The Leader‘s April 12 front-page headline “Blue Heron Middle School awarded grant for mental health” caught my attention, reminding me of a recent conversation with a high school teacher revealing that close to half of his students are in counseling for mental health issues.

This seems a staggering number, and reflects what is widely known: Our children are in the midst of a mental health crisis. Anything that might help our youth deal with anxiety and depression, easily accessed during their day at school, promises to be a good and positive change.

So that’s where School-Based Health Centers (SBHC) come in, with Blue Heron Middle School slated to become our county’s latest clinic in the fall of 2024. This article explores the SBHC concept, the entities and funding behind it, and what it all means for parents of students in Jefferson County schools.

More than likely, as a parent, in that pile of papers you signed at the beginning of the school year — and certainly, if your child received a sports physical from the school-based clinic at Port Townsend, Chimacum, or Quilcene — you, like me, signed a release giving permission to Jefferson School Based Health Centers to “perform such medical and therapeutic procedures as may be professionally necessary or advisable for me (or my child’s) health screening, diagnosis, and treatment.”

The form looks like this:

 

 

There is more to granting this permission than may meet the eye. In 2019, through highly controversial legislation, Washington State provided for out-patient mental health treatment for minors without parental consent. Parents’ rights were removed to even be informed about certain treatments and services that school personnel and outside professionals deemed advisable.

After citizens statewide successfully challenged that legislation earlier this year with the Parents Bill of Rights (more on that below), state policy appears to be in the process of shifting. But revised guidelines have yet to be developed. And local SBHC officials maintain that the parental rights initiative applies only to records kept by public schools, school staff, and school administrations. They contend SBHCs are separate entities from the schools and will not be required to share their records with parents even with the new law.

Parents need to be aware of what current guidelines allow for, who/what is behind the SBHC enterprise, and what is at stake. Even after researching this, the question of what parents are consenting to when they grant blanket permission to Jefferson School Based Health Centers remains shrouded in unknowns.

 

Where Did School-Based Health Come From?

Here is a brief history of SBHCs in Washington State from the website of the Washington-School Based Health Alliance:

In 1987, the Seattle City Council funded a three-year pilot of a SBHC at Rainier Beach High School, and services started in 1988. This successful pilot paved the way for Seattle levy funding for SBHCs in 1990 and King County levy funding in 2016. State and federal funding became available for SBHCs statewide in 2021.

 

There has been rapid growth of SBHC’s across the state in recent years, with diverse operational and funding models, with the number almost doubling since 2017. Today, there are more than 70 SBHC sites, sponsored by more than 25 healthcare agencies, in over 30 school districts – urban, suburban, and rural – across Washington.

According to Gerald Braud, writing for Informed Choice Washington, recent legislation in our state ensures this concept will continue to grow. HB 1225 created a school-based health center program office in the Washington State Department of Health in 2022, staffed with three and half employees at a cost of nearly $2 million a year.

It is not a new concept in Jefferson County, which currently has three SBHCs overseen by Jefferson County Public Health, located at Port Townsend High School, Chimacum High School, and Quilcene K-12. The clinic at Blue Heron, scheduled to open fall of 2024, will be the fourth.

According to the Leader, the grant covering the cost of remodeling the space for the clinic at Blue Heron is from the Washington State Legislature, but the concept and support for the Washington School-Based Health Alliance comes from the increasingly influential, parent non-profit, School-Based Health Alliance, founded in 1995, and based in Washington D.C.

From their website:

“School-based health care is a powerful tool for achieving health equity among children and adolescents who unjustly experience disparities in outcomes simply because of their race, ethnicity, family income, or where they live. It’s an idea that has gained currency across the country: place critically needed services like medical, behavioral, dental, and vision care directly in schools so that all young people, no matter their ZIP code, have an equal opportunity to learn and grow. At the School-Based Health Alliance, we’ve worked for over 25 years to:

• Advance national policy and legislative priorities for the field
• Advocate for greater support and funding
• Promote high-quality clinical practices and standards
• Support data collection and reporting, evaluation, and research
• Provide training, technical assistance, and consultation”

 

Funding Sources and National Partners

Here are the current entities listed as funding this national enterprise:

• Pivotal Ventures;
• MacKenzie Scott;
• Connecticut State Department of Public Health;
• Health Resources and Services Administration;
• NBA Foundation;
• No Kid Hungry by Share Our Strength;
• The Leon Lowenstein Foundation;
• JBS International – a Celerian Group Company;
• Rand Corporation;
• National Council for Well Being;
• Merck & Co.

I picked a few of these organizations that I thought might stand out for Jefferson County readers so we can understand who is funding the SBHA on a national level.

Pivotal Ventures manages the philanthropic efforts of Melinda French Gates, former wife of Microsoft’s Bill Gates.

MacKenzie Scott is the former wife of Amazon’s Jeff Bezos.

Together, in January 2024, these two donated $23 million to the School-Based Health Alliance to help launch school based health clinics in Atlanta, Chicago, Houston and Miami as well as fund general operations.

Rand Corporation (yes, that Rand!) is usually associated with the military and self-described as “a non-profit institution that helps improve policy and decision making through research and analysis.”

Merck makes, markets, and sells drugs and is self described as “aspiring to be the premier research intensive biopharmaceutical company.”

This enterprise also incorporates corporate interests and advocacy groups in its dozens of SBHA National Partners. Along with health associations and organizations like American Academy of Family Physicians and Boston Children’s Hospital, current partners include Colgate-Palmolive, National LGBTQIA+ Health Education Center, Beyond the Pill, Unity Consortium/United for Adolescent Vaccination, and Conrad Hilton Corporation (full list at bottom*).

As mentioned previously, the Washington School-Based Health Alliance is the state level outreach division of the national SBHA. Here is the current list of entities described as grant funders, event sponsors, and individual donors for the Washington School-Based Health Alliance:

• Kaiser Permanente;
• Ballmer Group;
• Washington Association for Community Health;
• ARCORA the Foundation of Delta Dental of Washington;
• Washington State Department of Health;
• Washington State Health Care Authority;
• Community Health Plan of Washington;
• Molina Health Care;
• Swedish Hospital.

Kaiser Permanente is a health insurance provider in Washington State and, in its own words, “exists to provide high-quality, affordable health care services and to improve the health of our members and the communities we serve.” The latest information I could find stated that in 2019 Kaiser Permanente entered a three year, $1.2 million agreement to provide start-up funds for two school-based health clinics in Washington State.

The Ballmer Group manages former Microsoft CEO Steve Ballmer and his wife’s philanthropic efforts. They donated $450,000 to general operations for the Washington SBHA from 2022 to 2025.

The federal pipeline for funding opened up in 2010 with the Affordable Care Act (ACA) aka Obama Care. According to the National Center for Safe and Supportive Learning Environments:

“The ACA, through section 4101(a), funded the Health Resources and Services Administration’s (HRSA) School-Based Health Center Capital Program, which provides $50 million a year for four years (2010 through 2013) for one-time funding for construction, renovation, and equipment for SBHCs.”

The pipeline remains open to this day. In 2023, the U.S. Department of Health and Human Services (HHS), through the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the Administration for Children and Families (ACF), announced $206 million in grant awards towards youth mental health.

 

Why This Matters – Losing Parental Consent

Why have I just overloaded you with information? Why should any parent, or anybody in Jefferson County, care about any of this?

“I give permission to Jefferson School Based Health Center to perform such medical and therapeutic procedures as may be professionally necessary or advisable for me (or my child’s) health screening, diagnosis, and treatment.”

What parent could imagine, with those few words regarding medical care at school, that they could be opening a door that allows access to their adolescent children for the massive conglomeration of federal, state, and private entities that populate the above lists? Or that the procedures they are allowing could potentially be provided without their consent?

What have we done by signing this release?

I wish we were talking about what many of us experienced in public school when life was a bit less complicated. You didn’t feel well, you went to the school nurse who looked you over, maybe gave you a band-aid. If you were running a fever, your parents were called to come pick you up.

But it’s not that way anymore.

Please look over the following chart from the website of the Washington School-Based Health Alliance, titled “Providing Health Care to Minors under Washington Law: A summary of health care services that can be provided to minors without parental consent.” School-Based Health Centers are an entry point providing access to these treatments through mental health care or referral to care providers off campus. Critics may note that this graphic is dated July 10, 2015, but I include it because it is posted on the Washington School-Based Health Alliance website, provides the best summary I could find, and continues to reflect the current state of the law.

One change not reflected in this chart regards recent house bills passed in Washington State that some suggest might open the door to gender reassignment surgery for adolescents (13 years and older) without parental consent via out-patient mental health treatment:

1. SB5904 allows “adolescents to confidentially and independently seek services for mental health and substance use disorders.”
2. SSB5889 requires insurance providers to communicate only with the person receiving the care regardless of who holds the policy.
3. And SB5313 bans insurance companies from rejecting gender affirming surgical procedures previously considered cosmetic, if they are deemed medically necessary.

 

The Pendulum Swings Back – Parents Bill of Rights

On March 4, 2024, the Washington State Legislature passed Initiative 2081 to establish a Parents Bill of Rights, by a wide bi-partisan margin. As a successful citizens initiative, signed by over 450,000 voters, it did not need the governor’s approval and became law ninety days later on June 4.

The opening paragraph of Initiative 2081 reads as follows:

“The legislature finds that: (a) Parents are the primary stakeholders in their children’s upbringing; (b) parental involvement is a significant factor in increasing student achievement; (c) access to student information encourages greater parental involvement.”

The initiative then lists the rights of parents and legal guardians of public school children younger than eighteen years old. Most of the rights mentioned already exist in state law. The key rights defined in this initiative, relative to medical care without parental consent, secures the parental right to inspect their child’s school records in accordance with RCW 28A.605.030.

It goes on to enumerate that public school records include all of the following: public school records, medical or health records, records of any mental health counseling, records of vocational counseling, records of discipline, records of attendance, also notifications of when medical services are being offered to their child, notification of any medical service or medications having been provided that result in any financial impact to the parent’s or legal guardian’s insurance payments or co-pays, notification when the school has arranged directly or indirectly for medical treatment that results in follow up care beyond normal school hours, and immediate notification if their child is taken or removed from their public school campus without parental permission.

Previously the schools followed administrative rules provided by the Washington State School Directors Association, WSSDA. In particular Policy 3211 — Gender Inclusive Schools, and Policy 3211 — Procedures – Gender Inclusive Schools. The key sentence in these procedures is: “Before contacting a student’s parents, the school will consult with the student about the student’s preferences regarding family involvement and consider whether safety concerns are present for the student.”

Parents might also want to know that these procedures seem to suggest setting up two sets of books — “Official Records” under the students legal name, the only one of which is the standardized high school transcript; and “Unofficial Records,” explained in the procedures, kept under the name chosen by the student to represent “how they choose to be addressed in their transgender or gender expansive status.”

The following paragraph from the procedures details the current policy In regards to what schools will release to parents (emphasis mine):

Information about a student’s gender identity, legal name, or assigned sex at birth may constitute confidential medical or educational information. Disclosing this information to other students, their parents, or other third parties may violate privacy laws, such as the federal Family Education Rights and Privacy Act (FERPA) (20 U.S.C. §1232; 34 C.F.R. Part 99). Parents have the right under FERPA to request their student’s records and if requested, the District will provide the student’s educational records to the parent according to 3231/3231P.

 

State and Local Responses to Requests for Clarification

In the second week of May, I contacted Annie Hetzal, the School Health Services Consultant, at the Office of the Superintendent of Public Instruction (OSPI), and asked if Washington State Superintendent Chris Reykdal had made any statements or issued instructions to school superintendents in regards to the parental rights initiative so that parents can access all their children’s school records, including from school-based health clinics, as soon as the initiative became law in June.

She told me in a text that the state Superintendent’s latest statement to district superintendents was “that OSPI is working on guidance for schools that is not yet finished.”

To clarify some of these issues on a local level, I contacted Jefferson County Public Health and spoke with Susan O’Brien, a family nurse practitioner in the Jefferson SBHCs.

Susan started with a brief history. Jefferson SBHCs got their start in 2007 with a grant from the Washington State Department of Health. Clinics were opened at Port Townsend High School and Chimacum High School for the 2008/2009 school year. The clinics were finished with donations of labor and materials from citizens and businesses in Jefferson County. This was the community coming together to fill a need that they believed wasn’t being met elsewhere.

The school clinics are primarily run by Jefferson County Public Health in cooperation with Jefferson Healthcare, and the Jefferson County School Districts. The hospital regularly provides funds for the clinics, and has a designated liaison, Dr. Sara Schmidt, who works as the main contact for requests coming from the clinics.

The recent funds from the state legislature are paying only for the remodel of the space at Blue Heron Middle School that will be used as a clinic. This was the first time that funding came from outside the community.

Students are allowed to come in with their friends, often just to ask questions like “What is going on with my body?”

Susan gave me an example of how these clinics can help families new to the community. A parent who just moved here had a child with asthma who needed help. Setting up a primary care provider can take months. The SBHC at the child’s school was able to utilize their close relationship with Jefferson Healthcare to shortcut the process and get the needed treatment for the child.

The Jefferson SBHCs track student use in two categories, medical visits and mental health visits. The information below also details how many “visits” translate into “users” or actual treatment:

• Chimacum: 200 medical visits from 89 users, 203 mental health visits from 89 users;
• Port Townsend: 325 medical visits from 157 users, 457 mental health visits from 42 users;
• Quilcene: 79 medical visits from 40 users, 392 mental health visits from 35 users.

 

Typical requests are sports physicals, birth control, concussion management, immunizations.

If needed, the SBHCs try to work directly with the student’s primary care physician. Other partners in the community include Discovery Behavioral Health and Jefferson Healthcare. Referrals for physical therapy to Jefferson Healthcare or Discovery Physical Therapy in Port Hadlock are not uncommon.

 

Obtaining Healthcare Without Parental Consent

When I ask about what I have found to be of greatest concern among parents — the ability of adolescents to obtain medical and mental healthcare without parental consent — Susan is clear in stating: “We follow the laws of Washington state. At the same time, we encourage the students to talk to their parents. Some students don’t feel safe. That’s why we have these laws in Washington state.”

If there is a problem with care received at a Jefferson SBHC, the practitioners, who are licensed employees of Jefferson Public Health, would be the responsible party. There is no direct state oversight. However, the Jefferson County Board of Health and Health Officer for Jefferson County, Dr. Allison Berry, provides oversight of the clinics at the county level.

Susan O’Brien stated, “The most important thing for parents to know is that school-based clinics are like clinics anywhere in Washington state — adolescents can receive mental health care without their parent’s consent.” She went on to explain that what the practitioners in the Jefferson SBHCs want is to support kids to be healthy in every way possible. Parents, she said, can choose for their children to not use the SBHCs if they so wish.

The Jefferson County Public Health website is not clear regarding that assertion. While their page about SBHCs notes that “students must be registered with signed parental consent to be seen for medical concerns,” it also displays a prominent notice assuring teens that they can access many services without their parents’ knowledge.

 

As to the parental rights initiative, Susan confirmed that the Jefferson SBHCs have yet to receive any guidance from the Office of the Superintendent of Public Instruction and “will be following the laws of Washington state.” As noted earlier, Jefferson County Public Health’s current position is that the Parents Bill of Rights will not affect their policies, that it applies only to records kept by public schools, school staff, and school administrations. Susan says the SBHCs are separate entities from the schools and will not be required to share their records with parents. She summarized it this way:

“We don’t share our records with the schools, and the schools don’t share their records with us.“

It remains to be seen how or if the parental rights initiative will be implemented as the law now goes into effect (assuming it survives an off-mission American Civil Liberties Union legal challenge).

Ultimately, if parents are unhappy with the current state of affairs, it will be up to these parents to become familiar with current state law to establish their rights, while working cooperatively with their school administrators, school boards, and School-Based Health Centers to get the information they need to care for their children.

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*Full list of SBHA National Partners:
AASA/The School Superintendents Association; American Academy of Family Physicians; Adolescent Health Initiative; Alliance for a Healthier Generation; American School Counselor Association; Apex; Association of Asian Pacific Community Health Organizations; ASTDD; Bi-State Primary Care Association; Beyond the Pill; The Center for Health and Healthcare in Schools, Child Trends, Coalitions for Community Schools; Institution for Educational Leadership; Community Health Center, Inc.; Conrad Hilton Corporation; Farmworker Justice; National LGBTQIA+ Health Education Center; Futures Without Violence; Health Outreach Partners; Johns Hopkins Consortium for School Based Health Solutions; Kaiser Permanente Thriving Schools; Mental Health Technology Transfer Center Network; Mid-Atlantic Tele-Health Resource Center; South Carolina Telehealth Alliance; Medical University of South Carolina; National Association of Community Health Centers; National Center for School Mental Health; National Health Care for the Homeless Council; Public Health Management Corporation’s National Nurse-Led Care Consortium; Trust for America’s Health; University of California/San Francisco; Unity Consortium/United for Adolescent Vaccination; American Academy of Pediatrics; Kaiser Permanente; National Association of Community Health Workers; Center for Adoption Support and Education; Prevent Blindness; Moses/Weitzman Health System; National Association of School Nurses; National Center for Safe Supportive Schools; Colgate-Palmolive; National Association of School Psychologists; Health Leads; Boston Children’s Hospital.

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