Beyond the Classroom: Health Services in Schools and How They Pay for Them

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Beyond the Classroom: Health Services in Schools and How they Pay for Them

May 2019

Anna Gu

By Anna Gu (@annaguber)
Center for Health and Social Policy Ambassador

My first year in the classroom, like those of most teachers, was filled with phlegm. I was managing not only my own cycle of sore throats and stomach bugs, but also those of the class – twenty-two small bodies with individual allergies, behavioral ticks, and swiss-cheese holes of attendance gaps. As the place where these children spent the bulk of their waking hours, school was the discovery point for new ailments as well as the rehabilitation center to put kids back into the flow of learning after a period of illness.

This experience gave me a particular interest in education initiatives that recognize schools as more than just a place to learn. Particularly for students whose families have major obstacles in accessing mental, health, or social services, schools play a vital role in supporting the whole child. Many schools have adopted full-time nursing staff, or even more comprehensive programs such as wraparound services.

Specifically with regard to health, several studies have shown positive effects for the addition of services. A project with San Jose Unified School District showed that students attending schools with a full-time nurse were less likely to visit the emergency room, more likely to visit a health care provider when addressing issues, less likely to miss school due to illness, and less academically disadvantaged by chronic health conditions. A research review in the Harvard Review of Psychiatry found that in-school mental health services reported reductions in anxiety, improved reading scores, and fewer school suspensions for students. An evaluation of the Massachusetts Department of Elementary and Secondary Education Wraparound Zones Initiative found improvements in student behavior, family engagement, and the student performance on language arts and math assessments. 

Although health services’ positive outcomes are evident, schools vary inability to pay for these programs. Fortunately, a change to the “free care rule” opens the door for schools to receive federal Medicaid funds for providing services. In December of 2014, Health and Human Services (HHS) announced that Medicaid reimbursement was available for services that are ordinarily provided for free to the community at large, such as a school nurse. As long as all other Medicaid requirements are met, schools have the opportunity to use Medicaid dollars toward health services.

These services extend beyond the roles of a school nurse. In Texas, the Schools Health and Related Services (SHARS) program provides reimbursement to school districts and charter schools for services provided to Medicaid-eligible special education students. For instance, a child may have an Individualized Education Program (IEP) that requires a teacher or aide providing adaptive physical education. Under SHARS, the school could be reimbursed for providing this service. Other eligible programs include physical and speech therapy, counseling, and early periodic screening diagnosis and treatment (EPSDT) benefits, which include vision, hearing, and diagnostic services.

A second program called Medicaid Administrative Claiming (MAC) allows Texas schools to receive funding for a broader range of services. Medicaid outreach objectives, facilitating and verifying Medicaid eligibility, Medicaid translation and transportation, and referral and coordination of Medicaid services are all eligible programs. These initiatives in particular work to identify and help enroll uninsured children into Medicaid, expanding access to health services both in and out of school.

Different states face a variety of administrative hurdles for schools to receiving this funding. For instance, North Carolina’s HHS only recently approved an amendment to the Medicaid State Plan that expands reimbursement for nursing, counseling, occupational therapy, speech/language therapy and physical therapy services. Policymakers and advocates wishing to improve educational outcomes for low-income students might consider the administrative hurdles that complicate their local schools’ access to Medicaid funds.

By strengthening supports outside the classroom, we can strengthen the learning inside the classroom.


Anna Gu is a first-year Master of Public Affairs candidate and CHASP Ambassador at the LBJ School of Public Affairs. After completing a BA in Comparative Studies in Race and Ethnicity at Stanford University, she supported research and advocacy for blended and personalized learning at the Christensen Institute. She then taught in a Montessori preschool before returning to her home state to oversee a $7 million statewide grant for public-private prekindergarten partnerships at the Texas Education Agency. Currently researching how schools receive reimbursement from Medicaid with the Children’s Defense Fund, Anna is interested in how workforce, family, and education policy interact to improve equity. After LBJ, she hopes to apply these interests to program evaluation and policy analysis.

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The views, information, or opinions expressed by blog contributors are solely those of the individual authors and do not necessarily represent those of the Center for Health and Social Policy, the LBJ School of Public Affairs, or The University of Texas at Austin or affiliated employees.