Health Insurance: Most College Students Are Covered through Employer-Sponsored Plans, and Some Colleges and States Are Taking Steps to Increase Coverage
Published: 2008-03-28T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: College students face challenges obtaining health insurance--they may not have access to insurance through an employer, and as they get older, they may lose dependent coverage obtained through a parent's plan. Federal law ensures continued access to health insurance for some, but not all, such students. Without health insurance, college students may be unable to pay for their health care, and the cost of this care may be passed on to federal and state payers, such as Medicaid. College students may have access to student insurance plans offered by their colleges. GAO was asked to report on uninsured college students, student insurance plans, and efforts to increase the number of insured students. GAO reviewed (1) college students' insurance status, (2) uninsured college students' characteristics, (3) the extent to which colleges offered student insurance plans and the characteristics of available plans, and (4) efforts to increase the number of insured students. GAO analyzed data from a national survey on college students' insurance status and uninsured college students' characteristics. GAO collected data from 340 colleges on the availability of student insurance plans and the characteristics of available plans, and also gathered detailed plan information from case studies of 10 colleges and interviews with experts and insurance industry officials. GAO also reviewed some states' laws.
section_title: What GAO Found
paragraphs: About 80 percent of college students aged 18 through 23 had health insurance in 2006. While 67 percent of college students were covered through employer-sponsored plans, 7 percent were covered through other private health insurance plans, such as student insurance plans, and 6 percent were covered by public programs, such as Medicaid. Most insured students were covered, for example, as a dependent, on a policy under another person's name. About 20 percent of college students aged 18 through 23 (1.7 million) were uninsured in 2006, and certain groups of students--such as part-time students, nonwhite students, and students from families with lower incomes--were more likely than others to be uninsured. The characteristics of uninsured students are consistent with those of the uninsured found in the general U.S. population. Over half of colleges nationwide offered student insurance plans in the 2007-2008 academic year, and plans' benefits varied. Colleges customized their plans to reflect their priorities in making premiums affordable for students while providing coverage that meets students' needs. The plans GAO reviewed varied in the services they covered and how they paid for covered services. Specifically, some plans excluded preventive services from coverage and some plans limited payment for benefits such as prescription drugs. In addition, plans also varied in terms of premiums and maximum benefits, with annual premiums ranging from $30 to $2,400 and maximum benefits ranging from $2,500 for each illness or injury to unlimited lifetime coverage. Colleges and states have taken a variety of steps to increase the number of insured college students. For example, GAO estimated that about 30 percent of colleges nationwide required students to have health insurance in academic year 2007-2008, and some states also have health insurance requirements for college students. Finally, some states have expanded dependents' eligibility for private health insurance, which makes insurance more available to college students who obtain coverage as dependents. Officials from the American College Health Association (ACHA)--an advocacy and leadership organization for college and university health--provided a technical comment, which we incorporated.

section_title: Letter
paragraphs: College students face challenges obtaining health insurance. They may not  have access to insurance provided through an employer or may lose  coverage they obtained through a parent’s plan. For example, as college  students get older, they may be unable to retain coverage as a dependent  child on their parent’s plan. While provisions of the Consolidated Omnibus  Budget Reconciliation Act of 1985 (COBRA) and the Health Insurance  Portability and Accountability Act of 1996 (HIPAA) ensure access to health  insurance for certain individuals, such as college students who lose or  change their source of coverage, these provisions are limited.1, 2 Without health insurance, college students may face adverse  consequences. Like other uninsured individuals, uninsured college  students may be more likely to forgo needed health care, face problems  accessing health services, and incur high-cost health care expenses. When  uninsured college students are unable to pay for the health care services  they receive, the cost of their care may be absorbed by providers, who in  turn attempt to recover these costs from the insured population in the  form of increased fees and insurance premiums, or from federal and state  payers, such as Medicaid.
College students may have access to a unique source of health insurance  coverage—plans offered by colleges to their students. These student  insurance plans may be a means to increase the number of insured college  students. However, it is unclear how many colleges offer these plans and  what type of coverage the plans provide.
COBRA, Pub. L. No. 99-272, 100 Stat. 82 (1986) (codified as amended in scattered sections  of 26, 29, and 42 U.S.C.).
HIPAA, Pub. L. No. 104-191, 110 Stat. 1936 (codified as amended in scattered titles of  U.S.C.).
You asked for information on uninsured college students, student  insurance plans, and other efforts to provide health insurance for college  students. This report describes (1) the insurance status of college  students, (2) characteristics of uninsured college students and the  financial impact of this population on health care systems, (3) the extent  to which colleges offered student insurance plans in the 2007-2008  academic year and the characteristics of available plans, and (4) efforts to  increase the number of insured college students.
To describe the insurance status of college students, we analyzed data  from the U.S Census Bureau’s 2007 Annual Social and Economic  Supplement to the Current Population Survey (CPS) on the sources of  health insurance used by college students aged 18 through 23 in 2006. To  describe the characteristics of uninsured college students, we analyzed  CPS data on the demographic characteristics of insured and uninsured  college students aged 18 through 23 in 2006. To describe the financial  impact of the uninsured college student population on health care  systems, we estimated the amount of uncompensated care uninsured  students incurred. To do this, we analyzed 2005 Medical Expenditure  Panel Survey (MEPS) data from the Department of Health and Human  Services—the most current data available at the time we performed our  work—on the amount and types of non-injury-related uncompensated care  incurred by college students aged 18 through 23 who were uninsured for  all or part of 2005. Uninsured college students may also incur  uncompensated care for medical events related to injuries. However, our  estimate does not include uncompensated care for injury-related medical  events because we could not reliably estimate the cost of this care. As a  result, our estimate understates the total amount of uncompensated care  incurred by uninsured college students in 2005.
About 93 percent of all undergraduate students at active U.S. colleges that participated in  Title IV federal financial student aid programs in 2006 attended 2-year public, 4-year public,  or 4 year private nonprofit colleges with an undergraduate enrollment of at least 200. In  addition, 70 percent of all active U.S. colleges that participated in Title IV programs and  had enrollments of at least 200 undergraduates in 2006 were either 2-year public colleges  (28 percent), 4-year public colleges (15 percent), or 4-year private nonprofit colleges   (28 percent). We excluded private for-profit colleges, 2-year private colleges, and all  colleges with enrollments of less than 200 students from our sample because, collectively,  they enrolled a small percentage (7 percent) of all undergraduate college students.
Pub. L. No. 89-329, §§ 401-467, 79 Stat. 1219, 1232-54 (codified as amended at 20 U.S.C.   §§ 1070-1099c-2).
2006 national employer health benefits surveys and a 2007 national  individual market survey.
To describe efforts to increase the number of insured college students, we  reviewed published reports and interviewed insurance industry officials to  identify and describe efforts that would either directly increase the  number of insured college students aged 18 through 23 or would increase  the availability of insurance for all or most college students aged 18  through 23. To describe these efforts in detail, we collected data from our  random sample of 340 colleges on colleges’ health insurance requirements  and participation in consortiums to purchase health insurance. We also  reviewed relevant state laws and higher education governing board  policies.
The results from our analyses of CPS and MEPS and our collection of data  on the availability of student health insurance and the health insurance  requirements at colleges are generalizable to certain populations, as noted  in earlier text. While some of our results are generalizable, other results,  such as those related to the characteristics of college student insurance  plans, are not. We reviewed all data for reasonableness and consistency  and determined that the data were sufficiently reliable for our purposes.  We performed our work in accordance with generally accepted  government auditing standards from May 2007 through March 2008.  Appendix I provides more detailed information on our methodology and  the characteristics and limitations of the data we report.
subsections: section_title: Background
paragraphs: College students have several options for obtaining health insurance. They  may obtain private health insurance through group market plans offered  by employers, colleges, and other groups or through individual market  plans. In addition, some college students may obtain coverage through  public health insurance programs, such as Medicaid or the State Children’s  Health Insurance Program (SCHIP).
subsections: section_title: Health Insurance Options for College Students
paragraphs: College students may obtain health insurance through employer- sponsored group market plans, which are plans employers offer to their  employees and their dependents. Under these plans, employers typically  subsidize a share of employees’ premiums for health insurance, and  premiums are calculated based on the risk characteristics of the entire  group. To offer health insurance, employers either purchase coverage  from an insurance carrier or fund their own plans. All plans purchased  from insurance carriers must meet state requirements, which vary by state.  For example, some states require employer-sponsored plans purchased  from insurance carriers to offer coverage to dependents. Although  requirements for dependent coverage vary by state, plans have  traditionally offered health insurance coverage for dependents through  age 18, and have generally continued coverage for dependents through age  22 only if they attend college full-time.
Under federal law, college students who have lost eligibility for dependent  coverage under a parent’s employer-sponsored insurance plan may be able  to use provisions in COBRA to continue their health insurance for a  limited period of time. Specifically, COBRA allows individuals such as  college students who have lost eligibility for dependent coverage the  option of purchasing up to 36 months of continuation coverage under the  employer-sponsored plan. COBRA does not require employers to pay for  or subsidize this continuation coverage, which can appear expensive in  contrast to the subsidized premiums that employees and their dependents  may be accustomed to paying for employer-sponsored coverage. COBRA  permits employers to charge 100 percent of the premium, plus an  additional 2 percent administrative fee.
College students may obtain health insurance through health insurance  plans offered by other groups such as their college. Colleges offer health  insurance plans to students because they have an interest in maintaining  the health of their students and helping them achieve their educational  objectives. These plans also can help students avoid high medical bills. To  offer a health insurance plan, colleges either contract with an insurance  carrier or fund their own plans. Unlike enrollees of employer-sponsored  plans, those enrolled in student insurance plans typically pay the full  premium for coverage. To make decisions about the plan’s eligibility  criteria, benefits, and premiums, colleges typically convene a student  health insurance committee, which generally includes college  administrators, student health center administrators, and student  representatives. These committees decide how the student insurance plan  will coordinate with a college’s student health center, if one exists. College  student health centers vary greatly in the services they provide—some  offer limited services from one nurse, and others offer extensive services  from multiple specialists. The committees may also consider college  student insurance program standards issued by ACHA. Among other  things, these standards suggest that colleges require students to have  health insurance as a condition of enrollment, and that student insurance  plans provide an appropriate level of benefits, including coverage of  preventive services and mental health services and coverage for  catastrophic illnesses or injuries.
College students may also obtain health insurance through individual  market plans, which are plans sold by insurance carriers to individuals  who do not receive coverage through an employer, college, or other group.  Because these plans are offered by insurance carriers, the plans must meet  state requirements, including those regarding eligibility for dependent  coverage. Individuals purchasing a health insurance plan in the individual  market typically pay the full cost of their health care premium. Insurance  carriers who sell plans in the individual market are typically allowed to  review the health status of each individual applying for insurance. Unlike  the employer-sponsored group market where premiums are based on the  risk characteristics of the entire group, premiums for individual market  coverage are based on factors associated with differences in each  applicant’s expected health care costs, such as health status, age, and  gender. Furthermore, applicants for individual market coverage may be  rejected.
Some college students may be able to obtain health insurance in the  individual market as a result of protections established by HIPAA.  Specifically, HIPAA protects eligible individuals, including college  students who have exhausted COBRA continuation coverage, by requiring  insurance carriers to offer individual market plans without a waiting  period for coverage of preexisting conditions. HIPAA also protects  eligible college students who were previously and continuously covered by  a group market plan and are seeking coverage under a different group  market plan. For these individuals, HIPAA requires insurance carriers to  limit the use of waiting periods for coverage of preexisting conditions to  no more than 12 months.
In addition to private sources of health insurance, college students may  obtain health insurance coverage through public health insurance  programs, such as Medicaid or SCHIP. Some college students may have  coverage through Medicaid, a joint federal-state program that finances  health care coverage for certain low-income families, children, pregnant  women, and individuals who are aged or disabled. Federal law requires  states to extend Medicaid eligibility to children aged 6 through 18 in  families with incomes at or below the federal poverty level. Some college  students may have coverage through SCHIP, which provides health care  coverage to low-income children through age 18 who live in families  whose incomes exceed their state’s eligibility threshold for Medicaid and  who do not have insurance through another source.
section_title: About 80 Percent of College Students Had Health Insurance in 2006, and Most Were Covered through Employer-Sponsored Plans
paragraphs: This estimate is within plus or minus 133,000 of the population value at a 95 percent  confidence level.
Compared with college students aged 18 through 23, young adults not enrolled in college  were more than twice as likely to be uninsured. Specifically, about 42 percent of  nonstudents aged 18 through 23 were uninsured in 2006.
section_title: Certain Groups of College Students Were More Likely to Be Uninsured in 2006, and Uninsured Students Incurred $120 Million to $255 Million in Uncompensated Care for Non-Injury- Related Medical Events in 2005
paragraphs: Of the 1.7 million college students aged 18 through 23 who were uninsured  in 2006, certain groups of students were more likely than others to be  uninsured; and uninsured students incurred from $120 million to   $255 million in uncompensated care for non-injury-related medical events  in 2005. In particular, we found that part-time students, older students, and  students from families with lower incomes were more likely than other  groups of students to be uninsured in 2006.
subsections: section_title: Certain Groups, Including Part-time Students and Older Students, Were More Likely Than Others to Be Uninsured in 2006
paragraphs: Of the 1.7 million college students aged 18 through 23 who were uninsured  in 2006, certain groups of students—including part-time students, older  students, and students from families with lower incomes—were more  likely than others to be uninsured. According to our analysis of CPS data  for 2006, we found that part-time students were more likely to be  uninsured than were full-time students. Specifically, 31 percent of part- time students aged 18 through 23 were uninsured in 2006, compared with  18 percent of full-time students of the same age. In addition, CPS data  show that older college students—those aged 22 and 23—were more likely  to be uninsured in 2006 than younger students aged 18 through 21.  Specifically, about 35 percent of college students aged 23 and 25 percent  of college students aged 22 were uninsured in 2006, in comparison with 16  to 19 percent of college students aged 18 through 21 who were uninsured  in 2006. (See fig. 2.)
College students of certain racial and ethnic backgrounds—specifically,  Hispanic, black, and Asian students—were more likely to be uninsured  than white students in 2006, according to our analysis of CPS data.  Specifically, we found that 38 percent of Hispanic, 29 percent of black,  and 26 percent of Asian college students aged 18 through 23 were  uninsured in 2006—in contrast with 15 percent of white college students  of this age group who were uninsured in 2006. (See fig. 3.) These  differences among uninsured college students from different racial and  ethnic backgrounds are consistent with characteristics of the uninsured  found in the general U.S. population. According to the U.S. Census Bureau,  Hispanic, black, and Asian individuals were more likely to be uninsured in  2006 than were whites.
In 2006, college students reporting lower family incomes were more likely  to be uninsured than college students reporting higher incomes that year.  Specifically, according to our analysis of CPS data, the average family  income for uninsured college students aged 18 through 23 was about  $52,000 in 2006, whereas the average family income for insured college  students was significantly higher—about $95,000. This difference in  income among uninsured college students is consistent with  characteristics of the uninsured found in the general U.S. population.  According to the U.S. Census Bureau, the likelihood of having health  insurance rises with income.
Based on our analysis of CPS data we also found that college students  aged 18 through 23 from states in the West and South of the country were  more likely to be uninsured in 2006 than students from states in the  Northeast and the Midwest. Specifically, about 22 percent of college  students aged 18 through 23 from states in the West and about 23 percent  of students from states in the South were uninsured in 2006, whereas  about 15 percent of college students from states in the Midwest and   18 percent of students from states in the Northeast were uninsured that  year, according to our analysis of CPS data for 2006. These differences  among uninsured college students from different regions are consistent  with characteristics of the uninsured found in the general U.S. population.  According to the U.S. Census Bureau, individuals from states in the South  and West were more likely to be uninsured in 2006 than were individuals  from states in the Midwest and Northeast.
section_title: Uninsured College Students Incurred from $120 Million to $255 Million in Uncompensated Care for Non-Injury-Related Medical Events in 2005
paragraphs: According to our analysis of MEPS data, uninsured college students  incurred from $120 million to $255 million in uncompensated care for  non-injury-related medical events during 2005. About 18 percent of  uninsured college students aged 18 through 23 incurred uncompensated  care in 2005, according to our analysis of MEPS data. Most of the charges  for non-injury-related uncompensated care incurred in 2005 by uninsured  college students were through visits to office-based providers and hospital  emergency rooms. Uninsured college students may also incur  uncompensated care for medical events related to injuries that our  estimate does not reflect because we could not reliably determine the cost  of this care. As a result, our estimate understates the total amount of  uncompensated care incurred by uninsured college students in 2005.
section_title: Over Half of Colleges Offered Student Insurance Plans in Academic Year 2007- 2008, and These Plans Were Customized and Plan Benefits Varied
paragraphs: Over half of colleges nationwide offered health insurance plans to their  students in the 2007-2008 academic year, and these plans were customized  and benefits varied across plans. We found that 4-year public and private  nonprofit colleges were more likely to offer student insurance plans than  were 2-year public colleges. Colleges that offered student insurance plans  often limited access to the plan for part-time students in an effort to  maintain premium affordability and plan sustainability. Colleges customize  their student health insurance plans to reflect their priorities in making  insurance premiums affordable for students while still offering plans that  meet the needs of students. Colleges’ student insurance plans are also  customized to coordinate in a variety of ways with colleges’ on-campus  student health centers. The benefits offered by student insurance plans  varied in terms of the services they covered and the extent to which they  paid for or limited payment for covered services.
subsections: section_title: Over Half of Colleges Offered Student Insurance Plans in Academic Year 2007-2008, with Some Types of Colleges More Likely Than Others to Offer Plans
paragraphs: Over half of colleges nationwide offered health insurance plans to their  students in the 2007-2008 academic year. Based on our review of a  random, generalizable sample of 340 colleges, 194 colleges offered student  insurance plans in the 2007-2008 academic year, and therefore we estimate  that about 57 percent of colleges nationwide offered student insurance  plans in the 2007-2008 academic year. The remaining 43 percent of colleges  did not offer student insurance plans, though some of these colleges  distributed information to their students on other sources of health  insurance, such as plans sold in the individual market.
Certain types of colleges were more likely than others to offer student  insurance plans. In particular, 4-year public colleges were more likely to  offer student insurance plans than other types of colleges in the 2007-2008  academic year. Based on our review of 340 colleges, we estimate that   82 percent of 4-year public colleges nationwide offered student insurance  plans in the 2007-2008 academic year, compared with 71 percent of 4-year  private, nonprofit colleges and 29 percent of 2-year public colleges. (See  table 1.)
Large colleges were more likely to offer student insurance plans than  medium-sized colleges. Specifically, we estimate that 64 percent of large  colleges (those with over 5,000 undergraduate students) nationwide  offered student insurance plans in the 2007-2008 academic year, compared  with 52 percent of medium-sized colleges (those with 1,501 to 5,000  undergraduate students). (See table 2.) No other differences in the  percentage of colleges, by size, that offered student insurance plans were  statistically significant.
We also found that colleges offering the student insurance plans we  reviewed varied in the extent that they made these plans available to their  part-time students. Most—151 of the 165—colleges that made  information available about part-time student eligibility for the plans we  reviewed made their plans available to at least some part-time students in  the 2007-2008 academic year. Specifically, about 30 percent of these  colleges made the plans available to all their part-time students, and   61 percent made these plans available to some part-time students (see   fig. 4).
Colleges often limit eligibility for their health insurance plans for part-time  students by setting a minimum number of credit hours that students must  maintain in order to be eligible for the insurance. Of the eight colleges we  reviewed in our case studies that had part-time students, seven colleges  required students to enroll in a minimum number of credit hours before  they could become eligible for their student insurance plans. Six of these  seven colleges required students to enroll in six or more credits to  establish eligibility for their student insurance plans.
Colleges may limit part-time students’ eligibility for student insurance in  an effort to maintain premium affordability and plan sustainability.  According to college administrators we interviewed, colleges that allow all  part-time students to access the student insurance plan may find that  individuals with medical conditions associated with high costs will enroll  in the college part-time in order to access the student insurance plan. This  could, over time, drive up costs for all students on the plan, resulting in a  plan that is less attractive to students and therefore more difficult to  sustain. In an effort to avoid this scenario, colleges may limit part-time  students’ access to the student insurance plan. For example, one college  we reviewed discovered that some of its student insurance plan enrollees  were senior citizens aged 60 to 70; these individuals registered in one- credit classes each semester to maintain eligibility for the insurance plan.  In response, the college tightened eligibility requirements for the plan by  allowing only degree-seeking students registered for a minimum number  of credit hours to enroll.
section_title: Student Insurance Plans Were Customized to Reflect Colleges’ Priorities, and Plan Benefits Varied
paragraphs: Student insurance plans were customized to reflect colleges’ priorities in  making health insurance premiums affordable for their students while at  the same time providing coverage that meets the needs of students.  College students typically pay the full premium for student insurance  plans, and college administrators we interviewed from most of the  colleges in our case studies explained that maintaining premium  affordability for their students is a priority. College administrators also  told us that they want to provide coverage that meets the needs of their  students so their students could avoid high medical bills and complete  their college education. When designing their plans, college administrators  vary in the extent to which they prioritize premium affordability over plan  benefits. For example, some plans we reviewed charged relatively low  annual premiums—$30 to $200. These plans also set relatively low limits  on the amount they pay for covered services—with some having limits as  low as $2,500 for each illness or injury. In contrast, other plans we  reviewed charged relatively higher premiums, set higher limits on the  amount they paid for covered services, and offered benefits such as  preventive services and prescription drugs. While college student  insurance plans offer varied combinations of premium levels and benefits,  a college’s ability to offer a plan with a specific package of premiums and  benefits is limited by several factors. For example, if a college receives  federal financial assistance, its plan will be required to comply with  applicable civil rights statutes. These requirements may affect the  variability of certain benefits or premiums. These factors also include the  plan’s historical claims experience—the amount the plan has paid in  claims and the number of claims paid per enrollee—and projected  enrollment in the plan.
We found that student insurance plan premiums varied widely, reflecting  the trade-offs colleges make in selecting plan premiums and benefits.  Specifically, for the academic year 2007-2008 student insurance plans we  reviewed that made information available about premiums, annual  premiums for plans ranged from about $30 to about $2,400, and the  average annual premium was about $850. Eighty-six of the 191 plans we  reviewed (45 percent) had annual premiums from $500 to $999. (See   fig. 5.)
Student insurance plans were also customized to coordinate with the  services available at a college’s student health center, if one exists. The  student insurance plans we reviewed in our case studies varied in the  ways that they coordinated with health centers. For example, we reviewed  some student insurance plans in our case studies that    covered certain services—for example prescription drugs—only at the  required students to use the health center before seeking outside care in  nonemergency situations;    provided students with financial incentives—such as reduced enrollee  cost sharing—to encourage use of the student health center instead of, or  before, seeking care from other providers; or   excluded services, such as preventive services, from coverage under the  insurance plan when the services were provided free, or at low cost, to  students at the health center.
While some plans coordinated with student health centers in various ways,  not all plans did so. In general, student insurance plans offered at colleges  with student health centers that provide more services may be able to  coordinate more with their health centers than can those offered at  colleges with health centers that offer more limited services. According to  insurance industry officials we interviewed, student insurance plans  coordinate with student health centers to provide services to students,  which can result in more affordable student insurance plan premiums.
The benefits offered by student insurance plans varied in terms of the  services they covered and the extent to which they paid for or limited  payment for covered services. Although the student health insurance plans  we reviewed in our case studies generally covered the same broad  categories of services—including hospital inpatient and emergency  services, physician’s office visits, mental health treatment, substance  abuse treatment, and prescription drug coverage—the plans varied with  respect to how they paid for or limited payment for services covered  within these categories. Some plans offered by colleges we reviewed in  our case studies limited coverage within the categories by excluding  treatment for specific services, and according to college administrators we  interviewed, this effort helps to keep premiums affordable. For example,  some other plans we reviewed excluded coverage for services such as  testing and treatment for allergies or treatment for injuries sustained as a  result of attempted suicide or while under the influence of drugs or  alcohol. Furthermore, according to our review of plans offered by colleges  in our case studies, plans also varied in the extent to which they covered  preventive services. One insurance industry official told us that student  insurance plans may exclude coverage for preventive services because  their plans are intended to cover treatment for illnesses and injuries—not  for wellness—and because doing so helps to keep plan premiums  affordable.
The student insurance plans we reviewed also varied widely in the total  amount—or maximum benefit—they would pay for all covered services.  Nearly all (96 percent) of the 194 student insurance plans we reviewed  established a maximum benefit amount, and most (68 percent) did so on  a per condition per lifetime basis. Under this type of plan, payments are  tallied for covered services treating each medical condition and the  maximum benefit amount renews for each condition. The maximum  benefit amounts for the 131 plans we reviewed that set a maximum benefit  on a per condition per lifetime basis ranged from $2,500 to $1 million per  condition per lifetime, with a median amount of $25,000. Sixty-nine of  these 131 plans (over half) had a maximum benefit amount less than  $30,000 per condition per lifetime, and 46 plans (35 percent) had a  maximum benefit amount of $50,000 per condition per lifetime. In  addition, 16 plans with a maximum benefit per condition per lifetime  established a maximum benefit amount greater than $50,000 per condition  per lifetime. (See fig. 6.)
While most student insurance plans we reviewed established a maximum  benefit amount per condition per lifetime, others set maximum benefit  amounts on a per condition per year, per year, or per lifetime basis. The  maximum benefit amounts set for these plans ranged from $2,500 per  condition per year to $1 million per lifetime. Figure 7 shows the  distribution of maximum benefit amounts, by type, for the student  insurance plans we reviewed. In addition, four other plans we reviewed  offered unlimited lifetime benefits.
The student insurance plans we reviewed also varied in how they limited  payment for and coverage of plan benefits. Some plans we reviewed  established limits (known as internal benefit limits) on the maximum  amount the plan would pay for a particular service or set of services. For  example, one plan we reviewed limited coverage for ambulance services  to $150 per condition per lifetime and another plan limited coverage of all  outpatient benefits (including doctor visits, emergency room visits, X-rays,  laboratory fees, radiation, and chemotherapy) to $1,200 per condition per  lifetime. Some plans we reviewed also used internal benefit limits to  constrain the number of visits covered for a particular service. For  example, we reviewed plans that limited coverage for outpatient doctor’s  visits to 10 visits per year or less. Some plans we reviewed set both  internal benefit limits and required enrollees to share in the cost of  covered services.
Low internal benefit limits can make it highly unlikely for enrollees’  coverage to meet the plan’s maximum benefit amount. For example, one  plan we reviewed in our case studies had a maximum benefit of $50,000  per condition per lifetime and an internal benefit limit of $1,200 per  condition per lifetime for all outpatient benefits, including coverage for  emergency services, diagnostic services, radiation, and chemotherapy.  Under this plan, students who require extensive outpatient services to  treat one condition (such as a chronic condition or serious illness like  cancer) would be unlikely to ever meet the $50,000 per condition per  lifetime maximum benefit amount.
section_title: Colleges and States Have Taken a Variety of Steps to Increase the Number of Insured College Students
paragraphs: To increase the number of insured college students, colleges and states  have taken a variety of steps, such as requiring students to have health  insurance. According to our analysis, we estimate that about 30 percent of  colleges nationwide required their students to have health insurance for  the 2007-2008 academic year and some types of colleges—such as 4-year  private nonprofit colleges—were more likely than others to have a health  insurance requirement. Like colleges, some states and higher education  governing boards have also required college students to have insurance.  Colleges and states have also taken other steps to increase the number of  insured college students. Specifically, colleges have jointly purchased  health insurance through consortiums, and states have expanded  dependents’ eligibility for private health insurance.
subsections: section_title: Some Colleges and States Have Required Students to Have Health Insurance
paragraphs: In order to increase the number of insured college students, some colleges  have required their students to have health insurance. Students attending  these colleges generally must enroll in the college student insurance plan  or present proof of coverage from another source. Based on our review  of health insurance requirements at a random, generalizable sample of 340  colleges, we estimate that about 30 percent of colleges nationwide  required all their full-time students to have health insurance for the 2007- 2008 academic year. In addition, 5 percent of colleges nationwide  required some of their full-time students to have health insurance—for  example, students living in dormitories or enrolled in certain degree  programs.
Some types of colleges were more likely than others to establish an  insurance requirement. Specifically, 4-year private nonprofit colleges were  most likely to require full-time students to have coverage, and 2-year  public colleges were least likely to require it. Based on our review of 340  colleges, we estimate that 62 percent of 4-year private nonprofit colleges  nationwide required all full-time students to have health insurance for the  2007-2008 academic year, whereas 22 percent of 4-year public colleges and  3 percent of 2-year public colleges had this requirement. (See table 3.)
Small colleges were generally more likely to require full-time students to  have health insurance than large colleges. We estimate that 40 percent of  colleges nationwide with 1,500 or fewer undergraduate students required  all full-time students to have health insurance for the 2007-2008 academic  year, whereas 16 percent of colleges nationwide with over 5,000 students  had such a requirement. (See table 4.)
In addition to increasing the proportion of students who are insured,  insurance industry officials we interviewed told us that colleges that  implement a health insurance requirement are generally able to offer a  plan with more comprehensive benefits or more affordable premiums.  According to insurance industry officials, more students enroll in college  student insurance plans when colleges require students to have health  insurance than when colleges do not have such a requirement.  Specifically, insurance industry officials we interviewed told us that from  15 to 40 percent of students enroll in student insurance plans offered by  colleges that have a health insurance requirement, whereas less than   10 percent of students enroll in plans that are offered by colleges without  such a requirement. In addition, students who enroll in plans offered by  colleges with health insurance requirements generally are healthier than  those who voluntarily enroll in plans offered by colleges without a  requirement. Because larger and healthier populations typically enroll in  student insurance plans offered by colleges with an insurance  requirement, these colleges are generally able to offer plans with more  comprehensive benefits or more affordable premiums than they would  otherwise have been able to offer if they did not have such a requirement.  For example, an administrator from one public college without a health  insurance requirement estimated that implementing such a requirement  could decrease student insurance plan premiums by as much as   50 percent.
Although requiring students to have health insurance can increase the  number of insured college students and allow the college to offer a more  attractive plan, colleges face challenges implementing such a requirement.  According to college administrators and insurance industry officials,  college administrators face challenges implementing a requirement  because doing so adds a fee to the total cost of attending college at a time  when many are concerned with the rising cost of attending college.  Administrators of public colleges are especially concerned about adding a  new fee because, as one insurance industry representative noted, public  colleges have lower annual tuition than private colleges, so the addition of  a health insurance premium to student fees results in a larger percentage  increase in the cost of attendance. According to college administrators we  interviewed, some colleges compete for students based on cost of  attendance and administrators of these colleges are concerned that  implementing a health insurance requirement would give them a  disadvantage in attracting students. Because of challenges in  implementing a requirement at the college level, some college  administrators and insurance industry officials would prefer to see such  requirements established by a higher authority, such as a state or higher  education governing board, or by a group of peer institutions in order to  “level the playing field” for colleges.
Some states and higher education governing boards have implemented  health insurance requirements for college students. For example,  Massachusetts and New Jersey require students attending college in their  states to have health insurance as a condition of enrollment.  Massachusetts, which implemented its requirement in 1989, requires all  students enrolled in college for at least three-quarters of full-time status to  either purchase a student insurance plan offered by their colleges or  present proof of comparable coverage. In 1991, New Jersey also began  requiring all full-time students attending college in the state to have health  insurance. Similar to states’ requirements, some higher education  governing boards, such as the Regents of the University of California and  the Idaho State Board of Education, have also implemented health  insurance requirements for college students within their respective state  postsecondary educational systems.
section_title: Some Colleges Have Jointly Purchased Health Insurance
paragraphs: Some colleges have jointly purchased health insurance through  consortiums, and this effort can increase the availability of health  insurance for college students and the number of students who are  insured. Consortiums are groups of colleges that join together to  participate in or pool resources for a common goal, such as purchasing.  Based on our review of published reports and student insurance plans and  our interviews with insurance industry officials, we identified 37  consortiums—comprising over 500 colleges—that jointly purchased  student health insurance plans in academic year 2007-2008. For example,  California’s 109 community colleges are part of a consortium known as the  Community College League of California, which jointly purchases student  health insurance. In addition, the Wisconsin Association of Independent  Colleges and Universities jointly purchases student health insurance for its  20 member colleges. We found that 32 percent of the 194 colleges we  reviewed that offered student insurance plans in academic year 2007-2008  purchased their plans through the consortiums we identified.51, 52 Consortiums provide small colleges and 2-year public colleges with a way  to purchase health insurance and offer it to their students when the  colleges may otherwise be unable to do so. While 2-year public colleges  were the least likely to offer student insurance plans for academic year  2007-2008, we found that 74 percent of the 2-year public colleges we  reviewed that offered plans purchased them through the consortiums we  identified.
section_title: Some States Have Expanded Dependents’ Eligibility for Private Health Insurance
paragraphs: Some states have expanded dependents’ eligibility for private health  insurance, and because most college students obtain health insurance as  dependents, this effort has made health insurance more available to  college students. Dependent coverage purchased through insurance  carriers must meet state requirements regarding eligibility for this  coverage. Although these requirements vary by state, plans have  traditionally offered health insurance coverage for dependents through  age 18, and have generally continued coverage for dependents through age  22 only if they attend college full-time.
Our analysis of the proportion of colleges that participate in consortiums may  underestimate the percentage of colleges that purchase student insurance through  consortiums because our list of colleges participating in consortiums is not comprehensive.
Most (48) of the 62 colleges we identified as purchasing health insurance through a  consortium did not require students to have insurance. addition, some states have made dependent coverage available beyond age  18 for those who are not full-time students. By doing so, states have  increased the availability of health insurance for part-time students and  those who need to leave college for any reason. For example, in 2006 and  2007, New Jersey and Connecticut passed laws requiring that dependent  coverage be available to certain state residents regardless of their student  enrollment status up to ages 30 and 26, respectively.
MICH. COMP. LAWS ANN. § 550.1409a (2007) (enacted by 2006 Mich. Pub. Acts 538  (effective 2007)). Michigan requires that dependent coverage be available for full-time and  part-time college students for up to 12 months up to the age at which dependent coverage  otherwise terminates when students take medical leaves of absence.
VA. CODE ANN. § 38.2-3525 (2007) (enacted by 2007 Va. Acts ch. 428). Virginia requires  that dependent coverage be available for college students for up to 12 months when  students up to age 25 take medical leaves of absence.
section_title: External Comments
paragraphs: We provided a draft of this report to ACHA, an advocacy and leadership  organization for college and university health. ACHA officials provided a  technical comment, which we incorporated.
We are sending copies of this report to interested congressional  committees. We will also provide copies to others on request. In addition,  the report will be available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staff have any questions on this report, please contact me at  (202) 512-7114 or at dickenj@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix II.
section_title: Appendix I: Scope and Methodology
paragraphs: We examined (1) the insurance status of college students,   (2) characteristics of uninsured college students and the financial impact  of this population on health care systems, (3) the extent to which colleges  offered student insurance plans in the 2007-2008 academic year and the  characteristics of available plans, and (4) efforts to increase the number of  insured college students. Unless otherwise noted, all of our estimates on  uninsured college students (from the Current Population Survey (CPS))  and uncompensated care (from the Medical Expenditure Panel Survey  (MEPS)) are subject to a sampling error of plus or minus 5 percentage  points, and all of our estimates on college student insurance plan  availability and requirements (from our data collection) are subject to a  sampling error of plus or minus 10 percentage points. We reviewed all  data for reasonableness and consistency and determined that the data  were sufficiently reliable for our purposes. We performed our work in  accordance with generally accepted government auditing standards from  May 2007 through March 2008.
subsections: section_title: Insurance Status of College Students
paragraphs: To describe the insurance status of college students, we analyzed data  from the 2007 Annual Social and Economic Supplement to CPS, conducted  by the U.S. Census Bureau for the Bureau of Labor Statistics. CPS is  designed to represent a cross section of the nation’s civilian  noninstitutionalized population. In 2007, about 83,200 households were  included in the sample for the Annual Social and Economic Supplement,  and the total response rate was about 83 percent. The supplement gathers  information about the type of health insurance coverage that respondents  had at any time during the previous calendar year, including private health  insurance, such as coverage provided through an employer (employer- sponsored plans) and insurance directly purchased by the beneficiary  (including college student insurance plans and individual market plans), as  well as through public health insurance programs, such as Medicaid. The  supplement also gathers data on demographic characteristics.
The 2007 Annual Social and Economic Supplement to CPS asked about  health insurance coverage during 2006. Specifically, the survey asked  whether a respondent was covered by health insurance in the last year,  and whether individuals had insurance “in their own name” or as  dependents of other policyholders. To identify college students, we  focused our analysis on individuals aged 18 through 23 who reported being  students and we excluded those who already had a bachelor’s degree,  master’s degree, professional school degree, or doctoral degree.
To assess the reliability of 2007 Annual Social and Economic Supplement  to CPS data, we (1) reviewed existing documentation related to the data  sources, (2) electronically tested the data to identify obvious problems  with completeness or accuracy, and (3) compared our results to published  sources. Based on these reviews, we determined that the data were  sufficiently reliable for the purposes of this report. Unless otherwise  noted, all of our estimates are within plus or minus 5 percentage points of  the population value at a 95 percent confidence level.
section_title: Uninsured College Students’ Characteristics and Financial Impact
paragraphs: To describe the characteristics of uninsured college students and the  financial impact of this population on health care systems, we analyzed  data from CPS and the Department of Health and Human Services’ 2005  MEPS. To describe the demographic characteristics of college students  more likely to be uninsured, we analyzed data from the 2007 Annual Social  and Economic Supplement to CPS on the demographic characteristics  (age, race and ethnicity, family income, and region) and enrollment status  of college students aged 18 through 23 who were insured and uninsured in  2006. Unless otherwise noted, our findings regarding the demographic  characteristics of college students who were more likely to be uninsured  in 2006 are significant at a 95 percent confidence level and all of our  estimates are within plus or minus 5 percentage points of the population  value at a 95 percent confidence level.
To describe the financial impact of uninsured college students on health  care systems, we estimated the amount of non-injury-related  uncompensated care incurred by uninsured college students by analyzing  2005 MEPS data, which was the most recently available data at the time  we did our work. MEPS is designed to provide nationally representative  data on health care use and expenditures of U.S. civilian  noninstitutionalized individuals. We used data from the MEPS Household  Component. This longitudinal survey collects information on health  insurance coverage and use of health care services of individuals over a   2-½-year period. The survey also gathers data on the demographic  characteristics of respondents. In 2005, the Household Component  surveyed 12,810 families representing 32,320 individuals, and had a total  response rate of about 61 percent. The Household Component collects  information directly from medical providers, such as hospitals, physicians,  and pharmacies, to validate self-reported information provided by survey  respondents.
We analyzed Household Component data to identify college students who  were uninsured for all or part of 2005. Specifically, to identify college  students, we included individuals aged 18 through 23 who reported being  students at any time during 2005. Of these individuals, we included those  who reported having a high school diploma, GED, other degree or who  had completed 11 or more years of education at the time they began the  Household Component survey. We excluded those who reported having a  bachelor’s degree, master’s degree, or doctoral degree. We identified  college students as uninsured if they reported being uninsured for any part  of 2005.
We estimated the amount of non-injury-related uncompensated care  incurred by these uninsured college students only during the time they  were uninsured. Uninsured college students may also incur  uncompensated care for medical events related to injuries. However, our  estimate does not include uncompensated care for injury-related medical  events because we could not reliably estimate the cost of this care. Our  estimate also does not include medical care provided to uninsured college  students for which a partial payment was made. As a result of these  limitations, our estimate understates the total amount of uncompensated  care incurred by uninsured college students in 2005.
To assess the reliability of the MEPS data, we reviewed existing  documentation related to the data source, and electronically tested the  data to identify obvious problems with completeness or accuracy. Based  on these reviews, we determined that the data were sufficiently reliable for  the purposes of this report. Unless otherwise noted, all of our estimates  are within plus or minus 5 percentage points of the population value at a  95 percent confidence level.
section_title: Availability and Characteristics of College Student Insurance Plans
paragraphs: To describe the extent to which colleges offered student insurance plans  and the characteristics of available plans, we collected data on student  insurance plans offered at a random sample of 340 colleges. We also  obtained more detailed information about the characteristics of plans  offered by 10 colleges by conducting case studies through which we  interviewed college administrators and reviewed plan documents. We also  interviewed experts as well as representatives from eight insurance  industry companies to obtain information on plan availability and  characteristics. To provide context, we also summarized characteristics of  employer-sponsored and individual market policies as reported by two  2006 national employer health benefits surveys and in a 2007 national  individual market survey.
subsections: section_title: Data Collected on Student Insurance Plans Offered by Colleges
paragraphs: We collected information on the availability and characteristics of college  student health insurance plans at a random sample of 340 colleges. We  drew the sample of colleges from the Department of Educations’  Integrated Postsecondary Education Data System (IPEDS), which contains  the most comprehensive data on all postsecondary institutions. The  sample consisted of active 2-year public, 4-year public, and 4-year private  nonprofit colleges that in 2005 had undergraduate enrollment of at least  200 and participated in federal student financial aid programs, such as  grant and loan programs, authorized by Title IV of the Higher Education  Act of 1965. We drew a stratified random sample of 340 colleges from the  population of 2,805 colleges that met these criteria. We grouped colleges  into one of three categories based on the size of their undergraduate  student population: small (200 to 1,500 students), medium-sized (1,501 to  5,000 students), and large (5,001 or more students). We selected our  sample from nine strata defined by size of undergraduate student  enrollment (small, medium, and large) and institution type (2-year public,  4-year public, and 4-year private nonprofit). Each college had a known  probability of being selected. The population and sample by strata are  shown in table 5.
To assess the completeness of the IPEDS data we used to generate our  sample, we reviewed technical documentation and we performed  electronic tests to look for missing or out-of-range values. On the basis of  these reviews and tests, we found the IPEDS data sufficiently reliable for  the purpose of generating a sample of colleges.
subsections: section_title: Data Collection
paragraphs: To gather information on the availability of health insurance plans for  college students during the 2007-2008 academic year and the  characteristics of available plans, we reviewed the Web sites of or spoke  to officials at each of the 340 colleges in our sample. Colleges vary in the  amount of information they post to their Web sites about their student  health insurance plans and insurance policies. We reviewed information  from each college’s student health center, student services, or student  affairs Web site. If information was not readily available from these Web  sites, we searched each college’s student handbook and general college  Web site. For those colleges that did not have Web sites or for which we  could not find information about the college’s student health insurance  plan or policies for academic year 2007-2008, we spoke with college  officials and asked structured questions to gather this information. We  reviewed information relevant to degree-seeking domestic undergraduate  students only.
For each of the 340 colleges in our sample, we gathered information for  academic year 2007-2008 on (1) whether the college required full-time  degree-seeking students to have health insurance; (2) whether the college  offered a student insurance plan; and if yes, (3) whether part-time  undergraduate students were allowed to enroll in the plan; (4) the plan’s  premium; and (5) the plan’s maximum benefit amount. We determined  that a college offered a student insurance plan when the college’s Web site  or a college official identified a health insurance plan that was specifically  intended for the college’s students. When gathering information on  maximum benefit amounts, we did not consider additional coverage that  college students may purchase if they enroll in the college’s basic plan  because, according to insurance industry officials we interviewed, a small  portion of college students—generally less than 5 percent of those  enrolled in the basic plan—purchase this supplemental coverage when it is  offered. When insurance plan premiums were based on student age or  enrollment status, we gathered information on premiums for full-time  students aged 18 through 23.
We obtained responses about the availability of college student insurance  from 100 percent of the colleges in our sample. However, we were unable  to gather complete information about the characteristics of all student  insurance plans offered by the colleges in our sample. Of the 194 plans  offered by colleges in our sample, we gathered information on part-time  student eligibility for 165 plans and premium information for 191 plans. We  collected information on the maximum benefits established for all 194  plans. Of these 194 plans, 186 plans established a maximum benefit  amount, and 5 of these 186 plans established two amounts. We therefore  reviewed and report on the 191 maximum benefit amounts used for 186  plans.
Using an electronic data collection instrument, we extracted data on the  availability and characteristics of college student insurance plans from  documentation of student health insurance plan offerings from August  2007 through October 2007 for a sample of 340 colleges. To ensure the  accuracy of the extracted data, we performed a verification audit for more  than 25 percent of the electronic records by comparing them to the source  documentation, and we corrected the errors we found. During our  analysis, we electronically tested the data for reasonableness, including  testing for out-of-range values and statistical outliers. Analysis programs  were also independently verified. Based on these reviews, we determined  that the data were sufficiently reliable for the purposes of this report.
section_title: Data Analysis
paragraphs: We weighted each sampled college in our analysis to represent all colleges  in the population, which allowed us to generalize our results on the  availability of student insurance plans to the population of U.S. colleges,  according to the types and sizes of colleges sampled. Because our sample  was of colleges, and not student insurance plans, our findings on the  characteristics of these plans are not generalizable to the universe of  student insurance plans offered nationwide. All of our estimates on college  student insurance plan availability are within plus or minus 10 percentage  points of the population value at a 95 percent confidence level. In addition,  unless otherwise noted, our results on the types of colleges more likely to  offer student insurance plans are significant at a 95 percent confidence  level.
section_title: Case Studies
paragraphs: To obtain detailed information on the characteristics of student insurance  plans, we conducted case studies of 10 colleges’ experiences offering  health insurance to their students. Through these case studies we  reviewed the plans offered by 10 colleges and interviewed officials from  each of these colleges. We judgmentally selected colleges for our case  studies that represented a range of three characteristics—college type  (private nonprofit or public), health insurance requirement (presence or  absence of a requirement), and companies involved in insuring and  administering the plan. The colleges we selected for review were Duke  University, Colorado State University, Ohio State University, Princeton  University, Santa Rosa Junior College, University of Colorado at Boulder,  University of Georgia, University of Minnesota Twin Cities, University of  Utah, and Washington University in St. Louis. Together, these 10 colleges  comprised 3 private 4-year colleges, 6 public 4-year colleges, and 1 public  2-year college. Six of these colleges required full-time students to have  coverage and 4 did not. These 10 colleges worked with a total of 16  insurance industry companies to insure their students and administer their  student insurance plans. We reviewed plan and policy documentation  available for each college plan, and interviewed officials from each college  regarding their college student insurance plan and policies. The results of  this review were used to gain contextual information and provide detailed  illustrations that are neither representative of all plans nor generalizable to  all colleges offering student health insurance plans.
section_title: Interviews with Officials from Insurance Industry Companies
paragraphs: To obtain detailed information about the factors that affect student  insurance plan characteristics, we interviewed officials from eight  insurance industry companies serving the college student insurance  market. We judgmentally selected these companies for interview based on  information we received from experts and college administrators.  Specifically, we interviewed officials from The Chickering Group (a  subsidiary of Aetna) and UnitedHealthcare StudentResources, as well as  officials from Blue Cross Blue Shield of North Carolina, Blue Cross Blue  Shield of Massachusetts, Koster Insurance, The Maksin Group, Student  Assurance Services Incorporated, and Wells Fargo Insurance Services.
section_title: Efforts to Increase the Number of Insured College Students
paragraphs: To describe efforts to increase the number of insured college students, we  reviewed published reports and conducted interviews with insurance  industry officials about efforts that would either increase the number of  insured college students aged 18 through 23 or increase the availability of  insurance for all or most college students aged 18 through 23. In addition,  to estimate the number of colleges with health insurance requirements, we  collected information on the health insurance requirements at a random  sample of 340 colleges. The sampling methods we used enabled us to  generalize our results regarding health insurance requirements at colleges  to the population of U.S. colleges, according to the types and sizes of  colleges sampled. Unless otherwise noted, our findings regarding the types  of colleges that are more likely to have a requirement are significant at a  95 percent confidence level, and all of our estimates are within plus or  minus 10 percentage points of the population value at a 95 percent  confidence level. As noted above, we took multiple steps to ensure the  accuracy of the data we collected on the health insurance requirements at  a sample of 340 colleges. Based on these reviews, we determined that the  data were sufficiently reliable for the purposes of this report.
To describe health insurance requirements implemented by states and  higher education governing boards, we reviewed relevant state laws and  higher education governing board policies. To describe colleges’ efforts to  jointly purchase student insurance plans through consortiums, we  developed a list of consortiums based on insurance industry officials’  knowledge of consortiums and our review of student insurance plans, and  we identified which of the 194 colleges in our review that offered student  insurance plans did so through a consortium on our list. Because our list  of colleges participating in consortiums is not comprehensive, we may  underestimate the percentage of colleges that purchase student insurance  through consortiums. Finally, to describe efforts to expand dependents’  eligibility for private health insurance, we reviewed states’ laws.
section_title: Appendix II: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the individual named above, Kristi Peterson, Assistant  Director; Krister Friday; Christopher Howard; Emily Larson; Lisa Motley;  Dan Ries; Patricia Roy; and Suzanne Worth made key contributions to this  report.