School-Based Health and Access to Care: Evidence from a School-Based Health Center Opening

• In Event: The Role of School-based Health in Improving the Health and Wellbeing of Underserved and At-risk Children

Abstract

School-based health centers (SBHCs) aim to expand access to health care for underserved children and youth by providing primary and preventive care in the school setting. SBHCs are sponsored by healthcare systems or hospitals and are staffed by multi-disciplinary teams of providers in consultation with a supervising physician. Key features of SBHCs that facilitate access to care are their location within the school, ease of making and keeping appointments, medical staff familiarity with the students, and provision of services regardless of insurance status and with no out-of-pocket costs to families (Kjolhede & Lee 2021; Itriyeva 2024).

A large research literature suggests that SBHCs improve health care access and health outcomes for medically underserved youth (Keeton et al., 2012; Knopf et al. 2016; Arenson et al., 2019), but the evidence basis is known to suffer from limitations associated with focus, samples, and methods. Some studies are limited to only Medicaid enrollees or are able to observe only patients who are enrolled in a SBHC; SBHC service differences or patient demographics may be uncontrolled for; selection effects into SBHC enrollment, and inability to follow students over time are other concerns (Boudreaux et al., 2023; Bersamin et al., 2015; Silberberg & Cantor, 2008). Moreover, most studies have been conducted in urban SBHCs, with limited understanding of the potentially important role of SBHCs in rural settings where  health care availability is often geographically constrained (Knopf et al., 2016).

This study adds to the literature by applying event study and difference-in-differences techniques to estimate the effects of opening a new SBHC in a rural school district. We have access to a de-identified dataset of all patient encounters with providers in a regional healthcare Network over multiple years. Patient addresses are geocoded to the school district level, and a unique patient ID allows us to observe health care visits for patients across service types and over time. The Network operates SBHCs in a subset of the school districts in the area, and is the only provider of school-based health care. All of the SBHCs are permanent structures within the schools, and provide comprehensive primary care under a single system of care model.

These characteristics facilitate comparison of health care utilization among children living in the studied district and in neighboring school districts before and after the SBHC opening. We examine (i) pre-post trends in health care utilization within the studied district; (ii) pre-post trends in health care utilization in the studied district compared with districts without SBHCs; and (iii) pre-post trends in health care utilization in the studied district compared with its neighboring district that opened a SBHC five years later. Pre-opening trends and enrollment changes are analyzed, and estimates control for student age and sex, and school district characteristics. Results show significant positive effects of the SBHC on health care access.

Authors

• Zhuang Han, Cornell University
  Presenting Author

• Xue Zhang, Pennsylvania State University
  Non-Presenting Co-Author

• Sharon Tennyson, Cornell University
  Non-Presenting Co-Author