Rehabilitating the rehabilitation delivery system: a commentary on the voucher system.
The purpose of this article is to discuss the advantages and potential problems of implementing a voucher system in rehabilitation. Among the major advantages of implementing such a system would be increasing client choices and expanding the roles, responsibilities, and utilization of private rehabilitation agencies and practitioners. Major problems would include developing a structure to administer, fund and monitor such a system and resisting the temptation to treat clients as potential sources of revenue rather than as individuals needing rehabilitation services. In view of the apparent congruence between the voucher-system concept and American ideals such as free trade, private initiative, competition, and individual empowerment, it is recommended that an effort be made to develop and field test the voucher system on a limited, experimental basis.
The concept of school choice has been an issue in American education since 1955 when Milton Friedman first proposed the idea of educational vouchers. Implementing choice through educational vouchers has gained support from presidents, governors, state legislators, and a variety of special interest groups throughout the country. Currently, several states such as Minnesota and Wisconsin have experimented with educational vouchers. In Minnesota, parents are allowed to enroll their children in any public school within the state. In Wisconsin, the Milwaukee Parental Choice Program provides state monies to subsidize tuition at a private school for students who come from households with incomes less than 1.75 times the poverty line. Both of these model programs have the goal of increasing educational quality, increasing parental involvement, and providing individuals a choice in education.
Trends in vocational rehabilitation have also stressed the need for increasing client involvement, client empowerment, and the quality of services provided. Emener (1990), for example, stated recently that it would be critical for proposed legislation and enacted public laws and policies to empower rehabilitation systems so that they would have the power and control they needed to establish and implement negotiations with other systems in ways that facilitate effective and efficient services to individuals with disabilities. The purpose of this article is to discuss the advantages and potential problems of implementing a voucher system as a viable means of reforming the current state-federal vocational rehabilitation system and empowering clients so that they can receive the maximum benefit from rehabilitation services.
History of Educational Vouchers
Milton Friedman (1955) originally proposed the idea educational vouchers as a method to improve the educational system in this country. Instead of tax monies being distributed directly to the public school systems, parents would be issued vouchers that could be spent at any acceptable school the parents preferred-- either public or private. During the 1960s numerous proposals for educational vouchers emerged, both from the political left and right. Each of these proposals promised major benefits from such reform, including better education and lower costs (Krushinsky, 1988). Under the Republican administrations of Ronald Reagan and George Bush, the idea of educational vouchers surfaced as a primary strategy for providing meaningful educational reform. In 1985, Education Secretary William Bennett unveiled a proposal that would give poor children a $600 voucher to be used each year at either a public or a private school (Krushinsky, 1988).
Vouchers have also been proposed for use at the university and college level (Friedman & Friedman, 1980). Qualified students would receive a voucher equivalent to what the state or federal government was already contributing, or would have contributed, toward their education at the local state university, which students could then use at the local state university or any other university of their choice.
Although support for vouchers has come traditionally from political conservatives who have advocated vouchers as a means for increasing parental choice and increasing competition in education, support has also come from some liberal groups, who believe that the availability of vouchers would improve the quality of education received by disadvantaged children. The use of vouchers has also been advocated by some educational reformers who believe that vouchers would increase parental involvement and allow the schools to be more responsive to change. Many inner city parents are also hopeful that parental involvement in education will increase as a result of implementing the voucher system. Wisconsin State Representative Polly Williams, for example, in her analysis of the Milwaukee Parental Choice Program, observed that under the voucher system parents have something to say about what is being taught to their children and how it is being taught (Conquest, 1992).
Witte (1991) identified three basic beliefs that make up the pro-choice perspective in education. First, proponents believe that freedom of choice is a primary value, and educational choice is one of the most important choices that Americans can make. Secondly, it is believed that equitable educational opportunities should be provided and that a system of educational vouchers would provide these opportunities, especially for low-income families that live in the inner city or in rural areas. Also, it is argued that by providing educational choice through vouchers, the percentage of low-income families becoming involved in education will increase because they would have a substantial interest in the amount of funding for education (Nathen, 1983). Thirdly, it is believed that schools should meet the educational needs of a diverse society and that the array of schools emerging from school-choice policies would be better equipped to meet these needs. A similar point of view was expressed by Pipho (1992), who argued that implementing the voucher system would encourage the development of new educational delivery systems. Advocates of school choice and vouchers have also expressed the belief that if school-choice is implemented, schools would become less bureaucratic, the staff would be more motivated, leadership would improve, parental involvement would increase, schools would become more diverse, student achievement would increase, and education would cost less due to greater efficacy under the market system (Witte, 1991).
Opposition to school choice and educational vouchers has traditionally come from political liberals, who claim that educational inequality and racial segregation would increase, and from the National Education Association and other members of the organized education establishment. Opponents of school choice and vouchers believe three things would happen if vouchers are adopted (Witte, 1991). First, it is believed that educational choice and vouchers would amplify an already unequal system of education. Secondly, it is felt that choice would cause inequity between schools, which in turn would increase segregation. Kozal (1992), for example, argued that the children of poor parents would not benefit from school choice because the reputation of schools will be passed on by word of mouth, and word of mouth always favors children from the most wealthy and best educated families. Thirdly, it is feared that the idea of the common school would be lost and that basic social, economic, and political facts would not be taught. Doerr and Menendez (1992), for example, warned that if the advocates of public funding for private schools are successful, American taxpayers will find themselves supporting some pretty unsavory points of view in at least some private classrooms. Opponents of school choice and vouchers have also argued that if school choice is adopted, inequities between schools will increase, accountability will be lost, minimal educational standards will not be met, students with special needs will not be served, distributing information about schools will be costly, and choice will be limited by geographic constraints.
Recent initiatives, most notably in Wisconsin, New Jersey, Georgia, Connecticut, and Arizona, are drawing renewed attention to using the voucher system. In fact, a Gallup poll conducted in 1991 indicated that the strongest support for the use of vouchers in schools was among non-white and inner city residents (57%). In the same survey, 50% of all respondents favored the use of vouchers with only 39% opposed (Doyle, 1992). Although a referendum to implement a voucher system in the schools was soundly defeated recently in California, the situation was somewhat idiosyncratic because the proposal was rather poorly drafted and was opposed by the state's Republican governor. By contrast, in Wisconsin the third-year report on the Milwaukee Parental Choice Program reported high parental involvement, greater parental satisfaction, and an overwhelming approval for the program (Witte, Bailey & Thorn, 1993). In other words, school choice is an idea that is attracting considerable national attention and some strange political bedfellows (i.e., political conservatives and inner-city minority group members).
Because there have been few initiatives to apply a voucher system to the delivery of rehabilitation services (personal communication with W. Graves, M. Davis, and R. Majunder, February 4, 1994), the idea has no organized support or opposition in the rehabilitation field. Thomas (1985), however, pointed out several years ago that in many ways the state-federal vocational rehabilitation program operates like a voucher system. That is, in the state-federal vocational rehabilitation program a procedure exists to determine eligibility, both the counselor and the client have input into the plan for spending service monies, and the monies are often spent for services provided in the private sector. The state-federal program is not, of course, a voucher system in the purist sense of the term because the services the client receives must be coordinated and approved by a state agency counselor. In a pure voucher system, the client would be able to decide whether he/she wanted to receive services from public or private counselors and agencies.
What would be the advantages of using a voucher system in rehabilitation?
There are some obvious advantages of using a voucher system in rehabilitation. One advantage would be that clients would be empowered to decide which services they wished to purchase and whether they wanted to receive these services from a public or private agency. In addition, clients would be free to supplement their vouchers if they wished (Weaver, 1991). Professionals could not, of course, be compelled to offer services that they felt were in appropriate (e.g., see Thomas, 1993a, 1993b) and there would probably be economic limits on the services that could be purchased using vouchers alone. But in general, clients would have a considerable amount of flexibility in deciding which services they wanted to receive and from whom. If, as advocated by Nosek (1993), respect for the right and responsibility to make judgments for oneself is the cornerstone of the new, enlightened field of rehabilitation, and if client empowerment is an important goal of rehabilitation (Emener, 1991), then providing clients with additional options and prerogatives would appear to be a reasonable clinical strategy.
Another advantage of a voucher system would be that agencies would find it necessary to provide quality and effective services in order to attract clients. That is, agencies and rehabilitation professionals would need to demonstrate that they could satisfactorily provide the services the client was purchasing. Realistically, this requirement is no different than what is currently expected of other professionals such as physicians, lawyers, and accountants, whose ability to attract patients and clients is based on their previous success records and reputations. In fact, one could argue that such a requirement might help to establish rehabilitation professionals as individuals who have something of real value to offer the public. Moreover, if the arguments are truly valid that master's level rehabilitation practitioners are more competent than other rehabilitation practitioners (e.g., see Szymanski, 1991; Szymanski & Danek, 1992; Szymanski & Parker, 1989a, 1989b; Thomas, 1990), then agencies would be compelled to hire master's level practitioners because it would be these practitioners who were providing the highest quality service. Another advantage might be that due to the limited amount of monies available, agencies and professionals would be encouraged to complete their interventions in a more timely manner; thus, there would be less of a tendency for clients to be placed in inactive statuses for extended periods of time because of the loss of revenue involved.
On the other hand, a potential disadvantage of using a voucher system might be that in order to generate business, rehabilitation agencies and "professionals" would be tempted to engage in glitzy and misleading advertising campaigns, offer services that were really unnecessary, or attempt to cut costs at the expense of necessary client services. In short, the integrity and effectiveness of rehabilitation agencies and professionals would be severely tested by the implementation of a voucher system. It would, in other words, be a very courageous step for rehabilitation professionals to take, especially for those rehabilitation professionals employed by the state vocational rehabilitation agencies.
Who would provide the greatest resistance to creating a voucher system in rehabilitation?
The greatest resistance to creating a voucher system in rehabilitation would likely come, of course, from those who have the most to lose in a more open and competitive system. In education, the greatest resistance to implementing a voucher system is, as noted above, from the National Education Association, state departments of public instruction, public school systems, and the federal government's education establishment. The pattern in rehabilitation would assumedly be essentially the same. Specifically, one could expect that state divisions of vocational rehabilitation and their employees and the U.S. Department of Education and its employees would offer the most resistance to such a proposal. If such a system were implemented, the public programs would lose enormous amounts of power, influence, and money. On the other hand, one might expect that client-advocacy groups and private-for-profit and non-profit organizations and their employees would support such a proposal. Ultimately, the question should not be which of these political coalitions has the most power, but rather, what is the best possible delivery system that can be created to meet the service needs of people with disabilities.
Is a voucher system needed in rehabilitation?
According to the most recently released statistics, the state-federal vocational rehabilitation program served 941,771 clients in fiscal year 1992-93. 0f these 941,771 clients, 202, 831 (21.5%) were closed as rehabilitated (Carney, 1992). It is not known how many of the clients still being served will eventually be closed as rehabilitated. Also, it is not known how many of the 202,831 clients closed as rehabilitated will, for legitimate reasons (i.e., for reasons unrelated to the quality of the rehabilitation plan and services received), require additional services in the future. It is known, however, that approximately 66% of clients served by the state-federal vocational rehabilitation program are employed at follow-up two to four years later (Bolton, 1981). While at first blush a 66%, success rate seems impressive, nothing is known about the quality of these placements, the level of case difficulty involved, or even the extent to which the state-federal vocational rehabilitation program was instrumental in facilitating the placements. Whether the implementation of a voucher system would improve the number or quality of successful case closures is uncertain; however, for about 34% of the clients served, the goal of employment has not been met in the present system.
Despite the wide-spread criticism about the educational system in this country, it would be foolish to place all of the blame for the nation's educational problems on the public school system. If that were the case, the public school system could also take credit for all of the successes, including the fact that an overwhelming majority of American Nobel Prize winners received at least some of their education in the public schools. Clearly, demographic characteristics related to the structure of the family, the hopelessness often associated with being a member of the underclass, the avalanche of state and federal regulations confronting the public school system, and changes in educational priorities have contributed to the plight in which many public schools, especially in major cities, find themselves. In other words, while the availability of a voucher system might help to improve the educational system, it would not be a panacea.
The situation is similar in rehabilitation. Although using a voucher system would give clients more choices, encourage competition between agencies, and promote accountability, many problems would remain, including the vagaries of an unstable global economy, the psychological and social barriers that often prevent people with disabilities from participating fully in the job market, and the unfortunate fact that many of the clients currently served in the state-federal vocational rehabilitation system would have a difficult time attaining competitive employment status under the best of circumstances. On the other hand, one could argue that the relative success (in comparison with other human service agencies) state vocational rehabilitation agencies have had in helping people to reduce their dependency status has, in large part, been due to those aspects of the system that have permitted the purchase of services from private-for-profit and non-profit agencies, facilities, and businesses. In other words, by expanding the role of the private sector and giving clients more choices, a good system might be made even better. At the very least, an effort should be made to explore on a pilot-project basis whether the private sector is capable of providing the range of services necessary to implement a voucher system.
How might a voucher system be implemented in rehabilitation?
A major difference between implementing a voucher system in rehabilitation versus implementing one in education is that in education there would be significantly less difficulty in determining who would be eligible to receive "benefits" and how large the benefits would be. For example, one could simply calculate the amount of money available and divide it among the number of school-aged children in the school district. In fact, even if a voucher system were applied at the college and university level, it would be a relatively simple matter to determine who was eligible to receive vouchers and how much public money was available for distribution. This application would be especially simple if it were decided that everyone who qualified for admission to college would be entitled to the same voucher amount regardless of the specific college attended.
In rehabilitation, on the other hand, one is faced with the problem of determining who would be eligible to receive vouchers, what kind of vouchers (e.g., vouchers for physical restoration services, job placement services, and/or vocational training), and how much money would be reasonable to spend on any particular client or service. In the present system the state agency counselor, in "consultation" with the client and the counselor's supervisor, makes these decisions. If appropriate criteria were established for "case managers," there is no reason why these same services could not also be performed by counselors employed by private agencies. It is not, for example, necessary for a physician to work for the government in order to treat Medicare patients. There is also no reason why "case managers" in private agencies could not work with eligible clients to decide what kinds of services were appropriate and from which professionals, agencies, and facilities the client was going to receive these services. In other words, if universal criteria were established for eligibility determination and for what constituted a "qualified rehabilitation professional" (e.g., see Graves, Coffee, Habeck, & Stude, 1987), there would be no reason why rehabilitation services could not be coordinated by professionals in either public or private agencies and facilities. A significant difference, of course, would be that clients being served in this new system would be able to choose whether they wanted to initiate and continue receiving services from a public or private agency.
One of the problems with the current delivery system is that agencies have a limited amount of case-service monies available. That is, a state agency is limited in terms of the money it has available to spend on client services. Similarly, individual counselors are limited in terms of the money they have available to spend on their clients. To make certain that the services counselors authorize are professionally appropriate and within the agency's budget, the counselor's purchases must be approved by her/his supervisor. In any human service setting having one's work reviewed by a colleague is good professional practice. In fact, as pointed out by McGinnis (personal communication, October 17, 1986), many of the abuses of clients by their psychotherapists could be prevented if all psychotherapists routinely received supervision from other psychotherapists. Instead, many psychotherapists practice privately without supervision or even an informal collegial support system. In addition to reviewing the counselor's clinical work with a client, the state agency supervisor must also, as noted above, make certain that the services the counselor is providing are warranted and affordable. Both of these supervisory functions would also be necessary if services were being provided in the private sector. Otherwise, a counselor or agency could attract "business" simply by authorizing whatever services (e.g., a sex-change operation or workshop in the Bahamas) or acquisitions (e.g., a Range Rover or fishing boat) a client desired. In order to prevent such frivolous services and purchases, it would be necessary to insure that only highly qualified rehabilitation professionals (i.e., those with appropriate educational credentials whose ethical practices were governed by a state or national certification or licensing board) were authorized to determine eligibility and assist the client in developing a rehabilitation plan. It would also be necessary to insure that these counselors were supervised by similarly educated and ethical professionals. In addition, it would be necessary to create some sort of superordinate review process to insure that monies were only provided for services that were reasonable and appropriate.
The implementation of a voucher system would not solve the problem of limited resources, although it might, through the mechanism of increased competition and the need for "providers" to demonstrate their effectiveness, improve the efficiency and effectiveness of the rehabilitation delivery system. Moreover, because private businesses and individuals with disabilities rather than governmental agencies would be viewed as the primary beneficiaries of such a system, it might eventually be possible to garner bipartisan political support for spending increases. For example, in an era where big government has apparently lost a considerable amount of its 1960s luster, it might be easier to sell a program that is intended to empower people by giving them more choices than by limiting the provision of public-supported rehabilitation services to one governmental agency (i.e., the state VR system) that is often (wrongly) confused with the welfare system.
Summary and Conclusions
This article represents a preliminary attempt to speculate on the possible advantages and potential problems of implementing a voucher system in rehabilitation. It must be emphasized that the intent of the article was not to castigate the state-federal vocational rehabilitation program. Rather, the purpose was to discuss whether the effectiveness of the current program could be improved by broadening the scope of individuals and agencies that would be able to participate in the eligibility-determination, rehabilitation-planning, and case coordination processes by giving clients more choices in terms of the professionals from whom they wished to receive services through a voucher system.
Although many questions remain about how, or if, a voucher system would work in rehabilitation, it is an idea that deserves further investigation. As acknowledged above, there is much that is good about the state-federal vocational rehabilitation program, and in modifying the program it would be important to retain those aspects of the system that have incorporated proven free-market principles such as freedom of choice, competition, utilization of the private sector, and the necessity of providing clients with a quality product at a reasonable cost. In expanding the range of client choices through the implementation of a voucher system it would be neither necessary, nor advisable, to eliminate the state-federal program; the state agencies in the program would, however, be only one of several choices from which clients could decide to receive services.
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Received: October 1993 Revision May 1994 Acceptance: June 1994
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|Author:||Strauser, David R.|
|Publication:||The Journal of Rehabilitation|
|Date:||Jan 1, 1995|
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