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 Americas 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 childrens 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
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 familys 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 childrens
health care. A report on Missouris 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 childrens
health care program increases the likelihood that more children
will be examined or treated at public schools without parental
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
Further, the results of tests, however subjective, become
part of a students 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.
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 mothers 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
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 ones 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
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 childrens 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
Research Associate, Institute for Health Freedom
This article was originally published in
Regulation, 1997, Vol. 20, No. 3. Copyright 1997 Cato Institute.