Dr. Marguerite Oetting remembers carting all her medical supplies and vaccinations from campus to campus when the first school-based health clinic opened in the Iowa City Community School District (ICCSD) in 2007.
Oetting, a pediatrician, is one of the founders of Healthy Kids School-Based Clinics, a free medical clinic for uninsured and underinsured kids and young adults in Johnson County. Every year, the clinic helps hundreds of children who need to see a doctor but can’t afford one.
“When it started, it was just me and one of the school nurses. And it was just four hours a week,” Oetting said. “We had to go from school to school. There was a lot of trying to find a little space to do exams, and we were kind of always in the way.”
In 2006, one out of 18 kids in Johnson County didn’t have health insurance. There were 1,535 uninsured children under age 19, or about 5.5 percent of the nearly 28,000 children in the county.
Three years earlier, ICCSD completed a community-needs assessment to uncover educational barriers, and it identified the lack of healthcare access for students. In 2004, an Unmet Needs Taskforce began work on a school-based health center (SBHC) program.
SBHCs are primary care clinics, staffed by nurses and doctors, who provide a variety of services for kids and teens, including check-ups, evaluations, vaccinations, lab work, mental health needs, dental care, dermatology, etc. Typically, a local school district will partner with local health centers, hospitals and community groups to operate the clinics.
“Health and education go together, and they go along with economic stability,” Oetting said. “Anything that we can do to give kids a healthy start in life, both medically and in their education, is well worth the challenge.”
Oetting, along with Susie Poulton, then head of health services, and Pete Wallace, a pediatrician and co-chair of the taskforce, opened the first Healthy Kids clinic in 2007. Poulton handled the administrative work, Wallace the fundraising and finances, and Oetting served as the volunteer doctor.
At the time, there were around 1,000 SBHCs in the country, Oetting said. She trained in one of the first centers when she was a resident in North Carolina. Today, there are over 2,000 SBHCs nationwide.
Starting the clinic came with a “steep learning curve.” Six months after opening, Oetting settled into a DIY clinic at South East Junior High that operated four hours a week. Stationing a medical clinic in an educational setting came with competing interests.
“Pediatrics and schools share some goals, but they also have some really different agendas,” she said. “We were trying to fit a square peg in a round hole, in some ways, and had to learn how to work together.”
Services were limited, and the need was abundant. But after 15 years of refining, Healthy Kids has new, improved clinics open for 12 to 15 hours a week, three primary care providers, a full-time clinic coordinator and two part-time assistants.
“Now we have three beautiful clinics, actual clinic spaces that the school district has built for us,” Oetting said. “We’ve expanded a lot of what we’re able to do for people.”
Healthy Kids provides physical exams, athletic physicals, immunizations, treatment of illnesses, basic lab tests and prescriptions for medication. It offers referrals for mental health, dental care, eye care, sexual health and x-rays. The organization also helps families apply for Iowa Medicaid and connect them with community resources.
“We serve kids who live in Johnson County, from birth through high school graduation. And they don’t have to be a student in Iowa City Schools,” she said.
Healthy Kids primarily serves uninsured and underinsured kids in Johnson County. The number of uninsured children has fallen since 2007, from 5.5 percent to 2.6 percent, according to U.S. Census data. That’s 819 out of 31,555 kids under the age of 19.
This downward trend in uninsured kids parallels a nationwide pattern, but both the local and statewide numbers of 2.6 percent is below the national 5.4 percent.
This data may be inaccurate, Oetting explained. Lower-income households may chose to omit the true number of people in their apartment for fear of eviction, and those experiencing homelessness may not be reached by census workers, due to language barriers, work schedule and general mistrust.
Some immigrant communities are also mistrustful of the census, especially in 2020 when the the Trump Administration attempted to add a citizenship question. They may have chosen not to participate in the census to avoid increasing the risk of deportation.
“Many helping agencies feel the poor are underestimated in every census, but the political climate over the past six years has likely made the underestimation worse,” Oetting said.
Around 5 percent of children in ICCSD were uninsured in the 2019-20 academic year, according to registration data provided by Oetting. This is nearly double the county’s 2.6 percent estimate.
And the number of underinsured kids — those who have gaps in their coverage, who don’t have adequate benefits to cover their needs, who can’t see necessary providers, and who have higher out-of-pocket expenses — is much greater. About one-third of children aged 0 to 17 were underinsured between 2016 and 2019, according to a report in the American Academy of Pediatrics (AAP).
The majority of patients at Healthy Kids are children new to the Johnson County area and over 90 percent of them are non-white students (71 percent Hispanic, 16 percent Black, 5 percent white, 3 percent “other,” 3 percent Asian, 2 percent multi-racial). This is typical for SBHCs, Oetting explained. Many uninsured children experience insurance gaps because of the public insurance process.
Medicaid is a federal program, but it’s administered by individual states. For families moving to Iowa, it can take at least two months, and often longer, to receive Iowa Medicaid. Parents must cancel the Medicaid in their state of origin, and then apply to Iowa Medicaid. And they may need to renew public insurance more often than private insurance.
Healthy Kids often sees immigrant children who are not eligible for Medicaid. This can include the children of international graduate students at the University of Iowa. Only those granted refugee status are eligible for Medicaid upon arrival in the U.S.; all others must go through the immigration process to become eligible for Medicaid, which can take years.
Private insurance can provide coverage for U.S. citizens and immigrants. But premiums, deductibles and copays are often too expensive for parents, or may not provide comprehensive benefits. The AAP report attributes underinsurance numbers to an increase in “unreasonable out-of-pocket medical expenses,” caused by expensive commercial plans that transfer costs to individuals and families.
“We found children with private insurance were significantly more likely to be underinsured, further building the evidence base that public insurance better protects families from out-of-pocket costs,” the report states.
In the 2021-22 academic year, Healthy Kids completed almost 900 appointments for 356 patients. Most patients are teens and pre-teens, though Oetting and the other providers regularly see infants, toddlers and small children. Despite their efforts, many children are falling through the cracks.
“We are not serving all of the kids that could benefit from our services. We’re seeing about half of the kids that we feel are out there in the community,” Oetting said.
To accomplish this goal, Healthy Kids needs to double their budget to hire additional staff and increase the provider time.
Healthy Kids’ operating budget is $180,000 for the 2022-23 fiscal year. United Way provided $73,000, Iowa City provided $15,000 through the emerging aid grant and Free Clinic of Iowa gave a $3,500 grant. The rest came from smaller donations directed through United Way.
Most of the budget’s expenses pays for the non-physician support staff, about $122,000. These staff include a medical assistant and clinic coordinators, who schedule patients, arrange for transportation, manage referrals and help families apply for insurance or assistance. Other expenses cover lab work, prescription medications, transportation and specialty services at the UI College of Dentistry. The budget doesn’t account for the time donated by physicians or for facility expenses covered by the ICCSD.
“We’re fortunate that the University of Iowa is providing the physician time,” said Chair of Healthy Kids Anne Vandenberg. “And our pediatricians and family practice people also work at the Children’s Hospital.”
After 15 years, Oetting’s days in the clinic keep getting better.
“The joy of every pediatrician is just seeing the kids grow up,” she said. “Some of the children that started with our clinic at the beginning are now graduating or are young adults.”
Occasionally, some of her former patients will stop by the clinic to say hello and tell her about their lives.
“We have one young woman who graduated from the high school, and then went on to nursing school. And she’s now a full-fledged RN [registered nurse], which is really exciting,” Oetting said.
To celebrate their 15th anniversary, the group is holding a fundraising campaign to expand services and inoculate the program from funding cuts. The campaign has set a goal of $250,000, which will fill those insurance gaps and provide care for children who need it. Donations can be made through their website.
“We believe every person and every child deserves to have healthcare, and the current system in our country doesn’t provide for that,” Oetting said. “Whatever we can do to try and fill in the gap is really important.”