Twenty Years Of School-Based healthcare Growth And Expansion

Love HE, Schlitt J, Soleimanpour S, Panchal N, Behr C
Source: Health Affairs
Publication Year: 2019
Population Focus: Vulnerable/disadvantaged
Demographic Group: Child
Intervention Type: Best practices
Study Design: Other Study Design
Type of Literature: White

Youth in underserved communities lack access to consistent sources of high-quality healthcare. School-based health centers (SBHCs) address this challenge through the provision of primary care, mental healthcare, and other health services in schools. This article describes the current status of SBHCs nationally, including changes over the past twenty years. Data were collected through the School-Based Health Alliance’s National School-Based healthcare Census. The number of SBHCs doubled from 1,135 in 1998–99 to 2,584 in 2016–17. During this time they adapted to the changing healthcare landscape and community needs. Sponsorship shifted predominantly to federally qualified health centers, and SBHCs provided access to primary care and, often, to mental, oral, and other health services to 10,629 schools and over 6.3 million students. SBHCs have grown steadily since 1998, and recent expansion through federally qualified health centers and telehealth technology forecasts even greater growth, innovation, and access for underserved communities.

Insights Results

Overview of article

  • This article describes the current status of school-based health centers (SBHCs) nationally, including changes over the past twenty years
  • School-based health centers (SBHC) are a type of model created to address challenges that underserved youth face in healthcare access and use
  • School-based health center can refer to 4 distinct primary care delivery models: 1) Traditional – patients access care at a fixed site on a school campus with provider on-site; 2) School-linked – patients access care at a fixed site near a school campus through linkages with schools; 3) Mobile center – patients access care at a specially equipped van or bus near a school campus; and 4) Telehealth exclusive center – patients access care at a fixed site on a school campus with providers remotely available for primary care services

Methods of article

  • Data from the Public Elementary/Secondary School Universe Survey Data of the National Center for Education Statistics for the 2015–16 school year were used to examine the characteristics of students and schools with access to SBHCs
  • Data for the 2016–17 Census were collected during May–December 2017 via an online portal. The survey asked that the person (or persons) with the most knowledge about the care delivered by the SBHC complete the survey
  • The final study sample consisted of the 2,317 centers. Of these 2,317 SBHCs, 1,894 were traditional SBHCs, 87 were school-linked, 69 were mobile, and 267 were telehealth-exclusive


  • In 20 years, there was a 128% increase in the number of SBHCs
  • There was also a rise in federally qualified health centers and a growth in SBHCs providing access to rural communities. of SBHCs. With the rise in federally qualified health center sponsorship, the %age of SBHCs sponsored by other organization types declined
  • To remain sustainable, SBHCs combine funding sources—including public and private insurance revenue; federal, state, and local grants; school and school district support; and private foundation grants
  • All SBHCs provided primary care. In 2016–17, 85% employed nurse practitioners, and this share has remained relatively constant over time, along with the proportion of centers employing
    physicians (41% in 2001–02 and 40% in 2016–17). In 2016–17, 65% of centers had behavioral health providers as members of the provider team—a smaller %age than in 2007–08, when the share peaked at 81%

Key takeaways/implications

  • Factors that likely contributed to the growth in SBHCs include: 1) Increase in state-level investments; 2) Federal expansion of the primary care safety net (through the ACA); 3) Growth in advocacy for SBHCs; 4) Convergence of SBHCs and federal qualified health centers; 5) Expansion of services and growth of telehealth; and 6) Better outreach to underserved communities
  • Future directions for research and practice include: 1) Use of telehealth to improve access to primary and mental healthcare; 2) Use of quality measurement to encourage voluntary reporting on the performance measures annually; 3) Impact of more federally qualified health centers through federal sponsorship; 4) Potential impact of SBHCs on educational outcomes; and 5) Opportunities for expansion
  • Limitations to the study include potential non-inclusion of all SBHCs, unavailability of some data, potentially underrepresented school data, and lack of longitudinal assessment