Health Insurance: Most College Students Are Covered through	 
Employer-Sponsored Plans, and Some Colleges and States Are Taking
Steps to Increase Coverage (28-MAR-08, GAO-08-389).		 
                                                                 
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.						 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-08-389 					        
    ACCNO:   A81439						        
  TITLE:     Health Insurance: Most College Students Are Covered      
through Employer-Sponsored Plans, and Some Colleges and States	 
Are Taking Steps to Increase Coverage				 
     DATE:   03/28/2008 
  SUBJECT:   Access to health care				 
	     Child health services				 
	     College students					 
	     Colleges and universities				 
	     Health care cost control				 
	     Health care costs					 
	     Health insurance					 
	     Health insurance cost control			 
	     Health policy					 
	     Insurance premiums 				 
	     Medicaid						 
	     Public health legislation				 
	     School health services				 
	     Statistical data					 
	     Health insurance portability			 
	     Standards (health care)				 
	     State Children's Health Insurance			 
	     Program						 
                                                                 

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GAO-08-389

   

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
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material separately. 

Report to the Committee on Health, Education, Labor, and Pensions, U.S. 
Senate: 

United States Government Accountability Office: 
GAO: 

March 2008: 

Health Insurance: 

Most College Students Are Covered through Employer-Sponsored Plans, and 
Some Colleges and States Are Taking Steps to Increase Coverage: 

GAO-08-389: 

GAO Highlights: 

Highlights of GAO-08-389, a report to the Committee on Health, 
Education, Labor, and Pensions, U.S. Senate. 

Why GAO Did This Study: 

College students face challenges obtaining health insuranceâthey may 
not have access to insurance through an employer, and as they get 
older, they may lose dependent coverage obtained through a parentâ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 studentsâ insurance status, (2) uninsured 
college studentsâ 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 studentsâ insurance 
status and uninsured college studentsâ 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 
statesâ laws. 

What GAO Found: 

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 personâs name. About 20 percent of college students aged 18 
through 23 (1.7 million) were uninsured in 2006, and certain groups of 
studentsâsuch as part-time students, nonwhite students, and students 
from families with lower incomesâ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 plansâ benefits varied. Colleges 
customized their plans to reflect their priorities in making premiums 
affordable for students while providing coverage that meets studentsâ 
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 dependentsâ 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)âan 
advocacy and leadership organization for college and university 
healthâprovided a technical comment, which we incorporated. 

Table: Percentage of Colleges Nationwide Offering Student Insurance 
Plans for Academic Year 2007-2008, by College Type: 

College type: Four-year private nonprofit; Percentage of colleges 
offering student insurance plans: 71. 
 
College type: Four-year public;
Percentage of colleges offering student insurance plans: 82. 

College type: Two-year public; 
Percentage of colleges offering student insurance plans: 29. 

College type: Average of all colleges; Percentage of colleges offering 
student insurance plans: 57. 

Source: GAO random sample of 340 colleges. 

Note: Differences in the estimates are statistically significant. All 
estimates are subject to a sampling error within plus or minus 10 
percentage points. 

[End of table] 

To view the full product, including the scope and methodology, click on 
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-389]. For more 
information, contact John E. Dicken at (202) 512-7114 or 
[email protected]. 

[End of section] 

Contents: 

Letter: 

Results in Brief: 

Background: 

About 80 Percent of College Students Had Health Insurance in 2006, and 
Most Were Covered through Employer-Sponsored Plans: 

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: 

Over Half of Colleges Offered Student Insurance Plans in Academic Year 
2007-2008, and These Plans Were Customized and Plan Benefits Varied: 

Colleges and States Have Taken a Variety of Steps to Increase the 
Number of Insured College Students: 

External Comments: 

Appendix I: Scope and Methodology: 

Appendix II: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Percentage of Colleges Nationwide Offering Student Insurance 
Plans for Academic Year 2007-2008, by College Type: 

Table 2: Percentage of Colleges Nationwide Offering Student Insurance 
Plans for Academic Year 2007-2008, by College Size: 

Table 3: Percentage of Colleges Nationwide Requiring All Full-time 
Students to Have Health Insurance for Academic Year 2007-2008, by 
College Type: 

Table 4: Percentage of Colleges Nationwide Requiring All Full-time 
Students to Have Health Insurance for Academic Year 2007-2008, by 
College Size: 

Table 5: Characteristics of the 2005 U.S. College Population and the 
Sample of Colleges Used for Data Collection: 

Figures: 

Figure 1: Insurance Status of College Students Aged 18 through 23, in 
2006: 

Figure 2: Percentage of Uninsured College Students Aged 18 through 23 
in 2006, by Age: 

Figure 3: Percentage of Uninsured College Students Aged 18 through 23 
in 2006, by Race: 

Figure 4: Part-time Student Eligibility for 165 Student Insurance Plans 
Offered in the 2007-2008 Academic Year: 

Figure 5: Distribution of Annual Premium Amounts for 191 Student 
Insurance Plans Offered in the 2007-2008 Academic Year: 

Figure 6: Percentage of 194 Student Insurance Plans Offered in the 2007-
2008 Academic Year That Established a Maximum Benefit, and Distribution 
of Maximum Benefit Amounts for 131 Plans with a per Condition per 
Lifetime Benefit: 

Figure 7: Distribution of Maximum Benefit Amounts by Type, for 191 
Maximum Benefits Offered by 186 Student Insurance Plans Offered in the 
2007-2008 Academic Year: 

Abbreviations: 

ACHA: American College Health Association: 

COBRA: Consolidated Omnibus Budget Reconciliation Act of 1985: 

CPS: Current Population Survey: 

HIPAA: Health Insurance Portability and Accountability Act of 1996: 

IPEDS: Integrated Postsecondary Education Data System: 

MEPS: Medical Expenditure Panel Survey: 

PPO: preferred provider organization: 

SCHIP: State Children's Health Insurance Program: 

[End of section] 

United States Government Accountability Office:
Washington, DC 20548: 

March 28, 2008: 

The Honorable Edward M. Kennedy: 
Chairman: 
The Honorable Michael B. Enzi: 
Ranking Member: 
Committee on Health, Education, Labor, and Pensions: 
United States Senate: 

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.[Footnote 1],[Footnote 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. 

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[Footnote 3] 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. 

To describe the extent to which colleges offered student insurance 
plans and the characteristics of available plans, we collected data on 
student insurance plans from a random sample of 340 U.S. 
colleges.[Footnote 4] Our sample consisted of active 2-year public, 4- 
year public, and 4-year private nonprofit colleges that in 2005 had an 
undergraduate enrollment of at least 200 and participated in federal 
student financial aid programs authorized by Title IV of the Higher 
Education Act of 1965.[Footnote 5],[Footnote 6] We reviewed the Web 
sites of or spoke to officials at each of the 340 colleges to determine 
if the college offered a health insurance plan for its college 
students[Footnote 7] during the 2007-2008 academic year. 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 its students.[Footnote 8] For colleges that 
offered a student insurance plan, we gathered information on part-time 
student eligibility for the plan as well as the plan's premiums and 
maximum benefits. To obtain more detailed information about the 
characteristics of plans, we also selected 10 colleges for case studies 
to represent 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 colleges' plans. While the case studies allowed us to learn about 
many important aspects of and variations in the characteristics of 
student insurance plans, they were designed to provide anecdotal 
information, not findings that would be representative of all student 
insurance plans. We conducted interviews with administrators from each 
of the 10 colleges and reviewed student insurance plan documents. We 
also interviewed experts and representatives from eight student health 
insurance industry companies to discuss the characteristics of student 
insurance plans. To provide context, we also summarized the premiums 
and benefits of employer-sponsored and individual market policies as 
reported by two 2006 national employer health benefits surveys and a 
2007 national individual market survey.[Footnote 9] 

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.[Footnote 10] 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. 

Results in Brief: 

About 80 percent of college students aged 18 through 23--nearly 7.0 
million individuals--were insured through private or public sources of 
health insurance in 2006. According to our analysis of CPS data, most 
college students aged 18 through 23 (67 percent) obtained their health 
insurance coverage in 2006 through employer-sponsored plans, which are 
private insurance plans employers offer to employees and their 
dependents; some (7 percent) obtained coverage through other private 
health insurance plans, such as student insurance plans offered by 
colleges; and others (6 percent) obtained coverage through public 
health insurance programs, such as Medicaid. Of those college students 
with any form of health insurance in 2006, most obtained coverage 
through another person's policy, for example, as a dependent on a 
parent's policy. CPS data also show that 20 percent of college students 
aged 18 through 23--about 1.7 million students--lacked health insurance 
in 2006. 

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. Based on our analysis of CPS data, we found 
that certain groups of students, including part-time students, older 
students, students from racial and ethnic minority groups, and students 
from families with lower incomes, were more likely than other groups of 
college students to be uninsured. The characteristics of uninsured 
college students are consistent with those of the uninsured found in 
the general U.S. population. Our analysis of MEPS data shows that most 
of the $120 million to $255 million in uncompensated care costs for non-
injury-related medical events incurred by uninsured college students in 
2005 was for visits to office-based providers and hospital emergency 
rooms. 

Over half of colleges nationwide offered student insurance plans in the 
2007-2008 academic year and benefits varied across plans. Specifically, 
we estimate that about 57 percent of colleges nationwide offered health 
insurance plans to their students, and some types of colleges were more 
likely than others to offer plans. For example, 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. Colleges that offered plans varied in the extent to which 
they made their plans available to part-time students. In general, the 
plans colleges offered 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. 
The plans GAO reviewed varied in the services they covered and how they 
paid for covered services. Specifically, plans varied in the extent to 
which they covered preventive services, and some plans set a maximum 
amount the plan would pay for a particular service. In addition, we 
found that student insurance plans' annual premiums and maximum 
benefits varied widely. Specifically, some plans we reviewed had annual 
premiums that ranged from about $30 to about $2,400, and offered 
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, some colleges have 
required college students to have health insurance. We estimate that 
about 30 percent of colleges nationwide required their students to have 
health insurance for the 2007-2008 academic year. Some states, such as 
Massachusetts and New Jersey, have also implemented health insurance 
requirements for college students. In another effort, colleges have 
jointly purchased health insurance to increase the availability of 
health insurance for college students and the number of students who 
are insured. Finally, some states have expanded dependents' eligibility 
for private health insurance plans, which have traditionally provided 
coverage for dependents through age 18 and have generally continued 
coverage for dependents through age 22 only if they attend college full-
time. Because most college students obtain health insurance as 
dependents, these efforts have made health insurance more available to 
college students. 

We provided a draft of this report to the American College Health 
Association (ACHA), an advocacy and leadership organization for college 
and university health. ACHA officials provided a technical comment, 
which we incorporated. 

Background: 

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). 

Health Insurance Options for College Students: 

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.[Footnote 11] 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.[Footnote 12] 

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. [Footnote 
13] 

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.[Footnote 14] 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.[Footnote 15] 

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. 

About 80 Percent of College Students Had Health Insurance in 2006, and 
Most Were Covered through Employer-Sponsored Plans: 

In 2006 most college students aged 18 through 23 had some form of 
health insurance. According to our analysis of CPS data, about 80 
percent of college students aged 18 through 23--nearly 7.0 million 
individuals--were insured through private or public sources of health 
insurance in 2006. CPS data show that most college students aged 18 
through 23--about 67 percent--obtained their health insurance coverage 
through employer-sponsored plans in 2006,[Footnote 16] while about 7 
percent of this population obtained their coverage through either 
individual market or other group market plans, which include college 
student insurance plans. In addition, about 6 percent of college 
students aged 18 through 23 were covered under public health insurance 
programs, such as Medicaid or SCHIP, in 2006. (See fig. 1 for a summary 
of the health insurance status of college students in 2006.) CPS data 
also show that of the nearly 7.0 million college students aged 18 
through 23 who had any form of health insurance in 2006, about 87 
percent obtained this coverage through another person's policy--for 
example, as a dependent on a parent's policy. About 20 percent of 
college students aged 18 through 23 lacked health insurance in 2006, 
according to CPS data. This uninsured population numbered about 1.7 
million.[Footnote 17],[Footnote 18] 

Figure 1: Insurance Status of College Students Aged 18 through 23, in 
2006: 

[See PDF for image] 

This figure is a pie-chart, depicting the following information: 

Insurance Status of College Students Aged 18 through 23, in 2006: 

Insured through employer-sponsored group market plans: 67%; 
Insured through individual market and other group market plans, 
including college student insurance plans: 7%; 
Insured through public health insurance programs: 6%; 
Uninsured: 20%. 

Source: GAO analysis of CPS data for 2006. 

Note: All estimates are subject to a sampling error within plus or 
minus 5 percentage points. 

[End of figure] 

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: 

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. 

Certain Groups, Including Part-time Students and Older Students, Were 
More Likely Than Others to Be Uninsured in 2006: 

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.) 

Figure 2: Percentage of Uninsured College Students Aged 18 through 23 
in 2006, by Age: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following 
information: 

Age: 18; 
Percentage uninsured: 18. 

Age: 19; 
Percentage uninsured: 16. 

Age: 20; 
Percentage uninsured: 16. 

Age: 21; 
Percentage uninsured: 19. 

Age: 22; 
Percentage uninsured: 25. 

Age: 23; 
Percentage uninsured: 35. 

20 percent of all college students 18-23 were uninsured in 2006. 

Source: GAO analysis of CPS data for 2006. 

Note: Differences in the estimates are statistically significant. All 
estimates are subject to a sampling error within plus or minus 5 
percentage points. 

[End of figure] 

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[Footnote 19] of 
Hispanic, 29 percent of black, and 26 percent[Footnote 20] 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.[Footnote 21] 

Figure 3: Percentage of Uninsured College Students Aged 18 through 23 
in 2006, by Race: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following 
information: 

Race: Hispanic; 
Percentage uninsured: 38. 

Race: Black; 
Percentage uninsured: 29. 

Race: Asian; 
Percentage uninsured: 26. 

Race: White; 
Percentage uninsured: 15. 

20 percent of all college students 18-23 were uninsured in 2006. 

Source: GAO analysis of CPS data for 2006. 

Notes: Only non-Hispanics were included in the black, Asian, and white 
categories. Differences in the estimates are statistically significant. 
Estimates for black, white, and all college students are subject to a 
sampling error within plus or minus 5 percentage points. Estimates for 
Hispanic and Asian are subject to a sampling error of plus or minus 6 
and 7 percentage points, respectively. 

[End of figure] 

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[Footnote 22] 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.[Footnote 23] 

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.[Footnote 24] 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.[Footnote 25] 

Uninsured College Students Incurred from $120 Million to $255 Million 
in Uncompensated Care for Non-Injury-Related Medical Events in 2005: 

According to our analysis of MEPS data, uninsured college 
students[Footnote 26] incurred from $120 million to $255 million in 
uncompensated care[Footnote 27] 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.[Footnote 28] 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. 

Over Half of Colleges Offered Student Insurance Plans in Academic Year 
2007-2008, and These Plans Were Customized and Plan Benefits Varied: 

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. 

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: 

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.[Footnote 29] (See table 1.) 

Table 1: Percentage of Colleges Nationwide Offering Student Insurance 
Plans for Academic Year 2007-2008, by College Type: 

College type: Four-year private nonprofit; 
Percentage of colleges offering student insurance plans: 71. 

College type: Four-year public; 
Percentage of colleges offering student insurance plans: 82. 

College type: Two-year public; 
Percentage of colleges offering student insurance plans: 29. 

College type: Average of all colleges; 
Percentage of colleges offering student insurance plans: 57. 

Source: GAO random sample of 340 colleges. 

Notes: Differences in the estimates are statistically significant. All 
estimates are subject to a sampling error within plus or minus 10 
percentage points. 

[End of table] 

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).[Footnote 30] (See table 2.) No 
other differences in the percentage of colleges, by size, that offered 
student insurance plans were statistically significant. 

Table 2: Percentage of Colleges Nationwide Offering Student Insurance 
Plans for Academic Year 2007-2008, by College Size: 

College size: Small (200-1,500 students); 
Percentage of colleges offering student insurance plans: 56. 

College size: Medium (1,501-5,000 students); 
Percentage of colleges offering student insurance plans: 52. 

College size: Large (over 5,000 students); 
Percentage of colleges offering student insurance plans: 64. 

College size: Average of all colleges; 
Percentage of colleges offering student insurance plans: 57. 

Source: GAO random sample of 340 colleges. 

Notes: The difference between the percentage of medium-sized colleges 
and the percentage of large colleges that offered student insurance 
plans is significant at 90 percent confidence level. No other 
differences in the estimates were statistically significant. All 
estimates are subject to a sampling error within plus or minus 10 
percentage points. 

[End of table] 

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.[Footnote 31] 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.[Footnote 32] 
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). 

Figure 4: Part-time Student Eligibility for 165 Student Insurance Plans 
Offered in the 2007-2008 Academic Year: 

[See PDF for image] 

This figure is a pie-chart, depicting the following information: 

Part-time Student Eligibility for 165 Student Insurance Plans Offered 
in the 2007-2008 Academic Year: 
Some part-time students eligible: 61%; 
All part-time students eligible: 30%; 
No part-time students eligible: 8%. 

Source: GAO random sample of 340 colleges. 

Notes: Percentages do not add to 100 percent because of rounding. 
Figure reflects part-time student eligibility for 165 student insurance 
plans offered by colleges in our sample. This information is not 
generalizable to other colleges. 

[End of figure] 

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,[Footnote 33] 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. 

Student Insurance Plans Were Customized to Reflect Colleges' 
Priorities, and Plan Benefits Varied: 

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[Footnote 34] 
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.[Footnote 35] 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.[Footnote 36] 

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,[Footnote 
37] annual premiums for plans ranged from about $30 to about $2,400, 
and the average annual premium was about $850.[Footnote 38] Eighty-six 
of the 191 plans we reviewed (45 percent) had annual premiums from $500 
to $999. (See fig. 5.) 

Figure 5: Distribution of Annual Premium Amounts for 191 Student 
Insurance Plans Offered in the 2007-2008 Academic Year: 

[See PDF for image] 

This figure is a vertical bar graph depicting the following 
information: 

Distribution of Annual Premium Amounts for 191 Student Insurance Plans 
Offered in the 2007-2008 Academic Year: 

Annual premium: $0 to $99; 
Number of plans: 51. 

Annual premium: $500 to $999; 
Number of plans: 86. 

Annual premium: $1,000 to $2,400; 
Number of plans: 54. 

Source: GAO random sample of 340 colleges. 

Notes: Figure reflects annual premiums for 191 student insurance plans 
offered by colleges in our sample. This information is not 
generalizable to other student insurance plans. Of these 191 plans, the 
lowest annual premium was $28 and the highest annual premium was 
$2,397. 

[End of figure] 

Student insurance plans were also customized to coordinate with the 
services available at a college's student health center, if one 
exists.[Footnote 39] 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 
student health center; 

* 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.[Footnote 40] 

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,[Footnote 41] 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.[Footnote 42] 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.) 

Figure 6: Percentage of 194 Student Insurance Plans Offered in the 2007-
2008 Academic Year That Established a Maximum Benefit, and Distribution 
of Maximum Benefit Amounts for 131 Plans with a per Condition per 
Lifetime Benefit: 

[See PDF for image] 

This figure contains both a pie-chart and a vertical bar graph. The 
following data is depicted: 

Did not establish a maximum benefit amount: 4%; 
Established a maximum benefit amount on another basis: 28%; 
Established a maximum benefit amount on a per condition per lifetime 
basis: 68%. 

The 68% that established a maximum benefit amount on a per condition 
per lifetime basis is further broken down as follows: 

Benefit amount: $2,500 to $9,999; 
Number of plans: 20. 

Benefit amount: $10,000 to $19,999; 
Number of plans: 16. 

Benefit amount: $20,000 to $29,999; 
Number of plans: 33. 

Benefit amount: $50,000; 
Number of plans: 46. 

Benefit amount: $50,000 to $1,000,000; 
Number of plans: 16. 

Source: GAO random sample of 340 colleges. 

Notes: Figure reflects the use of maximum benefit amounts for 194 
student insurance plans offered by colleges in our sample. This 
information is not generalizable to other student insurance plans. Of 
the 194 plans we reviewed, 131 plans (68 percent) established a maximum 
benefit amount on a per condition per lifetime basis, 55 plans (28 
percent) established a maximum benefit exclusively on another basis, 
and 8 plans (4 percent) did not establish a maximum benefit amount--4 
of these plans offered unlimited lifetime benefits, and the other 4 
plans limited benefits for all covered services without setting an 
overall maximum benefit amount. None of the student insurance plans we 
reviewed had maximum benefit amounts from $30,000 to $49,999 per 
condition per lifetime. 

[End of figure] 

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.[Footnote 43] 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. 

Figure 7: Distribution of Maximum Benefit Amounts by Type, for 191 
Maximum Benefits Offered by 186 Student Insurance Plans Offered in the 
2007-2008 Academic Year: 

[See PDF for image] 

This figure is a line chart depicting the following information: 

Per condition per lifetime: 
Number of plans: 131; 
Lowest maximum benefit amount: $2,500; 
Median maximum benefit amount: $25,000; 
Highest maximum benefit amount: $1,000,000. 

Per condition per year: 
Number of plans: 27; 
Lowest maximum benefit amount: $2,500; 
Median maximum benefit amount: $50,000; 
Highest maximum benefit amount: $100,000. 

Per year: 
Number of plans: 21; 
Lowest maximum benefit amount: $$15,000; 
Median maximum benefit amount: $50,000; 
Highest maximum benefit amount: $250,000. 

Per lifetime: 
Number of plans: 12; 
Lowest maximum benefit amount: $100,000; 
Median maximum benefit amount: $500,000; 
Highest maximum benefit amount: $1,000,000. 

Source: GAO random sample of 340 colleges. 

Notes: Figure reflects the 191 maximum benefit amounts established for 
186 student insurance plans offered by colleges in our sample; 5 of the 
186 plans we reviewed established two maximum benefit amounts, which 
are reflected in the figure. This information is not generalizable to 
other student insurance plans. 

[End of figure] 

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. 

Colleges and States Have Taken a Variety of Steps to Increase the 
Number of Insured College Students: 

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. 

Some Colleges and States Have Required Students to Have Health 
Insurance: 

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.[Footnote 44] 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.[Footnote 45] 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.) 

Table 3: Percentage of Colleges Nationwide Requiring All Full-time 
Students to Have Health Insurance for Academic Year 2007-2008, by 
College Type: 

College Type: Four-year private nonprofit; 
Percentage of colleges requiring all full-time students to have health 
insurance: 62. 

College Type: Four-year public; 
Percentage of colleges requiring all full-time students to have health 
insurance: 22. 

College Type: Two-year public; 
Percentage of colleges requiring all full-time students to have health 
insurance: 3. 

College Type: Average of all colleges; 
Percentage of colleges requiring all full-time students to have health 
insurance: 30. 

Source: GAO random sample of 340 colleges. 

Notes: Differences in the estimates are statistically significant. All 
estimates are subject to a sampling error within plus or minus 10 
percentage points. 

[End of table] 

Small colleges were generally more likely to require full-time students 
to have health insurance than large colleges.[Footnote 46] 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.) 

Table 4: Percentage of Colleges Nationwide Requiring All Full-time 
Students to Have Health Insurance for Academic Year 2007-2008, by 
College Size: 

College size: Small (200-1,500 students); 
Percentage of colleges requiring all full-time students to have health 
insurance: 40. 

College size: Medium (1,501-5,000); 
Percentage of colleges requiring all full-time students to have health 
insurance: 33. 

College size: Large (over 5,000 students); 
Percentage of colleges requiring all full-time students to have health 
insurance: 16. 

College size: Average of all colleges; 
Percentage of colleges requiring all full-time students to have health 
insurance: 30. 

Source: GAO random sample of 340 colleges. 

Notes: Differences between the percentage of small and large colleges 
and the percentage of medium-sized and large colleges are statistically 
significant. No other differences in the estimates were statistically 
significant. All estimates are subject to a sampling error within plus 
or minus 10 percentage points. 

[End of table] 

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.[Footnote 47] 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.[Footnote 48] In 1991, 
New Jersey also began requiring all full-time students attending 
college in the state to have health insurance.[Footnote 49] 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.[Footnote 50] 

Some Colleges Have Jointly Purchased Health Insurance: 

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.[Footnote 51],[Footnote 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.[Footnote 53] 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. 

Some States Have Expanded Dependents' Eligibility for Private Health 
Insurance: 

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. 

Recently, states have taken a number of steps to expand dependents' 
eligibility for coverage. Some states have increased the age up to 
which a child is considered a dependent on another person's health 
insurance policy. For example, in 2007 Idaho began requiring that 
dependent coverage be available to certain full-time students up to age 
25.[Footnote 54] In 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[Footnote 55] and 
Connecticut[Footnote 56] 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. 

Alternatively, some states have expanded dependent coverage so that it 
is available for dependents who cannot attend college classes on a full-
time basis because of medical conditions. For example, in June 2006, 
New Hampshire began requiring insurance carriers to make dependent 
coverage available for up to 12 months for college students who, as a 
result of medical conditions, leave college or continue as part-time 
students.[Footnote 57] Recently, a number of other states implemented 
similar laws. For example, in 2007, Michigan and Virginia began 
requiring that dependent coverage be available for a period of up to 12 
months for college students who take medical leaves of 
absence.[Footnote 58],[Footnote 59] 

External Comments: 

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 [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions on this report, please contact 
me at (202) 512-7114 or at [email protected]. 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. 

Signed by: 

John E. Dicken: 
Director, Health Care: 

[End of section] 

Appendix I: Scope and Methodology: 

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.[Footnote 60] 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. 

Insurance Status of College Students: 

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. 

Uninsured College Students' Characteristics and Financial Impact: 

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-Â½-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.[Footnote 61] 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. 

Availability and Characteristics of College Student Insurance Plans: 

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.[Footnote 62] 

Data Collected on Student Insurance Plans Offered by Colleges: 

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.[Footnote 63] 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.[Footnote 64] 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. 

Table 5: Characteristics of the 2005 U.S. College Population and the 
Sample of Colleges Used for Data Collection: 

College type: Two-year public;
Undergraduate enrollment size: Small; 
Population: 242; 
Sample: 30. 

College type: Two-year public; 
Undergraduate enrollment size: Medium; 
Population: 441; 
Sample: 53. 

College type: Two-year public; 
Undergraduate enrollment size: Large; 
Population: 412; 
Sample: 50. 

College type: Two-year public; 
Undergraduate enrollment size: Total; 
Population: 1,095; 
Sample: 133. 

College type: Four-year public; 
Undergraduate enrollment size: Small; 
Population: 72; 
Sample: 9. 

College type: Four-year public; 
Undergraduate enrollment size: Medium; 
Population: 169; 
Sample: 20. 

College type: Four-year public; 
Undergraduate enrollment size: Large; 
Population: 369; 
Sample: 45. 

College type: Four-year public; 
Undergraduate enrollment size: Total; 
Population: 610; 
Sample: 74. 

College type: Four-year private nonprofit; 
Undergraduate enrollment size: Small; 
Population: 560; 
Sample: 68. 

College type: Four-year private nonprofit; 
Undergraduate enrollment size: Medium; 
Population: 456; 
Sample: 55. 

College type: Four-year private nonprofit; 
Undergraduate enrollment size: Large; 
Population: 84; 
Sample: 10. 

College type: Four-year private nonprofit; 
Undergraduate enrollment size: Total; 
Population: 1,100; 
Sample: 133. 

Source: GAO analysis of Integrated Postsecondary Education Data System 
data for 2005. 

Note: 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). 

[End of table] 

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. 

Data Collection: 

To gather information on the availability of health insurance plans for 
college students[Footnote 65] 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.[Footnote 66] 
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. 
[Footnote 67] 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.[Footnote 68] 

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. 

Data Analysis: 

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. 

Case Studies: 

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.[Footnote 69] 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. 

Interviews with Officials from Insurance Industry Companies: 

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. 

Efforts to Increase the Number of Insured College Students: 

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.[Footnote 70] 
Finally, to describe efforts to expand dependents' eligibility for 
private health insurance, we reviewed states' laws. 

[End of section] 

Appendix II: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

John E. Dicken, (202) 512-7114 or [email protected]: 

Acknowledgments: 

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. 

[End of section] 

Footnotes: 

[1] COBRA, Pub. L. No. 99-272, 100 Stat. 82 (1986) (codified as amended 
in scattered sections of 26, 29, and 42 U.S.C.) 

[2] HIPAA, Pub. L. No. 104-191, 110 Stat. 1936 (codified as amended in 
scattered titles of U.S.C.) 

[3] We focused our analysis on college students aged 18 through 23 
because (1) the majority of undergraduate college students are of this 
age, (2) most college students of this age are undergraduate college 
students, and (3) data on the insurance status of college students and 
the characteristics and financial impact of uninsured college students 
were available for students in this age range. 

[4] Throughout this report, we use the term college to refer to 
postsecondary schools. 

[5] 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. 

[6] Pub. L. No. 89-329, Â§Â§ 401-467, 79 Stat. 1219, 1232-54 (codified as 
amended at 20 U.S.C. Â§Â§ 1070-1099c-2). 

[7] Unless otherwise noted, we use the term college students to refer 
to domestic undergraduate college students. 

[8] In contrast, we did not consider plans as offered by the college 
when the college made information available about several insurance 
options not specifically intended for its students. We also did not 
collect information on accident-only plans, dental or vision plans, or 
plans offered exclusively to student athletes. 

[9] Kaiser Family Foundation and Health Research and Educational Trust, 
Employer Health Benefits: 2006 Annual Survey (Menlo Park, Calif., and 
Chicago, Ill.: 2006); Mercer Health and Benefits, National Survey of 
Employer-Sponsored Health Plans: 2006 Survey Report (New York, N.Y.: 
2007); and America's Health Insurance Plans Center for Policy and 
Research, Individual Health Insurance 2006-2007: A Comprehensive Survey 
of Premiums, Availability, and Benefits (Washington, D.C.: 2007). 

[10] Unless otherwise noted, all of our estimates on uninsured college 
students (from CPS) and uncompensated care (from MEPS) are within plus 
or minus 5 percentage points of the population value at a 95 percent 
confidence level, and all of our estimates on college student insurance 
plan availability and requirements are within plus or minus 10 
percentage points of the population value at a 95 percent confidence 
level. In addition, unless otherwise noted, the results of our analysis 
on the demographic characteristics of college students more likely to 
be uninsured (from CPS) and our results on the number and types of 
colleges more likely to offer and require health insurance (from our 
data collection) are significant at a 95 percent confidence level. 

[11] When an employer purchases health coverage from an insurance 
carrier, the carrier assumes the risk of providing health benefits to 
enrollees. In contrast, employers that self-fund their health insurance 
plans and directly provide coverage to their employees and employees' 
dependents assume the risk of providing the insurance. 

[12] In contrast, plans offered through the Federal Employees Health 
Benefits Program in 2008 offered coverage for policyholders' unmarried 
dependent children, regardless of their college enrollment status, 
through age 21. 

[13] COBRA, Pub. L. No. 99-272, Title X, Â§Â§ 10001-10003, 100 Stat. 82, 
222-37 (codified as amended in scattered sections of 26, 29, and 42 
U.S.C.). Title X of COBRA requires employers that offer group health 
plans and have 20 or more employees to make available health insurance 
coverage for employees and their dependents who have lost eligibility 
for the employer's coverage because of certain events, including the 
loss of employment or the loss of eligibility as a dependent on a 
parent's plan. 

[14] Eligible individuals include those who (1) most recently had 
creditable health insurance coverage through an employer-sponsored or 
other group plan for at least 18 months; (2) had no subsequent breaks 
in coverage of 63 or more days; (3) are not eligible for a group health 
plan, Medicaid, or Medicare; and (4) have exhausted continuation 
coverage through COBRA, the Federal Employees Health Benefits Program, 
or other state continuation of coverage laws. HIPAA, Pub. L. No. 104- 
191, Â§ 111, 110 Stat. 1936, 1978-79 (codified at 42 U.S.C. Â§ 300gg-41). 

[15] The length of an allowable waiting period is based on any 
creditable coverage the individual may have. HIPAA allows states to 
provide more generous protections for eligible individuals, including 
but not limited to even greater limitations on waiting periods. HIPAA, 
Pub. L. No. 104-191, Â§Â§ 101, 102, 110 Stat. 1936, 1939-47, 1955-61 and 
1971-72 (codified as amended at 29 U.S.C. Â§Â§ 1181 and 1184 and 42 
U.S.C. Â§Â§ 300gg and 300gg-23). 

[16] CPS data do not show whether college students used provisions of 
COBRA to continue employer-sponsored health insurance plans. Insurance 
industry officials we interviewed told us that they were unaware of 
sources of data on the number of college students who use COBRA 
provisions to continue employer-sponsored health insurance, but thought 
that few students use COBRA to continue their health insurance. 

[17] This estimate is within plus or minus 133,000 of the population 
value at a 95 percent confidence level. 

[18] 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. 

[19] This estimate is within plus or minus 6 percentage points of the 
population value at a 95 percent confidence level. 

[20] This estimate is within plus or minus 7 percentage points of the 
population value at a 95 percent confidence level. 

[21] See U.S. Census Bureau, Income, Poverty and Health Insurance 
Coverage in the United States: 2006 (Washington, D.C.: 2007). 

[22] This estimate is within plus or minus 7 percentage points of the 
population value at a 95 percent confidence level. 

[23] See U.S. Census Bureau, Income, Poverty and Health Insurance 
Coverage in the United States: 2006. 

[24] We used the U.S. Census Bureau's definition of these geographic 
regions. The difference--between the percentage of college students 
aged 18 through 23 from states in the West and South who were uninsured 
in 2006, compared to those from states in the Northeast and Midwest who 
were uninsured in 2006--is significant at 90 percent confidence level. 

[25] See U.S. Census Bureau, Income, Poverty and Health Insurance 
Coverage in the United States: 2006. 

[26] For the purpose of this analysis, we use the term uninsured 
college students to refer to college students who were uninsured for 
all or part of 2005. We included uncompensated care incurred by these 
individuals only during the time they were uninsured. 

[27] Our estimate of uncompensated care includes medical care for which 
no payment was made, and does not include medical care for which a 
partial payment was made. Therefore, we may underestimate the total 
amount of non-injury-related uncompensated care incurred by uninsured 
college students. 

[28] In contrast, a smaller portion of the total amount of 
uncompensated care for non-injury-related medical expenses was incurred 
through other types of care, such as hospital outpatient visits and 
hospital inpatient stays. 

[29] In addition, students attending 2-year public colleges may be more 
likely to be uninsured than those attending other types of colleges in 
part because a higher proportion of students attending these colleges 
belong to certain groups that are more likely to be uninsured. 
According to Department of Education data, students attending 2-year 
public colleges were more likely to be enrolled part-time and were more 
likely to be from minority groups than those attending 4-year public or 
4-year private colleges in 2005, and as we reported earlier, students 
from these groups were more likely to be uninsured than students from 
other groups. 

[30] The difference between the percentage of medium-sized colleges and 
the percentage of large colleges that offered student insurance plans 
is significant at a 90 percent confidence level. However, the 
differences between the percentage of small and medium-sized colleges 
and between the percentage of small and large colleges that offered 
student insurance plans are not significant at a 90 percent confidence 
level. 

[31] Our data analysis reflects the college's or insurer's definition 
of full-time and part-time enrollment status. In the absence of such a 
definition, we considered a part-time student any student enrolled in 
at least 1 credit hour but less than 12 credit hours. 

[32] Of the 340 colleges we reviewed, 194 colleges offered plans and we 
were able to gather information on part-time student eligibility for 
165 of these plans. 

[33] Of the 10 colleges we reviewed in our case studies, 1 college had 
no part-time students and another college had less than 1 percent of 
its students enrolled part-time. 

[34] Preventive services include services such as routine physical 
exams and routine Pap tests. 

[35] See Title IX of the Education Amendments of 1972, Pub. L. No. 92- 
318, Â§Â§ 901-907, 86 Stat. 235, 373-75 (codified as amended at 20 U.S.C. 
Â§Â§ 1681-1688); section 504 of the Rehabilitation Act of 1973, Pub. L. 
No. 93-112, Â§ 504, 87 Stat. 355, 394 (codified as amended at 29 U.S.C. 
Â§ 794); and the Age Discrimination Act of 1975, Pub. L. No. 94-135, 
Title III, 89 Stat. 713, 728-32 (codified as amended at 42 U.S.C. Â§Â§ 
6101-6107). 

[36] If a college student insurance plan's historical claims experience 
shows that the plan has consistently paid more for benefits than the 
amount of premiums collected, the plan may have to increase premiums or 
decrease benefits. In addition, colleges whose plans are projected to 
enroll a larger and more diverse group of students--such as colleges 
that require students to have insurance--are generally able to offer 
plans with more affordable premiums or more comprehensive benefits than 
colleges with plans that enroll a smaller, less diverse group of 
students. 

[37] Of the 340 colleges we reviewed, 194 colleges offered plans, and 
we were able to gather premium information for 191 of these plans. 

[38] The average annual premium for student insurance plans (about 
$850) offered for academic year 2007-2008 was about 80 percent less 
than the average annual premium for employer-sponsored plans offered in 
2006, and about 37 percent less than that for individual market plans 
covering young adults aged 18 through 24 in December 2006 or January 
2007. According to two national employer health benefits surveys, 
surveyed employers' preferred provider organization (PPO) plan premiums 
averaged about $4,400 for single coverage in 2006. According to a large 
national survey of individual health insurance, individual market plans 
sold to those aged 18 through 24 in December 2006 and January 2007 had 
an average annual premium of about $1,360 for single coverage. (Kaiser 
Family Foundation and Health Research and Educational Trust, Employer 
Health Benefits: 2006 Annual Survey; Mercer Health and Benefits, 
National Survey of Employer-Sponsored Health Plans: 2006 Survey Report; 
and America's Health Insurance Plans Center for Policy and Research: 
Individual Health Insurance 2006-2007: A Comprehensive Survey of 
Premiums, Availability, and Benefits.) 

[39] The services available at college student health centers range 
from limited services provided by one nurse to extensive inpatient and 
urgent care services provided by multiple specialists. 

[40] Student health centers that offer services to students free of 
charge or at low cost may help to subsidize the cost of these services 
by using proceeds from a health fee charged to all students. 

[41] Of the 340 colleges we reviewed, 194 colleges offered plans and we 
gathered information on maximum benefits established for all of these 
plans. Of these 194 plans, 186 plans set maximum benefits and 5 of 
these plans established two maximum benefit amounts. We report our 
results based on the 191 total maximum benefit amounts established for 
186 plans. Eight plans we reviewed (4 percent of all plans) did not 
establish a maximum benefit--4 of these plans explicitly offered 
unlimited lifetime benefits, and the other 4 plans limited benefits for 
all covered services without setting an overall maximum benefit amount. 

[42] For example, if a student enrolled in a plan with a $50,000 per 
condition per lifetime maximum benefit amount and the student had two 
distinct illnesses, the plan would pay for covered services up to 
$50,000 for each illness. 

[43] In contrast to employer-sponsored plans, the student insurance 
plans we reviewed were more likely to limit total plan benefits. 
According to a national employer health benefits survey, over two- 
thirds of PPO plans offered by large employers limited total plan 
benefits in 2006. In contrast, 96 percent of the student insurance 
plans we reviewed established a maximum benefit in academic year 2007- 
2008. Similarly, according to a national survey of individual market 
plans in force during December 2006 and January 2007, over 90 percent 
of individual market single coverage PPO or point-of-service plans--the 
most common types of plans sold in this market--limited total plan 
benefits. Further, the student insurance plans we reviewed were more 
likely to set lower maximum benefit amounts than employer-sponsored or 
individual market plans. According to the employer health benefits 
survey, among PPO plans offered by large employers, plans with a 
maximum benefit per lifetime had a median maximum benefit amount of $2 
million. In addition, according to the survey of individual market 
plans, over two-thirds of all PPO or point-of-service plans that had a 
maximum benefit and were in force in December 2006 or January 2007 had 
a maximum benefit of $5 million or more, and nearly all had a maximum 
benefit of $2 million or more. In contrast, the median maximum benefit 
amount for the 12 student insurance plans we reviewed that had a 
lifetime maximum in academic year 2007-2008 was about $500,000. (Mercer 
Health and Benefits, National Survey of Employer-Sponsored Health 
Plans, 2006 Survey Report, and America's Health Insurance Plans Center 
for Policy and Research, Individual Health Insurance 2006-2007: A 
Comprehensive Survey of Premiums, Availability, and Benefits.) 

[44] Few colleges require all students to enroll in the college's 
student insurance plan regardless of students' other health insurance 
coverage. 

[45] As we noted earlier in this report, the student insurance plans we 
reviewed had premiums and benefits that varied widely. As a result, 
although implementing a health insurance requirement may increase the 
number of insured students, colleges that implement such a requirement 
without mandating an adequate minimum level of coverage and offering a 
plan that meets or exceeds this level of coverage standard may not 
increase the number of adequately insured students. 

[46] The difference between the percentage of small colleges and the 
percentage of medium-sized colleges that required all full-time 
students to have health insurance is not significant at a 90 percent 
confidence level. 

[47] Colleges that require health insurance can include the cost of the 
health insurance premiums in the college's overall cost of attendance, 
which establishes students' financial need and may enable students to 
receive financial aid to pay for their health insurance premiums. 

[48] MASS. GEN. LAWS ch. 15A, Â§ 18 (2007) (originally codified at MASS. 
GEN. LAWS ch. 15A, Â§ 7B (1989) as enacted by 1988 Mass. Acts ch. 23, Â§ 
22 (effective 1989)). In addition to requiring students to have health 
insurance, Massachusetts also requires students' plans--purchased 
through their colleges or through another source--to meet minimum 
standards, which include coverage for preventive and primary care 
services, emergency services, surgical services, hospitalization, 
ambulatory patient services, and mental health services. If plans limit 
benefits per condition, they must cover benefits up to $50,000 per 
year. 114.6 MASS. CODE REGS. Â§Â§ 3.04, 3.05 (2007). According to the 
Massachusetts Office of Health and Human Services, one of the primary 
reasons for the mandatory student health insurance program is to 
promote students' access to quality and comprehensive health insurance. 

[49] N.J. STAT. ANN. Â§ 18A:62-15 (2007) (enacted by 1991 N.J. SESS. LAW 
SERV. 187 (West)). An earlier version of this requirement was enacted 
in 1989 and expired in 1990. (N.J. STAT. ANN. Â§ 18A:62-14 (1989) as 
enacted by 1989 N.J. SESS. LAW SERV. 1 (West)). New Jersey requires 
that college students' health insurance covers basic hospital benefits. 

[50] The University of California requirement applies to all of its 
undergraduate students. The Idaho State Board of Education requirement 
applies to all full-fee paying students enrolled at institutions under 
the governance of the board, including undergraduate, graduate, or 
professional study students enrolled on a full-time or part-time basis, 
as well as to students admitted on a nonmatriculated basis. 

[51] 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. 

[52] Most (48) of the 62 colleges we identified as purchasing health 
insurance through a consortium did not require students to have 
insurance. 

[53] Consortiums may also provide colleges that are already organized 
together under the same board of regents or university system the 
opportunity to reduce plan administration costs and offer a similar 
plan to students across all campuses when purchasing health insurance. 

[54] IDAHO CODE Â§ 41-2103 (2007) (enacted by 2007 Idaho Sess. Laws ch. 
148). Individuals may be eligible for coverage as dependents in Idaho 
if they are unmarried children under the age of 21, unmarried full-time 
students under the age of 25 who are financially dependent upon their 
parents, or unmarried children of any age who are medically certified 
as disabled and dependent upon their parents. 

[55] N.J. STAT. ANN. Â§ 17:48-6.19(a) (2007) (enacted by 2005 N.J. Sess. 
Law Serv. 375 (West) (approved and effective 2006)). To be eligible for 
coverage as a dependent in New Jersey, individuals must be either state 
residents or full-time students who are unmarried and do not have their 
own dependents. 

[56] CONN. GEN. STAT. Â§Â§ 38A-497, 38A-554 (2007) (effective 2009) 
(enacted by 2007 Conn. Acts 07-185 (Reg. Sess.)) (effective date 
amended by 2007 Conn. Acts 07-2 (Spec. Sess.)). To be eligible for 
coverage as a dependent in Connecticut, individuals must be unmarried 
state residents. 

[57] N.H. REV. STAT. ANN. Â§Â§ 415:5 I(3-a)(b), 415.18 V(b) (enacted by 
2006 N.H. Laws 321). (This law, New Hampshire House Bill 37, is also 
known as Michelle's Law in honor of a full-time college student who was 
diagnosed with colon cancer and who, against doctor's orders, remained 
a full-time student during treatment so she could keep her dependent 
coverage.) As of 2007, an individual may be eligible for coverage as a 
dependent in New Hampshire if he or she is less than 26 years of age, 
unmarried, a resident of New Hampshire, or enrolled as a student at a 
public or private institution of higher education, and not provided 
coverage under any other group or individual plan. N.H. REV. STAT. ANN. 
Â§ 415:5 I(3)(a) (enacted by 2007 N.H. Laws 352). 

[58] MICH. COMP. LAWS ANN. Â§ 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. 

[59] VA. CODE ANN. Â§ 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. 

[60] Because a probability procedure based on random selections was 
followed for each of the surveys and our file review, the selected 
sample is only one of a large number of samples that might have been 
drawn. Since each sample could have provided different estimates, we 
express our confidence in the precision of our particular sample's 
results as a 95 percent confidence interval (e.g., plus or minus 7 
percentage points). This is the interval that would contain the actual 
population value for 95 percent of the samples that could have been 
drawn. As a result, we are 95 percent confident that each of the 
confidence intervals in this report will include the true values in the 
study population. 

[61] Because MEPS is a 2-1/2-year panel survey and does not directly 
identify college students, we included those who had completed their 
11th year of education at the time the MEPS panel survey began, and 
who, in 2005, identified themselves as students aged 18 through 23. As 
a result, we may have included a small number of 18-year-old high 
school seniors who did not enroll in college in 2005. However, 
according to the U.S. Census Bureau, about half of all 18-and 19-year- 
olds were enrolled in college in 2005. 

[62] Kaiser Family Foundation and Health Research and Educational 
Trust, Employer Health Benefits: 2006 Annual Survey (Menlo Park, 
Calif., and Chicago, Ill.: 2006); Mercer Health and Benefits, National 
Survey of Employer-Sponsored Health Plans: 2006 Survey Report (New 
York, N.Y.: 2007); and America's Health Insurance Plans Center for 
Policy and Research, Individual Health Insurance 2006-2007: A 
Comprehensive Survey of Premiums, Availability, and Benefits 
(Washington, D.C.: 2007). 

[63] IPEDS is a system of surveys designed to collect data from all 
primary providers of postsecondary education. These surveys collect 
institution-level data annually from approximately 9,600 postsecondary 
schools, including over 6,000 eligible for federal student aid 
programs. 

[64] About 93 percent of all undergraduate students at active U.S. 
colleges that participated in Title IV federal 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. In 2006, the 340 colleges in our 
sample enrolled about 1.7 million undergraduate students--12 percent of 
the total population of 14 million undergraduate students attending 
colleges that met our criteria. 

[65] Unless otherwise noted, we use the term college students to refer 
to domestic undergraduate college students. 

[66] Our data reflect the college's or insurer's use or definition of 
the terms full-time and part-time student. In the absence of a 
definition, we considered a full-time student any student enrolled in 
at least 12 credit hours and a part-time student any student enrolled 
in at least 1 credit hour but less than 12 credit hours. 

[67] We considered a plan as offered by the college when it was offered 
to the college's students, either through the college or through a 
consortium of colleges. In contrast, we did not consider a plan as 
offered by the college when the college made information available 
about one or more insurance options that were not specifically intended 
for its students. We also did not collect information on accident-only 
plans, dental or vision plans, or plans offered exclusively to student 
athletes. 

[68] The remaining eight plans did not establish a maximum benefit 
amount--four of these plans explicitly offered unlimited lifetime 
benefits, and the other four plans limited benefits for all covered 
services without setting an overall maximum benefit amount. 

[69] In addition, two of the colleges fully self-funded their insurance 
programs. 

[70] Our list of colleges participating in consortiums includes 
colleges that do not have undergraduate students, such as graduate 
schools. 

[End of section] 

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