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Key points
- Insurance plans offered to medical students often have high cost sharing for mental health services.
- Costs are notably high for out-of-network mental health services.
- Most medical schools offered free therapy sessions, but privacy concerns may prevent their utilization.
- Southern medical schools offer particularly poor coverage, with high out-of-pocket maximums.
This post was co-authored by Amelia Mercado, B.S.A., and J. Wesley Boyd, M.D., Ph.D.
Even before the pandemic, medical students were experiencing significant mental distress, including high rates of anxiety, alcohol use, depression, and suicidal ideation. And as is the case for the general population, the COVID-19 pandemic has only worsened things.
But medical students don’t always receive mental healthcare when they need it. Failure to obtain care may be due to stigma or fear of professional consequences, but poor insurance coverage might also be a contributing factor. Research from over a decade ago showed that medical schools needed to ramp up coverage, but there was no current data about the mental health insurance coverage that medical schools offer to students.
So my colleagues and I decided to change that. We obtained data on the health insurance plans offered by U.S. medical schools and just published our findings here in JAMA Internal Medicine.
In total, we obtained data from 88 percent of allopathic U.S. medical schools and found that the median out-of-network annual deductible (AD) was at least twice the median in-network AD. Most schools required co-payment without coinsurance for in-network outpatient services, where the median co-payment was $25. For out-of-network outpatient services, most schools required coinsurance without co-payment, where the median coinsurance was 40 percent. Lastly, for both in-network and out-of-network inpatient services, the majority of schools required coinsurance that doubled from 20 percent to 40 percent for out-of-network services.
Coverage differed by region as well, with insurance plans offered by southern medical schools having the highest median out-of-pocket (OOP) costs, regardless of network status. Most medical schools (124/157) offered free therapy sessions, with the number of sessions varying from one to unlimited. It should be noted that it is unclear how many students waive their school’s insurance plan or are on their parents’ insurance plan. Therefore, the impact of these costs may differ from student to student, depending on their waiver status.
These findings offer possibilities about why medical students, who, like others, have struggled during the pandemic, may not receive the mental healthcare they need. Not receiving needed care could be due to the stigma around mental illness or the fear of professional consequences.
But, as is suggested by our study, the expense of seeking such care may also play a role, given that the plans offered by medical schools often have high out-of-network AD and OOP as well as significant cost sharing. These findings are particularly relevant for students who return to their hometown for mental healthcare, which may be in a different city or state than their school and, therefore, would almost definitely be out-of-network. Additionally, given that medical students can come from vastly different financial backgrounds—with some going hundreds of thousands of dollars into debt—a lack of affordable mental healthcare becomes a health equity issue, too.
And even though it is laudable that so many schools offer free therapy sessions, students might have very legitimate concerns regarding the confidentiality and privacy of their treatment. These concerns seem justified to us since we have heard of instances in which student health services were in communication with university administrations about certain students. Even though health services might justify such communication by stating that they only do so in emergency situations, what constitutes an emergency can vary widely from one practitioner to another. This possibility further highlights why high out-of-network costs are alarming, as students may be left with no affordable options if they feel uncomfortable going through their school’s therapy service.
In conclusion, although some medical schools offer solid coverage for mental health conditions, that is not uniformly the case. As such, medical schools ought to improve mental health coverage by significantly lowering costs for students (especially when they opt to go out-of-network) and expanding access to confidential, third-party therapy resources.
Additionally, faculty and leadership in medical schools have a part to play in normalizing mental healthcare. First, they can aim to advertise resources for mental health that exist within their medical school and the greater community. To help reduce stigma, this information may be mentioned within orientation sessions that occur throughout medical school. Second, they should try to be supportive of students when it comes to their mental health. Some students may need to take leave for mental health or substance use treatment. Having procedures in place for a leave of absence and vocalizing their existence may help students feel more comfortable getting the care they need, when or if they need it. And most importantly, this care must be affordable and accessible for all students, irrespective of financial background.
Medical schools need to do all that they can to take care of the next generation of physicians and ensure access to inexpensive, confidential treatment. Eliminating as many barriers as possible for them to receive needed treatment is essential.
Amelia Mercado is a second-year medical student at Baylor College of Medicine.
