The Relentless School Nurse: Just Because They Can, Does Not Mean They Should.

The Centers for Medicare & Medicaid Services (CMS) rescinded key guidance on March 4, 2025, affecting Medicaid and Children’s Health Insurance Program (CHIP) coverage for services addressing health-related social needs (HRSNs).  This action reverses Biden-era policies and aligns with the Trump administration’s broader efforts to dismantle diversity, equity, and inclusion (DEI) initiatives while cutting Medicaid spending.

This exemplifies another example where administrative power is being wielded without consideration for its consequences, just because they can. This policy shift, which eliminates frameworks for addressing social determinants of health, has far-reaching implications for school nurses and our school communities. We are frontline professionals already stretched thin by systemic understaffing, expanding responsibilities, and untenable ratios.

The original guidance had opened doors for states to fund critical interventions to address housing, food insecurities, and access to medical care. These initiatives were designed to address the root causes of health disparities and reduce long-term healthcare costs. By rescinding this guidance, CMS has effectively pulled the rug out from under states that were in the process of implementing or planning HRSN programs. The shift to a case-by-case review process under the Social Security Act introduces uncertainty and potential delays in approving vital services for vulnerable populations, especially children and families dependent on these services. 

For school nurses, this policy change intensifies existing challenges in managing complex health issues for students, including chronic disease management, mental health screenings, and emergency care. The removal of HRSN guidance undermines our ability to connect families with resources like housing interventions, nutrition programs, and medical care, all services that directly reduce health barriers to learning. With many schools lacking full-time nurses and maintaining high nurse-to-student ratios, the loss of HRSN infrastructure forces nurses to compensate for systemic gaps.

The impact on students and families is likely to be significant and multifaceted. Reduced access to social services, increased health disparities, higher emergency department utilization, and fewer preventive care visits are just some of the potential consequences. These effects will disproportionately burden low-income populations and those living in states with limited social safety nets, further widening the gap in health outcomes across socioeconomic lines.

School nurses traditionally bridge healthcare and education systems by developing individualized healthcare plans, coordinating with counselors and community providers for mental health support, and advocating for accommodations under Section 504 plans. Without HRSN funding, nurses lose critical tools to address social determinants that influence the majority of health outcomes. This loss compromises our ability to manage chronic absenteeism, retain school nursing staff, and reduce health outcome disparities.

The policy change aligns with broader efforts to dismantle diversity, equity, and inclusion initiatives and tighten Medicaid spending. However, it fails to consider the well-documented links between social factors and health outcomes. Numerous studies have shown that addressing HRSNs can lead to improved health, reduced hospitalizations, and lower overall healthcare costs. By prioritizing short-term budget considerations over long-term health outcomes, CMS risks exacerbating health disparities and increasing healthcare expenditures in the long run.

While CMS has the authority to make such policy changes, the question remains: should they? The decision appears to prioritize political ideology over evidence-based policymaking and the well-being of vulnerable populations. It undermines years of progress in addressing social determinants of health and threatens to reverse gains made in health equity. This move may prove to be fiscally irresponsible in the long term, potentially leading to increased hospitalizations and higher overall healthcare costs.

The CMS decision exemplifies a dangerous disconnect between policymaking and on-the-ground realities. Policymakers must recognize that destabilizing HRSN frameworks doesn’t just impact budgets—it sabotages the professionals safeguarding child health at society’s most vulnerable intersections.

The rescission of HRSN guidance is a stark reminder that the pursuit of policy power should never come at the expense of people’s lives. By choosing to dismantle these vital programs, policymakers are not just making a policy decision—they are making choices about who will suffer the consequences, and that choice will be felt for generations to come.