Citing adolescent mental health statistics from CDC regarding increases in anxiety and depression, the Biden-Harris Administration released a guidance document urging states to embed more resources for children within schools.
Just over half of children in the US obtain health care coverage through Medicaid or the Child Health Insurance Program (CHIP). For these 40 million children, linking services to schools is intended to improve access to care, not only for mental health support but also for routine exams and immunizations. Community efforts to promote child well-being and counteract the challenges of growing up in poverty require a multi-faceted approach. The administration is leveraging schools to accomplish this mission.
Expanding access to care through school-based health centers
School-based health centers (SBHCs) provide a medical home for students who might not have ready access to care. Launched in the 1960s by the American Academy of Pediatrics (AAP), SBHCs are intended to promote better access to care and improve educational outcomes in underserved areas. There are over 2,300 SBHCs today, and expansions to the program have long enjoyed broad political support. The CDC strongly encourages the adoption of SBHCs, particularly in low-income communities, based on “sufficient evidence of effectiveness in educational and health outcomes.”
A typical SBHC employs a team of nurses, nurse practitioners, physicians, physician’s assistants, and mental health counselors. Additional support staff may include health educators, substance abuse counselors, dental hygienists, and nutritionists.
An effective SBHC addresses the whole of a child’s needs, both medical and educational. Services related to a child’s individual education plan (IEP) are provided at no cost to the family through Medicaid. Speech therapy, for example, helps a child succeed at school and Medicaid agencies are expected to work with schools and families to make sure the child’s needs are met.
Expanding funds for mental health services
The Biden-Harris Administration guidance to expand access to mental health services in schools draws on a body of evidence linking persistent poverty and mental health outcomes in children. A child struggling with anxiety and attention issues in the context of a loving family struggling to make ends meet can still experience significant stressors which may affect the child’s ability to concentrate and thrive. A team-oriented approach to identify resources—for childcare, housing, tutoring and meals—can make a real difference to a family in crisis.
However, innovations to promote child and community wellbeing have not always been intentional in building systems tightly linked to science. Community leaders must develop practices and policies that promote parent education and engagement, provide quality preschools, and consider how the built environment promotes healthy lifestyles. This is where the new Biden-Harris guidance seeks to offer some structure by promoting three steps that states and school systems can take:
- Early and periodic screening, diagnosis and treatment (EPSDT).
- Prompt states to build SBHCs with nine points related to policy and payment.
- Mandatory reporting to Medicaid and CHIP improve to improve quality.
The Medicaid program requires early identification and treatment for vision, dental, hearing and “other measures” to “correct or ameliorate physical and mental illness.” Behavioral health services must be provided by states to children who are identified through screening. Several state spotlights are provided in the guidance memo as examples of care coordination and coverage.
In the second memo linked to the guidance, the administration directs states to specific policies related to launching or expanding SBCHs as the vehicle for delivering the services identified in part 1 (EPSDT).
Linking children and families to insurance
Although Medicaid provides the financial reimbursement necessary to make school-based care possible, many children remain unenrolled. One study estimated 2.3 million children were eligible for coverage in 2019 but were not enrolled. In issuing this package of guidance documents, the Biden-Harris administration aims to improve both linkage to coverage and access to care. Schools can access technical support to navigate the complexities of eligibility, provider contracting, billing and payment.
To this end, the administration has committed $300 million to improving access to mental health services in schools. The funds are earmarked with the dual purpose of building the pipeline of mental health professionals and helping schools hire these professionals to serve the needs of children. The President hopes to double the number of school counselors and social workers available to serve children in need, and over five years, the administration plans to invest $1 billion in delivering school-based mental health services.
An additional $1.7 billion authorizes or funds a wide range of programs, including Community Based Behavioral Health Services, School-Based Mental Health, oversight of Medicaid’s EPSDT screening program, access to mental health through telehealth, training for primary care doctors and first responders, a 24/7 suicide hotline, and after-school and out-of-school programs.
Recovery from trauma must consider the context of poverty and social isolation
Defined by the CDC in the 1990s, an adverse childhood experience (ACE) is defined as a stressful experience during childhood that directly impacts a child or affects the family environment. The pandemic certainly qualifies as a traumatic event for children living in poverty before the pandemic. Although the literature is rich with systematic reviews seeking to identify the most effective therapy for those recovering from an ACE, the evidence is mixed. Individual treatments likely need to be situated in a broader context which addresses social factors, such as poverty and isolation.
Although SBHCs enjoy broad support and seem like a logical lever to help children recover, infusions of cash must consider the greatest threats to childhood wellbeing: poverty and social isolation. States and schools alike must carefully consider policies which exacerbate either condition to avoid compounding the long-term consequences for the most vulnerable in society.