To the Editor:

Bryan A. Liang's recent commentary on college health-insurance plans and college health services ("How College Health-Care Plans Fail Students," The Chronicle, May 16) unfortunately fails to offer a fair and accurate portrayal of the current state of college-student health in America.

The American College Health Association years ago recognized the limitations and flaws of the college health-insurance market. Our association has promulgated, and periodically updated, guidelines for Student Health Insurance/Benefit Plans (known as SHIBP's). Our guidelines are consistent with the New York attorney general's recommendations to colleges and universities. Some colleges choose not to follow these guidelines. Exactly how many colleges fail to meet these guidelines is not clear, but even the attorney general's office has been unable to determine the exact number. However, the ACHA believes that the vast majority of professionals in higher education and college health are reasoned, well-meaning, and dedicated people who operate with the welfare of students and their health as a paramount concern.

ACHA has been actively engaged in the drafting of the recent health-care legislation as it relates to college-student health insurance. The new laws will likely eliminate the very plans criticized by Dr. Liang and the attorney general, Andrew M. Cuomo, and ACHA has supported those elements of the bills. During the legislative process, we met with Senate Finance Committee staff members to assure them that colleges and universities can offer high-quality/low-cost SHIBP's. Legislation signed into law in March retains our suggested language and allows institutions to offer high-quality insurance plans, but ACHA will continue to work with HHS regulators to ensure that student plans are regulated as part of the group-insurance market. Regulating student health insurance as group plans permits colleges to have a risk pool composed of only students. Dr. Liang suggests exchanges are the answer. But students would be placed in a risk pool for the entire region, virtually guaranteeing much higher premiums for comparable benefits.

Dr. Liang also suggests that all college health services should accept parental or outside insurance and bill those plans for services. The college-health-service delivery and financing systems are not homogenous, and each and every college has independently decided which financing mechanism works best in its case. ACHA has never advocated for one financing model over another, and believes it is best for individual colleges to decide on how to fund their services based on their unique student populations. Many colleges prefer to capitate services through a health fee, many charge for all services and file insurance, and many use a combination of financing strategies.

Nonetheless, a large and growing number of colleges accept parental or outside insurance for certain services. These can be quite successful in generating additional revenue, but there are potential drawbacks. As Dr. Liang should know, creating an administrative billing service can be costly. Outsourcing through a private company may add substantially to overhead expenses. In addition, students frequently see us for conditions that they would not want their parents to know about (e.g., pregnancy, substance abuse, sexually transmitted infections), and we commonly hear from students that because of confidentiality concerns, they don't want tests and services billed to parental insurance. Significant barriers exist for billing insurance when colleges have student populations that are geographically diverse. In other words, students attend college out of state, perhaps hundreds of miles from home. When filing for insurance, we frequently find out that parental plans have much lower out-of-network benefits, including higher deductibles and co-insurance. As is common among many medical practices, health services may refuse to file claims for out-of-network services because reimbursements are nonexistent and balance-billing students is administratively costly.

For a college health service to join all the students' health-insurance networks is not the answer. At my own university, we tried insurance filing in the mid-1990s, only to find that our 21,000 students represented 900 different insurance plans from 50 states and 70 countries, and the plans changed by 15-20 percent every year with a new group of students. It would cost my health service hundreds of thousands of dollars in administrative costs to try to maintain network affiliations with all these insurance plans and would significantly increase health-care costs for students and parents. However, for those colleges that draw students from one geographic region (e.g., a metropolitan area) they can in fact easily join the 10-15 dominant insurance networks and successfully bill for services.

Finally, I would assert that the college-health-care system represents a blueprint for America's currently byzantine health-care system. We provide primary, episodic, and urgent health care as well as mental-health services for our students. Health services tend to be multidisciplinary and collaborative. Using the principles of the patient-centered medical home, we utilize team-care approaches that include professionals across the entire health-care spectrum. We are deeply committed to patient education and encourage students to seek information using the latest electronic information systems. College health services have been leaders in innovating health-care-delivery systems, including relying on salaried clinicians, which promotes quality care over quantity of care, and with the implementation of electronic health records.

Decades ago we recognized the importance of community and public health. Because of our unique financing sources, in which we don't rely solely on clinical-visit fees, we are able to devote significant resources to health promotion on campuses. A few examples of the success of these initiatives include:

• 60- to 80-percent reductions in alcohol-related negative consequences on campuses.
• Declining campus outbreaks of mumps and meningococcal meningitis as a result of aggressive vaccination campaigns.
• Reductions in rates of students presenting with unplanned and unwanted pregnancies, as well as sexually transmitted infections.
• Suicide rates among college students at half the rates of their noncollege peers.
• Deaths resulting from alcohol-related motor-vehicle accidents are one-tenth the average for same-age peer groups.
• Health-care workers at colleges with higher immunization rates against H1N1 this past winter, about 75 percent, than any other group.

These accomplishments are the result of an intricate fabric of support services established by colleges and universities, which include health and counseling services. And an important component of this fabric is institutional student health insurance. Many institutions have endorsed health-insurance plans for students, and some even require that students have health insurance as a condition of enrollment. But the importance of health insurance goes far beyond simply generating revenue for a college health service. Health insurance enhances access to specialty, inpatient, emergency, and long-term health-care services that cannot be offered in a campus health service. From a risk-management standpoint, universal insurance minimizes liability exposure for colleges, enhances working relationships with community hospitals and doctors, and ensures that academic medical centers (including anesthesiologists like Dr. Liang) don't face significant unpaid bills from students.

ACHA is confident that the current health-care legislation will help eliminate poor-quality insurance plans and assure that the type of insurance plans that we have promoted for years through our guidelines will become the norm. We are also confident that colleges and universities understand their own unique student populations and can make reasonable decisions about financing strategies, while at the same time making those decisions in the best interests of their students. There is no one prescription for success in the financial arena.

Finally, our system of college health, assisted by high-quality insurance products, is making a profound difference in the health of our students and their academic success. I would hope Dr. Liang and others in higher education would recognize the critical importance of college health services.

James C. Turner, M.D.
President, American College Health Association
Executive Director, Department of Student Health
Professor of Internal Medicine
University of Virginia
Charlottesville, Va.