with managed care organizations in the hope of achieving cost savings (Lipson and Naierman, 1996). Other health departments are seeking to form networks with CHCs, public hospitals, and other traditional safety net providers so that they can continue to serve their traditional patient populations.

School-Based Health Centers

During the 1995-1996 school year, more than 900 school-based health centers provided care to children and adolescents. According to a national survey, 65 percent of the centers delivered both primary and mental health care, with the remaining 35 percent providing primary care only (Making the Grade, 1997). Most centers have multidisciplinary teams of nurse practitioners, clinical social workers, physicians, and other health professionals working cooperatively with school nurses, athletic coaches, counselors, teachers, and school administrators to help the health center become an integral part of the school's activities.

School-based health centers operate in 43 states and the District of Columbia. Nationally, the majority (43 percent) are in the northeastern and mid-Atlantic states. The 10 states with the largest number of centers are New York, Florida, Texas, Connecticut, Pennsylvania, Maryland, California, Massachusetts, Michigan, and Arizona.

State governments are a primary source of financial support for these centers. In 1995-1996, 34 states allocated $41.9 million in state and federal block grant funds, which was an increase of 8 percent from 1994. The primary sources of these funds included Maternal and Child Health Block Grants and state categorical sources. Other sources of federal support are the Preventive Health Block Grant and funds provided through the Drug-Free Schools and Communities Act. Support also is provided through Medicaid, although that amount has not been tracked.

The centers are located in all types of schools. High schools are the primary sites, housing 41 percent of all centers; 32 percent are in elementary schools, and 17 percent are in middle schools. Studies have shown that the students who use school-based health centers are similar in gender, ethnicity, and age to the rest of the school population (McCord et al., 1993) although they are more likely to be uninsured (Kisker and Brown, 1996).

Implications

In a market-driven health care system, the impact of providing unreimbursed or partially reimbursed care is profound. No managed care organization will compete to care for uninsured individuals, and government subsidies to care for low-income and uninsured individuals are generally being reduced.

Uncompensated care costs are not generally broken down by age group, but the number of uninsured children has been increasing steadily for several years. With the new children's health insurance programs initiated through the Balanced Budget Act of 1997, states that increase their Medicaid eligibility thresholds and otherwise subsidize coverage for previously uninsured children can raise the rates of insurance coverage and thus reduce the burden of providing uncompensated care among safety net providers. However, in order for SCHIP funds to make significant reductions in the numbers of uninsured children, states must draw down all of the available funds, actively pursue effective outreach and enrollment strategies, and also minimize the risk of replacing existing private coverage.

Over the next several years, it will be important to measure the extent to which the new children's health insurance programs alleviate the pressure on other sources of funding for uncompensated care. Unless better data systems are developed, with more consistent age breakdowns, this will be extremely difficult to measure. Thus, the advent of the SCHIP program offers a unique opportunity to track and measure changes in the number of uninsured children and to assess the program's effectiveness from its onset. Lessons learned from the evaluation of the program will have important implications for the likelihood and nature of future insurance expansions.

The lack of consistent data also could limit the evaluation of changes in SCHIP funding in terms of



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