In the United States, medical bills cause 60 percent of all bankruptcies. Worse, premiums are rising faster than both wages and inflation, and they show no sign of slowing. Though college students may sometimes be dismissed as a privileged, carefree group that doesn’t need to worry about health insurance, the reality is far from that. The commonly repeated aphorism is just as relevant to college students as the rest of the population: In the United States, you’re just one major illness away from financial ruin.
Our country is on the brink of historic change. Two months ago, the House of Representatives passed a bill proposing a far-reaching overhaul of the nation’s health care system; last month, the Senate followed suit with a modified health care reform bill of its own. When the Senate returns to session on January 19, Democrats will work to reconcile the differences between the two bills and enact a total health care overhaul in time for President Obama’s State of the Union address at the end of this month. Extending coverage to an estimated 31 million individuals and reshaping one-sixth of the nation’s economy over the next decade, the proposed changes in both bills will affect virtually every American.
Although there is a great deal of debate on many aspects of health care reform, one thing is clear: There is plenty of room for improvement in our current system, both on a national level and here at RIT.
Insurance Limbo Land
“Do you have insurance?” Dr. Brooke Durland, RIT Medical Director, asks students coming into the Student Health Center. The answer is often a shrug, saying, “I don’t know. I guess so.” Durland will then go through every card in the student’s wallet, or call his or her parents. Sometimes, insurance information is listed on a student’s freshman year health history form, but it may be outdated.
“Part of our challenge is we have young adults who haven’t necessarily had to deal with the health care system or manage insurance,” said Durland. “So as we’re trying to provide care and evaluate a problem, we’re also trying to educate them ... Part of our job is helping students become more savvy about being an educated healthcare consumer.”
For many students, college marks a period of transition from dependence to independence. Many leave their childhood homes, entering an environment where they may be exposed to drinking, drug use, and/or risky sexual behavior for the first time. On top of this, chronic sleep deprivation and high levels of stress make for a population with a unique set of health concerns.
According to the Commonwealth Fund, a nonprofit research organization, young adults are the fastest growing age group among people who lack health insurance in the United States. They are disproportionately represented among the uninsured, and nearly two out of every five college graduates can expect to spend at least some time uninsured within their first year after graduation.
“There are many plans that cover children,” said Durland. “But then at the magic age of 18, they’re no longer children. And if they’re fortunate enough to be in college but their parents aren’t covered on a work related plan, then they’re in this limbo land until they can find a job that then covers them.”
Within this limbo land, the Government Accountability Office estimates that approximately 1.7 million (20 percent) college students aged 18 through 23 were uninsured in 2006. Since nearly 40 percent of college students are 25 and older, however, this significantly underestimates the uninsured college student population. Including those 24 and older, the total number of uninsured college students is estimated to fall somewhere between 4 and 5 million — the largest, cohesive group of uninsured Americans.
The Uninsured Student
Although most college students are young and healthy, Durland stresses that health insurance is still an important concern. Aside from the high costs that a student can incur, “I’ve seen the consequences and the life choices that people make when they don’t have insurance. It doesn’t encourage preventative medicine. It doesn’t encourage taking care of known and identified health problems at early stages to prevent the consequences.”
To Durland, what happens in college life reflects what is going on in the workplace outside of college life. “As insurance has become more expensive, fewer employers are offering it. It becomes less affordable [for families] to purchase when an employer is not helping subsidize it, and so we’ve seen larger numbers of students uninsured.” The same applies when a family member is laid off; oftentimes, students do not think to purchase health insurance of their own once they have lost coverage under their parents’ plan.
Even with parent coverage, the abundance of five-year programs here means that it is common for students to “age out” of their parents policies during their time at RIT. Since September of this year, New York has allowed unmarried young adults who are not eligible for employer-sponsored insurance to be covered under a parent’s group health insurance policy through the age of 29. Outside of New York, however, there’s little standardization in the age cutoff. As such, it is difficult for the SHC to advise students on their individual plans; typically, students must call their insurers directly if they have any questions about coverage. In the House bill, coverage is extended until 27; in the Senate bill, 26.
Another common issue at the SHC is insurance with geographic restrictions. Medicaid, for example, a common source of insurance for NTID students, is a state supported insurance plan that will not cover expenses that occur outside of a student’s home state.
“If there were some screening process where people had to submit their insurance coverage before they got here, then those individuals could plan for the additional cost of insurance before they got here,” said Durland. Under the current system, however, many students go uncovered.
“It’s very difficult once [a student is] here to encourage them to then fork over another 700 some dollars for another insurance policy.” While most commercial health insurance plans will say that they cover emergencies out-of-area, the definition of “area” is variable and the definition of “emergency” is typically not stated. If students want to know what they can expect to receive coverage for, it is important to ask insurers to tell them about their policies in very specific details.
Student Health Insurance at RIT
At the present time, RIT offers students a Student Accident and Sickness Insurance Program, underwritten by the Aetna Life Insurance Company. The annual premium is $780 for 2009-2010 and is fully voluntary for domestic students. Certain international students are automatically enrolled in RIT’s basic plan, with a semi-annual rate of $390.
During fall quarter of this year, there were 1,436 students (1,130 international and 306 domestic) enrolled in the school-sponsored plan. Over the next three quarters, several hundred more students are expected to enroll on a quarterly version of the plan. The institute does not regularly collect data on how many students are covered by outside insurance, but GAO research has shown a nationwide average of 67 percent of college students to be covered under employer-sponsored plans (mostly as dependents on a parent’s policy), and an average of 6 percent covered by state programs such as Medicaid.
RIT requires all registered students to carry medical insurance, but as Durland noted, “It is mandatory, but it’s mandatory without any consequence. There’s no structure for following up on that.” Incoming freshmen receive a questionnaire asking for their insurance information, but there are no formal checks in place after the form is released.
“For us to check 16,000 people to see if they have insurance in place would be impossible” said Melinda Ward, Director of Risk Management & Insurance at RIT. “I mean, to track it — you could come in with insurance and cancel it the next day. There’s really no good way to make sure. We state that it’s mandatory.” The current check is part of a letter mailed out to students in the summertime before the fall quarter.
Prior to 2004, RIT students were automatically enrolled in the student health insurance program offered by the Institute. Opting out required a hard waiver and proof of insurance. Since then, the institute has moved to an opt-in program — a change that was neither initiated, nor recommended, by the SHC.
A benefit of the hard waiver policy was that it “required students to think about it, consider it, and take it off if they didn’t want it there,” said Durland. Now that it is gone, the number of insured students has drastically dropped.
Ward attributes the policy change to a desire within the Institute to simplify paperwork for incoming students. “Some parents didn’t like having to actually fill out an extra form to get out of insurance that they already had. This way it’s completely voluntary.” With the summer mail sent out, students are made aware of the program that RIT group purchases and it becomes completely voluntary whether or not to enroll. “If you already have insurance and you don’t need it, you don’t care for it; then we’re not making you do an additional waiver. You know, one more piece of paperwork that was irritating to people. I think that’s ultimately why the decision was made.”
A Costly Conundrum
Since switching to the opt-in policy, RIT has seen a sharp drop in participation rates — two or three fold, according to Durland. Because of this, premiums rose a substantial amount, more than doubling in the first three years on the new plan.
A July 2006 article in “The Chronicle for Higher Education” explains:
“Unlike traditional insurance plans, which spread risk over a large group of participants, student plans tend to have low participation rates. Because 10 percent of private colleges and 75 percent of public colleges do not require students to have health insurance, insurers must deal with the conundrum of ‘adverse selection’ — only those students who expect to use health insurance choose to enroll ... When only a small proportion of students enrolls, the cost of paying out claims rises, and premiums go up. And that, in turn, tends to reduce the number of students who buy insurance, spreading risk across an even smaller group. The plan becomes even more expensive, and more students drop out.”
In the last couple years, RIT insurance price increases have leveled off. This past year, it rose only 8.3 percent, from $720 to $780. Compared to the rising costs of health care nationwide (an average of $2,985 for a single coverage, up from $2,613, an increase of 14.2 percent), Ward noted that RIT has been very successful at managing these increases. RIT monitors the performance of the student health insurance plan on a monthly basis and works very closely with their insurance broker to keep costs down. Every three to five years, Global Risk Management reevaluates the options on the market, going out to bid for both an agency and a broker. A committee including representatives from the SHC reviews the plan and benchmarks against similar schools to ensure that RIT students are receiving an appropriate amount of coverage while keeping the overall cost down.
Ward stresses that the school is not profiting from their health insurance. “We don’t require kids to buy our program. It’s completely voluntary. There’s obviously no kickback whatsoever. We really are just kind of a run-through. We help negotiate the contract, we make it available. If students want to buy it, they go online, they purchase it, they either put it on a student account, or they pay for it themselves. We’re just the buying center for that policy.”
The Future of Health Insurance
As the situation continues to evolve, it is difficult to predict exactly how the outcome of the health care debate will impact college students. During the early stages of the health care debate, many colleges were concerned that student health insurance plans were going to be completely eliminated. A prominent bill known as “America’s Healthy Future Act of 2009,” used unclear and ambiguous language, prompting the American College Health Association to request clarification from the Senate Finance Committee on what the changes would mean for college sponsored student health insurance plans. The Committee assured them that college plans would not be restricted. “That was a concern for us initially,” said Ward, “but we’re monitoring that situation and we don’t think that that’s going to be an issue for us going forward.”
One item that is likely to be an issue for students: required health insurance, enforced by the government. Both the House and Senate bills require nearly all Americans to obtain health insurance or pay financial penalties for failing to do so. In the short term, this may cost students money, especially if they are presently uninsured. Over the long term, however, the broader insurance pool along with the proposed extension of dependent coverage is expected to help students save money.
In the end, reining in medical costs remains both a driving factor behind health care reform as well as one of the biggest hangups of today’s debate. “If you project 5, 10, 15, 20 years in the future, your generation is going to be really, really impacted in terms of that trickle down into employment and hiring,” said Durland. “What I do believe is accurate is that something has to be done. There have to be reforms because the costs of healthcare are escalating at a rate that is unsupportable.” Ultimately, this may be the area where college students have the most to gain; if some sort of reform does not happen, it is our generation that will be forced to pay.