Despite gains in expanding health coverage to children over the past decade, we still have about 3.3. million uninsured children nationwide. And most of them, growing up in low-income and working-poor families, qualify for public insurance programs such as Medicaid and the Children’s Health Insurance Program (CHIP). So, what can we do about this?

Schools have an essential role to play, quite simply because that’s where the kids are. We know that educators already have a vested interest in ensuring children are healthy. In fact, according to a nationwide survey of over 500 school leaders, more than half of superintendents said they have taken steps to increase the number of students enrolled in Medicaid.

This is in large part because states and schools can increase revenue going into their school districts through federal reimbursement for Medicaid school-based claims. Increasing student Medicaid enrollment can infuse needed resources into school districts and provide opportunities to address health barriers to learning that may be impeding academic progress. This all matters because insurance coverage and access to preventive health care are key to setting children on a trajectory for healthy development and academic success.

We also know that schools serve as an important access point to health insurance coverage for low-income children and families. A recent study published in the Journal of School Health reinforces the growing body of evidence showing schools are among the best places to find and enroll low-income children who could be eligible for free or low-cost health insurance coverage. This study also teaches us that schools serve as a trusted source of health coverage information for parents.

The author of the study, Healthy and Ready to Learn: Effects of a School-Based Public Insurance Outreach Program for Kindergarten-Aged Children, examined the effectiveness of an intervention called “Healthy and Ready to Learn” (HRL) that focused on both enrolling low-income children in North Carolina into Medicaid or CHIP and increasing the well-child exam rates for these children.

Funded by a federal grant under the CHIP Reauthorization Act (CHIPRA), this school-based intervention was targeted at North Carolina’s highest-need counties during the 2009-2011 school years. Its goals were in lockstep with the National Association of Boards of Education and the Centers for Disease Control and Prevention’s long time “Fit, Healthy, and Ready to Learn” joint school health policy initiative.

So, what did the Healthy and Ready to Learn intervention do? And, how was it implemented?

• The HRL intervention provided regional trainings for school nurses and administrative staff, in high-need North Carolina school districts on how to use the state-required Kindergarten Health Assessment form, submitted at school entry, to identify uninsured children who could be eligible but were not currently enrolled in CHIP and Medicaid.
• During the HRL trainings, school-based personnel were directed to the section of the health form where parents specify whether or not their child has Medicaid, private insurance, or no insurance.
• School nurses and staff were then encouraged to identify uninsured children in their school and refer families to local partners to facilitate their enrollment into CHIP or Medicaid.
• HRL intervention staff conducted similar web-based trainings with the broader health care provider community, including community physicians and nurses, encouraging them to have conversations with families about health insurance coverage during well-child visits to fill out the required health form.
• To identify which elementary schools and school districts would be invited to participate in the intervention, researchers developed a need index that incorporated county-level data on two measures—the percent of children 10 and younger living in poverty and the unemployment rate for April/May 2009—along with the number of children who could potentially be reached by the HRL intervention, that is children ages 6 to 8.

What did this evaluation study find?

• The author calculated county-level enrollment and preventive care usage from the Medicaid and CHIP administrative claims data made by children living in North Carolina who were kindergarten age in the 2007-2008 through 2010-2011 school years.
• The intervention yielded a 12.2 percentage point increase in health insurance enrollment rates and an 8.6 percentage point increase in the rate of kindergarten-age children receiving well-child exams.
• Four focus groups and five key-informant interviews were also conducted across the intervention regions.
• Evidence emerged indicating the HRL intervention was most successful at raising general awareness about public health insurance programs and in amplifying the importance of having parents and physicians fill out the required health assessment form correctly.

What recommendations came out of this study?

• Integrate health insurance screenings into other K-12 school documents and routines
• Train K-12 school personnel and medical care providers on CHIP and Medicaid to enable them to communicate with parents face-to-face about these public health insurance programs
• Expand health insurance outreach to older children in K-12 settings
• Use clear and concise outreach messages and steps for local action
• Adapt to individual needs to make enrollment possible for children and their parents

As my CCF colleague, Cathy Hope, wrote previously in a blog post, “Schools experience first-hand the needs of students who are unable to come to school ready to learn because their families can’t afford to get them the health care they need. While teachers and school personnel are already doing so much it seems unfair to put another task on their ‘to do’ list, however, helping kids get health care is so inter-connected with their ability to learn that it can’t be ignored.”

To learn more about action steps child health advocates can take to encourage states and school districts to help eligible students and their families enroll in affordable health coverage and improve school-based health, check out the Healthy Students, Promising Futures toolkit, offered by the U.S. Department of Health and Human Services and the U.S. Department of Education.