for the Future

We are very thoughtful and specific about what we spend our money on. This (children’s health) is one of the things that is a priority. But if we only talk about it as health care, then it becomes difficult to sustain.  If we talk about wellness and preventive health, it all becomes part of the fabric of our district.


Martin Galindo
Superintendent, El Rancho Unified School District

Why is Sustainability Important? Sustainability planning is a critical element of child health insurance enrollment in schools because it allows a project team to better understand what program components are necessary for long-term success. Ultimately a sustainability plan will help a team turn big ideas into manageable and actionable steps. It’s important to remember that you may need to make adjustments along the way because your team needs time to assess the current project and determine which activities are and are not working. This flexibility allows teams to continue to improve on systems and strengthen buy-in. Having your sustainability plan in writing allows project team members to communicate and even market their efforts to a broader group of school district and community stakeholders.


Who is Essential to Sustaining Health Outreach and Enrollment? In order to conceptualize and organize around project goals and objectives it is beneficial to have a sustainability plan in writing that has been sanctioned by your school or district leaders. This plan provides a roadmap for successful program implementation by the project team and lasting collaboration among project partners.


How to Achieve Sustainability. There isn’t one way to think about and plan for sustainability. Ultimately effort committed to planning for sustainability early on provides your district team with a path to follow as you and your partners work toward the goal of insuring children.

Through CDF and AASA’s work in schools, and our systematic approach to program evaluation, we have outlined a way to think about and plan for program sustainability while incorporating concepts shared in research completed at the Center for Public Health Systems Science at Washington University.37 One of the first steps while meeting with your project team is to brainstorm answers to this statement: “For this project to successfully continue over time it needs…”  The answers will provide a framework for developing a sustainability plan.

Below is an exercise to do with your project team to help increase program capacity and plan for sustainability.

Check out this Team Exercise for Sustainability Planning.
Learn More

1. Political Support
When thinking about political support and sustainability, it is necessary to consider both the internal and the external environments which influence program funding, initiatives and acceptance. For example, internally every school district has a school improvement plan. Usually this plan is multi-year and is built on research-based strategies to improve outcomes for students. Children’s health insurance must be a part of every district’s school improvement plan. The data on the connection between health and education is clear. And the strategy of adding the question about health insurance to an annual district form makes collection of information on eligible students routine and almost effortless to sustain.

Externally, superintendents and other school district leaders can spread the message to local legislators with whom they often have direct contact and to other superintendents in their area. When superintendents get on the agenda of a local legislative convening, they have the stage to talk about health insurance, what it has done for children and schools in their district, and how improved school achievement will benefit the community. Superintendents who often are consumed by work in their own districts often appreciate learning what works from their peers. Encourage the district superintendent to contribute to newsletters or write letters citing examples of what has been done for children in their district, including impact on local district policy.

Policy Change Can Help School Districts Initiate and Sustain Their Outreach and Enrollment Work38

States can take steps to facilitate school district action to connect uninsured students to health insurance. Children's health advocates in California, led by the California Coverage and Health Initiative, developed a policy idea for legislation that would incorporate schools as key messengers and a natural outreach conduit to impact the health trajectory of uninsured children. After working closely with health advocates, schools and members of the state legislature, California passed legislation in 2014 mandating that public school districts provide information to families about health insurance options and enrollment assistance on school enrollment forms for the school years 2015 – 2018. Learn how California advocates achieved policy change.

2. Funding Stability
Medicaid Administrative Claims: Medicaid provides health coverage and medical services to millions of low-income children and their families. Schools are the logical place for Medicaid outreach activities that inform students and their families about the availability of Medicaid and CHIP and for Medicaid eligibility and enrollment activities, and arranging for services including outreach and some service coordination activities. Schools should establish a system to appropriately identify those activities and costs which are claimable under Medicaid in accordance with federal requirements. Learn how to prepare appropriate claims in the Medicaid School-Based Administrative Claiming Guide.39

Because each state is responsible for the operation of its Medicaid program, it is important for the school district to work closely with the State Medicaid Agency for policy and technical assistance. This collaboration will help to ensure compliance with administrative claiming requirements.

To maximize and sustain revenue for services provided to our special education students, Beacon Analytics implemented a full-scope program…Engaging with Beacon has helped the district manage the changing environment of Medicaid.

Third Party Billing Agent: The Jefferson Parish Public School System in Louisiana turned to a third-party billing agent to ascertain how many students were newly enrolled in Medicaid or Louisiana’s CHIP program known as LACHIP. After the school districts efforts to enroll more eligible children in Medicaid and LACHIP, reports generated by Beacon Analytics confirmed that Jefferson Parish had 5,000 more students in their district receiving services that were reimbursable by Medicaid/LACHIP.

Opportunities for Schools to Secure Funding for School Health Services and for Efforts to Connect Education and Student Health

The Medicaid Free Care Rule
A critically important Medicaid rule change made in 2014 allows public schools to receive funding for health services they provide to students enrolled in Medicaid. Known as the Free Care rule, it expanded the ability of schools meeting the Medicaid requirement to receive payment as Medicaid providers for providing free care to Medicaid-eligible students. Reimbursable services include routine preventive care, on-going primary care, immunizations and services provided by on-site school clinics.

The Every Student Succeeds Act
The Every Student Succeeds Act (ESSA), which replaced No Child Left Behind (NCLB), devolves much power back to the local level, challenging states and districts to re-think how they are supporting schools and students to accomplish their missions. ESSA explicitly recognizes the need for schools to support the total child and offers a “well-rounded education” as the new goal of public education. This responsibility to focus on the importance of the social, emotional, physical and civic development of children and youths, and not solely their academic development should help build strong children and make stronger communities tomorrow.

Through ESSA’s school-wide Title I programs, local school districts can consolidate and use Title I and other federal, state, and local funds for programs where at least 40 percent of the students are from low-income families. Schools will be able to implement school-wide health programs, such as hiring a school nurse and counselors, adding school-based mental health programs and more. Schools will also now report chronic absenteeism, which is closely related to a child’s health. ESSA specifically mentions the services under this provision may be delivered by a nonprofit or for-profit external provider with experience using effective strategies. This creates an opportunity for collaboration between the local health and education sectors. Local school districts must reserve one percent of this funding to support parent engagement, critical to successfully identifying and enrolling eligible students in health insurance.

ESSA also maintains “21st Century Schools” and adds a new program requiring states to spend 20 percent of Title IV funds on well-rounded educational opportunities. Twenty percent of those funds are to be focused on “safe and healthy students” and can be used to support wrap-around services, including case managers, counselors and psychologists allowing schools to think more holistically about student health and to create a healthy, safe school environment.

3. Partnerships
Fostering relationships and collaborative agreements with partners is the key ingredient for the sustainability of your work. Community partners have unique skills and resources to contribute to your project. Partnering with community clinics, health and social service agencies, nonprofit organizations, and others increases the number of individuals concerned with your project’s sustainability and offers more access to a range of resources.41 In the ENROLL CHILDREN BY ENGAGING PARTNERS section of the toolkit, there are great tips on partnerships and their role in children’s health insurance outreach and enrollment.

4. Organizational Capacity
In 2015 CDF and AASA convened a Community of Practice meeting to provide a forum for our school district partners to share lessons learned. Staff from the Mountain View School District in California found they were continually finding ways to build lasting infrastructure for the long term sustainability of serving the whole child. With the leadership of Superintendent Lillian Maldonado-French, Mountain View designated a director of wellness, a coordinator of health, a dietitian, a public information officer and an information technology employee to implement various areas of wellness including identifying uninsured children and families in their school district. The superintendent identified the staff and resources she felt necessary to effectively manage the program and its activities. One of the best practices from the Mountain View School District is the work of the information technology personnel who revised the student database to require the health insurance question as a mandatory prompt as part of enrollment. The Mountain View School District has a dynamic team working hard to increase the organizational capacity of this work.

5. Program Evaluation
Without program evaluation, CDF and AASA would not be able to share this valuable toolkit full of best practices and lessons learned in children’s health insurance outreach and enrollment. It is through the evaluation work of Shattuck and Associates, an independent planning and evaluation firm, that the Telling Your Story (TYS) Template and the Monthly Reporting Template were created to routinely collect important process and outcome information. We are pleased to share the templates and the best practices from our time doing this work. We encourage all school districts beginning this work to establish a way to monitor and evaluate along the way. By committing to program evaluation at the beginning of your work, districts can be most effective in building strong teams to identify, reach, enroll, and sustain children’s health insurance outreach and enrollment. Learn more about how to use EVALUATION to sustain success.

6. Program Adaptation

Leaders in education need to create not just a structure of change, but a culture of change. A culture in which new ideas and practices are critically assessed and selectively incorporated on a continual basis.

Don’t expect your plan for implementing children’s health insurance outreach and enrollment to be perfect the first time around. At every step along the way, take the time to identify areas that need improvement. Some goals may simply not be attainable. Other goals may need revised timelines. In some areas you may be doing better than expected. Whatever the case, seek out feedback and adapt program practices, because the importance of connecting children to health insurance to improve educational outcomes is well-established. Project leaders who are open to feedback and show a willingness to adapt and improve practices over time are better positioned for building lasting programs.

7. Communication
Not only do teams need to be flexible and willing to adapt, but teams must establish open communication among everyone involved. Communication is absolutely pivotal. Broadly speaking, there are three groups to ensure open and lasting communication with: administration and teachers; schools and families; and student support services and community partnerships. Taking the time to assign people to routine communication and follow-up with all involved will build trust and rapport and advance program sustainability and potentially change policy.

A centralized school district website is an excellent way to communicate with administrators, teachers, families and community partners. On your website teams can share and connect with people through storytelling. CDF and AASA recognize the importance of connecting and making the experience real. A true story can be one of the most effective ways to communicate with 1) policymakers on a needed policy change; 2) funders on the effectiveness of your program; 3) potential partners on reasons they should become engaged in your work; and 4) supporters on why they should continue to champion your work. Stories make programs and policy real; they create connections between people. Read or share a story.

8. Public Health Impacts
CDF and AASA's VISION emphasized what we all know, the fact that poor health severely limits a child’s ability to learn and in order to improve academic achievement, later success, and upward social mobility, it’s necessary to ensure a child’s access to health insurance.42 When you begin this extremely rewarding work of enrolling children in health insurance through schools, orient your team around a vision statement: one that considers your overarching goal to ensure students are happy, healthy, and ready to learn. Establish a vision that considers and incorporates ways to integrate health metrics and health goals into school improvement plans.

9. Strategic Planning

What really helped us as a school district was alignment. We wanted to fully support our students and we needed to engage with other programs, efforts and resources. We had to engage in a collaborative education with others and the strategic plan became the foundation. As a result of the conversations, and thanks to the support of our board and leadership, we wanted to support the whole child. We were able to identify our gaps and bring in the social workers and caseworkers and that has an impact on attendance, suspension and academic achievement.

It takes a visionary team with a strategic plan to succeed with enrolling students in health insurance through schools. Every school district has a school improvement plan that is often multi-year and built on research-based strategies to improve outcomes for students. These district improvement plans are shaped by the advice of the School Health Advisory Council (SHAC). The SHAC will help the district ensure that local community values are reflected. Be sure the SHAC is a part of and informed about the district’s work on health insurance enrollment, as members are often required to make annual reports to the school board, which in turn, sets local district policy.

At Alief (ISD), the Director of Special Populations, understood the importance of being part of the SHAC committee and informing members about the district’s work on health insurance enrollment. She led the effort in making change happen. Through her leadership, Alief ISD has systematically incorporated districtwide policy support for children’s health insurance enrollment through the district’s strategic plan. It was through her involvement and the collaborative decision-making between partners within and outside the district that policy change occurred. Just like Alief ISD, your project team can ensure that information on identifying and enrolling eligible students in health insurance is part of your district’s School Wellness Policy. But remember, don’t stop there — spread the word to local legislators with the help of your superintendent.

The Children’s Defense Fund Leave No Child Behind® mission is to ensure every child a Healthy Start, a Head Start, a Fair Start, a Safe Start and a Moral Start in life and successful passage to adulthood with the help of caring families and communities. 

CDF provides a strong, effective and independent voice for all the children of America who cannot vote, lobby or speak for themselves. We pay particular attention to the needs of poor children, children of color and those with disabilities. CDF educates the nation about the needs of children and encourages preventive investments before they get sick, drop out of school, get into trouble or suffer family breakdown. 

CDF began in 1973 and is a private, nonprofit organization supported by individual donations, foundation, corporate and government grants.

AASA, the School Superintendents Association, represents, works alongside, supports, and is the voice of superintendents and education leaders across the United States. Thirteen thousand strong and 151 years old, we remain committed to excellence and equity for each and every child in public schools. Leveraging our 49 state affiliates and national partners, we focus on developing school system leaders who can meet the challenges facing 21st century students and beyond.