Money! Money! Money! Increasing Need for Services vs. Limiting Taxation

"As the principal of a public school, I don't understand why the parents of general education students have not filed a class action lawsuit demanding that their children have equal access to public money. At our school, we spend about twice the money given to us by the government for special education students... For example, when a child enrolled in our school with a need for a one-on-one adult assistant, I had to cancel the after-school tutoring that served about 60 low-income students who were behind grade level in reading and math." 

"When we have the annual meeting to discuss what support an individual special needs child should have, we are forbidden by law to discuss or take into account the cost of the services being discussed."1

"If the goal of public education is to give everyone a roughly equal start by the time they reach adulthood, it simply doesn't make sense… that (someone with) a medical diagnosis (should be considered) over those that derive from poverty – which may be the greatest handicapping condition of all." 2

"Texas's brilliant plan to cut Medicaid for disabled children: should kids really lose therapy services to help pay for property tax relief?" 3

INDIVIDUALS WITH DISABILITIES EDUCATION ACT (IDEA)The federal legislative program (Education of All Handicapped Children Act enacted in 1975 was renamed in 1990 as the Individuals with Disabilities Act) ensuring students with a disability are provided with free appropriate public education that is tailored to their individual needs. In the 2012-2013 school year, 6.4 million children 3-21 years, or about 13% of all public school children, were registered under the IDEA program. Some 35 percent of students receiving special education services had specific learning disabilities. (see Figure 1)

A specific learning disability is a disorder in one or more of the basic psychological processes involved in the understanding or use of language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. The percentage of children and youth served under IDEA was highest for American Indians/Alaska Natives (16%), followed by blacks (15%), whites (13%), Hispanics (12%) and Asians (6%). 4 In the 1999-2000 school year, the United States spent an estimated $50 billion on special education services and an additional $27.3 billion in general education funds for those students in spe cial education who spent part of their time in general education classroom settings, for a total of $77.3 billion. (Expenditures increased to $70 billion in 2014, plus funds for students who spent part-time in general education settings.) 5-7 Yes, many children with disabilities are expensive, but so too are other conditions and behaviors!

END STAGE RENAL DISEASE (ESRD) In 1972, federal legislation authorized the ESRD program under Medicare for all ages. Previously, only those over 65 could qualify for Medicare benefits. This entitlement is nearly universal, covering over 90% of all U.S. citizens in the last stages of severe chronic kidney disease. The most common causes of ESRD in the United States are diabetes and high blood pressure. The rate of ESRD among blacks is 3.5 times the rate for whites; and among Native American and Hispanics it is 1.5 times the rate for whites. In 2011, 113,136 patients in the U.S. started treatment for ESRD. In 2009, ESRD cost $57.5 billion ($72,064 per person), or about 28% of all Medicare spending. The average life expectancy on dialysis (without a transplant) is 5-10 yrs. 8-11

STAYING AWAY FROM THE BLAME GAME:While children with disabilities are expensive, so too are other conditions and behaviors. The resolution to this mounting and all consuming dilemma does not lie in pointing our proverbial finger at one group, be it the special education students, the frail elderly or any one in between.

ALZHEIMER'S DISEASEIt is the most common form of dementia, a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. Alzheimer's disease accounts for 60 to 80 percent of dementia cases. Symptoms of Alzheimer's disease worsen over time, although the rate at which the disease progresses varies. On average, a person with Alzheimer's lives four to eight years after diagnosis, but can live as long as 20 years, depending on other factors.12 In 2013, there were 5.1 million cases of Alzheimer's disease in the U.S. Prevalence doubles every five years after 65 years of age. It is estimated that in 2050, there will be 13.8 million cases.12 In 2010, the cost for people 70 years and over with Alzheimer's disease ranged between $157 and $210 billion with an average per person of between $51,000 and $56,000.13 "A withered person with a scrambled mind, memories sealed away. That is the familiar face of Alzeimer's disease that strikes an American every 67 seconds."14

SMOKINGIn 2010, 55.8 million U.S. residents smoked cigarettes and 8.8 million residents used smokeless products (chewing and snuff). Annually, almost $170 billion were associated with direct medical costs associated with smoking. In addition, $156 billion was lost in productivity due to premature death and exposure to second hand smoke. More specifically, the average cost per pack of cigarette was $6.36, with a $35 health related cost. 15.16

MOTORCYCLES AND HELMETS In 2010, $3.3 billion were saved as a result of helmet use by motorcyclists in the United States. Another $1.4 billion could have been saved if at the time of an accident the motorcyclist had used a helmet. In 2008-2010, 14,283 motorcyclists were killed; 

DRUG ABUSE Abuse of tobacco, alcohol and illicit drugs exacts more than $700 billion annually in costs related to crime, lost work productivity and health care. TobaccoAlcoholllicit drugsHealth Care$130 Billion $25 Billion $11 BillionOverall costs$295 Billion$224 Billion$193 Billion

MEDICAID SPENDINGIn 2011, $397.6 billion were spent by the Medicaid programs.The distribution of spending by age was:Disabled (< 65 yrs) 42% Aged . . . . . . . . . . . . . 21%Children . . . . . . . .21%Adults . . . . . . . . . .15%19The proportional costs for children are far from the highest. 

THE DILEMMA"The trustees of the Medicare program have projected that Medicare will, in effect, go bankrupt in 10 years. It faces a projected annual cost increase of some 7 percent, which will raise the program's cost from $427 billion in 2007 to $844 billion in 2117. Many policy analysts have determined that, for the program to survive in a viable way, the government will need to double the taxation for it, cut its benefits in half, or combine these two approaches in some way. Doubling the taxation would be a great burden on the young, who will have to pay those taxes, while cutting benefits in half would harm the old, whose medical treatment Medicare reimburses." 

The health professionals, ethicists and the lay press increasingly are consumed with the conflict between costs and demand for health services. The exponential growth in knowledge and technology has permitted increasing numbers of: 1) youngsters to survive for decades, 2) adults to overcome any number of physical and emotional difficulties and lead successful and satisfying lives and 3) elderly with the countless physical and intellectual limitations to continue with into their nineties and beyond— all with significant personal and governmental financial investments. When we speak in the abstract, it seems reasonable to control costs. However, when it becomes personal (my child, my parent and my grandparent or my individual rights), the discussion takes on a different tone.

• Should we ensure the continuation of special education program for youngsters at the price of reducing the care of the older adult on kidney dialysis or the elderly with Alzheimer's disease? Surely, children have so many more years of life.

• Do we have the right to outlaw the growth and import of tobacco in an effort to cease the manufacture of cigarettes, in an attempt to reduce the associated costs of health care?

• Do we have the right to interfere with the rush of air on one's face as motorcyclists ride helmet-less in an effort to reduce the costs for health service when accidents occur?

• As far as alcohol – we tried that one with prohibition in the early 20th century without much success (to say the least).

• Similarly, we have not been very successful in either the 20th or 21st century in dealing with the dilemma and costs of illicit drugs.

While there is no ready-made solution to this mounting and all consuming dilemma, the resolution does not lie in pointing our proverbial finger at one group (be it the special education students, the frail elderly or any one in between). An objective (if such a thing is possible) review of the demanding forces is essential. A review that takes into consideration a future which will become even more complicated as we learn to keep more and more of our populations (including our families, neighbors and yes, even strangers) alive and hopefully, well!

ABOUT THE AUTHORS:H. Barry Waldman, DDS, MPH, PhD - Distinguished Teaching Professor, Department of General Dentistry at Stony Brook University, NY; E-mail: Steven P. Perlman, DDS, MScD, DHL (Hon) is Global Clinical Director, Special Olympics, Special Smiles and Clinical Professor of Pediatric Dentistry, The Boston University Goldman School of Dental Medicine, Matthew Cooke, DDS, MD, MPH is Associate Professor, Departments of Anesthesiology & Pediatric Dentistry University of Pittsburgh School of Dental Medicine Pittsburgh PA; Assistant Clinical Professor, Departments of Oral & Maxillofacial Surgery and Pediatric Dentistry Virginia Commonwealth University School of Dentistry, Richmond, VA.

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