Youth Health Clinics Create New National Body

Heather Szerlag
September 1, 1995

School-based clinics— providers of primary medical services to hundreds of thousands of adolescents — are banding together into a new national organization lo deal with radical changes overtaking the health field, especially managed care.

The newly created National Assembly on School-Based Health Care (SBHC) headed by Donna Zimmerman of Health Start, Inc., St. Paul, Minn., will be based in Washington and represent the growing number of school-based clinics around the country now totaling some 650.

Formation of the Assembly has been supported by several foundations active in the youth field, among them the Carnegie, W. K. Kellogg and the Ewing Marion Kauffman Foundations. Financial help also came from the federal bureau of Maternal and Child Health (MCH), the Center for Disease Control and Prevention, and bureau of Primary Health Care.

"We hope the Assembly will turn into a strong multidisciplinary organization," Zimmerman told YOUTH TODAY. "Down the road we would like to target the provision of technical assistance to people already doing or working on starting up clinics, leach them advocacy at the state and national levels and also provide opportunities for professionals, paraprofessionals and parents and students who are all working in these programs to come together and have some good networking and continuing education possibilities."

Of immediate concern, she said, is the operation of school clinics through hook-ups with HMOs— managed care—at a time when the Republican-led Congress is expected to chop back Medicaid funds. Zimmerman's own non-profit agency operates seven Medicaid-financed clinics in Minnesota through health maintenance organizations (HMOs).

"In the urban areas our clinics take care of a lot of low income kids and a lot of uninsured kids. So that's the issue that is before us: how do you as a school or a community health clinic now work with a different entity in terms of payment mechanism?"

Experts note that increasingly HMOs are operating state Medicaid programs and if school-based clinics in these states fail to make an HMO tie-up, they could lose an important source of funding.

Bur their part HMOs are questioning the cost-effectiveness of school-based clinics. Advocates have estimated each student patient costs a school clinic an average of $64 per visit, which HMOs say is too expensive. The accuracy of that estimate, however, is also subject to question because, as Zimmerman notes, very little data has been collected on the clinics. Not even the actual total of students served a year is known, she said.

Clinics' Expanding Role

Since the first one was established in 1970 for inner-city youngsters in Dallas, Tex., school-based clinics have played a constantly expanding role in delivering medical services, including reproductive health services, to needy young people. Dependence upon such clinics could grow even greater as communities across the country from New York to California move to curtail spending on the poor by closing public hospitals or drastically reducing services. Many low income families rely on these hospitals' emergency rooms for their health care needs.

"If they're going to close hospital out-patient clinics and some of the other special services then its going to make the school clinics more important than ever," commented Joy Dryfoos a Carnegie consultant and author of Full Service Schools who participated in the Assembly's launching in June.

But cuts in Medicaid could affect the school clinics' ability to be paid for handling more patients. "If Republicans force hospitals to close by cutting Medicaid, what are they going to do — let the poor die in the streets? School clinics couldn't handle the problem," commented an authority in the education field who asked not to be identified. "It's criminal what they're doing to give the fat cats a tax break."

So far, the school-based clinics have escaped any direct federal funding reductions but advocates are wary of "stuff ‘n cut" block grants pending Congressional approval this fall, as part of his health reform plan last year. President Clinton proposed spending $3 billion to greatly expand school-based services. That the then Democratic-controlled Congress killed the entire plan has had no negative effect on the school clinics. Indeed, their number continues to grow.

Julia G. Lear of Making the Grade, Washington, D.C., another of the Assembly's organizers, said states are investing both federal Maternal and Child Health and their own tax dollars in the clinics, along with cities and counties.

"Probably one of the most significant is Portland, Ore., where Multnomah County is putting in 64 percent of the cost of running 10 comprehensive school-based health centers. With so many different funding sources it makes it difficult to figure out how you're going to improve the funding. But on the other hand it has provided an enormous base of political support for the growth of clinics around the country. And that is their strength. They are community-driven — no one in Washington is telling them to do it," she said.

"But I'm not thrilled that the Clinton reform plan didn't work because Title III would have been a wonderful assist for communities who would like to start school-based clinics."

The ‘Abortion’ Issue

Making the Grade, an arm of the Robert Wood Johnson Foundation, is investing $23.2 million this year alone to establish school-based health clinics in 12 states. The program requires states to answer the "hard questions" of securing long term funding for the clinics after the foundation's funding ends in four years. The foundation's initiative plus other such assistance by Kellogg ($4 million for Detroit clinics) and the Graustein Foundation ($2 million for Connecticut school clinics) are among the factors that have accounted for a 145 percent jump in the number of clinics between 1992 and 1994.

Politically, Lear notes New York's new conservative Republican Gov. George Pataki "protected school-based health centers while culling a number of other school initiatives. The fact that Republicans don't see them as politically controversial or fiscally irresponsible says a lot about the changing politics of clinics."

The religious right, however, remains a staunch opponent — focusing on the reproductive health issue. In Colorado Springs Paul Hetrick of the conservative Christian group Focus on the Family charges that some middle and high schools won't give a student an aspirin without checking with parents. "Yet school-based clinics will, if a young woman is pregnant, give her an abortion or help her get an abortion, and will have the entire process occur and parents never find out about it."

Debra Mauser McKinney of DC-based Advocates for Youth (formerly the Center for Population Options), another of the Assembly's organizers, acknowledged: "The far right is clearly after school-based health centers in claiming they're the contraceptive and abortion link for young people. But there isn't a school-based health center in the country that has anything to do with abortion and only 34.7 percent did any kind of counseling around options. Most refer out."

Contraceptive services are a matter of local governance subject to parental approval. McKinney said 42 percent of school clinics make oral contraceptives available to students; 32 percent issue condoms.

Some more sophisticated criticisms of the right are harder to rebuff. Kathleen Sullivan, a crony of Phyllis Schaffly and director of the 10-year-old Project Reality, a Chicago-based program promoting abstinence through classroom education, said: “The bottom line is to look at the results. Have the clinics been a success in any area? In helping kids become healthier? Holding jobs? We keep pushing, asking where are the results?"

One Chicago school clinic — Austen High School — she said received $187,000 in public aid "and the graduation rate is still only 27 percent."

Making the Grade's Julia Lear conceded Sullivan has hit upon something of an Achilles heel. “There's not a lot of studies or documentation out there establishing direct links between school health clinics and positive effects on students," Lear said. Still another reason for developing more informative data via the new Assembly.

Lear said she was surprised at the enthusiasm of youth health workers around the country for pushing ahead with the Assembly. "You'd think most people would say 'My God, not another organization!' But we had planned to have 350 at the conference and finally had to cut off registration at 500 and turn people away."


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Szerlag, Heather. "Youth Health Clinics Create New National Body." Youth Today, September/October 1995, p. 48.

©2000 Youth Today. Reprinted with permission from Youth Today. All rights reserved.