In some schools, nurses deliver the first dose of asthma medicine to students who need it every morning. In others, dentist technicians show up to clean children’s teeth and look for cavities. Across the country, school-based physical and mental health therapists support students with disabilities.
With more than 120,000 schools nationwide shuttered for the foreseeable future, millions of students have lost access to an important source of health care. As school districts and health providers cobble together solutions, Congressional funding and new regulatory flexibility could help deliver some needed support.
A key source of funding for the school-based health care is Medicaid, which covers 37 percent of school-age children and reimburses $4 billion to $5 billion in services at schools annually. That figure increased in recent years after a 2014 regulatory change allowed schools to seek reimbursement for services provided to all eligible children.
The Families First Coronavirus Response Act, approved in mid-March, temporarily increases the federal match to states for Medicaid. To receive those extra dollars, states must commit to a “maintenance of effort,” keeping current eligibility standards and cost-sharing requirements and to limit disenrollment.
Beyond legislative efforts, federal authorities are granting wide latitude on billing Medicaid for using telehealth to deliver services and urging states to expand offerings. This allows students to visit their doctors virtually, using a smart phone or computers, without risking a visit to an office or hospital. State Medicaid programs can reimburse these providers for telehealth services just as they do for in-person visits without obtaining federal approval, the Centers for Medicare and Medicaid Services (CMS) explained in a recent release.
CMS also makes it easier for state Medicaid programs to expand access to healthcare during the coronavirus emergency through waivers. Arizona, for instance, just received approval to provide 12 months of continuous Medicaid eligibility for children during the national emergency.
Several states seeking Medicaid reimbursement for school-based services rely on studies showing how much time school nurses or clinics spend working with eligible students. Those “random moment in time” studies have been disrupted by the sudden closure of schools. CMS has agreed to grant waivers allowing states to use existing data.
The stimulus bill that passed in late March, known as the Coronavirus Aid, Relief, and Economic Security Act, or CARES Act, earmarks $13.2 billion for K-12 schools and includes several aspects of student health in allowable uses. The money goes to state education departments, then flows through to schools as part of their Title I funding. Another $3 billion in education funding goes directly to governors to use for “significantly impacted” school districts or higher education institutions. The Center on Budget Policy and Priorities has conducted an analysis showing how much money each state is expected to receive.
The law lists 12 allowable uses for the $13.2 billion fund, specifically mentioning mental health services for students and training school staff in cleaning techniques to limit the spread of ineffective diseases. The funding also includes $100 million grants under Project SERV, which is dedicated to helping school districts recover from “a violent or traumatic event that disrupts learning.” The text of the law specifically mentions mental health counseling and disinfecting schools, as well as distance learning.
In addition, U.S. Secretary of Education Betsy DeVos has proposed a set of “continue to learn” microgrants aimed at disadvantaged students. At this point, there’s not much detail about the scope and scale of these grants.
Students with Disabilities
Other questions surround how schools will meet their obligations to support students with disabilities. Schools are grappling with how to deliver hands-on services—such as physical or occupational therapy—or meet timelines set in individualized education plans (IEPs) required under federal law. Or even get the required signatures for IEPs.
Some districts initially declined to provide instruction to any students because they could not address the needs of those with disabilities. The Education Department discouraged that sort of thinking but has not yet resolved whether it will grant waivers to give districts relief. Disabilities rights groups have argued against granting waivers.
Meanwhile school districts are coming up with creative solutions. Some therapists are developing videotapes of exercises that parents can do at home with their children. Others are holding IEP meetings on Zoom calls and securing electronic signatures. The CARES Act allows funding for “activities to address the unique needs” of children with disabilities, among other populations and specifies the funding can go to outreach and delivery of services.
Mental Health Services
Beyond the need for special education services, students could be suffering additional trauma during the coronavirus outbreak. One fifth of low-income parents surveyed said their children were exhibiting more uncooperative behavior since the coronavirus began. Some of that stems from the fear and anxiety of the pandemic itself. These could grow worse if the lost wages lead to hunger or homelessness and as students lose their connections to friends and teachers at school. The CARES Act specifically mentions mental health counseling as an allowable use for spending by K-12 schools.
Here again, telehealth could play a role in delivering those services. Some districts are going further: The Los Angeles Unified School District has launched a mental health hotline for students. “Their world has been turned upside down and we need to make sure students have the support they need,” Superintendent Austin Beutner said in a release.
Another important aspect of student health is nutrition The Families First Act provides greater flexibility for schools to serve free meals beyond the school grounds. Some schools are allowing families to pick up food at community centers or using school buses to deliver meals. The measure also allows student who qualify for free and reduced-price meals to receive benefits from the Supplemental Nutrition Assistance Program (SNAP).
The CARES Act passed later in March provides $18.5 billion toward SNAP and $8.8 billion for child nutrition programs. So far, the benefits have yet to reach many of those who need them most. One analysis shows that only 11 percent of those who have been laid off have picked up a “grab-and-go” meal at school.