RESEARCH AND PRACTICE

Health and Economic Benefits of Reducing the Number

of Students per Classroom in US Primary Schools
Peter Muennig, MD, MPH. and Steven H. Woolf, MD. MPH

With health costs soaring and student per- Objectives. We estimated the costs associated with reducing class sizes in
formance falling, the United States is in jeop- kindergarten through grade 3 as well as the effects of small class sizes on se-
ardy of losing its economic dominance. As lected outcomes such as quality-adjusted life-years and future earnings.
low-skilled jobs ai'e outsourced, tlie availabil- Methods. We used multiple data sets to predict changes in the outcomes as-
ity of highiy skilled workers is increasingly a sessed according to level of educational attainment. We then used a Markov
detemiinant of global competitiveness.''^ At modei to estimate future costs and benefits incurred and quality-adjusted life-
the same time, govemment and corporate years gained per additional high school graduate produced over time.
budgets are stru^ling under the weight of Results. From a societal perspective (incorporating earnings and health out-
soaring health costs. '^ One partial solution to comes), class-si2e reductions would generate a net cost savings of approximately
both problems I'esides in America's schools. $168000 and a net gain of 1.7 quality-adjusted life-years for each high school
graduate produced by small classes. When targeted to low income students, the
In recent years, ttie performance of stu- estimated savings would increase to $196000 per additional graduate. From a
dents in the United States has been declining governmental perspective (incorporating public expenditures and revenues), the
relative to the performance of students in results of reducing class sizes ranged from savings in costs to an additional cost
competing countries; however, a variety of of $15000 per quality-adjusted life-year gained.
innovative school-based interventions and Coriclusions. Reducing class sizes may be more cost-effective than most pub-
programs are beginning to show promise.^"' lic health and medical interventions. {Am J Public Health. 2007;97:2020-2027.
In the case of 1 intervention, implementation doi:10.2105/AJPH.2006.105478)
of small class sizes, long-term follow-up data
are now available from a lar'ge, multischool
i-andomized controlled trial.^ This tiial. Proj- goods and services, ranging from healthful school graduation rates. Because we focused
ect STAR (Student Teacher Achievement foods to [lrescription drugs and good housing, on a rieiadvely expensive intei-vention (one that
Ratio), is the highest qualify long-term experi- that contiibute to improved health.'^''^ included limited estimates of lliture cost sav-
ment to date in the field of education. If Proj- Beyond the intuitive mechanisms just de- ings) and examined outcomes over a range of
ect STAR is proven to be repn)ducible on a scribed, there is growing evidence that the efficacy values, our resuits should provide a
national scale, it could markedly improve the overall link between educational achievement conservative h-amework for evaluating tliis and
human capital of the United States.^'^ and health is causal in nature.^"""*"'^ If so, it other interventions as long-term data on edu-
Reducing class sizes may also represent an would be informative to explore whether the cational interventions become more plendflil.
effective health intervention. Improvements in potential net economic benefits would offset
educational attainment have long been linked the massive societal investment that would be METHODS
to increases in botli health status aiid longev- required for widespread adoption of an effec-
ity. Potential mechanisms include improved tive educational intei"vention, such as reduc- Study Design
cognitive abilities, higher earnings, and better ing class sizes, on a national scale. We used data from Project STAR to con-
job quality.'" Improved cognition and knowl- We estimated the health and economic duct 2 separate analyses of (1) ali students
edge enable people to make better lifestyle effects of reducing class sizes from 22-25 and (2) low-income students eligible for
and heaith care choices, conferring a range students to 13-17 students in kindergarten school free-lunch progi'ams. In each analysis,
of skills" allowing them to better survive in tlirough grade 3 nationwide, the intervention we examined costs from a societal pei-spective
their environmental niche. Higher earnings Unsted in Project SIAR. We acknowledge that (incoiporating the individuals' eai nings and
and better job quality enhance access to some uncertainty remains regarding whether health outcomes only) and from a govern-
health insurance coverage, reduce exposure the effect size observed in that trial Is i-epro- mental perspective (incorporating puhlic
to hazardous work conditions, and provide dudble or will produce substantive health ben- expenditures and revenues only). We ad-
individuals and Families with the necessary re- efits. However, we used iLsfindingsas a start- hered to the standards recommended by the
sources to move out of unfavorable neighbor- ing point for constructing a model exploring IMnel on Cost-Kffectiveness in HctUth and
hood environments (where exposure to crime how those luicertainties define the boundaries Medicine.'^ However, rather than adheiing to
and pollution, and inadequate access to of the potential costs and benefits of educa- the panel's recommendation that all costs be
health care are heightened) and to purchase tional interventions designed to improve high included in all calculations, we included crime

2020 I Research and Practice | Peer Reviewed | Muennig and Woolf American Journal of Public Health | November 2 0 0 7 , Voi 9 7 , No, 1 1
 RESEARCH AND PRACTICE

and various other sources of cost savings only Medical Expenditure Panel Survey then followed untii tiie age of fi5 years. To
in the sensitivity anaiysis to ensure that our We Lised data fi-om the 2003 Medical Ex- calailate quiility-adjusted life-yeai's gained
estimates were as conservative as possibie. penditure Panel Survey (MEPS), which fo- when the hypothetical cohort members gradu-
cused on a nationally representative sampie ated fmm high scii(«)l or coiiege. we exam-
Project STAR of 34 215 noninstitutio)ia]ized individuals, to ined the effects of reducing dass sizes on
We used efficacy data from Project STAR quantify the effects of smaller class sizes on health-related quality of iife scores and age-
to generate efTectivencss estimates—i.e.. a health-related quality of life. Medicare and .specifk- mortaiity,"'' We obtained data on risk
12"''(i increase in the high school graduation Medicaid enrollment, and health care expen- of deatli according to diOerent levels of educa-
rate among the general population of students ditures.'^' We eliminated respondents younger tionai attainment from an anaiysis of the Na-
anti an \8% inctT'ase iti the high school grad- than 25 years and older than 65 years, tional Longitudinal Mortality Survey; in that
uation rate among free-lunch students—and foreign-bom respondents, proxy respondents, study. Backlunti et al, examined edticational
tested these estimates in a bniad sensitivity and those with missing values, which resulted attainment-specific moiiaiity patterns among
analysis,'** lYoject STAR, a randomized tiial in a final .sample size of 12 229. 400000 persons aged 25 to 64 years,"^
of 12000 students tliat began in 1985, was MKPS participants compieted the EuroQol- Individuals with a bigher ievei of education
conducted in 329 dassmoms across 46 5D,^^ a health-reiated quality of bfe measure are less likely than an? those with lower levels
.school distrirts in Tennessee, Both students that captures data in the areas of mobility. to qualify either for Medicaid or for Medicare
and tf'achei-s were randomly assigned to self-care, typical activities, pain oi- discomfort, before tlie age of 65 years. To estimate en-
classes containing either 22 to 25 students and anxie^ or depression. Health-related roiiment rates in these progi-ams according to
or 1,'i to 17 students. quality of life scores were scaled from 0 to highest degree completed, we constructed 2
Some oftlie more than 100 studies of 1.0, witli 0 representing death and 1.0 repre- logistic regression models. I with Medicaid
small ciass sizes conducted before Project senting perfect health. Thus, 10 years lived enroliment as the dependent variable and 1
STAR showed iittie or no elTect on graduation at a healtli-related quality of iife rating of 0.7 with Medicare enrollment as the dependent
rates of reducing ciass sizes; taiten as a wiiole, is equal to 7 (10 x 0,7) quality-adjusted iife variable. We then multiplied these enroliment
however, these investigations indicated that years, A quality-adjusted liTe-year i.s a year of rates by the mean cost per cnrollee to esti-
small class sizes increase high schooi gradua- perfect bealtli. We used point-in-time data for mate per capita eosts.
tion rates, especiaiiy among iow-income stu- Medicare and Medicjud enrollment rather Because educational attainment influences
dents, '" Because none of these earlier studies than enrollment throughout the year. an array of modifiable eovariates, ranging
had invoived randomized designs. Project from marriage rates to occupations, in our re-
STAR hciped solidiFy the conciusion that Other Data Sources gres,sion modeis, we controlled only for non-
small class sizes are effective, Aithough a We used combined data from the March modifiable covariates: age (25 to 65 yeaj-s).
single randomized trial—albeit a large, multi- 2003 and March 2004 versions of the Cur- gender, race (White. Biack. Asian. American
center triai—cannot guarantee i"eproducibility, rent Population Survey to generate earnings indian. Hawaiian, or membership in more
Project STAR provides die best avaiiabie esti- and welfai-e inputs.^^ We used the TAXSIM than 1 racial group), etlmicity (Hispanic or
mate of the efficacy of smail classes in pro- program version 5,1 (National Bureau of non-Hispanic), and highest level of education
ducing additionai high schooi graduates, Economic Research, Cambridge. Mass) to compieted (no high schooi, high school or
I'roject STAR provides high-quaiity data calcuiate federal tax rettims according to dif- general equivalency diploma, or coiiege).
on dilfci-ences in educationai attainment ac- ferent levels of educationai attainment The Consistent with the income-specific varia-
coixling to ciass size, but information was weifare programs examined included Tempo- tions in medicai expenditures obsei^ved in a
not collected on relevant health or economic rary .'\s.sistance for Needy Families, housing randomized triai focusing on health insurance
outcome.s. We used regression analyses to es- assistance, and food stamps. We obtained cover^e.^' we found that educational attain-
timate the extent to wKicb educational level crime data from the Federal Bureau of Inves- ment exerts littie influence on health expendi-
inlluences earnings, health, and longevity. tigation's Uniform Crime Report,~'' Crime tures; tiitis. we did not inciude health expen-
There is good evidence from a variety of costs inciuded costs associated with violent ditures in our sodetai analysis. Expenditure
studies differing in design that regression crime, property crime, and dnig offenses. ieveis according to educational attainment
analyses prodtice valid e.stiniates of the effects We excluded crime data from tlie primary (or its correlate, income) appear simiiar in
of educational attainment on earnings.*''' analysis to ensure conservative estimates; part because iess-educated peopie arc less
There is also evidence that by using regres- however, we included the data in our sensi- likely tlian are more iiighiy educated peopie
sion analyses, it is possible to conservativeiy tivity to be insureci {atid tlietelbie consume care at
predict catisal effects of educationai attain- lower rates when they are not ill) but are in
ment on bealtb status '""^ However, regres- Statistical Analyses worse health (and therefore more likely to
sion analyses may underestimate effect sizes Our model calculations focused on a hypo- need costly treatment).
for low-income populations and ovei^estimate thetical cohort of children aged 5 years who Using the more complete National Health
effect sizes for higb-lncome populations,"^" were exposed to small classes and who were Accounts data.'"'^" we derived data on

November 2007, Vol 97, No, 11 I American Journal of Public Health Muennigand Woolf \ Peer Reviewed I Research and Practice I 2021
 RESEARCH AND PRACTICE

Medicare and Medicaid per-enroliee costs our discount rate of 3% over 12.5 years, be- (1)
from the 2003 MEPS and adjusted these cause the benefits of these expenditures
data for costs not included in the MEPS. such would not be realized until students graduate where C is the overall per student cost of
as disproportionate-share hospital payments, from high school, Tliis pmcedure yielded an small classes, c is tlie per student co.st of re-
which support hospitals in poor neighbor- estimated cost of $ 13 555 per student in pres- ducing class sizes (the cost of the program it-
hoods. We estimated that mean costs for ent terms. self), Pg is the probability that small classes
adult Medicaid eiiTOllees and Medicare bene- We estimated that students in small classes will produce an additional high sclmol gradu-
ficiaries (i.e., tho.se aged 25-64 years) were woioid complete an averse of 1,5 additional ate, c^ is the cost of additional high school at-
$7695 and $11 894, respectively. years of h i ^ school (dropouts complete less tended by students in small classes {as a restUt
schooling and thus incur lower costs}, at an of fewer dropouts). c_ is the cost of additional
Using the methods of Levin and Belfield,
average national cost of $14394 (Table 1).''' college attendeil. and p^. is the probability of
we based mean national costs of classroom
Also, we estiniated that students who went on students attending college. Tlie overall costs
size reductions on data derived from the
to college would inaii" additional expenses of of producing an additional graduate are
education literature and on general salary
$49081 to the govemment and $65860 to $79211 from a societal pei-spective and
and school construction costs {at a 5"/i) amor-
sodety as a whole'" and that they would delay $78 876 from a governmental perspective.
tization rate over 30 years),"^•"' Construction
and salary costs average $8076 per student entering the laboi- force for 4 years. Thus, we We used a Markov model to compare life
in smaller (13-17 students) kindergarten calculated the total cost of small classes per expectancy, healtli-related quality of life
through grade 3 classes. We then applied eadi adtlitional graduate as follows; scores, costs, and earnings over the lifetime

TABLE 1-MaJor Modeling Assumptions and Supporting Evidence Used to Justi^ the Assumptions

Assumption Supportiiig Evidence

A higher level of educatioi) produces aii inci^ase In wages consistent with that preiJIcted by linear Data from randomized controlled (rials, natural experiments, and instrumental variable

regressioii analyses^

A higher level oi education leads to better health outcomes and thus results In a reduction in Data from instrumental variable analyses and raiidomized educational trials^'""

Medicare errollment and an increase in quality-adjusled life expectancy

A higher level at education produces improvements in health-related quality of lite and mortality Ttie literature suggests that regression analyses may underestimate the real-world

consistent witti those predicted by linear regression differences in mortality associated with compulsory schooling"

Benefits will accnje only among those students who actually ^ d u a t e ftom high school as a result of There is some evidence that nongraduates also benefit from early schooling inten/entions,

small class Sizes but this is difficult to quantify and mostly takes the form of reduced sociai pathology

(a cost excluded from the present analyses)^

A generic class size inten/ention modeled after Project STAR will produce increases in h i ^ school Project STAR was a large miiltischool trial: this critical assumption was tested in a broad

graduation rates similar to those obsen/ed in Project STAH'^ sensitivity analysis ranging from no additional graduates produced up to the

number observed in Project STAR

Project STAR will increase college graduation rates by 4% Aithough Pmject STAR did not examine college completion rates, it did report that students

randomized to small class sizes were 4% more likely to take college eiitrance

examinations^'; some students probably enter via 2-year colleges that do not
require entrance examinations

Students who graduate from high school rather than drop out will incur costs associated with Students who do not drop out of high school as a result of exposure to smaller class sizes

1.5 years of additional schooling incur costs associated with 7 additional years of schooling, on average": these costs
may be offset by decreased demand for speciai education programs and reduced

chances of being heid back from advancing 1 grade while still in school (grade

retention)

Medical expenditures are constant across levels of edjcational attainment, and thus medical There is little difference in medical expenditures according to educational attainment or

expenditures should no! be included in societal analyses income'"'''; whereas health status improves with increasing education, so too do

rates of health insurance coverage and use of medical care

Approximately 11% of low-income tiigh school graduates produced by smaller class sizes will go on In Project STAR, roughly 22% of the additional low-income high school graduates produced

to complete college by small class sizes took college preparatory examinations^'

The governmental costs of violent ciime and dmg offenses should not be inciuded in baseline analyses This consen/ative assumption was made to simplify the overall analysis; tliese costs were

included in the sensitivity analyses, however

Students who drop out of college or cam an associate degree experience no additional benefit This assumption was made to simplify the overail analysis

beyond the health effects associated with earning a high school diploma

2 0 2 2 I Research and Practice I Peer Reviewed | Muennig and Woolf American Journal of Public Health I November 2 0 0 7 . Voi 9 7 . No. 1 1
 RESEARCH AND PRACTICE

TABLE 2-Selected Values Used In the Analyses, Along With High and Low Estimates of of our hypothetical cohort of high school
These Values Used In ttie Monte Carlo Simulation dropouLs, high schooi gradiiales. and college
graduates. To obtain life expectancy for each
Parameter Overail Sampie High Value Low Value education catejjory. we muitipiied niorlalily
High school graduates. %
among high school dropoutji" by educa-
All stiidents
tional attainment-specific ri.sk ratios,^'* The
Full-sized classroom 76.3 7ao 74.0
model considered the costs associated with
Reduced-sized classroom 87.8 90.0 82,0
reducing class sizes for students aged 5
Free-lunch students through 9 years, but it was assumed that
Full sized classroom 70.2 74.0 66.0 benelits would not begin accruing until co-
Redjced-sized classroom 88,2 92.0 84.0 hort members were aged 20 years. Calcula-
Increase in coliege attendance. %
tions were discontinued after the age of 65
Ail students 3.7 5.0 2.0
years, when all of Uie coht)rt members be-
Free-luncti students 4.0 5,0 2.0
come eligible for Medicare and other retire-
Health-related quality of life score*
ment benefits irrespective of their educa-
Higti school dropoLts 0.74 0.75 0,74
tional attainment. Model inputs are listed in
High school graduates 0.78 0.79 0.78
Table 2,
College graduates 0.87 0.86 0.87 We conducted 1 -way sensitivity analyses
Medtcald enrollment, % to i.solate the most influential variables in our
High school dropouts 24.8 25.4 24-8 model. In addition, we used Monte Carlo
High school graduates 8.2 8.8 8.2 simulations, based on the values shown in
College graduates 4.8 5.3 4.8 Table 2. to generate confidence intervals
Medicare enrollment. % around the estimates deiived, '^ We used
High school dropouts 7.6 7.9 7,2 DATApro 2006 (Ti-ceAge Software, Morris-
High school graduates 3.7 4.1 3,3 town, Mass) in constructing the model.
College graduates 3.4 3.8 3,0
Earnings, $'
RESULTS
High school dropouts 12349 12871 11827
High school graduates 23007 23427 22587
Health Effects
College graduates 33701 34105 33297
Our i-pgression analyses showed that students
Tax payments, $
enrolled in small classes would achieve im-
High school dropouts 1302 1360 1244
proved health status. The mean health-nutated
High school graduates 3085 3139 3031
quality of life scores were 0,74 for high .sch(«)l
College graduates 5954 6012 5896
dropouts. 0.78 for high school graduates, and
General costs, S
0.87 for college graduates (Table 2). 'ITie healtli
Per student cost ot small class sires 13555 16266 10844
status of tht" average college gimhiate aged
Cost ol additional time in high school' 14394 15834 12955
45 years was comparable to tliat of tbe aver-
Cost of additional time in college'
age high school dropout aged 25 yeai-s, witJi
Public 49083 53991 44175
botli having a healtli-related quality of lil'e
Private 65860 72446 59274
score of approximately 0.89,
Total cost, Project STAR"
Public e
78876
Pnvate 79211 • Future Earnings and Tax Revenues
^4edicaid cost per enrollee 7695 8521 6869 Results showed that the earnings of high
Medicare cost per enrollee 11894 13842 9946 school gi-aduates would be almost twice
those of high school drop{iuts ($23 000 and
'Range-0 to 1.0, with 0 representing death and 1.0 representing perfect health,
$ 12 000. respectively; Table 2). Because the
"Obtained from the March 2003 and 2004 versions of the Current Population Sun/ey. Figures reflect the high and low
estimates that are because of random error, which was used lo generate confidence inten/als in the Monte Carlo simulation. tax ciii-ve is progre.ssive, taxes paid by high
Effects were also tested using plausible ranges of nonrandom error in I-way sensitivity analyses. school graduates would be approximately
'Students exposed to small class sizes are less likely to drop out and more likely to complete additionai schooling, which is
2.5 times as great as those paid by high
associated with additional costs,
"Per additional high school graduate. Includes cost of high school and college attendance. scliool dropouts ($3000 and $1300. respec-
'High and low vaiues used in the model varied according to (1) number of additional high school graduates produced, (2) tively), and those gi^adiiating from college
number of additional college graduates produced, and (3) error in eacti cost input. would pay about 4.5 times more in taxes
thaii would high school dropouts ($6000).

November 2007, Vol 97. No. 11 I Amefican Journal of Public Health Muenn^ and Woolf I Peer Reviewed I Research and Practice I 2023
 RESEARCH AND PRACTICE

TABLE 3-Cost-Effectlveness Values From Societal and Governmental Perspectives for All and crime were included in tlie calculations.
Students and for Students Receiving Free Lunches From a governmental perspective, small class
sizes would save at least $2700 for each stu-
Incremental dent by reducing demand for welfare pm-
TotBl Total Quality- Quality- Incremental
grams. and $31 000 by lowering the costs
Lifetime Incremental Adjusted Life- Adjusted Life- Cost-
Strategy Costs,' $ Cost,' $ Years' (SE) Years'' Gained Effectiveness, S
of crime over the lifetime of the averse high
school graduate.
AJI students These additionai savings render small
Societal perspective"^ classes cost saving for all students. However,
Small classes -454294 -168431 19,7 (0,09} 1,7 when targeted towaiti free-lunch students,
d
Regular classes -285863 18,0 (0,06} small classes result in cost savings whether
Governmental perspective' or not crime and welfare costs are consid-
Smal! classes 60038 25685 19,7 (0,09) 1,7 15415 ered. Were tbe government to tai-get this low-
fiegular classes 34353 18,0 (0,06) income group alone, it would save $9738
Free-lunch students over each additional graduate's lifetime.
Societal perspective"^

Small classes -482129 -196266 19,7 (O.!0) 1.5' Sensitivity Anaiyses

d
Regular classes -285863 18,0 (0.06) Tbe standaid deviations for costs and quality-
Governmental perspective* adjusted lifc'-yeai-s gained arc presented in
Sm3ll classes 24615 -9738 19,7 (0-10) 1.5' Table 4. The Monte Carlo simulations were
i
Regular classes 34353 18,0 (0,06) not affected by random and nonrandom error
in Uie parameter estimate; all interventions
Note. Incremental values represent the cost or effectiveness of small class sizes minus tiie cost or effectiveness of regular-
sized classes. remain(;d cost saving witli the exception of
'Lifetime earnings of students are greater than costs of schooling; thus, societai values are negative, the analysis that focused on all students li-oin
"A quality-adjusted life-year is calculated from the health-related quality of life scores,TIiese scores were scaled from 0 to 1,0,
a governmental perspective, whicb was asso-
with 0 representing death and 1.0 representing perfect health,Ter years lived at a health-related quality of life rating of 0,7 is
equal to 7 (10 x. 0,7) quality adjusted life years.A quality-adjusted life-year is a year of perfect health, dated with a confidence interval of $19000
^The societal perspective incorporated individual income earnings aid quality-adjusted life-years, to $33 000 per quality-adjusted life-year
"Both more expensive and less effective than small classes, gained.
^The governmental pe^pective incorporated public expenditures and revenuK only.
'Differences here were because of rounding, Free-Inch students were assumed to have lowerratesof college attendance, thus Tbe variable to which cost savings were
resulting in slightly lower predicted gains in qusiity-adjusted life-years. most sensitive in 1 -way sensitivity analyses
was the efficacy of small classes in producing
additional numbers of bigh school graduates.
Medicare and Medicaid Enrollnfient In addition, greater savings accme when From a societal pei-spective, smalt classes
Medicaid enrollments and costs among reductions in class sizes are targeted toward must produce at least 5 additional graduates
high .school graduates would be about one free-lunch students, among whom tlie lifetime per 100 students to remain cost saving.
third those of high school dropouts (8.2% net gain is $196266 per additional graduate When crime and welfare costs are consid-
and 24,8%, respectively). The effect of edu- (again, after accounting for the cost of the in- ered, tbis number falls to 4 per 100.
cational attainment on Medicare enrollment tervention). The total gain in quality-adjusted The cost of rt^ducing class sizes was an-
among individuals aged 25 to 65 yeai-s would life-years was slightly lower (1.5) in this gi^oup other important vai iable. Prom a societal per-
not be as steep, with 3.4% of high school hecause fewer of these students were as- spective, any educational intervention that
graduates enrolled in Medicare relative to sumed to enter college. produces 12 additional bigh school graduates
7,6<'/i) of high school dropouts. From a governmental perspective, reducing per 100 must cost less than $49000 per
class sizes for all students would generate an graduate produced in net present terms to
Cost-Effectiveness additional governmental cost of $25686 remain cost-effective. Excluding the benefits
Class-size reductions are cost saving from over each student's lifetime but would add associated with coiiege atteutianre bad little
a sodetai perspective (Table 3). According to 1,7 quality-adjusted life-years to a given stu- effect on outcomes, with total savings drop-
our model, a student graduating fi-om high dent's life expectancy, resulting in an incre- ping to $141 000 and total quality-adjusted
school after attending smaller-sized classes metital cost-efTectiveiiess ratio of $15415 per life-yeai-s to 1,3.
gains an average of 1.7 qualily-adjusted lile- quality-adjusted life-year gained. Removing discounting greatly increased the
years and generates a net $168431 in life- Small class sizes targeted toward all stu- predicted benefits and rendered all 4 scenar-
time net revenue (increase in wages minus dents becaine cost saving from a governmen- ios cost saving. From a sodetai perspective,
intervention cost) relative to a high school tal perspective once the economic effects of small class sizes targeted toward either all
dropout who attended regular-sized classes. smaller classes on other welfare programs students or free-lunch students would remain

2024 I Research and Practice \ Peer Reviewed | Muennig and Wootf American Journal of Public Heaith | November 2007. Vol 97, No, 11
 RESEARCH AND PRACTICE

TABLE 4-Standard Deviations of Values would generate more quality-adjusted life-year genetically endowed, on average, than high
gains per doilai' invested than the majority of school graduates, Otiier potential confound-
in Monte Carlo SImuiation
medical interventions'^ and would compare ing variables include family structure, social
Incremental Quality- favorably with childhood vaccinations in support, and parenting skills; health habits
Cost- Adjusted terms of the quality of life years gained per (e.g.. nutrition and physical activity); pre.sence
Effectiveness Life-Years'
dollar i t ^ ' ^ ^ ' of infectious diseases; environmental expo-
Ratio, $ Gained
sures at home (e.g,. exposure to lead and en-
Poiicy impiications
All students vironmental tobacco smoke) and in the com-
Societal perspective^
The national implications of these savings munity (e.g.. exposun? to air pollution);
Small classes 6898 0,09
are considerable, given that approximately exposure to stress, family dysfunction, sub-
Regular classes 6101 0,058
600000 to 800000 American students do stance abuse, violence, and abuse or neglect;
not complete high school by their 20th biith- and neighborbood conditions such as access
Incrementalcosf 8000
day, '^'"' Reducing class sizes would increase to health care and oppoitunities to engage in
GovemmefHal perspective'^
graduation rates, piwdiidng 72000 to physical activity.
Small classes 4923 0.09
140000 additional graduates each year. These
Regutat classes 555 0,058 Whereas not accounting for these genetic
additional graduates would in tum product' a
Incremental ratio 3300 and environmental covariates could [jroduce
net savings totaling $14 to $24 billion and
Free-lunch students overestimates of the effects of class-size re-
111 000 to 240000 quality-adjusted life-
Societai perspective"
years over {heir lifetiines. Although these na- ductions, other factors could lead to underes-
Small classes 5685 0,10
tional estimates rely on data fi'om a single trial timations. For example, the 12"/i) to 18"/(J of
Regular classes 6085 0,058
(Project STAR) and similai' results may not be students who would otlierwise have dropped
Incremental cost 11000
achievable in all settings, our sensitivity analy- out of high school but graduate as a result of
Governmental perspective^
ses indicate that cost savings from a sodetai their enrollment in small classes^ are likely to
Small classes 2347 0,10
perspective will be realized even if sincill dass be the healthiest, brightest anti ieast exposed
Regular classes 551 0,058
sizes are half as effective as shown here. to adverse environmental conditions unre-
Incremental cost 1700 lated to schooling among students at risk for
Whether reducing class sizes is cost saving
dropping out. Because we considered only
*A quality-adjusted Itte-year is calculated from tfie from a governmental perspective is less clear.
fieatth related quality of life scores, Tfiese scores were tlie marginal health gains in this advantaged
Our sensitivity analysis showed that savings
seaied from 0 to 1.0, witfi 0 representing death and 1,0 subset of the dntpout cohort, effect sizes pre-
representing perfect fiealtfi. Ten years lived at a fiealtfi- accrued by the government were contingent
dicted by our regression analyses (in which
retafed quality of life rating of 0,7 is equal to 7 (10 x on reductions in ciime or targeting reductions
0,7)quality-ad)usted life yeafs,AquBfity-adjusted life- we controlled for race, gender, and etlinicity)
in class sizes toward low-income children.
year is a year of perfect health, may have been consei-vadve. Moreover, tJic
""The societal perspective incorporated individual However, whether or not it is cost saving our
select few additional high school graduates
income eamings and quality-adjusted life years only, estimate of tlie cost-effectiveness of reducing
'The governmental perspective incorporated pubiic
produced by small class sizes are often from
class sizes far exceeds the incremental cost-
expenditures and revenues only. iow-income lamiii(?s. and studios suggest tbat
eflectiveness ratio for most health care services
low-income students are at a considerably in-
currently funded by tlie govenunent'^""
creased likeiihood of being held back as a re-
Limitations sult of rectifiable environmental variabies
cost saving were the discount rate to increase Even if educational attainment is causally (e.g,, school quality) as opposed to genetic fac-
to 5*'/(i. However, from a governmental per- linked to health.^'""^ we cannot be certain of tors.^"
spective, small classes targeted toward all the magnitude of the effect of educational at- Our study involved other limitations as
students and free-lunch students would be tainment on heaith or eamings. Although the well. First and foremost, we based our effect-
associated with incremental cost-effectiveness effect sizes in experimental studies examining size estimates on a single trial. Although the
ratios or$43()()() per quality-adjusted life- the impact of education on health tend to be sample size in Pi-oject SI AH was large-
year gained and $ 14 000 per quality-adjusted lai^e and there is some evidence that simple 12000 students spread over 46 school dis-
life-year gained, respectively. correlations might undercstimalo tlie effects tricts—the project's findings may not be gener-
of educational attainment on moitality and alizable to other settings, Altlioiigli the STAR
DISCUSSION earnings,^'"* a variety of confounders could findings are corroborated by many, but not
influence the acairacy of the health-related all. earlier studies of small class sizes, these
We found that reducing class sizes would. quality of life score, life expectancy, and fu- earlier studies involved weaker designs."*
ill all likelihood, be cost saving from a societal ture eamings effect sizes we predicted using and a national program might not meet with
pei"spective. Although educational interven- linear regression,""^ similar success, For example, the intervention
tions ocair ouLside ihc ambit of medicine, our One such factor is innate intelligence: chil- discussed here involved kindergarten tlirough
analysis suggests that class-size reductions dren who drop out of high school may be less grade 3 classes only, and it would be ex-

November 2007. Vol 97. No, 11 | American Journal of Public Healtfi Muennig and Woolf \ Peer Reviewed | Research and Practice I 2025
 RESEARCH AND PRACTICE

pected to confer less benefit in communities point to the importance of looking more 6. Kanily LA. Bigelow JE, TTie Economics of Investing
overrepresented by children who are more broadly at the option.s available for improving in Universal Preschool Education in Caiifomia. Santa
Monica. Calif: Rand Corp; 2005.
likely to enter the school system at later ages healtii outcomes—including those outside the
7. Finn JI). Gerber SB. Achilits CM. 'ITie enciuring
or whose greatest setbacks occur after grade 3, boimdaries of clinical medidne—and of the
effects of smali classes, feachoTi Coll Rec. 2001,103:
Nonetheless, our sensitivity analysis demon- fallacy of assutning. without evidence, that 145-183,
strated that a program roughly one third as investinents in medical care contribute more 8. Finn JI), GeriierSB, Boyd-Zdiarias J, Small classes
efTective as Project STAR would still lead to to health than do investments elsewhere, in in the early grades, noiclemic achievement, anti gradu-
cost savings. short, it is more appropriate to address under- ating fh.m high schcxiVJEducP^/chol. 2005:97:214-223,

interventions other than class-size reduc- lying conditiotis than it is to treat the victims 9. Camiero P. Hcckman Jj. Human capitai policy,
in: I leckniaii |. Krueger A, eds, Inei/uality in America:
tion merit study because they could be less of social deprivation only to return them to
117ia( Role for Human Capital Pnliiies'.' Cambridge,
expensive and more effective than class-size the conditions that bi ought about their situa- Mass: MIT Press; 2003:77-241).
reductions. Pi-ekindergarten inlerventions, tion ill thefii"stplace. • U). Muctinig P I lealth returns lo iihication intervejitioas.
high school tutonal and coiiege pi"e[)arator}' Avaiiabie at: bttp://devweb.tc.coliinibia.ec!u/ceiik'rs/
i!quityCa!Tipaign/symp()siiim/Files/8l_Mueniiig_paper.
programs, and some charter school models
About the Authors ed.fxir. Arc['s.sed November 5. 2005.
are examples of educational interventions that
Peter Muennig i^ with the Department of Health Policy and 11. Gotthfcison I^. inleiligenrc: is ii tht- epidemiolo-
may hold promise. We examined class-size Management. Mailman School of l^blic Health. Columbia gists' eluslvf- "fundamental eause" of social class in-
reduction because this is the only interven- Universilif, New York. NY. Steven H. Wbolfis with the De- equalities in health? JPer^iSoc l^hol. 2004;86:
tion to have been evaluated in a multicenter partments of Family Medicine. Epidemiology, and Com- 174-199.
munity Hecdtk. Virginia Commonuiealth Universiiy. Rich-
randomized controlled trial.'" mond.
12. Kling J, Liebman J, Katz L, Sanbontnatsu L. Mov-
ing to Opporttinit}! and Trunquility: Neighborhood F.ffects
Second, we did not examine the feasibility Requests for reprints should be .sent to Peler Muetmig.
on Adult Ikonomic Self-Sufficiency und Health I mm ii
MD. MPH. Mailman School of Public Health. Department
of nationwide implementation of the class-size of Health Policy and Management. 600 W 168th St.
Randomized Housing Voucher Experiment. Cunibridgc,
mduction tested in Project STAR. Determin- Mass: National Buniau of ixoiiumic Research; 2004.
New York. NY 10032 (e-mail: [email protected]).
ing whether the potential costs and benefits This artide was accepted February 8. 2007. 13. Reynolds AJ, Temple JA. RobtTLson DL, Mfinn BA,
Long-term clleds of an early childhood intervention on
of an intervention are. favorable, the focus of
educational achievement and juvenile anx'st: a 15-year
our study, is a necessary first step in deter- Contributors follow-up of low-income children in public schools,
R Muennig originated the study, conducted the data
mining whether the feasibility of an interven- JAMA. 2001 ;285:2339-2346,
anaiyses, and contributed to (ievclopment of the article,
tion deserves closer scrutiny. Third, our anal- S.H, Wooir contr(billed to the origination of the study 14. Liems-Muney A. Tiie Relationship Between Educa-
ysis excluded potentially relevant costs. For and to deveiopmenl of tht- arlide. tion and Adult Mortalitij m the United States. Cambridge,
Mass: National Bureau of [.economic Rcscan;h; 2002.
example, an expansion in teaching positions
15. Grooi W. van den Brink HM. /fie Healtb Effects
would probably foster competition among Acknowledgments uf Education: Survey and Mela-.'\nalyst'i. Amsterriam,
schools for qualified teachers, which in turn ITiis T'esean^h was .supported by the WT Gi-ant Founda-
the Nedierlaniis: Umvereity of Ainsterdani; 2004.
tion (grant 8211).
could increase teacher salaries. We thaiii( economists Henry Levin. Clive Belfield. 16. Lochner L. Moretti E. The efTect of education on
Finally, our college progression rates were and Cecilia Rouse for their hard work in generating the crime; evidence from prison inmates, arrests, and self-
initiai eslliiiates of prograni cost, aime cost, ajid earn- reports. Am Econ Rev. 2004;94:155-189.
based on increases in rates of students taking ings used in liiLs artieic aiHi for i-eviewing [n-cvioiis ver- 17 Gold M, Siegel ], Russell L, Weinstciri M. Cost-
college preparatory examinations rather than sions of the article. Effectiveness in Heaith und Medicine. New York, NY:
actual college attendance. However, incre- Oxford University Press; 1996,
mental cost savings and quality-adjusted lile- Human Participant Protection 18. Robinson G, Syntlicsis of research on the effects
years gained would be little changed even il' No protocol approvai was needed for this study. of small da.ss size, Editc Ltadership 1990;47:80-90.
no students went on to college, with savings 19. Rouse C. The labor market eoiiscqiiences of inad-
dropping from $168000 to $141 000 and References equate education. Available at: htt|j://w\vw,tc.cokimbia.
1. Spring |ii. lldiicalion und the Rise of the Global edu/centcrs/l^quitySymposium/sy mposi u m/resoiirce
quality-adjusted life-years gained falling fi-om Details.asp?Pre.'^ld=3. A<:cc'ssed August 28, 20()fi.
Economy. Hilisdaie, NJ: I.awrencc EHbauni A-ssociates;
1.7 to 1.3. 1998. 2i). Turkheinier E, Malt'y A, Waldnin M, Oiuifrio B,
2. Brown P. Glohaiization and the political economy Cottesman II, Soeioeeononiic status modilies beritabil-
Conclusions of high sitills. In: Brown F, Green A, Lauder 11, eds. ity of iQ in young children. Psychol Sci. 2003;14:
High Skills: Globalization. Compeliliueness, and Skill For- 623-628.
Despite these limitations, our findings raise mation: New York, NY: Oxford University Press; 2001.
2L Agency for Healthcare Research and Quali^.
the intriguing question of whether invest-
3. Hcffler S. Smit]i S, Kwhari S, Bother C. Qemens MK. Medical Expenditure Panel Survey. Available at:
ments in social determinants of health can be Tniffer C, Trends: US healtli spending projections for http://www.meps.ahrq,goV. Accessed August 17, 2006.
more cost-effective than investments in con- 2004-2014. Health Affi 2OO5(Web suppl):W5-74-
22. Rabin R, de Cban-o F. EQ-3D: a measure of
W5-85.
ventional medical care. More intriguing still, health status from the EuroQol Group. Ann Med 2001;
each dollar invested in education could po- 4. Iglehart JK. The dilemma of Medicaid. N EnglJ 33:337-343,
Med 2003;348:2140-2148,
tentially produce long-term returns. Further 23. National Bureau of Economic Research. CuiTent
5. Schweinhart LJ. The H^h/Scope Perry Preschool Population Survey supplement Available at: http;//
research is needed to refine models and pro- Study nrough Age 40. Ypsilanti. Mich; www.nber,oi^/data/eps,html, Aecessed Seplemlx-r 23,
duce more-predse estimates, but our findings 2004, 2006.

2026 I Research and Practice | Peer Reviewed | Muennig and Woolf American Journal of Public Health I November 2007, Vol 97, No. 11
 RESEARCH AND PRACTICE

24. Crime in tlie United Slates. Available at: http://

www.lbi.gov/ucr/ucr.htm. .Aa-essed Derember 20, 2005.
25. Hoyert DL. Kung HC. Smith BL. Deaths; prelimi-
nary data for 2003. Nad Vital Slat Rep. 2OO5;53:15,
The End of Polio?
2fi, Barklund V.. Sorlie PD, Johnson NJ. A coinpaiison
of tl)e relationships of etiucatiiin and income with mor-
Behind the scenes of the campaign to vaccinate
tality; Ihe Nalional LongiUidinal Mortality Study, Soc
SdMed 1999;49:1373-1384.
every child on the planet.
27. NewhoiLse JP, Rand Coqi, Free for AlP Lessons Tim Brookes luith Omar A. Khan, MD, MHS
Fnmi the Hand Heallh Insumnce Expetiment. Cajubindge,
Mass: llarvan! University Press; 1993, We are close to eradicating polio from the earth. Throuj^h a
28. Sclden TM, Levil KR, Cohen JW, et al. Reconciling collaborative effort on the part of muny health organizations,
medical ('.\jieiidituiv estiTnates from the MEPS and the including CDC, WHO, Rotary International, and many
NHA. 1996. Heatth Cure linatic fiev. 2001 ;23:16l -178, others, there has been a global campaign to vaccinate every
29. Brewer DJ. Krop C. Gill BP, Reichardt R. Estimat- child on the planet agaitist this dreaded disease. Travel with
ing the costs of national class size reductions under dif- our authors as they take part In one ot the last vaccination
fi'ii'til [X)lic7 ttlteniatives. Educ Eval Policy Anal. 1999;
21:179-192,
campaigns, and read about the successes and obstacles
affecting the fmaJ goal. With numerous photos of campaigns
30. Bureau of Labor StatisUes. Occupational oullook
handbook, 2006-2007. .Available at: http://www.bls. in various parts of the world, including an 8-page insert of
jiov. Accessed September I, 2006 C(i!or photos.
31. Kn»!ger Ali, Whilmon; DM, The effect of attend-
ing a small class in the early grades on college test tak-
iiiR antl niiddie schooi test results: evidence from Proj-
ORDER TODAY! American Public Health Association
ect STAR, Econ}. 2001 ;111 ;468, ISBN: 978-0-87553-186-1 PUBLICATION SALES
208 pages, softcover, 2007 WEB; www.apha.org
32. National Center for Education Statistics. Digest of
education stalisti<s, Table 167 Avaiiabie at: http://nces. S35.00 APHA Members (plus sAh) E-MAIL: [email protected]
ed.gov/piiograms/cligest/d()5/tabk's/dt05_I67.asp. Ac- TEL 888-320 APHA
S39.95 Nonmembere
cessed August 28, 2006.
FM: 888-361-APHA
:i3. National ('enter Tor I'xliication Statistics. Digest of
education sUttistiis. 'lable 312. Available at: http://nces,
(•rd ,goV /programs/d igest/ dO 5 / tables/dtO 5_312 ,asp. Ac-
cessed August 28, 2006,
34. Kochanek KD. Murphy SL, Andersen RN, ScoU C,
Deatlvs: I'inal clala for 2002. Nati Vital Stat Rep. 2004;
53:5,
35. Tengs TO, Adams ME. Plisldn JS. et al. Fiw-hundred
life-saving intei^entions and their cost-effectiveness. Risk
Anal. 1995; 15:369-390.
36. Szucs T. Cost-benefits of vacdnation programmes.
Vaaim 2000; I8(suppl 1):S49-S51,
3 7 Maciosek MV, CofTield AB. Edwards NM.
Rottemeseh TJ, Goodman MJ, Solherg LI. Priorities
among effective clinical pit'vcntive services: ri'sutts of
a systematic review and analysis. .•\mf l^v Med.
2OO6;:il:52-61,
38. Himey W, Madaus G. Abrams U VVheelock A,
Miao J. Gruia 1. The EAwation Pipeline in the United
Stales. 1970-2000. lioston. Mass: National Uoanl on
Educational testing and Public l\>licy. Boston College;
2004.
39. Greene JP. Forsler C.. Pidilic High Schoiyl Gradua-
tion and College Readmats Rates in the United Stales.
New York, NY, Manhattan Institute For Riticy Research;
2003.
40. Lain! J, Lew S, DeBell M, Chapmaji C Dropout
Rciles in the United States: 2002 and 2003. Washing-
ton, DC: US Department of Education; 2006,
41. Mueruiig P. Franks P, Gold M. The cost effec-
tiveness of health insurance. AmJ Prev Med. 2005;
28:59-64.
42. Puchs V. Reflections on the sodo-economic corre-
lates of hmdth / HeaUk Econ. 2004;23:653-661,

November 2007, Vot 97, No, 11 I American Journal of Public Health Muennig and Woolf \ Peer Reviewed | Research and Practice | 2027