In the mid-1970s, the St. Paul Maternal and Infant Care Project was developed in select public high schools in Minnesota to address poor rates of prenatal care participation and birth complications among teenage mothers. This comprehensive, interdisciplinary prenatal care program was the first model of school-based health care in the secondary school setting, and its initial success was seen as a promising model to pursue as a means of primary and repeat teenage pregnancy prevention. This generated tremendous national attention and began to prioritize a school-based, clinical services’ approach to prevent teenage pregnancy by providing reproductive health care to teens, especially among those who had never experienced a pregnancy. It also reinforced the model’s potential for providing a comprehensive array of services, beyond the original reproductive health services. This was reflected in the decision by the Minnesota clinics to expand their portfolio of services and, thus, attract both male and female students.

Awareness of the need to improve and expand the availability of clinical services to all teenagers was increasing during this time as well, especially after a Surgeon General report highlighted the deteriorating health status of adolescents in the USA. This attention, combined with an increase in public and private funding opportunities in several states, facilitated the growth of SBHCs in high school settings. Today, approximately 80% of all SBHCs in the USA serve at least one grade of adolescents (6th grade or higher). Although reproductive health remains a cornerstone of the services that adolescent SBHCs provide, attention to the primary and mental health care needs of students drives the continued interest in the model and the gaps it aims to close.

Beginning in the early 1980s, national foundations played a key role in SBHC replication in several states, such as California, Louisiana, Colorado, and New York. For example, the Robert Wood Johnson Foundation founded the National Healthy Children Program and the School-Based Adolescent Health Care Program in an effort to expand community-based efforts aimed at increasing access to health care for children and adolescents in underserved communities.

Health care and education policy makers across the country also increasingly became more aware and supportive of the value of school-based health care delivery in meeting the need for greater access to health care among youth. By 1988, there were approximately 120 SBHCs in the country.

During the 1990s, the number of SBHCs multiplied nearly 3-fold, largely owing to private funding investments. For example, in 1994, the Robert Wood Johnson Foundation launched “Making the Grade: State and Local Partnerships to Establish School-Based Health Centers,” a multi-year $23.2 million initiative to stimulate state-level policy changes to advance the SBHC model and work toward long-term sustainability. Since then, other national and local foundations, such as the W.K. Kellogg Foundation, have played a key role in providing funding to develop and implement programs. Such foundations have also assisted with the provision of technical assistance to state-level associations to further solidify the sustainability of these efforts. As a result, a number of state governments have invested in funding new SBHCs through state general funds. In addition, their institution of public policies to support the long-term sustainability of SBHCs has been instrumental, for example, mandating contracts between SBHCs and managed care organizations to support reimbursement of SBHC services provided to Medicaid enrollees. During this time, several states also allocated part of their Maternal and Child Health Services Title V block grant funds to SBHCs. The Title V funds aim to extend and improve health and welfare services for mothers and children, and thus, SBHCs were consistent in this mission. The expansion of the Federal Medicaid and State Children’s Health Insurance Programs (SCHIP) also provided significant resources for this growth.

In recent years, the acknowledgment and acceptability of SBHCs has continued to grow. For example, in 2008, California’s government passed the School Health Centers Expansion Act, with the aim of establishing a grant program for SBHCs. However, this legislation did not result in the addition of new SBHCs, primarily because no funding was allocated to the Act.

Nevertheless, the Oakland and Los Angeles school districts (2 of California’s larger districts) have continued to expand the SBHCs in their communities through local voter-approved bonds and philanthropic donations. In Oakland, Kaiser Permanente, one of the region’s largest health care providers, provided significant support for sustaining several existing SBHCs and the development of 4 new SBHCs, even though only a subset of students’ families are formally enrolled in the Kaiser health care system. In this case, Kaiser recognizes the importance of investing in the health of the population in general, with a special focus on schools as a means of promoting health, including the prevention of childhood obesity. In 2005, Atlantic Philanthropies selected Baltimore, Chicago, Oakland, and the State of New Mexico as sites to roll out integrated educational, after-school, health, dental and community services in middle schools, known as the Elev8 project. Each Elev8 site is supported by a combination of private and public funds and has an SBHC with dental services as an integral component of the program. The University of California, San Francisco Schools of Nursing and Dentistry have recently been funded to support the sustainability of the Elev8 sites in Oakland, with evaluation by the Philip R. Lee Institute for Health Policy Studies. Despite all of these private and public funding efforts, it is important, as previously noted, to stress that it was not until the recently passed national health care reform legislation that SBHCs were included as a noted health care delivery mechanism that warrants national investment. Overall, funding sustainability continues to be a challenge and has contributed to the relatively small number of SBHCs across the country.