School health clinics face obstacles — and how Arne Duncan could help
By Richard Rothstein, The Washington Post
A contentious debate in education policy concerns whether the low achievement of disadvantaged children is attributable primarily to social and economic conditions that bring them to school relatively unready to learn, or to public schools whose ineffective teachers fail to instruct. Certainly, differences in home literacy, health, out-of-school time, and teacher effectiveness all may play a role. But how you balance your view of their relative importance influences the policy choices you make.
Clearly, keeping children in good health must be part of that balance – children cannot learn otherwise. In disadvantaged neighborhoods, school-based health centers may be the only practical way to keep children in good health. But adequate promotion of such centers has been distressingly absent from the Obama administration’s education policy. This would be easy to fix.
It is conventional in our political culture for politicians and pundits, when faced with difficult choices, to claim to favor both, or to have a middle position that avoids extremes, or to be the voice of reason when others are shrill. So we should not be surprised that Secretary of Education Arne Duncan has now staked a claim to be above the fray. In a Feb. 7 speech at Harvard, he charged his critics with “maintaining ideological purity and making false choices.” For them, “the perfect, too often, becomes the enemy of the good.”
He, in contrast, claimed to believe that “boosting student achievement is not an either-or solution. Educators and the broader community should be attacking both in-school and out-of-school causes of low achievement.” And he insisted, he said, that while “I welcome debate, I don’t find that debate which is detached from real world challenges, or driven primarily by ideology, advances the interests of children.”
Secretary Duncan’s critics accuse him and his allies of ignoring the role that poverty and associated challenges play in depressing student achievement. We note, for example, that his proposal for re-authorization of the Elementary and Secondary Education Act demands that all schools be held equally accountable for getting every child “college and career ready” by 2020 — whether children come to school from families where they are read to at home; from neighborhoods that are violence free; from economic environments with full parental employment and stable housing; and in good health that supports regular school attendance and attention.
And if any school fails to achieve the goal, the administration proposal suggests several turnaround strategies, none of which emphasize early childhood literacy programs, or high quality after-school programs, or school health clinics, but instead mostly emphasize firing principals and teachers.
In his Feb. 7 speech, Mr. Duncan partly conceded his critics’ complaints, insisting “that great schools and great teachers are the most effective anti-poverty tool of all.” But this belief is consistent, he said, with his being “a huge fan of out-of-school anti-poverty programs.” He went on to note his prior efforts, as chief executive of the Chicago Public Schools, to implement full-service school health clinics, including free vision and dental programs.
“It never made sense to me,” he said, “that poor children should be expected to learn just as readily as other students when they couldn’t see the blackboard, or when their mouths ached from untreated cavities and gum disease. So we dramatically expanded our free vision and dental programs in the schools.”
Indeed, as Chicago school leader, Arne Duncan was so committed to this strategy that he was a charter sponsor of the Broader Bolder Approach to Education campaign that asserts that the “fundamental challenge facing America’s education policy makers” is weakening the “powerful association between social and economic disadvantage and low student achievement.”
The mission statement of this campaign, embraced by Secretary Duncan in 2008, went on to say that narrowing the achievement gap required all four of these important initiatives: continue to pursue school improvement efforts; increase investment in developmentally appropriate and high-quality early childhood, pre-school, and kindergarten education; locate full-service health clinics in schools; and increase investments in longer school days, after-school and summer programs, and school-to-work programs that do not exclusively focus on academic remediation.
But Mr. Duncan has abandoned this commitment as Secretary.
Consider perhaps the most urgent example: promotion of full service health clinics in schools. Such clinics are essential props for student achievement, not only because children who are absent because of illness can’t benefit from good teaching, or because children with untreated dental cavities are distracted by oral discomfort, or because untreated asthma (an epidemic in polluted urban neighborhoods) keeps children awake at night and drowsy in school, or because children can’t read well if they have uncorrected vision difficulties, but because there are few primary care physicians located in low-income neighborhoods. And where primary care is available, parents working low-wage hourly jobs cannot get time off to take children for routine and preventive visits. Often, such visits can happen only if they occur on school campuses and within the school day.
In his Feb. 7 speech, Secretary Duncan demonstrated his commitment to school clinics by boasting that under President’s Obama’s health care legislation: “[T]he administration has provided more than 275 school-based health clinics with about $100 million to provide more health care services at schools nationwide. Those grants will enable school-based health clinics to serve an additional 440,000 patients — a jump of over 50 percent.”
This claim is not quite accurate. There have been no Affordable Care Act appropriations for health care services at school clinics. Rather, the funds to which Mr. Duncan referred can be spent only on capital construction and equipment and may not be used for health care services themselves.
The secretary apparently got his 50 percent figure from the Department of Health and Human Services (HHS) that administers these funds; but HHS arrived at this figure simply by adding up claims made by clinic sponsors of what they hoped to do. Fifty percent is highly implausible. Not many clinics have big pools of uncommitted service funds that remain untapped only because facilities are inadequate. Some schools have built new health centers with the funds, but for others, while it is a wonderful thing to be able to replace dental chairs or expand examining rooms, these important improvements are unlikely to generate a 50 percent increase in children served.
There is, in the health care law, an authorization for funding clinic services, but not a cent has been appropriated, and it is virtually certain that none ever will be — perhaps for the same reasons that the already appropriated funds are restricted to capital. Congressional Republicans block funds for health care services in schools, in part from fear that such funds will be used to distribute birth control information or condoms.
This, of course, is not Secretary Duncan’s fault. I am certain he would have wished that Obamacare provided not only for school clinic construction and equipment, but also for services, and at an even higher level than authorized. Rather, skepticism about his commitment to “both-and,” not “either-or,” strategies (i.e., improvements in teacher quality AND school-based health centers) is based on the unbalanced way in which he has pressed states to change their policies to qualify for Race to the Top funds and to receive waivers from No Child Left Behind’s requirement that all students be proficient by 2014.
States qualified for Race to the Top funds if they accumulated points on a complex scale devised by the Department of Education. The scale was not a “both-and” scale of the sort that Mr. Duncan claims to favor. States were given points for adopting the administration’s favored in-school reforms — such as linking teacher records to student test scores so that teacher evaluation can be based, at least in part, on such scores, or expanding the number of charter schools. But states were given no points for increasing the number of school-based health centers, or making it easier for such centers to operate.
In some cases, to qualify for desperately needed Race to the Top funds, governors had to go to their legislatures for politically difficult changes in state laws; in New York, for example, the teacher tenure law prohibited student test scores from being used for teacher evaluation, and over the bitter objection of the state’s teachers, the law was amended.
If the secretary truly favored a “both-and” approach, could the Department of Education have demanded similar state law changes affecting school clinics as a condition of receiving Race to the Top funds? It would have been a simple matter.
One of the biggest impediments to the establishment of such clinics is the bureaucratic maze such clinics often must navigate in order to get reimbursement. In most states (but not in all), school-based health centers must get prior authorization from managed care organizations (into which Medicaid recipients are required to be enrolled) for each visit made by a child to a school clinic. In most states (but not in all), managed care organizations are not even required to negotiate contracts with school-based health centers, and if they do negotiate such contracts, reimbursement rates are far below the Medicaid fees that managed care organizations themselves receive for these services. In most states (but not in all), school-based health centers are not defined as providers eligible to bill Medicaid directly.
For the majority of states that make it difficult for school clinics to function, changing these requirements would be politically difficult — managed care organizations and local medical societies protecting their monopolies could offer resistance — but no more difficult than changing teacher tenure laws. Conditioning Race to the Top eligibility on changes in state laws to define school-based health centers as eligible providers, to prohibit prior authorization requirements for clinics’ routine and preventive care, or to mandate full value contracts between managed care organizations and school-based health centers, might have been sufficient incentive for states to make these changes.
Secretary Duncan is now issuing waivers to states from their No Child Left Behind requirements. Again, he is conditioning such waivers on in-school reforms only. States can qualify for waivers by promising to tie teacher records to student test scores, by purchasing textbooks with higher standards, by firing teachers and principals at schools with low test scores, but not by promising to facilitate school-based health centers, or for adopting other reforms to improve children’s readiness to learn when they enter school.
He should add such requirements now. It is not too late for him to rescue his reputation as a “both-and” kind of guy. Former Texas Agricultural Commissioner Jim Hightower famously said, “There’s nothing in the middle of the road but yellow stripes and dead armadillos.” I’d like to see Arne Duncan prove him wrong. 2/26/2012