For the school year 1998- 1999, the National Federation of State High School Associations (NFHS) reported that there were about 11.8 million public high school students in the 50 states and the District of Columbia. School-based sports programs include about 6.5 million participants in more than 17,850 high schools across the nation. Of the total number of participants, 3.8 million were boys and 2.7 million were girls. As would be expected, large states have high numbers of student athletes. Texas, for example, had the greatest number of participants with 783,751 high school athletes, followed by California with 584,590 athletes. Among individual sports, basketball is the most popular high school sport, with 16,763 programs for boys and 16,439 programs for girls. In terms of individual participants, football is the most popular boys’ sport with 983,625 participants. Basketball is the most popular girls’ sport, with 456,873 students playing on high school teams. Athletic injuries among high school athletes are common. A 1999 study conducted for the National Athletic Trainers Association estimates that the national student athlete population experiences more than 2 million injuries of varying degree per year, around 500,000 doctor visits, and 30,000 hospitalizations. The study recorded injury data collected on 10 sports from a national sample of high schools and found that football was associated with the greatest number of injuries and involved the highest likelihood that some type of injury would occur. Furthermore, of all injuries recorded for all sports, 56 percent occurred during practice and 74 percent restricted the student athlete from participating in a sports program for fewer than 8 days. Another ongoing study conducted by the National Center for Catastrophic Sports Injury Research examined serious and fatal injuries suffered by high school sports participants from 1982 through 1998. During this period, football players suffered 67 fatalities, 161 nonfatal injuries, and 175 serious injuries.With the exception of these studies, national injury data are not routinely collected, maintained, or published. To help address the health insurance needs of low-income children, which could include those participating in high school sports, the Congress established the State Children’s Health Insurance Program (SCHIP).From fiscal year 1998 to fiscal year 2008, this program will provide more than $40 billion to states for the child health system under the federal/state Medicaid program or other state-established health insurance programs. The Department of Health and Human Services distributes the funds to states based on a formula that includes the state’s number of low-income children, the state’s number of uninsured low-income children, and the state’s health care costs as compared with other states. States are afforded a significant level of flexibility in defining the groups of children targeted for coverage under the new program. Specifically, under SCHIP, states choose to spend the new funds by (1) expanding Medicaid and building on the existing program; (2) establishing a separate, stand-alone program; or (3) combining these two approaches. The program targets funds at uninsured children in families whose income is too high to qualify for Medicaid but is at or below 200 percent of the federal poverty level, that is, $32,900 for a family of four. States also have discretion as to how to calculate income (gross, net, or countable income). More significantly, states have flexibility in establishing nonfinancial eligibility criteria. For example, SCHIP can use criteria such as residency, geographic area, and access to other health coverage. About 2 million children have been enrolled to date, but it remains uncertain the extent to which additional children will enroll in SCHIP. Of the 13 million children without basic health insurance, more than 3 million are of high school age (14- 18).Substantial differences in the uninsured rate among children of high school age exist across states. For example, the estimated uninsured rates among the states we either visited or contacted range from a high of 27.9 percent in Texas to a low of 5.7 percent in Massachusetts (see fig. 1 for uninsured rates among large states). The extent to which any of these children are prevented from participating in high school sports is unknown. We found no systematic data collection efforts or single data sources that document the number of high school students prohibited from participating in school-based sports due to the lack of insurance. In our survey of high school athletic associations, officials were unaware of any instance in which a high school student was prohibited from playing high school sports due to a lack of health insurance. Some states and school districts require high school student athletes to have basic health insurance prior to and while participating in a sports program. Our survey of high school athletic association officials found that only 10 states and the District of Columbia have a statewide requirement that student athletes have health insurance to participate in a sports program. However, according to officials of high school athletic associations, many school districts require health insurance for athletes. Of the 18 school districts we reviewed, 17 required that their student athletes have basic insurance to participate in high school sports.Within some of these districts, school officials we spoke to stated that athletic staff at each school collect information about the status of each student athlete’s private insurance. For example, Fairfax County District Schools in Virginia collect insurance information as part of establishing the eligibility of student athletes, which generally includes a physical examination and a signed parental consent form. We found, however, that local schools often do not verify health insurance information before students participate in sports, nor do they follow up on this during the school year. High school officials in many of the 18 districts reviewed pointed out that this information is usually collected only once during the school year and that schools are unable to verify the accuracy of the data collected due to time and expense. Further, an expert on uninsured populations noted that it is not unusual for students to lose their insurance coverage at some point during the school year due to a change in their parent’s job status. For example, an athlete’s parent may lose his or her job at some point during the school year, resulting in lost insurance benefits for the child. In addition, several school and health care officials we spoke to suggested that it is not uncommon for students or parents to misrepresent their current insurance status so that the student can participate in a school’s sports program. School districts and health care organizations in the locations we visited have developed strategies to make athletic accident insurance available to student athletes and to provide access to athletic accident-related care. Most school districts provided catastrophic athletic accident insurance to all student athletes regardless of their insurance status and also offered health insurance to student athletes free of charge or at low cost. School district officials reported that both the school district and local community organizations addressed instances of uninsured students who required care due to athletic accidents. In addition, in all 18 school districts we reviewed, including hospitals, medical centers, and sports assisted local school districts by offering free medical services to student athletes. Sixteen of the 18 school districts we reviewed offered free catastrophic coverage to high school athletes. The other two school districts are self- insured for catastrophic situations. Catastrophic injury insurance is meant to cover the medical costs for serious injury, such as a fractured vertebra or paralysis. In most of the school districts we contacted, this insurance coverage commences when the athlete’s medical bills reach $25,000. The maximum amount of coverage ranges from $1 million to $5 million depending on the district. School officials we spoke to stated that catastrophic injuries within their districts are rare but that catastrophic insurance is nonetheless important. For example, one school official from the El Paso Independent School District in Texas said that one student had experienced head trauma in a football game and had been hospitalized for 6 months. The school districts we visited emphasized that the premiums they pay for catastrophic insurance are relatively low. For example, the Austin Independent School District in Texas pays approximately $13,000 to provide catastrophic insurance coverage to all 10,000 students participating in school sports. In addition to catastrophic injury insurance, 17 of the 18 school districts we reviewed either provide free supplemental athletic accident insurance to student athletes or offer athletic accident insurance to student athletes for a fee. Eight of the public school districts we contacted purchased supplemental athletic accident insurance for their student athletes. These plans are blanket policies purchased for a specific number of student athletes at a set rate. For example, the San Antonio Independent Schools in Texas pay approximately $260,000 to cover about 17,000 sports participants. Other examples of similar strategies are in effect across the nation. The El Paso Independent School District in Texas insures all high school athletes at no charge to the student. The policy provides secondary insurance coverage to most student athletes and acts as a primary plan for student athletes who are injured during a sports activity and do not have other insurance coverage. The District of Columbia insures high school students participating in sports at no charge to the student. Although the policy has a $100 deductible should the student athlete file a claim for needed care, very seldom is the deductible fee charged for low-income students. The Indianapolis School District in Indiana provides for and pays the insurance premiums for high school students participating in sports. The policy is intended to be a supplemental policy. However, if a student does not have basic health insurance coverage, the school policy becomes the primary insurance if the student is injured during athletics. App. II presents an example of a supplemental athletic accident coverage plan that is provided to student athletes’ parents or guardians. Nine school districts we reviewed offer students the opportunity to purchase low-cost athletic accident insurance. In these districts, the student athlete may purchase an athletic accident policy through the school. These policies cover only accidents occurring during authorized events such as games or formal practices. App. III, provided by Fairfax County School District of Virginia, is an example of such a policy. While most of the districts that offer these accident policies require them only when the student athlete does not have insurance, some school districts require that all student athletes—regardless of insurance status— purchase a policy through the district. For example, the Hillsborough County Public Schools in Florida require all student athletes to purchase a policy through the district regardless of whether the athlete has private insurance. The cost to the student is one-half of the total cost to the district. For instance, if the cost to the district for football insurance is $90 to $95, the student pays $45 to $48. One Hillsborough County school official cited the fact that many families do not have a steady source of insurance. School officials believe that having a policy for the mandatory purchase of insurance is the best way to protect the school district from liability. These officials also believe that the policy protects the athlete and his or her family from the financial burden of paying for health care out of pocket. In addition, some school districts have implemented methods to provide insurance to students of low-income families on a case-by-case basis. For example, the Hillsborough County Public School District in Florida has an annual “Football Jamboree.” The proceeds of this event go into a trust fund designed to help poor families pay the cost of the district’s mandatory insurance. In cases of financial hardship, the principal of each school can obtain funds from the trust to cover an athlete’s insurance costs. School officials acknowledge that in some instances high school athletes participate in sports without the benefit of health insurance. As we indicated earlier, school officials cited a number of factors that contribute to this situation, including the lack of resources to verify students’ insurance status, a family member’s loss of insurance coverage during the sport season, or parents who misrepresent their insurance status at the beginning of a season. Although student athletes who lose or have no insurance would be covered by the district’s free catastrophic accidental insurance policy, their families would be at risk for medical expenses up to the catastrophic threshold. However, school officials also reported that instances of uninsured students requiring athletic accident care were infrequent. The school districts we reviewed had various measures to meet the health care needs of an injured athlete when the school district does not know that the student is participating in sports without health insurance. According to school officials, the school and community actively respond to athletic accidents among uninsured students to address health care needs and minimize costs to the family. School district efforts included fundraising drives, booster club contributions, and the provision of free care by health care providers such as physicians and clinics. In some locations, school districts rely on their health care partners to provide free medical service to the injured student athlete. For example, districts such as the Los Angeles Unified School District in California benefit from athletic trainers provided by the University of Southern California Center for Athletic Medicine Foundation and the West Coast Sports Medicine Foundation. The athletic trainers, who are present at games and often during practices, provide on-the-spot free care for many less serious injuries. School officials also told us that, for more severe injuries, local hospitals and community and school organizations such as booster clubs help ease the financial burden on the athlete’s family. These athletic accident plans and medical services are limited to sports-related injuries incurred by students with no basic health insurance. Many high school districts we reviewed have developed partnerships with local health care organizations to provide a range of health-related services to student athletes. These organizations provide student athletes with free pre-participation physicals, injury evaluation services, access to physicians, and rehabilitation services. More specifically, The West Coast Sports Medicine Foundation, a nonprofit charitable organization, provides approximately 12,000 high school students at 25 Los Angeles area schools with the opportunity to participate in school- based sports. The foundation provides student athletes with (1) free (no cost to the athlete or family) athletic accident insurance coverage, (2) athletic training to reduce and mitigate injuries, and (3) access to sports. The Sport Physiology and Orthopaedic Rehabilitation Treatment (SPORT) Clinic in Riverside, California, has contracted with area high schools to provide a program for the care and prevention of athletic injuries. Health care officials at the SPORT Clinic educate student athletes to prevent or reduce athletic injuries, advise athletes on the care and treatment of their injuries, and provide treatment of minor athletic injuries. In addition, the clinic’s facilities are available for use by high school athletes. Medical consultation, treatment, and facilities are available free of charge for each injury, for two weeks from the initial visit. The Methodist Sports Medicine Center at the Methodist Hospital and St. Vincent’s Medicine in Indianapolis have had informal agreements with the Indianapolis Independent School District for more than15 years. These medical providers furnish athletic trainers and doctors free of charge for all games and tournaments. In addition, athletic trainers visit each high school within the Indianapolis School District twice a week. Finally, some districts use local health providers to conduct pre- participation exams. The Healthsouth Doctor’s Hospital of Coral Gables, Florida, has an arrangement with Dade County Public Schools to provide physicals free of charge to all high school athletes within the county. We provided the Department of Education with the opportunity to comment on a draft of this report. Education concurred with our findings (see app. IV). We will send copies of this report to The Honorable Richard W. Riley, Secretary of Education, and to school officials in the states we visited. We will also make copies available to others on request. If you have any questions regarding this report, please contact me at (202) 512-7215. Key contacts and staff acknowledgments for this report are listed in app. V. We designed our study to collect data on whether high school students are prevented from participating in sports because they lack health insurance. We also sought to determine the number of uninsured high school students in the United States, the extent to which the lack of health insurance posed a barrier to participation in high school athletic programs, and the strategies health care organizations and school districts have developed to assist student athletes with health insurance or health care. We interviewed education, health, and athletic officials at the national, state, and local levels and contacted 18 large public school districts. We visited 8 public school districts and conducted telephone interviews with officials at 10 public school districts. We also administered a survey to high school athletic association officials in all 50 states and the District of Columbia to help determine whether students participate in sports without the benefit of health insurance. For our statistical analysis of uninsured children and school districts, we used the 1999 Current Population Survey (CPS) and the National Center for Education Statistics’ (NCES) database, respectively. We performed our work between July 1999 and July 2000 in accordance with generally accepted government auditing standards. We visited 8 school districts and telephoned officials at another 10 school districts that used a variety of methods to provide assistance to student athletes. All districts were among the largest in the nation. Within each school district we interviewed athletic directors, business and insurance managers, athletic health care service coordinators, and other relevant staff involved with student athletes (see table 1). the interscholastic athletic associations of the 50 states and the District of Columbia. The survey focused on five areas: insurance requirements for student athletes, insurance plans available to student athletes, premiums and types of coverage offered to the student athletes, instances of students participating in sports without health insurance, and innovative methods to provide student athletes with health insurance. We received 49 completed questionnaires. We interviewed education and health officials at the national, state, and local levels to identify federal, state, and local health insurance requirements for student athletes. We also collected information on whether any of these agencies had data on uninsured student athletes (see table 2). The Indianapolis Public Schools pay for health insurance that covers high school students for injuries suffered in sports. The policy is intended to be a supplemental athletic accident policy; however, if a student does not have other insurance coverage, the school policy becomes the primary insurance. Also, if a student is covered by Medicaid or SCHIP, the district’s supplemental policy becomes the primary coverage. Only accidents that occur while the student is involved in an athletic event or practice are covered. This policy defines an accident as an unexpected, sudden, and definable event that is the direct cause of a bodily injury, independent of any illness, prior injury, or congenital predisposition. Coverage is only for care not covered by any family or employer group coverage or plan. This policy has no deductible. The following page gives an example of a letter that the Indianapolis Public Schools send to parents and guardians explaining the insurance coverage provided to student athletes. Ten of the school districts we reviewed offer students the opportunity to purchase low-cost supplemental accident insurance. The specifics of the policies offered vary from district to district. Generally, such a policy would cover only accidents that occur during school-sponsored and -supervised sporting events, practices, or transportation in a school-furnished vehicle to such an event. The policies act as primary coverage for student athletes without insurance and as secondary coverage for those with insurance. Additional coverage, such as 24-hour accident coverage, may be obtained for an additional charge. The following pages are an illustration of the supplemental accident insurance policy offered to student athletes of the Fairfax County School District. In addition to the individuals named above, Christopher Galvin and Kevin Murphy made key contributions to this report. Employee Benefit Research Institute. SourcesofHealthInsuranceand CharacteristicsoftheUninsured:AnalysisoftheMarch1999Current PopulationSurvey. Washington, D.C.: December 1999. Herz, Elicia, and Baumrucker, Evelyne. StateChildren’sHealthInsurance Program:ABriefOverview. Washington, D.C.: Congressional Research Service, March 14, 2000. National Center for Catastrophic Sport Injury Research. SixteenthAnnual Report.Fall1982- Spring1998, updated September 8, 1999. Chapel Hill, N.C.: University of North Carolina, 1999. Powell, John W., and Barber-Foss, Kim D. “Injury Patterns in Selected High School Sports: A Review of the 1995- 1997 Season.” JournalofAthletic Training, Vol. 34, No. 3 (1999): pp. 277- 284. Smith, Madeleine. HealthInsuranceCoverage:Characteristicsofthe InsuredandUninsuredPopulationsin1998. Washington, D.C.: Congressional Research Service, updated October 6, 1999. —. HealthInsuranceCoverageofChildren. Washington, D.C.: Congressional Research Service, updated January 12, 2000. —. HealthInsurance:UninsuredChildrenbyState,1996- 1998. Washington, D.C.: Congressional Research Service, updated October 28, 1999. —. HealthInsurance:UninsuredbyState,1998. Washington, D.C.: Congressional Research Service updated October 6, 1999. Young, Beth Aronstamm. Characteristicsofthe100LargestPublic ElementaryandSecondarySchoolDistrictsintheUnitedStates:1997- 98. Washington, D.C.: U.S. Department of Education, National Center for Education Statistics, July 1999. NCES 1999- 318. MedicaidandSCHIP:ComparisonsofOutreach,EnrollmentPractices,and Benefits(GAO/HEHS-00-86, Apr.14, 2000). MedicaidinSchools:ImproperPaymentsDemandImprovementsinHCFA Oversight(GAO/HEHS/OSI-00-69, Apr. 5, 2000). IntercollegiateAthletics:ComparisonofSelectedCharacteristicsofMen’s andWomen’sPrograms(GAO/HEHS-99-3R, June 18, 1999). Children’sHealthInsuranceProgram:StateImplementationApproaches AreEvolving(GAO/HEHS-99-65, May 14, 1999). IntercollegiateAthletics:StatusofEffortstoPromoteGenderEquity (GAO/HEHS-97-10, Oct. 25, 1996). HealthInsuranceforChildren:PrivateInsuranceCoverageContinuesto Deteriorate(GAO/HEHS-96-129, June 17, 1996). HealthInsuranceforChildren:StateandPrivateProgramsCreateNew StrategiestoInsureChildren(GAO/HEHS-96-35, Jan. 18, 1996). The first copy of each GAO report is free. Additional copies of reports are $2 each. A check or money order should be made out to the Superintendent of Documents. VISA and MasterCard credit cards are accepted, also. Orders for 100 or more copies to be mailed to a single address are discounted 25 percent. Ordersbymail: U.S. General Accounting Office P.O. Box 37050 Washington, DC 20013 Ordersbyvisiting: Room 1100 700 4th St. NW (corner of 4th and G Sts. NW) U.S. General Accounting Office Washington, DC Ordersbyphone: (202) 512-6000 fax: (202) 512-6061 TDD (202) 512-2537 Each day, GAO issues a list of newly available reports and testimony. To receive facsimile copies of the daily list or any list from the past 30 days, please call (202) 512-6000 using a touchtone phone. A recorded menu will provide information on how to obtain these lists. Web site: http://www.gao.gov/fraudnet/fraudnet.htm e-mail: fraudnet@gao.gov 1-800-424-5454 (automated answering system)

Summary: Pursuant to a legislative requirement, GAO reviewed high school interscholastic athletics, focusing on the: (1) number of uninsured high school students in the United States and the extent to which the lack of health insurance poses a barrier to participation in high school athletic programs; and (2) strategies school districts have developed to provide health insurance and health care to high school sports participants. GAO noted that: (1) in 1998, an estimated 3.4 million uninsured children were of high school age; (2) among highly populated states, there were wide differences in the percentage of uninsured children of high school age; (3) GAO was unable to identify any national, state, or local information on the extent to which these high school students were prevented from participating in athletic programs because they lacked basic health insurance; (4) the officials of the 51 athletic associations GAO surveyed were unaware of any instance in which a high school student was prohibited from playing high school sports because he or she lacked health insurance; (5) however, according to these officials, while 10 states and the District of Columbia require high school students to have health insurance before joining a school's athletic program, the other 39 states leave this decision to the discretion of local school districts; (6) in 17 of the 18 large school districts, district policy required student athletes to have health insurance to participate in high school sports; (7) in addition, many of these districts required student athletes to document insurance coverage before participating in sports; (8) however, school officials in four of these large districts reported that they did not have the resources to monitor the accuracy of health insurance information before or during a sport's season; (9) 16 of the 18 school districts provided free catastrophic athletic accident insurance to all student athletes regardless of their insurance status; (10) in most cases, the catastrophic accident policy would cover all medical costs once a family's expenses exceeded $25,000; (11) further, in all school districts GAO reviewed, local schools have adopted strategies to provide access to low-cost athletic accident insurance to student athletes; (12) in eight school districts, free supplemental athletic accident insurance was automatically provided to all student athletes; (13) in nine districts, the families of student athletes were given the opportunity to purchase low-cost athletic accident insurance; (14) school officials in these districts reported that instances of uninsured student athletes requiring athletic accident care were addressed through such activities as accident trust funds established at the school district level and through direct community involvement; and (15) private organizations such as hospitals and clinics assisted local school districts by offering free medical services to student athletes for sports-related injuries and other services such as pre-participation physicals or injury evaluation.