To Norwich Superintendent of Schools Abby Dolliver, the three health clinics that operated inside her district’s public schools provided more than health care.
Students who needed help with their asthma, or a physical or a strep test, could get care from a nurse practitioner without having to leave school – a major convenience for parents who would otherwise have to leave work to take their kids to a doctor’s office.
Children who needed help dealing with trauma or other mental health issues could get counseling on site – and a sense, Dolliver said, that the schools supported them.
“The need is greater than what we have the availability to do ourselves in schools,” Dolliver said.
School-based health centers – which provide medical and mental health care and sometimes dental services and health education, often in schools with many low-income or high-risk students – have historically received widespread backing from policymakers in Connecticut. Research has linked them with improved academic performance and graduation rates, as well as better health measures, such as higher vaccination rates, reduced asthma complications and lower emergency department use.
The report of the Sandy Hook Advisory Commission – established after the 2012 shootings – noted the clinics’ potential to make it easier for students to get behavioral health care without the stigma sometimes associated with mental health facilities.
“For many children, schools offer the only real possibility of accessing services,” it said.
A separate state plan for children’s behavioral health called for expanding the number of school-based health centers.
But in Norwich, the opposite happened last year: After years of state funding cuts and attempts to adapt by reducing hours, the agency that ran the in-school clinics eliminated them at the three schools. Richard Calvert, CEO of Child and Family Agency of Southeastern Connecticut, which had run the sites, estimated the closures meant about 800 students who previously used a school-based clinic no longer had access to one.
The Norwich schools recently partnered with a community health center to provide mental health services in the clinics, but there’s no medical care.
And Calvert and others who run school-based health centers say the model could soon be imperiled elsewhere in Connecticut.
Gov. Dannel P. Malloy’s proposed budget calls for a 10 percent cut to grant funding for the 93 school-based health centers and associated sites that receive money from the state Department of Public Health. That follows a series of cuts in recent years. In the 2015 fiscal year, the clinics were budgeted to receive $12 million in state grants; under Malloy’s proposal, they would receive $10.2 million next year.
“A proposed 10 percent cut looks like nothing other than a pretty relentless dismantling of the school-based health centers across Connecticut,” Calvert told members of the council that oversees state-funded behavioral health services last month. His agency continues to operate 14 school-based health centers. “When we’re talking about issues of access and bringing services to where the children and adolescents are, it’s pretty hard to fathom what the impact will be. Reduced services for sure.”
State officials offered a different view and suggested the effect of the cut could be mitigated if school-based health centers bring in more money by billing students’ health care coverage. They also pointed to changes in the business model as an option.
“School based health centers are a tremendous asset to the students and communities they serve,” said Maura Downes, a spokeswoman for the state Department of Public Health. “The trend in Connecticut is toward expansion, not contraction, of school-based clinics run by federally qualified community health centers.”
In the past two years, the number of licensed clinics providing services in schools has increased from 150 to 205, Downes said. Some operate without state grants, which Downes said indicates an ability to sustain the services without state money. But Jesse White-Fresé, executive director of the Connecticut Association of School Based Health Centers, said many of those sites might offer more limited services, such as mobile dental programs, or mental health services without medical care.
Of the 205 clinics in schools, 110 are now operated by federally qualified health centers – organizations that provide primary care and behavioral health services, often at multiple sites, and serve many patients covered by Medicaid or without insurance. Those community health centers receive a higher payment rate from Medicaid than other freestanding medical clinics, including for services delivered in schools.
The proposed budget cut reflects the increasing ability of the facilities to bill students’ health care coverage, which reduces the need for state subsidies, Downes said.
But officials at community health centers say it’s not so simple.
What cuts could mean
In appealing to legislators to prevent the cut, leaders of school-based health centers offered a glimpse at what less grant funding would mean.
In Bridgeport, where Southwest Community Health Center relies on state grants to operate five school-based health centers, Malloy’s proposed cut would make it “near impossible” to continue staffing all five health centers, President and CEO Katherine S. Yacavone wrote in testimony.
“Would you cut behavioral health services? Medical services?” she asked. “Why are we in the position of sacrificing access to health care for our most needy children?”
The organization runs two other health centers in Bridgeport schools that don’t receive state grants; altogether, the seven sites provided 10,594 visits last year for care ranging from physicals and immunizations to treatment for students with depression, anxiety and post-traumatic stress disorder.
The health center bills patients’ insurance, Yacavone wrote, but that has limits: 18 percent of students are uninsured at one school, she said; at another school, 20 percent lack coverage. (Some are undocumented, Yacavone said, and some come from families that earn too much for Medicaid but don’t have private insurance.)
Sue Peters, director of the New Haven Public Schools’ school-based health centers, wrote that further cuts would have a “devastating impact” on the health, learning and well-being of thousands of students. At the district’s 17 school-based health centers, clinicians provided 5,890 medical visits and 2,644 mental health visits between September and December 2016.
And she said addressing mental health issues led to lower suspension rates, improved attendance and increased focus and attention in class.
Stephen Karp, executive director of the National Association of Social Workers, Connecticut Chapter, suggested another potential consequence of reduced funding.
“A loss of 10 percent in funding will greatly hamper the work of the [school-based health centers] and put pressure on other community-based mental health services that are already stretched beyond capacity for children’s mental health,” he wrote.
Asked about the cut, Chris McClure, a spokesman for Malloy’s budget office, pointed to the projected deficit the state is facing during the upcoming fiscal year.
“We have an obligation to present a balanced budget proposal to the General Assembly and to close a projected $1.7 billion deficit, there were difficult program reductions,” McClure said. “In this slow growth economic environment, we are aligning state government spending to revenues just like the households and businesses of Connecticut, and those expenditure cuts – $850 million last year and a proposed $1.36 billion this year – are going to impact the services the state can and will provide.”
Is a different business model the way forward?
When legislators asked Public Health Commissioner Dr. Raul Pino about the proposed cut, he noted that the grants for school-based health centers represent the largest account in the department, aside from salaries.
And Pino said the impact of the cut could be reduced if more school-based health centers change their business models, such as by becoming operated by community health centers. The department has pushed school-based health centers to bill students’ insurance, giving them another revenue source that has in some cases, led them to do pretty well, he said.
In some ways, the Norwich schools are an example of that change in business model.
After going without services in the clinics for part of this school year, the Norwich schools partnered with United Family & Community Services, a local community health center, which began offering mental health services at the three sites in January.
In the first two months, 30 students received counseling. Seven more were referred for services. Dolliver, the superintendent, hopes the services can be expanded to include medical care, something she considers critical.
The organization that now runs the Norwich school-based health centers doesn’t receive any state grant funding. In theory, that makes the model more sustainable, since it’s not subject to the state’s budget woes.
But Jennifer Granger, the community health center’s president and CEO, said it’s not that simple. None of the school-based health centers her organization runs break even, she said. The rate Medicaid pays doesn’t cover costs, and private insurers pay less, Granger said.
And for confidentiality reasons, some services provided to students – such as pregnancy tests or mental health services – can’t be billed to their parents’ insurance if the student requests it, she said. That’s the case for all pediatric providers, but Granger said it’s more common at school-based clinics, which students can more easily get to on their own.
“You can absorb one practice like that, where you can kind of make it up elsewhere, but you can’t continue to open five, six, seven school-based health centers that are not covering their costs,” Granger said. “All we’re looking to do really is break even.”
Because of that, she added, adding medical services in the Norwich schools would require either state or federal funding. Equipment and staffing costs for medical care are higher than for mental health services.
“Will the reductions in the state funding impact the school-based health centers and the future of the school-based health center program? Absolutely,” Granger said.