Medical Examiner

School-Based Health Centers Provide Health Care for Rural Americans—but for How Long?

The programs expanded under the ACA. The AHCA makes their future less certain.

Valley View Health Centers in Adams County, Ohio
Valley View Health Centers in Adams County, Ohio.

Valley View Health Centers

At the end of a long, curving dirt driveway, inside a yellow-sided double-wide mobile home with green shutters, Tina King is juggling backpacks, signing homework, and trying to wrangle four kids out the door for school. And then her daughter, 10-year-old Tessa, says the words every parent dreads: “Mommy, I don’t feel so good.”

There was a time when these six words would have meant a crisis for King. Out here in southern Ohio hill country, the closest doctor is almost half an hour away, and King’s job at a bakery was more than an hour away in the opposite direction. Even if she could finagle an appointment and afford the extra gas money, she could lose as much as a whole day’s pay.

But today, things are different: King can drive 10 minutes to the elementary school, walk three kids to the school doors, and take Tessa 50 paces away to the on-site health center. There, a nurse practitioner will see her right when the clinic opens at 7:30 a.m. King will be back on the road by 8 a.m.

“It’s just such a blessing—you can get right in, they can do the strep test or whatever you need right there, and if your kid is cleared to go to class, a lot of times they’re not even tardy,” says King. “It’s just wonderful.”

The health center, which was established five years ago and is owned and operated by Valley View Health Centers, represents one of the ways the Affordable Care Act has helped improve access to care for Americans. First founded in the 1970s with a combination of government and private foundation dollars, school-based health centers gained traction in the 1990s with increased state funding; there were 153 at the start of that decade and more than 1,000 by its end. But it was the ACA, passed in 2010, that changed the game, designating $200 million to build or upgrade school-based health centers across the country. The Manchester, Ohio center is one of more than 500 sites across the nation that received a grant, which it used to fund the construction of the small brick building and its bright, well-equipped exam rooms. While the majority of school-based health centers are still located in urban areas, rural areas are seeing the fastest increase in new centers; 60 percent of all new centers built since 2011 have been in rural regions.

Although they’re still only in about 2 percent of the nation’s public schools, the nation’s approximately 2,300 school-based health centers have garnered interest from diverse quarters—including folks not typically known for their support of programs involving the Affordable Care Act or Medicaid patients. The Manchester center, for example, has strong support from its Republican state Sen. Joe Uecker, state Rep. Terry Johnson, and Brad Wenstrup, a Tea Party–backed congressman. “They’ve all been here to our ribbon-cuttings, they’ve written letters to help us get grants—they’ve all been very supportive,” says Karen Ballengee, the school district treasurer who spearheaded the establishment of the Manchester center.

Valley View Health Centers hires and supervises the staff, handles appointments and billing, and runs day-to-day operations (it took over from the original provider, Adams County Regional Medical Center, in 2014). The clinic accepts payments through Medicaid or private insurance, or patients can pay out-of-pocket on a sliding scale according to their income. To attract enough patients to be viable, the center is open to all members of the community, including students’ families, teachers, and other local residents—Tessa’s mom has received mammograms there, for instance. As a federally qualified health center serving an impoverished community, the health center is reimbursed by Medicaid at a higher per-patient rate, which helps the center stay above water.

The center’s existence is critical beyond treating sick kids in the moment. It also makes preventive care much easier. Parents no longer have to miss work for their kids to get it: The kids can be pulled from class for shots, or physicals, or even dental cleanings, and can be back in class 40 minutes later—a big improvement over missing several hours or even a whole day of school to travel to and from a distant appointment. Since the center is sandwiched between the elementary school (grades K–6) and high school (grades 7–12), the kids can walk back to class without even going outside.

For many families in this rural school district—where some kids have an hour-long bus ride just to get to school, and more than 60 percent of the students qualify for reduced-price school lunch—the on-site health center isn’t just a convenience; it’s the difference between having medical care and not having it at all. “The very few doctors we do have in the region usually take only a limited number of Medicaid patients, and we have almost a total lack of dentists,” says Ballengee. “If the family can’t afford to take the day off, or doesn’t have the gas money or a car reliable enough to make a long trip, they just don’t go.”

For many students, their visits to nurse practitioner Lori Rumfield are their only access to immunizations, physicals, mental health screening, or care for ongoing conditions like asthma or diabetes. And for some, their first visit to the health center’s dentist is their first visit to any dentist, ever. “We’ve had a few kids where their tooth decay was so advanced that we had to get them transported to the children’s hospital,” an hour and a half away in Cincinnati, says Ballengee.

From a health standpoint, the benefits of school-based health centers are obvious: Kids get immediate access to medical care when they need it either for free or at a cost their families can afford. The academic benefits are significant, too—on-site health centers improve school performance and student attendance. “Our motto is that a healthy child is a learning child,” says Rumfield. “That’s why we’re here.” The team also offers critical mental health services, screening children and referring them to an on-site counselor as needed. “We screen every kid for depression, even if they come in for a sore throat,” she says. “I had several just last week who failed their screenings—and often, we’re the only ones even asking them about these things.”

Running such a rural clinic is not without drawbacks. “We’re a little dot on the map: There’s just not much here,” says Rumfield. “It’s hard to attract people—especially dentists—to work here if they’re not from here already. If you’re not used to driving an hour to the mall, it’s hard to get used to.” Rumfield, the nurses, and the receptionist are all from the area. The current dentist is a 2016 dental school graduate who’s leaving in July to complete her residency. It’s unclear where her replacement will come from. Other rural health facilities have experimented with job-sharing arrangements where a different dentist from a nearby city comes for the day on a designated day of the week. It sacrifices continuity of care, but at least you have a dentist. And of course, there are plenty of specialized medical problems the center cannot solve but Rumfield can direct them to the proper specialist elsewhere—and sometimes even provide transportation if the child has no other way to get there.

The center also faces a bigger looming threat to its existence. Proposed deep cuts to Medicaid—through the block-granting or per capita caps of the Republican American Health Care Act, something supported by the White House’s proposed budget—could make it harder for the clinic to keep its doors open. “A great percentage of school-based health center patients are enrolled in Medicaid or [the federal Children’s Health Insurance Program], so any changes to Medicaid could have a significant impact,” says John Schlitt, president of the School-Based Health Alliance in Washington. With a smaller pool of federal dollars available to serve low-income citizens, cash-strapped states would likely change eligibility requirements to cover fewer people, resulting in fewer patients whose insurance is guaranteed. That would strain the center’s financial viability. States might also reduce the number of covered services, possibly repealing the requirement that Medicaid cover mental and behavioral health services.

The knee-jerk narrative about little towns like this is one of Rust Belt decline and admittedly, some of the narrative fits: There are the crumbling, mostly empty downtown storefronts in Manchester, and a tired-looking mobile home park next to the faded Family Dollar store just outside of town. The two largest employers, coal-fired Duke Energy power plants, are set to close next year, supplanted by lower-cost natural gas producers. The closure will cost the county hundreds of their county’s best-paying jobs. There are widespread struggles with heroin and meth: Tina King’s four school-age children are her biological great-nieces and great-nephews whom she adopted after her niece succumbed to drug addiction. Rumfield has struggled to get drug-addicted parents to sign paperwork approving their kids’ medical care.

Yet the high school gym was filled with cheering families at last Friday’s basketball game, and 1,000 students walk through the doors of Manchester schools every day—1,000 kids who need shots and dental cleanings and strep tests and antibiotics and eyeglasses and depression screenings and dental fillings … today, and tomorrow, and the next day, and the next. For the time being, the health center is here to give it to them.