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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,

/s/
      /s/Sylvia Burwell
      John B. King, Jr.Secretary of Health and Human Services
      Acting Secretary of Education


cc:
    GovernorsEnclosure

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 ]**

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 ]**

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 ]**

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 ]**

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 ]**

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 ]**

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 ]**

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 ]**

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 ]**Last Modified: 03/02/2017