Every year, millions of American schoolchildren sit in a gym or hallway and get screened for vision problems, hearing loss, or cavities. 

A nurse or technician runs through the protocol. Some kids pass. Some don’t. The ones who don’t get a slip of paper telling their parents to follow up with a doctor.

And then, for most of those children, the trail goes cold.

The lack of data about what happens to children flagged for follow-up is not a failure of individual programs or overworked school nurses. It is a design problem built into the architecture of school health screening across three of its most common programs: vision, hearing, and dental. 

Most school health programs operate under a detect-and-refer model, meaning the program’s job is to find a potential problem and point families toward care. What happens after that point is largely invisible to the data systems’ we rely on to tell us whether these programs are working.

Now, as federal policymakers debate what it means to collect equity-focused data in schools, it is worth asking a question that rarely gets asked: Are school health programs generating data capable of answering equity-related questions? 

Even where federal programs exist, the follow-up gap is striking. 

If a screening system documents referrals but not outcomes, disaggregating that data by sex or race/ethnicity will tell you who got a slip of paper, not who got care. Equity-focused analysis of incomplete data does not produce equity; it produces the appearance of it.

The detect-and-refer model is not going away. But the monitoring systems built around it need to be redesigned with equity built in from the start. Until that happens, we will keep sending referral slips home and children will continue to fall through the cracks.

How the Data Gets Made

The federal government has invested meaningfully in school health screenings. The Early Hearing Detection and Intervention (EHDI) Act, reauthorized in 2022, funds state programs to screen children for hearing loss and connect them to early intervention services. 

The proposed Early Detection of Vision Impairments for Children (EDVI) Act, reintroduced in 2025, would establish the first federal program dedicated to children’s vision, explicitly modeled after EHDI (H.R. 2527, 119th Congress).

Dental screening has no equivalent federal infrastructure; twelve states mandate it, but none require tracking what happens after a referral is issued.

Even where federal programs exist, the follow-up gap is striking. 

In dental care, disparities in access and utilization persist for Black children at every income level, meaning the problem is structural, not just economic.

A 2025 Government Accountability Office report on the hearing program found that while 96% of infants are screened, fewer than half receive timely diagnostic follow-up after a failed screen, and the agency could not determine whether any state’s equity efforts had worked because states were never required to set measurable goals.

For vision, despite more than 80% of U.S. states mandating school-based vision screenings, disparities persist in who receives screenings and who follows up on referrals. Race, ethnicity, and socioeconomic status shape outcomes at every step.

And for dental, only 19% of low-income children referred after a school screening received follow-up care.

The children falling through this gap are not falling randomly. Black and Hispanic children present to vision screenings with higher rates of visual impairment and less prior eye care than their white peers.

In a national sample, Black and Mexican American adolescents have three times the odds of reporting poor vision and twice the odds of presenting with visual acuity worse than 20/40 compared to non-Hispanic white adolescents.

A 2025 study of New Jersey’s EHDI program found Black infants were significantly more likely to be lost to follow-up than white infants, even after controlling for social determinants of health.

In dental care, disparities in access and utilization persist for Black children at every income level, meaning the problem is structural, not just economic.

So we have programs designed to detect but not follow through, and evidence that the children most likely to need follow-through are the least likely to receive it. What we do not have, in almost any of these systems, is data broken down by sex.

This is where the problem gets particularly timely. My doctoral research at Drexel University’s Dornsife School of Public Health examined school-based vision screening programs across three provider organizations in Philadelphia, serving more than 17,000 students in 87 public schools. 

What I found was that the monitoring systems built to track these vision programs reflect program workflows rather than health equity outcomes. Nobody was asking whether males, females, or other gender minorities were being referred at different rates, following up at different rates, or receiving different recommendations. The data infrastructure was not built to answer those questions. This reflected a national pattern in school-based vision screenings; a systematic review showed sex being used more as a descriptive variable more than anything.

To date, no equivalent peer-reviewed analysis of sex-disaggregated outcomes exists for school-based hearing or dental screening programs in the U.S., a missing piece of scholarship that is itself part of the problem. The question has not been asked because the systems were never designed to answer it.

A Way Forward

The monitoring systems behind school health screening programs need to be redesigned with equity built in from the start. Researchers Rosemary Morgan and colleagues at Johns Hopkins have laid out what that can look like in practice: moving beyond simply counting who was screened towards asking who followed up, who got care, and whether outcomes differed by sex, race, or income. 

That framework has been applied to vision screenings in the school district of Philadelphia, where it revealed exactly the kind of gaps described above. For hearing and dental, it has not been applied at all yet.

The children following through these cracks are not hard to find. They are hard to count because nobody built a system to look for them yet.

At the federal level, Congress should pass the EDVI Act to give vision screenings the same national infrastructure that hearing has had for over two decades. For dental, no equivalent federal program exists yet at all, and that gap needs to be closed. Both programs also need to be required to track what happens after the referral slip goes home, and not just whether a child was screened.

For researchers, the most glaring gap is that we do not have a national picture of sex/gender-disaggregated outcomes for school-based hearing or dental screenings programs in the United States. A systematic review of what data exists across these programs and what it does and does not capture would be a meaningful starting point. 

Without this evidence case, any federal push toward equity-focused data collection in these programs will be building on a foundation that nobody has actually examined yet.

Lastly, for parents, if your child was screened at school and you followed up, tell the school nurses. If your child got glasses, saw an audiologist, or had a dental appointment, notify the school. That information almost never makes it back into the program’s data system, which widens the gap even more about whether a referral slip worked. 

The children following through these cracks are not hard to find. They are hard to count because nobody built a system to look for them yet.