Policy debates about reauthorizing and expanding the State Children’s Health Insurance Program (SCHIP) and its related Medicaid programs for kids are about providing access for poor kids to health insurance. School-based health care is about reaching kids where they spend half or more of each weekday. The larger issue in creating high-quality health care accessible to all kids is how we make these systems meet.

Five days a week, six or seven hours a day, nine months a year, kids are at school, and their health needs are at school. If we don’t want a society where school secretaries hand out stimulants and ambulances routinely stop to take asthmatic kids to emergency rooms, we need to figure out both parts of this equation. Julia Lear’s piece in Health Affairs describes the alternative universe of health care in schools, often hidden from view of policymakers in Washington, D.C. Funded and staffed by local and state authorities, it tends to run under the radar of policy debates on SCHIP.

School Services:

School-based health care is made up of many moving parts. School nurses, guidance counselors, health educators, and sometimes full-service clinics make up this system. For many adolescents, who are not likely to show up at a medical office, it is the only means of access for a health care provider. From related work by Linda Juszczak, deputy director of the National Assembly on School-Based Health Care, we know that many U.S. adolescents prefer and receive their mental health services through schools.

On the other hand, barely half the schools in this country have a full-time school nurse.

The Challenge of Reimbursement:

One of the greatest challenges involved in providing good health care to our children in school and in the physician’s office is how to combine the mission-driven model of the school nurse, founded out of a social work model by Lillian Wald at the dawn of the 20th century, with the business model of a medical office. How does a school nurse or clinic, draw upon health plans, Medicaid, and SCHIP to deliver health care and bill for myriad services, including checking insulin pumps, dispensing stimulants for ADHD, keeping tabs on seriously depressed students to prevent suicide (a growing problem for high schools), and maintaining children on asthma protocols? How do schools then measure outcomes for these funders, and indeed what are outcomes for schools?

Michigan is initiating a program with the help of the Kellogg Foundation, Blue Cross Blue Shield of Michigan Foundation, and Blue Cross Blue Shield of Michigan to help school health centers devise coding and billing procedures to access reimbursement for their services and help make the centers self-sustaining. A pioneering program in at the Whitefoord Elementary School in Atlanta, which has housed a school-based health center since 1994, has collected data showing that children served by the school center had lower emergency department expenses and higher Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) preventive care expenses than comparison Medicaid-enrolled children.

Work by Howard Taras (subscription required) and others (subscription required) suggests that the availability of health and dental care services in school settings has a positive effect on school attendance. We also know from work done by Ed Schor and the Commonwealth Fund how important it is for young children to access EPSDT care to succeed in school.

The Need for Transformation:

One of the challenges for all who advocate for children’s health and success at school is how to integrate services that meet their needs across multiple systems and funding streams. Neal Halfon and his colleagues challenge us to be creative and to transform our current and very fragmented system into one that truly meets our future needs for the 21st century.