The Other 60 Percent

Medicaid money a boon for wellness in schools

Most school districts have gotten used to shrinking or stagnating funding streams in recent years, but there’s at least one pot of money that’s defied that trend. Administrators across Colorado are quick to call it “amazing,” “unbelievable” and “wonderful.”

<em>                 Photo credit: Queen’s University</em>

It comes in the form of Medicaid reimbursements for therapy or personal care services provided to low-income special education students by their school districts. Regardless of whether districts choose to participate in the Medicaid reimbursement program, federal law requires them to find the money to provide special education services. Thus, districts that join the Medicaid program are able to recoup some of the money that they would have spent anyway.

The payments, which can total millions in the biggest districts, must be used for health-related expenses by law. While special education equipment or staffing certainly qualify, increasingly school districts are using the money for health and wellness efforts that touch all students.

This may mean suicide prevention curriculum, anti-bullying programs, more mental health personnel, or efforts to curb obesity. It can also take the form of health and wellness coordinators tasked with leading health policy discussions at the district level and establishing school wellness teams and initiatives. Many districts also use a portion of the money to reach out to families who don’t have health insurance, in an effort to connect them to Medicaid, CHP+ or some other form of coverage.

Cassandra Reese, the Medicaid coordinator and a school nurse in Academy District 20, said in the next couple years, “I’m hoping to see more wellness…It’s still in the toddler stages.”

She said the district has taken some small steps in that area using Medicaid funds, including handing out magnets with healthy snack suggestions to all elementary families.

Academy District 20 gave this magnet, paid for with Medicaid reimbursements, out to all elementary families.

In Adams 12 Five Star, which expects to receive about $1.2 million in reimbursements this year, there’s been a shift toward overall wellness efforts in the last couple years, according to those who run the program. In fact, earlier this month, the district filled a brand new position: Manager of Coordinated School Health.

Expanding and sustaining health efforts

Administrators in Adams 12 were chagrined when the annual KIDS COUNT in Colorado! report came out last spring. The county had fallen from 23rd to 24th in a ranking of the state’s 25 most populous counties on child well-being.

While that grim statistic helped create the momentum for a more coordinated approach to school health and the creation of the new manager position, Medicaid money gave them a way to pay for it.

As in all districts that participate, Adams 12 Five Star divvies up the money based on a five-year “Local Services Plan” created by district and community stakeholders. Among other things, the reimbursements pay for suicide prevention training, more nursing hours, outreach to uninsured students and help for students who need food, clothes or specialty items like glasses.

The reimbursements also help leverage money from community partners, demonstrating the district has skin in the game so to speak. For example, the district funds school-based mental health therapists partially with Medicaid money and partially with funds from a community mental health center.

“We’re all in it together,” said Sandra Sellstrom, coordinator of the district’s Medicaid School Health Services Program.

Denver Public Schools, which joined the reimbursement program when it started in Colorado in 1997, receives the largest reimbursement in the state: about $2.5 million last year. The district spends that money on a variety of things, including its four-member “Healthy Schools” team, which oversees district health policy, promotes use of school-based health clinics and works with individual schools on health and wellness efforts.

The district also uses a portion of the reimbursement money to advance the goals in its five-year plan of health priorities, called “DPS Health Agenda 2015” For example, to help meet one of its social-emotional health goals, the district spent nearly $18,000 last year on suicide prevention curriculum for sixth- and ninth-graders as well as staff training on the topic. Now, 22 of the district’s school psychologists and social workers are certified as suicide prevention specialists, up from one previously.

Although the district has raised $18 million to implement its Health Agenda through grants, donations and other sources, administrators say Medicaid reimbursement represents an integral funding stream, especially because it isn’t a one-time sum like some other sources.

“It’s been a very consistent and growing source of revenue for districts,” said Bridget Beatty, DPS Coordinator for Health Strategies. “It is one of the only sources that has been increasing in the last few years.”

Who’s in and who’s out

All told, 50 Colorado districts or Boards of Cooperative Educational Services, known as BOCES, are currently participating in the Medicaid School Health Services Program, which is administered jointly by the Colorado Department of Education and the Colorado Department of Health Care Policy and Financing. Reimbursements for participating districts totaled $16.6 million in 2011-12, the most recent year for which figures are available.

In general, participants include large and medium districts along the I-25 corridor, but there are a number of small, rural districts that participate as well. In addition, participants such as Pikes Peak BOCES serve more than a dozen small districts.

It used to be that almost 80 percent of the state’s 178 school districts participated in the program either individually or through a BOCES. But rule changes in 2008 changed how reimbursements were calculated, moving from a fee-for-service model to a cost-based model. The new rules, which required much more documentation, also eliminated reimbursements for non-special education services, such as bandaging a Medicaid-eligible child’s scraped knee in the nurse’s office.

The new focus was exclusively on special education services. For many small districts, particularly those that used BOCES staff not district staff to provide special education therapies, that meant fewer opportunities for reimbursement, said Jill Mathews, senior consultant for the Medicaid School Health Services Program at the Colorado Department of Education. As a result, many districts dropped out. The number of districts and BOCES participating fell from 114 in the 2006-07 year to 54 five years later.

“It’s not always worth it for the smaller districts to participate,” said Matthews.

Despite the drop in participation after 2008, she noted that the 50 current participants serve about three-quarters of the state’s schoolchildren. This year, there will be a push to attract more BOCES participants.

New rules beneficial

Although dozens of districts dropped out after the 2008 rule changes, those that stayed laud the new cost-based methodology, saying it helped produce major increases in their annual reimbursements. For example, Adams 12 Five Star has seen its Medicaid revenue double over the last five years. The reimbursements under the fee-for-service model were very low, said Sellstrom.

“It wasn’t even comparable to actual costs,” she said. “Before, you did what you could, but it was smaller in scope.”

Reese, from Academy 20, said the district’s reimbursement has increased six-fold since the district joined the program in 1997, jumping from about $97,000 to nearly $600,000 last year.

“It’s so exciting,” she said. “It’s money well worth looking into.”

Buena Vista, a district of 994 students west of Colorado Springs, rejoined the program last year after dropping out in 2010 because the program wasn’t yielding any reimbursements. In fact, the district had to pay money back at one point, said Stefani Franklin, principal of Avery-Parsons Elementary school and the district’s special education director.

After Mathews and another state administrator provided a detailed review of the new system, the district rejoined the program. Last year, the district got $40,000 in reimbursements, enough funding for a full-time nurse to cover two of the district’s four schools. Previously, one nurse was responsible for the district’s entire student body.

Franklin said of the second nurse, “One person seeing 400-450 kids. That’s a pretty important position. Every little bit helps.”

How I Help

Students were obsessed with social media. Here’s what this middle school counselor did about it.

PHOTO: Hero Images | Getty Images

In our “How I Help” series, we feature school counselors, social workers, and psychologists who have been recognized for their work. You can see other pieces in the series here.

Students at Eagle Valley Middle School in western Colorado were spending lots of time on social media, and too often their comments turned mean. Counselor Kayleen Schweitzer decided things needed to change, so last year she spearheaded a schoolwide campaign urging students, staff and parents to take a five-day break from social media. More than 150 people signed the pledge.

The results were encouraging. Participating students reported that they had more free time and were getting to bed earlier. Some even said the break made them realize they had been addicted to social media.

Schweitzer, who was named 2018 Middle School Counselor of the Year by the Colorado School Counselor Association, talked about how campaign organizers got students to participate, what she wants parents to know about middle-schoolers, and why she wants students to regard visiting a counselor as normal.

This interview has been condensed and lightly edited.

Why did you become a school counselor?

When I was 15, I lost my father. It was very unexpected and I found out at school. When I returned to school no one checked on me or followed up to see if I was doing OK. I remember wishing I had more support at school. That was the first time I realized that one day I wanted to be someone who could be there for students going through a hard time or transition.

When I was in college my favorite classes had to do with child development. I went on to pursue a degree in family and human services and a graduate degree in school counseling. I’m definitely happy with my decision to be a school counselor and I look forward to going to work every day.

Tell us about an effort or initiative you spearheaded at your school that you’re particularly proud of?

In the 2016-17 school year, my principal Katie Jarnot and I identified a need for something that would help with some of the conflicts occurring at our school. Katie came across a national program called No Place For Hate. It was just what we were looking for. In the 2017-18 school year, we brought No Place For Hate to our school. It has been amazing and powerful.

We noticed a lot of mean behavior on social media and that our students were spending so much time online. Also, with a surge of recent research into the detrimental effects of screen time, social media, and the correlation to depression and anxiety, it was clear there needed to be a change. So Eagle Valley Middle School’s No Place for Hate Coalition created a schoolwide activity that attempted to give students, staff, and parents a glimpse into positives that can come from limiting social media use and taking back control of our lives. We asked our school community to commit to giving up social media for five days.

During those five days, everyone who took the pledge was asked to do a daily reflection on the differences that they noticed. We offered a chance to win prizes as an incentive. To our surprise, we had 110 students (about one-third of our school), 18 staff, and 30 parents sign up.

Though not everyone completed the five days, we felt we brought some awareness to this problem. Students noticed how much more time they had when not using social media and they were able to get to bed earlier. Some actually admitted this activity helped them realize that they are addicted to social media. A few parents reported they were able to be more present with their family at night and have fewer distractions.

Is there a tool, curriculum or program you couldn’t live without in your job?

The tool I couldn’t live without is Google forms. Students can fill out a form to let me know they need to see me. When they fill out the form it notifies me with an email and I can see who is requesting to see me. It also allows me to keep data on what issues my students need support with. This helps me plan what supports I need to put in place through classroom guidance lessons, small groups, and individual counseling.

What’s the biggest misconception you’ve encountered about your role in the school where you work?

The biggest misconception I have encountered is that it’s a bad thing to go to the school counselor and that you need to have a huge problem. I have noticed that some middle school students are embarrassed to be seen going to the school counselor. I have worked really hard to make it normal to come to me and teach them that the strongest, most successful people need help sometimes.

You spend lots of time with students. Knowing what you know, what advice would you give to parents?

I would remind parents that students’ frontal lobes are not fully developed and when they say they don’t know why they did something, they are probably being honest. I would also let them know that even if a student says they want parents to give them space and leave them alone, it’s not really what they want or need.

Tell us about a time when you managed to connect with a challenging student or a student facing a difficult situation. How did you do it?

I have a student who is now in eighth grade and has been coming to see me on a regular basis when she needs support. As a sixth-grader, she was so closed off and worried about being seen coming to talk to me. I have been very consistent with her and kept reminding her that I’m always here if she needs anything. I ended up running a group with her and a lot of her friends. She saw that her friends loved coming to see me and were willing to talk to work through some of their problems. I also spent time with her and showed her it was a safe place to talk. Over time she broke down her walls and was able to trust me. Today, she stops by when she is doing well and when she is struggling. She loves to come and eat lunch with me. She has grown so much and I’m going to miss her dearly when she goes to high school.

What is the hardest part of your job?

The hardest part of my job is going home and worrying about my students. You always wish you could do more or make students see things can get better and they are enough. Middle school is such a hard time for students as they struggle to find where they fit in and deal with personal changes.

Tell us about a memorable time — good or bad — when contact with a student’s family changed your perspective or approach.

In my first years as a school counselor, I had a student who was consistently falling asleep in class and missing a ton of school. When I had a meeting with his family, I found out that his mother was a single mom and his grandma, who also lived in the house, was very sick. The student was staying home to help take care of his grandma and his siblings so his mom could work and make money for the family. His father was an alcoholic who was in and out of rehab.

I realized that different cultures have unique values and priorities. It also taught me that you never know what someone is going through so we need to really take time to talk to kids to figure out what is happening in their personal lives before jumping to conclusions.

You spend your days trying to help students and staff with any number of things. How do you wind down after a stressful day?

The way I wind down after a stressful day is to come home and spend time with my children. They are still young and innocent. I try to really enjoy this precious time with them when they have fewer worries and just want to have fun. I also love spending time with friends and clearing my mind of the worries of my job. Last, I enjoy catching up with email and work-related tasks as every time I scratch out something on my to-do list I seem to get stress relief.

Chilling effect

Five ways a proposed immigration rule could impact Colorado students and schools

PHOTO: JGI/Jamie Grill | Getty Images

Advocates for immigrant families fear that a proposed federal rule governing green card decisions could lead to more children going hungry and losing housing and health care. That, in turn, could pose challenges for educators and schools.

The proposed rule would allow the government to penalize some legal immigrants who have used public benefits by denying them permanent residency — a possibility that could prompt families to forgo any kind of government help. For children in those families, many of them citizens, the result could be hunger pangs, untreated illness, or outsized worry that their parents won’t be able to stay in the U.S. Inside schools, the new rule could mean more time and energy spent addressing students’ basic needs and the loss of funding from some public programs.

Fear that immigrants will shy away from benefit programs is nothing new. Stricter immigration rules since President Trump took office — stepped-up raids, efforts to discontinue the DACA program, and family separations at the U.S.-Mexico border — have already led to a chilling effect on the legal use of public benefits by immigrants. Advocates say changes to the so-called “public charge” rule will only exacerbate the problem.

The rationale behind the proposed rule, a stricter version of one that’s been in place for years, is to prevent immigration by people who will end up dependent on government help. Opponents of the rule say it punishes working-class immigrants who may need short-term aid, but contribute much more to the country’s economy over the long term.

The existing public charge rule penalizes immigrants for using programs such as Temporary Assistance for Needy Families or long-term care. The proposed version adds several more to the list, including Medicaid, food stamps, and housing vouchers. Free and reduced-price school meals aren’t included in the existing or proposed rule.

Mónica Parra, program manager of the Denver school district’s migrant education program, said families she works with are reluctant to sign up for any kind of help, even assistance heating their homes during the winter.

“They’d rather struggle or find other ways to get support,” she said. “It’s going to be very challenging to keep students motivated, but also safe. Maybe they’re going to be cold. Maybe they’re going to get sick.”

The proposed public charge rule doesn’t apply to refugees and asylum-seekers, and doesn’t penalize immigrants for public benefits used by their children. Still, like other advocates, Parra said she hears anxiety about the proposed rule from all kinds of immigrants, including citizens and those who already hold green cards.

They worry that using public benefits could get their own legal status revoked or hurt their chances to sponsor family members who want to immigrate to the U.S.

“The fear has always been there in these communities,” she said. “Now, people are even more afraid.”

The new public charge rule likely won’t take effect for months. First, there will be a 60-day public comment period, scheduled to start Wednesday, and then Trump administration officials will consider the comments and decide whether to make any adjustments.

Here’s a look at some of the ways the proposed rule could affect Colorado schools and students.

More kids come to school hungry

There are at least two ways schools could see more hungry students walking through their doors due to the public charge rule. First, families may be afraid to take advantage of food stamps — either by deciding not to enroll, or by dis-enrolling current recipients, such as citizen children.

Both Denver and Adams counties have seen dips in the number of people participating in the program over the last couple years. In Denver, about 2,000 fewer children receive the benefit now than in November 2016 when President Trump was elected. However, city officials caution that it’s hard to make a direct connection between falling participation and federal immigration policies since historically low unemployment rates may also be contributing to the trend.

While free and discounted school lunches are not part of the public charge rule, some advocates report that immigrant parents have been wary of enrolling their kids since Trump’s election. By law, public schools must serve students regardless of their immigration status and can’t ask for information regarding a family’s or student’s status.

A week after the Department of Homeland Security released a draft of the new public charge rule on its website, the Eagle County school district emailed parents asking them to help squash the rumor that signing children up for free or reduced-lunches “will inform ICE,” a reference to the U.S. Immigration and Customs Enforcement agency.

The letter concluded, “There is NO RISK in applying for free and reduced lunch, help us spread the word.”

So, what happens when kids go to school hungry? They may have trouble paying attention, misbehave more easily, or suffer from headaches or stomach aches. In short, less learning.

More children without health insurance, more student absences

The public charge rule’s chilling effect could have a major impact on child health, according to a recent Colorado Health Institute analysis. An estimated 48,000 Colorado children — the vast majority of them citizens — could be disenrolled from one of two public health insurance programs, Medicaid or Child Health Plan Plus. That would double the state’s rate of uninsured children from 3 percent to 6.7 percent, according to the institute.

The reason for so much dropoff is that health insurance is typically a family affair. So even when different rules govern adults and children in the same family, they tend to be enrolled as a group or not at all.

When students don’t have health insurance, school attendance and performance can suffer. For example, children may be absent more if they lack help managing chronic conditions like asthma, or if they’re not getting treatment for acute illnesses or painful dental problems.

Loss of health-related funding for schools and school-based clinics

School districts stand to lose two health-related funding streams if the number of uninsured children swells. The first would impact the state’s 62 school-based health clinics, which would likely see a drop in Medicaid and Child Health Plan Plus reimbursements if fewer students enroll in those programs.

Such an enrollment decline, which some clinic leaders have already reported, could make it harder for school-based clinics to stay afloat financially, said Bridget Beatty, executive director of the Colorado Association for School-Based Health Care.

With more uninsured students, “The need will go up,” she said, “but conversely the ability to financially sustain them will get more challenging.” 

In addition, 53 Colorado school districts receive funding through a program that could be affected by the proposed public charge rule. It’s called the School Health Services Program and allows districts to seek Medicaid reimbursements for services provided to low-income students with disabilities. That money can be used for health-related efforts that benefit all students, such as the addition of school nurses, wellness coordinators, or suicide prevention programs.

Funding received through the program ranges from a couple thousand dollars in small districts to a few million in large districts.

High-poverty schools have a harder time offering universal free meals

Nearly 40,000 students in 20 Colorado school districts can eat school meals for free because their schools participate in a federal program designed to make breakfast and lunch easily accessible to low-income students. But that number could drop if the public charge rule decreases food stamp participation.

The special meal program, called Community Eligibility Provision, is open to schools or districts where at least 40 percent of students come from families that use certain public benefits, including food stamps or Temporary Assistance for Needy Families. Unlike in traditional school lunch programs, parents don’t have to fill out applications for free or reduced-price meals.

“Any time when you have eligible families not participating in SNAP, it does have a negative impact on community eligibility,” said Crystal FitzSimons, director of school programs at the national nonprofit Food Research and Action Center.

Even if schools or districts remain eligible for the program, a drop in students getting public benefits could mean a change in how schools are reimbursed for the free meals, she said. That, in turn, could make the program less financially viable for schools or districts to participate.

Immigrants could turn away from publicly funded early childhood programs

Crystal Munoz, who heads the nonprofit Roots Family Center in southwest Denver, worries that the Spanish-speaking families her program serves will stop using programs like Head Start, state child care subsidies, and the Denver Preschool Program, which provides tuition assistance to the city’s 4-year-olds.

Even though those programs aren’t part of the proposed rule, there’s still trepidation, she said. It’s because of the constant flurry of rule changes and the generally negative tone around immigration right now.

“We find ourselves very afraid to even give out resources or referrals to certain programs because we’re not sure,” she said. “For us, it’s waiting and seeing.”

She said if families do drop out of Head Start or other child care programs, it could push children — many of them citizens — into unlicensed care with relatives or neighbors, or force parents to cut back work hours to stay at home with them.