Whitney BrimfieldIf you’re a parent, back to school time means endless preparation – does your child have the right teacher, the right backpack, the right school supplies, the right jeans? Not to mention that you have to find that piece of paper that proves your child has the right vaccinations. And what if they’re not up to date? How are you going to get to the doctor’s office between vacations, work, and life’s demands that pull you in 1,000 different directions?

Well, if your child is one of the estimated 1.7 million that has a school-based health center (SBHC) in his or her school, then you won’t have to figure out how they will get that vaccine or any of the other health care they might need. SBHCs provide primary care, mental and behavioral health, preventive and oral health services to kids and teens where they are: in school.

Right now you might be thinking, “Wow, that makes sense!” You’re right. Giving kids and teens access to high-quality, comprehensive, culturally competent care in their school, where they can access it easily, just makes sense. Secretary of Education Arne Duncan agrees:

“It’s a triumph of common sense. I think schools should be the heart of the neighborhood. You’re putting a critical, critical resource right there at the school building.”

SBHCs serve urban (56.7%), rural (27.2%) and suburban (16.1%) communities across the country. About a third of SBHCs are located in high schools and a large majority (80%) report serving at least one grade of adolescents (sixth grade or older). Students in schools with SBHCs are predominantly members of minority and ethnic populations who have historically experienced under-insurance, uninsurance, or other health care access disparities. SBHCs serve Latino (36.8%), African American (26.2%), White (29.5%), Asian (4.4%) and Native (1.7%) populations, among others.[1]

Many people wonder how parents are involved in their kids’ SBHCs. SBHCs require parental permission to enroll students in the SBHC and 54% report that parents have the ability to restrict their child’s access to specific services. Many SBHCs also serve family members of students in the school (42%), school personnel (42%), students from other schools in the community (58%) and out-of-school youth (34%).

SBHCs have a 40-year history, starting in the 1970s in Dallas, TX, St. Paul, MN and Cambridge, MA. In 1988 there were 120 SBHCs in the United States. Right now, there are more than 2,000 SBHCs in all but 2 states – North Dakota and Idaho. As a result of funds appropriated by the Affordable Care Act (ACA) for SBHC construction, renovation, and equipment, SBHCs are currently starting up in three states that have never had SBHCs before – Montana, Hawaii, and Wyoming. Much of the expansion happened in the 1990s thanks to significant investments from the Robert Wood Johnson Foundation Making the Grade program.

Who pays for this?

With the country’s focus on the Affordable Care Act and the current conversation about health care reform, it makes sense to wonder where the money comes from. SBHCs are funded by a mix of foundation support, state health or education funds, public and private insurance reimbursement and funding from federal programs including Title V maternal and child health funds, Title X family planning funds and Section 330 community health center funds. Despite not having the full federal support SBHCs need and should have, the model is a long-standing, high quality way to deliver care to underserved kids and teens.

The triple aim of health care reform – improved access, decreased cost and high quality – is not new to the school-based health care movement. Numerous studies have proven SBHCs’ ability to meet the triple aim:

  • Decreased cost: A study of Medicaid-enrolled children served by a SBHC in Atlanta, Georgia found significantly lower inpatient, nonemergency department transportation, drug, and emergency department Medicaid expenses as compared to children without a SBHC. In 1996 the total yearly expense per individual for the SBHC was $898.98, as compared to $2360.46 for individuals without a SBHC.[2]
  • Improved access: Two separate studies showed that adolescents are 10-21 times more likely to come to a SBHC for mental health services that a community health center network or HMO.[3], [4]
  • High quality: A study comparing adolescent health quality of care in populations with and without a SBHC showed that SBHC users were more likely to have made a primary care visit, less likely to visit the emergency room, and more likely to have received a health maintenance visit, influenza vaccine, a tetanus booster, and a Hepatitis B vaccine.[5]

Why aren’t there more SBHCs?

With all of the strong evidence in support of SBHCs, you might think it would be a no-brainer for the federal government to make school-based health care a centerpiece in our nation’s health care safety net by fully investing in SBHCs. More than a decade of advocacy, however, tells a different story. Operations funding (the money necessary to staff, supply, and run SBHCs) has not yet been included in the budget of any White House administration. The funds appropriated by Congress in the ACA for SBHC construction, equipment and renovation were restricted from supporting funding to operate clinics. As of right now, recipients of those funds are required to demonstrate that they have other funding sources for operations.

Without reliable and consistent funding, starting up and operating a SBHC is a tricky proposition. The school-based health care movement is full of dedicated, passionate people who work tirelessly to ensure that the kids and teens in their communities have access to the critical services that SBHCs provide. But it’s not easy. While just over half of SBHCs have been open for ten or more years, the struggle to stay afloat still threatens many SBHCs, particularly in the 31 states without a state-funded SBHC program.

To ensure that our nation’s children – especially the most vulnerable – have the best chance at a successful future, Congress and the White House must acknowledge the inextricable link between health care and education by elevating this issue to a national policy priority. SBHCs need long term investments – articulated in the president’s annual budget – to ensure that every child across our nation has the best chance at a bright future. We can invest now and ensure the next generation of leaders, teachers, and scientists, or, we can fail our nation’s young people by leaving them vulnerable to the ever-widening poverty gap.

What can you do to help?

You can speak up and speak out. You can join the call to make our nation’s underserved children a national priority. We are in this together and together we can work to put our nation’s children on the path to success.

Learn more about the link between education and health care and why SBHCs are a winning model for our children, our communities, and our nation.

[1] All SBHC statistics are from: Strozer J, Juszczak L, and Ammerman A. (2010). 2007-2008 National School-Based Health Care Census. Washington, DC: National Assembly on School-Based Health Care.
[2]Adams EK, Johnson V. An elementary SBHC: Can it reduce Medicaid costs? Pediatrics 2000 Apr; 105(4 Pt 1):780-8.
[3] Juszczak L, Melinkovich P, Kaplan D, Use of health and mental health services by adolescents across multiple delivery sites. J Adol Health 2003;32S:108-118.
[4]Kaplan DW, Calonge BN, Guernsey BP, Hanrahan, MB. Managed care and SBHCs. Use of health services. Arch Pediatr Adolesc Med. 1998 Jan;152(1):25-33.
[5] Allison MA, Crane LA, Beaty BL, Davidson AJ, Melinkovich P, and Kempe A. School-based health centers: Improving access and quality of care for low-income adolescents. Pediatrics 2007 Sep; 120(4): e887-894.

Whitney Brimfield is the Director of Engagement for the National Assembly on School-Based Health Care. She holds a Master of Health Science degree from Johns Hopkins Bloomberg School of Public Health.

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4 Responses to “School-based health care: It just makes sense”

  1. Wendy Young, LMSW, BCD Says:

    I remember reading about “school-based clinics” decades ago and remember thinking, “Wow! That is too good to be true! I would love to work in one of those some day!” But this facility was based in NY and I lived in the middle of nowhere in Michigan. Well, a few decades have passed and I am honored to serve the mental health needs of underserved kids in on rural School-Based Health Center and one rural-based School Wellness Center. Why can’t Johnny read? There are about a hundred thousand reasons, none of which have to with his abilities! For starters: depression, anxiety, domestic violence, substance abuse, and the list goes on from there. The mental health needs are great. I hope all will support School-Based Health Centers. Our evidenced-based outcomes and success rates speak for themselves!

    Thank you for your very eloquent post!

    Wendy @Kidlutions

  2. ALLEN SMART Says:

    Whitney, as you know we are big fans of the SBHC concept and have been a local and state funder in North Carolina for years.Your post is a really great summary of historical context matched with the realities faced by existing and dreamed-of SBHC’s. Your question- “Why Arent There More SBHC’s” is a great one because given all the evidence, one would think there would be an immediate and long-term embracing of the idea. You touch upon the federal funding issue- certainly needed and well worth pursuing.

    I think, however, there are other “barriers” on the local and state levels that dont get discussed enough. There can be competition with local pediatricians. There is disconnect from state mandated school health policies. There is the age-old struggle for education systems to work with health systems for mutual gain. There is perceived duplication with school nurses. And the list goes on. Short term fixes vs. long-term outcomes. All of these questions can be answered but my point is that money isnt the sole barrier. People working on SBHC development on the state and local levels need to have a pretty strongly equipped toolbox to move this work ahead in a sustainable way. We know your organziation is a strong help to these efforts and we hope that other state and local funders will ramp up their interests!

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