One of the unintended effects of the Senate’s Obamacare repeal bill would be to slash money that pays for a project popular among Republicans — using long-distance video hookups called telemedicine to connect sick kids in rural schools to big-city medical experts.
In poor and rural areas, many of them in deep-red Trump Country, the school nurse is not just handing out Band-Aids anymore; she’s become a de facto medical guide, marshaling medical care for poor kids with obesity, asthma and diabetes, while on the lookout for issues like child abuse and teen pregnancy.
“In many of our situations … the school nurse is the only health care provider a child ever sees,” said Kelli Marie Garber, who runs a growing school-based telemedicine program out of Charleston, South Carolina.
Telemedicine has become a powerful tool for these nurses, and Republicans like it — Health and Human Services Secretary Tom Price calls it an “exciting innovation.” But the 26 percent cut to Medicaid planned by the administration and Congress for the next decade would deplete the funds that dozens of states are drawing on to make public schools a place of healing for schoolkids.
Medicare and private insurers often won’t pay for doctors to use telemedicine to treat adults. There is evidence it might save money, but congressional budget analysts are not convinced that’s the case for the older patients covered typically by Medicare. Medicaid, however, is increasingly covering use of the remote technology.
Many states have been rapidly expanding telemedicine-in-the-schools programs, which generally serve parts of the country where the uninsured are plentiful, health problems are grave, and school-based medical care is vital to children.
Nearly half the country’s Medicaid programs now pay for school-based telemedicine visits — six have added the service just in the last year, according to the American Telemedicine Association. States are becoming more comfortable with allowing doctors to treat patients they’ve never laid a stethoscope on in person.
GOP leaders are often the strongest proponents of the technology, seeing it as a way to get health care at low cost to farflung and underserved areas where doctors are few and far between.
At his confirmation hearings, Price said telemedicine would allow rural areas to tap “intellectual capital” to better treat patients. The country needs to look for more ways to pay for the technology, Price said, which is growing in areas of the Deep South in particular.
Telemedicine is about “promoting cost savings and quality care through the use of technology,” said Budget Chairwoman Diane Black (R-Tenn), the lead House sponsor of a major bill in Congress to expand payments for telemedicine.
But the Trump administration and the GOP-led Congress are pushing policies that could undermine telemedicine’s future in schools.
The Senate health care bill would cut $772 billion from Medicaid over the next decade, according to the CBO. The Trump administration’s budget proposal mirrors the House and Senate bills, which transform Medicaid into a per capita cap or a block grant.
The CBO estimates the two bills will mean about 14 million fewer Medicaid enrollees. School-based clinics get their money from insurance payments, grants and private support. But Medicaid, which covers more than 70 million Americans, predominantly serves children, and schools rely heavily upon it to support use of telemedicine. If Medicaid coverage is jeopardized, it throws the future of school clinics into doubt.
“If the Medicaid reimbursement isn’t there, you’re not going to make it,” Steve North, medical director and founder of the Center for Rural Health Innovation, said of school-based clinics. “You’re not even going to come close.”
If Medicaid is funded through block grants, states may have to be pickier over eligibility and coverage. Core services like hospital care will probably be maintained, but novel services like school-based telehealth would be vulnerable.
Well-funded school districts may be able to afford the tens of thousands of dollars required to purchase and maintain telemedicine equipment and train people to use it. But the districts that need the service most often can’t afford it without state support.
“Schools are going to be much more likely to get on board with this if there’s a little bit of money coming back,” said John Schlitt, president of the School-Based Health Alliance, the country’s leading advocate of school-based clinics.
While school-based health centers are supported by many Washington lobbies like pediatricians and community health centers, they aren’t generally a priority.
“It falls so far down on an administrator’s list of things, it’s tough to find regular advocates for the programs outside of those school systems that already have school-based health centers,” North said.
“If we continue to weaken access points for low-income kids, then the schools are going to be having to figure out a way to meet those needs,” said Schlitt. “There’s only so many ways in which states are going to be able to absorb that kind of a financial cut.”
The expansion of telemedicine in schools reflects the changing status of school nurses. Where they used to treat “boo boos,” and make sure kids were vaccinated and screened for diseases like scoliosis, now their responsibilities may even include dentistry and primary care.
“It has changed from the school nurse who used to deal with colds, headaches, and stomach aches to caring daily for some very complex children — seizures, cerebral palsy, diabetes,” said Nancy Cavanaugh, health policy chair for the National Association of Pediatric Nurse Practitioners. “It is an exhausting job.”
“They’re having more and more added to their plate,” North said. This makes telehealth more attractive, especially for kids who lack access to health care and need to see a specific kind of doctor.
“The goal of school-based telehealth is to support school nurses and be a resource for them when do they do have a student who needs care above what they can provide,” said Kathryn King Cristaldi, a member of the American Academy of Pediatrics section on telehealth.
Research generally shows telemedicine in schools helps kids avoid the costly emergency room because it forestalls the need for in-person care. It has helped reduce absenteeism and saved families money, according to a 2014 literature review from Brigham Young University.
“The reasons kids fail in school and the reasons they have poor health are all the same,” Schlitt said.
School nurses are typically registered nurses or social workers. When a nurse can’t handle a child’s illness, he or she can use telemedicine to communicate with a better-equipped school clinic, or draw in a universe of doctors who can treat at a distance.
South Carolina sees telemedicine as a solution to its provider shortage. The state invested in telemedicine equipment for several schools, and its Medicaid program covers the treatment costs. A school telemedicine pilot began four years ago and now offers the service in 45 locations, a majority of those in “very rural areas,” Garber said. Nearly the entire state is considered medically underserved.
The telemedicine program at Children’s Health of Dallas connects to more than 90 schools in the Dallas-Fort Worth area and reaches schools as far east as Tyler and as far south as San Antonio.
Bassett Health Care in Upstate New York connects 19 rural schools that lack pediatric subspecialists to doctors in Rochester.
The telemedicine industry wants more states to follow Washington state’s lead in liberally reimbursing the technology. Washington recognizes “any location determined by patient receiving the health service” as an acceptable originating site for coverage. Medicare generally pays for telemedicine only when the patient is in a clinic or hospital.
Public schools in Howard County, Maryland, introduced telemedicine in 2014 and have since expanded its use to six elementary schools. The program’s success caught the eye of Rep. John Sarbanes (D-Md.) who has sponsored the Hallways to Health Act (H.R. 1027), which would create a demonstration program for school-based telemedicine programs nationally.
The bill is backed by Debbie Stabenow (D-Mich.) in the Senate, but its future is uncertain because it lacks a Republican co-sponsor.
Despite their general enthusiasm for telemedicine, GOP members are turned off by the bill’s likely hefty price tag.