Earlier this year the federal government announced changes aimed at making it easier for schools to get reimbursed for services that they are already providing to children on Medicaid. The program has the potential to serve students where they already are, get schools more needed funding and shift the paradigm on how to approach childhood disability and neurodiversity. But many challenges remain. Portland-based freelance journalist Shasta Kearns Moore is the mother of school-aged twins with severe disabilities and runs Medicalmotherhood.com. She joins us to explain the potential impact of the additional funding and share more about the barriers schools still face.
The following transcript was created by a computer and edited by a volunteer:
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. Schools across the country are struggling to handle a wide range of medical and behavioral needs these days. Medicaid says it can help. In May, the federal agency announced changes that it hopes will make it easier for schools to get reimbursed for services that they are already providing to children on Medicaid. The program has the potential to help kids where they are, while providing more funding for schools. But there are still challenges. Shasta Kearns Moore is a Portland-based journalist who focuses on issues related to childhood disability. She joins us now. Shasta, welcome back.
Shasta Kearns Moore: Thank you.
Miller: What kinds of school-based health care or services are we talking about?
Moore: Yeah, it turns out there’s a whole range of things that Medicaid can pay for and this change makes it so even more stuff qualifies. That’s stuff like speech or physical therapy or nursing, but also stuff like specialized transportation and screening or diagnostics.
Miller: What’s the benefit of providing these services at schools as opposed to hospitals or clinics?
Moore: Well, that’s where the kids are. It means less running around for parents, but also a greater chance to access these services for kids who just otherwise wouldn’t get it or get it too late.
Miller: So, we’re talking today, because of your reporting on this relatively recent change, to make it easier for schools to get reimbursed for this. But my understanding is schools have had the ability to bill Medicaid for a while now, right?
Moore: That’s right. They made a change all the way back in 1988 to allow schools to bill for health services provided through an IEP, or Individualized Education Plan. And Congress said, when they passed the special education law, that they would fund 40% of those services. But they’ve never even come close. A lot of people see Medicaid as backfilling for that. And then there was another change in 2014 that opened up billing for the rest of the student population on Medicaid too. And that’s about half the kids in the country.
Miller: So why haven’t schools been billing this whole time?
Moore: That is a very good question. And it was a very difficult one to answer. It took really months for my co-reporter Emily Harris and I to track down people who would speak plainly, and on the record, about that. We finally got in touch with Wendy Niskanen. She leads the Oregon School Nurses Association and is on the board of the National Association of School Nurses.
She peeled back the veil and showed us it’s not just as simple as asking Medicaid to write a check. You have to document the interaction, follow both school and medical privacy laws. And there’s also some worries from staff that they’re gonna do all this extra work to qualify for the reimbursement. And then that money just goes back into the general fund and not to improving care for that particular student or even health services in general.
Miller: So what can be done about all those concerns that you heard about?
Moore: Well money in schools, almost all goes to staffing. And a lack of staff in schools across Oregon means that some kids can’t even go to school. There was a recent court appointed report that found that about 1,000 Oregon children aren’t able to attend school full-time, in part, due to staffing issues. And this can be this downward spiral ‚where nurses know they’re not able to give safe care in schools. And so they leave. Here’s Wendy explaining that phenomenon:
Wendy Niskanen [recording]: There are definitely examples where nurses are put into situations where they’re having to make really hard choices. And when you’re with a one on one student and you’re there to maintain their airway and you’re typically responsible for students who need to receive insulin and you’re overseeing the calculation of their insulin dosage, you really can’t do those two things. So that’s kind of this conflict that nurses are constantly seeing in. And I will say there are nurses who step away from this profession because they don’t feel like there’s an answer that is a safe answer, and they feel like they’re put in a place where they can’t keep students safe. So they step away. Across the country that happens all the time. And Medicaid billing really would be a solution to that. We would have enough nurses to fund the services, not just of the students who have IEPs, but also our students on 504s and all of our other students who need care.
Miller: What’s the connection that she’s talking about there between Medicaid billing and hiring extra nurses?
Moore: Well first of all, we have to understand that you can only bill Medicaid on students who are signed up to Medicaid. So that’s one. But in Oregon, most kids do qualify either due to income or disability. For example, a family of four can make up to $7,625 a month and their kids will still qualify. So that means a lot of the health services that are already being performed in school could be billed for and that money could be used to boost wages or offer more positions.
Miller: Can schools afford to pay for these medical billing systems?
Moore: Well, the software is expensive and some people would probably say no. But Wendy says it could really pay off if they can figure out that initial investment. Here’s her talking about that,
Niskanen [recording]: Will it be expensive to put systems in place so that we can do this work and make those dollars accessible? It will. Can we get some of the funds to do that back? Yes, we probably can. Again, cite somebody else on that. Once they’re in place, we’re leaving a lot of money, millions and millions of dollars, on the table. That would do great things for kids in schools in Oregon.
Miller: Are people that you talked to saying that these tech investments are going to be a cure all?
Moore: Well, no, I mean, that’s just one of the problems. There’s also quite a few turf wars going on. For example, a big part of this new push is to increase access to mental and behavioral health. But several years ago, the Oregon Board of Psychologists restricted access to this Medicaid funding to only certified psychologists. And a lot of school-based mental health professionals don’t have that so they wouldn’t qualify. Proponents of that measure say that school psychologists and clinical psychologists don’t have the same training. So if the goal is to get kid’s mental health problems diagnosed and treated early, it would be better to hire a new clinical psychologist into the school rather than, in their view, watering down the requirements. But then others say that school psychologists have their own specialty and should be valued as such.
Miller: This sounds complicated.
Moore: It’s all so complicated. Medicaid is so complicated.
Miller: Is there evidence that this works broadly? Meaning that this expanded use of Medicaid dollars for services in schools improves outcomes for students?
Moore: Well, there was actually a pilot program that Oregon tried out a few years ago. Most people know it is Senate Bill 111 and nine districts participated in that one. And one even said that they were able to afford a new school nurse.
Miller: Was Portland Public Schools (PPS), the state’s largest district, a part of that pilot?
Moore: No, I’m pretty sure Hillsboro participated, but not PPS. But PPS does say that as a result of the changes that Medicaid made in May, they will start rebilling Medicaid for administrative tasks, which is something they stopped doing last fall. And they estimate they’ll get more than a million dollars just this first year.
Miller: The Medicaid change in the spring, in May that we’ve been talking about, came from a law called the Bipartisan Safer Communities Act. Can you remind us just about the context of that law?
Moore: Yeah. So that was a law introduced by Marco Rubio and signed by President Biden last year. It was aimed at curbing gun violence and the youth mental health crisis. It was sort of this omnibus bill to make it easier for schools to use those changes that happened in 2014.
Miller: What’s the connection that people are hoping to see between this change in medical billing and mental or behavioral health care for kids?
Moore: Yeah, they absolutely want to see more mental health support in schools. There’s this crisis of behavioral needs and teen suicide and all of that. And they just want to make sure that’s addressed. That is for the whole range of kids. But those 1,000 kids who are blocked from their civil right to an education, maybe we can get them back in school.
Miller: Meanwhile, you have mentioned in your reporting another potential change on the horizon. Can you explain the US Department of Education’s proposals to get rid of parental consent requirements for Medicaid services?
Moore: Yeah, that’s become the new controversy. So that was announced at the same time as these Medicaid changes, on May 18th. And it’s already kind of a kerfuffle. Proponents are saying, “Look, this is just gonna streamline the process and get kids access to these services that they could get funded without additional paperwork to sign for busy parents.” And others worry that it’s a way for the government to overstep in a child’s healthcare decisions.
Miller: What are examples of the kinds of care that opponents to this potential change are fearful of?
Moore: Well, I know as a parent of a disabled child, when you have a disabled child, there are a lot of healthcare decisions that happen at school. Perhaps you disagree with the school team’s feeding plan or maybe you don’t want your autistic child treated with applied behavioral analysis techniques. Or maybe you do want your autistic child treated with ABA [techniques]. The feds say that those decisions and parental consent can still happen in the IEP process. So they’re not taking that away. But I did speak to a lawyer at the National Disability Rights Network who says that they would prefer the extra check and balance they put on so that parents still have to sign that form saying, “Yes, you can bill Medicaid for my child’s services at school.”
Miller: Shasta, thanks very much.
Moore: Thank you.
Miller: Shasta Kearns Moore is a freelance reporter, a writer at Medicalmotherhood.com. She joined us to talk about a recent change to Medicaid that could mean more services are available to kids in schools. That’s if schools and states make some necessary changes.
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