Whether by design or unexpected consequence, it’s becoming increasingly clear that the Affordable Care Act (ACA) has thrown a gigantic monkey wrench into the provision of student health insurance plans at universities.

Since most of my research is on health insurance at the other end of the age spectrum, I had not paid much attention to student health insurance after my days as a graduate student at Rutgers.  While I was in graduate school, I actual served as a member of the graduate student employees’ union, and worked on the bargaining team during contract negotiations. Part of my work was benchmarking stipends and benefits at Rutgers compared to other major universities.  Until 2014, I had not given the topic much thought for 25 years.

That spring, however, Penn State and its students were surprised by a huge change in the health insurance plan being offered.  Two years before, Penn State had negotiated a fantastic deal, with graduate students having nearly full coverage above a small deductible. The third year of the contract, however, gave the insurer great latitude on premium changes and coincided with changes from ACA.  Because of the interpretation of ACA by federal government agencies, student health plans purchased from insurers could no longer be regarded as group plans, which, if they met “minimum essential coverage”, would have allowed students and universities to negotiate with insurers in a less regulated marketplace.  Instead, these plans were to be considered individual plans, and thus subject to the same regulations as plans on the ACA exchanges. On the one hand, students covered by these health plans now had the protections afforded other consumers.  But, that hasn’t been without consequences.

For Penn State and other students impacted by this, this meant that benefits had to fall in one of the ACA metallic tiers. In Penn State’s case, this occurred simultaneously with a plan year that had high expenses and the imposition of the new ACA taxes and fees.  The end result was a sizable cut in benefits AND a premium increase of more than 20 percent.

Unlike the health insurance market for employees, universities have few options to try to address any problems.  There are only a few insurers that provide health insurance plans targeted to students. In many states, self-insured plans are not permitted for students, thus eliminating that competitive option.

And this challenge is growing.  Recent regulations and guidelines have determined that university health insurance subsidies to graduate students may violate ACA regulations on employers and have clarified that rate review regulations also apply to student health plans. By reducing demand and raising costs, a thin market for insurance thins even more.

As a result, some universities are eliminating student health insurance plans. Others are eliminating health insurance subsidies, raising graduate student salaries, and encouraging students to look at the variety of plans available to younger consumers–student plans, catastrophic plans, parental plans, or ACA plans. And, to the extent that students do enter the ACA market, their low health care costs may keep insurance premiums in those exchanges down for all. By accident or design, it seems as if more and more students are being directed elsewhere.

Providing good health insurance to students has always been difficult. Students have diverse needs. Some are international students with little familiarity with America’s complex health system. Out of state students have to consider whether a plan from home can provide an adequate network of providers while they are at school. Low income students may be covered by Medicaid, but coverage issues can be an issue for them, too.  And student health plans were always plagued by risk selection issues. Students are new to purchasing health care and health insurance and often ned good support making their decisions

Perhaps, ACA plans will reduce those problems for students. They’ll offer their own challenges for students.  Universities and ACA exchanges, along with others, ought to build a more robust system to support students in finding their path to adequate health coverage.

A little over 19 years ago, I was sitting in my office in Henderson Building, when I heard a loud “CRACK”. It startled me enough that I stepped out into the hallway, and saw a few other faculty and staff who also had heard the sound. One faculty member commented, “That was a gunshot-no doubt.”  Over the next terrifying minutes and hours, we watched as just yards from our offices, Penn State joined the growing list of campuses where students were killed and injured by gunfire.

During the warmer months, I love to take my lunch out into the Peace Garden next to Henderson.  The quiet, shady garden, built in remembrance of that day, provides such a contrast to the chaos of the events of 1996. And as each of the events that followed piled tragedy upon tragedy, I just can’t grasp the reactions that seem to follow.

Americans recognized when our cars and road were unsafe.  We invested in research and education. We improved our roads, and created smart regulations that made our vehicles safer–airbags, better structural safety, seatbelts, and more.  And, as a result, deaths from motor vehicle accidents plunged from more than 54,000 per year to close to 30,000 per year. In other words, almost 25,000 Americans EVERY YEAR are saved by our efforts to make make roads and vehicles safer.

Americans recognized the dangers associated with tobacco.  We invested in research and education.  We improved fabrics and furniture, and created smart regulations that reduced access to cigarettes among youths and in public places where they harmed others. And, as a result, the number of people who use tobacco in the U.S. plummeted from more than 45 percent of the population to less than 20 percent. As a result, smoking related deaths in the U.S. have leveled off and should, in coming years, begin to decline. In other words, over the next several decades, tens of thousands of Americans EVERY YEAR will be alive, saved by our efforts to address the dangers associated with tobacco.

Public health works. Research and education and product improvement and smart regulations save lives.

There is absolutely no reason why the same principles cannot be applied  with guns.  To me, this isn’t about gun control. It’s about GUN SAFETY.  It’s about research and education that helps us understand how we can make guns safer. It’s about product improvement that can reduce accidental deaths by gun. It’s about smart regulations that reduce the likelihood that a gun is available to someone likely to use it to harm themselves or others.

For too many years we’ve been barred from even doing research. We’ve refused to talk about education on gun safety. We’ve made it impossible to have manufacturers take responsibility for making their product safer and accountability when they fail to do so. And we’ve abandoned the idea that smart regulation can improve safety, reduce harm, save lives and still preserve our freedoms. More than 30,000 Americans die every year from an incident involving firearms. I hope that’s about to change. I hope our HHD students are part of that change.