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Kidcare: Socialized Medicine Through Government Schools

January 20, 1998

Though the Clinton administration lost its initial battle to socialize health care in United States, it is moving steadily towards that goal through America’s public schools. More than thirty states have already implemented school-based health care programs. The Balanced Budget Act of 1997 provides states with $24 billion over the next five years (and $48 billion over ten years) for children’s health care, with strong incentives through the Kidcare portion of Medicaid for a school-based approach. The results will be less quality or freedom in health care, and parents will relinquish more control of their children to government.

Like the federal school lunch program--originally meant to help the poorest of the poor--school-based health care is expanding into a middle class entitlement. Since 1967, Medicaid has required states to offer "Early, Periodic, Screening, Diagnosis and Treatment" (EPSDT) benefits to all Medicaid-eligible children under age 21. Medicaid reimbursed schools for examinations, immunizations, and other basic services for poorer students but with the understanding that most health care would still be the primary responsibility of parents, in conjunction with a family’s physician. The program grew to cover 30 percent of eligible children. It paid physicians, nurses, psychologists, social workers, and physical therapists for services such as family planning, unclothed physical examinations, immunizations, and psychological counseling.

In 1989, Congress mandated that, by 1995, states increase the portion of eligible children receiving EPSDT services from 30 percent to 80 percent. States were encouraged to actively seek to enroll children in preventive health care programs and to offer coverage for a range of services.

The new Kidcare program offers more federal funds to states that can expand the number of children covered. And supporters have not disguised the fact that they favor health services through the schools. Specifically, state governments would grant a community health care provider the exclusive right to provide what has been an expanding list of services to an expanding number of students. A George Washington University study entitled Making the Grade found that the number of school-based facilities already has grown from 40 in 1985 to 913 currently.

Schools of Scandal

The argument for school-based Medicaid programs is that healthy kids learn better than unhealthy ones, and that schools are a convenient place for reaching children. Those premises are true. But it is doubtful that government schools can deliver quality health care when decaying schools are not even fulfilling their principal task of teaching kids to read, write, and think. The decline in education standards has corresponded with the growth of the federal role in education, suggesting that a similar pattern will evolve with federal involvement of health care through the schools.

Many schools cannot even provide a safe learning environment for students. Metal detectors, security guards, close circuit cameras, and locker searches to cope with serious crime and violence make some schools more like prisons than institutions of learning. With that miserable record, it hardly seems prudent to give government schools health care responsibilities.

A central problem with increased EPSDT Medicaid services is that parents will continue to lose control over their children’s health care. A report on Missouri’s efforts to create school-based Medicaid programs, entitled "A Strike for Independence," acknowledged that fact, stating that, "School districts should not consider the EPSDT/Medicaid program if their philosophy is that it is the sole responsibility of parents to attend to the health care needs of children."

Some school districts currently provide EPSDT screening services to all children, whether they are eligible or not, and whether parents approve or not. A case in point is a recent incident in which a Pennsylvania public school administered genital examinations to fifty-nine sixth-grade girls, without parental consent and against the objection of some of the students. The physician who conducted the examinations was looking for sexually transmitted diseases and for "signs of abuse." In another incident, the Kentucky Board of Education, over the objection of many parents, required genital examinations for sixth-grade girls to check for child abuse. The new children’s health care program increases the likelihood that more children will be examined or treated at public schools without parental consent.


Part of the expansion of the EPSDT program has been the inclusion of psychological examinations as part of routine school-based health services. Some school districts require parental consent for psychological testing, but others do not. Once diagnosed with a psychological disorder or behavioral problem, children can be referred to a psychiatrist or a psychologist for treatment.

Today many forms of irresponsible behavior are labeled as "psychological disorders," requiring treatment. There is considerable doubt about how much of that approach is based on sound science and how much simply on ideological inclination or outright quackery. For example, "Oppositional Defiant Disorder" is supposedly characterized by the repeated challenging of authority. In many cases such behavior is called "free inquiry." In the old Soviet Union, the claim that anyone who asks too many questions must have a psychological problem was used as an excuse to confine critics to mental institutions.

Incidence of misuse of power by government school employees is well-known: Students have been suspended for giving aspirins to fellow students; a girl was suspended for bringing a dinner knife from home to cut a piece of chicken; and a six-year old boy was disciplined for "sexual harassment" after kissing a little girl on the cheek. The probability is high that government school bureaucrats will misapply questionable definitions of "disorders" to the detriment of students. Since more "disturbed" children translates into more Medicaid dollars flowing into the pockets of health care providers, more children likely will be diagnosed with psychological disorders.

Further, the results of tests, however subjective, become part of a student’s permanent school record, which then can affect his future career opportunities. State Medicaid programs are responsible for keeping detailed records on children, such as contact with the Department of Family Services and Medicaid, telephone conversations, and interactions with parents. There have been cases of such misuse of information. In Maryland, for example, physicians now are required to turn over to state bureaucrats detailed patient records. In 1996, several dozen state employees were indicted for planning to sell those records.

Bureaucrat Coparents

Since Kidcare will make more money available to contract with community-based health providers, and since school-based care will be the principal means to secure those funds, states indeed are likely to offer more such programs. And with more health care personnel in schools looking to justify their positions, parental control over children will continue to slip away. Worse still, parents and families could find themselves subject to Orwellian oversight.

The EPSDT program already allows pediatricians to bill the government for counseling children (and their parents) about their manners, use of money, need for affection and praise, competitive athletics, place of child in family, and attitude of father (for some reason, the mother’s attitude is not mentioned). That is a license to regulate families, and more money and personnel makes the expansion of government power even more likely. Bureaucrats are making themselves coparents.

Smoke and Fire

The pattern can be seen in the current government campaign against cigarettes. Already there have been cases of courts trying to take children away from parents because of the parents’ smoking habit. Some courts have ordered parents not to smoke around children. In the state of Pennsylvania, legislation was introduced to bar parents from smoking in cars when accompanied by children under sixteen years of age.

Anti tobacco activist John Banzhaf maintains, "smoking is the most pervasive form of child abuse." Some of the language in the Kidcare program creates a new tool that activists like Banzhaf can use to pressure parents to stop smoking or face the possibility of having their children taken away from them. Whatever one’s view concerning cigarettes, it takes little imagination to picture school-based health providers trying to dictate what kind of diets parents can provide for their children, what kind of discipline is appropriate, and whether certain forms of entertainment constitute psychological abuse.

Money and Policy

School-based health care for children has been strongly promoted by a number of foundations with strong ideological agendas that stand to benefit financially by becoming health care providers in schools. The Robert Wood Johnson Foundation, for example, already has granted to state and local governments $23.2 million to establish school-based health care. Those funds often require government funds to be spent as well. Pennsylvania, for example, spent $4.4 million on Johnson-backed efforts. The Annie E. Casey Foundation paid for a genital examination program in Kentucky. That foundation also helped foot the bill for the Strike for Independence report on how to establish school-based health care.

State legislators now face the strong temptation to seek federal Kidcare funds, which became available on 1 October, by designing or expanding school-based children’s health care programs. Those lawmakers would do well to resist the temptation. Other innovative alternatives for covering uninsured children, such as vouchers or tax credits for private health insurance, could help provide for those with real problems. But the Kidcare program simply moves the United States closer to a system of socialized medicine that serves neither health care nor kids.

Sue A. Blevins
President, Institute for Health Freedom

SuYoung Min
Research Associate, Institute for Health Freedom

This article was originally published in Regulation, 1997, Vol. 20, No. 3. Copyright 1997 Cato Institute.