Chapter 6, Part I: Medicaid-Funded School-Based Clinics, School/Community-Linked Services, and Parental Consent

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The only difference between a school-based clinic and school/community-linked servicesÂ? is the location.Â? Both obtain the same end of accessing children and families to implement socialized universal health care.Â? If schools choose not to provide certain services such as family planning, the case managerÂ? is obligated to refer to a Medicaid provider who will provide the service.

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well known and respected pastor explained to me that in 1989, Missouri’s Governor at the time, John Ashcroft, was the chairman of the Governor’s Conference from which came President Bush’s Goals 2000.� The Conference included then-Governor, and now-President Clinton� from Arkansas, then-governor Robert Riley� (presently President Clinton’s� Director of Education), and then-governor Lamar Alexander� from Tennessee (who later became Director of Education under President Bush).� How could they NOT see the infrastructure being created that allows schools to funnel families and minors� into government health clinics� for contraceptive chemicals and devices without parental consent?

The March/April, 1985 issue of Planned Parenthood’s “Family Planning Perspectives” carried an article by Joy Dryfoos titled “School-Based Health Clinics: A New Approach to Preventing Adolescent Pregnancy?” The following are quotes from that article: “School-based clinics provide comprehensive health care, including family planning; they also generally employ social and educational approaches–Each provides individual counseling about sexuality, gynecologic examinations and follow-up examinations for family planning patients.Â? They either offer contraceptive prescriptions in the clinic or refer students to off-site birth control clinics.Â? In addition, they perform laboratory tests, screen for sexually transmitted diseases (STDs), provide nutrition education and refer students with other problems to social service agencies–Most school-based clinics began by offering comprehensive health care, then added family planning services later, at least partly in order to avoid local controversy” (emphasis added). “Organizing a school-based clinic has proved to be a long and arduous task.Â? It generally takes from six months to one year to develop a program, find funding, recruit staff and obtain the necessary approval from the school and local health and community groups–The school nurse usually is not allowed to dispense medications-even aspirin.Â? One advantage of the school-based clinics, then, is that because they are run by an outside agency, their medical practice is not covered by school law–(I)n most clinics new patients (whether male or female) are asked at their initial visit if they are sexually active.Â? If they are or plan to be soon, they are encouraged to practice contraception. If a young woman is interested in obtaining a birth control method, she is given a pelvic examination and a Pap smear as part of her physical examination.Â? Contraceptives are generally prescribed following counseling.Â? In a few schools, prescriptions are filled on the premises; in most, students are referred either to a collaborating clinic or hospital or to a local physician to have their prescription filled. Several programs provide only family planning information, counseling and referral–It is also important to gain the acceptance of parents, so that parents will permit their children to be treated in the school clinic.Â? School-based clinics generally require parental consent before they will provide medical services to teenagers.Â? In some clinics, parents are asked to sign a blanket consent form unrelated to any specific clinic visit.Â? In others, the form lists each service, including family planning, and a student may receive only the services that have been checked.Â? Most consent procedures apply for the entire period of the student’s enrollment– In one school-based program, noncomplying parents were called, and their verbal permission was recorded” (emphasis added). “The Robert Wood JohnsonÂ? Foundation funded 20 diverse programs in needy areas in 1982 through its Program to Consolidate Services for High-Risk Young People–Under the conditions of the grant, recipients are to collaborate with existing efforts, use community resources and train physicians in adolescent medicine.Â? Thus, placing an adolescent multiservice unit in a high school and staffing it with university physicians fits the grantor’s guidelines well–Family planning and health education in several school programs are covered by grants from Title X of the Public Health Service Act, with funds granted through state or local health departments or Planned Parenthood affiliates–Medicaid reimbursement can be claimed by school-based clinics that are certified by the state as providers of medical services.Â? Some physical examinations are charged to the Early and Periodic Screening, Diagnosis and Treatment Program, a state-administered effort to screen and treat Medicaid-eligible children up to age 21.Â? These data indicate that school-based clinics are called upon most often to treat injuries and accidents, do physical examinations, offer general health care and provide family planning services, either on site or by referral.Â? Improved attendance and lower dropout rates have been attributed to school-based clinics.Â? No actual data have been presented to confirm these claims–School-based programs allow health education and promotion in the classroom to be combined with medical care and treatment in the clinic.”[1]

Schools providing “one-stop shopping” offer comprehensive health� education, services, referrals, and follow-up through school/community-linked services, or school-based clinics.� The clinic may be located on school grounds, or a school district may enter into a contract� with local health care providers like the County Health Department for services.� The end results are the same.� Schools which provide Medicaid-funded administrative case management� arrange transportation� and appointments as well as provide “anticipatory guidance” which the Medicaid forms say includes “family planning� services and contraception.”� (See the chapter titled “Medicaid, Family Planning, and a ‘Health Care Home.’”)� Referrals to a community health provider may result in the provision of contraceptive drugs, devices, and abortion� referrals to minors� without parental consent.[2],[3],[4]

Pages 69 and 70 of Missouri’s health care reform bill (HB564) states, “Contraceptive devices or contraceptive drugs shall not be provided by school personnel or their agents.� When a child seeks contraceptive devices or contraceptive drugs, the child shall be referred to the previously designated family practitioner.”

Page 69 of the bill says:� “The fact that a family practitioner� has a contractual relationship with the public school or school district shall not prohibit the family practitioner from being selected by the parent, guardian, or legal custodian to be the designated family practitioner for his child.”

Poorer families typically go to public health departments and family planningÂ? centers for care.Â? Such facilities which receive federal family planning fundsÂ? called Title X, are not to discriminate against minorsÂ? regarding the distribution of contraceptives, and may do so without parental consent.

The St. Louis County Health Department’s Teen Clinic� brochure� states, “For teens aged 12-18, a parent/legal guardian is required to come for visits for general medical concerns (physical exams, colds, asthma, etc.).� A parent is NOT required to consent� for services such as family planning, sexually-transmitted diseases� or prenatal care” (emphasis added).� In other words, CONTRACEPTIVES ARE DISTRIBUTED TO MINORS WITHOUT PARENTAL CONSENT.

Chemical Laboratories which produce contraceptives� seize every opportunity to distribute their little booklets on pregnancy through schools and to “health care professionals as an aid in counseling� patients.”� Statements such as those found in Ross Laboratories’� booklet Teenaged and Pregnant include “Don’t feel you have to follow the advice your friends or family gives you.� They mean well but are not the best source of information.”

Regarding “Consent to surgical or medical treatment–.” Missouri State Statute 431.061 states:

“–Any one of the following persons if otherwise competent to contract, is authorized and empowered to consent, either orally or otherwise, to any surgical, medical, or other treatment or procedures not prohibited by law:

(1) Any adult eighteen years of age or older for himself;

(2) Any parent for his minor child in his legal custody;

(3) Any minor who has been lawfully married and any minor parent or legal custodian of a child for himself, his child and any child in his legal custody;

(4) Any minor for himself in case of:

(a) Pregnancy, but excluding abortions;

(b) Venereal disease;

(c) Drug or substance abuseÂ? including those referred to in chapter 195, RSMo;

(5) Any adult standing in loco parentis, whether serving formally or not, for his minor charge in case of emergency as defined in section 431.063;

(6) Any guardian of the person for his ward;

(7) During the absence of a parent so authorized and empowered, any adult for his minor brother or sister;

(8) During the absence of a parent so authorized and empowered, any grandparent for his minor grandchild;

What this says is that ALL minors� can be provided services regarding pregnancy, venereal (sexually transmitted) diseases, and substance abuse� WITHOUT PARENTAL CONSENT by State law! “Any adult standing in loco parentis, whether serving formally or not” could be any counselor, teacher, social worker, school nurse, etc.� Be sure to obtain a copy of this legislation from your State Representative.� For purposes of consent� to hospitalization or medical, surgical or other treatment, the state considers any person 18 years of age or older an adult.� Any person under 18 years of age is considered a minor, and may not be provided medical care without parental consent� (except for pregnancy, sexually transmitted diseases and substance abuse as explained above).� An emancipated minor is a person under the age of 18 who has been lawfully married, has a child, or has otherwise been legally granted the status of an adult.� An unemancipated minor� is a person under the age of 18 for who medical care cannot be provided without parental consent EXCEPT in the areas of pregnancy, venereal disease (sexually transmitted disease), and substance abuse as explained above.

Title X� providers are to give “non-directive” counseling, and referrals� for “prenatal development, infant care, foster care or adoption, and pregnancy termination” i.e., abortion� (emphasis added).

The following question was asked of Missouri’s Department of Health director:� “Since providers which receive federal Title X� family planning� funds� must give abortion� as an option, are they disqualified from collaboration with schools?”� The response was:� “The many programs which the St. Louis County Health Department provides, including Title X family planning services, in no way preclude them from working with local schools to provide services under HB564.” [5]

Shouldn’t parents be told that comprehensive health� care offered through school/community-linked services� may provide and/or refer our children for contraception� without parental consent?� Parental rights and responsibilities are being undermined.�

National organizations such as the National Center for Youth LawÂ? and The Center for Population OptionsÂ? have projects which include working state by state to change state laws on public funding, emancipation of minors, informed consent, confidentiality, and child abuseÂ? reporting.[6]

It is interesting to note that the same names of individuals involved in such endeavors crop up in numerous places.� For instance, the name of Abigail English, J.D.� appears on two key documents: School-Based Clinics: Legal Issues, written jointly by the National Center for Youth Law� and the Center for Population Options, as well as in a federal document titled Adolescent Health Volume I: Summary and Policy Options by the Congress of the United States Office Of Technology Assessment� as a member of its Adolescent Health Advisory Panel.� Review the chapter titled “Lexicon Is Lingo - What’s in a Word?”

In November 1988 the Center for Population Options� and the National Center for Youth Law� published School-Based Health Clinic: Legal Issues.� They propose to legally emancipate minors� from parental consent.� “It would be inappropriate to list any service, particularly with any procedure for parents to ‘check off’ or refuse consent for the service, if it will ever be provided based on the minor student’s own consent.”� Page 28 says: “Parents may not have a right to limit access to medically necessary services where the minor’s right to consent to the service is established by statute or is constitutionally protected.”

The Missouri Department of Mental HealthÂ? writes that “–There is a conflict between two federal statutes.Â? The Family Educational Rights and Privacy ActÂ? (FERPA) of 1974 states that parents have the right to obtain information about their child’s participation in a school-based alcohol and drug abuse program.Â? The federal confidentialityÂ? statute, on the other hand, safeguards the confidentiality of alcohol and drug abuse records.Â? It would be in the best interest of all parties for the school-based programs to seek to comply with both federal laws.Â? Whenever a parent requests program records, the program should ask the minor student if he/she will sign a consentÂ? form, allowing the information to be disclosed to the parent.” [7]

Since the Drug-Free Schools and Communities� Grant has been expanded to include comprehensive health� programs, parents may not have access to information regarding their child’s activities in programs funded through substance abuse� grants� without the student’s permission.

The Missouri Departments of Social Services and Education address “points of concern” in a document related to school Medicaid� case management.� It states:� “Another major concern of staff may involve accessing and sharing confidential student information, such as social security numbers, health care information, etc.� An appropriate response to such questions is that the Family Educational Rights and Privacy Act� (FERPA) and other related statutes which apply to educational organizations and the records they maintain, including student health records, provide for the collection and dissemination of data� for educational purposes.� These statutes support the disclosure of such records to appropriate officials and agents of the district who are charged with the carrying out of its purposes.” [8]

During the hearing on HB564, Judith Widdicombe� (key author of the bill and foundress of Missouri’s largest abortion� clinic) said that collaborative practice (an agreement between the school and local health care providers for health services through the school) was the benchmark of HB564.� She also stated that she supports parental involvement, but when asked by a committee member if she supported parental consent, her one word response was “NO.”

HB564� mandates� a “checklist” to be sent to parents to check off “services,” such as contraceptives, that they do not wish provided to their child(ren).� The checklist is MEANINGLESS since contraceptives may legally be provided to minors� WITHOUT parental consent� through health clinics� which receive federal Title X� family planning� funds, such as the St. Louis County Health Department, to which schools may refer children and their families.� “Courts and legislatures have carved out a variety of exceptions to (parental consent) requirement(s).” [9],[10]� Areas of exception to parental consent include family planning, sexually transmitted diseases, and substance abuse, even for unemancipated minors!� An unemancipated minor� is a child who is not on his/her own, and for whom it is necessary to obtain parental consent for all other general health services!� Goals 2000� says, “The Department of Health and Human Services� and the Department of Education� shall ensure that all federally funded programs which provide for the distribution of contraceptive devices to unemancipated minors develop procedures to encourage, to the extent practical, family participation in such programs.” [11]� Goals 2000� does NOT say it will develop procedures to guarantee or even encourage parental consent.

In a letter dated June 30, 1993, the Missouri Department of Health stated,

“–I assure you that the Department of HealthÂ? strongly supports open communication between parent and child.Â? When possible, they are encouraged to discuss their health needs with each other.Â? Where this is not possible, state law permits treatment of minorsÂ? for the conditions of pregnancy, sexually-transmitted diseases Â? and drug and substance abuse–Again, I assure you that the Department of Health actively promotes communication between parents and teens for responsible decision-making, in all areas related to health and healthy life styles.”Â? This SAME letter stated,Â? Â? “Laws which cover the right to privacy and the preventionÂ? of discrimination due to age have been used in defending the provision of care to minors without parental consent .”

Have schools considered the liability� of such services?� The state has considered it. Page two of HB564� created a State Legal Expense Fund� which “provides malpractice liability coverage for physicians under contract� to local health departments for pregnancy, delivery, and child health services when those services are provided for no compensation or compensation only from a government source.� The Attorney General’s staff litigates any claims and any judgment is paid from state funds.� The physician’s personal assets cannot be used to pay claims nor can his personal malpractice insurance.� Physicians employed by federally funded Community Health Centers are also covered for up to a one million dollar cap.� The Legal Expense Fund� was expanded to cover volunteer physicians, nurses, and other health professionals who receive no compensation for providing non invasive primary care services in nonprofit local health clinics� and public schools.” [12]

Page 6 of HB564Â? states that in the case of any claim or judgment that arises under this paragraph against health care providers providing treatment to public, private, or parochialÂ? elementary or secondary students, “the aggregate of payments from the state legal expense fund shall be limited to a maximum of five hundred thousand dollars, for all claims arising out of and judg­ments based upon the same act or acts alleged in a single cause and shall not exceed five hundred thousand dollars for any one claimant–”Â? Is this the value of a life?Â? One wonders how much taxesÂ? will increase due to health-related lawsuits?Â? But then, WiddicombeÂ? says, “poor people don’t sue.” [13]

Children who are sent to school are “committed to the temporary custody of the State as schoolmaster.� In that capacity, the State may exercise a degree of supervision and control greater than it could exercise over adults.” [14]