Rastelli was diagnosed with melanoma his freshman year of high school. He underwent a short and successful treatment, but the risk of recurrence has necessitated follow-up visits to the dermatologist ever since. Insurance companies often deny coverage to people with medical histories like Rastelli's.
"I just think of actuaries and bean counters being like, 'Well, he had cancer at 14, his mother had cancer, his father had cancer. ... The genes aren't that good,' " he said.
If Rastelli's melanoma recurs while he is uninsured, he will have to cover the full costs of treatment himself. "So that's absolutely not an option," he said. Since he will no longer be covered by his parents' health insurance and will have trouble qualifying for an individual policy, Rastelli's only feasible option is to work for a firm that offers coverage. "I have to treat it as part of my pay," he added. "I would be willing to accept a lower salary in order to get health benefits."
Rastelli's dilemma is one few Brown students have faced. The University mandates that all 8,025 students have health insurance. Most undergraduates are exclusively covered by their parents' plans, while some graduate students purchase individual coverage. The remaining 3,200 are covered by Brown's Student Health Insurance Plan, or SHIP.
"Many colleges and universities require health insurance," Jeanne Hebert, director of the University's Office of Insurance and Risk, told The Herald in an e-mail. "If students are faced with unexpected medical expenses, they may not be able to continue their enrollment in college."
After graduation, students no longer have access to SHIP, and most are barred from their parents' policies when they turn 22 or cease to be full-time students. Some, like Rastelli, apply for jobs with firms that provide insurance. Others enter graduate programs, many of which have policies similar to Brown's. But those who don't receive insurance, and have no mandate to purchase it, face a difficult choice.
Nationwide, 19-to-24-year-olds have the lowest rate of health insurance coverage in the nation, with 34.9 percent uninsured in the first half of 2006, according to the federal Agency for Healthcare Research and Quality. In 2004, the agency reported that 17.7 percent of 18-to-29-year-olds believed they were healthy enough not to need insurance, while 26.3 percent claimed it wasn't worth the cost.
"Most post-college students are young, they think they're going to live forever and that nothing terrible can ever happen to them, and so they're willing to take that risk for a couple of extra bucks in their pocket every month," said Vincent Mor, professor of medical science and chair of Brown's community health department. "So the rational choice for most 23-year-olds - healthy as hell - is to not be covered, because they're very unlikely to get sick unless they're run over by a truck."
Weighing the options
For graduating students who want, or need, insurance, several options exist.
Recent graduates can extend their Brown plan, SHIP, for up to three months after its Aug. 15 end-date, said Bill Devine, president of University Health Plans, which administers the program. Once SHIP expires, a "bridge" policy can cover a brief gap between SHIP or parental insurance and a work-based or individual plan. The University's Office of Alumni Relations offers information on a bridge policy provided by New Jersey-based Meyer and Associates that can last from one to six months for upwards of $100 per month.
For longer-term coverage, growing numbers of recent grads are seeking to remain on their parents' insurance. Rhode Island now permits full- and part-time students to do so up to age 25, as part of a bill signed by Gov. Donald Carcieri '65 last year. Massachusetts and New Jersey have raised their limits to 26 and 30, respectively. Several other states have similar proposals in the works, but in most states non-students are still kicked off their parents' plans when they turn 19.
The federal Consolidated Omnibus Budget Reconciliation Act provides another option. COBRA allows children to remain on parents' work-sponsored plans for up to three years after graduation, but it comes with a catch: In addition to their normal contribution, parents must pay the portion of insurance costs normally covered by their employer. For a healthy young person, this often costs more than an individual plan.
Claire Galya '08 used COBRA coverage for six months in 2005, between three semesters at Smith College and her transfer to Brown. Her father's work as an environmental scientist had provided Galya insurance, but when she ceased to be a full-time student she was booted from the plan in accordance with California law. Galya's asthma necessitated insurance coverage, so her parents purchased it through COBRA until she started at Brown.
Now she's unsure what to do after graduation. "I will try not to be uninsured," Galya said. "I would have to stop seeing my pulmonologist for asthma, and that would be really scary. If I had an asthma attack and had to go to the emergency room, I don't know how I would pay for it."
Grads who don't receive insurance through work or their parents must purchase it themselves. In Rhode Island, only Blue Cross & Blue Shield of Rhode Island, the state's largest insurer, offers individual plans. State law mandates that BCBS offer such coverage, even though it is typically unprofitable, said product manager Kim Holloway. BCBS Rhode Island lost $6 million on the plans last year alone.
For young people, this individual coverage is often quite cheap. In Rhode Island, a healthy male under 25 can get a plan with a $5,000 deductible for $92.32 per month, while one with a $400 deductible would run $179.30. (A policy's deductible is the amount an individual must pay for care before insurance will kick in.) Plans cost somewhat more for women because they could become pregnant, Holloway said, and tend to visit the doctor more often.
Cost of coverage
But individual insurance policies like the BCBS plans can be prohibitively expensive for students who have pre-existing medical conditions. In Rhode Island, BCBS screens its patients for such conditions, which can include diabetes, asthma and past cases of cancer like Rastelli's. Applicants who fail such tests are offered rates about three times the cost for a "healthy" 25-year-old. Thirty-three other states mandate the availability of such coverage, but in others, individual insurance can be unobtainable for or beyond the means of applicants with current or past medical problems. This makes sense, Mor said. "If you've had a condition, you'll use the doctor more often, whether you want to or not. Any insurance company is going to know that."
Working for a large firm is often the best option for grads with medical problems, Mor said. Such firms "have sort of made the calculus that as long as you're a valuable worker it's okay because ... one sick person who's otherwise valuable is not a detriment to them." Spokespeople for Microsoft and Verizon told The Herald that, upon hiring, their companies grant employees immediate coverage that fully funds treatment for pre-existing conditions.
David Dryer '07 has lived in Massachusetts and remained on his parents' coverage since graduating in May, and he's already received a few job offers that would provide insurance. "The health compensation ... is a big part of the pitch," Dryer said. "Salary is the first thing and the second is, 'Here are the health benefits!' They seem to be basing their pitch on the understanding that graduates are pretty concerned with it."
Smaller companies often have less generous plans. Many don't offer immediate health coverage, and some that do place restrictions on spending for pre-existing issues, Mor said. Nonprofits often have even tighter policies. Congressionally-funded AmeriCorps - a third of whose 70,000 members are recent grads - offers a comprehensive health plan, but excludes treatment for all pre-existing conditions, spokeswoman Siobhan Dugan told The Herald. Other organizations offer no coverage at all.
