Editor’s Note: At its meeting on January 7, 2010, the AHA’s Council endorsed the following essay prepared for the AHA’s Professional Division.

The following essay is based on: a general search of universities’ requirements for health insurance for graduate students; responses to questions on this issue from the AHA’s Graduate and Early Career Committee and a sample of faculty colleagues from private and public institutions with graduate programs; and a search of health insurance policies of various other schools that make such policies visible on their web sites. Schools surveyed or researched include: University of Southern California, Stanford University, University of Houston, The College of William and Mary, University of Iowa, Northwestern University, New York University, California State University System, University of California System, University of Wisconsin– Madison, Oregon State University, University of Oregon, Utah State University, Emory University, Yale University, Harvard University, and Rice University. Recognizing that the lack of a national healthcare system has diverse and detrimental effects on a range of populations, this document is intended to offer a brief statement on and recommendations in relation to current university policies and practices on graduate student health insurance.

Imagine, if you will, a graduate student who has accepted an offer of admission to a doctoral program in history. Let’s say this student has been guaranteed an annual stipend of $ 17,000 for a specified number of years (usually four or five). As this student finds housing and arranges to move to the new location and register for classes (among other priorities) s/he is notified by the graduate school that s/he must enroll in the health insurance plan offered by the university or offer proof of alternative insurance coverage, and that this “proof” of “enrollment” must be accomplished prior to registration for classes. The information forwarded to the student by the graduate school indicates that the university’s health insurance plan carries an annual cost of $1,700 and that this total amount must be paid up front. With a first stipend check not due to arrive until the second week of classes, the student finds that s/he must somehow come up with the lump sum necessary to cover the full cost of this insurance if s/he expects to start graduate school.

Increasing numbers of states have passed requirements that all students at public institutions must provide evidence of health insurance coverage prior to enrollment. While many undergraduates continue to be carried on their parents’ or families’ insurance policies, the same cannot be said for the majority of graduate students. Thus, at an increasing number of institutions, graduate students are required to either show proof of coverage that they have obtained elsewhere or buy into the “group” policies offered by the universities (Mega Life/Mega Health and the Aetna Chickering Group seem to be the most common carriers at the time I conducted my survey). At some institutions graduate students who have not offered proof of coverage are automatically enrolled in the policy offered by the institution and the fees are deducted from their paychecks. At other institutions graduate students who have not offered proof of coverage are not allowed to register for classes until they have acquired coverage. In other words, many institutions require that graduate students provide proof of health insurance as a condition of enrollment.

Types of Coverage

The health coverage made available to students by their institutions often begins with the Student (or University) Health Center. Most institutions require that all students pay an annual fee to the student health center, that this facility is the first visited by graduate students on health matters, and from there referrals to other “specialists” may be offered.

Most institutions that require graduate students to have health insurance as a condition of enrollment also provide access to health insurance plans offered by the university itself or by a third-party carrier through the university.1 The types of coverage available through these plans also vary widely, but can be generally grouped into two categories: “Basic,” which carries with it a $1,000 to $1,500 deductible before insurance payments are made to health care professionals with co-pays standard after the deductible amount has been reached. “Basic” coverage generally covers routine health care (annual physicals for instance), and most often does not include prescription drug benefits, hospitalization, or extended care. “Comprehensive” coverage usually includes mental health (usually at 80 percent for “in-group” providers) though whether mental health, dental, and vision plans are covered varies by institution. For some institutions “comprehensive coverage” does not include dental and vision, which must be purchased separately by students when it is available. Key to what institutions define as “comprehensive” coverage is no deductible required, a prescription drug benefit, and hospitalization costs for medical procedures, though co-pays are standard for such coverage. Most institutions do not cover graduate student health insurance costs during summers. Such costs (and remuneration) then, seem to be linked to stipends for graduate students (in the form of fellowships or other types of assistantships), which usually cover the academic year, not summers. That said, increasingly some institutions (especially private universities) are moving to offer either 12-month stipends for graduate students or summer “supplements” for two to three years that might enable graduate students to gain access to insurance benefits during these months.

Costs of Coverage

The costs of healthcare policies available to graduate students through their institutions range from $1,300 per year for basic coverage to $3,500 per year for comprehensive coverage with additional costs often required to purchase the dental or vision elements of these plans. At Stanford University, for example, the 2008 cost of Cardinal Care (the Stanford health plan) was $684 per quarter. Students who are enrolled for classes are automatically enrolled in this health insurance program. Those not registered for classes in a quarter must enroll themselves through the health insurance office prior to the start of the quarter.

Who Pays for Health Insurance?

The Institution:

• Completely for “fully funded” graduate students or graduate student “employees”—those who are listed as teaching assistants, research assistants, graduate instructors, or graduate assistants. Most institutions that completely pay insurance fees do so at the level of “basic” coverage, not “comprehensive.”

• Partially for fully funded graduate students or graduate student “employees”—that is, they are subsidized at rates of 25 to 80 percent, depending on the institution.

• Subsidized for all graduate students regardless of “employee” status at rates of 25 to 80 percent depending on the institution. The “out-of-pocket” payments for such students depend on whether they select the basic or comprehensive coverage plan, with the former on a 65 percent subsidy, as at Northwestern University (2008), which averages $645 per year for the basic plan and $1,432 per year for the comprehensive plan.

• Supplement Programs—in the form of flat payments provided to all funded graduate students on top of their regular stipends for the purposes of healthcare. At the University of Houston this amount is $150 per month; in the brief (now discontinued) experiment at William and Mary this amount was a one-time $300 lump sum that was far below the cost of health insurance. At universities where such a program exists but graduate students are not required to purchase insurance, there has been some concern as to whether these funds are actually spent by students to acquire insurance. At universities where such supplements exist and graduate students are required to purchase health insurance the amounts are usually far too little to offset the costs of insurance.

The Students:

• When students are required to pay for the cost of health insurance either through a private carrier or by purchasing insurance through a “group” carrier provided by their institution.

• When purchasing coverage via their institution:

  • Some institutions require students to pay the complete cost of this coverage for the academic year up front prior to enrollment.

  • Some institutions allow for payments to be made per semester—so the academic year coverage can be made in two payments.

  • A few institutions allow for monthly payments for health insurance coverage to be deducted from stipends (similar to full-time faculty health insurance allocations).

International Students

• A few institutions mandate full proof of health insurance coverage for international students but not for domestic students.

• Most institutions require the same types of coverage for all graduate students, regardless of international or domestic status.

Coverage for Dependents

Most institutions that require coverage for graduate students as a condition of enrollment or provide opportunities for graduate students to buy into health plans offered through the university also offer health coverage for dependents and spouses (but for the most part not for “domestic partners”). This “buy-in” for dependents and spouses is usually quite expensive, with most health plans requiring payments of $4,500–$7,000 for spouses and $2,500–$3,400 for each child per year. These “additional” costs are not covered by most graduate institutions.

Conclusions and Recommendations

It is important to note that the situation of graduate student health insurance, including the various scenarios outlined above, is in a constant state of flux. Thus, what might be the current policy of many programs could change in the near future. In fact, at several institutions that I surveyed, health insurance fees that had been covered by the institution in past years are not covered now. This fluctuation in institutional responsibility for health coverage for graduate students seems to be linked, as we might expect, to the fiscal situation of the university and/or the state in which it is located in the case of public institutions. Some public institutions that had previously subsidized health care costs for graduate students ceased doing so due to cutbacks in state funding to their universities; others stopped funding graduate student health care during the summer months for similar reasons.

Recommendations

• At the very least that departments call on their institutions to move to fully cover fees for graduate student health insurance. This might be accomplished by including such fees as an addition to the stipends already offered to graduate students.

• During the interval between full funding and the current situation that departments call on their institutions to make it possible for graduate students to have allocations to cover health insurance fees deducted monthly.

• That departments call on their institutions to include the spouses/domestic partners and children of graduate students in the regular health insurance programs offered to them – not as an “add on” requiring additional payment.

• That departments call on their institutions to include mental health plans as a standard element in the health insurance policies they offer to graduate students.

Leisa Meyer (Coll. of William and Mary) is the Class of 1964 Distinguished Associate Professor of American Studies and History at the College of William & Mary. She was an elected member of the AHA’s Professional Division from to January 2007 to January 2010.

Note

1. Both Yale and Harvard Universities are examples of this model. See below for one example.

The Harvard Plan (2008)

The Harvard University Student Health Plan consists of two parts:

Part I: The Student Health Fee (SHF) covers most services provided at Harvard University Health Services (HUHS) and includes a prescription drug benefit. Primary Care Providers are available at clinics on each Harvard campus for routine health care. Urgent care is available 24 hours a day, 365 days a year at HUHS in Holyoke Center.

Part II: The Blue Cross Blue Shield PPO (BCBS) Plan of Massachusetts is designed to complement the health care provided under the SHF at the HUHS. This plan covers medically necessary hospitalization, emergency care, and some services and procedures not available through HUHS.

Rates Effective August 1, 2007–July 31, 2008

Rates for Student Only

One Term (Fall or Spring)
Student Health Fee (SHF) $713
Blue Cross Blue Shield (BCBS) Fee $681
Combined Rates: SHF and BCBS Fee $1,394

Two Terms (Full Plan Year)
Student Health Fee (SHF) $1,426
Blue Cross Blue Shield (BCBS) Fee $1,362
Combined Rates: SHF and BCBS Fee $2,788

Rates for Dependents Only

One Term (Fall or Spring)
Spouse $1,751
Child $909
Second child $457

Two Terms (Full Plan Year)
Spouse $3,502
Child $1,818
Second child $914

Some institutions offer plans through their student health center with complementary options through a standard national carrier such as Blue Cross Blue Shield (BCBS). Harvard’s plan is fairly typical of such approaches, requiring that all students, unless already insured, pay a Student Health Fee that covers most services provided at Harvard University Health Services for routine health care and includes a prescription drug benefit. Harvard then offers an optional complementary plan through Blue Cross Blue Shield of Massachusetts that covers “medically necessary hospitalization, emergency care, and some services and procedures not available through Harvard University Health Services.” The student health fee cost is $713 per term; the BCBS optional “complementary plan” cost is $681 per term. Thus the combined rate for these plans in 2008 was $1,394 per term. Harvard University also offers optional coverage for spouses and children of students. This “dependent” coverage is only available when students purchase the BCBS complementary plan and the 2008 costs were $1,751 for spouses per term and $909 for children, with a $457 per term fee for a second child, with no additional charges for additional children. The costs for the 2008–09 academic year increased slightly for the complementary plan and dependents.