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Objective: Higher life expectancy has lead to an increase of elderly patients in dental practices, thus also causing an increase in high-risk cardiovascular patients. But one of the fastest-growing types of school-choice program does not fit the typical voucher mold. Far more students are enrolled in special education than the average taxpayer realizes, and many of those students have disabilities so mild that they are not easily distinguished from their "normal" classmates.
The oldest (and best known) special-education voucher initiative is Florida's McKay Scholarships for Students with Disabilities Program, established in 1999 under the governorship of Jeb Bush. Florida's experience with the McKay program demonstrates the enormous potential of special-education voucher programs. Special-education vouchers are a tested public policy that leads to better education at a lower cost to the taxpayer. Since 1975, federal law has required that all schools receiving federal funding (virtually all public schools in America) provide equal education to children with physical and mental disabilities. In 1976, when these federal policies began, about 8.3% of public-school students were enrolled in special education. These numbers may seem impossibly high, in part because most people think of disabled students as children with severe impairments such as Down Syndrome, autism, and other intellectual disabilities. By far the largest special-education classification is Specific Learning Disability (SLD), which includes conditions such as perceptual handicaps (mostly difficulty processing sight and sound), developmental aphasia (delayed language acquisition), and dyslexia. One interesting feature of the expansion of special education over the past few decades is that not all categories have grown uniformly.
The increase in students with mild disabilities is particularly relevant because such students are educated primarily in classrooms shared with non-disabled students.
Also relevant is the fact that, as the percentage of public-school students with disabilities has grown, the issue of special education has become a concern for a broader swath of American families.
That disabilities affect households across the income spectrum has enormous significance for the political and policy potential of special-education voucher programs.
Given the growing number of students classified as having disabilities, and their distribution throughout America's classrooms and families, the rapid growth of special education over the past three decades should be of increasing concern to policymakers.
Several factors have contributed to the growth in the number of disabled students enrolled in American public schools. Nevertheless, there is reason to believe that factors beyond the incidence and identification of true disabilities have played a substantial role in the growth of special-education enrollments.
If a child manifestly suffers from a severe disability, there is not much his school can do to influence whether he is placed into special education.
Because referring students for testing and classifying them with mild disabilities is so dependent on subjective analysis, the door is open to strategic diagnosis. It thus stands to reason that schools might also alter the rate at which they diagnose students with disabilities in response to underlying financial incentives.
A growing body of research suggests that such incentives do influence whether children are classified as disabled. It is true that the education of disabled students has come a long way in the past few decades.
But as with all legal protections, the disabled student's claim to an appropriate education is only as powerful as his ability to enforce it. Perhaps the biggest disadvantage faced by parents who would sue for private placement is time.
In order to address these problems, several states are beginning to experiment with programs that supplement the legal protections offered to disabled students with a market mechanism allowing them to attend any school that they choose — without the burden of an expensive and time-consuming lawsuit. To participate in the program, private schools must meet safety requirements and must employ teachers with at least a bachelor's degree. McKay is also distinguished from other voucher programs by the generosity of the scholarship it provides.
Unfortunately, largely because students using McKay vouchers to attend private schools are not required to take the state's standardized tests, we currently know very little about the experiences of disabled students who use a voucher to attend a private school.
Today, the more common arguments against school-choice policies focus on the effects of these initiatives on students who remain in public schools.
The worrisome aspect of school-choice programs, then, is that they might pull the best and brightest students out of public schools.
But while the argument that choice could harm public schools is a plausible one, it is not borne out by the facts. Of course, such research probably won't ever stop hardened critics from arguing that vouchers pose a threat to public schools. Almost by definition, vouchers that are available only to disabled students do not allow private schools to "skim" a public school's highest achievers. Beyond the typical anti-voucher crowd, there are those who would oppose McKay-style vouchers because of concerns specific to children with disabilities.
It should thus be clear that special-education vouchers can boost the academic achievement of both the disabled students who use them and all students who remain in public schools. A fascinating feature of special-education voucher programs is that, unlike means-tested programs, public schools play an important role in determining which students are eligible for vouchers. In the absence of vouchers, a school will have a financial incentive to diagnose a child as disabled if the cost of providing him with special-education services is outweighed by the additional revenue that the school will receive for providing those services. In a recent study, University of Arkansas professor Jay Greene and I put these theories to the test, assessing two important potential effects of the McKay program on Florida's public-school students. Essentially, our analysis looked at whether a public school's student achievement and a child's likelihood of being diagnosed with an SLD were related to the number of private schools nearby willing to accept McKay vouchers. The results of our analysis showed that Florida public schools have in fact responded to competition from McKay in a way that benefits students who remain in public schools. We also found that regular-enrollment students benefited academically when their public schools faced competition from the McKay program. One might argue that these patterns and relationships existed before the McKay program introduced the public schools to outside competition. First and foremost, a special-education voucher policy must provide generous scholarship amounts. Another important attribute of McKay that states should retain is the ability of private schools to refuse some applicants while accepting others. The substantial increase in school-voucher programs this year demonstrates that there is renewed interest in helping families send their children to the schools of their choice.
We apologise for the inconvenience but an error has occurred when trying to service your request. Study Design: In all, 3012 patients had oral surgery with local anesthesia at the Department of Oral Surgery, Oral Radiology and Oral Medicine at the University of Basel. Prevalence of blood pressure levels and hypertension-related diseases in Japanese dental patients. Cardiovascular and neuroendocrine response during acute stress induced by different types of dental treatment. Blood pressure outcomes of dental patients screened chronobiologically: A seven-year follow-up. WINTERSIn the fraught arena of school reform, few policy proposals have been more contentious than vouchers. Legislatures across the nation are once again taking up bills to adopt or expand programs that use public dollars to help students pay for private schools.
They differ by the populations of students that they are designed to serve, the generosity of the voucher amount, and the manner in which the money is awarded to parents in order to pay for educational expenditures. Nor has it received much attention from either side in the voucher debate, as the focus tends to remain on "conventional" voucher programs serving children in low-income homes or in districts with underperforming public schools. The pool of students who can be served by special-education voucher programs is thus both wide and deep. Today, the McKay scholarships constitute one of the nation's largest and fastest-growing school-choice programs, serving more than 22,000 kids in the 2010-11 school year.
Especially in this difficult moment for state finances, they are exactly the sort of education policy that reformers and lawmakers should be embracing.
The currently operative law is the Individuals with Disabilities Education Act of 1990, or IDEA, which mandates that all students receive a "free and appropriate" public education, even if they are disabled. Of course, severely disabled students are in special education; the categories of disabilities covered range up to the very severe, such as Traumatic Brain Injury. SLD accounts for more than one-third of all students in special education, and includes about one out of every 20 public-school students. Over time, the average disability classification has become less severe: The most substantial portion of the growth in special education has come from its mildest category, SLD, which has increased enrollment by 211% since 1976.
It is true that males, minorities, and children from lower-income families are more likely to be diagnosed with a disability than are other students. Most voucher programs attempted over the past several years have been specifically targeted to lower-income students in poorly performing urban school systems; they have thus been relevant to only a narrow band of the electorate that generally lacks political might.

To begin, there is the question of whether these rising numbers reflect manipulation of the system or a genuine health problem among school-aged children. Many are linked to real differences in the number of kids with disabilities: Improved medical technology, for instance, has led to an increase in the survival of low-birth-weight babies, some of whom suffer from health problems as children and adults as a result of their underdevelopment in the womb. In particular, it appears that, when determining whether to classify a student as disabled, public schools strategically consider their own financial interests. The process of identifying a student as disabled begins with a referral from a school employee or a parent. In the case of mild disabilities, however, there is a meaningful subjective component to diagnosis. Last year, Florida allocated more than $980 million to school districts in order to fund special-education services for students in the lowest three (of five) severity classifications for disabilities. For instance, in a study published in the Journal of Public Economics, University of California professor Julie Berry Cullen estimated that financial incentives accounted for nearly 40% of the growth in student disability rates in Texas during the 1990s.
Unfortunately, it is just one of many examples of inefficiency and skewed priorities that riddle our current approach to educating special-needs children.
Before IDEA gave disabled students the legal right to a publicly financed education, they routinely went uneducated by the public schools.
Once a child is classified as having a disability, the school district is required to develop an Individualized Education Program specifying the education services that the public school will provide to him.
Many parents are unfamiliar with the legal process and can't afford legal counsel; they are thus at a disadvantage when suing deep-pocketed school districts and their teams of lawyers. They leave students stuck in schools unable to serve them, and without the resources they need in order to leave. Arguably the national leader in education reform, Florida was the first state to develop a voucher program to increase the choices available to disabled students. From the time it was first adopted statewide in 2000 through 2010, the number of students using a scholarship has increased from 970 to 20,926.
Some of the schools specialize in serving students with severe disabilities, but many others are conventional private and parochial schools focused on serving more general populations.
An eligible student is given a voucher equivalent to either the total amount that would have been spent on educating him in the public school he is exiting, or the total amount of tuition charged to the student at the accepting private school — whichever is less. To be sure, if special-education voucher programs helped disabled children at the expense of students who stayed in their public schools, we would rightly worry about such policies. The most compelling line of this argument is that choice harms public-school students by reducing the quality of the peers with whom they share classrooms. After all, in order to enroll in a choice program, a child must have parents who are engaged enough to want to identify an educational alternative, active enough to know that the choice program exists, and savvy enough to maneuver through the enrollment process. The past two decades have yielded considerable research on public-school responses to school-choice policies, including vouchers. But special-education vouchers add a new wrinkle to their tired argument: The "cream-skimming" claim used against more conventional school-choice policies simply does not apply in the case of disabled students. Special-education students are usually among the lowest-performing students in a school; most students who have been identified as having a mild disability were tested precisely because they were struggling academically. In particular, many advocates for disabled students are wary of special-education voucher programs like McKay because private schools are not subject to the legal requirements imposed by IDEA. It stands to reason that if public schools respond to such policies strategically, the use of vouchers will reduce the number of students improperly placed into special education by shrinking the financial incentives to diagnose a child as disabled. As discussed above, a growing body of empirical research suggests that schools do in fact respond to such financial incentives by increasing the number of students they diagnose as having disabilities.
Diagnosing a child as disabled might bring a school additional revenue, but it would also make the child eligible to receive a voucher. First, we measured whether and to what extent competition from the program influenced the academic achievement of students who remained in the public schools. This sort of geographical measure is commonly used as a proxy for the competition that a public school faces from a choice program: The idea is that, when a public school is surrounded by many private alternatives, it is more likely to lose students and thus faces greater competitive pressure. We found that, as a public school's exposure to the program increases, a student in that school is less likely to be classified as having an SLD. As the number of private-school competitors surrounding a public school increased, the test scores of students who remained in that public school went up as well. But in a powerful robustness test, we looked at public-school outcomes in a given school year, and at the number of nearby private schools choosing to accept vouchers in the next school year — a factor unknowable to a public school at the time when it is diagnosing students with SLDs. These growing programs offer a public-school system's neediest students access to a high-quality education without their having to file lawsuits in order to get it. It is an unusual case of a revolutionary policy that essentially got it right the first time. McKay's calculation seems about right: The voucher should be worth the lesser of the private school's tuition or what the public school would have spent to educate the student. Means-tested voucher programs often require private schools to accept all applicants to stop them from enrolling only the public-school system's best students. As more and more states seek ways to increase options for students, legislatures would do well to give special-education vouchers a serious look.Marcus A.
In allocating taxpayer dollars to children whose parents want them to leave failing public schools to attend private and parochial institutions, voucher programs have drawn the ire of teachers' unions and church-state separatists, as well as these groups' political allies.
In August, the Associated Press reported that at least 30 states had introduced legislation allowing the use of public funds to support students attending private schools. Of course, most people associate vouchers with efforts to help low-income children, and indeed, the most common programs subsidize the educations of children from families that fall below a certain income level. It is certainly a mistake, however, to overlook one of the most promising avenues for advancing school choice: voucher programs serving students with disabilities. And such programs have a proven track record: Special-education vouchers have been around for more than a decade. Indeed, several states have used the McKay approach as a template for special-education vouchers of their own: Similar initiatives are now operating in early stages in Georgia (about 2,000 students), Louisiana (1,600), Oklahoma (6 as a pilot), and Utah (624). They provide a powerful market mechanism that can help save cash-strapped states millions of dollars.
In other words, over the past 35 years, the proportion of public-school students enrolled in special education has increased by a staggering 60%. Thus, in many ways, special-education students do not differ meaningfully from non-disabled kids.
Moreover, as a matter of fiscal policy, providing special-education services is quite costly — and the substantial growth in special-education enrollments could strain public-school budgets, pushing enormous costs onto already burdened taxpayers. The child is then evaluated for the presence of a disability by an expert employed by the school district. In determining whether a child has an SLD, for example, the federal government requires the evaluating expert to assess the child using criteria such as: "[T]he child does not achieve adequately for the child's age or to meet state-approved grade-level standards .
They certainly respond to changes in the incentives to diagnose students: For example, recent research finds that schools place additional low-performing students into special-education programs in order to exempt them from state accountability provisions based on high-stakes tests. Many states fund special education on a per-child basis; if the amount of money that a school receives for educating a child as a special-education student is greater than the additional cost of providing those services to the student, then the school has a strong financial reason to diagnose the child.
That comes to about an additional $2,400 per disabled student on top of the base financial allocation to educate the child — an amount that represents the school district's premium for educating the disabled child. That IEP is a legally binding agreement between the school district and the child's guardians: If the child's parents believe that the school is not living up to the letter of the IEP, they can challenge the district in court. As a result, when school districts challenge orders to pay for a disabled child's education at a private school, they usually win: According to research by Thomas Mayes and Perry Zirkel, school districts in fact triumph in about 63% of such cases. During that time, the child remains in a public school that his parents believe is not meeting his needs.
And they highlight the many ways in which the current system for educating disabled students is expensive, legalistic, and often counterproductive. Under the McKay program, if a parent thinks that a public school is not addressing his disabled child's needs, he can use a voucher to send the child to another public school or a private school. The substantial increase in the number of students using McKay vouchers stems mostly from the increase in the number of private schools willing to accept them — a figure that grew from 100 schools in 2000 to 959 schools in 2010.
Only 30.2% of parents surveyed said that their children's previous public schools provided the services legally required by their children's IEPs.
By and large, however, the critics' objections are the same familiar complaints lodged against vouchers everywhere — complaints that have either by now been mostly discredited, or that simply don't apply in the case of special-needs students. Fortunately, however, empirical research indicates that school choice broadly speaking does not harm public-school students. Research shows that peer quality is important to school productivity, though just why this is true is unclear: It may be because high-quality peers influence school quality by serving as good academic and behavioral role models, or because low-performing students are more likely to cause classroom disruptions or attract disproportionate attention from teachers.
The findings of a recent review of the existing research by Brian Gill and Kevin Booker are typical: They conclude that there is reason for "cautious optimism" that school-choice programs not only do not harm public schools, but actually tend to improve the quality of the education they provide. Thus, unlike more conventional voucher programs that are utilized by regular-enrollment students, special-education vouchers should improve overall peer quality within a school — since some of the lowest-performing students will leave for private schools.

Second, we tested whether competition from the program is related to the probability that a student will be newly identified as having an SLD.
When there are few nearby private schools willing to accept vouchers, the public school is essentially unaffected by the choice program in question.
For a student in a school with average exposure to the McKay program, the likelihood of being diagnosed with an SLD was reduced by about 12%. Consistent with prior research on vouchers, the academic effect of the special-education vouchers on students who remained in public schools was relatively mild.
We found that the number of nearby private schools accepting vouchers in the following academic year was not systematically related to SLD placement, and only minimally related to public-school achievement. Both theory and empirical research suggest that these policies benefit students who remain in public schools, while also helping to slow the unnatural, almost certainly erroneous, and potentially damaging increase in the diagnosis of disabilities.
Before tinkering with the McKay strategy too much, states considering similar reforms should keep in mind some of the program's essential features. Only such substantial vouchers are likely to truly help disabled students find suitable private schools capable of meeting their needs. But, as discussed above, special-education vouchers offer no such potential for "cream-skimming." Further, many private schools that are perfectly willing to accept students with mild disabilities simply do not have the resources necessary to accommodate students with more severe disabilities. Winters is an assistant professor in the College of Education at the University of Colorado at Colorado Springs and a senior fellow at the Manhattan Institute for Policy Research. The patient's heart rate, blood pressure, and oxygen saturation were routinely checked, both before and during the procedure.
Of late, these voucher opponents have had some high-profile successes: In 2006, for instance, the Florida Supreme Court ruled that a key component of the state's Opportunity Scholarship Program was unconstitutional. In fact, they grew at a considerable pace even in the years leading up to the recent renewal of legislative interest in school vouchers. This year, Ohio expanded a scholarship program for autistic children to include all special-education students, and North Carolina began offering parents of disabled students a tax credit for private-school tuition (or for special-education expenses in the case of home-schooling families). And my own research demonstrates that the incentives inherent in special-education vouchers have helped to improve the quality of education that public schools provide to all of their students.
Most kids classified as needing special education suffer from considerably more minor handicaps. The reasons for the decline in students with severe disabilities are not known for certain, but it is likely that they include, for instance, the introduction of safer cars (which decrease the likelihood of severe injuries) and the elimination of lead-based paint.
Clearly, then, the rise of special education, and particularly the factors contributing to it, deserve more attention than they have received to date. If the expert diagnoses the child with a disability, federal law requires that the school district develop a plan for educating him. Though many disabled kids obtain a high-quality education from their public schools, some parents of disabled students find that the legal protections guaranteeing their children a right to an education aren't worth much more than the paper they are printed on.
A judge who sides with the parent might order the school district to increase the services it provides to the child.
And this figure almost certainly understates the problem, since many unhappy parents don't have the resources to bring lawsuits in the first place, or simply choose not to go through the hassle given the small chance of success and the discomfort that comes from suing the very people who educate their children. Unlike many other school-voucher programs, McKay does not require private schools to accept the voucher amount as full tuition payment, nor are private schools required to accept all applicants. Meanwhile, 86% of the parents reported that the private schools in which they had enrolled their children were providing the services they had promised — even though they were not legally required to do so. Moreover, the particular nature of special-education vouchers turns the common argument of school-choice opponents on its head. In any event, it has been established that a student will learn more in a year if he is surrounded by high-performing classmates than he will if he is surrounded by lower-performing classmates. Furthermore, unless the choice program's guidelines prohibit the practice, many suspect that private schools will enroll only voucher students who meet the schools' academic admission criteria — thus opening their doors to high-performing students while keeping out low performers. While it is true that school choice is not provoking the dramatic turnarounds in public schools that its champions had hoped for, there is no convincing evidence that it has diminished the quality of public schools anywhere it has been tried. And especially because students with mild disabilities usually spend most of the school day sharing classrooms with non-disabled students, this improved peer quality should in turn drive up the academic performance of regular-enrollment students, allowing them to achieve at higher levels than they would have without the voucher program. It is true that, under a McKay-style voucher program, a parent cannot sue a private school for failing to correctly administer a child's IEP.
When determining whether to place a marginal student into special education, the school would now have to weigh the premium it would receive if the child stayed enrolled against the likelihood that he would leave for a private school. Our full study appears in the June issue of the peer-reviewed journal Educational Evaluation and Policy Analysis, published by the American Education Research Association. But contrary to voucher opponents' usual claim, the choice program certainly did not harm public-school students, and in fact tended to help them.
In other words, nearby private schools have no influence on these outcomes in public schools until they make themselves available to educate students with vouchers — at which point the outcomes for public-school students change.
Requiring private schools to accept all voucher applicants would dramatically reduce the number of options available to students. Results: The oral surgical procedure had to be discontinued 17 times, because the patient developed significantly elevated blood pressure. So far this year, voucher programs in more than a dozen states have either been initiated or significantly expanded.
That plan takes the form of an Individualized Education Program (IEP), which describesthe services that the public school is to provide to the child. For instance, in the case of one disabled student in California, a judge lambasted the school district for "willfully and vexatiously" dragging out the case for so long that, by the time it was resolved and the judge handed down his decision, the child in question was 23 years old.
Department of Education, Florida spent an average of $12,744 to educate a public-school student in 2007-08 (the most recent year for which figures are available). In these ways, conventional school-choice programs could "cream skim" the nearby public school's brightest students — leaving the lowest performers to share classrooms together, and hence further driving down their academic achievement. But a parent who is unhappy with the services provided by a private school can always move his child to a different private school — or simply return his child to the local public school, which is legally required to follow the provisions of the IEP. Vouchers should thus make public schools hesitate before classifying as "disabled" a student who is simply behind. This is strong evidence that public schools in Florida are responding to the influence of competition for disabled students brought about by the McKay program.
They include Ohio, which expanded its program by quadrupling the cap on voucher recipients, and Oklahoma, which implemented a tax credit for donors to scholarships that fund education at private schools. And some members of Congress have raised the idea of legislation that would allow federal special-education dollars to follow a student into the school of his choice rather than flowing directly into state coffers. It thus costs the state about 43% less to pay for a disabled student's tuition at a private school that his parents have chosen for him than it does for the state to educate an average student in the public school to which his zip code has assigned him. Programs like McKay do not undermine the legal protections of the current system: They supplement them by creating a market and empowering parents as consumers, free to walk their children to different schools if they feel they can get better education elsewhere. Thus, a decrease in the patient's oxygen saturation level during local anesthesia with or without premedication before the first clinical symptoms manifest themselves can be detected. Indiana launched the nation's broadest private-school voucher program, which provides a voucher to any child in a family of four with income of less than $60,000 a year. Indeed, a 2001 study by Donald MacMillan and Gary Siperstein found that, generally speaking, public schools use low achievement alone when diagnosing SLD. Other research shows that many SLD students are indistinguishable from low-achieving regular-enrollment students.
An example for this would be to inject local anesthesia to a hypotonic patient while he is laying down and to help him sit up slowly. If there is a problem, it is vitally important to be able to measure the patient's blood pressure to obtain some diagnostic findings.
Especially for patients with circulation problems, and also in general, high blood pressure measurements can be an early warning sign for hypertension. It increases the patient's morbidity and mortality risk and is usually discovered by chance. If the patient's medication is insufficient, the dentist needs to refer the patient to his primary care physician or internist.
If the patient has a somewhat elevated blood pressure before or during the procedure, the dentist should inform the patient about the results and advise him that there could be pathological causes for this and that he should have this checked out by his primary care physician or internist. The dentist himself should not diagnose "hypertension" based on individual momentary results.The quantity of possible events in this context is not yet evaluated.

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