For the last several years, school nurses have been “the enemy.” In some large districts, they can’t see patients, cannot physically transport them and often don’t know why students with developmental delays are being sent to their office. This creates a negative “therapy funnel” system: The longer the nurse spends in a child’s office, the more likely it is for that child to get lost in an autism facility or another adult’s hospital.
Neuro-developmental pediatricians (NDPs) have taken the lead in the movement to strengthen the mental health of children in school. For decades, NDPs have been seeking greater flexibility in dealing with the most complex health problems facing today’s child. At the same time, as NDPs struggle with accommodating the needs of children with special needs in school, all too often parents are losing their children to other administrators.
Over the last several years, two pieces of federal law have provided a good vehicle for improving some aspects of this issue. In 2014, the Foster Care Reform Act (FCRA) was enacted. The legislation included provisions designed to improve the mental health of children entering foster care and promote the well-being of the foster children they come into contact with. FCRA stipulates that the federal government will award state funding to states to provide mental health services to young people in foster care with a severity rating in the category of “serious mental health crisis.”
But more important is the child health parity law (CHL), which Congress passed in 1998. CHL covers all private health insurance. It provides each state with a set of data to use to plan and provide services. States can use these data to make determinations on the costs and effectiveness of care. Most recently, for example, states have used the data to determine if they are reimbursing health providers at a rate sufficient to cover basic mental health services. They must submit to the U.S. Department of Health and Human Services (HHS) any data indicating that the states meet CHL’s goals.
What if a school nurse is not authorized to see the child, and if the child does not have a heart condition, which is recognized as such by the state? CMS currently makes no distinction between covered mental health services and medically necessary physical health services when granting Medicaid enrollment waivers, including waivers to provide mental health services, since Medicaid funds only cover physical health services. The main problem with this strategy is that the waivers designed to ensure adequate mental health care must be modified by local school administrators. When state waivers run out, school nurses are left to fill in the gaps.
This leaves state waivers on a “hot topic” list. Local health departments typically receive, or contribute, to these hot topics, which means often that a local medical group or school district champions a health service regardless of the state of its readiness. When a waiver is denied or when a waiver to expand the number of hours that a nurse can care for children is denied, it is often perceived as a punishment for a nurse who has the courage to speak out on a hot topic that affects a small percentage of local school districts and administrators.
The people who need their voices heard should be the health-care providers who best understand child mental health and advocate for policies that better meet children’s needs.
The American Academy of Pediatrics, the Council on Economic Priorities, the National School Boards Association, the National Association of School Psychologists, and the National Association of Secondary School Principals are among those who have proposed commonsense changes to address these issues. They include the following:
The federal government should require states to modify CHL waiver requests in cases where children in foster care lack proper health care access.
State waivers for children in foster care must be modified to allow local school nurses to see children who do not have at least a moderate difficulty of interaction with others, such as psychosocial and behavioral challenges.
Additionally, as patients gain more access to mental health services, our federal policy must respond to this, too. At the end of high school, high school counselors should also have access to grants to help them become more effective at coaching young people and developing them as adults.
The last 25 years have been marred by ill-advised “studies” that espouse a narrow view of mental health issues and pay lip service to the need for broad-based health care access. Why not apply a more comprehensive definition of mental health? We have always tolerated a narrow definition of body-based disorders. Why not this now?