Approximately 19 million full- and part-time students were enrolled in U.S. colleges in 2018.¹ Although they are generally healthy, many of these individuals have special health care needs such as asthma, diabetes mellitus, mental health concerns, and learning disorders. Understanding and managing the needs of this dynamic population involve addressing the unique psychosocial stressors related to this life transition that manifest before and while attending college. Common self-reported medical conditions among college students are presented in Table 1.²

Transition to College

College students are often assuming responsibility for their health care for the first time; however, the transition from a childhood model of care to an adult model of care is often given a lower priority than other transitions that students are experiencing.³ Approximately 20% of U.S. youth have special health care needs.⁴ Although many children and adolescents have taken steps to comanage their diseases, most of these youth do not receive a structured transition to an adult care model,⁵ and the situation is complicated by poor care coordination.³ Students may have to reconcile recommendations from multiple sources of care, such as an ongoing childhood physician and a new clinician at college if living away from home. Physicians may perceive that youth are poorly informed regarding their own health care matters. Simultaneously, some physicians may be poorly informed about patients' childhood conditions that continue into adulthood, such as cerebral palsy and cystic fibrosis.⁵ Problems with this transition result in declines in treatment adherence, increased emergency department use, and increased hospitalizations.³ Improved adherence to health care, better patient experience, and increased appropriate use of ambulatory services are reported with structured health care transition visits that prepare the student for self-care and help to transfer the student to the adult model of care⁶ (Table 2).

Health Care Coverage

Under the Patient Protection and Affordable Care Act (ACA), students younger than 26 years have four options for qualifying health coverage: coverage under a parent's insurance plan, school-offered health plans, marketplace plans, and Medicaid and the Children's Health Insurance Program.⁷ Despite these options, 72% of college students and recent college graduates indicate that finding health care coverage remains difficult, and 1.6 million students remain uninsured.⁸

A parent's insurance plan may be the least expensive option, but it may also limit confidentiality for the young adult because notices of service are sometimes sent to the primary enrollee. Participation in one of the other three options results in bills and explanations of benefits being sent directly to the student. Many school-offered plans do not provide coverage during summer breaks and may leave the student uninsured if other options are not pursued.

Under the ACA, all but the school-offered health plans are regulated by the Department of Health and Human Services. These plans are required to provide the following coverage without an annual or lifetime limit: ambulatory services; emergency services; hospitalization; laboratory tests; maternity and newborn care; mental health care, including substance use treatment; prescription medications; and rehabilitation services.⁷ Copays for these services vary widely.

Institutions of higher education vary with regard to testing, immunization, and prevention practice, depending on state law and exemption practices, in their health care resources and responses to the COVID-19 pandemic.⁹

Common Learning and Mental Health Issues

The learning and mental health needs of college students remain a growing concern. College counseling center directors report an increase in the number of students who arrive on campus already taking a psychotropic medication,¹⁰ with at least 40% of these directors reporting increases compared with the previous five years of depression and anxiety disorders, learning disorders, sexual assault, and crisis issues requiring immediate responses.¹¹ In colleges, most health center visits (60%) are to primary care clinics, whereas a smaller proportion of these visits (13%) are to mental health clinics.¹¹ Students in higher education are protected by the Americans with Disabilities Act and Section 504 of the Rehabilitation Act¹²; however, the ACA does not support costs associated with diagnosis and treatment of learning disorders.¹³ Students should meet with their college office of disabilities to understand school policies and resources and to self-advocate regarding insurance requirements.¹⁴