Graduation is seven months away. For a 22-year-old undergrad whose post-baccalaureate plans are nebulous, this might seem like forever. Not for me. In January 2000, at the age of 42, I returned to college after a long academic hibernation. I've been a part-time college student ever since, creeping up on a long-delayed graduation.
There is no single, overriding reason why I returned to college after so long away, but I felt trapped between a spouse wrapping up work on her M.A. in journalism and a son in high school who demanded to know why his college dropout father was pushing him into higher education. Unless I returned to college immediately, I would soon be the least-educated person in the house. Baylor's then-generous tuition remission program for employee family members -- my wife is managing editor of an academic journal -- eased my concerns about the financial burden of returning to school and ensured that Baylor was the only university to which I applied.
Since returning, I have been challenged in unexpected ways. Baylor does little to accommodate nontraditional undergraduate students, offering no weekend classes and few evening classes. Some offices close during the lunch hour, and entire buildings are sealed tighter than Tupperware promptly at 5:00.
Initially, I held a traditional full-time job, and I often flew across town with minimal regard for traffic signals, hoping to beat the English department's noon lock-down. Each time I arrived to find the office door handle still warm from the hand of the person who locked it, I taught new and imaginative curse words to Baylor's abundant squirrel population.
Back then, registration and payment of tuition and fees required a day off work, a beach ball-sized bladder, and the endurance of a sequoia as lines moved slower than frozen molasses. While Baylor's adoption of electronic solutions reduced my frustration by allowing me to register and pay fees online, the university's constant upgrading of hardware and software soon outpaced my personal budget. Now I must travel to campus just to find a computer powerful enough to complete these tasks.
Even though I successfully overcame real and imagined obstacles, I had no specific plan when I returned to school. At first, I enrolled in one course each semester. I soon realized that I would qualify for AARP membership while I was still receiving student discounts, so I began doubling and tripling my class load.
When presented with the opportunity to move from conventional employment to self-employment, I embraced it. Rather than forcing my class schedule fit my work schedule, I could adjust my workload to fit my class schedule. This becomes increasingly important as I approach the end of undergraduate life, when only single sections of required courses may be offered each semester.
Hardest to adjust to was the realization that I am no longer young. Desks are too small for someone who gained his "freshman 15" and then spent nearly 30 years developing middle-aged spread, and what's left of my hair is now more salt than pepper.
Despite raising one of my own, members of the wired generation confound me. While my family didn't own a television until I reached third grade, my classmates came out of the womb clutching a computer mouse and a cell phone. A once-peaceful walk across campus is now interrupted at every step by the nonstop chatter of the connected, and the beep, chirp and moan of student cell phones regularly disturb classes.
When I was born, there were only 49 states, and I soon learned that most important events in the constitutional history of the United States have happened during my lifetime. This means that my fellow students study history, while I study current events.
In many classes, I've been the oldest person in the room, leading to an awkward sorting out of social convention. Will the instructor treat me with the respect due my age, or with the disdain appropriate for an undergrad?
At the beginning of each semester, professors often question students' about their future plans, and my classmates mention doctor, lawyer and engineer. Me? I want to be a Social Security recipient because there isn't enough time between graduation and retirement to actually have a career.
When I tell my wife about some of my class discussions -- discussions where life experience clearly colors my opinions -- she says, "Don't frighten the children." And it's difficult not to think of my classmates as children, even though many of them are in early adulthood, because my 21-year-old son is among them, and I often find myself enrolled in courses with members of his high school graduating class.
In a university where students of my generation can probably be counted in single digits, there's little opportunity to develop friendships. Even sincere attempts make me feel like the creepy neighbor my mother always warned me about.
But I have tried to experience college life the way a traditional undergrad might.
I've eaten cafeteria food, quickly realizing that the cast-iron stomach I had as a teenager is now one of the seven largest methane producers in Texas, and I must monitor my diet.
My wardrobe slowly devolved, and T-shirts emblazoned with one of Baylor's many logos are now my apparel of choice.
I joined three academic fraternities, but soon decided that my days as a chaperone ended with my son's high school graduation party.
Although I've yet to pull an all-nighter, I've certainly had my share of late-nighters, not opening my textbooks until my family finally retires for the night.
Along with other Baylor students, I've sat in the stands through losing season after losing season of football, and sat glued to the television as our women's basketball team advanced through the NCAA tournament to take the title.
While my son speeds through college without stopping for marriage, children and career, I relish the few advantages of being a college student at my age. I especially enjoy the reaction at the local multiplex when I request the "student discount," and my wife takes great pleasure in telling people that she sleeps with a college student.
I'll be 48 when I finally receive my B.A. in professional writing, having spent six years finishing half of my undergraduate requirements. At this glacial pace, dare I even consider grad school?
Michael Bracken is a 47-year-old senior at Baylor University. His latest book is Yesterday in Blood and Bone, a collection of short stories published by Wildside Press.
Given tightened state budgets stemming from a deteriorating economy, public colleges and universities face unprecedented financial challenges. The phrases “hiring freeze” and “no spending increases” are dominating headlines of campus newspapers (and this Web site). On the consumer side, declining 401(k) and 529 college savings plans are contributing to greater financial demands on students and their families.
Will colleges and universities continue to push this economic burden to families at this difficult time, in the form of higher tuition, room and board, and various fees? Or will the institutions find alternative solutions?
Here at the Center for Student Health and Life, our concerns relate specifically to how this new, harsh reality affects student health and wellness on campus. Exacerbating the problem, health care costs generally have been increasing about 10 percent a year since 2000.
Despite these realities, we believe that every college student deserves access to high quality health and wellness services. Given rising costs, more creative solutions must be found to improve the quality of health care. While reducing the financial burdens placed on students and their families may not be in the realm of the possible, rising costs must end.
Unfortunately, many schools are increasing the fees that all students are required to contribute toward a student health center (which further increases financial aid demands). For example, the health fee at North Carolina State University is now slated to increase to $247 from $196 three short years ago. At the University of Maryland at College Park, budget cuts have translated into a hiring freeze, causing a position for a staff psychologist to become vacant in January. The University of Nevada at Las Vegas student newspaper recently printed an article titled “Hiring Freeze Hurts Health Center.”
But hiring freezes and/or fee increases at student health centers can be averted at many medium and large-sized schools by dealing with some cultural obstacles and following the lead of some of their peer schools.
There are several approaches that could work for many schools, including:
Making it easier for a family’s health plan to be accepted at student health centers; and
Negotiating more effectively with private insurance companies for those who are not covered under their family plans.
According to a recent Government Accountability Office study, 80 percent of college students have health insurance, with two-thirds of college students covered under a parent’s employer sponsored plan. More good news is that recently passed legislation which has now been signed into law ensures that a student’s family coverage continues even if the student takes a break from their studies due to illness (a tragic loophole that has now been fixed). And many states are increasing the age under which a child can remain on their parent’s plan, including New Jersey, which raised the age limit to 30.
But the reality is that only about 25 percent of the “out of network” costs are reimbursed when the health center is not “in network,” according to The History and Practice of College Health, by H. Spencer Turner and Janet L. Hurley (University Press of Kentucky, 2002).
Most parents with whom we’ve talked are surprised that most schools do not make it easy to use a family’s current health insurance coverage. And most students are pretty oblivious as well: in our survey earlier this year, most students did not know whether their health center accepted their family plan or not. To be sure, going “in network” does not necessarily work for all schools, particularly smaller schools with limited facilities for whom the administrative costs would be too high.
The reasons many medium- and large-schools do not make it easy to use family coverage involves historical and cultural obstacles to health centers doing coding, “credentialing” (also necessary to become “in network”) and the paperwork and additional administrative costs involved with filing insurance claims. On one hand, who can blame them? Who wants to deal with insurance companies when many of us rightly or wrongly feel that their goal in life is to “delay, deny and frustrate?” Many doctors and nurses are attracted to college health centers because they can avoid some of these “headaches” and focus exclusively on providing care.
However, budgets are too tight to allow the cultural barriers to continue to stand. Accepting a family's current health insurance policy can eliminate the need for fee increases and prevent staffing cuts. Ohio University and the University of South Florida are two recent examples of schools that recently moved to insurance billing to address financial challenges, keeping administrative costs down along the way.
Ohio University had been facing a $400,000 shortfall for its health center. Inside Higher Edcovered Ohio University’s change to become “in network” providers and accept family insurance policies to deal with its budget crunch. Inside Higher Ed states that "[w]ith the revenue [Ohio University] hopes to tap into, the university is considering a renovation and addition to its health facility, and is expanding its services this fall." The school plans to hire additional psychologists with the added resources, and increase evening and weekend hours.
The University of South Florida now accepts multiple insurance providers, and “this means that going to the clinic will be cheaper for students,” according to The Oracle, the college paper. To reduce administrative costs associated with processing claims, USF teamed up with its medical center, USF Health. Ohio University contracted with a third party billing company to minimize up-front expenditures and administrative costs associated with accepting a student’s family insurance.
Colleges must also do a better job of negotiating insurance policies for the one-third of students who are not covered under their family plan.
Under many insurance plans offered by schools, there’s a lot of fine-print. Just because the school has endorsed a plan on some level, doesn’t mean it has the “Good Housekeeping” seal of approval. Prescription drug coverage is often minimal; there are many exclusions, out-of-pocket maximums are generally high, and benefit ceilings are low. Lab work often has higher costs where the health center is paid for largely by student fees. Schools and students can and should expect more for their coverage, and colleges need to use their purchasing power to negotiate better deals.
The financial challenges facing public colleges and universities have been accentuated during this recent market meltdown. And while every college student deserves access to high quality health and wellness services at their school, these students should not bear such a heavy financial responsibility. Given the rising costs, more creative solutions -- like accepting a family’s current health insurance policy -- must be explored to protect the quality of care while keeping a lid on the rising fees. With schools like Ohio University and the University of South Florida proving the success of this approach, the bar has been set for others to follow.
Jon Englund is the executive director of the Center for Student Health and Life, a national not for profit organization dedicated to improving the health and wellness of college students. You can find more information on the organization on its Web site.
In the 1990s, the anthropologist T.R. Luhrmann did a period of fieldwork among psychiatrists in residency at a hospital, observing young members of that tribe as they acquired its skills and assimilated its mores. The title of her book on this research, Of Two Minds (Knopf, 2000), pointed to a divide within the profession between approaches to mental illness.
One is psychodynamic: It regards symptoms as the most visible dimension of conflicts and tectonic strains deep within the individual personality. The other is biomedical: The psychiatric disorder reflects a problem in the organism, usually at the level of neurochemistry. The distinction points to old philosophical problems. (Are mind and body composed of different substances? What is the relationship between an event within consciousness and something observable happening in the brain?) But for psychiatric practice it amounts to differences in modes of treatment -- between the couch and Prozac, to put it in shorthand.
As Luhrmann’s ethnography showed, it also corresponded to different professional cultures, which were in flux under the double impact of brain research (the elder president Bush had proclaimed the Decade of the Brain on January 1, 1990) and the changing economics of health care. The tools available to biomedical psychiatry had once been very blunt, but the new pharmaceuticals were much more precise. Insurance companies and HMOs were making it harder for patients to get coverage for “talk therapy,” whether Freudian or otherwise. The psychodynamic approach had once enjoyed higher prestige than the biomedical, but this was no longer true. While new practitioners continued to be exposed to both during their residencies, it was pretty clear which one was riding the crest of prevailing trends.
A decade after Of Two Minds appeared, it remains a vivid study of how people become initiated into a professional culture – selecting, and then being shaped by, their path through one of its sub-sectors. An interesting and sometimes riveting counterpoint to it is Danger to Self: On the Front Line with an ER Psychiatrist by Paul R. Linde, just published by the University of California Press. Linde, a clinical professor of psychiatry at the University of California at San Francisco, also serves as a doctor in the city’s General Hospital.
He belongs to the generational cohort described in Luhrmann’s study. But his first stint in a psychiatric emergency room left him with a sense that the vital distinction was not between biomedical and psychodynamic approaches. Instead, it was the distinction between the more buttoned-up, careerist wing of the profession and what his emergency-room colleagues sometimes call “meatball psychiatry.” (The phrase suggests that they are fans of M*A*S*H and identify with the surgeons.)
“I wasn’t obsessive enough to be a psychoanalyst or a researcher,” Linde writes. “I was a little too glib, a little too forthright, and far too much of a nonconformist, rebellious toward authority figures, to submit to the prevailing doctrines of either of American psychiatry’s dominant paradigms: one rapidly rising, the biomedical explosion; the other gradually declining, Freudian psychoanalysis.... The work [in a psychiatric ER] appeals to folks whose temperaments combine an odd mixture of low-grade attention deficit disorder with a high tolerance, but a distinct need, for maximal stimulation.”
It also requires a degree of egalitarianism: “In the psychiatric emergency setting, nurses and doctors work very closely, side by side, with each other.... While it is the physician who has the final say and ultimate responsibility from a practical and medico-legal perspective, it is a foolish emergency psychiatrist who does not collaborate with his or her knowledgeable and experienced psychiatric nurse colleagues in making clinical decisions.”
Linde’s book is a series of essays -- some of them case studies, and some reflections on his continuing education in the structural problems in the world outside the ER that leave wreckage at his door.
Psychiatric dehospitalization is sometimes portrayed as the result of efforts to draw an emancipatory lesson from Foucault’s Madness and Civilization. But the shutting down of six state hospitals during Ronald Reagan’s administration as governor of California might have had more to do with it. “Not only did psychiatrists begin seeing more patients out in the community,” he writes, “but they were also seeing sicker and sicker patients, many of whom just a few years earlier would have been taken care of in state hospitals. It’s not too big a stretch to posit that the explosion of hardcore drug abuse and infectious disease transmission of the 1980s and after was at least partially due to this dehospitalization.”
This had the effect of imposing new responsibilities on the psychiatric ER staff -- duties that were “more and more consistent with police powers than with medical ones.” Obliged to assess the patient’s likelihood to pose “a danger to self or others," Linde says his colleagues are held to “the crystal ball standard." At the same time, there are limits to how much care they can dispense when the law allows them only 72 hours of observation. Medications are now available to treat severe psychiatric problems such as chronic schizophrenia. But they do little sustained good while the revolving door keeps spinning.
“The practice of emergency and acute care psychiatry,” writes Linde, “is more highly influenced today by health-care policy makers, insurance and pharmaceutical companies, regulators, activists, and lawyers than it is by those who actually provide the care.... It’s become convenient for cynical advocates of ‘no new taxes,’ and for politicians and government bean-counters, to ally themselves with impassioned advocates of individual freedom who champion a person’s right to refuse treatment rather than a person’s right to [get] treatment.”
The texture of Danger to Self is more memoiristic than the passages I have quoted may suggest. The author is frustrated with a system that so often puts him in the untenable position of trying to help people while feeling helpless himself.
But most of the essays are stories of trying to do so anyway -- using whatever he can draw from the available stock of drugs while also practicing the mode of active listening taught by the psychodynamic tradition. All the while, he has the complicated and ultimately thankless task of evaluating the patient’s potential for suicidal or homicidal violence.
That, in turn, poses the danger of turning the whole thing into an exercise in voyeurism for the reader -- a danger that, in my opinion at least, Linde avoids. In the final pages, he quotes from the autobiography of William Carlos Williams, where the poet and small-town doctor reflects on his work:
“I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness which was affecting them, it was as though I was awakening from a sleep. For the moment I myself did not exist, nothing of myself affected me.”
Can someone manufacture a pill that will produce this mental state? I doubt there is much profit in it, so probably not. For now, we have this book -- a study in empathy charged up with adrenaline, and functioning against very long odds.
The recent suicides of college students at Yale and Cornell Universities are rightfully cause for shock and sadness, but also a call to action. No doubt, we wonder how young people with so much talent and promise could end their own lives. In struggling to make sense of these tragic events, it is all too appealing – and unhelpful – to resort to simple explanations and casting of blame. In fact, the science of suicide is highly complex, and suicide prediction and prevention present mental health clinicians, and college administrators, with formidable challenges. Even institutions with quality prevention services, like Cornell and Yale, are not immune from these calamities.
Consider that, after accident, suicide is the second leading cause of death among college students. It is estimated that in any given year approximately 7.5 suicides occur for every 100,000 college students, a figure that translates into some 1,400 suicides. Nevertheless, while any death of a young person is heartbreaking, suicides are numerically rare.
At the same time, we know from our own work and much other research that each year about 10 to 15 percent of college students seriously think about suicide, and approximately 2 to 4 percent will make an attempt. This means that for every college student who dies by suicide, there are hundreds who have tried and thousands who have thought about it. Yet, we still have no overarching psychological theory to explain exactly what moves someone from thinking about suicide to taking action.
We do know that most young people who die by suicide have a diagnosable, and often treatable, psychiatric condition, and, frequently, they have told someone of their plan. Regrettably, numerous studies have found that less than 50 percent of depressed college students seek help. And not all manifest obvious signs of their depression.
Recent research has shown that the brain continues to mature throughout one’s 20s, with the area most responsible for decision-making developing last. Some young people, therefore, may act impulsively, without fully appreciating the real consequences of their actions. As a result, suicide in young people sometimes occurs without any apparent warning, either in a setting in which the young person -- most often a young man -- has hidden his despair from others, or as the result of an abrupt and intense impulse, often in the context of judgment-blurring intoxication.
Despite this, it is important to keep the issues in perspective. While universities are seeing larger numbers of students with psychiatric difficulties -- in part because improvements in treatment make it possible for more students with such problems to successfully attend college – the number of suicides on campuses has remained stable over the past 10 years. This suggests that we may be doing a better job at identifying and treating the underlying causes of suicide, such as depression, bipolar disorder, schizophrenia and substance abuse.
We also know that elite colleges do not have higher rates of suicide than others. Academic competition and pressures are not frequent precipitants of suicide in undergraduates. More often, suicide is precipitated by family or relationship problems, often in the context of substance use.
Moreover, we have learned quite a bit about college suicide prevention in the past 15 years. We know that keeping the means used for self-harm out of the hands of potentially suicidal people will save lives. College students have about half the rate of suicide of non-college-attending young people, in part, it appears, because few guns are allowed on college campuses. And there are definitive measures that can prevent an impulsive young person from taking tragic action. The securing and alarming of windows and roofs have been helpful deterrents. Actions such as Cornell’s adding barriers on its bridges are therefore prudent and sensible.
Educational outreach programs are also effective in assisting students, faculty and administrators to identify psychological problems and decreasing the stigma often associated with seeking treatment. Preparing entering students with previously treated disorders to establish a system of continuing care while on campus is vital, as is communication with parents on the importance of such care.
Interestingly, we have learned that we don’t prevent suicides by focusing solely or even too intensively on suicide prevention. Rather, it is essential that colleges offer comprehensive, accessible and affordable systems of general physical and mental health care, and that they utilize community and public health approaches to educate parents, students, faculty and administrators about the need to communicate, support and care for each other. Steps such as "gatekeeper training," in which people most likely to have direct contact with troubled students (resident assistants, writing instructors, academic advisers, athletic coaches and chaplains, among others) are taught to identify and refer such students for counseling and peer education programs, have a proven track record. For example, the award-winning Active Minds on Campus, with chapters across the country, provides a forum in which students present programs focused on promoting acceptance and understanding of people with mental illness.
Many colleges employ online surveys to help students identify problems and utilize other technology-based modes of support, including appointment and medication reminders, to engage troubled students in a way they feel comfortable.
Among all key members of the college community, communication focused on the support and care of students in distress, while respecting the students' privacy, is also essential. Finally, we know that whenever possible, it is best for troubled students to remain in school among their friends and working toward a positive future. At the same time, colleges and universities must allow for students who temporarily cannot function to return home for more intensive assistance and treatment.
In fact, it turns out that when it comes to suicide prevention, students, faculty, administrators and parents are all in this together.
Victor Schwartz and Jerald Kay
Victor Schwartz is university dean of students at Yeshiva University and associate professor of clinical psychiatry at Yeshiva's Albert Einstein College of Medicine. Jerald Kay is professor and chair of the psychiatry at Wright State University’s Boonshoft School of Medicine. They are the editors of Mental Health Care in the College Community (Wiley).
Submitted by Kevin Brown on September 24, 2010 - 3:00am
Previously in these pages, I wrote an essay about my not having a cell phone and what I try to teach students about my choice. I have written online articles before, but I was not prepared for the responses I received. Almost all of them were negative, with some people asking me how I felt about the horseless carriage or suggesting that I begin wearing underwear on my head. What I found most interesting about the debate in the comments section, though, was the overall belief that I should not be trying to change the students’ behavior in any way, that I am not a role model for anything other than my discipline (and perhaps not even there).
I have been thinking about this experience over the past year, as there have been several colleges and universities in the news for trying to adjust their students’ behavior outside the classroom, especially as it relates to health. Last year, Lincoln University, in Pennsylvania, planned to require its incoming students to have their BMI (Body Mass Index) calculated. They proposed a plan where the students would take a course to help them get in better shape. Though Lincoln ultimately rescinded its plan, the University of Texas at Arlington did put into place a course that officials there believed would help encourage students to get in better shape. This plan seems to be working well, as students were so interested that the university had to add extra sections and instructors.
In May, the University of California at Berkeley announced a health-related plan of its own. Berkeley hoped to obtain DNA samples from incoming freshmen, then notify those students about their alcohol and lactose tolerance, as well as their need for folic acid. After a state Department of Public Health ruling, though, they adjusted the program, making it voluntary for students to participate; and the university will not release information to individuals, instead only revealing aggregate results.
All of these stories raise a question that comes from the Lincoln University case, as shown in an Inside Higher Ed article from last fall. In that article, James C. Turner, then-president of the American College Health Association, argued that Lincoln’s requirement “raises questions about personal rights and which trumps, personal rights or university policy.” It is this question that intrigues me and relates to my experience about the role of professors and universities.
I would guess that most professors would be unable to recite or reference any portion of the mission statement of their institution. Most professors argue that it is their primary job to communicate their discipline to students or to engage in research, depending on the type of school. Beyond that, they might argue that they are to be involved in shared governance, advising, and possibly the community. However, I wonder if taking the time to look at our mission statements, which we at least theoretically agree with, might remind us of a larger role that we might play in students’ lives.
I teach at a primarily undergraduate, church-related, teaching-focused institution, all of which one can find in our mission statement. Thus, I decided to look at other colleges in our area that are decidedly different from mine to see what their statements might say on issues that go beyond teaching. At the local community college, they say that their institution “delivers developmental education, university transfer programming, workforce training, and community services”; as one might expect the emphasis is on practical goals that will help students move on to their next stage of life, be that a four-year school or work.
The flagship university for the state system lists its first goal as wanting to “advance the community of learning by engaging in scientific research, humanistic scholarship, and artistic creation,” moving the focus to research and scholarship, not teaching. The preeminent private institution in the state lists only three goals: “quest for new knowledge through scholarship[;] dissemination of knowledge through teaching and outreach[;] creative experimentation of ideas and concepts,” goals that are similar to those of the larger state university.
However, out of the four institutions, three of them also mention some aspect of students’ lives that goes well beyond the idea of academic training and moves into the area of changing their lives in some rather drastic ways. The community college, for example, says that it will “enhance quality of life, and encourage civic involvement,” while the state university will “prepare students to lead lives of personal integrity and civic responsibility in a global society,” “conduct research, teaching, and outreach to improve human and animal medicine and health,” and “contribute to improving the quality of life.” Here at Lee, in addition to the spiritual goals we have for students, we hope to foster “healthy physical, mental, social, cultural and spiritual development.” Only the private institution does not go beyond the basic academic goals in its mission and values.
I’m guessing that, at this point, most professors would respond that these goals are perfectly fine for the institution, but that they have no part in them. They can be handled by the student life function at the school. Let students play intramurals or serve in student government if they are worried about their physical development or want to learn how to become better citizens.
However, these same professors have no trouble attempting to change students’ lives in other, equally dramatic, ways in the classroom. Gerald Graff, former president of the Modern Language Association, wrote in his presidential address from December 2008, “All this [complaint about classroom indoctrination] might be the end of the story if it were not that since the 1960s ‘transforming’ the political consciousness of students has been widely defended in print as a legitimate goal of teaching, as is seen in such self-described trends as ‘the pedagogy of the oppressed,’ ‘critical pedagogy,’ ‘teaching for social justice,’ ‘radical pedagogy,’ and ‘anti-oppressive education.’ ”
The way we approach these subjects and others too numerous to mention does not convey a neutral statement to the students, and most of us have long since ceased claiming that our teaching does. If that is true, then, our approaches to cell phones in classrooms and students’ weight, health, and self-image, among other issues, are also not neutral.
In the same way that a literature class that ignores female authors (or even ignores the fact that it ignores female authors) would be seen as a political act, though no political statement is ever made, an institution that ignores other issues that affect our students is also political. Thus, colleges and universities take a political stance by a lack of action as much as by acting one way or the other.
Of course, such an approach can easily lead to a school becoming Big Brother, watching students’ every move, waiting for them to light a cigarette, go binge drinking, eat an extra doughnut, or spend all of their free time online playing video games or texting their friends. In the same way, though, that we try to educate students about both smoking and drinking, often creating tobacco- and alcohol-free campuses, we can also educate students about health and the importance of face-to-face community.
The real problem is not, though, that professors do not want students’ quality of life to improve; they are afraid that they will then have to be role models for those students. We, like Charles Barkley, do not want to be role models. It smacks of the image of the spinster teacher from the early 1900s who had to have chaperones on dates and bring in coal for the fire in our one-room schoolhouse. It’s old-fashioned to think that students are watching us to see what we’re doing, to see what we value.
They are, though, as those who respect us want to take from us as much as they can. Thus, we must watch not only what we say, but what we do not say, and, perhaps most importantly, what we do.
Kevin Brown is an associate professor of English at Lee University.
Six months after passage of the Affordable Care Act (ACA), health care reform has finally moved off the front pages of America’s newspapers and is no longer the lead story on the nightly news. But below the surface, the controversy and political fights over the issue continue to roil.
Evidence of that came when higher education was recently drawn into the fight. On August 12, the American Council on Education and several other higher education associations wrote to the Department of Health and Human Services and the White House Office of Health Reform to ask for guidance regarding key ACA provisions to ensure colleges and universities could continue to offer students affordable, high-quality health care plans.
The response by the news media, spurred by interest groups following the issue, was almost immediate, and in the last few months organizations ranging from The Wall Street Journal to the College Parents of America have mischaracterized our effort as an attempt to carve out an “exemption” or “waiver” from ACA requirements. Some groups have suggested that we actually oppose efforts to enhance the quality of student health plans, while others say we’re only in it for the money.
They couldn’t be more wrong. Read the letter for yourself.
First, colleges are not seeking either an exemption or a waiver from the law. Historically, student health plans have operated under federal law as so-called “limited duration plans” because they provide coverage for a specific time period and are neither employer-based group plans nor plans offered on the individual market. These programs are tailored to meet the primary care needs of students as well as additional services such as mental health coverage.
Each is priced according to the eligible campus population and provide coverage to all eligible students and their dependents, do not vary premiums based on an individual student’s health status, and typically do not impose pre-existing condition exclusions. They are particularly important for international and graduate students. In short, these plans provide coverage that is responsive to the unique needs of the student population.
While the law specifically states that institutions may continue to offer student health plans, ACA is silent on how the law’s new requirements affect these unique plans. Federal agencies will need to write numerous regulations to implement ACA. Our letter seeks to include among them regulations that clarify how student health plans can continue operating as “limited duration plans” under a structure that incorporates reforms in the ACA -- and not, as some claim, to elude those reforms.
Specifically, we have asked HHS to provide rules of the road on two key topics:
What insurance reforms in ACA apply to student health plans? ACA includes many insurance reforms, such as prohibiting preexisting condition exclusions or other discrimination based on health status, but it is not clear which apply to student health plans.
Assuming student health plans incorporate required insurance reforms and provide at least a minimum ACA-defined level of coverage, will that satisfy the individual mandate to purchase health insurance under ACA?
We seek answers to these questions now because although many of the reforms in ACA don’t take effect until 2014, a number of institutions will soon be negotiating with insurers for new long-term contracts that will define the benefit coverage of their student health plans through 2014.
Are we opposing efforts to enhance the quality of student health plans? Absolutely not. In fact, we are following the lead of the American College Health Association, which has a longstanding set of standards to guide colleges and universities in structuring high quality coverage for student health plans. We also believe ACA will inevitably lead to improvements in the quality of student health plans, which is important because while the majority of institutions offer health plans of high quality — some continue to lag behind and must be improved. The key for us is ensuring that the changes brought about by ACA will result in plans that are both high-quality and affordable.
It is also wrong to characterize our efforts as an attempt to shield a major higher education profit center. The money made off these plans by colleges are modest, and revenue — if any — is returned to campus health centers or used to help maintain stability in the premiums paid by students.
In short, student plans respond to the unique health insurance needs of undergraduate and graduate students. They provide coverage over a limited time period for students under the age of 26 whose parents are uninsured and nontraditional students who are too old to access their parents’ plans. In some instances, student plans offer better coverage than students can get under parental plans, especially if they’re going to college hundreds or thousands of miles away from their parents’ networks or parental coverage does not adequately cover out-of-network care, making it prohibitively expensive.
Colleges and universities recognize the importance of ACA’s reforms and want high-quality health insurance options for their students. We are confident we can work with the administration on a constructive solution to ensure students have access to affordable, high-quality health coverage that is consistent with the reforms in ACA.
Terry W. Hartle and Steven M. Bloom
Terry W. Hartle is the senior vice president and Steven M. Bloom is the assistant director of federal relations for the American Council on Education.
In a recent “Views” piece, representatives of the American Council on Education argued that the higher education community is not attempting to “dodge the health care law” by seeking “clarification” about the application of Affordable Care Act (ACA) mandates to school-sponsored health insurance plans (SHIPs). The authors, Terry Hartle and Steven Bloom, said that ACE is only seeking guidance about ACA mandates for its members.
However, upon analysis, we believe that the authors’ assertions are incorrect. Under no federal regulatory scheme have school-sponsored health plans been deemed to be limited duration plans, and ACE, is, in fact, seeking a waiver from ACA mandates. Let us explain.
Under the federal code, “Short-term, limited-duration insurance means health insurance coverage provided pursuant to a contract with an issuer that has an expiration date specified in the contract … that is less than 12 months after the original effective date of the contract.”
In contrast, SHIP contracts signed between schools and insurers are typically one-year coverage contracts, not limited duration plans as defined by law. For example:
United Healthcare states in some marketing messages to students and contractual language on policies that SHIP is a “one-year non-renewable term policy.”
An Aetna Student Health SHIP vendor policy states that “Coverage for all insured students enrolled for the Fall Semester, will become effective at 12:01 a.m. on August 15, 2010, and will terminate at 12:01 a.m. on August 15, 2011.”
In addition, a ”clarification” of ACA provisions will not waive the applicable state provisions, further complicating the patchwork of uneven regulation and undermining student and parental protection as consumers in these states. This conflict provides an important basis to ensure that ACA’s mandates are followed, namely to create a unified regulatory system with an appropriate floor for beneficiary health care services that harmonizes conflicting legal definitions.
Historically, SHIPs have been treated by federal law as individual health insurance plans. As noted by the Department of Health and Human Services, “health coverage might be provided through an association or other group, such as groups of college students … it is still considered to be ‘individual’ health insurance ….”
Consistent with this policy, SHIPs are considered individual health plans under ACA, since they are not group plans. SHIPs are therefore subject to ACA individual plan mandates, which include free preventive care, medical loss ratio requirements of 80 percent, prohibition of discrimination based on preexisting conditions, the ban on lifetime/annual benefit caps, and other protections.
Through the letter to HHS, ACE seeks to avoid these mandates for their constituents, yet ACE claims that the higher ed community is not requesting a waiver. However, it wishes SHIPs to be considered “limited duration plan[s]” that “can continue to provide coverage under ACA without altering their design.” Quite plainly, ACE is requesting a waiver, both of SHIPs’ actual status as individual plans as well as ACA patient protection requirements.
These SHIPs should not be granted a waiver of any sort. In fact, SHIPs are exactly the types of low-quality plans ACA was designed to address, and across the country they are plagued with access problems, poor quality performance levels, and inappropriately low spending on health care services.
Let’s look closely at just one of ACE’s arguments, in which they indicate that SHIPs “typically do not impose pre-existing condition exclusions.” In fact, most SHIPs do have pre-existing exclusion elements that do not allow for coverage of pre-existing conditions until after a waiting period, usually three or six months after coverage is purchased. For example:
A $2,152-a-year Aetna SHIP notes that only “persons who have remained continuously insured under this Policy or other Policies will be covered for any pre-existing condition.” The policy then goes on to list 45 exclusions.
A Blue Cross/Blue Shield SHIP costs $1,598 and yet has only a $200,000 maximum benefit. "[T]here is a 12-Month preexisting condition exclusion period” and “the Plan will allow up to $500 per lifetime for Covered Medical Expenses related to all preexisting conditions combined.”
Perhaps the State University of New York at Stony Brook provides the most telling indication of pre-existing exclusions in SHIPs: it markets its SHIP by noting others’ limits: “Unlike most student health insurance plans, [our] SHIP does cover pre-existing conditions for our students.”
While ACE indicates that it is not opposed to efforts to enhance the quality of student health plans, its request to allow SHIPs to continue “without altering their design” only ensures continued low-level SHIP performance. Repeated analyses, including examinations by the New York attorney general (and now Governor) Andrew Cuomo and by the Government Accountability Office, have shown these are generally poor-quality plans that represent conflicts of interest between the school and student, and are not “responsive to the unique needs of the student population.”
Finally, granting a waiver for SHIPs will raise costs for a majority of students and parents. Since most students have their own insurance and pay for coverage through their parents, providing SHIP waivers will result in many students again having to purchase the redundant SHIP plans for services already paid for, increasing student and parental debt. College tuitions are rising 20-120% faster than consumer inflation; students and parents should not be subject to additional, avoidable, and redundant costs.
Instead, SHIPs should be subject to ACA standards and reach high performance levels as other schools plans have done. For example, some schools have been highly successful in revamping their SHIP programs, including institutions as diverse as Boston University with its extensive service levels and Brigham Young University with its 93 percent medical loss ratio.
Since ACA is a consumer protection law, SHIPs should not be permitted to avoid its requirements. Rather, schools should renew their fiduciary duty to students and parents by having SHIPs fulfill ACA requirements, attaining service and performance levels such as that of BU and BYU, and working to ensure that student health is designed to keep the most students at their books for the most amount of time. Only through this process will students be protected as the ACA intended.
Bryan A. Liang and Tim Mackey
Bryan A. Liang is Shapiro Distinguished Professor of Law and executive director of the Institute of Health Law Studies at California Western School of Law, and professor of anesthesiology and director of the San Diego Center for Patient Safety at the University of California at San Diego School of Medicine. Tim Mackey is a senior research associate at the California Western health law institute and a doctoral student.
For five years, graduate students facing stress or feeling suicidal have had a hotline that they could call 24/7.
On Monday, the founders of the hotline announced that they had turned it over to another group. While about 50 universities have publicized the service, many others have declined to do so because it was created by a religious organization, the Campus Crusade for Christ. The hotline organizers decided it would be best to find a secular home for the hotline, so it could reach more people.