School-Based Health Clinics Work

On Monday, the House Committee on Government Oversight and Accountability passed HB 1052, a bill to encourage the construction of school-based health care clinics in high-poverty school districts. Many other states, most notably Texas, have robust school-based clinic programs. The following is a memo from my Legislative Assistant Emily Walker summarizing research on these clinics. Conclusions: they work to save money, reduce unnecessary ER visits, and improve the health and education outcomes of students in schools where these clinics exist. 

To:       Representative Barnes

From:   Emily Walker

Re:       School Based Health Clinics

Date:   February 6, 2014


Question:        What are the value of School Based Health Clinics based on academic studies and real world data?


            School Based Health Centers (SBHCs) have developed in the past three decades as a solution to health care access problems in younger populations.  These in-school clinics help to “overcome utilization barriers in a way not previously documented in other clinical settings, even when serving populations that suffer from significant health disparities.”[1] Based on census data collected by the School-Based Health Alliance for 2010-2011, there were 1381 school based clinics that provided primary care and responded to the surveys.[2] SBHCs are found in a variety of communities: 54.2% in urban areas, 27.8% rural areas, 18.0% suburban areas.[3]  Of the responding clinics, 94.4% are located within school buildings.[4] The numbers of these clinics are growing and Missouri already has four located within our state.[5]

            There is no set funding or structured mechanisms for SBHCs.  Financing may come from a variety of sources and control comes from multiple levels (private sector, local government, state government, etc.)  Other states have successfully implemented these clinics on a state level.  Texas recently passed an expansion measure in 2009 to further support SBHCs.[6] HB 281 was a bipartisan bill passed unopposed in the House Public Education and Senate Education committees and signed into law by Governor Perry.[7]  This expansion of the program included stabilized and increased grant funding for the programs.[8]  According to the Census data collected by the School-Based Health Alliance, Texas had 87 school-based health clinics at the time of the survey.[9]

            There are many benefits to the school-based health clinic system.  These clinics have consistently shown decreases in emergency department visits, increases in primary care access, increases in immunizations, and better quality of health care for children who traditionally lack health care resources.  SBHCs knock down many of the barriers that children from high-risk families often battle, including: lack of private health insurance, transportation to appointments, parental absence from work, lack of awareness, and other stressors that keep children away from health professionals.[10] Not only do these programs give children access to health care, the ultimate goal of the clinics serves the ultimate goal of education programs.  As Adams and Johnson explain, “the program is aimed at improving school attendance and classroom performance and the longer-term prospects for these children as they mature”[11] 

            Numerous studies have found the cost saving measures that school-based clinics provide for public insurance programs. In Adams and Johnson’s article, An Elementary School-Based Health Clinic: Can it Reduce Medicaid Costs?, the authors answered the title question in the affirmative.[12]  This study compared children served by a school-based clinic to demographically similar children who did not have access to the same kind of clinic.[13]  There were no significant differences between the groups before the clinic opened, but two years after its opening, the children with access to the clinic had significantly lower instances of inpatient visits, non emergency department transportation, drug, and emergency department Medicaid expenses.[14]  These lower instances of high cost health care items meant that the school-based clinic helped to curb costly health care mechanisms for the children who had access to the SBHC.

            Another study also examined the affect of school-based clinics on the frequency of emergency department visits.  In Young, D’angelo, and Davis’ 2001 article Impact of a School-Based Health Center on Emergency Department Use by Elementary School Students, the authors wrote that emergency room visits are often non-urgent and have the negative effects of increasing medical costs and fragmenting health care.[15]  In their study, the authors examined elementary aged children (5-12) from an inner city neighborhood.[16]  The clinic served a school that had a student population of 95% of the population on free/reduced lunch and 60% African American/40% White.[17]  This study used a retrospective audit of emergency department records that compared the year before implementation of a school-based clinic to the year after its inception.[18] There was a significant drop in emergency room visits after the school-based clinic was introduced to the school.[19]  The results of this study show that SBHCs help to decrease non-urgent emergency department visits, and therefore the higher costs of these visits.

            Key, Washington, and Hulsey provided their findings of lesser emergency department visits by adolescents enrolled in SBHCs into their 2002 article, Reduced Emergency Department Utilization Associated with School-Based Clinic Enrollment.  This was another retrospective cohort study that examined emergency department utilization rates before and after adolescents enrolled in a SBHC.[20]  The subject school was an urban, public high school that’s student population was made up of 80% free/reduced lunch recipients and 99% African American.[21] The study showed a decrease in the emergency department visit rate for both groups from the base year, but this decrease was only statistically significant for the students who chose to enroll in the SBHC (enrollees had a 41% decrease of emergency room visits after enrolling in the clinic).[22]  The authors noted that because the study compared a population with prior emergency room use and then recorded the changes following the enrollment in a SBHC, the SBHC should be attributed as the cause of the decrease.[23]

            Beyond the scope of saving money on decreased emergency room visits, SBHCs serve other important interests as well.  One major benefit to note is the ability of SBHCs to help with vaccination rates in adolescents. In the article Addressing Adolescent Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery, the authors performed a study to determine if SBHCs can improve rates of immunizations among at risk children and adolescent populations.[24] The study was a retrospective cohort analysis of children and adolescents who were split into groups that received health care from either a Denver SBHC or Community Health Center (CHC).[25]  For most types of vaccinations, children and adolescents were more likely to be up-to-date on their immunizations if they received health care from SBHCs.[26]  Along with this, for vaccines that require multiple doses over a set period of time, SBHCs were more likely to guarantee children received all doses.[27]  The authors noted a variety of reasons for why SHBCs are better for vaccinations, including: easier access to care, reminders to come back for care are easier, the tracking system is easier within the school system, many SBHCs see patients without any payment requirements, parents do not have to leave work, and students do not have to leave campus for the care.[28]

            Finally, a more recent study addresses all of the issues discussed above and the overall strong benefits of SBHCs.  In the article School-Based Health Centers: Improving Access and Quality to Care for Low Income Adolescents, the authors wanted to examine all of the advantages of SBHCs.[29] This was a retrospective cohort study that tracked the use of health care and markers of quality of care for adolescents enrolled in SBHCs compared to adolescents who used other community care entities.[30]  The SBHCs helped to increase uninsured adolescents access to care for primary health care.[31]  This increase in access to care through SBHCs led adolescents to report a higher likelihood to have three or more primary care visits, less emergency department visits, more health maintenance visits, and a higher likelihood to receive a flu vaccine, a tetanus booster, and a Hepatitis B vaccine.[32]  The authors of this study strongly established that SBHCs provide underserved adolescents and children with better access to care and an overall higher quality of health care than traditional community health systems do.

            There are multiple studies available to show the benefits of SBHCs to serve populations of children and adolescents that traditionally have not received quality health care.  These clinics have statistically shown they can reduce Medicaid expenditures through better preventive care measures, they increase immunization rates, and overall, they provide higher quality of care for a population that is often underserved.

[1] Steven Federico, et. al., Addressing Adolescent Immunization Disparities: A Retrospective Analysis of School-Based Health Center Immunization Delivery, 100:9 American Journal of Public Health,1630-1634 (2010).

[2], 2010-2011: Census Report of School-Based Health Centers, School Based Health Alliance, 2012, (last visited February 6, 2014).

[3] Id.

[4] Id.

[5] Id.

[6], Legislative Efforts, Texas Association of School-Based Health Centers, 2009, (last visited February 6, 2014).

[7] Id.

[8] Id.

[9] 2010-2011: Census Report of School-Based Health Centers.

[10] Thomas Young, et. al., Impact of a School-Based Health Center on Emergency Department Use by Elementary School Students, 71:5 Journal of School Health, 196 (2001).

[11] E. Kathleen Adams and Veda Johnson, An Elementary School-Based Health Clinic: Can it Reduce Medicaid Costs?, 105 Pediatrics, 780-788 (2000).

[12] Id.

[13] Id.

[14] Id.

[15] Young, D’angelo, and Davis.

[16] Id.

[17] Id.

[18] Id.

[19] Id.

[20] Janice Key M.D., E. Camille Washington, M.D., Thomas C. Hulsey M.S.P.H., Sc. D., Reduced Emergency Department Utilization Associated with School-Based Clinic Enrollment, 30:4 Journal of Adolescent Health, 273-278 (2002).

[21] Id.

[22] Id.

[23] Id.

[24] Id.

[25] Id.

[26] Id.

[27] Id.

[28] Id.

[29] Mandy A. Allison, MD, MSPH, et al. School-Based Health Centers—Improving Access and Quality of Care for Law-Income Adolescents, 120:4 Pediatrics, 887-894 (2007).

[30] Id.

[31] Id.

[32] Id.