By skyforbes 
“Ms Ricker? My mom told me to ask you if I could go see the nurse about my thumb.”
I looked down and there was my student’s left hand resting on a Baggie of melted ice and a wash cloth, multiple shades of purple I didn’t think could be natural spanning from his thumb to his wrist and the joint joining his thumb to his hand over-swollen and taught, easily three times its normal size.
“Oh dear, of course! Just go and I’ll call Ms Grant to expect you so you don’t have to wait for a note.”
I later found out he had hurt his thumb over the weekend and, because his family didn’t have insurance, his mother kept him as comfortable as she could until school Monday morning when she told him to see the school nurse, the most reliable access to healthcare her son had.
I wish this story were rare, but in the last decade, as school nurses have become rationed more and more, while the need for school nurses has only grown, more and more local unions like mine have been bringing the real need for reliable school-based health services directly to our bargaining tables to demand the healthcare services our students deserve, some of us going so far as being ready to strike over it.
It was because I was so steeped in advocating for the need for access to school-based healthcare that I was so encouraged by the change in the “free care rule” when I first learned about it and so ready to help states make the most of it. I’ll explain the “free care rule” in a moment, but first, let me back up a little and tell you how ensuring that every child has access to a school nurse fits into AFT’s broader work on student health.
Excellent school-based Medicaid programs could streamline federal and state reimbursements to school districts for health services provided to all Medicaid-eligible students and ultimately contribute to children’s equitable, easy access to high-quality healthcare providers.
As we outlined in “Helping Children Thrive,” American Federation of Teachers members and leaders prioritize efforts to (1) Promote children’s mental health and social-emotional well-being; (2) Improve children’s equitable access to high-quality healthcare; and (3) Advance children’s food security by reducing hunger and increasing access to nutritious foods.
The AFT celebrates partnership as a critical strategy to providing to wraparound services that address children’s well-being — as in community schools and school-based health centers. We’ve also long championed specialized instructional support personnel who tirelessly provide services — our school nurses, psychologists, social workers, occupational and physical therapists, counselors, speech pathologists and more.
AFT’s advocacy at the national level has catalyzed an incredible new opportunity for states and districts to strengthen their in-house work. It’s time to talk about taking Medicaid back to school to protect and promote student health.
Now, remember that “free care rule” I promised to explain? Since 1997, schools have been constrained a rule stating that if a health service was provided “without charge” to students without Medicaid coverage, it needed to be ‘free’ to Medicaid, as well — meaning districts were not eligible to access federal reimbursement. Exceptions were reserved for health services required for students with an Individualized Education Program (IEP). In response, districts effectively designed their school health programs to exclusively serve students in special education — and occasionally pay upfront for other health services. In the face of such budget limits, it’s no surprise that only about half of today’s students have access to a full-time school nurse, while even fewer regularly connect with other school health professionals.
In 2004, Oklahoma demonstrated just how unwieldy the rule was for schools and the Departmental Appeals Board of the Centers for Medicare and Medicaid Services (CMS) declared that the rule didn’t flow from federal policy. Yet states and districts continued to face audits and requirements to return funding for health services provided to students. Thanks to repeated calls from the AFT and others, in December 2014, CMS sent a letter to state Medicaid directors clarifying that the free care rule does not apply to schools. This opens the door to thoughtfully coordinating and streamlining reimbursed care for millions of students who are enrolled in Medicaid but do not have an IEP.
But the federal change isn’t automatic — each state needs to amend policy to take advantage of this change. Louisiana amended its Medicaid state plan to align with the new guidance — and more than tripled federal reimbursements for school nursing services. Districts can use this money to invest in more school health professionals, improved equipment or wellness activities. But Louisiana is the only state to formally adopt the change so far.
Early this year, the U.S. Departments of Education (ED) and Health & Human Services (HHS) jointly launched “Healthy Students, Promising Futures.” A letter to state chiefs and a complementary toolkit highlighted strategies to improve students’ access to care by collaborating across sectors, including with school-based Medicaid. We welcomed the letter. Yet we worried that states still didn’t have the support needed to fully implement the change. So we rallied 25 national organizations to send a clear message to the Centers for Medicare and Medicaid Services (CMS) about the important need for more nuanced technical assistance.
On July 27, three federal agencies heeded the call, connecting small teams from 10 states — California, Colorado, Massachusetts, Mississippi, New Jersey, New York, Ohio, South Carolina, Tennessee, Washington, DC — with ED, HHS and CMS staff in a new “Healthy Students, Promising Futures” community of practice. This initiative is an exciting step in the work to support kids and families! Still, there’s more we can do to take Medicaid back to school:
[1] Keep learning and sharing with others.
Elevating this conversation and raising awareness among stakeholders — including educators, parents, school health experts, public health professionals and child advocates — is an important step towards making decisions, plans and changes that will best serve your community. Start here: http://www.aft.org/childrens-health-safety-and-well-being/childrens-access-care and stay tuned for more AFT conversations on school-based Medicaid and improving children’s access to healthcare.
[2] Uplift the voices of frontline practitioners in program design, planning, assessment and improvement.
Labor-management-community partnerships are a great vehicle to ensure that workers systematically participate in decision-making processes that directly impact their students. Growing school-based Medicaid programs grow and shifting student health services could impact teachers and especially special educators, school health professionals, as well as the health aides and other non-licensed personnel who support them, among others.
[3] Challenge programs to address physical and mental health with parity.
In any given year, an estimated 1 in 5 children experiences mental illness. Despite historically high rates of insurance coverage, many children still do not access mental health professionals when they need care. One key step forward is to boost schools’ capacity to address and manage mental illness and emotional disturbance. Strong school-based Medicaid programs would facilitate increased use of early and periodic screening, diagnosis and treatment (EPSDT) services, including for behavioral health. Helping states achieve excellence in school-based Medicaid could also support more full-time equivalent positions for mental health professionals.
[4] Advocate for investment in robust staffing of specialized instructional support personnel.
“Healthy Students, Promising Futures” encourages states to investigate opportunities for expanded Medicaid reimbursement. However, districts are minimally accountable for how they use reimbursements. Local advocacy can help assure a transparent flow of public funds and maximize opportunities to reinvest reimbursements in health and wellness.
As the American Academy of Pediatrics explained in its recent State of the Child, “Protecting children’s health is not a political choice, but an imperative investment in our nation’s future.” I’m proud of the role the AFT has played in getting federal policy to this point — and look forward to seeing what we can achieve together in states and districts for children and families.