The billionaires’ investment in the School-Based Health Alliance, the leading national nonprofit that promotes the expansion of school-based health centers, substantially increases the alliance’s revenue, which was less than $4 million in 2022, the most recent year for which data is available.
01/16/24 BIG PHARMA › NEWS
By Brenda Baletti, Ph.D.
Billionaires Melinda French Gates and MacKenzie Scott this month invested a total of $23 million in the School-Based Health Alliance (SBHA), the leading Washington, D.C.-based, national nonprofit that promotes the expansion of school-based health centers (SBHCs).
Gates’ contribution ($16 million), made through her Pivotal Ventures company, will launch SBHC “care coordination initiatives” in Houston, Atlanta, Chicago and Miami. Scott’s funding ($7 million) will support general operations for the alliance.
The funding substantially increases the alliance’s revenue, which was less than $4 million in 2022, the most recent year for which data is available. Before the new $23 million investment, most of the nonprofit’s funding came from federal grants.
SBHA tweeted the grant announcement:
The organization’s mission is to increase the number of SBHCs nationally among schools that receive federal funding through policy advocacy, technical support to existing centers and support securing funding for new and existing centers. There are approximately 3,900 SBHCs in the U.S.
SBHCs are intended to provide healthcare to kids by offering “primary care, mental healthcare, 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,” typically with a focus on advancing equity.
Promoting equity is also a key platform for Pivotal Ventures, which Gates founded in 2015 to “accelerate social progress in the United States by removing barriers that hold people back.” It is a venture capital fund that primarily makes return-seeking investments rather than providing philanthropic donations, but it also has grantees like the alliance.
SBHCs ‘completely unregulated’
Justine Tanguay, an attorney and director of Children’s Health Defense’s (CHD) Reform Pharma initiative, told The Defender there is a long history of private equity firms investing in healthcare in pursuit of their own interests.
“Many philanthropists and donors claim that funding SBHCs provides underserved and low-income families with equity and access to affordable healthcare,” Tanguay said. “But it’s not about improving children’s health, it’s about making money.”
The Pivotal Ventures-backed care coordination initiatives will fund staff positions for SBHC “care coordinators” in schools serving low-income families. Coordinators will set up information-sharing “among all those concerned with a student’s health needs and care,” including students, parents or guardians, school staff and/or healthcare professionals.
They will also address issues such as housing, food security and transportation as part of student care.
Workgroups comprised of staff from SBHCs and “community members” in each city will select the coordinators. The initiative also will lobby for policies to take over payment for the care coordinators through Medicaid.
Tanguay said these kinds of models for SBHCs have the potential to circumvent parents’ rights to make healthcare decisions for their children by allowing care providers direct access to minors, potentially without parental consent.
“Here, the opportunity to circumvent both parental rights and informed consent is ripe for abuse since SBHCs are completely unregulated and therefore, have no oversight,” she said.
Georgia attorney Nicole Johnson, co-director of Georgia Coalition for Vaccine Choice and a consultant to the CHD legal team, also told The Defender the $23 million investment raised concerns about who was making decisions and what kind of regulations might be in place to protect children and families.
“The large federal grants combined with this Gates/Scott funding seem to be putting SBHCs on a fast track across the nation,” Johnson said.
“As beneficial as some of these services may be, shouldn’t we slow down and consider who is leading the charge for these SBHCs and what their motives may be? Shouldn’t we make sure there are proper regulatory frameworks in place to protect children and parents?” she asked.
Scott’s award is the largest “unrestricted” gift in the alliance’s 28-year history, meaning that it is not earmarked for any particular project and will be used to support general organizational costs for the nonprofit, to use as its leadership sees fit.
“I believe that SBHCs could be of benefit and service to many families, of any income,” Johnson said. “But as they are being rolled out, there are few guardrails in place to safeguard children’s medical data/privacy, ensure continuity of care and protect parental rights,” she added.
Philanthropic funding key to SBHC expansion for decades
SBHCs are typically full-service health clinics physically situated within school buildings, although a small percentage of them are mobile units or, increasingly, telehealth clinics.
The Association of American Pediatrics (AAP) began to establish the first SBHCs in the 1960s in Massachusetts, Texas and Minnesota. Since their inception, they have focused on providing services to low-income children who lack access to regular healthcare.
Until the late 1980s, there were just a handful of SBHCs, primarily located in “urban communities” across the country. Their work focused on family planning, along with general youth health and well-being.
Early controversies over SBHCs focused on issues of reproductive healthcare and parental rights, but efforts to establish new SBHCs expanded rapidly in the 1990s.
The Center for Population Options, which was dedicated to reducing unintended teenage pregnancy, was the first organization to offer technical support and conduct periodic qualitative studies of existing SBHCs and their services. By 1998, the School-Based Health Alliance took over those roles.
SBHCs numbered 1,135 in 45 states by 1998-99, with the expansion largely funded through more than $40 million from the Robert Wood Johnson Foundation and allocations by state governments.
Medicaid expansion in the 1990s also helped to
shore up funding for SBHCs through coverage to low-income patients, along with congressional funding earmarked for SBHCs beginning in 1995 through the Healthy Schools, Healthy Communities program, which ended by 2005.
After that, funding for SBHCs was available from the Health Resources and Services Administration, as long as the grantees were federally qualified health centers. SBHCs also receive funding from third-party insurers and patient fees.
Through the Affordable Care Act in 2010, Congress appropriated $200 million over four years toward construction, renovation and equipment for SBHCs. The U.S. Department of Health and Human Services (HHS) distributed that money in 520 awards across the country.
By 2017, there were at least 2,317 SBHCs.
The Biden administration’s HHS in 2021 awarded $5 million in grants to expand school-based healthcare in the U.S. It continued this grant program the next year in May 2022, awarding $25 million in grants to 125 SBHCs. In 2023, HHS awarded another $25 million to 77 health centers for school-based service expansion.
Congress and President Joe Biden in June 2022 also passed the Bipartisan Safer Communities Act, which allowed 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.
The legislation charged the Centers for Medicare & Medicaid Services with expanding access to Medicaid healthcare services — including behavioral health services — in schools, and reducing the administrative burden for states and schools.
Since 2008, the number of telehealth SBHCs has also grown substantially, increasing from 7% of SBHCs to 19% from 2016-17.
Concerns over parental rights remain central to the debate over SBHCs today. Tanguay said that SBHCs can provide adolescents with confidential health services without parental consent, based on the assumption that some services, like family planning, could have negative consequences for the child if the parents were involved.
This often means that parents are denied access to their children’s health information due to confidentiality rules, but that information can be shared with providers including school nurses and other interested parties on the care team.
“It’s a very slippery slope that appears to eliminate barriers to sharing a student’s private health information, rather than protecting them,” she said.
While the early focus of SBHCs was on family planning and reproductive health, today the literature focuses more on their potential “to address lagging immunization rates” and to provide mental health services to children and teens facing a reported mental health crisis.
Groups like the AAP, a strong supporter of SBHCs, have used the mental health crisis to call on the Biden administration to fund expanded access to screening, diagnosing and treatment for children, arguing access to “school-based mental health care” should be a priority.
The administration responded with new policy measures, including the Bipartisan Safer Communities Act — which made $1 billion available for mental health services — and the American Rescue Plan Act. Both offer funding explicitly for school-based mental health services for students, KFF Health News reported.
Many of these resources have funded the expansion of SBHCs.
Pivotal Ventures Senior Manager of the Adolescent Mental Health strategy Sara Bathum indicated the corporation’s interest in mental health was a key motivation for its funding to the alliance.
“School-Based Health Alliance’s unique approach embeds mental health resources for youth and families within existing centers of care, making it easier to access trusted, culturally responsive support. We are proud to partner with them in this important effort in these communities and look forward to seeing their impact,” she said.
“Mental health is clearly a significant focus of these centers,” Johnson said. “But Parents should be very concerned about how these centers treat mental health issues.”
Johnson gave the example of a case in Maine where a federally funded school-based health center reportedly gave prescription anti-depressant pills in a plastic baggie to a 17-year-old girl without her parents’ knowledge or consent.
Pharma vs. parents in the SBHC rollout
The School-Based Health Alliance calls itself the “national voice for school-based healthcare.” It consults for organizations seeking to start SBHCs — helping them secure funding, providing technical support and even providing direct funding. It also tracks and lobbies for SBHC-friendly policies on the local, state and federal levels.
In addition to Gates and Scott, SBHA funders include Merck, maker of the Gardasil human papillomavirus (HPV) vaccine. Merck funded SBHA’s “vaccine toolkit” along with a 2023 SBHA program to increase vaccinations through child wellness visits.
Military think tank Rand Corporation also is a funder. Previous funders include Gilead and insurance giants Kaiser Permanente and Aetna.
Tanguay said the alliance’s ties to Big Pharma are concerning, given that SBHCs are such a“ windfall” for Pharma, particularly if they provide a way around parental consent.
She said:
“Big Pharma is a trojan horse that if given the opportunity, will have direct access to our children at school without the need for parental involvement.
“It’s no surprise that Big Pharma is supporting SBHCs because the goal is to diagnose and medicate as many students as possible for the sake of ‘improving’ the health of the child. Big Pharma’s business model anticipates that the more prescriptions written the more money they will make.”
The alliance’s board members also have ties to major healthcare conglomerates, and their resumes often highlight their success in vaccinating low-income people of color against COVID-19.
Board member Mark Masselli is CEO of the Moses Weitzman Health System, formerly Community Health Center, in Connecticut, which boasts of having administered over 500,000 COVID-19 vaccines and winning “national acclaim for its educational messages addressing vaccine hesitancy among people of color.”
Board member Alexandra Quinn, former Kellogg Foundation fellow, co-founded the Vaccine Equity Cooperative during the COVID-19 pandemic, to vaccinate people of color, largely by training “trusted messengers” to promote the idea that the vaccines are “safe and effective” — a strategy advocated and funded by federal public health institutions.
Another board member, Dr. Gillian Barclay, is the vice president of Global Public Health & Scientific Affairs at Big Pharma’s Colgate Palmolive, and previously worked at the Kellogg Foundation and World Health Organization.
Board member Cecilia Oregón works at healthcare giant Kaiser Permanente, where she is an advocate for universal internet access (digital equity) to get people telehealth access.
Robert Boyd, the alliance’s president and CEO, has been instrumental in getting federal appropriations for new and expanded SBHCs. In the meantime, Johnson said, the onus is on parents to advocate for state laws that ensure that SBHC expansion happens in a way that is regulated and offers protection for parents and children.
“In New Hampshire, for instance, a proposed bill regarding the establishment of SBHCs includes a provision that would require parents to be present when services are provided,” she said.
“I believe that requiring a parent’s presence is a win-win — the parent can share information about the child’s health history and any current treatments/medications and can also participate in and consent to any additional treatments.”
