Association for Public Policy Analysis & Management

Despite widespread recognition of the existence and persistence of income-based achievement gaps in the United States, successful policy interventions to close them have eluded both researchers and policymakers alike. In this paper, we investigate the effects of a school-based intervention designed to address achievement gaps by aiming at a new target: students’ health. Students struggling with physical and mental health issues who have unmet healthcare needs may miss school entirely, suffer from diminished ability to engage in the classroom, or act out in ways that are disruptive to other students. These problems may be more acute among low-income students because relative to their high-income counterparts they are less likely to have a regular source of healthcare and more likely to have unmet healthcare needs (Larson et al., 2016).

School-based telemedicine centers (SBTCs) provide students with access to healthcare – regardless of their health insurance status – during the regular school day at clinics located within schools. While similar to traditional school-based health centers (SBHCs) in many respects, SBTCs allow a single physician to deliver healthcare to students across multiple schools at once. SBTCs eliminate the need for a full-time physician at each school, typically use videoconferencing as well as data-transmitting medical equipment, and leverage the expertise of existing school staff. Thus, SBTCs may enable the provision of healthcare in high-need, low-resource settings where delivery of healthcare using traditional models (such as SBHCs) would be cost-prohibitive.

In this paper we exploit the staggered introduction of SBTCs at the school-level across four school districts to produce causal evidence on whether and how access to healthcare in a school-based setting affects student outcomes. Previous work from the medical and public health literatures suggests that school-based health centers (SBHCs) are associated with increased access to healthcare (e.g., higher preventative care use, lower emergency department use) and improvements in some measures of student performance (Knopf et al., 2016). More recent work with stronger causal warrant finds that SBHCs reduce rates of teen fertility but that they do not affect high school dropout rates (Lovenheim et al., 2018). Related work on school counselors suggests that school-based health centers may be particularly important for addressing students’ unmet mental health needs and improving student behavior (Carrell & Carrel, 2006; Carrell & Hoekstra, 2014), especially to the degree that they involve increased funding for counselors (Reback 2010a, 2010b). However, to our knowledge, no work has examined the impacts of SBTCs on student outcomes.

We combine data on student exposure to SBTCs with detailed, student-level microdata to investigate the effects of access to healthcare in school on student achievement, chronic absenteeism, and exclusionary discipline (i.e., suspensions). We complement these results with a detailed investigation into three candidate mechanisms through which SBTCs might operate: increased identification and treatment of physical and mental health conditions, increased instructional time, and decreased incidents of disruptive and/or violent behavior.