January 15, 2016

Dear Chief State School Officers and State Health Officials:

We share common ground in the belief that every child in our country deserves the opportunity to live a healthy and successful life. Today, at the U.S. Departments of Health and Human Services (HHS) and Education (ED), we are renewing our commitment to deliver on this belief by supporting quality health care and education for every child. Your work is essential to achieving this goal. This letter and accompanying toolkit offer resources and suggest practical steps for you and your colleagues to take and share to better connect health and education services.

We know that healthy students are better learners who are more likely to thrive in school and in life. ^{[  1  ]} In communities across the country, educators, health care providers, and families are working each day to help children grow into healthy and well-educated adults. They cannot do this alone. This work depends on strong and sustainable partnerships and commitments between health and education agencies at the local, state, and federal levels.

Over the past several years, major advances in laws and policies have created new opportunities to support our nation's children. For example, as a result of the Patient Protection and Affordable Care Act (ACA), many more students and their families are now eligible to obtain insurance through Medicaid, the Children's Health Insurance Program (CHIP), or a Qualified Health Plan (QHP) in the Health Insurance Marketplace. The ACA also invested $200 million to modernize or build new facilities, purchase much-needed equipment, and increase access to health services for children at school-based health centers throughout the country.

Our collective work is critical to increasing access to health care and quality education that can narrow disparities, promote achievement, and build a reliable system of support for every young person. Schools, for example, can provide on-site screenings to catch health concerns early and health providers can ask questions about school attendance and success during routine physicals and regular checkups. School districts can partner with public health agencies and local hospitals to ensure that all children receive preventive and necessary health care in order to attend school regularly and stay on track toward high school graduation. These partnerships can result in comprehensive care for a sick child, help manage a student's disabilities ^{[  2  ]} or chronic conditions, and make sure a student gets a well-rounded education that includes opportunities for physical activity, nutrition, and health education.

The tools and resources we are releasing today can help state and local stakeholders take practical steps to strengthen the link between health and education. We encourage you to use these and the other materials provided to explore high-impact opportunities to:

• Increase access to health insurance to promote better academic outcomes;
• Create school environments with the physical and mental health supports to help students succeed academically and lead healthy lives; and
• Strengthen coordination and collaboration between health and education systems at the local and state levels.

To increase access to health insurance to promote better academic outcomes, you can:

• Help Eligible Students and Family Members Enroll in Medicaid, CHIP, or the Marketplace. Research strongly suggests that when young people have insurance and receive necessary and preventive health care, their academic and other important life outcomes improve. ^{[  3  ]} One recent study, for example, found that children who gained access to Medicaid as a result of coverage expansion are more likely to do better in school, miss fewer school days due to illness or injury, finish high school, graduate from college, and earn more as adults. ^{[  4  ]} It is helpful to families registering a child for school to have the opportunity to enroll in health insurance programs at the same time. As one example, local educational agencies (LEAs) can use school registration processes to help eligible students and family members enroll in Medicaid or CHIP, or receive financial assistance for a plan in the Health Insurance Marketplace.

To create school environments with the physical and mental health supports to help students succeed academically and lead healthy lives, you can:

• Provide and Expand Reimbursable Health Services in Schools. Schools and LEAs are now eligible, subject to an approved State plan, for reimbursement for many Medicaid services provided to students enrolled in Medicaid. This includes services provided by school-based health centers, which can significantly improve key educational outcomes among students. ^{[  5  ]} State Medicaid agencies, State educational agencies (SEAs), and LEAs can work together to explore opportunities for reimbursement of Medicaid-covered services for Medicaid-enrolled students. Recent guidance from the Centers for Medicare and Medicaid Services (CMS) explains changes in the federal "free care" policy, which addresses Medicaid payment for services available without charge to the community at large ("free care"). This CMS guidance identifies the Medicaid requirements that must be met in order for Medicaid reimbursement to be available. As a first step in this process, state and local health and educational agencies can come together to identify the scope of allowable school-based services under the state's Medicaid plan. Schools and LEAs should determine if they meet the criteria to become a Medicaid provider or should partner with Medicaid providers. In consultation with State Medicaid agencies, they can then provide Medicaid-reimbursable services at their schools, like immunizations, health screenings, oral health care, substance abuse programs, and mental health care.

• Provide or Expand Services That Support At-Risk Students, Including Through Medicaid-funded Case Management. Wraparound services benefit children, including those who are low-income, chronically absent, homeless, or otherwise at risk of falling behind in school. ^{[  6  ]} Case managers can work to refer Medicaid-enrolled students to necessary health and related support services, such as housing and transportation. In accordance with an approved state Medicaid plan, SEAs, LEAs, State Medicaid agencies, and State departments of health and child welfare services can use Medicaid funding to support district and school-based case manager positions.

• Promote Healthy School Practices Through Nutrition, Physical Activity, and Health Education. More physical activity and more nutritious food throughout the school day can improve a student's health and academic outcomes. ^{[  7  ]} School learning environments should be designed to include opportunities for daily physical activity and high-quality, nutritious school food. To create these opportunities, schools can assess the effectiveness of their policies and practices using the Centers for Disease Control and Prevention's (CDC) School Health Index and School Health Guidelines to Promote Healthy Eating and Physical Activity. Schools can get access to even more technical assistance and support materials by signing up to be school champions through the Let's Move! Active Schools initiative. LEAs can develop strong Local Wellness Policies that are deeply integrated into individual school improvement plans. As research has shown, comprehensive health education leads to fewer students using tobacco or alcohol, and fewer delinquent behaviors. ^{[  8  ]} Schools can use CDC's Health Education Curriculum Analysis Tool (HECAT) to determine how well their health education programs address these and other topics.

To strengthen collaboration between health and education systems at the local and state levels, you can:

• Build Local Partnerships through Partnering with a School-Based Health Center or Participating in Hospital Community Needs Assessments. Research suggests that multiorganizational partnerships can improve public health. ^{[  9  ]} When schools partner with other community institutions, they can gain new resources for school-based activities, and help students be healthier and learn more. School-based health centers often are operated as a partnership between the school and a community health organization, such as a community health center, hospital, or local health department. Students and their families rely on school-based health centers to meet their needs for a full range of age-appropriate health care services, typically including primary medical care, mental/behavioral health care, dental/oral health care, health education and promotion, substance abuse counseling, case management, and nutrition education. In addition, one new opportunity resulting from the Affordable Care Act is that hospitals claiming 501(c)(3) charitable, tax exempt status must identify area health needs and adopt strategies to address them. LEAs can partner with local hospitals and identify the health care needs of children, especially at-risk youth. To develop a local partnership based on the specific needs of your community, contact your local nonprofit hospital's Community Benefit Department. They can help you find out how to participate in their community health needs assessment process. This process could involve hospitals working with school districts to decide how they can contribute resources and services to promote student health.

Every day, people in your states work tirelessly in schools and health care systems to provide the loving care and support that young people need. But too many students still face disparities in health and education. We've provided a few ideas to spur collaboration, and want to hear about the ideas that have worked in your community. The health and education of young people today are the building blocks of our communities tomorrow. We are committed to working in partnership with you to ensure that every child leads a productive life.

Sincerely,

Enclosure

1. Ickovics, J., A. Carroll-Scott, S. Peters, M. Schwartz, K. Gilstad-Hayden, and C. McCaslin. (2014). "Health and Academic Achievement: Cumulative Effects of Health Assets on Standardized Test Scores Among Urban Youth in the United States." Journal of School Health, 84 (1): 40-48. ^{[ Return to text ]}

2. This letter is not intended to address situations in which a school district may seek to access a child's or parent's public benefits or insurance, e.g., Medicaid, to pay for special education and related services for children with disabilities under Part B of the Individuals with Disabilities Education Act, 20 U.S.C. 1400 et seq. and its implementing regulations in 34 CFR part 300. For more information about the requirements that apply to children with disabilities who are covered by public benefits or insurance, see 34 CFR §300.154(d). ^{[ Return to text ]}

3. Institute of Medicine (IOM) of the National Academies. (2009). America's Uninsured Crisis: Consequences for Health and Health Care. Washington, DC: The National Academies Press. ^{[ Return to text ]}

4. Cohodes, S. et al. (2014). The Effect of Child Health Insurance Access on Schooling: Evidence from Public Insurance Expansions. (No. w20178). National Bureau of Economic Research. ^{[ Return to text ]}

5. Walker, S.C. et al. (2010). "The Impact of School-Based Health Center Use on Academic Outcomes." Journal of Adolescent Health 46(3): 251. ^{[ Return to text ]}

6. Suter, J.C. and E.J. Bruns. (2009). Effectiveness of the Wraparound Process for Children with Emotional and Behavioral Disorders: A Meta-Analysis. Clinical Child and Family Psychology Review, 12(4): 336-351. ^{[ Return to text ]}

7. See for example: (1) Centers for Disease Control and Prevention. (2010). The Association Between School-Based Physical Activity, Including Physical Education and Academic Performance. Atlanta, GA: U.S. Department of Health and Human Services; (2) Basch, C. E. (2011). Physical Activity and the Achievement Gap Among Urban Minority Youth. Journal of School Health, 81: 626–634; and (3) Basch, C. E. (2011). Breakfast and the Achievement Gap Among Urban Minority Youth. Journal of School Health, 81: 635–640. http://www.nal.usda.gov/fnic/pubs/learning.pdf. ^{[ Return to text ]}

8. Dent, C.W. et al. (1995). Two-Year Behavior Outcomes of Project Toward No Tobacco Use. Journal of Consulting and Clinical Psychology, 63(4): 676-677. ^{[ Return to text ]}

9. Mays, G.P and F.D. Scutchfield. (2010). Improving Public Health System Performance through Multiorganizational Partnerships. Prev Chronic Dis 7(6): A116. http://www.cdc.gov/pcd/issues/2010/nov/10_0088.htm. ^{[ Return to text ]}