Background
The Center for Health and Health Care in Schools, has undertaken five surveys of the 50 states and the District of Columbia to assess the growth of school-based health centers across the country and to examine the state policies associated with that growth. Those surveys, conducted in the summers of 1994, 1996, 1998, 2000, and 2002 have documented the remarkable expansion over the past decade. The number of centers reported by those surveys was 607, 900, 1157, 1380, and 1498, respectively.1

Chart 1
Methodology
The 2002 State Survey of School-Based Health Centers Initiatives consisted of 31 questions organized into 10 categories. It was available to respondents both online at the Center’s website (www.healthinschools.org/survey2002/download.asp) and in a paper version. The survey was mailed to individuals who had responded to the 2000 survey.

In most states, the survey respondent was a representative from the state health department. In a few states, the survey respondent was a representative from the state education department. For many states, the state representative did not have a complete count of the number of school-based health centers. In order to gather this information (Questions 1 and 2), staff at the Center called individual school-based health centers in each state to confirm the total number. The National Assembly on School-Based Health Care (NASBHC) provided their list of individual centers by state. The Center cross-checked those lists with their own.

All 50 states and the District of Columbia completed the survey thereby yielding a 100% completion rate. Twenty-one states filled out the survey online. For more information on the methodology, please see the Background and Methodology summary at www.healthinschools.org/sbhcs/method.asp.

School-Based Health Center Growth
Data from the 2002 State Survey of School-Based Health Center Initiatives identified a total of 1,498 school-based health centers providing in-school care to children during the 2001-2002 school year. This number represents a nine percent increase over the past two years, an increase of 147% since 1994 and an estimated increase of 650% since 1990.2

School-based health centers are located in forty-three states plus the District of Columbia. The ten states with the largest number of school-based health centers are: New York (170), California (135), Arizona (97), Florida (89), Connecticut (68), Massachusetts (67), Texas (63), Maryland (57), Louisiana (53), and Michigan (53). These 10 states represent over half of the centers across the United States.

Over the past two years, eight states have seen growth of at least 50%. Among these states are Kentucky, Maine, Massachusetts, New Mexico, and Tennessee. Increased funding has been the primary reason for the growth. For example, Maine doubled its funding through the tobacco settlement dollars resulting in 10 additional school-based health centers. Other sources of support have also contributed to the growth of centers. In Kentucky, 15 new centers over the last two years are the direct result of increased funding by the Greater Cincinnati Health Foundation.

Top Ten States

Geographic and School Location of School-Based Health Centers
School-based health centers are found in urban (61%), rural (27%), and suburban (12%) communities and in all regions of the country. Three hundred and forty-eight (23%) of the centers are located in the Mid-Atlantic States; 288 (19%) are located in the Southeast & South Central states; 253 (17%) are in the Southwestern & Rocky Mountain states; 239 (16%) are in the Midwest; and 192 (13%) are on the Pacific Coast. The remaining 178 (12%) of the centers are located in New England.

School-based health centers once primarily found in high schools are now located in all types of schools. The 2002 survey found that thirty-seven percent of centers are housed in elementary schools, thirty-six percent are in high schools, eighteen percent are in middle/junior high schools, three percent are in k-12 schools and the remaining five percent of centers are found in a mix of other schools such as alternative schools. Since 1996, elementary schools have seen the largest growth in centers – growing from 32% to 37% of the total.

School-based health centers are staffed with a multidisciplinary team of nurse practitioners, physicians, mental health providers and others. To be included in the survey, a school-based health center had to have a primary care provider on site at the school or from a remote location by use of interactive or telemedicine technologies. According to the survey, primary care providers (physicians, nurse practitioners, or physician assistants) work full-time in 54% of the centers and part time (25 hours per week or less) in the remaining 46% of the centers.

Funding for School-Based Health Centers
State funding has been a leading factor in the growth of school-based health centers over the past decade primarily through state general funds and the Maternal and Child Health Block Grant under Title V of the Social Security Act. In recent years, states have tapped into other resources such as tobacco taxes and dollars from tobacco settlement dollars to fund school-based health centers.

The 2002 State Survey found twenty-six states and the District of Columbia utilized a combined total of $71.1 million dollars to fund school-based health centers. This is an increased of fifteen percent over the last two years and an increase of nearly seventy percent since 1996. Thirteen state governments allocated $27 million from their general fund and 13 states and the District of Columbia designated $10.4 million of their federal Maternal and Child Health Block Grant funds to support school-based health centers.

Other state funding for school-based health centers include dollars from tobacco taxes, tobacco settlement dollars, and a mix of other sources. Eight states (CO, FL, IL, KS, LA, ME, MA, and NV) used tobacco settlement dollars totaling $12.4 million to support the centers and four states (AZ, CT, MA, and NY) used tobacco tax dollars totaling $12.6 million for school-based health centers.

In addition, New Jersey access dollars for their school-based health centers through the Preventive Health and Health Services Block Grant. Illinois used dollars from the Title XX Social Services Block Grant to help fund their school-based health centers.

State Funding
Revised May 2003
State Criteria for Funding School-Based Health Centers
Of the 26 states that allocate dollars for these centers, eighteen of them plus the District of Columbia fund school-based health centers through competitive grant programs specifically for school-based health centers. These states include CO, CT, DE, IL, KS, LA, MA, MD, ME, MI, NC, NJ, NM, NY, OR, RI, TX, and WV. The remaining eight states reported supporting the centers through other means such as EPSDT reimbursements or grant programs to support community-based primary care.

State grant programs use various criteria to guide funding decisions. The number of low-income children to be served is the most often used criterion for funding school-based health centers. Other criteria used by the states and the District of Columbia include the number of adolescents to be served, the number of uninsured children in the community, and the capacity of the centers to overcome other barriers to care. Barriers cited include transportation and a shortage of community providers.

Supporting Policies for School-Based Health Centers
One of the purposes for the survey is to learn about the policies and programs that support school-based health centers in each state. The survey asked about the presence of operating standards, third party reimbursements, and prevention services.

Operating standards provide guidance for planning and developing new school-based health centers as well as guidelines and principles for existing centers. These standards are found in the eighteen states and the District of Columbia identified as having grant programs. Four states recommend these standards for their state-funded school-based health centers while fourteen states and the District of Columbia require them. The other two states that reported having operating guidelines but no state-funded sites are Hawaii and Vermont.

Though state funding has been growing over the last few years, school-based health centers are increasingly seeking to diversify their funding mix. One approach is to secure third-party reimbursement dollars. At least seventy-five percent (n=38) of the states permit school-based health centers to bill for services under fee-for-service (FFS) Medicaid and the State Child Health Insurance Program (SCHIP). Thirty-nine states reported that nurse practitioners are eligible to bill for their services under FFS Medicaid and in thirty-four states, nurse practitioners are eligible to bill for services under FFS SCHIP. The survey found that in some states, other providers such as psychologists and social workers are also eligible to bill for services provided within school-based health centers.

Through legislation, managed care contracts and regulations, some states took additional actions to encourage school-based health centers to seek third-party reimbursements. In five states, Medicaid managed care provider networks are required either by law, managed care contracts, or regulations to include school-based health centers and in 11 states, Medicaid managed care provider networks are encouraged to include school-based health centers. For SCHIP managed care provider networks, five states require and nine states encourage the inclusion of school-based health centers.

Managed Care Plan

Prevention and Health Promotion Programs
Of the 30 states that report encouraging or supporting school-based health centers, nutrition was cited as the most important prevention-related topic for school-based health centers. Prevention of HIV and other sexually transmitted diseases, pregnancy prevention, alcohol and other drugs, and violence and conflict resolution skills were also noted as important topics to address.

Membership Organizations
Twenty-one states reported the presence of SBHC-member organizations that provide technical support to members as well as advocacy on their behalf in the state legislatures. These include: Arizona, California, Colorado, Connecticut, Florida, Illinois, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Mexico, New York, North Carolina, Ohio, Oregon, Rhode Island, Tennessee, Texas, and West Virginia.

All of the top ten states in terms of number of school-based health centers have school-based health center associations or coalitions. They vary by state in terms of organization, how often they meet, and their priorities.

For more information on the 2002 State Survey of School-Based Health Centers Initiatives, please visit our web site at www.healthinschools.org/sbhcs/2002rpt.asp.

Footnotes:

1 In 1990, the number of school-based health centers was estimated at 88 and in 1992/1993, a count of centers by Making the Grade program office at the George Washington University and the School Health Policy Project at Columbia University identified 350.

2 The survey defines a school-based health center as one that is on school grounds and has a primary care provider (physician, nurse practitioner, or physician’s assistant) on site delivering care in person or from a remote location by use of interactive or telemedicine technologies at least once a week.