About a year ago, six months after her mother was laid off from her job, Kate Simpson's health insurance coverage expired.
A month later, the University of Texas student went to university health services for a sinus infection and found out her heart was beating three times faster than the normal rate, which soon led to a diagnosis of severe hyperthyroid disorder.
It became a pre-existing condition that prevented her from getting new coverage, even through her father's employer. She eventually decided to take off the next semester from school after her symptoms worsened.
As more and more college students become uninsured or underinsured because of a parent's job loss or strict insurance policies, an increasing number of colleges and universities are choosing to mandate health insurance coverage for students. The reasons they cite are many: retention rates, student safety and cost burdens to local hospitals.
A 2008 survey by the American College Health Association (ACHA), a group that sets standards for higher education insurance coverage, estimated that 38 percent of public four-year colleges require coverage, up from less than 25 percent in 2006.
Simpson said a mandate would have helped her because she didn't think she was vulnerable to serious health issues as a young person and thus didn't make coverage a priority.
"When you have it, you take it for granted," Simpson, 22, said of insurance coverage. "I never realized what a doctor bill cost or what medicine cost. I had amazing insurance where I paid $15 for a prescription, and I never thought twice about it. And then, when I didn't have it, I didn't think it would be a problem. I was going to get around to getting it but neither of my parents or I did anything about it."
Mandating Health Insurance
The University of North Carolina system will require insurance coverage for students at all of its 16 institutions starting in fall 2010. Only five schools in the system, including the flagship campus at Chapel Hill, did not have an insurance requirement already, but the 11 that did had different providers.
Bruce Mallette, senior associate vice president of academic and student affairs for UNC general administration, said the system did a study that showed it could provide cheaper comparable coverage with lower premiums if it sought a vendor to cover the entire system.
That means the students at schools that once relied on voluntary insurance plans will pay $650 instead of more than $1,000 for their insurance coverage, Mallette said.
Increasing Number of Public Universities Consider Mandating Insurance
At many state schools in the U.S., $1,100 is 15 percent or more of total tuition for a year.
"They look at $1,100 or $1,600 a year and it scares them away from even considering it," said Mallette, describing students at UNC schools with voluntary insurance.
Stephen Beckley, a health insurance consultant who has helped more than 170 colleges and universities design health insurance plans and policies, said 22 states, including Utah and Florida, currently are researching or discussing student health insurance mandates.
As more universities choose mandates, Beckley said, more and more will likely catch on as they realize the benefits of knowing students are covered in case of an accident or illness.
"We expect more states to do mandates given that college students often bubble up as one of the largest groups of uninsured persons nationally," said Beckley.
Under most state laws, when a person turns 24 or 25, he or she is no longer eligible for coverage under parents' employer insurance -- even as a full-time student.
Statistics show that many young people may forgo coverage, either because of costs or because they think they don't need it.
The Lookout Mountain Group, a non-partisan group that researches the impact of health care reform on the college student population, estimated that anywhere from 25 to 30 percent of college students attending four-year institutions are uninsured.
Young adults in general make up the largest uninsured group nationally, according to a 2008 U.S. Census survey. In Texas, where Simpson lives, 46 percent of people ages 19 to 24 were uninsured in 2008.
The Florida State University system implemented mandatory insurance at Florida State University a few years ago to analyze the benefits of mandatory insurance against the costs.
Bill Edmonds, director of communications for the systems board of governors, said the task force charged with examining the results has yet to make a recommendation for the entire system.
"The board is treating it as a pilot project and it has been reluctant to make any recommendations until we have time to see what the impact is," Edmonds said. "It's obviously a benefit to students, but it comes at a cost. We just want to see how it works out and if it is possible that some modified version of the plan might be better than the original plan. It could be an unmitigated success or a huge failure."
Pros and Cons of Health Insurance Mandates
Several other universities, including Minnesota State, also are looking into a requirement via pilot programs or task forces.
The University of Maryland is one of a few schools that began requiring coverage this year, although it chose to require it only for incoming freshman and transfer students.
The policy is "designed to limit students' financial liability and keep them in school when faced with a health emergency," according to a university press release.
Stacy Pogue, a senior policy analyst at the non-partisan Center for Public Policy Priorities, said coverage mandates for students have pros and cons, but providing an optional student insurance plan has clear benefits.
"Requiring students to [have coverage] really comes with trade-offs," Pogue said. "You would know that all your students are insured and that's good. That could mean lower cost for emergency rooms in the community. It might have the effect of bringing more reimbursements into the student health center. It might mean a healthier campus population.
"But the downside is that health insurance is expensive and there are some students who we know if you added an extra fee for tuition wouldn't be able to afford coverage or to go to school or to go full-time," Pogue added.
Beckley said universities choose mandates for a variety of reasons, including issues associated with access to mental health care, liability, retention rates and cost burden on local hospitals.
He said a requirement can serve as a safety net for students who are increasingly precariously insured by private health coverage, and may lose coverage after a parent's job loss, like Simpson did.
Chad Henderson, director of health services at the University of Rhode Island and former ACHA president, said Rhode Island chose to mandate health insurance for students decades ago because paying for health care for the uninsured was having such an economic impact on local hospitals. Retention also was a factor, he said.
"If students stay well, they persist better, they do better academically and, hopefully, they graduate in a reasonable amount of time," Henderson said.
But some schools are not so sure. Joyce Roosz, the business office and student insurance supervisor at Purdue University, said a mandate has not been discussed seriously among the higher ups at Purdue, but it is something the department that runs the optional insurance plan has talked about before in meetings.
"At this point in time, I don't think we're going toward that policy right now," Roosz said. "I just don't think that this is the economic climate where we want to push mandatory health insurance. Students are sometimes just having difficulty getting money for tuition. Even though we think it's very important and encourage students to have coverage through their parents or to get a catastrophic plan, I just don't think this is the time to pursue it."
Health Insurance Mandates: From the Bottom Up
Many universities, especially private ones, have had health insurance mandates for years.
And many of the major public university systems in the U.S., including the University of California system, the University of Minnesota and the University of Montana, require students not covered through a parent or private plan to purchase university-sponsored coverage.
Most mandates have come from the bottom up, after major state universities choose on their own to require insurance. Massachusetts was the first state to mandate coverage via a state legislature for full- and part-time students in 1989.
About 50 percent of undergraduate students and about 80 percent of graduate students are covered under the University of California at Berkeley plan, which offers medical, dental and vision coverage.
Berkeley mandated coverage in 1990 after students voted for a referendum requiring health coverage as a condition for enrollment.
"It was the students saying, 'We want health insurance. We want adequate coverage so that were not suffering under large medical bills,'" said Heather Pineda, director of the student health insurance plan.
A decade later, the University of California system board of regents passed a regulation requiring coverage for undergraduates at all the system schools. They are expected to pass a similar regulation for graduate students in November, Pineda said.
"The mission of the university is to educate students and anything the university can provide to the students to help them accomplish that goal is a benefit to the university," she said.