This article first appeared in the St. Louis Beacon, April 6, 2009 - Twenty-somethings are known to feel invincible, which helps explain why so many of them, about 30 percent, are without health insurance. But plenty of people this age are troubled by the thought of being uninsured -- and notably by the threat of financial devastation. Dan Rask is among them.
The 20-year-old St. Louis college student is acutely aware of the high cost of health care. A diabetic, Rask relies on insulin that can cost more than $1,000 a month. That's why, when he temporarily lost health insurance that pays for a high percentage of his medication, he had to act quickly.
It happened over the summer, just before the start of Rask's sophomore year at Webster University. He was without coverage for three weeks until he proved to his insurance provider that he was a full-time student, a precondition for getting the health plan he wanted. (Though Rask can get health insurance through work, he said his school plan covers more of the insulin costs.)
Then late last year, unable to pay tuition, Rask left Webster and immediately enrolled at Jefferson College so that he could keep his coverage. After a brief time at the two-year school, he changed course again and plans to start this month at the Art Institute of Chicago.
Remaining a full-time student is Rask's main objective. But what happens when he's no longer in school?
"I'm always worried about getting a job right away when I'm out of college," said Rask, who is one of seven siblings. "My biggest concern is health insurance. It's definitely something that needs to come with the job."
Rask's concerns are shared by many students and first-time job seekers. His story illustrates how easy it is for young people to lose health insurance and helps explain why many under-30 have experienced a lapse in coverage.
In all, close to 50 million Americans lack health insurance. Of that group, more than 13.2 million are between 19 and 29, according to the latest figures from the Commonwealth Fund, a nonprofit research foundation. Sara Collins, the group's assistant vice president for the Program on the Future of Health Insurance, said there's been a steady increase in uninsured people in their 20s, a trend she expects to continue with the troubled economy.
THE NEED FOR COVERAGE
There are many reasons people in their 20s lack medical insurance. Some aren't in college or don't qualify for coverage because they are enrolled in school only part time. Others are unemployed or have jobs that don't offer health insurance. Signing up for an individual plan can seem daunting to young adults who earn little or no money and might lack experience in sorting out the maze of coverage options and policy terms.
Timothy McBride, a health economist and associate dean for public health at Washington University's George Brown School of Social Work, said young people often don't realize that they can be covered cheaply, relative to other groups, through individual plans. These plans, sold by many insurers, will run less than $100 a month, but have very high deductibles. They protect against catastrophic illness or accidents.
Those who have chronic illnesses, however, are faced with the prospect of expensive options. When major problems arise, the young and uninsured can face financial disaster. "They think, 'Well, I'm healthy, and I can make do,' and then they have a skiing accident and everything falls apart," McBride said.
It's not just the possibility of an injury that has people in the health field concerned. For those without coverage, avoiding medical care is too often the coping strategy of choice. Collins said surveys show that young people without health insurance are more likely than others to skip a visit to the doctor or fail to fill a prescription. Instead, they might self-diagnose or share prescription medication with a friend who has insurance -- a practice that McBride said he's noticed with alarming frequency.
Problems that could be handled by primary care physicians go untreated and fall to emergency room doctors. Dr. Denny Keithly, chairman of the emergency department at St. John's Mercy Medical Center, said the number of people who are uninsured and whose only option is the emergency room is increasing.
Collins said it's important for people in their 20s to get preventive care.
"We tend to think of them as a healthy population," she said. "But there's a high level of obesity; sexually transmitted diseases are common. It's not an age group that we can dismiss as young and not needing care."
THE EARLY DANGER ZONE
Children are often covered under their parents' health insurance. But under most family plans, they lose coverage upon turning 19 or finishing college. Most people covered through public programs such as Medicaid or the State Children's Health Insurance Plan (S-CHIP) also lose eligibility for the program when they reach 19, regardless of their status.
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Least likely to be insured
Eighteen- to 24-year-olds are the least likely age group to have health insurance, with nearly 30 percent lacking coverage, according to the National Coalition on Health Care, a membership organization that includes businesses and primary care providers.
A 2008 report from the Commonwealth Fund about why adults become uninsured showed that almost two in five high school graduates who don’t enroll in college and one-third of college graduates are uninsured for a time during the first year after graduation.
Nearly 60 percent of group plans obtained through employers only insure adult dependent children who are students, according to the Commonwealth Fund study.
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Collins said she thinks many states are doing what they can to "patch the system" in the absence of a federal solution. Extending eligibility for public insurance programs beyond age 18 and ensuring that colleges require students to have health coverage and offer it to full- and part-time students would help uninsured young adults get coverage and prevent others from losing it, she added.
A number of states have passed laws to expand coverage of dependents up to age 24 or 25 under parents' insurance policies. Utah became the first state in 1994 to pass a law that allows unmarried dependents to keep coverage until they are 26, regardless of school enrollment status. An Illinois provision allows people who served in active duty in the U.S. Armed Services between the ages of 19 and 23 to retain their dependent status for the amount of time they served until they are 25 so long as they are a full-time student.
In Missouri, insurers can elect to cover dependents through college or make the cut-off age earlier. But they must extend dependent coverage until age 25 if a consumer so asks, according to Travis Ford, a spokesman for the Missouri Department of Insurance, Financial Institutions and Professional Registration. The rule applies to state residents who aren't married or covered by another health plan.
The state also requires health maintenance organizations with coverage of a dependent child that would otherwise end sooner to continue it until age 25, while the dependent remains unmarried and "incapable of self-sustained employment by reason of mental or physical handicap and chiefly dependent upon the enrollee for support and maintenance."
State legislative attempts to require a broader range of health plans to cover unmarried dependents with chronic illness through age 25 have failed.
"They should not have to be unemployed to continue to access their parents' health insurance," said Dr. Sam Page, a former Missouri state representative who sponsored dependent coverage legislation. "We want people to work."
Insurance companies and some state lawmakers argue that such changes would result in an increase of health insurance costs for everyone. Page said the increases would be negligible and worthwhile as an investment in the health of young residents.
McBride, the Washington University associate dean, said that changing state law to extend the dependency age is a step in the right direction but not a panacea. For one thing, he said, an employer that is self-insured is exempt from state regulation.
THE EMPLOYMENT PIECE
Most Americans with health insurance get it through their employers. But increasingly, having a job doesn't mean you get health coverage. Rising premiums make it more difficult for small employers to afford health insurance to their employees. Collins, of the Commonwealth Fund, said employer-sponsored coverage continues to decline. The increase in unemployment is certain to push the uninsured rate higher.
More than one-third of workers between ages 19 and 29 have jobs that pay less than $10 an hour, and low-paying jobs are unlikely to offer health insurance, according to a Commonwealth Fund report. It found that 40 percent of workers in this age and wage category are uninsured.
Companies that offer health insurance typically require employees to contribute more toward their coverage than in the past, which means more workers choose not to take advantage of job-based health insurance.
There's also the well-recognized tendency for young workers to job-hop early in their careers -- by choice or necessity.
"That's the problem," McBride said. "As economists, we say we want them to move from job to job. At that time in their life, they should be searching for the best career path, and we don't want that impeded by insurance questions. But in fact we make it quite impossible for them to do that."
Once a person leaves a job, the gap period of unemployment can be costly. According to the National Coalition on Health Care, only 7 percent of the unemployed can afford keeping their insurance plan through the Consolidated Omnibus Budget Reconciliation Act (COBRA). Individuals can be required to pay the entire premium for coverage up to 102 percent of the plan's cost.
"What really needs to happen is repairing holes in the system where people lose employer-based plans because they are in transition," Collins said. "What people are talking more and more about is fixing the individual insurance market," so that obtaining such plans between periods of group coverage becomes more viable."
McBride supports the idea of a health-insurance exchange, in which employers could help subsidize the cost of a pool of health plans (both public and private) if the company didn't want to provide insurance itself. Individuals could buy into the exchange even if they are unemployed. The key, he said, is to make the exchange so large that it spreads the administrative costs.
Recognizing a growing problem, private health-insurance companies have in recent years begun to develop less expensive health-insurance plans to cater to young adults. President Barack Obama recently announced a proposal that would let private insurers offer their health plans alongside a federal plan that would be open to people of any age.
The insurance industry has argued that federal intervention will push out private insurers. But it said late last month that it might be willing to stop charging higher premiums to sick people if Congress passes a plan mandating that all Americans carry insurance. The private companies have long argued that if they couldn't take past health problems into account in setting premiums, the rates charged to young people would rise. Insurers said they are looking into ways of preventing that by spreading the costs across a larger group of people.