never went to college.

Today, Kim Sweet, Executive Director of Advocates for Children of New York (AFC), issued the following statement in response to the release of the New York City Department of Education’s special education data report for the 2018-19 school year:

New York City continues to fall short when it comes to educating its students with disabilities. While the percentage of City students fully receiving their recommended special education instruction continued to trend in the right direction in 2018-19, we are nevertheless dismayed that more than 15 percent of students with disabilities—a total 28,960 children, more than the total enrollment of the Yonkers public schools—still did not fully receive the instruction to which they are legally entitled.
...
 The modest decrease in the timeliness of evaluations in 2018-19 is a clear signal that the City must invest in additional school psychologists, as a delay in evaluating a student inevitably means a delay in providing appropriate services if that student is found eligible. For more than one in four students who were evaluated for special education for the first time last year, more than two months passed before an IEP meeting was held to determine what learning support should be put in place, in large part because current staff are burdened by unmanageable caseloads. Two months can feel like a lifetime to a child who is struggling in school, falling behind their peers, and rapidly losing confidence in their own abilities. The special education process can be a lengthy one, even when all timelines are followed; these additional delays in getting students the help they need are simply unacceptable.
Yoav Gonen and Alex Zimmerman at Chalkbeat:
The information gap between evaluations provided by the city compared to those done privately — which typically cost over $5,000 — is not unique to Jorge. Interviews with more than two dozen advocates, parents, and experts revealed a flawed two-tiered evaluation system that leaves many students’ needs unaddressed.
Like many aspects of the city’s public school system, the evaluation process is complicated for parents to navigate — and savvy families who can pay for private evaluations have a big advantage.

School psychologists, who are responsible for conducting special education evaluations, work under heavy caseloads, which can make it challenging to conduct quality evaluations. The assessments themselves are often delayed, leaving students without vital services for months.
Meanwhile, families who can afford neuropsychological evaluations, often not covered by insurance, can get a clearer sense of their child’s disabilities — along with pages of recommendations that spell out what services are needed.
By contrast, the city’s evaluations don’t offer specific diagnoses, like dyslexia or attention deficit disorder.

Friday, November 1, 2019

Texas and the Impacts of Special Education

Over 13 percent of US students participate in Special Education (SE) programs annually, at a cost of $40 billion. However, the effect of SE placements remains unclear. This paper uses administrative data from Texas to examine the long-run effect of reducing SE access. Our research design exploits variation in SE placement driven by a state policy that required school districts to reduce SE caseloads to 8.5 percent. We show that this policy led to sharp reductions in SE enrollment. These reductions in SE access generated significant reductions in educational attainment, suggesting that marginal participants experience long-run benefits from SE services
The conclusion:
Our results strongly indicate that SE services prepare students with disabilities better
for long-run success. We find that in the average school district (with initial SE enrollment of 13 percent), 5th grade SE cohorts experienced a 3.5 percentage point increase in the likelihood of losing SE four years after 5th grade, a 1.9 percentage point decrease in the likelihood of high school completion, and a 1.2 percentage point decrease in the likelihood of college enrollment. These outcomes are strong predictors of adult success. The magnitude of the estimates is larger among less-advantaged youth and among those attending school in districts with lower wealth and lower average achievement. Our results are robust to a number of specification checks, including student attrition from the sample and differences in trends across the types of districts that would have been closer to or further from compliance with the 8.5 percent threshold prior to implementation.
Having demonstrated that the imposition of the SE enrollment target impacted the likelihood of SE participation, we employ an IV approach that allows us to identify how SE removal impacts long-run educational outcomes. We use policy exposure as an instrument for SE removal and find that SE removal decreases the likelihood a student completes high school by 52.2 percentage points and decreases the likelihood of college enrollment by 37.8 percentage points. Again, we find that these results are driven by less-advantaged youth. Our results suggest there are large, meaningful, long-run returns to investing in SE services in the public K-12 school setting for students on the margin of placement, especially those from disadvantaged backgrounds.
While this paper shows robust evidence on the direct impact of SE placement on educational attainment decisions, the limited time after the policy does not yet allow us to fully follow students into the labor market. The large wage differential associated with one’s decision to enroll in college suggests that reduced college enrollment is likely to have negative effects on later labor market outcomes, once these outcomes are able to fully realize. Understanding the longer-run labor market effects will be the focus of future research.