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The Affordable Care Act presents challenges for college students

By Aldebra Schroll, M.D.
KevinMD Blog, Oct. 1, 2016

The school year is back in session, and our student health center is busy.  As a college health doctor, I have been able to watch the rollout of the Affordable Care Act (ACA) among this population. Since its passage, more of our students are now insured, but many unique challenges still persist for this population.

Young adults have historically demonstrated high rates of un-insurance. An estimated 30 percent of those 19 to 25 years old were uninsured prior to passage of the ACA. They may have been working in jobs that did not offer coverage. Often, they had been excluded from health care when they aged out of their parents’ plan, or they were denied access due to pre-existing conditions.

Referred to as the “young invincibles,” young adults are considered an important part of the insurance marketplace. This population is generally healthy, not requiring a great deal of medical care, thus providing a balance by subsidizing the older, usually sicker population. The concern is that without the young adults buying health plans, the insurance exchanges will be burdened with the cost of an older, sicker population producing what has been called a “death spiral” where in the cost of insurance rises beyond what people can afford.

Since passage of the ACA, young adults have benefited with an expansion of health insurance coverage allowing them to stay on their parents’ plan until the age of 26. An estimated three million young adults have gained coverage through their parents’ health insurance plans. However, that assumes the parents have a health plan. I frequently find our students have been uninsured and had no regular access to health care in the years prior to arriving at college.

For those who are covered under a family plan, there is a cost in terms of privacy. College students are young adults; many of whom prefer to have their medical needs managed without parental knowledge or oversight. Those who remain on their parents’ healthcare plan into young adulthood often express concerns about their privacy. This is particularly apparent when addressing issues of sexual health, psychiatric care or treatment for alcohol or drug abuse. Although their medical chart remains private; if they use their insurance for a referral, testing or treatment, the explanation of benefits (EOB) will go to the primary insurance holder, usually a parent. At an age when medical providers are trying to encourage this population to take on the responsibility for their health; this is a persistent challenge.

Furthermore, I have found the policy to rescind insurance coverage at the age of 26 to be arbitrary. Many of our graduate and even undergraduate students are still enrolled at this age. Suddenly they find themselves uninsured, which can lead to major interruptions in their health care management, particularly for those who have an emergency, need hospitalization or specialty care.

Another concern for this population is cost sharing and issues of underinsurance. Cost sharing for silver plans is about $3,000 and over $5,000 for the bronze level plans. When considering the increasing costs of higher education, the added expense of health care can stretch the budget of a student, creating another stressor.

Expansion of Medicaid has also aided young adults; particularly in those states that agreed to accept the Medicaid expansion. Unfortunately, twenty states have chosen to “opt out” of the Medicaid expansion. This has led millions of citizens to find themselves in the “coverage gap.” They do not qualify for tax credits to purchase a plan; while at the same time, they are ineligible for coverage through Medicaid. This is a common dilemma for students who are working while attending college.

For our students who are eligible for Medi-Cal, the California State Medicaid program they often wait several weeks to get enrolled and then find there are no local providers taking new patients. For those who are enrolled in managed care Medi-Cal in their county of origin but attending school in another county, sometimes hundreds of miles away, they find themselves out of network, limiting their access to care. This issue also arises when students enroll in a private plan, then relocate to attend college far from home.

Meeting the needs for students with mental illness is a growing concern for campuses across the country. Greater numbers of students arrive on campus, having previously been treated for mental health issues. Finding appropriate specialists that are in network and taking new clients is a constant struggle for a semi-rural campus such as ours.

Many of our students remain uninsured for a variety of reasons. They may not understand or see the need to get coverage. Some find “shopping” for options on the state website to be daunting. They are also confused thinking that having access to our student health services is the same as insurance.

Despite the implementation of the ACA, our current health care delivery system is convoluted, creating a maze of challenges to those seeking care. It is inefficient and enormously costly, rife with bureaucratic waste. A single-payer national health system would provide comprehensive health care through a system that covers all medically necessary care, with simple enrollment and allowing the free choice of doctor. Such a plan, often referred to as “Medicare for all” would save an estimated $400 billion a year by eliminating the costly administrative expenses associated with the private insurance industry. Anticipated benefits include the elimination of the insurance networks that bind people to a particular geographic area. Further benefits are anticipated through job growth; as employers would no longer carry the burden of providing health care insurance.

The Affordable Care Act was a laudable attempt at guaranteeing health care access to all. However it has fallen far short. Millions remain uninsured; those who obtained coverage must deal with high co-pays, deductibles, and limited networks. The college-age population has many unique challenges as they transition to adulthood and take on the responsibility for managing their health care needs. This population could benefit greatly in a single-payer health care model offering affordable, comprehensive coverage, with geographic flexibility while ensuring their privacy.

Aldebra Schroll is a family physician.

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