Episode 21: School-Based Healthcare Is Expanding. How Can Schools Sustain It?
Marley Arechiga in conversation with Lisa Eisenberg, Child and Youth Health Financing Project Director at WestEd.
Lisa Eisenberg:
It’s a lot of work to deliver comprehensive health services in a school setting. And the thing I would tell schools is you don’t have to do it by yourself.
Marley Arechiga:
Welcome to Leading Voices, the podcast where WestEd experts break down pressing challenges in education and human development, and provide insights you can apply to practice and policy. I’m Marley Arechiga.
In the last couple of decades, thousands of schools have started providing health services on site in addition to school nurses. Things like vaccines, dental and preventative care, and mental and behavioral health support. But funding streams across education and healthcare systems are fragmented. How you might fund a traditional health clinic, for example, doesn’t always apply in a school setting.
As more schools embrace on-site healthcare, they need to wrestle with how to finance those services in a way that makes sense for school context and how to fund those services for the long-term. Here to talk with us about how leaders can sustain school-based health services is Lisa Eisenberg. Lisa is the Child and Youth Health Financing Project Director at WestEd. She has over a decade of experience in school-based health policy and implementation.
Hi, Lisa. Welcome to the show.
Lisa Eisenberg:
Thank you. I’m excited to be here.
Marley Arechiga:
So, Lisa, let’s start with why schools are taking on a bigger role in healthcare in the first place. What’s driving that?
Lisa Eisenberg:
I first want to clarify that schools have been providing health services in school settings since the ’70s. So they have been required to meet the healthcare needs of students in special education since the ’70s. What is leading to the growth in school-based health has, I think, been this growing trend that students have needs beyond their academics that they bring with them into the classrooms and to the schools. So we’ve seen a lot of focus in schools on multi-tiered systems of supports, community schools. The COVID pandemic put a huge spotlight on the needs of students and what they were receiving in school settings and the role of schools to provide those services.
Marley Arechiga:
How do schools typically fund school-based healthcare now?
Lisa Eisenberg:
It looks like a lot of different things. I think what is most common is that schools receive short-term grants to fund a school-based health program, and they often use the schools, the education system’s state and federal funding to sustain school-based health services. We’re seeing more and more schools leverage direct billing through Medicaid. We’re also seeing schools leverage community healthcare partners such as clinics, hospitals, health plans that are bringing funding and billing and services with them into school settings with the partners. And I think that this is a big question for schools.
In the past couple years, we’ve seen a lot of investment in school-based health services, school-based behavioral health services with one-time funding, for example, from COVID relief dollars. And a lot of schools are facing this question about, “What do we do next? How do we sustain these investments we’ve made and built over the last five years?”
Marley Arechiga:
So a question around sustaining. They’ve already launched stuff or they used short-term funds and now they want to figure out how to sustain it for the long-term.
Lisa Eisenberg:
How to keep going what they’ve already put their dollars into.
Marley Arechiga:
Yeah. Okay. So when I think of schools, I don’t think about copays or a surprise medical bill when I go home. I’m sure there are differences in the system. So where do you see the biggest disconnect between education and health systems when it comes to funding?
Lisa Eisenberg:
I think in terms of financing, I’ve been thinking about this a lot recently. Healthcare services in community settings are financed by a per-person model. So a patient comes into a clinic or a hospital, they get a service, and that clinic and hospital gets paid a dollar amount for that service. I’m oversimplifying, but that’s generally what I think that the healthcare system is looking at.
Schools and education operate really differently. They may receive state and federal funding on a per-student basis, but that goes into a budget that they then have to spend on costs that support the education and needs of all students in their district, in their local educational agency.
I think an interesting and complicated mismatch when it comes to schools leveraging healthcare dollars, because they are faced with having to adapt to a healthcare financing system where they see a student for a service and they get paid for that service. And then what to do with that funding and how to think about leveraging is often really complicated for schools.
Marley Arechiga:
Medicaid is often mentioned as a solution for funding school-based health. Can you give us an overview of how schools can use Medicaid to sustain school-based health services?
Lisa Eisenberg:
Sure. And this podcast is two hours long, right? How much time do I have? I’ll give you the Medicaid synopsis in one minute. First, as a point of setting the stage, Medicaid is health insurance for low-income children and adults in the United States. And about 50% of US children are eligible for Medicaid. So that’s at least half of students in states are eligible for Medicaid. We’re talking about coverage for a lot of students.
Medicaid is also a state and federal partnership. So the federal government puts up a share of funding and the states put up a share of funding. I think almost every state has what I call a school Medicaid program. And this is a way for schools to generate Medicaid dollars for the health services that the school is providing to students that are enrolled in Medicaid.
And I will say this is an adage that I’ve heard lots of folks say over the years, is if you’ve seen one state’s school Medicaid program, you’ve seen one state’s school Medicaid program. So they look different across the country, but it is a way for a school to generate Medicaid dollars for health services they’re providing to students enrolled in Medicaid.
Marley Arechiga:
What are some misconceptions about how Medicaid reimbursement actually works in schools?
Lisa Eisenberg:
There’s sometimes an oversimplification that the cost of delivering this health services to students will be 100% matched by Medicaid dollars, and that’s just not possible. Medicaid funding will not 100% meet the costs of delivering these services. Now, I say it’s a great way to generate some dollars. $50 is better than $0. And so I often think when we are talking to schools about leveraging Medicaid is they have to think about what they are blending these dollars with and with other funding streams, whether that’s their state and federal general education dollars, whether it’s other grants, whether it’s other funding sources that will match with Medicaid dollars.
Marley Arechiga:
Yeah. That goes back to your adage from earlier about how every state system is very unique, and so it sounds like people want to braid funding streams. There are likely resources available, but they probably have to do some legwork to find out which hospitals might be providing grants or which community partners might have some funding sources that they can braid. Going back to Medicaid specifically, there’s been a lot of changes in the Medicaid program over the last year. What should schools know about those changes?
Lisa Eisenberg:
That is a complex question that I am still trying to figure out the easy way to explain this to school leaders. The first point I would make is that the federal government made a lot of changes to how Medicaid has to be administered by states, and those changes are being rolled out over many years. So the changes we all heard about last year aren’t happening tomorrow, they’re happening over many years.
The second thing I would tell school leaders is that by and large, many of those federal changes impact how states make decisions about providing Medicaid coverage for single adults. So, if we remember, the Affordable Care Act expanded access to Medicaid for single adults. What happened in this last year rolled back some of those changes and specifically made changes to adults.
So the third thing I would tell school leaders is a lot of the changes we heard may not directly change Medicaid coverage for students. So the students that were eligible for Medicaid a year ago are going to continue to be eligible for Medicaid today, and tomorrow, and going forward.
Then, the fourth thing I would say is, the list is getting long. The fourth thing I would say is how schools will adapt to Medicaid changes for students is going to be really dependent on how their state makes adaptations, and there are probably going to be 50 different ways of adapting to those federal changes. So I think a lot of what will impact children, youth, and students will be driven by state decisions.
And then the last thing I would just point out for schools that are playing a role in helping children, youth, and families get enrolled in health coverage is to take resources from their states and how to communicate about health coverage options for children, youth, and families.
There are 14 states plus the District of Columbia that provide Medicaid coverage for undocumented children and youth. And there was a court decision last December that said that Medicaid information that’s collected by the state for undocumented populations has already been shared with the federal government and that the federal government can share that with the Department of Homeland Security.
So if you are a school that is enrolling children, youth, and families into health coverage, including Medicaid, that is an important detail to share with children, youth, and families. Now, I am not the expert on how to do that, but there are a lot of organizations in every state that will support schools and anybody in the community that’s helping families enroll in health coverage with the right talking points.
Marley Arechiga:
So a lot of considerations there. I want to get to how school-based health contributes to other areas of student success. What does research tell us about the effect of school-based health services on things like attendance or behavior or academic performance?
Lisa Eisenberg:
So there’s not really one research that says like, “This is school-based health writ large,” but I think research kind of looks at the impact of school-based health centers, school nurses, school mental health services and programs, and research looks at it like those interventions a little separately, so answering this question is a little bit challenging.
I will say across those interventions, we see generally that school health services are correlated to improved attendance, improved graduation rates. Some states and schools measure indicators on student connectedness to schools, and so school health shows that students feel more connected to their school campus. They can identify an adult that they trust on school campus.
And a lot of research also shows benefits on healthcare factors such as reduced emergency room visits, increase in access to preventative healthcare visits. So we see benefits across the board, and the specifics are a little bit nuanced depending on what intervention we’re talking about.
Marley Arechiga:
Schools are already doing a lot. I think we hear the classic example of teachers. Teachers play many roles for students. Is it a fair critique to ask, why would schools play a bigger role in healthcare when they’ve already got really big challenges to contend with?
Lisa Eisenberg:
I have two answers. The first thing I will say is students are already coming to school with challenges that schools are in a position to address. And the research shows that when schools and education systems provide these services, it helps schools and education systems meet their academic goals. So it helps them get students graduated. It helps get students attending classes. So I think school health services are tied deeply to the goals of schools.
The second thing I would say is yes, it’s a lot of work to deliver comprehensive health services in a school setting. And the thing I would tell schools is you don’t have to do it by yourself, that there are partners in the community that already have the responsibility of making sure kids get to see their doctor on an annual basis, that kids are getting vaccinations, that kids are getting in to see mental health therapists. So find those partners in your community. It could be a clinic. It could be a hospital. It could be a youth development agency. Those are the partners that will work with schools to provide some of these health services so schools don’t have to feel like they’re doing it all by themselves.
Marley Arechiga:
One thought I had was the possibility of school-based health services maybe shifting away responsibility from healthcare systems, but it sounds like if you’re making the right partnerships, healthcare systems, and education system, schools can share that responsibility in, really, community-oriented ways. When leaders try to measure return on investment or success for school-based health services, what are some indicators they should be looking at?
Lisa Eisenberg:
Most of the return on investment studies or cost benefit studies have looked a lot of savings on the healthcare side. So there’s been studies of school-based health centers and visits at school-based health centers reducing the number of emergency visits, so seeing cost savings on the healthcare side. There’s a Massachusetts study that showed that for $1 invested in school nurses, it saved the health system $2.20. So we’ve seen a lot of it on the healthcare side, and I think that that’s often because a lot of the big expenses are captured in the healthcare side.
For our education partners, I think what is most common for return on investment is looking at stuff like student attendance. So we know that access to school-based health services can increase attendance. Increased attendance can look like more per-student funding available to the schools.
There was a really interesting study done in Los Angeles that saw that one visit to a school-based health center was correlated with an increase in attendance, and that was an even greater increase in student attendance when that visit to the school-based health center was for mental and behavioral health services. So we know that access to school-based health services is aligned with an increase in student attendance, which can be captured in a return on investment by increase per-student funding.
Marley Arechiga:
I was thinking earlier in the conversation too about a convenience factor for parents and families to have all of those things in one place. I don’t know how you measure that, but it’s like a nice community or a hub that families can go to.
Lisa Eisenberg:
I will say some of the cost benefit studies or return on investment studies that I have seen have monetized the parent amount of time saved from not missing work.
Marley Arechiga:
Oh, interesting. So maybe family time saved is another indicator to look at. So, in your work, like we’ve been discussing, you’ve encountered a lot of districts who’ve already launched school-based health services or school-based health centers. If you were advising a district today on how to sustain what they’ve already built, what would you say to them?
Lisa Eisenberg:
School Medicaid programs are challenging. They’re difficult, and they’re worth the effort. So I think the first thing I would say is understand what percentage of your students are on Medicaid. We know that low-income students are often clustered in specific school districts, and so that is where I would start. Understand what your population of Medicaid kids are, and then ask, “Are you leveraging reimbursement for those services? Do you need to start?” because you can bring in dollars into your system to support funding for these services.
The second thing I would say, and I feel like I’m often a broken record around this, is asking who are your partners that are serving the same students. You have community-based healthcare providers that are trying to see the same students that are coming to your school every day, so they can help you. They can help by coming onto your campus. They can help by working with you to refer students out to their services. There are lots of ways that you can partner with the healthcare community to help make sure that the needs of students are being addressed before they’re walking into your school campus.
Marley Arechiga:
Okay. So there’s a lot there for local leaders to consider. What about leaders at the state level? What can they do to help build sustainable funding for school-based healthcare?
Lisa Eisenberg:
So, over the years, I’ve seen a lot of schools adapt to healthcare systems, whether that’s the school Medicaid program, whether that’s partnering with health plans, whether that’s billing for health services. And my general recommendation for state leaders is to focus on removing barriers to this work with healthcare partners, whether that’s removing barriers to how schools participate in the school Medicaid program or adapting other healthcare programs to meet the needs of schools, and then also encouraging healthcare partners to build relationships with schools.
So focusing on the healthcare side of this equation in meeting schools where they are. And there’s lots of ways to do that, but that’s where I would encourage state leaders to start. Don’t build something new, don’t fund something new, focus on what there is, and remove some of the challenges that schools face in accessing the resources that are currently available on the healthcare side.
The second thing I would encourage state leaders to think about is understanding what billing can support for school-based health services and working with school partners to fill in the gaps. Billing, whether it’s the school Medicaid program, whether it’s something else, is not going to sustain 100% of what we want to see in school-based health services. And there are really important parts of that comprehensive school health services model that aren’t going to be sustainable through billing. So that is the other thing I would have state leaders focus on is what are those important gaps that can’t be filled with billing, and what is the state’s role in helping schools figure out how to finance and find the right puzzle piece to fit in that gap?
Marley Arechiga:
Okay. So plenty of considerations and questions for local and state leaders. Lisa, before we close, what’s one thing you hope listeners take away from this conversation?
Lisa Eisenberg:
Yeah. The one thing I hope listeners take away, and it shouldn’t be a surprise, I’ve said this already in today’s conversation, is that there’s no single approach that is going to single-handedly sustain comprehensive health services. The challenge and the task that I would offer education leaders in this space is to leverage healthcare funding and to leverage healthcare partners to the extent possible.
If you can participate in your state’s school Medicaid program, those dollars are there in the system to support eligible students. You should take advantage of them. And in addition to that, leverage community partners that are already committed to supporting and providing health services to children and youth that are coming to your schools.
The last thing I would say is that education leaders should know that they don’t have to solve the sustainability question on their own, that they should reach out to their healthcare partners to support this work.
Marley Arechiga:
All right. Thank you, Lisa. We’ll wrap it up there. Thank you for being on the show.
Lisa Eisenberg:
Thank you for having me.
Marley Arechiga:
Yeah. Of course. To our listeners, if you want to continue the conversation with Lisa, you can find her on LinkedIn or email her at [email protected]. That’s [email protected]. In the show notes, you’ll find publications that Lisa has co-authored about how to sustain school-based health services. There’s also one in there specifically about using Medicaid. You can also meet up with Lisa at the National School-Based Healthcare Conference in June and the National Alliance for Medicaid in Education Conference in September. We’ll have more details in the show notes about those events as well. While you wait for the next episode, consider subscribing to our podcast on Apple Podcasts, Spotify, YouTube Music, Pandora, or iHeart.
This podcast was brought to you by WestEd. WestEd is a nonpartisan research, development, and service agency. We work to promote excellence, improve learning, and increase opportunity for children, youth, and adults. Special thanks to our audio producer, Sanjay Pardanani, and to Gretchen Wright for her editorial support. Thanks so much for tuning in. Until next time.