National Survey of State School-Based Health Centers Initiatives
School Year 1997-98
(Revised January 1999)

Background. During the 1990s, the Making the Grade National Program Office has undertaken three surveys of the 50 states and the District of Columbia to assess the growth of school-based health centers across the country and determine the extent of state policies supportive of that growth. Those surveys, conducted in March 1993, and the summers of 1994 and 1996 documented the remarkable expansion that was occurring. The number of centers reported by those surveys were 301, 607 and 900 respectively. In the summer of 1998, the Making the Grade office returned to the field, particularly interested in assessing the degree to which widespread changes in the health care system and the retreat from government-supported health services had affected the growth of centers. The following paragraphs, graphs and charts describe what was learned.

Methodology. The Making the Grade office developed a three-page survey that asked respondents to report on the numbers of centers in their states, and various characteristics, e.g. the types of schools in which they provide care, the locales in which they are located, and whether they are full-time or part-time. The survey also asked for information about state financial support for the centers and policies that may have been undertaken to promote health center growth. In most states, the survey respondent was a representative from the state health department. In a few states, individual centers helped piece together the picture of school-based health centers. The survey and information provided by individual states is available from the Making the Grade Program Office.

School-based health center growth. Data from the 1998 National Survey of State School-Based Health Centers Initiatives identified a total of 1,157 school-based health centers providing in-school care to children during the 1997-98 school year.1 This number represents a 29 percent increase from the 900 health centers reported in 1996 and a near doubling of the 607 centers reported in 1994.

Geographical Spread. School-based health centers are located in forty-five states plus the District of Columbia. The ten states with the largest number of school-based health centers are: New York (158), Arizona (82), Texas (77), California (64), Florida (64), Connecticut (51), Maryland (43), Michigan (41), New Mexico (40), Oregon (39), and North Carolina (39). These ten states represent sixty percent of all school-based health centers. Since the last survey conducted in 1996, Arizona experienced the largest growth in school-based health centers, followed by California, Indiana, and South Carolina.

The Mid-Atlantic and New England regions of the country are still home to the largest number of school-based health centers (422), although over the last two years, the Midwest has experienced the largest expansion of school-based health centers, a 61 percent increase. The distribution of school-based health centers for all the regions is as follows: Pacific Coast, 114; Southeast and South-central, 212; Midwest, 176; Southwestern & Rocky Mountain, 233; and Mid-Atlantic and New England, 422.

School-based health centers are located in all types of schools. While thirty-seven percent of centers are housed in high schools, 34 percent are located in elementary schools and 16 percent are found in middle schools. Most centers, 63 percent, are still concentrated in urban centers, but an increasing number, 26 percent, are located in rural areas, and 11 percent are found in the suburbs.

All school-based health centers included in the survey have a primary care provider on-site at least part-time. More than half the centers, 57 percent, report a full-time provider (25 hours per week or more). The survey defines a primary care provider as either a physician, nurse practitioner, or a physician’s assistant.

Sources of Funding. State governments continue to provide substantial funding for school-based health centers through state general funds and through the targeting of Maternal and Child Health block grant moneys. However, since 1996, state Maternal and Child Health dollars have decreased, while Medicaid reimbursements appear to have increased. Anecdotal evidence suggests that contributions from the private sector, particularly hospitals and health systems, have been important to the continued expansion of the centers.

In 1997-98, states contributed about $29 million in general funds to school-based health centers, an increase of $2 million since 1996. State-directed Maternal and Child Health dollars declined by over $3.5 million during this time period to $9.27 million in 1998. The level of state contributions to school-based health centers varies greatly. Four states account for nearly three-fourths of state-directed Maternal and Child Health dollars for school-based health centers: New York, Texas, Minnesota, and Illinois. In addition, five states account for nearly sixty percent of state general revenues flowing to school-based health centers: New York, Connecticut, Delaware, Arizona, and Michigan.

The 1997-98 survey also gathered information on school-based health centers activity in billing Medicaid and private insurers. Fifteen states reported $8.2 million in payments from Medicaid fee-for-service billing, five states reported nearly $700,000 in payments from Medicaid managed care, and seven states reported nearly a half million dollars in payments from commercial insurers. Other sources of support include local revenues, Title XX (Social Services Block Grant) moneys, and funding from the federal Preventive Services Block Grant.

State policies regarding school-based health centers. Below are the survey’s major findings regarding state policies and school-based health centers from those 45 states and the District of Columbia which have at least one or more school-based health centers. Note that some states may not have established policies because they do not have any school-based health centers. Other states may not have established policies because their centers have chosen not to raise the issue. For example, in Arizona, there is no “state policy” on Medicaid reimbursement for school-based health centers because the Arizona centers are currently well-funded through state grants and have not chosen to seek approval as a provider under the Arizona Health Care Cost Containment System — the state’s Medicaid program. However, many states report explicit policies that create climates of opportunity; a smaller number have taken specific measures such as developing operating standards for school-based health centers to foster quality of care and effectiveness and a still smaller group of states are aggressively promoting the replication of centers and taking an active role in shaping the role they will play in the child health care system.

  • Twenty-eight states reported having taken specific measures to encourage school-based health center participation in Medicaid managed care. These states represent seventy-six percent or 879 school-based health centers.
  • Twenty-seven states report having taken specific measures to encourage school-based health center participation in State Child Health Insurance Program. Affected by these measures will be seventy percent or 815 school-based health centers.
  • Twenty-four states have a governmental unit or office explicitly charged with developing and supporting school-based health centers. The remaining 21 states and the District of Columbia do not.
  • Since most school-based health centers are staffed with nurse practitioners, it is particularly important that 39 states and the District of Columbia allow nurse practitioners to participate as primary care providers in managed care provider networks.
  • Twenty-three states have established operating standards for school-based health centers. In 15 of these states the standards are recommended; in 8 they are required.
  • In seven states, school-based health centers are licensed by state health licensing authority. These states include: Connecticut, Kentucky, Massachusetts, Nebraska, New York, Rhode Island, and West Virginia.

1.The survey defines a school-based health center as one that is on school grounds and has a primary care provider (physician, nurse practitioner, of physician’s assistant) on site delivering care at least once a week.

A manuscript describing these data in greater detail has been submitted for publication. Further information should be available during the summer of 1999.

Making the Grade: State and Local Partnerships to Establish School-Based Health Centers is a national grant program of the Robert Wood Johnson Foundation that is based at The George Washington University. The program assists states in developing long-term financing policies to sustain school-based health centers, and is a national information center on this model of health care delivery. For more information, visit the MTG web site at