Medical students experience significant mental distress, including high rates of anxiety, alcohol use, depression and suicidal ideation, and it’s only gotten worse since the start of the Covid-19 pandemic. The data also show that medical students don’t always get care for these conditions when they need it.
And as we found during a recent research study published in JAMA Internal Medicine, the reasons for this are not just stigma and fear of professional repercussions. With our colleagues, we found that insurance plans offered by U.S. medical schools have high out-of-network annual deductibles and out-of-pocket maximums as well as significant cost sharing, which might dissuade students from accessing mental health care when they need it.
To arrive at this conclusion, we obtained data on the health insurance plans offered by U.S. medical schools from the schools’ websites or via telephone call. For each plan, we recorded both in-network and out-of-network information regarding annual deductible, out-of-pocket maximum, and copayment and/or coinsurance amounts for mental health outpatient and inpatient services.
We obtained data from 88% of allopathic U.S. medical schools (that is, those that grant M.D.s) and found that the median out-of-network annual deductible was at least twice the median in-network annual deductible. For in-network outpatient services, most schools required copayment without coinsurance, and the median copayment was $25. For out-of-network outpatient services, most schools required coinsurance without copayment, where the median coinsurance was 40%. Lastly, for both in-network and out-of-network inpatient services, the majority of schools required coinsurance that doubled from 20% to 40% 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 costs, regardless of network status.
These findings suggest that medical students, who like others have struggled during the pandemic, may not be receiving the mental health care they need. High out-of-network annual deductibles and out-of-pocket expenses as well as significant cost sharing pose significant obstacles for students trying to access care — depending on the type of care necessary, these costs could be tens of thousands of dollars. Students are most likely to run into these high costs when they seek care near their hometowns instead of to near their medical school: Providers near the medical school are more likely to be in-network.
Think about it. If a medical student needs inpatient hospitalization, they’re probably much more likely to want to receive services near their home, where friends and family can visit and offer support. But seeking such treatment could saddle a medical student with tremendous amounts of debt.
To their credit, most medical schools offered free therapy sessions, with the number of sessions that they offer varying from one to unlimited. But students might have very legitimate concerns about how confidential and private that treatment would be. And medical students — who are all-too-familiar with situations in which confidentiality might be breached — might be especially wary.
One of us is a current medical student, and one of us is an M.D. and a medical school professor. We have both heard of instances in which student health services were in communication with university administrations about certain students, unbeknownst to the student. 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 or institution to another.
Medical schools ought to improve mental health coverage by significantly lowering costs for students, especially when they opt to go out of network. Additionally, schools could be explicit with their students about if and when their confidentiality would ever be broken if they utilize on-campus resources. And even more, medical schools could offer significantly greater access to confidential, third-party therapy resources. We had hoped our findings might provoke change, but so far, we haven’t heard about any medical schools updating the coverage they offer their students.
Besides making changes along the lines we advocate for above, the faculty at medical schools should aim to be supportive with students when it comes to mental health care, and to dispel any myths regarding its impact on their career. For example, many students believe that if they ever access mental health treatment for any reason, they will need to disclose that information when they eventually apply for licensure. In reality, only a small percentage of states ask intrusive questions about past histories of receiving mental health care. The large majority of states concern themselves only with whether or not an applicant is currently impaired by reason of mental or physical health. Faculty therefore need to be informed about state licensure questions so that they can be reassuring to students who need to access mental health services.
One sad fact is that the insurance plans that medical schools offer their students are not uniquely terrible — they are similar to what many employers offer their employees. But medical schools need to do better than average. They need to offer privacy-respecting low- or no-cost mental health treatment options no matter where students choose to access care. Being able to access health care is a fundamental human right, and medical schools need to step up and lead the charge in guaranteeing that right.
Amelia Mercado is a second-year medical student at Baylor College of Medicine. J. Wesley Boyd is professor of psychiatry and medical ethics at Baylor College of Medicine and a lecturer on global health and social medicine at Harvard Medical School.