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School-Based Health Centers

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October 2011 

The 2010 Affordable Care Act (ACA) appropriated $50 million in competitive grant funds for each fiscal year from 2010 to 2013 for school-based health centers (SBHCs). Section 4101(a) intends to build SBHC capacity through land or facility acquisition, building improvements, construction or equipment purchases.1 The ACA also authorized a grant program in section 4101(b) to support the daily operations of SBHCs; on May 4, 2011, the U.S. House of Representatives voted to eliminate the remaining funding under section 4101(a) for SBHC capacity building for fiscal years 2012 and 2013. The Senate had not yet considered the legislation by the end of summer 2011.2

Services provided by school-based health centers vary greatly; they are tailored to meet the needs of the communities they serve. Students, with parental consent, generally have access to the health centers regardless of their ability to pay. Limited primary care services are available in all SBHCs. Typical services available through these centers can include immunizations, acute illness treatment, prescriptions, collection of blood or urine samples for lab analysis, substance abuse counseling, and health education on topics such as nutrition and reproductive health. Many health centers also manage students’ chronic conditions, such as asthma or diabetes, and educate them on how to keep healthy.3 Basic mental health services such as baseline assessment and counseling are available in approximately 45 percent of SBHCs; general dental care, such as fillings and basic cleanings, are available in about 10 percent of SBHCs.

SBHCs are almost always located in schools or on school grounds and cooperate with the school to meet the unique needs of students in the community. They often have sponsoring facilities such as hospitals, public health departments, community health centers or nonprofit health care agencies that serve as their primary administrative home.

Nearly 2,000 SBHCs in 46 states and the District of Columbia serve about 2 million children and young people. More than half (57 percent) are located in urban communities, 27 percent are in rural areas and 16 percent are in suburban communities. Students who receive services from SBHCs are predominantly members of minority and ethnic populations who are underinsured or uninsured. SBHCs may be the only convenient primary care provider in rural communities and in urban areas where residents lack access to transportation services. As of 2008, 58 percent of SBHCs accepted students from other schools in the community, 42 percent accepted school employees, 42 percent accepted family members of students and 24 percent treated community members.

SBHCs are governed by school board and sponsoring facility policies, as well as by local and state laws. Nearly every state with school-based health centers has at least some regulations for their operation. Examples of these laws include requirements for center standards, licensing and practitioner requirements; regulations for sponsoring facilities also are closely governed by state and local laws. Parental consent generally is required for all health care services provided to minors. Some state laws have made exceptions for specific groups of minors or particular health services, and SBHCs follow these laws—and often stricter school district or local policies—in their parental consent practices.

Key Federal Provisions
Eligibility. To be eligible to receive a grant under section 4101(a) for capacity building, applicants must be an SBHC or a sponsoring facility. An SBHC is defined as “a health clinic that is located in or near a school, is organized through school, community, and health provider relationships, is administered by a sponsoring facility, and provides primary health services to children in accordance with state and local law through health professionals.”4 Sponsoring facilities include hospitals, public health departments, community health centers, nonprofit health care agencies and local educational agencies. They serve as the administrative home for the school-based health center. Sponsoring facilities often operate a network of SBHCs and can also serve as the treatment facility when SBHCs make referrals for additional services.

The first round of section 4101(a) grants totaling $95 million were made on July 14, 2011, to SBHCs in 41 states and the District of Columbia. Awards ranged from $10,000 to $500,000. Recipients of the first round of awards currently serve 790,000 students. The grants are expected to allow centers to increase capacity to serve an additional 440,000 students.5 California and New York had the largest number of grant recipients; more than 30 SBHCs or sponsoring facilities received awards in both states. Examples of grant recipients include the Denver Health and Hospital Authority, which received $500,000 to build its 14th and 15th school-based health centers in Denver.6 In Alabama, Health Establishments at Local Schools Inc., the sponsoring facility, will use funds to help build two new centers and invest in an electronic health record system.7

Preferred Grantees. An objective review committee created by the secretary of Health and Human Services is responsible for reviewing applications and awarding section 4101(a) grants to school-based health centers. Preference for funding is given to SBHCs that serve a high percentage of children who are eligible for Medicaid or CHIP. Preference also is given to communities that have barriers to primary/mental health care for children and adolescents, communities that have high per capita numbers of children who are uninsured, underinsured or enrolled in a public health program, and those who have difficulty accessing health services.

Conditions for Grant Money. Section 4101(a) grants can be used for capacity-building activities such as land or facility purchases or improvements, construction, equipment and similar expenditures approved by the secretary. Grant money cannot be spent on personnel or to provide health services. Applicants can submit applications proposing no more than 10 projects.

For funding awarded through section 4101(b)—that currently is authorized but not appropriated—the secretary of Health and Human Services may require applicants to provide matching funds for up to 20 percent of the grant. The secretary also may make funding contingent upon satisfaction that the grant funding will be used to supplement, not supplant, funds otherwise available for the SBHC.8

State Roles in Implementation
States have long been the main supporters of schoolbased health clinics. Nationwide, 76 percent of SBHCs receive funding from state governments. Before the ACA grants became available, 39 percent of schoolbased health centers received funding from the federal government.9 As SBHCs use the section 4101(a) grants to expand their capacity and the number of patients they treat, states may have a larger role in regulating them, especially as SBHCs expand availability to 440,000 more students and, in some cases, the community at large.

Other actions states have taken regarding school-based health centers include expanding access to SBHCs, staffing state program offices, convening a statewide network, collecting data from centers, weighing in on issues regarding parental consent for treatment, licensing SBHCs, and setting standards for and monitoring SBHCs and defining them as a Medicaid provider.10 This oversight role for states, especially in regard to licensing, standard and coordination requirements, will become even more important as the role of schoolbased health centers in the states’ health care network expands with new and improved centers.

1. The Patient Protection and Affordable Care Act of 2010, Section 4101(a), 111th Congress, H.R. 3590.
2. Sam Baker, “Healthwatch: House Passes Healthcare Defunding Bill,” The Hill, May 3, 2011.
3. J. Strozer, L. Juszczak, and A. Ammerman, 2007-2008 National School-Based Health Care Census (Washington, D.C.: National Assembly on School-Based Health Care, 2010);
4. U.S. Social Security Administration, Compilation of Social Security Laws, “Definitions” (Baltimore, Md.: SSA, 2011);
5. Department of Health and Human Services, Health Resources and Services Administration, “HHS announces new investment in school-based health centers” (Washington, D.C.: DHHS, 2011);
6. Michael Booth, “Colorado wins millions to boost school clinics.” Denver Post, July 15, 2011.
7. Health Establishments at Local Schools, “Providing Free Health Care to Children at School-Based Clinics” (Huntsville/ Madison County Ala.: HEALS, 2011);
8. The Patient Protection and Affordable Care Act of 2010, Section 4101(b), 111th Congress, H.R. 3590.
9. J. Strozer, L. Juszczak, and A. Ammerman, 2007-2008 National School-Based Health Care Census.
10. National Assembly of School-Based Health Centers, State Government Financing of School-Based Health Care Census (Washington, D.C.: National Assembly on School-Based Health Care, 2005).

NCSL Contact: Megan Foreman, Denver  (Written by Matthew Valeta)
© 2011 by the National Conference of State Legislatures. All rights reserved.