Tuesday, February 12, 2008


“I Need This Class to Stay on My Parents' Health Insurance”

As a political liberal – and proud of it, thank you very much – I believe that it's immoral for a wealthy country to leave tens of millions of its own without health insurance.

That said, I find myself in the weird position of making decisions that effectively deny some people coverage. And I'm not even talking about adjuncts, a topic that has been amply covered here and elsewhere.

I'm talking about students.

Every single semester I get students registering late, or trying not to get dropped, making the argument that they need the class to stay on their parents' health insurance.

This strikes me as somewhat less drastic than the old “I need a C or I'll get drafted” of Vietnam days, but still disconcerting. Given the number of students with chronic conditions – whether it be asthma, or ADHD, or diabetes, or whatever – a cavalier “well,who cares, they're young and healthy” really doesn't cut it. Besides, having young and healthy people paying into the insurance pool (whether directly or indirectly) actually lowers costs for the rest of us.

A fair number of health insurance plans, I'm told, will cover dependents in their late teens and early twenties, as long as they have 'full-time student' status. In concrete terms, that means they need to be registered for at least twelve credits.

Some students (and, presumably, parents) have figured out that it's cheaper to pay tuition for an extra class or two than to try to buy individual coverage. (This is particularly true at cc tuition levels, and even more so when they can get financial aid for the tuition.) So they do, often with little or no intention of taking the actual course (or of taking it seriously). I've had multiple conversations with students at the last possible moment to register, desperately looking for an available slot in any course at all – they really don't care – just to hit that magic “12” number. They're working part-time at low-paying jobs that don't offer insurance; they'd rather come here part time, too. But the material incentives strongly favor full-time status. I get more of these awkward conversations when the midterm warnings go out, telling students that they'll be dropped for non-attendance. They don't dispute the fact of non-attendance; instead they make a humanitarian plea not to effectively deny them health insurance.

Yuck, yuck, yuck.

Reason #396 to support single-payer health care: it would decouple 'full-time student' status from health insurance. I don't want people making academic decisions – whether it's students or me personally – based on health insurance. I don't want to choose between upholding our academic standards and cutting off some kid from the medical care he needs.

I've never knowingly been a party to insurance fraud. If the student didn't follow the rules for registering, I don't make exceptions based on my willingness to divert some miniscule fraction of an HMO's profits. But I've certainly seen students register, um, let's go with halfheartedly.

As an open-admissions college, there's no way to prevent that. Most students register online anyway, so even if I wanted to be a one-man Attitude Police, I couldn't. (And folks seeking health insurance certainly have no monopoly on shaky attitudes.)

But there's something fundamentally wrong with a system that rewards people taking that extra class just to get the insurance. I don't entirely blame them for doing it – they've found a loophole in a ridiculously unfair system – but it certainly distorts what we're trying to do. These folks show up in our attrition numbers, our outcomes assessments, and our (non)-graduation rates, all of which get blamed on us. And they get lower GPA's than they probably ought, simply from spreading themselves unrealistically thin.

Other than supporting single-payer, I don't have a clean answer to this one. This probably isn't as common at the elite schools, given their tuition levels, so it mostly escapes media notice. But in my neck of the academic woods, this is very real, and very messed up.

I'm relatively new to the community college system. I'm in the second year of a full time TT position. I am so glad that you have written about this. I was truly surprised when I first starting hearing about this on my campus. As soon as it was explained to me, I fully understood why. I am pained that our students are not in a position to understand the long term consequences of a number of Fs on their transcripts. They are so (correctly) focused on the here and now of their health care, that they can't see that these Fs may prevent them from being able to transfer to a 4-year school. I know that my campus takes the hard road too. We also "unenroll" students for nonattendance, and since that's our policy that's the way it should be done. I, too, wish that national health care was able to step in and prevent this problem.
I'm not a fan of the national health care idea. Why? Because I've seen it in action.

I don't have health insurance in the US. I'm too old to be a dependent on my parents' insurance and I don't have a full-time job. And temporary individual insurance is useless. It's very expensive, it's really meant for serious emergencies, and it doesn't cover pre-existing conditions. If you get something while you have the temporary insurance, it won't cover that condition when you try to renew.

As you know, I live in the UK for most of the year. While I am here, I am covered by the National Health Service. And it frightens me how poor the system is. I've gone to the doctor for serious conditions and have been told, "We'll watch it." One of the conditions was a knee injury that left me black and blue across my entire leg, and THE DOCTOR DIDN'T EVEN TOUCH MY KNEE. No x-rays, no nothing. Another time I had a cough that was so bad it made me vomit, and I couldn't even sit in a chair properly because it made it hard to breathe. He told me to "have some tea with lemon." If you have an urgent condition, sometimes you have to wait days to see the doctor.

I have a friend here who fell and twisted her ankle, and she didn't get an x-ray because the doctor said that if he gave her an x-ray and his original diagnosis was wrong, he'd have to take the x-ray course over again.

I know some retirees who think that the system is wonderful. I've been told that this is because doctors are more likely to give them referrals, thinking that young people are healthy and don't need all kinds of extra care. I wouldn't be surprised if this were true.

It's sad that some people are in school primarily for health insurance, but to be honest, I'm not sure if national health care is the best alternative.
Kait ancedotes are nice. I can give similar ones for myself and my family here in the US when covered with insurance. My father was misdiagnosed for two and a half years, why? Because the HMO would not pay for the simple diagnostic test and bet that it was something else (it was cancer). At the end of the day all care is rationed the question is how are resources allocated. National health care would significantly eliminate the advertising dollars spent, get people in to get treated earlier (i.e. before needing to go to the emergency room), and lower the administrative costs. To me those would enable better allocation of resources for treating more people.
As long as HMOs and insurance bureaucrats are in charge of the health care system, nothing will change. Universal coverage isn't the answer; a complete overhaul of the system is!

Short Joke: An HMO offical died and went to the Pearly Gates. St Peter asked him what he did and he responded "I work for an HMO." St Peter said "Welcome to Heaven....you can only stay for two days and can't get access to the fluffy clouds. After that, you get to go to hell."
Disclaimer: I am an American who has lived in Canada for over 20 years and I have always received good healthcare under our national scheme in the three provinces in which I have lived. I am a supporter of national, universal healthcare.

The comments so far are mixing two distinct categories: quality of care and access to care. NO system has perfect quality of care, and most systems could use at least some tweaking if not overhauling at this point in the game. But what the students are seeking through this loophole, is access to care. They just want the opportunity to have care, we aren't even talking quality yet. The fact that they will shell out money for extra classes and risk Fs on their transcripts so that they can have access to healthcare, and that this is cheaper than getting health insurance of their own, indicates that the HMO/private insurance system is broken.
I fail to see what the problem is with those students doing that. Certainly, it isn't ideal for the students involved, but why should you stop them from giving you money? You get money, the students save money which allows them to spend more time working on the classes they're actually taking. The only party that gets hurt by denying students the option to "take" those extra few credits is the insurance companies. Community colleges are for a lot of things, but I'm pretty sure that making sure students don't try to take advantage of a loophole in insurance plans isn't one of your stated goals.
The reason you have to drop enrolled but non-attending students is because of laws related to financial aid. If students are enrolled and non-attending, and if that is discovered, it means the school is in violation of Department of Education regulations (committing financial aid fraud), which can then mean sanctions for the university. Not good. In other words, the way these two issues are bound together means that the consequences for just letting a student be enrolled for insurance purposes are farther reaching than might initially be apparent.
I can completely see the lure of taking the extra class or 2 to get full time status, but here is my question: why are these people not at least attending the classes? That is part of the "cost" of enrolling. They know that they will be unenrolled if they don't attend. I agree that the health care system could use an overhaul, and I support universal health care, but in the mean time I don't think it's unreasonable to expect people to attend classes they register for.
If the parents health care plan is eligible for COBRA, then these students can elect COBRA coverage for three years, the parents would have to pay any extra premium + a 2% Admin. fee for the coverage. I'm not sure what tuition costs at your college, but I'm guessing it would be cheaper to work and pay for the COBRA coverage.
A few operational observations.

We have a state-reported census date each term on which we certify enrollment to our public higher ed state agency. That is the one date by which we judge status for purposes of insurance certifications. Unless the insurance company requests status as of a specific date (a few do), we go with hours enrolled on Count Day. Solves the withdrawal problem where classes drop off during the term.

Dr. Crazy is correct that federal fin aid rules & regulations play a role, but mandatory withdrawal by the institution is not a carved-in-stone Washington edict. If a student departs prior to the semester end (either by institutional drop or student self withdrawal), their last date of participation impacts how the Title IV Refund is calculated. This is the money that the student owes back from their original aid package, including Pell.

Dean Dad, my favorite pleading at the 23rd hour is the student begging for late enrollment because of judicial-ordered probation requirements. If I am not in college, they are putting me in the slammer! College as behavioral rehab!

A tired old Mighty Favog
Mighty Favog offered a nice clarification of my comment, for it is true that schools aren't required to drop non-attending students. According to my university, the reason that they do this is because 1) it somehow saves the university money (though I'm not entirely clear on why or how) and 2) since the policy has been in place, it has discouraged the practice, thus making enrollments in courses more stable and assuring that students who want/need to take a course and plan on attending can enroll.

As for Becky's question, I think many students don't see attending as part of the cost that they pay in order to enroll. I think that many see themselves as paying for the *option* to attend, and they would give an argument like it is their business if they choose not to attend a course that they've paid for, just as it would be their business not to drive their car, even though they'd paid to put gas in it.
I think in most cases, I'd have difficulty drumming up sympathy. If I want health insurance, I have to go to work every day. Either the student needs to get a job and purchase their own insurance, or show up to class and do their homework.

Adults take responsibility for themselves. College students should be adults.
Two complicated issues mixed together! Sweet and sour academic gumbo, yum, yum.

We don't "drop" students for non-attendance, we withdraw them. (Some places actually drop them from the roll. Ours get a grade of W but it does count as an attempt at the class, which dropping does not.)

Now I know there are financial aid consequences for a withdrawal, but I don't know what we would report to an insurance company. Withdraw from all classes and you have dropped out, of course.

In any case, we decouple the financial aid issue from the withdrawal issue. A student who does not attend after the 60% point simply does not get their remaining money, whether enrolled and failing or withdrawn by the instructor. We don't let an instructor's preference for or against using a particular grade affect whether we follow the letter of the financial aid laws.

As for single payer, you would first have to spend the same fraction of the GDP on health care in the UK as in the US before you can fairly compare levels of service. A key question is whether we could get overall better medical care without facing national bankruptcy in the near future as Medicare and Medicade and VA costs continue to explode.
I agree Dean Dad, but isnt it better for a young adult to be getting an education [even if its for the insurance], rather than working a low-paying job, and mooching off their parents coverage for the rest of their lives?! I think maybe the only time you're logic can slide, is if the student was obviously ill, still going to school, and for some FREAK reason, couldnt register in time, but then again, if you're very ill, wouldnt you understand the importance of health insurance?!?

this mirrors the same argument "if you give me this D, my gpa will fall below 2.0, then I wont get financial aid!!"
CCPhysicist is right: As long as the US spend roughly twice as much money on health care per person as Western Europe, comparisons are difficult. In Europe, there is a substantial movement in favour of privatized medicine, with the - to me - highly surprising argument that it would be cheaper. Beats me, where people get the data for this assertion.
As a Canadian/British dual citizen living in the US, I have sampled a range of systems. I have no problems with US healthcare, because I have a tenured position and am thus privileged to have healthcare. I am acutely aware that my students don't necessarily do as well. I took a friend of my daughter's with us sledding and she remarked that she had to be careful, because "we don't have health insurance and my mom will kill me if I get hurt". Personally I found that little window onto their supposedly middle class life pathetic. But, anecdotes are just that, anecdotes. For every horrible thing that has happened to Kait at the hands of the NHS in Britain, there are counter stories. At times I too have been shocked by the nonchalant attitude of the doctors in England. "Oh, your ear drum has actually burst? Oh Dear." On the other hand, a nurse actually comes to visit my sisters at home every week for several weeks after giving birth. Here, it was, "it's been a few hours, time to go home - good luck".
Sure... I will bite... and continue down the rat hole...

The problem with discussions about quality of health care (and dismissing bad care as being an "anecdote") is that we somehow feel that there is some "acceptable" level of poor quality in healthcare.

What quality level do you want? In many things we accept an 85% success rate. Heck, we give an A for only a 95% success rate. Is that a "sufficient" level of quality?

Do you want an airplane engine to be 99% reliable? Only 1% of the time failing in flight? Hmm... 1 out of 100 flights having engine problems... and just HOW many flights do we have a DAY in this country?

Anecdotes (as I wrote over at my blog as a response to a comment from this very blog) are very often very useful data, especially when delivering a service. I can always "fix" a product, but I can't fix a bad meal, or a missed cancer diagnosis.

All that said, which type of system has the greater likelihood of providing quality care? Does a "single Payer" system (really an "everyone pays" system) get there? And can it really encourage "quality" if everyone gets paid the same for the same service, regardless of quality of delivery, or accuracy in diagnosis?

As it stands now we have choices. Poor quality (even in the single instance) leads to bad "word of mouth" which leads to lost customers which leads... Well, you are all smart. You should see where that leads...
Not that anyone would WANT to read my blog entry, but since the fancy smancy link didn't work, here it is:

Evil HR Lady:

It doesn't seem like you're being as charitable as you could be: Yes, college students (even CC students, ha-ha) should be adults. Some are; some aren't. That's largely irrelevant here.

Consider -

1. Many - most, even - people straight out of HS with no college and minimal job experience will be unable to find jobs that offer health care at all. Certainly there are far fewer of such jobs available then seekers. Unless we're just going to throw our hands up in the air and say "everyone for themself!", this is not an acceptable option.

2. Many students are unable to go to college without working. Their families can't support the tuition, even CC tuition (which, in my area, has tripled in the last eight years). Some of these folks have the sort of health insurance that requires a 12-credit enrollment.

3. These students are faced with a choice: Go to school at 12 credits, and either quit working to pass classes (but be stuck with tuition and living expenses you can't afford without a job, thereby having to either assume debt or eventually drop out of school, losing the health insurance anyway); or, drop below 12 credits and permanently get kicked off your parents' plan while maintaining short-term financial solvency and avoiding short-term exhaustion (and a good thing to, what with the loss of health insurance and all! Ha....)

Let's assume, as well, that for many, taking 12 credits and working enough to be self-sufficient are exclusive, or, at least, that they would require an unsustainable amount of time.

The choices simply aren't good ones. Being an adult about it doesn't automatically lead to a good solution.

What do you do? I'm with Dean Dad on this one - it's s crappy situation, and the best solution removes the conditions that create the problem entirely. However, given the political realities of America, I guess I'd actually favor supporting some sort of undergraduate filler credit that require a flexible sort of work - something that students can enroll in to maintain the level but doesn't cause them to go under in terms of work required. Like thesis credit, but for undergrads.

Pipe dream, I know. But still.
I worked as a CNA (Certified Nursing Assistant) through my undergraduate career. I recommend it to all the broke students I know who are in decent physical shape -- the job is hard, but the pay is decent, considering I didn't have any qualifications whatsoever except the CNA license, not even a high school diploma, benefits are usually available, they're ALWAYS hiring, and they'll usually work around your school schedule, *especially* if you're willing to work extra weekends.

Maintaining 12 credits and working 30+ hours a week shouldn't be undoable, unless you have small children or other obligations -- even assuming that you spend 3 hours outside of class for every hour inside class, that's 48+30=78 is roughly equivalent to two jobs, which many in the generation of my parents found eminently doable. Not fun, but doable.
This is an interesting discussion, because I am going through this right now with my daughter. She's a senior in HS and starts at the local CC in the fall.

She asked me last month if she could take a year away from school and just work full-time, and I had to tell her that it wasn't a good idea as she wouldn't be able to stay on my insurance unless she's a FT student (she has a health issue that needs ongoing monitoring). And she won't be able to afford it on a min wage job if she works FT.

By contrast, 10 years ago her older brother (18 at the time) found FT work that paid a portion of his health insurance, so he didn't go to college at all and had adequate health insurance coverage at age 18.

We've already decided that my daughter will have to live at home while in college so that she can get by with PT work instead of FT, thereby taking FT classes. But it sucks that she has to make that choice based on health insurance.

As a new FT faculty, I haven't run into this issue with a student yet. I'm not sure how I'll respond when it finally does.
TheProfessor, what has your "work of mouth" argument to do with how the health care system is set up? Back in Europe, when I didn't like my doctor, guess what I did? I just went to another one the next time! Nifty, isn't it? And this neat and simple solution didn't even require me to fill out tons of paperwork as changing my primary care physician in the US would...

Honestly, I am glad you had a good experience.

My "point" was that, if one has a bad experience, one can to another doctor. That's the way it should be, and I am glad (in your case) that you had that choice.

The bigger issue though is how to provide/control access to the better (and thus more in demand) doctor, and encourage doctors to be excellent with the only rewards being higher patient loads and a sense of "doing good."

Can the better (more capable, more reliable, higher quality) doctor charge more for their increased expertise? Are they in any way provided incentives to perform "better" than average?

And, stepping back from the "incentive" idea (since ideally, Doctors are motivated out of a sense of humanity and not a desire to earn a living) what about controlling demand?

You changed to a "better" doctor. Who else changed? Many? Most? How do you control access to the "best" doctors? A "great" doctor with outstanding diagnostic abilities charges a higher amount for their skills.

My biggest point here is that the answer isn't as "simple" as having a single-payer system. There are issues of motivation, compensation, controlling access, appropriate levels of access. It's very complex, and simple solutions inevitably lead to even more problems than they solve. Heck, it's why government involvement has caused so many of the pathologies in our health care system already!
Unsurprisingly (in human discourse in general), we seem to be exchanging information on the surface while the core issues (the underlying assumptions and values) remain swirling darkly in the morass below.

The original poster (and many of the responses) seem to presume that "we all know" that:

- Access to health care is a fundamental right to be guaranteed by civilized society; and
- Access to higher education is a fundamental right, to be guaranteed by civilized society

Both of these are somewhat challengeable, in that "we all already know" that neither of the two are "infinitely satisfiable" rights.

So the question becomes- *how much* "health care and higher education provided by civilized society" are we willing to accept- or tolerate?

So where does *your* particular slippery slope lead?

[Our campus is currently dealing with a student "dying of AIDS" (since 1988, when he graduated from high school) who has migrated from campus to campus collecting hundreds of units of Ws and WFs along the way . . . with health care *and* "education" paid for out of the seemingly limitless pool of sympathetic civilized society. Hmmmm. To this reformed hippie, that suggests that perhaps we don't live under the conditions of Darwinistic Capitalism we all railed about so passionately in the 1970s after all.]

yet another confused professor
Intersting comments; I would strongly recommend those proponents for "universal health care" first take a detailed look at the financial problems and delivery problems with Medicare and the VA. Then think again about whether or not the US government could effectively (both cost-wise and delivery of services) administer a national health care plan.

Tks very much for post:

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