Improving Access to Care with School-Based Health Centers

By Emily Heller | Vol . 25, No. 18 / May 2017

NCSL News

Did you know?

  • The number of school-based health centers increased by 20 percent nationally between the 2010-2011 and 2013-2014 school years. 
  • More than two-thirds of school-based health centers offer primary care and behavioral health services.
  • School-based health centers are associated with improved educational status, including higher grade point averages and higher rates of high school completion.

As states continue to grapple with ensuring access to health care services—particularly for underserved areas and populations—many have turned to school-based health centers. These health clinics, located in or near schools, combine resources to improve access to care for children, adolescents and other community members. School-based health centers often operate as a partnership between a school and a community health center, hospital or local health department.

More than 2,300 school-based health centers served students across 49 states and the District of Columbia during the 2013-2014 school year, according to the School-Based Health Alliance. Services provided to students in pre-kindergarten through 12th grade included well-child visits, preventive screenings and immunizations. In addition, 56 percent of school-based health centers reported serving other community members, such as students from other schools, faculty or school personnel, family members of students and others. Such services can extend to primary care, behavioral health care, oral health care, nutrition and health education, although they vary based on community needs and state and local policy. 

Some say this model can increase access to care for children, adolescents and other community members in a safe and convenient setting, as well as reduce student absenteeism. Others express concern over parents’ ability to maintain control over their children’s health care, particularly related to reproductive health services offered by some centers.   

Growing evidence supports school-based health centers as a cost-effective model. A recent systematic review concluded that such centers improve educational and health status in low-income communities. For example, the presence of a school-based health center or use of school-based services was associated with higher student grade point averages, an increase in immunizations and other preventive services, and reduced emergency department visits and hospitalizations. An economic systematic review of several studies found that using school-based health centers resulted in net savings to state Medicaid programs of between $30 and $969 per visit.

State Action 

School-based health centers have a decades-long history as a health care model, with overall state investments in school-based health centers more than doubling over the past 15 years. In addition to supporting and funding the centers, states have taken steps to promote their quality and effectiveness.

School-based health centers receive financial support from a wide variety of sources, including local, state and federal government grants; reimbursement through Medicaid or private insurance; and private sector or foundation grants. According to the School-Based Health Alliance report, 70 percent of school-based health centers received state funds to support their operations during the 2013-2014 school year. Eighteen states disbursed $85 million in funding to these centers, comprised of state general funds and federal block grant dollars, according to a School-Based Health Alliance survey.

Oregon, for example, has supported school-based health centers since 1985, with current funding of $18.5 million for physical and mental health services. In 2013, the legislature directed the Oregon Health Authority to award grants to expand and continue school-based health centers, create financial incentives to improve care delivery and coordination, and increase the number of centers certified as patient-centered primary care homes.

At least 13 states support Medicaid reimbursement for services delivered at school-based health centers. Medicaid policies can include defining the centers as a specific provider type, waiving prior authorization requirements, and requiring Medicaid managed care organizations to pay for self-referred visits, even if they are out of network. North Carolina, for example, requires the state Division of Medical Assistance to enroll school-based health centers as a specific Medicaid provider type, reimburse for services provided by these centers, and exempt credentialed centers from the Medicaid primary care provider authorization requirement. 

The Delaware General Assembly enacted legislation in 2016 requiring all public secondary schools to have a school-based health center compliant with state regulations. The state will finance the establishment and initial operating costs of each new center at the rate of one per year for the three schools without health centers.

States have promoted standardization, quality and effectiveness in school-based health centers by defining them in law or regulation, requiring certification or credentials, and collecting performance data. According to the School-Based Health Alliance, 17 states require state-funded school-based health centers to meet state operating standards. Several states, such as Nebraska and Maryland, have created advisory councils to ensure stakeholder interests are met or to promote integrating school-based health centers into state and local health and education systems. 

Federal Action

Federal funding has historically supported more than half of all school-based health centers, through programs including the U.S. Department of Health and Human Services Office of Population Affairs’ Title X grants and the Health Resources and Services Administration’s (HRSA) Health Center Program. HRSA’s School-Based Health Center Capital Program awarded $200 million in grant funds to more than 500 organizations in 47 states, the District of Columbia and Puerto Rico from 2010 to 2013. The funds were used to support construction-related activities or equipment purchases at new and existing centers.  

The federal Centers for Medicare and Medicaid Services funded Colorado’s and New Mexico’s School-Based Health Center Improvement Project through a Children’s Health Insurance Program Reauthorization Act (CHIPRA) demonstration grant. The five-year cross-state collaboration aimed to demonstrate school-based health centers’ effectiveness in meeting health needs, improve understanding of how this model contributes to the health care system, and enhance the centers’ function. Between 2010 and 2015, 22 school-based health centers in Colorado and New Mexico received training on topics such as data collection, referral and care coordination, and engaging adolescents in their own health care.