Health Care: School-Based Health Centers Can Expand Access for Children
(Chapter Report, 12/22/94, GAO/HEHS-95-35).

American children face increasing physical and mental health risks, such
as infection with the AIDS virus, alcohol abuse, and suicide.  Yet many
children lack access to regular health care needed to prevent disease,
disability, and unnecessary hospitalization.  A small but growing number
of communities have turned to an innovative approach to reach children
with limited access to health services.  School-based health centers
afford children easier access to needed health services by bringing
providers to the children, furnishing free or low-cost services, and
supplying the atmosphere of trust and confidentiality adolescents need.
The centers do not, however, provide all the health services required by
students and cannot reach adolescents who have dropped out of school.  A
lack of stable financing is a major concern for the centers, with some
centers reporting insufficient funds to meet all children's needs.
Centers have also had difficulty recruiting and keeping appropriately
trained nurse practitioners and physician assistants, who are their key
primary care providers.  Community debates over the appropriateness of
providing reproductive health services in the centers have limited the
centers' ability to meet some adolescents' health needs.  Communities
lack access to information on establishing new centers and solving
problems at existing ones.  Furthermore, research measuring the impact
of the centers on health and education outcomes is sparse.  Coordination
of school health programs within the federal government has begun, but
the Department of Health and Human Services lacks a focal point to
answer outside inquiries, provide technical assistance, or develop a
research agenda.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-95-35
     TITLE:  Health Care: School-Based Health Centers Can Expand Access 
             for Children
      DATE:  12/22/94
   SUBJECT:  Health resources utilization
             Health insurance
             Health services administration
             Disadvantaged persons
             School health services
             Students
             Cost sharing (finance)
             Federal/state relations
             Birth control services
             State-administered programs
IDENTIFIER:  Maternal and Child Health Block Grant
             AIDS
             Early and Periodic Screening, Diagnosis, and Treatment 
             Program
             Healthy Schools, Healthy Communities Grant
             HHS Outreach and Primary Health Services for Homeless 
             Children Program
             Special Supplemental Food Program for Women, Infants, and 
             Children
             WIC
             TennCare
             CDC Comprehensive School Health Program
             California Medi-Cal Program
             Healthy Start Program
             
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Cover
================================================================ COVER


Report to the Chairman, Committee on Government Operations, House of
Representatives

December 1994

School-Based Health Centers Can Expand Access for Children

GAO/HEHS-95-35

School-Based Health Centers


Abbreviations
=============================================================== ABBREV

  AIDS - acquired immunodeficiency syndrome
  AAP - American Academy of Pediatrics
  AMA - American Medical Association
  BPHC - Bureau of Primary Health Care
  CDC - Centers for Disease Control and Prevention
  CPO - Center for Population Options
  EPSDT - Early and Periodic Screening, Diagnostic, and Treatment
  HCFA - Health Care Financing Administration
  HHS - Department of Health and Human Services
  HIV - human immunodeficiency virus
  IDEA - Individuals with Disabilities Education Act
  MCHB - Maternal and Child Health Bureau
  NHSC - National Health Service Corps
  OIG - Office of Inspector General
  PCP - primary care provider
  PHS - Public Health Service
  SBHC - school-based health center
  SLHC - school-linked health center
  WIC - Special Supplemental Food Program for Women, Infants and
     Children

Letter
=============================================================== LETTER


B-252731

December 22, 1994

The Honorable John Conyers, Jr.
Chairman, Committee on Government
 Operations
House of Representatives

Dear Mr.  Chairman: 

This report, prepared at your request, reviews the role of
school-based health centers in expanding children's access to health
care and the financial and other obstacles school centers must
overcome to launch and maintain their services. 

We are sending copies of this report to interested congressional
committees and are making copies available to others on request.  If
you or your staff have any questions, please call me at (202)
512-7119.  Other major contributors to this report are listed in
appendix II. 

Sincerely yours,

Mark V.  Nadel
Associate Director, National and
 Public Health Issues


EXECUTIVE SUMMARY
============================================================ Chapter 0


   PURPOSE
---------------------------------------------------------- Chapter 0:1

American children face increasing physical and mental health risks,
such as human immunodeficiency virus (HIV) infection, alcohol abuse,
and suicide.  Yet many children lack access to the regular health
care needed to prevent disease, disability, and unnecessary
hospitalization.  Over nine million children lacked health insurance
during 1993, and millions more were uninsured for part of the year. 

A small but growing number of communities are using an innovative
approach to reach children with limited access to health services. 
School-based health centers (SBHC) provide students with a range of
preventive, medical, and mental health services, on the basis of the
needs and priorities of local communities. 

In response to a request from the Chairman of the House Committee on
Government Operations, GAO examined (1) how school-based health
centers expand access to health services for both adolescents and
younger children who have had limited access to care and (2) the
financial and other obstacles SBHCs must overcome to launch and
maintain their services.  To address these questions, GAO completed
case studies at eight school-based health centers in California, New
Mexico, and New York; many of these schools are in neighborhoods with
high rates of poverty and health problems, including HIV infection,
drug use, and tuberculosis.  GAO also interviewed public and private
officials who work with SBHCs and conducted a review of the
literature. 


   BACKGROUND
---------------------------------------------------------- Chapter 0:2

States and communities have responded to children's lack of access to
health services by establishing several hundred SBHCs since 1980. 
State, local, and private funds supply most of the financing for
centers; several federal programs supplement these funds.  Federal
funding consists primarily of reimbursement from the Medicaid program
and grants from the Maternal and Child Health Block Grant program. 
Only a small amount of money--2 percent--comes from payments by
students enrolled in SBHCs and private insurers. 


   RESULTS IN BRIEF
---------------------------------------------------------- Chapter 0:3

Communities are using school-based health centers to fill a niche in
the nation's health care delivery system.  SBHCs afford children
easier access to needed health services by bringing providers to the
children, furnishing free or low-cost services, and supplying the
atmosphere of trust and confidentiality adolescents need.  SBHCs do
not, however, provide all health services required by students and
cannot reach adolescents who have dropped out of school. 

A lack of stable financing is a major concern for SBHCs, with some
centers reporting insufficient funds to meet all children's service
needs.  SBHCs often have difficulty obtaining reimbursement from
public and private insurers, including Medicaid.  States' increased
use of Medicaid managed care could further reduce centers' ability to
receive Medicaid payments.  Centers linked with established health
care providers can more easily bill insurers as well as offer more
comprehensive services to students. 

In addition to financial problems, SBHCs nationwide face other
problems.  Centers have difficulty recruiting and retaining
appropriately trained nurse practitioners and physician assistants,
who are their key primary care providers.  Community debates over the
appropriateness of providing reproductive health services in
school-based centers have limited centers' ability to meet some
adolescents' health needs. 

Communities lack access to information on establishing new centers
and solving problems at existing ones.  Furthermore, research
measuring the impact of SBHCs on health and education outcomes is
sparse.  Although efforts to coordinate school health programs within
the federal government have begun, the Department of Health and Human
Services (HHS) does not have a focal point to answer outside
inquiries, provide technical assistance, or develop a research
agenda. 


   PRINCIPAL FINDINGS
---------------------------------------------------------- Chapter 0:4


      SBHCS IMPROVE CHILDREN'S
      ACCESS TO HEALTH CARE
-------------------------------------------------------- Chapter 0:4.1

Health and education officials believe that SBHCs improve children's
access to health care by removing financial and other barriers in the
existing health care delivery system.  Providing health services to
children in school-based settings enables children to get both
periodic preventive care and treatment for chronic and acute medical
conditions.  SBHCs provide services either free of charge or at
minimal cost to students, which can particularly help children who
lack health insurance and those whose insurance may not cover all the
services they need.  Locating services where the children are
increases convenience for students and parents.  Additionally, SBHCs
provide adolescents with an environment of greater trust and
confidentiality than that of other health care settings. 


      CENTERS ARE CONCERNED ABOUT
      FINANCING
-------------------------------------------------------- Chapter 0:4.2

SBHC staff report difficulties in financing their operations.  School
centers often rely on fragmented sources of funding.  Private
foundation funds that have played a large role in establishing new
centers are frequently short term, leaving centers with an uncertain
future.  Because of resource limitations, some sites cannot offer
care during all the days or hours the school is open.  Others cannot
meet the large demand for mental health and dental care. 

Difficulties in billing both private and public insurers further
constrain funding.  Problems include centers' lack of administrative
capacity, low-income families' inability to pay insurance
deductibles, concern that adolescents will lose confidentiality if
parents receive insurance statements, and insurers' exclusion of some
needed services from coverage. 

Despite serving large Medicaid-eligible populations, SBHCs do not
always receive Medicaid reimbursement because of problems such as the
difficulty of determining students' Medicaid eligibility and states'
restrictions on services they cover.  The growth of Medicaid managed
care could further reduce Medicaid payments to SBHCs.  Managed care
providers are often reluctant to reimburse SBHCs for services
provided to their members, partly because they do not control the
type and quality of care provided at SBHCs. 


      SBHCS FACE STAFFING AND
      OTHER DIFFICULTIES
-------------------------------------------------------- Chapter 0:4.3

The key health professionals at SBHCs are nonphysician primary care
providers--that is, physician assistants and nurse practitioners--who
are generally in short supply.  SBHCs face a particularly acute
shortage because their staff may need special qualifications such as
bilingual ability or training in adolescent health.  SBHCs have
difficulty competing for staff with other health care settings, such
as hospitals and health maintenance organizations, because they offer
less desirable salaries and working conditions.  HHS' support of
training programs for school health providers may help expand the
number of skilled providers capable of working in SBHCs.  In
addition, the National Health Service Corps' recent initiatives to
place nonphysician primary care providers in underserved areas might
give SBHCs a new source for staff. 

Adolescents who are sexually active are at risk for problems such as
unintended pregnancies and sexually transmitted diseases--including
AIDS--and could benefit from reproductive health services.  Some
community members, however, consider it inappropriate to provide
these services in schools, and the resulting controversy has led some
SBHCs to limit or eliminate family planning services.  Other SBHCs
have had their funding withheld. 

A third problem faced by SBHCs is the difficulty communities have
getting guidance on establishing SBHCs or solving the problems at
existing centers.  No central source of information on SBHC
operations and potential funding sources exists.  Although HHS
supports internal coordination for federally supported school health
programs, it has not established a focal point to answer outside
inquiries or provide technical assistance. 


   RECOMMENDATIONS
---------------------------------------------------------- Chapter 0:5

GAO is not making recommendations in this report. 


   AGENCY COMMENTS
---------------------------------------------------------- Chapter 0:6

Officials from several bureaus and offices in the Departments of
Health and Human Services and Education reviewed a draft of this
report.  They generally agreed with our findings and made several
technical comments and clarifications, which we incorporated as
appropriate. 


COMMUNITIES USE SCHOOL-BASED
HEALTH CENTERS TO PROVIDE HEALTH
SERVICES TO CHILDREN
============================================================ Chapter 1

Many American children lack access to the regular health care needed
to prevent disease, disability, and unnecessary hospitalization as
well as to treat acute and chronic conditions.  Barriers to
access--such as inadequate or no health insurance, few available
caregivers, and lack of convenient transportation--particularly
affect poor children.  Over nine million children had no health
insurance during 1993, an increase of about one million uninsured
children from 1992, and millions more were uninsured for parts of the
year. 

In response to this problem, the Chairman of the House Committee on
Government Operations asked us to study an approach that a small but
growing number of communities are using to deliver care to children
with limited access to health services:  school-based health centers. 
School-based health centers (SBHC) are innovative programs designed
to deliver health services where the children are--in the nation's
schools.\1 Located on school grounds, SBHCs provide students with a
range of preventive, medical, and mental health services, on the
basis of the needs and priorities of local communities.  This report
examines (1) how school-based health centers expand access to health
services for both adolescents and younger children who have had
limited access to care and (2) the financial and other obstacles
SBHCs must overcome to launch and maintain their services. 


--------------------
\1 In 1990, about 44.4 million school-aged children (5 to 17 years)
lived in the United States. 


   CHILDREN NEED REGULAR HEALTH
   CARE SERVICES
---------------------------------------------------------- Chapter 1:1

Children of all ages need regular health services both for periodic
preventive care and for treatment of chronic and acute medical
conditions.  Additionally, the need to provide mental health services
to both adolescents and younger children is increasing. 


      PREVENTION AND TREATMENT
      NEEDED
-------------------------------------------------------- Chapter 1:1.1

The American Academy of Pediatrics (AAP) and the American Medical
Association (AMA) recommend that children receive a range of
preventive services, including immunizations, physical assessments,
developmental and behavioral assessments, dental examinations, and
vision and hearing screenings.\2 Other children's health services
recommended by HHS include counseling on substance abuse, diet and
exercise, sexual development and behavior, and dental health; and
observation of signs for abuse, neglect, or depression. 

Many children also need care for serious health problems.  For
example, 4.1 million children aged 1 to 19 are limited in their usual
activities because of chronic illnesses and impairments, including
asthma and heart disease.  Asthma is the most common chronic disorder
among youth and is the leading cause of school absences;
hospitalizations of children because of asthma have been increasing. 
Tuberculosis is another rapidly growing problem, and infected
children require treatment to ensure that they do not develop active
cases later in life.\3 Additionally, many children have severe dental
problems resulting from poor nutrition and hygiene. 

The health problems of adolescents often involve a complex web of
physical, emotional, and social issues requiring more than simple
medical care.  Many of these problems, such as sexually transmitted
diseases, unplanned pregnancies, and intentional and unintentional
injuries, are caused by risk-taking behavior rather than specific
diseases.  For example, 39 percent of high school seniors reported
having had five or more drinks at one time in the past 2 weeks,\4

and about 15 percent of adolescent deaths result from motor vehicle
accidents involving alcohol.\5 Adolescents often need mental health
services or health education to help them avoid these risky
behaviors. 


--------------------
\2 The AAP suggests that children aged 5 to 12 receive preventive
services about every 2 years, and the AMA recommends that children
aged 11 to 21 receive preventive services annually. 

\3 One SBHC we visited found that over 18 percent of tested students
were infected with tuberculosis.  We completed case studies at eight
SBHCs as part of our review.  See the scope and methodology section
on page 16 for more detail. 

\4 National Association of State Boards of Education and the American
Medical Association, National Commission on the Role of the School
and the Community in Improving Adolescent Health, Code Blue:  Uniting
for Healthier Youth (Alexandria, Va.:  1992). 

\5 Ellen L.  Marks and Carolyn H.  Marzke, Healthy Caring:  A Process
Evaluation of the Robert Wood Johnson Foundation's School-Based
Adolescent Health Care Program (Princeton, N.J.:  Mathtech.  Inc.,
1993). 


      CHILDREN'S NEED FOR MENTAL
      HEALTH SERVICES IS
      INCREASING
-------------------------------------------------------- Chapter 1:1.2

The need to provide mental health services to children is growing. 
HHS' Healthy People 2000 reports that psychological, emotional, and
learning disorders are rising among children, as are reported cases
of abuse and neglect.\6 In 1991, 2.7 million cases of suspected child
abuse or neglect were reported.  From 1960 to 1988, the suicide rate
among 15- to 19-year-olds more than tripled, and the number of
attempted suicides is many times higher than the number of completed
suicides.\7 At one of the high schools we visited, 21 percent of the
female students and 7 percent of the male students responding to a
health survey reported having attempted suicide; 40 percent of the
female students said they had seriously considered suicide at some
time. 

SBHC providers told us that they often encounter children who have
experienced abuse, neglect, or depression and require mental health
services.  Mental health services account for half of all visits to
New Mexico SBHCs.  The providers believe that many students' problems
result from family or community situations, such as parents abusing
drugs or feeling the pressures of being unemployed.  An elementary
school mental health counselor told us that the children at his
school have mental health problems such as feelings of hopelessness,
depression, low self-esteem, and aggressive behavior. 


--------------------
\6 Healthy People 2000:  National Health Promotion and Disease
Prevention Objectives, HHS, Public Health Service, 91-50212 (Sept. 
1990). 

\7 Ann F.  Garland and Edward Zigler, "Adolescent Suicide Prevention: 
Current Research and Social Policy Implications," American
Psychologist, Vol.  48, No.  2 (1993), pp.  169-182. 


   CHILDREN DO NOT RECEIVE NEEDED
   HEALTH CARE
---------------------------------------------------------- Chapter 1:2

Many American children are not receiving the health care services
they need.  For example, about 12 million children do not get basic
preventive care such as periodic physical examinations or
immunizations at the proper intervals.\8 The U.S.  Department of
Education reported that only about half of all elementary school
children routinely receive health care.\9 Although 7.5 million
children under the age of 18 require mental health services, fewer
than one in eight actually receive them.\10

Poor children in particular typically receive only episodic and
crisis-related care, leaving preventive, chronic, and dental health
needs unmet.  For example, of the 19 million children eligible for
Medicaid's Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT) program in 1992, fewer than 7 million had been screened.\11

Poor children have more health problems than other children, their
conditions are often more severe, and they are less likely to receive
regular health care.  Over 40 percent of poor school-aged children
had no dental visits in 1989, compared with 28 percent for all
children.  HHS has reported that 27 percent of children aged 6 to 8
and 23 percent of 15-year-olds have untreated dental caries.  In
addition, children from poor families (those with less than $10,000
annual income) are nearly twice as likely to be hospitalized and
spend more than twice the number of days in the hospital than
children from higher income families ($35,000 or more annual income). 


--------------------
\8 Robert F.  St.  Peter, Paul W.  Newacheck, and Neal Halfon,
"Access to Care for Poor Children," Journal of the American Medical
Association, Vol.  267, No.  20 (May 27, 1992), pp.  2760-64. 

\9 Improving America's Schools Act of 1993, U.S.  Department of
Education (Washington, D.C.:  1993). 

\10 HHS, Healthy People 2000. 

\11 EPSDT is a comprehensive, preventive health care program for
Medicaid-eligible children up to age 21.  It requires states to cover
periodic health screenings for children, including comprehensive
physical exams and health histories, as well as dental, hearing,
vision, and any other health services necessary to treat conditions
identified during screenings. 


   COMMUNITIES DEVELOPED SBHCS TO
   PROVIDE NEEDED CARE
---------------------------------------------------------- Chapter 1:3

School-based health centers, which began as a grassroots effort, have
become an increasingly popular way to provide health care to needy
children around the country.  As of the early 1980s, about 30 SBHCs
were operating in communities nationwide, and estimates of the
current number of SBHCs range from over 500 to about 600.\12

Although the number of SBHCs has grown rapidly in the last decade, it
represents a fraction of the nation's schools, which totaled 84,578
in 1991-1992.  According to one recent survey, by the Robert Wood
Johnson Foundation and Columbia University, New York has the greatest
number of SBHCs--140; the remaining sites are located in 40 other
states and the District of Columbia.  Almost half (48 percent) of the
centers serve high school students, 26 percent serve elementary
school children, and 16 percent serve middle/junior high school
students.  The remaining 10 percent of SBHCs are located in
alternative schools.\13

Most SBHCs provide primary care, physical examinations, and injury
treatment, but specific services vary by location.  Other services
that SBHCs may offer include immunization, counseling, laboratory
tests, chronic illness management, health education, substance abuse
treatment, and reproductive health care.  (For more detailed
information on the kinds of services that may be available at an
SBHC, see fig.  1.1.) SBHCs refer students to local health providers
for services that they cannot provide on site.  Most SBHCs require a
parental consent form, which typically allows parents to specify
which services the center may provide to their children.  SBHCs in
elementary schools often involve parents more directly in care than
those in middle and high schools because providers may need to obtain
a younger child's medical history or instruct a parent on a child's
medication regimen. 

   Figure 1.1:  Types of Services
   SBHCs May Provide

   (See figure in printed
   edition.)


--------------------
\12 The exact number of SBHCs is difficult to estimate because no
reliable national database exists, states may be unable to track
independent community-based programs, and the definition of SBHCs is
imprecise.  Available data sometimes combine information on SBHCs
with information on school-linked health centers (SLHC), which are
either located on a school campus and serve more than one school or
are located off campus and may serve one or more schools. 

\13 Robert Wood Johnson Foundation, Access to Comprehensive
School-Based Health Services for Children and Youth (Washington,
D.C.:  1994).  The survey identified 608 SBHCs. 


   SBHC MANAGEMENT AND FUNDING
   VARY
---------------------------------------------------------- Chapter 1:4

The organizations that manage SBHCs vary; they include state and
local health departments, community health centers, hospitals, and
school systems.  Staff usually comprise an interdisciplinary team
that often includes a nonphysician primary care provider, such as a
nurse practitioner or physician assistant; the number and types of
other personnel, such as physicians, mental health counselors, or
health educators, may vary.  Many SBHCs depend on links with
established health facilities and donated services to provide support
for their operations and to increase the range of services available
onsite.  While many centers are open only during the school day or
the school year, over 70 percent refer patients to some other health
care source for after-hours care.\14

State, local, and private funds supply the majority of SBHC funding
and are supplemented by funds from several federal programs (see fig. 
1.2).  Only a small amount of money comes from payments by SBHC
enrollees and private insurers.  Nationwide, the median SBHC budget
for the 1991-92 school year was $132,500, with centers receiving on
average an additional $20,000 in donated services from other
providers.\15

   Figure 1.2:  SBHC Funding
   Sources, 1991-1992 School Year

   (See figure in printed
   edition.)

\a Medicaid/EPSDT may include state matching funds. 

\b Other includes school districts, SBHC enrollees, private insurers,
and other state and local programs. 

\c State and Local Human and Social Services and Title V funds may
not be mutually exclusive. 

Source:  Center for Population Options; n=202. 


--------------------
\14 Center for Population Options (CPO), School-Based and
School-Linked Health Centers:  Update 1993, (Washington, D.C.: 
1994).  Data are for both school-based and school-linked health
centers.  CPO data are for the 1991-92 school year and are based on
the 202 responses received from 510 SBHCs and SLHCs surveyed.  Of
these 202 health centers, 123 were school based and 75 were school
linked.  (The other four centers could not be classified.) Unless
otherwise noted, all other CPO data we present are for SBHCs.  (In
March 1994, CPO changed its name to Advocates for Youth.)

\15 CPO; data on median budgets are for SBHCs only, while data for
donated services are for both SBHCs and SLHCs. 


      FEDERAL FUNDING SOURCES
-------------------------------------------------------- Chapter 1:4.1

SBHCs receive funds from several HHS programs, but most federal
funding comes from two sources:  grants from the Maternal and Child
Health Block Grant program (Title V of the Social Security Act,
administered by the Public Health Service's (PHS) Maternal and Child
Health Bureau (MCHB)) and service reimbursement monies from Medicaid
(administered by HHS' Health Care Financing Administration (HCFA)). 
HHS' Family Planning program (Title X of the Public Health Service
Act, administered by the Office of the Assistant Secretary for
Health) also provides grant funds that support services at some sites
but to a much smaller extent.  Federal officials could not identify
the amount of dollars currently financing SBHCs because, except for a
new grant program announced in May 1994, no existing federal program
funds are specifically earmarked for SBHCs. 

HHS announced the first federal program targeted specifically to
SBHCs in May 1994.  Two HHS offices are implementing the Healthy
Schools, Healthy Communities grant program to support SBHCs.  Under
Public Law 103-112,\16 $3.25 million was provided in fiscal year 1994
for the Bureau of Primary Health Care (BPHC) to fund school-based
primary care services for homeless and at-risk youth at 15 to 20 new
sites.\17 Complementing this program, MCHB provided an additional $1
million of federal funds to these same sites for health education and
promotion programs.\18 MCHB also funded a separate $1.5 million grant
program to states and universities for SBHC staff development. 

Additional HHS and Department of Education programs support other
school health programs, such as health education, that may be
provided in the schools but are not typically housed in SBHCs.  An
Education official told us that the Department's current efforts
support locally designed school health initiatives that promote
better student learning.  For example, states and school districts
may use funds authorized by the Goals 2000:  Educate America Act
(P.L.  103-227) to develop programs that provide students and
families with coordinated access to social services, health care,
nutrition, early childhood education, and child care. 

SBHCs can also benefit from funds provided to 10 states by HHS'
Centers for Disease Control and Prevention (CDC) under its
Comprehensive School Health program.  This program provides funds to
a state's education and health agencies for planning, organizing, or
developing statewide policies and resources to help schools implement
comprehensive school health programs. 


--------------------
\16 The Departments of Labor, Health and Human Services, and
Education, and Related Agencies Appropriations Act, 1994. 

\17 These funds were provided through the Outreach and Primary Health
Services for Homeless Children program. 

\18 Both BPHC and MCHB are in PHS' Health Resources and Services
Administration. 


   SCOPE AND METHODOLOGY
---------------------------------------------------------- Chapter 1:5

This report expands on preliminary information in our May 1994
report.\19 Our approach consisted of case studies, interviews with
public and private officials, and a review of the literature.  We
conducted case studies at eight SBHCs in California, New Mexico, and
New York.  We chose locations to ensure that we visited urban and
rural SBHCs in elementary, middle, and high schools.  These locations
were low-income communities that established SBHCs to deal with a
multitude of concerns, including high rates of teenage pregnancy,
drug and alcohol abuse, violence, and problems resulting from the
effects of poverty.  Following are the schools we visited (see app. 
I for more detailed information about each location). 


--------------------
\19 Health Care Reform:  School-Based Health Centers Can Promote
Access to Care (GAO/HEHS-94-166, May 13, 1994). 


      CALIFORNIA
-------------------------------------------------------- Chapter 1:5.1

  Luther Burbank Elementary School, San Jose

  William C.  Overfelt High School, San Jose

  Thomas Edison High School, Stockton


      NEW MEXICO
-------------------------------------------------------- Chapter 1:5.2

  Espanola Valley High School, Espanola

  Escalante High School/Middle School, Tierra Amarilla


      NEW YORK
-------------------------------------------------------- Chapter 1:5.3

  William Howard Taft High School, Bronx

  Intermediate School 136, New York

  Primary School 155, New York

During the 1992-93 school year, over 11,000 students attended these
schools, of which over 3,700 used SBHC services, accounting for
almost 20,000 individual visits.  At the centers we visited, budgets
ranged from $21,481 for a part-time rural SBHC at a school with 289
students to $285,000 for a full-time SBHC at a school with 3,300
students.  At the centers, we toured the facilities and talked with
health care providers, administrators, students, and parents.  We
interviewed health providers at backup facilities, other providers in
the community, and state and local health and education officials. 
We supplemented our detailed case studies with visits to SBHCs in
Colorado, Georgia, and Washington, D.C. 

We discussed health and financing issues for SBHCs with HHS,
Education, and local and national foundation and association
officials, as well as other experts on SBHCs.  Among the people we
spoke with were representatives of the Robert Wood Johnson
Foundation, American Academy of Pediatrics, National Association of
State Boards of Education, Council of Chief State School Officers,
CPO, and New York State Catholic Health Care Council.  We conducted
telephone interviews with administrators of SBHCs and managed care
systems to obtain information on managed care systems' methods of
reimbursing school centers and to determine the impact of managed
care on SBHCs in Baltimore, Maryland; Minneapolis and St.  Paul,
Minnesota; Portland, Oregon; and Memphis, Tennessee.  Additionally,
we reviewed studies on the general status of children's health and on
the experience of SBHCs.  The scope of our study did not include
evaluating the quality of care provided by SBHCs or the impact on
students' health or educational status. 

A draft of this report was reviewed by officials from the HHS Health
Resources and Services Administration's Maternal and Child Health
Bureau, Bureau of Primary Health Care, and Bureau of Health
Professionals; Health Care Financing Administration's Medicaid
Bureau; and Office of Disease Prevention and Health Promotion; and
the Department of Education Office of Special Education and
Rehabilitative Services, Office of Elementary and Secondary
Education, Office of Intergovernmental/Interagency Affairs, and the
Office of the Undersecretary.  They generally agreed with our
findings and made several technical comments and clarifications,
which we incorporated as appropriate. 

We did our work from April 1993 to October 1994 in accordance with
generally accepted government auditing standards. 


SCHOOL-BASED HEALTH CENTERS
IMPROVE CHILDREN'S ACCESS TO
HEALTH CARE
============================================================ Chapter 2

Communities are using SBHCs to fill a niche in the nation's health
care delivery system.  SBHCs afford children easier access to needed
health services by bringing providers to the children, furnishing
free or low-cost services, and supplying the atmosphere of trust and
confidentiality adolescents need.  SBHCs do not, however, provide all
health services required by children enrolled in school and cannot
reach those who do not attend school. 

SBHCs may also offer other benefits, such as improved educational
attainment and the achievement of public health goals.  States and
local communities have demonstrated their support for SBHCs by
allocating increasing resources to them.  Nonetheless, research
measuring the impact of SBHCs on health and education outcomes is
sparse. 


   SBHCS FILL A NEED FOR
   CHILDREN'S ACCESS TO HEALTH
   CARE
---------------------------------------------------------- Chapter 2:1

SBHCs improve children's access to health care by removing financial
and other barriers in the existing health care delivery system. 
These centers are a unique delivery option that gives children,
especially those who are poor or uninsured, easy access to services. 
Providing services in schools is a particularly effective way to
reach adolescents and also yields benefits for younger children. 


      LOW-COST ACCESS TO PROVIDERS
-------------------------------------------------------- Chapter 2:1.1

SBHCs provide students with health services at no fee or minimal
cost, which helps children who lack health insurance and whose
parents have difficulty paying for needed health services.  Having
access to free or low-cost services at school also helps children who
are among the 21.4 percent of American children covered by Medicaid
because they cannot always find physicians willing to treat them. 

Even when a child has private health insurance, parents may be unable
to pay the deductible or the insurance may not cover needed services. 
For example, most private insurers do not cover psychological or
substance abuse counseling, services that SBHCs often provide.  Some
SBHCs offer or arrange for students to receive dental care.  An HHS
study indicated that 50 percent of children aged 5 to 17 do not have
private dental insurance, and that, for those with insurance,
copayments and deductibles may be as high as 50 percent of the cost
of services.\20 One teenager we met at an SBHC said that her family
did not have money to pay for dental services and that, when a dental
need arises, they must choose between seeing a dentist and paying for
basic necessities like food and rent. 


--------------------
\20 "Toward Improving the Oral Health of Americans:  An Overview of
Oral Health Status, Resources, and Care Delivery," Public Health
Reports, Oral Health Coordinating Committee, PHS (Nov.-Dec.  1993). 


      INCREASED CONVENIENCE FOR
      STUDENTS, PARENTS, AND
      PROVIDERS
-------------------------------------------------------- Chapter 2:1.2

SBHCs improve children's access to health care by being more
convenient for students.  Children using the SBHC can quickly receive
care and return to class instead of going home.  Additionally, both
SBHC providers and students told us that if the SBHC weren't there,
ill students often would not seek treatment elsewhere, and their
conditions might worsen.  Bringing providers to students is
especially important in rural and inner city communities with few
health practitioners. 

By being on the school site, SBHCs eliminate the need for parents to
leave work or provide transportation, which may be unavailable or
inconvenient.  Health care facilities often have long waiting times,
especially public facilities such as county hospitals, further
increasing the time parents and students must take off from work and
school.  Both students and parents told us that waiting times at
other facilities often range from 1 to 4 hours, even with an
appointment.  At one SBHC we visited, a student health survey found
that, of the students who reported missing school for a doctor's
appointment, nearly half missed at least six class periods.  These
problems are exacerbated in rural areas, where parents may have to
travel considerable distances to pick up students, and providers may
not be located nearby.  At one rural SBHC, parents told us that some
health services require drives of 60 to 100 miles or more.  New
Mexico officials said that SBHCs provide specific services that rural
communities often lack, such as mental health services and suicide
and violence prevention counseling. 

SBHCs also make it easier for providers to contact and treat
students.  By being where the students are, SBHC staff are better
able to follow up with students to ensure that they make and keep
appointments with other providers and if necessary can call students
out of their classes.  This is especially useful when working with
adolescents, who often do not make and keep needed appointments and
may be deterred by long waits. 

Additionally, being on site enables SBHC staff to work directly with
teachers and parents to improve student health.  An SBHC
administrator told us that quick access to teachers, students, and
parents, along with students' medical and school records, allows
providers to better integrate information, develop diagnoses, and
provide prompt treatment.  SBHC providers said that teachers play an
important role in identifying students with potential health
problems, referring students to the SBHC, and working with providers
to help them better understand students' problems. 


      SBHCS MEET ADOLESCENTS'
      NEEDS FOR TRUST AND
      CONFIDENTIALITY
-------------------------------------------------------- Chapter 2:1.3

SBHCs are particularly suited to meet the special needs of
adolescents.  To discuss their health concerns, teenagers require an
atmosphere of trust and confidentiality.  Additionally, their health
care providers must be willing to ask probing questions to identify
underlying problems.  Both students and providers believe that other
types of facilities often do not provide these conditions. 

SBHC staff earn the trust of students by getting to know them,
listening to their problems, and offering objective advice in a
friendly, familiar environment.  SBHCs also encourage trust by
providing greater continuity of care; students can often see the same
provider every visit, which they cannot always do at other types of
facilities.  Adolescents often will not discuss their problems until
they spend time in the facility and feel comfortable with the staff. 
Providers noted that some students view SBHC staff as members of an
extended family. 

Once this trust is established, students coming in for apparently
simple medical needs will often discuss more serious concerns--like
depression, thoughts of suicide, or pregnancy--if the staff ask
probing questions.  At one center we visited, for example, a nurse
practitioner talked with a girl who seemed overly withdrawn, who then
revealed that she had been raped. 

Students we talked with emphasized the importance of feeling
comfortable with SBHC staff and especially appreciated the
confidentiality of services.  Both students and parents noted that
adolescents often do not feel comfortable talking about personal
health concerns, especially those involving risky behavior. 
Teenagers we talked with appreciated that SBHC staff do not scold or
lecture them and noted that in some cases students have trouble
talking with parents about their problems because they stem from
their relationship with their parents.  Confidentiality is
particularly a concern in rural areas where many people are related
and "everyone knows everyone else." A rural school superintendent
told us that adolescents hesitate to go to the local clinic because
they fear that someone will see them there and tell their parents. 

Students told us that other facilities in their communities are
impersonal and inconsiderate of adolescents' concerns.  Providers at
these facilities tend to have less time to spend with patients,
limiting their ability to identify the underlying causes of
adolescents' problems.  These facilities also cannot readily serve
patients without appointments and may not ensure continuity of care
by the same provider. 

Providers from other community facilities generally agreed with these
observations.  One physician in private practice told us that
pediatricians often do not ask probing questions, tending to address
only the immediate concern rather than underlying issues.  Another
non-SBHC physician noted that pediatricians are accustomed to
communicating with parents, not patients, and often are not willing
to provide reproductive health services to teenagers confidentially. 
A private practice physician who also works at an SBHC told us that
when she sees adolescents in her office, she usually has time only to
treat acute symptoms, while at the SBHC she can spend time
identifying additional problems or providing health education. 


      SBHCS ALSO HELP ELEMENTARY
      SCHOOL CHILDREN
-------------------------------------------------------- Chapter 2:1.4

While SBHCs provide particular benefits to adolescents, they can also
help elementary school children.  For example, monitoring and early
treatment of chronic conditions, such as asthma, can prevent
unnecessary hospitalizations and deaths.  Health providers told us
that mental health services are particularly effective at the
elementary level when problems first appear because younger children
are more malleable, feel less peer pressure, and are more open to
discussing their problems than adolescents. 

Parents and providers told us that like adolescents, elementary
school children are more likely to use the SBHC than other health
care facilities.  A principal at an elementary school with an SBHC
believes this occurs because parents and students are already
familiar with the school and view the SBHC as part of the school.  An
SBHC provider at an elementary school noted that parents are often
intimidated by other health facilities and find the SBHC a much
friendlier place for their children to receive care.  Parents of
elementary school children told us that SBHC staff communicate well
with the children and always seem to ask the right questions, adding
that other providers tend to pay less attention to and seem to be
less concerned about the children. 


      CENTERS ADAPT TO DIFFERENT
      CULTURAL NEEDS
-------------------------------------------------------- Chapter 2:1.5

By providing bilingual, culturally sensitive staff, some SBHCs are
better able to respond to the health needs of minority students. 
Some students experience cultural and language barriers that
discourage them from going to traditional health care facilities. 
For example, many families who are recent immigrants are not familiar
with the health care system and do not know how to obtain services. 
Also, some of these families fear authority figures and thus do not
seek services from the health care system.  Providing services to
students who have recently immigrated is especially important because
they may not have received needed health care, such as physical
examinations or immunizations, before coming to the United States. 

Some SBHCs attempt to overcome these problems by providing bilingual
staff and materials.  For example, two SBHCs we visited had staff
bilingual in English and Spanish and translated most forms and other
written materials into Spanish.  Another SBHC with large Hispanic and
Asian populations translated many of its materials into both Spanish
and Vietnamese and provided translators for Vietnamese, Cambodian,
Chinese, and many other languages and dialects.  An elementary school
principal noted another reason for the importance of providing
bilingual staff:  even children who are comfortable with English as a
second language often revert to their first language when injured or
under stress. 


      CENTERS CANNOT REACH ALL
      CHILDREN
-------------------------------------------------------- Chapter 2:1.6

SBHCs do much to improve children's access to health care, but they
do not provide all needed services to all children.  School centers
are not always open during the summer or other times when school is
not in session, and some are not open at all times the children are
in school.  SBHCs cannot provide the entire range of services
students may need, and the comprehensiveness of referral networks
varies.  It can be particularly difficult for SBHCs to meet the total
demand for mental health services either onsite or through referral
to community providers. 

Furthermore, SBHCs generally do not serve children who are not in
school, such as those younger than age 5 or adolescents who have
dropped out.  About 383,000 students in grades 10 to 12 dropped out
of school in 1992, and these young people may be especially
vulnerable to adolescent health problems like sexually transmitted
diseases and pregnancy. 


      SBHCS CAN PROVIDE ADDITIONAL
      BENEFITS
-------------------------------------------------------- Chapter 2:1.7

SBHCs can also provide benefits beyond meeting children's basic needs
for health care.  These include improving children's ability to
learn, providing a means for children to receive additional
comprehensive services, and helping communities achieve public health
goals. 

By treating children's health problems, SBHCs may also improve
children's educational achievements.  Students with physical and
mental health problems do not learn well, and poor school performance
often discourages students from attending.  A recent report on
adolescent health cosponsored by the AMA concluded that

     "education and health are inextricably intertwined.  A teen who
     is depressed and doing poorly in school may begin relying on
     alcohol or drugs--and as a consequence, fall further and further
     behind.  And a teenager with a baby is far more likely to be
     absent from school and eventually drop out."\21

Others also stress the importance of good health to education.  For
example, a principal and a school counselor told us that by meeting
children's health needs, SBHCs raise students' self-esteem, increase
their connection with the school, and keep them from dropping out. 
An elementary school principal related that some students were placed
in remedial classes when they could not keep up in their regular
class because of undiagnosed or untreated vision problems.  Sometimes
these problems were undiagnosed or untreated for years, with severe
consequences for the children's education.  The SBHC helped reduce
the number of such instances, but the principal told us that the
center did not have sufficient resources to meet all students' needs
for examinations and eyeglasses. 

SBHCs can serve as a vehicle for providing more comprehensive
services in schools.  HHS reports that improving children's health
requires a wide range of social and economic services.  One SBHC we
visited works with a dozen different outside organizations to provide
services.  These services include mental health counseling, alcohol
and drug treatment, grief counseling, physical abuse counseling for
women, and assistance from the federal Special Supplemental Food
Program for Women, Infants and Children (WIC).\22

Another SBHC has a Medicaid eligibility worker on site and provides
day care for the children of teen mothers. 

By providing health education, preventive care, and treatment, SBHCs
can help improve public health conditions.  For example, a New York
City SBHC we visited provides tuberculosis tests, immunizations, and
physical exams to all new students of area schools, as required by
the New York City Department of Health.  Similarly, a California SBHC
we visited provides state-mandated immunizations and physicals to new
students. 

HCFA has promoted the potential role of schools in conducting
outreach for Medicaid's EPSDT program.  In an EPSDT guide for
educational programs published in 1992, HCFA points out that SBHCs
could play a role in providing important preventive and periodic care
to eligible children.\23 The agency's EPSDT participation goals say
that states should have screened 75 percent of eligible children by
the end of fiscal year 1994 and 80 percent by the end of fiscal year
1995.  Many states have had difficulty meeting the participation
goals; for example, New Mexico had screened only 22 percent of
eligible children by the end of fiscal year 1994.  Officials in both
Georgia and New Mexico told us that SBHCs could assist in their
efforts to meet EPSDT goals. 


--------------------
\21 Code Blue:  Uniting for Healthier Youth. 

\22 WIC provides supplementary food and nutrition education to
eligible low-income pregnant, breast-feeding, and postpartum women;
infants; and children up to age 5. 

\23 States are required to conduct outreach to inform eligible
Medicaid recipients about EPSDT. 


   RESEARCH MEASURING IMPACT OF
   SBHCS IS SPARSE
---------------------------------------------------------- Chapter 2:2

Health care providers, educators, and parents told us that SBHCs
bring a variety of benefits to students:  improved school attendance
and performance, lower drop-out rates, and improved health status. 
The resources that states and local communities have committed to
SBHCs demonstrate their belief in the benefits SBHCs provide to
children.  For example, 27 states have allocated Title V Maternal and
Child Health Block Grant money or general revenue to SBHCs.\24
However, data that measure the impact of SBHCs are generally not
available. 

Utilization data--such as SBHC enrollment levels, students' insurance
status, and types of services used--suggest that SBHCs are filling an
important function.  Outcome data that reliably answer questions on
the effects of SBHCs on students' immediate and long-term health and
educational achievements are lacking, however.  Also lacking is
research comparing SBHCs with other health providers on measures such
as cost-effectiveness and impact on health status.  Many health
professionals associated with SBHCs recognize the need for such
information but have often lacked the resources to produce
methodologically sound research.  Conducting research on SBHCs is
particularly challenging because of students' mobility and because of
the long-range nature of some potential effects.  The evaluation
component of HHS' Healthy Schools, Healthy Communities grant program
should contribute to developing data on SBHCs; it will include an
outcome analysis examining impacts of SBHCs funded by the program on
health and education indicators. 


--------------------
\24 Robert Wood Johnson Foundation. 


SCHOOL-BASED HEALTH CENTERS FACE
FINANCING ISSUES
============================================================ Chapter 3

SBHC staff throughout the nation report that they encounter problems
in financing their operations.  School centers often rely on
fragmented and sometimes short-term sources of funding to operate. 
Funding is further constrained because SBHCs have difficulty billing
both private and public insurers.  This problem is exacerbated by the
growing tendency of state Medicaid programs to pay managed care
systems to treat Medicaid beneficiaries because most state Medicaid
agencies will not reimburse SBHCs for services provided to children
enrolled in managed care.  Some SBHC providers report that they do
not have enough resources to meet children's needs, especially for
mental health and dental services.  Using varied approaches, some
states are working with SBHCs and local communities to try to solve
financing problems. 


   FINANCING IS FRAGMENTED
---------------------------------------------------------- Chapter 3:1

SBHCs rely on a patchwork of state, local, private, and federal
funding to cover their start-up and operating costs.  Financing from
private foundations has played a large role in establishing new
centers, but grants are frequently short-term, leaving centers with
an uncertain flow of funds after the first few years.  The experience
of San Jose School Health Centers, which operates eight SBHCs,
illustrates this pattern.  For school year 1992-93, San Jose's budget
consisted of about $515,000 from 10 private and 4 state and local
grants and about $100,000 in state and federal Medicaid funds.  A
6-year annual private foundation grant for $100,000 expired that
year; each of the other grants was awarded for 1 year.  Thus
Medicaid, which supplied only about 16 percent of the budget, was the
sole continuing source of funds. 

Problems in billing insurers further constrain SBHCs' ability to
finance services.  Local health and education officials cite the
difficulty of handling the extensive paperwork process for billing
Medicaid and private insurers due to the typically small number of
SBHC staff.  SBHCs we visited that were not sponsored by an
established health care provider, such as a hospital or community
health center, often lacked the administrative capability to
implement a billing process.  Centers with sponsors often relied on
the sponsoring agencies' billing systems.  Even these centers,
however, sometimes faced problems in linking on-site billing to the
sponsoring facility, especially when the SBHC lacked a computerized
system to maintain patient data and generate bills.  At one Georgia
site, patient data had to be recorded twice:  providers manually
filled out forms and sent them to the sponsoring community health
center, where the information was entered into the computer system
for billing. 

Additionally, private insurers may not cover certain services that
SBHCs provide, such as preventive care and health education.  Getting
insurance reimbursement is further hindered because low-income
families cannot pay insurance deductibles.  Another problem with
billing insurers is concern that adolescents will lose
confidentiality if parents receive insurance statements.  Because of
these problems, some SBHCs do not bill third parties.  Private
insurance billing comprises only 1 percent of SBHC funding.\25


--------------------
\25 CPO; data are for both SBHCs and SLHCs. 


   CENTERS HAVE DIFFICULTY GETTING
   MEDICAID REIMBURSEMENT
---------------------------------------------------------- Chapter 3:2

Although they serve many Medicaid-eligible children, SBHCs often face
difficulties getting Medicaid reimbursement for the care they provide
to these students.  The growth of Medicaid managed care could further
reduce Medicaid payments to school centers, because SBHCs cannot
claim reimbursement for services they provide to children enrolled in
managed care plans.  Some managed care organizations are reluctant to
include SBHCs in their networks, partly because they do not control
the quality of care provided there. 

SBHCs often serve large Medicaid-eligible populations.  Four sites we
visited reported that from 23 to 39 percent of students enrolled or
using the center were insured by Medicaid.  At three of those sites,
the insurance status of another 29 to 59 percent of the students was
unknown, which means that the Medicaid population of these SBHCs
might be even larger. 

SBHC administrators and providers identified three key problems that
hindered their ability to get Medicaid reimbursement.  First and
foremost, providers do not always know which patients are eligible
for Medicaid.  Students may not know if they are eligible or may be
reluctant to tell anyone if they are.  Further, their eligibility
status can change from month to month.  Second, SBHC providers
hesitate to use scarce administrative resources to handle what they
consider to be a burdensome billing process.  SBHCs that are managed
by health care providers that already have administrative systems for
billing report greater ease in getting Medicaid reimbursement. 
Finally, SBHCs' ability to receive Medicaid reimbursement may be
limited by restrictions in state Medicaid programs.  In Colorado, for
example, services provided by nurse practitioners are not eligible
for Medicaid reimbursement, yet nurse practitioners are key primary
care providers at SBHCs. 


      GROWTH OF MEDICAID MANAGED
      CARE COMPLICATES
      REIMBURSEMENT FOR SBHCS
-------------------------------------------------------- Chapter 3:2.1

The trend toward managed care arrangements in the American private
health care sector has spread to the Medicaid program as well, and a
growing number of states use managed care organizations to provide
services to people enrolled in Medicaid.  As of June 30, 1994, 45
states and the District of Columbia were operating at least one
managed care program for Medicaid beneficiaries. 

SBHC staff and state and local officials whose programs support SBHCs
emphasized their concerns about the relationship between SBHCs and
both Medicaid and private managed care providers.  State Medicaid
agencies generally will not reimburse SBHCs for services they have
already contracted with managed care plans to provide. 

Managed care providers told us they are reluctant to incorporate
SBHCs into their networks because of concern that they lack control
over the type and quality of care provided.  Issues related to the
sharing of information, such as concern for patients' privacy and
control over medical records, can further complicate cooperation
between managed care providers and SBHCs.  Additionally, it may not
be in the financial interest of managed care organizations to
reimburse school centers.  When SBHCs do not receive reimbursement
for care they provide to children enrolled in Medicaid managed care,
they are in effect subsidizing the managed care plans. 

SBHCs in a few locations have attempted to make arrangements with
Medicaid managed care providers with mixed success.  For example,
SBHCs in Minneapolis and St.  Paul, Minnesota, have reached
agreements or are negotiating with all the major Medicaid managed
care providers in their areas to reimburse SBHCs for services
provided to students enrolled in their plans.  California is
conducting a project that may experiment with one or more of the
following relationships between Medicaid managed care providers and
school-linked Child Health and Disability Prevention (CHDP)
services:\26

  direct fee-for-service reimbursement by the managed care provider
     to the school provider for covered services;

  a cooperative relationship, such as the managed care provider's
     sending staff to provide CHDP services at the school site; or

  a protocol arrangement for the school site to refer patients to the
     managed care provider for required services. 

Tennessee's new TennCare plan requires all Medicaid beneficiaries to
enroll in managed care and to designate a primary care provider
(PCP).  TennCare encourages managed care organizations to include
SBHCs in their networks; most of the managed care organizations,
however, have not allowed students to designate a PCP independent of
the one selected by their parents.  For two Memphis SBHCs, this
change in the state Medicaid program has resulted in an average
annual loss of about $72,000 in Medicaid funds, or 40 percent of
their budgets. 

Most Medicaid managed care organizations in Multnomah County, Oregon,
have refused to include the county's seven SBHCs in their networks. 
One managed care official said this was partly because the SBHCs are
not true PCPs, since they do not provide a full range of care or
provide for after-hours care when the SBHCs are closed.  In
Baltimore, Maryland, one Medicaid managed care provider reimburses
the seven SBHCs operated by the city health department but only under
certain conditions, such as when students have not yet seen their PCP
or when the PCP is unavailable.  A managed care official told us the
plan hesitates to reimburse SBHCs further because it was already
paying PCPs to provide services to plan enrollees and because it
could not adequately control the quality of SBHC-provided care. 
Although the SBHC administrator believed they could resolve these
issues, the managed care official said that her organization has no
plans to expand its reimbursement of the SBHCs.  Instead, the
organization is planning to open its own SBHCs where it would serve
both its own enrollees and other children.  The HHS Office of
Inspector General (OIG) recommended in a December 1993 report that
PHS, HCFA, and the states should encourage cooperation between SBHCs
and managed care providers.\27


--------------------
\26 CHDP is California's EPSDT program. 

\27 School-Based Health Centers and Managed Care, HHS OIG
(OEI-05-92-00680) (Dec.  1993). 


      HCFA'S FREE CARE POLICY MAY
      NOT ENCOURAGE SCHOOL-BASED
      SERVICES
-------------------------------------------------------- Chapter 3:2.2

HCFA has a long-standing "free care" policy under which Medicaid will
not reimburse providers for services given to Medicaid patients if
the same services are offered for free to non-Medicaid patients.\28
HCFA bases the policy on federal Medicaid law, which requires state
Medicaid plans to take available resources into account when
determining which services to reimburse.\29 HCFA officials told us
that the free care policy may contradict the agency's efforts to
encourage school-based health services.  Therefore, they have been
re-examining the free care policy through a work group looking at
Medicaid's payment provisions for school health services.\30

There are exceptions to the free care policy.  For example, Medicaid
will reimburse for services provided to Medicaid enrollees regardless
of whether the provider collects payment for services given to other
patients if the Medicaid services are provided (1) by a facility that
receives federal Maternal and Child Health Block Grant funds
(provided the facility has an agreement with Medicaid) or (2) to
disabled children with Individualized Education Plans or
Individualized Family Service Plans under the Individuals with
Disabilities Education Act (IDEA).\31

Some officials who manage or work with school health programs believe
it is inappropriate to apply the free care policy to SBHCs.  For
instance, one administrator responsible for several SBHCs said that
the potential income from insurers and student fees is negligible. 
Because of the large percentage of students enrolled in private and
public managed care plans and the reluctance of managed care
providers to reimburse SBHCs for services provided to their
enrollees, he would expect his SBHCs to receive little income from
third-party reimbursement.  In addition, the SBHCs are located in
low-income areas, and uninsured students would likely pay little, if
anything, for services under a fee schedule that takes into account
family income. 

The SBHC administrator said that he would also need to weigh the
probability of limited income against the potentially negative impact
on students of billing them or their insurers.  Any fee, even $5,
could, in his view, deter students from seeking services when they
need them and compromise the qualities that make SBHCs unique,
particularly the promise of easy access.  The administrator explained
that the SBHCs for which he is responsible receive grants to provide
an underserved population with free health care, and these funds
cover the cost of services that are not billed.  He also expressed
concern that students would lose confidentiality if parents received
insurance statements. 


--------------------
\28 The facility must have a fee schedule in place and bill other
responsible third-party payers to bill Medicaid. 

\29 Section 1902(a)(17) of the Social Security Act. 

\30 Work group members include representatives of federal, state, and
local government and private organizations. 

\31 These two exceptions are based on the following statutory
provisions:  for Title V, 42 U.S.C.  1396a (a)(11)(B)(ii); and for
IDEA, 42 U.S.C.  1396b (c). 


   FUNDING PROBLEMS LIMIT
   AVAILABILITY OF SERVICES
---------------------------------------------------------- Chapter 3:3

Administrators and health providers at some sites that we visited
reported that budget limitations affect the services they can offer. 
For example, despite the demand for more services, some SBHCs cannot
be staffed during all days or hours that the school is open. 

SBHC providers consistently emphasized the large demand for mental
health services at both elementary and high school facilities and
told us that they could not always provide care or find providers in
the community who would treat students.  Both public and private
health insurance coverage of mental health services tends to
emphasize acute or emergency conditions rather than ongoing care,
which limits SBHCs' ability to receive reimbursement for services
their patients need.  Many SBHCs in New York State eliminated social
workers from their staffs because of funding constraints.  Providers
at one New York site said they use group sessions to work with
students on certain problems because they do not have enough social
workers to provide individual treatment for everyone. 

Providers also reported great difficulty in meeting children's need
for dental care.  Few SBHCs can give care on-site:  CPO reported that
about 13 percent of SBHCs do so.  Obtaining these services in the
community can be difficult because of prohibitive costs, long waiting
times for referrals, or a lack of dentists.  Providers at one site
said children had to wait 2 to 3 months for a nonemergency referral
appointment with a dentist. 


   STATES PLAY ROLE IN ADDRESSING
   FINANCING PROBLEMS
---------------------------------------------------------- Chapter 3:4

Recognizing that local communities have difficulty financing SBHCs,
some states have taken an active role in encouraging and supporting
local efforts.  The states where we conducted our case studies--New
York, New Mexico, and California--are among those that have tried to
address financing problems.  Some state efforts are not targeted
directly to SBHCs but rather support comprehensive service programs
that can include health-related activities. 

State efforts have been encouraged by other public and private
agencies.  The CDC's Comprehensive School Health Program promotes
state-level participation by funding two full-time senior state
positions--one in health and one in education--in 10 states to
facilitate statewide planning, implementation, and evaluation of
activities to help schools implement comprehensive school health
policies and programs.  In a recent grant program, the Robert Wood
Johnson Foundation similarly emphasized the importance of state
participation in funding SBHCs by including a component that supports
state-level efforts to reduce barriers to financing, organizing, and
staffing SBHCs. 


      NEW YORK SUPPORTS MULTIPLE
      SITES
-------------------------------------------------------- Chapter 3:4.1

New York has 140 SBHCs, many more than any other state; 112 of the
SBHCs are in New York City.  The state has actively supported SBHCs
both by allocating funds to them and passing legislation that
facilitates their operation.  The New York State Department of Health
is the principal funder of 110 of the centers.  State-controlled
funding for SBHC operations for the 1993-1994 school year included
$3.64 million in state-appropriated funds.  This appropriation
increased to $6.5 million for the 1994-1995 school year; the increase
was intended to enhance staffing and services at existing centers and
establish five new SBHCs.  The state also allocated $3.5 million in
federal Maternal Child Health Block Grant funds to SBHCs each
year.\32 Medicaid reimbursement is the only other source of federal
funding supporting New York SBHCs; in the 1991-1992 school year, it
represented about 10 percent of the total $8.6 million budget. 

New York has supported SBHCs in several ways.  The state, which first
legislated authority for model SBHC programs in 1978, has implemented
a state-level approval process for SBHCs and requires every SBHC in
the state to be linked to a backup provider that provides 24-hour
access to care.  Additional 1981 legislation exempts SBHCs from
meeting certain state requirements for medical facilities, such as
minimum door widths.  They are also exempt from the
certificate-of-need process required of other facilities, which
typically takes 2 years to complete.  Instead, the state has used
indicators of a high need for primary care--such as high levels of
nonimmunized children and inappropriate emergency room use--to
identify locations for SBHCs.\33 These waivers make it easier for
SBHCs to be designated as state-approved medical facilities, which
allows them to get Medicaid reimbursement. 

Additional legislation that benefitted SBHCs included expanding the
authority of nurse practitioners to provide certain services.  This
made those services eligible for Medicaid reimbursement.  The state
also absorbed the additional costs of four SBHCs whose private
foundation monies ended in 1992.  Further, in 1993, the state
authorized all SBHCs to claim the Medicaid rates of their backup
facilities.  Previously, SBHCs received a special, lower Medicaid
rate for patient visits.  This change was expected to increase
Medicaid funding for most centers. 


--------------------
\32 New York State received $41.4 million in its fiscal year 1994
Maternal and Child Health Block Grant. 

\33 Inappropriate emergency room use includes relying on the
emergency room as a regular source for primary care, an inadequate
and costly way to provide regular care to children.  For additional
information on emergency room use, see GAO's report, Emergency
Departments:  Unevenly Affected by Growth and Change in Patient Use
(GAO/HRD-93-4, Jan.  4, 1993). 


      NEW MEXICO ACTIVELY SUPPORTS
      SBHCS
-------------------------------------------------------- Chapter 3:4.2

Like New York, New Mexico has used Maternal and Child Health Block
Grant funds to support its SBHCs.  For 1994, the state allocated
$218,000 of these funds in contracts ranging from $4,000 to $20,000
to support 23 SBHCs.\34 An additional six SBHCs are supported
primarily by other New Mexico Department of Health funds or private
funds.  The state places high priority on maximizing the use of
available Title V dollars to support SBHC activities; the funds are
mainly used to pay nonphysician primary care provider salaries. 

The state requires every SBHC to identify a health care provider to
which it can refer students for treatment the SBHC cannot provide. 
The state Medicaid program also requires a referral network to be in
place before the SBHC can be eligible for Medicaid reimbursement. 

CDC's Comprehensive School Health Program is funding positions in New
Mexico's Departments of Health; Education; and Children, Youth and
Families.  These departments are charged with creating better support
at the state and local level for coordinating school health programs
that have been the responsibility of separate departments.  They join
other agency staff in a State Interagency Committee, initiated by the
governor in 1993, which oversees all comprehensive school health
programs in the state.  Because of the CDC program and related
projects, the state is developing a pilot comprehensive school health
program in one school district, scheduled to begin in January 1995. 
Officials hope to receive additional state funds that would allow
them to expand the pilot project to four more sites during the
1995-1996 school year. 

New Mexico has also begun other efforts to expand health services in
schools.  For instance, the state is training school nurses to
complete EPSDT screenings.  At the completion of our work, the state
had signed agreements with seven school districts to implement this
program. 


--------------------
\34 New Mexico received $4.6 million in its fiscal year 1994 Maternal
and Child Health Block Grant. 


      CALIFORNIA SUPPORTS SBHCS
      INDIRECTLY
-------------------------------------------------------- Chapter 3:4.3

The 26 SBHCs in California have received less direct support from the
state government than the centers in New York and New Mexico, but the
state supports related efforts.  State funding for SBHCs has
generally come from Medi-Cal and state tobacco tax dollars, although
the amount of funding going to SBHCS is unknown.\35 For certain
sensitive services, such as family planning services, Medi-Cal allows
teenagers to qualify on the basis of their own income rather than
their parents' income.  The state cannot receive federal
reimbursement for these services so funds them alone.  Title V
funding, which is widely used in the other two states, has not funded
any California SBHCs; however, the state is using Title V dollars to
develop a computerized billing process for SBHCs. 

California has created a separate school-related project called
Healthy Start.\36 This program is a statewide effort to place
comprehensive support services at or near schools, with an emphasis
on integrated health, mental health, social, educational, and other
services for children and their families.  The state allocated $55
million from July 1, 1991, through June 30, 1993, to fund planning
and operational grants that cover 890 elementary, middle, and high
schools.\37 The program received an additional allocation of $20
million for grants to be awarded by June 30, 1995. 


--------------------
\35 Medi-Cal is California's Medicaid program. 

\36 The program was enacted under the Healthy Start Support Services
for Children Act of 1991. 

\37 Grants are generally awarded to a body that includes a consortium
of schools. 


   CONCLUSIONS
---------------------------------------------------------- Chapter 3:5

The people who administer and provide care at SBHCs consistently
identify a lack of stable financing as their greatest problem. 
Public and private health insurance plans that cover children
enrolled in SBHCs could be important sources of reliable funding for
the centers, but getting reimbursement from both Medicaid and private
insurers often presents a difficult challenge for SBHC staff. 

SBHCs that are closely linked with established health care providers,
such as hospitals and community health centers, generally find it
easier to bill Medicaid and other insurers than do centers without
such an affiliation.  The established providers usually have a
billing system in place and can take over this function for the
SBHCs.  Connection with an established health care institution also
gives an SBHC the advantage of a readily available referral network
to provide needed services beyond the capacity of the SBHC, such as
24-hour emergency care or specialized medical care.  This network of
care could also increase SBHCs' attractiveness to managed care
providers. 

SBHCs that follow a variety of organizational models are operating
successfully.  However, the administrative and treatment advantages
that come with affiliation with an established health care provider
suggest that forming such an alliance from the outset can give an
SBHC greater stability and enhance the range of health services it
can offer its patients. 

SBHCs serve many adolescents and younger children who are covered by
Medicaid, and HCFA supports using such centers to provide needed care
to children.  Easing SBHCs' ability to get reimbursement for services
they provide to Medicaid beneficiaries could improve the centers'
financial viability.  We agree with the recommendation of the HHS OIG
that, as states enroll an increasing number of children covered by
Medicaid in managed care plans, it would be beneficial for HCFA to
encourage state Medicaid officials to promote cooperation between
these plans and SBHCs serving their enrollees. 

Another positive step that could help SBHCs get Medicaid
reimbursement is HCFA's reexamination of its free care policy.  If
HCFA were to create an additional exception to Medicaid's free care
policy for services provided by SBHCs, SBHCs could bill Medicaid for
care given to children enrolled in Medicaid regardless of whether
they collect fees for care given to other students. 


SCHOOL-BASED HEALTH CENTERS FACE
OTHER COMMON PROBLEMS
============================================================ Chapter 4

Communities that wish to establish and maintain SBHCs often face
problems other than financing.  One difficulty is finding an adequate
supply of appropriately trained personnel to provide primary care to
students.  A second is controversy stemming from concerns that SBHCs
would provide reproductive health services that some members of the
community consider inappropriate.  Finally, SBHC staff lack easy
access to information that would help them operate their centers. 


   APPROPRIATELY TRAINED STAFF
   DIFFICULT TO RECRUIT AND RETAIN
---------------------------------------------------------- Chapter 4:1

The shortage of primary care providers in the United States is
reflected in the increasing number of unserved and underserved rural
and inner city areas.\38 SBHCs face a particularly acute shortage
because they often need providers with special qualifications, such
as training in work with adolescents or bilingual ability.  The main
health care providers at SBHCs are nonphysician primary care
providers--that is, physician assistants and nurse practitioners. 
SBHCs are hindered in their efforts to recruit and retain these
practitioners because the demand for nonphysician primary care
providers exceeds the supply, especially for providers with
appropriate skills to work in a school setting.  SBHCs'
noncompetitive salaries and working conditions exacerbate the
situation. 

State officials we visited consistently identified the recruiting of
SBHC providers as a problem.  For instance, New York officials
reported a need to expand the number of nonphysician primary care
providers to staff SBHCs.  To increase the supply, they applied for
private foundation funds to develop targeted training programs,
practicum placements, and incentives for employment in school-based
settings.  Similarly, California state officials said that the demand
for nurse practitioners and physician assistants with experience
treating school-age children exceeds the supply.  Fewer than 40 nurse
practitioners with school health experience graduate from approved
programs each year in California.  Health officials in New Mexico are
working with the state's school of nursing to try to increase the
supply of nurse practitioners.  The school had only nine people
enrolled in its program in November 1993. 

The nonphysician primary care shortage is exacerbated for SBHCs
because they cannot offer competitive salaries and working conditions
compared with those of other health care settings, such as hospitals
and HMOs.  For example, in New Mexico SBHC nonphysician primary care
providers are often reimbursed directly by the state's Maternal and
Child Health office, and state regulations limit state-funded
nonphysician primary care salaries to $20 per hour, half the rate in
the private sector.  Similarly, some SBHCs in New York City have been
unable to match the salaries nurse practitioners can earn in other
settings.  State officials in New York told us that the prevailing
compensation for a nurse practitioner in New York City--where most of
the SBHCs are located--was about $75,000 to $85,000 in 1994.  SBHCs
in New York City are at a competitive disadvantage because their
typical compensation for nurse practitioners ranges from about
$55,000 to $65,000.  In some instances, the SBHC sponsor, for
example, a hospital, pays the difference between the amount available
for salary under the state-awarded contract for SBHC operations and
the salaries paid by the sponsor to its other employees.  Other
facilities without these resources, such as community health centers,
have had vacancies for SBHC nurse practitioners that they cannot
fill.  The part-time status of some SBHC positions further limits
salaries. 

School locations in potentially dangerous urban neighborhoods or
remote rural areas further hamper SBHCs' recruiting efforts.  We saw
the effect of this in New Mexico, where seven rural sites wishing to
open SBHCs have been unable to find providers.  One of these--only 20
miles from Albuquerque--could not use a state grant because of its
inability to recruit a nonphysician primary care provider during a
2-year period.  In California, we were told that some nonphysician
primary care providers come to SBHCs to gain experience, then leave
to work for a private facility. 

Another factor that may limit the appeal of SBHCs is that providers
must work more autonomously there than in other settings.  They may
be isolated from colleagues and lack access to training and
opportunities to exchange ideas with other providers. 


--------------------
\38 An Agenda For Health Professions Reform, HHS, PHS (Feb.  1993). 
Primary care providers include family physicians, general internists,
pediatricians, nurse practitioners, physician assistants, and
certified nurse midwives. 


      FEDERAL PROGRAMS FOCUS ON
      TRAINING AND RECRUITING
-------------------------------------------------------- Chapter 4:1.1

HHS' Health Resources and Services Administration sponsors several
programs designed to enhance the skills of school health care
providers, some of whom might work in SBHCs.  For example, MCHB
supports training in adolescent health issues, and the Healthy
Schools, Healthy Communities' staff development grants are intended
to help prepare health care providers and education personnel to
implement comprehensive school health programs.  Additionally, the
Bureau of Health Professions supports programs that provide training
to nurses who work in school settings. 

Another potential source of nonphysician primary care providers for
SBHCs is the National Health Service Corps (NHSC).\39 Other health
settings for the underserved, such as community and migrant health
centers, rely on physicians and other health professionals recruited
from NHSC to overcome problems similar to those faced by SBHCs.  Like
SBHCs, these other settings cannot offer competitive salaries and
sometimes require personnel to work at facilities located in less
desirable areas.  Approximately half of the physicians working in
community and migrant health centers in 1989 were recruited from
NHSC. 

SBHCs have never applied to obtain NHSC staff, but NHSC officials we
talked with were receptive to participation by SBHCs that meet
program requirements.  They noted that such SBHCs could benefit from
ongoing changes in the program.  For its primary care placements,
NHSC recently expanded its earlier focus on physicians to include
nonphysician primary care providers.  The 1990 reauthorization act
for the NHSC
(P.L.  101-597) reserves 10 percent of the appropriation for
scholarships and loan repayments to people studying for certification
as a nurse practitioner, nurse midwife, or physician assistant.  In
addition, NHSC expects to increase the number of placement slots
fourfold between 1994 and the year 2000.  An NHSC official told us
that this increase would expand the opportunity for SBHCs to
participate in the program.  NHSC wants to add more NHSC-approved
sites to its roster to accommodate all of the health personnel
seeking placements. 


--------------------
\39 The Bureau of Primary Health Care's National Health Service Corps
program, established by the Health Professions Educational Assistance
Act of 1976 (P.L.  94-484), encourages the placement of health
professionals in geographic areas and public health programs that
lack health personnel.  The program encompasses two major activities: 
a field program that places qualified health professionals in
shortage areas, and scholarship and loan repayment programs that
provide educational assistance to students of various health
professions in return for an obligated service period. 


   CONTROVERSY OVER REPRODUCTIVE
   HEALTH SERVICES CONSTRAINS
   SBHCS' ABILITY TO MEET SOME
   ADOLESCENT HEALTH NEEDS
---------------------------------------------------------- Chapter 4:2

Many adolescents are sexually active.  Because they are at risk for
disease and pregnancy, they could benefit from access to reproductive
health services.  Some community members, however, consider it
inappropriate for this age group to have access to these services in
schools.  The resulting controversy has sometimes affected the
funding, services, or operations of SBHCs.  SBHC proponents have
found ways to mitigate the potential effects of opposition and
controversy. 

Sexually active adolescents are at risk for problems associated with
unprotected sexual intercourse.  HHS recently reported that over half
of all high school students are sexually active, and 80 percent of
sexually active girls reported that their partners do not use
condoms, the only contraceptive method known to protect against HIV
infection.  Every year, more than 1 million adolescents get pregnant,
representing nearly 1 teenage girl out of every 10 in the United
States, a rate that is at least twice as high as in other
industrialized countries.  Additionally, three million adolescents
contract a sexually transmitted disease each year.  The incidence of
gonorrhea increased 325 percent among 10- to 14-year-olds and
increased 170 percent among 15- to 19-year-olds between 1960 and
1988.  Furthermore, CDC reported a total of 1,412 cases of AIDS among
adolescents through September 1993.\40

The reproductive services that adolescents use include counseling,
gynecological exams, pregnancy testing, sexually transmitted disease
diagnosis and treatment (including HIV testing), prescription and
distribution of contraceptives, and prenatal care.  Many SBHCs
provide all or some of these services, although the majority do not
provide contraceptives.  (For additional information on SBHC
services, see fig.  1.1.)

Opposition to some reproductive health services expressed by groups
of citizens, elected officials, and religious leaders has led some
centers to limit or eliminate family planning services, move their
operations off the school campus, or not open.  Other sites have had
their funding withheld.  Several sites that we visited had
encountered opposition at some point. 

Opponents stopped two separate efforts to establish SBHCs in
neighboring towns in Louisiana.  One proposed site had the backing of
a medical facility and the school board, and the second site--which
also had school board support--had been approved for state funding. 
While proponents of the SBHCs stressed a need for health services and
psychological counseling, opponents expressed concerns about the loss
of parental involvement in an adolescent's health care decisions and
adolescents' potential ease of access to birth control and abortion
services.  Opponents also suggested that a school center would
duplicate existing health services. 

Sites have initiated several actions to garner support for SBHCs. 
For example, the sponsors of an SBHC we visited in California took
steps--before opening the center--to answer the concerns of those who
oppose some SBHC services.  Their efforts included forming a
facilitating committee that included representation from a wide range
of community groups, conducting a needs assessment, promoting
parental support, educating the school board about the children's
need for services, and developing a parental consent procedure that
allowed parents to restrict the services their children could
receive.  The SBHC opened without opposition. 

A school board in New Mexico prohibited an SBHC from continuing to
dispense contraceptives in response to community concerns.  The
decision was reversed after the school experienced an apparent
increase in the number of teen pregnancies, parents expressed strong
support for the services, and students collected about 1,000
signatures on a petition. 


--------------------
\40 CDC noted that while the number of adolescents with AIDS was
relatively small, many additional young people are infected with HIV. 
Since one in five reported AIDS cases is diagnosed in the 20- to
29-year-old age group and the median incubation period between HIV
infection and AIDS diagnosis is about 10 years, many people who were
diagnosed with AIDS in their twenties became infected as teenagers. 


   GETTING GUIDANCE IS DIFFICULT
---------------------------------------------------------- Chapter 4:3

Communities have difficulty getting information on establishing new
SBHCs and solving problems at existing centers.  No central source of
information exists on SBHC operations and potential funding sources. 

People with experience in operating SBHCs or otherwise knowledgeable
about them said that they regularly receive requests for information
on issues such as the relationship between the school and SBHC,
staffing, services, funding, outreach, quality assurance, and
budgeting.  However, experienced SBHC staff sometimes lack time to
answer the large number of requests for assistance.  Officials at one
SBHC site began charging a consultation fee because requests for
information required so much of their time. 

Both potential and established centers have difficulty getting
information on funding sources because of the multitude of programs
affecting varied school health issues, particularly at the federal
level.  SBHC officials told us that centers would also benefit from
information on successful practices for providing care, doing
outreach, and financing SBHCs, including examples of coordination
between managed care providers and SBHCs. 


      NO CENTRAL POINT EXISTS FOR
      INFORMATION AT THE FEDERAL
      LEVEL
-------------------------------------------------------- Chapter 4:3.1

HHS does not have a focal point to handle outside inquiries or to
centralize information on federal programs for SBHCs.  An HHS
official told us that staff regularly receive technical assistance
requests from officials interested in school-based services but said
that the agency lacks the infrastructure to handle these requests. 
In its December 1993 report, HHS' OIG recommended that HHS establish
contacts in its agencies for interested parties outside the
department who required information about SBHCs, but, as of October
1994, HHS had not implemented this recommendation.\41

A multitude of federal programs support health-related activities in
schools, including health services, health education, and staff
training.  Multiple agencies--and offices within these agencies--have
responsibility for these programs.  In June 1992, HHS and the
Department of Education began an effort to coordinate and improve the
delivery of these services in schools by initiating the Interagency
Committee on School Health.  In April 1994, the Secretaries of both
departments issued a joint statement that announced their cooperative
efforts.  Committee members identified 23 HHS, Education, and
Department of Agriculture programs as potential federal funding
sources for school health programs.  In addition, they have formed
three subcommittees and multiple work groups to study various issues,
including technical assistance, financing, and school-based service
models.  The Health Services Subcommittee is examining ways the
federal government can support school-based health services,
including actions related to funding. 


--------------------
\41 School-Based Health Centers and Managed Care. 


   CONCLUSIONS
---------------------------------------------------------- Chapter 4:4

SBHCs' difficulty in attracting an adequate supply of qualified
providers could grow more serious with a substantial increase in the
number of SBHCs.  HHS' support of training programs for school health
care providers may help expand the number of skilled providers
capable of working in SBHCs.  Furthermore, NHSC officials'
willingness to consider participation by SBHCs could make available
to school centers an additional pool of caregivers; at the same time,
SBHCs would provide additional placement opportunities for NHSC
practitioners. 

Another problem for SBHCs and people who would like to establish new
SBHCs is the lack of a central source of information on the wide
range of issues that affect SBHC operations, including financing,
staffing, and quality of care.  SBHCs first developed at the
grassroots level, with states and local communities creating programs
to respond to the particular needs and circumstances in their
locales.  As interest in using SBHCs to bring health care to children
has expanded, so have the quest for information about how to
establish and operate SBHCs and the desire to learn from the
experiences of pioneering centers. 

HHS could fill this information gap if it were to follow the
recommendation of its OIG and establish a focal point in the
department to respond to requests for information on SBHC operations
and the many federal programs that are potential sources of financial
support for SBHCs.  This focal point could also organize a technical
assistance function to help communities develop SBHCs that best meet
the needs of their families.  An additional contribution the focal
point could make would be to work with federal health research
agencies to include in the national research agenda questions about
the best ways to provide health care to children and the role and
impact of SBHCs. 


DESCRIPTIONS OF SCHOOL-BASED
HEALTH CENTERS
=========================================================== Appendix I

The following information was provided by the staffs of the SBHCs we
visited and state officials.  Health center staff include both
full-time and part-time personnel.  All data are for the 1992-1993
school year unless otherwise noted. 


   THOMAS EDISON HIGH SCHOOL,
   STOCKTON, CALIFORNIA
--------------------------------------------------------- Appendix I:1


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:1.1

Population:  2,308 students in grades 9-12; 40 percent Hispanic, 33
percent Asian, 17 percent African-American, 6 percent white, 4
percent other

Health Needs:  The county has a high teen pregnancy rate.  A student
health assessment indicated high levels of unprotected sex and
alcohol, tobacco, and drug use, and a need for health education and
mental health services. 


      OPERATIONS
------------------------------------------------------- Appendix I:1.2

Year opened:  1993

Linked facility:  Health Service Agency

Hours:  Approximately 40 hours per week; open during summer

Staff:  Nurse practitioners, physician assistant, school nurse,
medical assistant, health clerk, physician, mental health workers,
nutrition counselor, site coordinator

Health services:  Immunizations, physical exams, minor illness/injury
treatment, chronic illness test/management, prescriptions (written
and dispensed), lab tests, reproductive/family planning services;
various health education and counseling programs

Annual budget:  $192,575 (1993)

Funding sources:  Federal--Medicaid; state--multiple state programs;
other--private insurance, private foundations

Utilization (1993-94 school year):  1,750 consent forms on file;
1,049 students involving 2,272 visits


   LUTHER BURBANK ELEMENTARY
   SCHOOL,
   SAN JOSE, CALIFORNIA
--------------------------------------------------------- Appendix I:2


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:2.1

Population:  367 students in grades kindergarten-8; 64 percent
Hispanic, 20 percent white, 6 percent African-American, 5 percent
Asian, 5 percent other

Health needs:  The community has high poverty, a high crime rate, and
high drug use.  The school district is in an unincorporated area with
few resources. 


      OPERATIONS
------------------------------------------------------- Appendix I:2.2

Year opened:  1991

Linked facility:  Hospital

Hours:  7 hours per day, 3 days per week; open during summer

Staff:  Nurse practitioner, medical assistant, physician

Health services:  Immunizations, physical exams, acute/chronic
illness treatment, prescriptions (dispensed), lab tests

Annual budget:  $52,576 (fiscal year 1993)

Funding sources:  Federal--Medicaid, state--multiple state programs,
other--private foundations

Utilization:  About 275 consent forms on file, 102 students involving
383 visits


   OVERFELT HIGH SCHOOL,
   SAN JOSE, CALIFORNIA
--------------------------------------------------------- Appendix I:3


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:3.1

Population:  1,950 students in grades 9-12; 61 percent Hispanic, 14
percent Asian, 5 percent African-American, 5 percent white, 15
percent other

Health Needs:  The school is in an area of lower-middle- to
low-income housing.  Census data from 1985 show 60 percent of
families in the area on Aid to Families with Dependent Children and
30 percent of households headed by a single parent. 


      OPERATIONS
------------------------------------------------------- Appendix I:3.2

Year opened:  1986

Linked facility:  Hospital

Hours:  Approximately 40 hours per week; not open during summer

Staff:  Physician assistant, medical assistant, physician, pregnancy
prevention counselor, mental health counselors, substance abuse
intervention and treatment staff

Health services:  Immunizations, physical exams, acute/chronic
illness treatment, prescriptions (dispensed), lab tests, family
planning, pregnancy testing, prenatal care, sexually transmitted
disease diagnosis and treatment, health education, counseling

Annual budget:  $97,052 (fiscal year 1993)

Funding sources:  Federal--Medicaid, state--multiple state programs,
other--private foundations

Utilization:  466 students involving 3,115 visits


   ESPANOLA VALLEY HIGH SCHOOL,
   ESPANOLA, NEW MEXICO
--------------------------------------------------------- Appendix I:4


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:4.1

Population:  1,238 students; 83 percent Hispanic, 10 percent white, 7
percent Native-American

Health needs:  The school is located in an impoverished area, with a
high incidence of drug abuse, alcoholism, and violence.  The county
has the highest teen pregnancy rate in the state.  The SBHC was
established to address the teen pregnancy rate and the spread of
sexually transmitted diseases. 


      OPERATIONS
------------------------------------------------------- Appendix I:4.2

Year opened:  1985

Linked facility:  None

Hours:  35 hours per week; not open during summer

Staff:  Nurse practitioner, registered nurse, physician, secretary

Health services:  Physical exams, primary and preventive health care,
prescriptions (written and dispensed), family planning, health
education, alcohol and drug counseling, counseling on adolescent
concerns, various workshops and teen groups. 

Annual budget:  $80,000 (1993-94 school year)

Funding sources:  Federal--Maternal and Child Health Block Grant,
state--state grant; other--school district

Utilization:  619 students involving about 4,500 visits


   ESCALANTE HIGH SCHOOL/MIDDLE
   SCHOOL,
   TIERRA AMARILLA, NEW MEXICO
--------------------------------------------------------- Appendix I:5


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:5.1

Population:  160 high school students (grades 9-12) and 60 middle
school students (grades 6-8) on a shared campus.  The SBHC also
serves 75 middle school students from a nearby town.  Of students
using the SBHC, 82 percent are Hispanic and 18 percent are white. 

Health needs:  The community is in a rural area and has a large
low-income, minority population with a high incidence of
hypertension, heart disease, obesity, alcohol abuse, and diabetes. 


      OPERATIONS
------------------------------------------------------- Appendix I:5.2

Year opened:  1992

Linked facility:  None

Hours:  15 hours per week (spread over 4 days); not open during
summer

Staff (1993-94 school year):  Nurse practitioner, registered nurse,
public health nurse, health educator, clerk/coordinator

Health services (1993-94 school year):  Immunizations, sports
physicals, primary care, prescriptions (written and dispensed),
family planning, health education

Annual budget:  $21,610 (1993-94 school year)

Funding sources:  Federal--Maternal and Child Health Block Grant;
state-state grant; other--private foundation, school district

Utilization:  About 65 students involving 684 visits


   INTERMEDIATE SCHOOL
   136, NEW YORK,
   NEW YORK
--------------------------------------------------------- Appendix I:6


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:6.1

Population:  1,057 students in grades 6-9; 60 percent Hispanic, 40
percent African-American

Health needs:  The community's poverty rate is much higher than in
other sections of New York City and is one of the major drug areas in
the city.  The area also has a high teen pregnancy rate. 
Seventy-nine percent of students using the SBHC report having no
regular source of medical care. 


      OPERATIONS
------------------------------------------------------- Appendix I:6.2

Year opened:  1991

Linked facility:  Hospital

Hours:  40 hours per week; open during summer

Staff:  Nurse practitioner, health educator, physician, social
workers, health advocate, office manager, numerous other part time
staff

Health services:  Immunizations, physical exams, trauma response,
first aid, chronic illness management, prescriptions (written), lab
tests, health education, stress management, counseling, crisis
intervention

Annual budget:  $275,000 (1993-94 school year)

Funding sources:  Federal--Medicaid, other--New York City Department
of Health (matched in part by the state)

Utilization:  1,105 consent forms on file, 902 students involving
5,022 visits


   PRIMARY SCHOOL 155,
   NEW YORK, NEW YORK
--------------------------------------------------------- Appendix I:7


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:7.1

Population:  468 students in grades kindergarten-6 plus 100 students
in a collocated "alternative" middle school; 70 percent Hispanic, 25
percent African-American, 3 percent white, 2 percent Asian

Health needs:  The community is one of the poorest in the area, with
high unemployment, poor education, and a high number of single-parent
households.  About one-third of area residents receive public
assistance. 


      OPERATIONS
------------------------------------------------------- Appendix I:7.2

Year opened:  1982

Linked facility:  Community Health Center

Hours:  Approximately 38 hours per week; open during summer

Staff:  Pediatric nurse practitioner, school health workers,
physician, program director, school health secretary

Health services:  Immunizations, physicals exams, screenings, dental
services, episodic care, first aid, chronic illness management,
prescriptions (written), health/nutrition education, psychosocial
counseling

Annual budget:  $80,200 (1993-94 school year)

Funding sources:  Federal--Medicaid, Maternal and Child Health Block
Grant; state--multiple state programs; other--private insurers

Utilization:  435 consent forms on file, 346 students involving 1,118
visits


   WILLIAM HOWARD TAFT HIGH
   SCHOOL,
   BRONX, NEW YORK
--------------------------------------------------------- Appendix I:8


      SCHOOL PROFILE
------------------------------------------------------- Appendix I:8.1

Population:  3,300 students in grades 9-12; 50 percent Hispanic, 40
percent African-American (including Caribbean), 10 percent other

Health needs:  The school is located in the poorest U.S. 
congressional district in the country.  The area around the school
has one of the highest rates of HIV infection in the country.  Over
75 percent of students using the SBHC have no health insurance, and
many lack basic health care.  Providing care is complicated by a high
level of student transience. 


      OPERATIONS
------------------------------------------------------- Appendix I:8.2

Year opened:  1987

Linked facility:  Hospital

Hours:  40 hours per week; not open during summer

Staff:  Nurse practitioner, coordinator/social worker, licensed
practical nurse, health aides, outreach worker, social worker,
physician

Health services:  Immunizations, physical exams, screenings (dental,
vision, hearing), chronic illness care, prescriptions (written),
routine lab tests, family planning information, pregnancy tests,
sexually transmitted disease treatment, health education, nutrition
counseling, mental health counseling, general social services

Annual budget:  $285,000

Funding sources:  Federal--Medicaid, Maternal and Child Health Block
Grant; state--multiple state programs; other--Bronx-Lebanon Hospital,
United Way, private insurers

Utilization:  2,486 consent forms on file, 948 students involving
4,163 visits


GAO CONTACTS AND STAFF
ACKNOWLEDGMENTS
========================================================== Appendix II

GAO CONTACTS

Bruce D.  Layton, Assistant Director, (202) 512-6837
Mary A.  Needham, Evaluator-in-Charge, (303) 572-7311
Helene F.  Toiv, Assignment Manager, (202) 512-7162

ACKNOWLEDGMENTS

In addition to those named above, the following individuals made
important contributions to this report:  Joe Sikich, Evaluator;
Frederick K.  Caison, Senior Evaluator; Robert G.  Crystal, Assistant
General Counsel; Sylvia L.  Shanks, Senior Attorney Advisor; and
Cynthia Schilling, Reports Analyst. 

