‘So Many Pitfalls’: Feds Push School-Based Health Centers as Critics Sound Alarm Over Lack of Parental Consent

By Suzanne Burdick in today's Defender. Many thanks for her deep dig into this subject.

Supporters of school-based health centers tout improved access to healthcare for the underserved — but critics say rapidly expanding the centers could allow children to get vaccines and mental health counseling without parental consent.

The recent push by the U.S. federal government to rapidly expand the use of school-based health centers (SBHCs) across the country has some critics concerned children will receive, or be pressured into receiving, unnecessary or unwanted medical interventions — including vaccines — without their parents’ knowledge or consent.

Georgia attorney Nicole Johnson, co-director of Georgia Coalition for Vaccine Choice and a consultant to the Children’s Health Defense’s (CHD) legal team, told The Defender:

“It’s scary because these health centers sound really good. In some of the rural and poor communities especially, this is going to seem like a really good way for children to get this care.

“And while there may be some conveniences, there are so many concerns with allowing medical exams and treatments at school. Parents need to be involved in all medical decisions and I fear they are being left out of the equation.”

SBHCs are intended to provide high-quality healthcare to kids by offering “primary care, mental health care, and other health services in schools,” particularly in underserved communities.

This includes services “to prevent disease, disability, and other health conditions or their progression” such as “immunizations” and “well-child care.”

According to the Centers for Disease Control and Prevention’s (CDC) Community Preventive Services Task Force, SBHCs can improve educational and health outcomes.

The CDC also considers SBHCs as integral to its Whole School, Whole Community, Whole Child model because they provide health services and mental health counseling.

But critics like Johnson worry that though there may be benefits to SBHCs, there are also downsides — including lack of regulation of the centers and the fact that parents may not be aware of the broad range of medical and behavioral services being provided in their children’s schools.

SBHCs have been linked to higher human papillomavirus (HPV) vaccination rates, according to a 2022 report by Harvard University’s Center for Health Law and Policy Innovation and the University of California Davis Comprehensive Cancer Center.

The report — written expressly to “address vaccine hesitancy” — concluded: “These results suggest SBHCs create a considerable opportunity … to implement successful school based HPV vaccination programs.”

Merck, the maker of the Gardasil HPV vaccine, is one of the funders of the School-Based Health Alliance, a large networking organization that “works on policy, standards, data, and training issues” regarding SBHCs.

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The idea of running full-service health centers in public schools has been around for more than two decades, but events in 2022 caused SBHCs to catch on like wildfire.

Congress and President Joe Biden in June 2022 passed the Bipartisan Safer Communities Act, which allowed the U.S. Department of Health and Human Services (HHS) to award $50 million in grants to states “for the purpose of implementing, enhancing, or expanding the provision” of healthcare assistance through SBHCs using Medicaid or the Children’s Health Insurance Program (CHIP).

The legislation charged the Centers for Medicare & Medicaid Services (CMS) with expanding access to Medicaid healthcare services — including behavioral health services — in schools, and reducing the administrative burden for states and schools.

A CMS spokesperson told The Defender that Medicaid and CHIP now can provide reimbursement for services given in SBHCs for children and youth who are covered by those programs.

Additionally, in May 2022 HHS awarded $25 million in grants to 125 SBHCs “to improve and strengthen access to school-based health services in communities across the country.”

State public officials also are dedicating funds to expand SBHCs. For instance, the governor of Georgia in fall 2022 announced an investment of $125 million to expand school-based health services to rural communities in Georgia.

Pediatricians can ‘partner’ with schools

The American Academy of Pediatrics (AAP) supports SBHCs and said in a policy statement that pediatricians may act as “sponsors” by partnering with a school to establish the SBHC as an extension of their practice or by supervising the care given at a SBHC.

“Sponsors also include local hospitals that can provide prearranged after-hours and school vacation coverage and financial support for SBHCs,” the AAP said.

The Defender reached out to the AAP statement’s lead authors for comments on how parental consent is handled in SBHCs, but they did not respond by our publication deadline.

SBHCs also have the support of the School-Based Health Alliance. In addition to funding from Merck, the alliance receives financial support from HHS’ Health Resources & Services Administration.

Documents obtained in June by CHD revealed that the HHS gave $4.7 million to research headed by a Merck consultant that focused on developing “The Announcement Approach Training,” where providers simply “announce” a child will be receiving the HPV vaccine as part of a routine office visit, instead of discussing it with the family first.

The government-funded research also is testing whether financial incentives and peer pressure can “nudge” doctors to change how they talk to their patients in order to increase HPV vaccine uptake among adolescents.

Meanwhile, a fierce battle is taking place in multiple states where some lawmakers are pushing legislation that would allow minors to receive treatments to prevent sexually transmitted diseases — including Merck’s HPV vaccine — without parental knowledge or consent.

‘So many pitfalls … so many ways for someone else to be making parental decisions’

Justine Tanguay, an attorney with nearly 20 years of experience advocating for children in various areas of the law, told The Defender:

“Don’t be fooled! This year many schools will be sending home blanket consent-to-treat forms for parents to sign.

“Parents need to be aware that these forms are not the traditional authorization requests for the school nurse to give first-aid or to treat minor illnesses.”

Tanguay, CHD’s director of campaign and research, explained that the forms may give those who run the SBHC the legal authorization to provide “comprehensive healthcare.”

This could include — but may not be limited to — “the ability to provide preventative treatment, behavioral and mental health services, reproductive counseling, lab and prescription services, various medical screenings, immunizations and disease management,” Tanguay said.

Moreover, SBHC staff will have “direct access” to a minor child, Tanguay said, “as well as the ability to encourage a minor child to make personal healthcare decisions without the need to consult with and seek approval from a parent.”

“The opportunity to circumvent both parental rights and informed consent is ripe for abuse,” Tanguay warned.

Johnson agreed, saying, “There are just so many pitfalls here, so many ways for someone else to be making parental decisions.”

Johnson shared with The Defender a consent form currently used in a school district north of Atlanta, Georgia.

The form says nothing about parents being notified before, during or after treatment. It reads:

“I hereby voluntarily give my consent for [my child] to receive health services with Georgia Highlands Medical Services at Cumming Elementary School.

“I further authorize any health care provider and professional staff working for the clinic to provide such medical tests, diagnoses, procedures, and treatments as are reasonably necessary or advisable for the medical evaluation and management of my child’s health care.”

The form does not clarify who determines what services are “reasonably necessary or advisable” and does not explain how parents will be involved in that process. It states:

“I understand that my signing this consent allows the health care provider and professional clinic staff of Georgia Highlands Medical Services at Cummings Elementary Schools to provide comprehensive health services which includes physical and behavioral health services.”

Again, the form does not clarify what specifically falls into the category of “physical and behavioral health services” or how parents will be involved in the determination for what services their child may need.

“I think about my own kids when they were in school,” Johnson said, “how easily they could have been swayed to get a vaccine or a medical treatment just because an adult told them that they should.”

“It’s really dangerous to have all of these things offered to them without the parents even being aware,” she said. “A lot of kids — most kids — are compliant. They want to do what the adults are telling them to do.”

According to the CDC, a key component of its Whole School, Whole Community, Whole Child model, which includes SBHCs, is “family engagement.”

However, the agency’s 37-page document about family engagement mentions parental permission only once and does not discuss parental consent for medical treatment beyond the application of sunscreen during recess.

According to a CMS spokesperson, SBHCs “follow the same practices as any other medical center or Medicaid or Children’s Health Insurance Program (CHIP) provider … including parental consent requirements.”

The spokesperson did not go into detail on whether consent would be requested generally or for each specific medical treatment.

Where’s the regulatory oversight?

Tanguay pointed out that SBHCs exist without proper regulatory oversight.

According to Stand for Health Freedom, a nonprofit “dedicated to protecting informed consent in medical care,” SBHCs are “completely unregulated.”

For instance, it is presently unclear how HIPAA law (the Health Insurance Portability and Accountability Act of 1996) and FERPA law (the Family Educational Rights and Privacy Act) will be applied to SBHCs and students’ health information.

Stand for Health Freedom also pointed out that although in-school clinics may relieve busy parents of the burden of taking their children to the doctor, “medical ethics do not allow physicians to treat minors without a parent or guardian present, which is why parents cannot simply drop their child off at the doctor’s office and come back later to collect them.”

Stand for Health Freedom said:

“Parents must engage politically and work with state health freedom leaders to ask lawmakers to either ban SBHCs in favor of the existing limited school-nurse model, or place guardrails on SBHCs to protect parental consent and involvement in their minor children’s medical care.”

Meanwhile, proponents of SBHCs, such as the School-Based Health Alliance, argue that SBHCs are a “powerful tool for achieving health equity among children and adolescents who unjustly experience disparities in outcomes simply because of their race, ethnicity, or family income.”

Johnson said she disliked being “so skeptical of something that may potentially benefit some people” but added, “as a parent, it is your job and your right to be a part of the decisions that affect the health and well-being of your child.”

Johnson said parents who experienced or witnessed vaccine injury would be particularly skeptical of putting medical decisions in the hands of government agencies, including schools.

“And the COVID response created even more skeptics,” she said, adding:

“It’s unfortunate that we have to approach this [SBHCs] with the thought, ‘How could this be abused?’ But that’s where we are.”

The Defender on Aug. 3 reached out to the School-Based Health Alliance to ask how parental consent in SBHCs is handled and what they’d like parents who may feel distrustful of the U.S. medical system to know about SBHCs. The alliance did not respond by our publication deadline.