Nardin R, Zallman L, Frank C, Day B, Boyd JW. US Medical Students’ Health Insurance Coverage for Mental Health and Substance Abuse Treatment. JAMA. 2011;306(9):931–933. doi:10.1001/jama.2011.1262
Author Affiliations: Departments of Medicine (Drs Nardin, Zallman, and Frank) and Psychiatry (Dr Boyd), Cambridge Health Alliance, Cambridge, Massachusetts (firstname.lastname@example.org); and Physicians for a National Health Program, Chicago, Illinois (Mr Day).
To the Editor: Medical students experience high levels of distress, including burnout, depression, and suicidal ideation.1,2 They use alcohol and tranquilizers at rates comparable with those of their peers.3 This distress has serious consequences, negatively affecting student empathy and altruism and contributing to postgraduate medical error.1,2 However, few students seek help. Limited data suggest cost is one reason students avoid seeking care.4 As no previous study has documented health insurance coverage offered to US medical students by their schools for mental health treatment (MHT) and substance abuse treatment (SAT), we set out to determine coverage standards.
Between June and December 2010, data on health insurance offered by all US medical schools were obtained from each school's Web site, sending a questionnaire to the dean of students for schools without insurance information online. For schools with more than 1 plan available, we recorded data from the least expensive plan.
For each plan, we recorded the following for both inpatient and outpatient MHT and SAT: annual maximum dollar limit; annual maximum visit limit; co-payment amounts; and coinsurance (defined as the percentage of total costs paid by the patient). If maximum visit or dollar limits were not specified, we assumed no limit. When maximum dollar limits were specified only for all medical care, we used that value to represent the maximum limits for MHT and SAT.
The Cambridge Health Alliance institutional review board approved the study.
Health insurance benefit data were obtained for 115 of the 129 medical schools in the United States (89%), exclusive of Puerto Rico. All schools provided some coverage for outpatient MHT, but 6 schools offered no coverage for inpatient MHT, SAT, or either.
Table 1 shows the annual dollar and visit limits of medical student health insurance plans. A minority of schools provided unlimited coverage: 43 schools (37.4%) for outpatient MHT, 32 schools (28.6%) for outpatient SAT, 48 schools (43.2%) for inpatient MHT, and 40 schools (36.4%) for inpatient SAT. Annual dollar limits varied widely, with a range of $1000-$200 000 for outpatient MHT, $800-$200 000 for outpatient SAT, and $1000-$2 000 000 for inpatient MHT and inpatient SAT.
Table 2 shows the cost sharing required from students. Few schools provided complete coverage without cost sharing (ie, no co-payments or coinsurance): 13 schools (11.3%) for outpatient MHT, 17 schools (15.2%) for outpatient SAT, 22 schools (19.8%) for inpatient MHT, and 23 schools (21.1%) for inpatient SAT. Median co-payments were $20 for the 36 schools (31.3%) requiring co-payments for outpatient MHT, $25 for the 26 schools (23.2%) requiring co-payments for outpatient SAT, and $500 for the 11 schools (9.9%) and 10 schools (9.2%) requiring co-payments for inpatient MHT and inpatient SAT, respectively. Median coinsurance was 20% for all services and was required by 46 schools (40%) for outpatient MHT, 50 schools (44.6%) for outpatient SAT, 70 schools (63.1%) for inpatient MHT, and 68 schools (61.5%) for inpatient SAT.
Visit and dollar limits, as well as cost sharing, are common features of medical student insurance coverage for MHT and SAT. Only around a third of schools provide unlimited dollar and visit benefits. Although plans vary widely, the maximum dollar benefits can be very low. Fewer than 22% of schools provide coverage without cost sharing. This is worrisome because of evidence that cost sharing discourages students from seeking both MHT and SAT.5 The study may have underestimated the MHT available to medical students, who may access care through student health centers or have more generous coverage through their schools or parents.
Coverage offered by US medical schools is unlikely to be worse than that available to the nonstudent population. Most private insurance plans have annual limits; for example, one study found that 90% of plans limit outpatient MHT and 93% limit outpatient SAT.6 This parity is not reassuring given the importance to the medical profession and patients of aggressively treating these disorders. Medical schools should consider improving student insurance coverage for mental health and substance use disorders.
Author Contributions:Dr Nardin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Nardin, Day, Boyd.
Acquisition of data: Nardin, Frank.
Analysis and interpretation of data: Nardin, Zallman, Day, Boyd.
Drafting of the manuscript: Nardin, Frank, Boyd.
Critical revision of the manuscript for important intellectual content: Nardin, Zallman, Day, Boyd.
Statistical analysis: Nardin, Zallman, Day.
Obtained funding: Zallman.
Study supervision: Nardin, Day.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: Dr Zallman's work was supported by an Institutional National Research Service Award (T32HP12706).
Role of the Sponsor: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
Additional Contributions: We thank Diane Saint-Victor, BA, Physicians for a National Health Program, for her help in data collection and Steffie Woolhandler, MD, MPH, and David Himmelstein, MD, CUNY School of Public Health, for early inspiration for the study. No compensation was received by Ms Saint-Victor or Drs Woolhandler and Himmelstein for their work.