School-Based Health Centers:

Available Information on Federal Funding

GAO-11-18R: Published: Oct 8, 2010. Publicly Released: Oct 8, 2010.

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Cynthia A. Bascetta
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Many of our nation's children have difficulty accessing needed health care services. In 2008, the Robert Wood Johnson Foundation reported that about 25 percent of children with insurance and about 55 percent of uninsured children did not receive a recommended routine checkup within the previous year. According to the Department of Health and Human Services (HHS), children face growing risks from chronic physical conditions such as asthma and obesity and from mental health disorders such as depression, and yet, as we have reported, their access to services may be impeded by a number of barriers, including a lack of health insurance and a lack of convenient transportation to medical appointments. Access to mental health care services may also be impeded by concerns about stigma--negative attitudes and beliefs often associated with receiving such care--which can be a deterrent to seeking these services. To help increase children's access to primary health care and other health care services, states and communities have established school-based health centers (SBHC). SBHCs are located on school grounds, provide health care services regardless of ability to pay, and offer a broader range of services than a school nurse generally provides. Almost all SBHCs provide primary care, and they vary in the extent to which they provide other health care services, such as immunizations, behavioral health care, oral health care, health and nutrition education, and reproductive health care. SBHCs improve children's access to health care services by reducing financial and other barriers to care, especially for children who are poor or uninsured. For example, as we reported in our July 2009 report on children's access to mental health care services following Hurricane Katrina, SBHCs in Louisiana have emerged as a key approach to providing access to primary health care and mental health care services. Although the principal sources of financing for SBHCs overall are state, local, and private funds, some federal program funds have been used by SBHCs to provide health care services to school-aged children. The three key sources of federal grant funds are HHS's Health Center Program, Title X Family Planning program, and Maternal and Child Health (MCH) Services Title V Block Grant program. In addition to receiving grant funding through grantees of these programs, SBHCs may bill Medicaid for certain services provided to children enrolled in Medicaid. SBHCs may also bill private insurance and other types of public programs for covered services, such as the State Children's Health Insurance Program (CHIP). The Patient Protection and Affordable Care Act (PPACA) appropriated additional federal funding for SBHCs. This funding is to be made available through a program established specifically to fund equipment and facilities. HHS also provides partial funding for a biennial survey of SBHCs that is conducted by the National Assembly on School-Based Health Care (NASBHC)--a private nonprofit organization that advocates on behalf of SBHCs. The survey for the 2007-2008 school year was made available to the 1,909 SBHCs in NASBHC's database and included information such as the services SBHCs provided, the types of organizations that sponsored them, the sources of grant funds they received, and the types of insurance they billed. The Health Care Safety Net Act of 2008 required that we study the economic costs and benefits of SBHCs. However, we informed cognizant committee staff that data on economic costs and benefits were unavailable. In this report, we describe (1) what is known about federal grant funds received by SBHCs, and (2) what is known about Medicaid reimbursements received by SBHCs.

Over 40 percent of the SBHCs that responded to NASBHC's survey (538 of the 1,224) reported receiving funds from at least one federal grant source. The most common source was HHS's Health Center Program. Of the 538 SBHC survey respondents that reported receiving federal grant funds, 255 said they received funds from the Health Center Program, 138 said they received funds from HHS's Title X Family Planning program, and 86 said they received funds from HHS's MCH Services Title V Block Grant program. The amount of federal funding that SBHCs receive is not known, however, because SBHCs generally receive the funds from a sponsoring organization that is the federal grantee, and the federal agencies that administer the programs generally collect information at the grantee level and not at the SBHC level. Although SBHCs may bill Medicaid for services provided, the amounts of Medicaid reimbursements that SBHCs receive overall and that specific SBHCs receive are unknown. According to a CMS official, CMS collects or maintains claims data on the basis of certain categories described in Title XIX of the Social Security Act, including clinic services and FQHC services, and because SBHC services is not one of these categories, CMS claims data cannot be used to determine the amount of reimbursements received for services provided in SBHCs. Although CMS's claims data cannot be used to identify SBHC Medicaid reimbursements, some information on SBHCs' billing of Medicaid is available from NASBHC's survey. According to the survey, 72 percent of all SBHC respondents reported billing Medicaid. According to NASBHC officials and some individuals involved with managing or sponsoring SBHCs, some SBHCs may not bill Medicaid for services because infrastructure costs and personnel expenses associated with implementing and maintaining a Medicaid billing system could exceed the reimbursements the SBHC would receive and many services SBHCs provide are not covered by Medicaid.

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