In the United States, a child in 2023 had a 15 percent to 20 percent higher chance of having a chronic health condition than a child in 2011. As children's health continues to decline, with rising rates of chronic diseases and mental health problems, there is a shared priority to improve the health and well-being of children in the U.S. The COVID-19 pandemic significantly exacerbates existing health challenges faced by underserved children including those from low-income families, rural communities, children with disabilities, and racial and ethnic minorities. Schools serve as an ideal, convenient care setting for delivering health services to children by meeting them where they are.
In 2015, CDC launched the Whole School, Whole Community, Whole Child (WSCC) framework to emphasize the interconnectedness between a child’s health and their academic achievement. Schools can be transformed into community hubs that provide important services to address the full needs of students—academic, emotional, physical, and social well-being. School health services (SHS) encompass a wide range of critical health services including speech pathology, occupational therapy, psychological counseling, physical therapy, and nursing services. These services can be delivered by school nurses, contracted community providers, or school-based health centers.
In communities where children lack access to quality health services due to long travel distances and a shortage of medical providers, students can receive timely care and preventive services through SHS. A recent survey found that nearly one in five students utilized school-based mental services in the 2024-2025 school year. Compared to primary care settings, youth with severe mental health symptoms or diagnosis were twice as likely to use school-based mental health services. From managing students’ chronic health conditions to supporting students’ mental health, school health services expand access to care and address students’ health care needs. Prioritizing students’ health in education settings helps create a strong foundation for students to thrive both in school and beyond.
What is school Medicaid?
Since the late 1980s, Medicaid has played a critical role in financing and expanding school health services. It serves as a sustainable funding stream to support SHS. In 2024, Medicaid provided more than $8 billion dollars annually in state and federal funding to support SHS. Schools can receive Medicaid reimbursement for medical services such as periodic health screenings like vision and hearing, speech pathology, occupational therapy, physical therapy, diabetes, and asthma management. Additionally, schools can also be reimbursed for administrative activities including Medicaid outreach and coordination to help eligible students enroll in Medicaid. The types of reimbursable services vary by state and are determined by each state’s Medicaid plan.
Prior to 2014, school Medicaid programs only paid for services documented in a student’s Individualized Education Program (IEP) or Individualized Education Services Program (IESP) or delivered through the Maternal and Child Health Block grant. Under the “Free Care Rule,” school Medicaid prohibited the reimbursement of services or activities that were provided to the general student population at no cost. This Medicaid policy restricted funding to a small group of students, forcing schools to either absorb the health care costs associated with providing care to all students or limiting services to those with IEP or IESP. The Free Care Rule was reversed by CMS in 2014 to allow schools to seek Medicaid reimbursement for Medicaid-coverable services for all Medicaid-enrolled children, regardless of whether the services were provided free of charge to other students.
School districts can use Medicaid reimbursement to fund and sustain health-related initiatives within schools. According to a survey conducted by The School Superintendents Association (AASA), 86 percent of school districts use Medicaid funding to support salaries for school health staff such as school nurses and school psychologists. Of the 1,440 school districts that responded to the survey, 59 percent use Medicaid funds for mental and behavioral health services, 46 percent reinvests Medicaid funding in assistive technology and specialized equipment for students with disabilities, and 42 percent use Medicaid funds for care coordination and referral services.
Although school Medicaid helps advance school health services, persistent challenges relating to program implementation, administrative burdens, billing complexity, and parental consent hinder the use and impact of school Medicaid. In the next two blogs of the series, I will discuss the expansion of school Medicaid programs, the challenges faced by rural school districts, and how H.R.1 could jeopardize the sustainability of school health programs and put children’s health at risk.