Cracks in campus health care

After days of sharp pain shooting up her left abdomen, Rose Wong hobbled from her history class to the student health center at Duke University.

A nurse pressed on the 20-year-old’s belly and told her it felt like gas. Wong questioned the diagnosis but said the nurse dismissed her doubts and sent her to the campus pharmacy to pick up Gas-X that afternoon in February 2019.

The next morning, Wong doubled over in pain, and a roommate drove her to an emergency room in nearby Durham, N.C. In the hospital, doctors discovered her condition was far more serious: Her left kidney had a massive hemorrhage. The bleeding, she later learned, was caused by a cancerous tumor that required surgery and chemotherapy and forced her to miss an entire school year.

Wong said she worries that when she returns to the Duke campus next month, the university and its medical clinic will be incapable of keeping her and 15,500 other Duke students healthy and safe in the middle of the coronavirus pandemic.

“Everyone I know says that student health is awful,” Wong said. “It’s an open secret.”

Wong’s misdiagnosis at Duke is among the scores of problems documented by The Washington Post at college health centers nationwide. As millions go back to school during the pandemic, the ability of campus health services to safeguard and care for students will be tested as never before — and many colleges appear unprepared for the challenge.

To assess the landscape of student health services at roughly 1,700 four-year residential campuses, The Post interviewed more than 200 students, parents and health officials and examined thousands of pages of medical records and court documents and 5,500 reviews of student health centers posted on Google.

College students reported they commonly waited days or weeks for appointments and were routinely provided lackluster care. Dozens of students ended up hospitalized — and some near death — for mistakes they said were made at on-campus clinics, including misdiagnosed cases of appendicitis at Kansas State University and meningitis at the University of Arkansas.

Many students, including low-income individuals on Medicaid, said they avoided seeking treatment altogether because the care was too costly.

On college campuses nationwide, the health-care facilities available to students vary widely, from multistory buildings with comprehensive services to a single exam room run by one nurse who is not licensed to prescribe medications. While some students praise the care they’ve received, others say there are major shortcomings.

Student health centers are akin to the Wild West of medical care. There are no national regulations, and most are not licensed by states. Only about 220 campus medical clinics of the thousands nationwide are accredited by outside health organizations as meeting best practices, according to a Post analysis. In one case, Georgetown University stated on its website that its student health center was accredited but removed the claim after being asked about it by reporters.

More than 80 percent of colleges expect to resume in-person classes this fall or offer a hybrid of online and in-person instruction, according to a Chronicle of Higher Education list of more than 1,000 colleges.

Students are planning to descend on campuses in a matter of weeks as many states are experiencing a surge of coronavirus cases, including an increasing number of young people who have tested positive. Health experts have described colleges as cruise ships on land, ideal places for the novel coronavirus to spread quickly through shared dorm rooms, communal bathrooms and dining halls. Pennsylvania State University announced this month it was conducting contact tracing after a 21-year-old student who visited the campus died of complications related to covid-19, the disease the virus causes.

University leaders are publicly lobbying for federal protections from coronavirus-related lawsuits when they reopen, arguing that costly litigation would take away from already scarce resources needed to support students.

College health officials, meanwhile, are privately discussing insufficient stockpiles of personal protective equipment, inadequate access to coronavirus testing on campus and a short supply of rooms to quarantine students, according to interviews, emails and presentations reviewed by The Post.

Health professionals at historically black colleges and universities have said they are concerned about the risks to their students and faculty because of the disproportionate number of covid-19 diagnoses and deaths among black people.

“I don’t get to make those decisions about whether students are coming back, but they are coming back,” Mari Ross-Alexander, assistant vice chancellor for health and wellness at the historically black North Carolina Central University, said in a recently recorded panel discussion.

“What I’m preaching is, we have to have the space to take care of sick students because that’s what we are going to get — we are going to have sick students.”

Because of the pandemic, returning students at some institutions will have a harder time obtaining in-person medical care. Officials plan to lock the doors of campus clinics, refuse drop-in visits and shift many appointments to telemedicine. The goal is to prevent the virus from spreading inside health-care facilities.

After Wong’s experience at Duke, she began writing a column for the student newspaper that exposed chronic problems at the campus health clinic, including allegations that the medical staff misdiagnosed a concussion as anxiety and pneumonia as asthma. Wong said she will refuse to set foot in the health center when she returns to campus next month.

Duke, which declined to detail the medical care of individual students, plans to pay for coronavirus tests for all those living on campus before they begin classes. In addition, students will be asked to complete daily health checks through a monitoring app and report symptoms to the university’s health department.

“Duke Student Health and Wellness will provide the highest level of care and is connected to one of the most advanced health-care systems in the world, with extensive experience in coronavirus prevention, detection and treatment,” said Erin Kramer, a Duke spokeswoman.

While private universities with large endowments such as Duke have the budget to fund widespread testing, many institutions are struggling financially and have not invested in student health care in years.

Glenn Egelman, a health-care consultant, said campus health clinics “most definitely will not have the depth and breadth and resources to manage a significant outbreak.”

Egelman, the former head of George Washington University’s health center, resigned from the college and wrote a letter in 2018 to the university president, saying that he could not reassure the community of “the quality, safety, or appropriateness of care provided.” He said he had concerns about health-care employees working without proper credentials and “minimal patient safety efforts.”

Since then, the college has hired a new leader to oversee the health center, extended its hours and made other changes, according to a university spokeswoman.

“The field of student health has so many issues,” Egelman said in an interview. “It has been unrecognized and unappreciated — the importance of it and the dysfunction in it.”

‘A source of increasing concern’

Many college students are living on their own for the first time, and they have little experience navigating the health-care system. And parents interviewed said they assumed that the high cost of attending college guaranteed reliable medical care on campus.

When 19-year-old Makenzi Marek visited Iowa State University’s Thielen Student Health Center as a sophomore in 2018, she had no clue that consultants three years earlier had issued a scathing public report about the clinic on the Ames campus.

Keeling & Associates, an educational consulting firm, had warned Iowa State that poor leadership, inadequate training and understaffing had made the health center “a source of increasing concern and serious complaints.” This included misdiagnosing a student with a potentially life-threatening case of appendicitis and failing to notice a stress fracture in another student, prolonging the recovery.

In November 2018, Marek worried that she had the flu after battling a painful headache and cough. A doctor at the student health center tested her for flu, but before the results came back, she was given two vaccines in nearly the same spot in one arm: one for the flu and another for pneumonia, even though this vaccine is typically recommended for elderly patients.

After Marek came down with a fever, she returned to the student health center, and another doctor prescribed antibiotics. The medication didn’t help, she said, and her left arm became so swollen and difficult to move that her boyfriend had to cut her shirt off her body.

With chills, a fever and a growing rash, Marek headed three miles off campus to Mary Greeley Medical Center, where she was hospitalized for five days with cellulitis, a potentially life-threatening bacterial skin infection, according to medical records.

After racking up thousands of dollars in medical bills, Marek filed a claim against the university stating that the hospital staff all agreed that she should not have received the pneumonia vaccine, especially because she was sick at the time. Marek eventually received a $5,000 settlement.

Angie Hunt, a university spokeswoman, said that Iowa State did not admit any wrongdoing in its agreement with Marek, and that the care provided at the center uses “evidence-based guidance.” The college has also implemented all the recommendations from the 2015 Keeling & Associates report, Hunt said, including hiring new medical staff members.

The university, which enrolled more than 33,000 last year, is offering coronavirus testing at the student health center and requiring students and staffers to wear masks on campus.

Marek is eager to return to college in August and have her younger sister join her on campus as a freshman. But she and her sister made a pact to avoid the student health center and drive the 2½ hours to their hometown or go to another clinic if either one gets sick.

“I absolutely lost my trust,” Marek said of the student clinic. “All college students need a safe place to go and make sure that they’re getting the right help. … I wish that were the case for me.”

Stephen Beckley, a consultant with Hodgkins Beckley Consulting, which has evaluated health programs at more than 200 colleges and universities nationwide, said many schools treat on-campus clinics as if they are no different from the bookstore, dining hall or any other student service.

“There are such significant problems among college health programs,” Beckley said. “We’ve seen some amazing turnarounds, but there’s a lot that colleges do in managing these programs that’s not right.”

For prospective students considering colleges, health centers are rarely among the top priorities compared to expensive new dorms or fitness centers, according to Egelman. While some clinics provide extensive health services and partner with academic medical centers, others may have a single nurse available and refer students off campus for other medical needs.

In 2017, colleges on average spent only about $185 per student for their health centers, according to a Post analysis of clinic expenses and enrollment at roughly 200 schools. Nearly 70 percent of colleges surveyed did not have a full-time psychiatrist, and one-third did not have a full-time physician.

At Ohio University’s rural campus in Athens, with roughly 19,000 students, consultants at Keeling & Associates in August 2007 flagged problems at the on-campus clinic, including a cockroach-infested building and medical equipment that hadn’t been replaced since the center opened 60 years earlier.

The consultants also warned university leaders that the health center was significantly understaffed and risked “missing the extraordinary problem hidden among many ordinary ones.”

Weeks later, in September 2007, freshman Molly Millsop walked into the student health center on the second day of classes complaining of a headache, a fever and a stabbing pain in the back of her right arm.

Over the next several hours, a doctor at the center diagnosed the 19-year-old with a muscle strain and then anxiety as Millsop reported having trouble breathing and increasingly severe arm pain, according to medical records and court documents.

Before leaving for lunch, the doctor dropped off Millsop in an observation room, where the teenager sat on the floor and vomited twice.

Distraught and crying, Millsop called her father, who drove three hours across the state to intervene. He took her one mile down the road to O’Bleness Hospital, where doctors quickly recognized that she had a rare flesh-eating bacterial infection known as necrotizing fasciitis. The infection had spread while she writhed in pain at the student health center.

By the end of that night on Sept. 7, 2007, Millsop, an aspiring journalism student, had her entire right arm and shoulder amputated — and almost lost her life.

“I trusted the health center. At the very least, I expected them to recognize that this was beyond their capabilities and move me to someone who could handle it,” Millsop said. “They just see us as young and healthy and that there can’t be anything particularly wrong with us.”

In February 2010, 18-year-old freshman Andrea Robinson had a headache, stiff neck and fever of 103.8. She was too weak to walk up a hill to the student health center, so her boyfriend called the clinic for advice.

The employee who answered the phone suggested Robinson take Tylenol, drink water and rest. She wasn’t warned that a serious strain of meningitis had been circulating around the campus — one student had tested positive just a week earlier.

Robinson’s condition deteriorated the next day, and her friends called an ambulance to take her to O’Bleness Hospital, where she was diagnosed with meningitis, according to medical and court records and interviews with Robinson’s father. The freshman died a couple of days later.

That August, Ohio University turned over operation of the student health center to a physicians group that was affiliated with the university’s medical school. The clinic was later contracted out to OhioHealth, the state’s largest hospital system.

Millsop’s and Robinson’s families filed lawsuits against the college that resulted in settlements. But student concerns about substandard medical care persisted.

In June last year, after a student at Ohio University asked people to share their experiences with the school’s health center on Twitter, more than 100 people recounted problems, including allegations that employees misdiagnosed broken bones and dismissed salmonella poisoning as a hangover.

Last year, Jake Wendling said he went to the student health clinic with chest pains, feeling lightheaded and out of breath. After waiting a half-hour, Wendling said, the doctor suggested the 19-year-old was having an anxiety attack.

The physician eventually agreed to perform a heart test, known as an electrocardiogram, but couldn’t make sense of the results. In the meantime, Wendling became glassy-eyed and passed out, according to medical records. The doctor then sent the teenager to O’Bleness Hospital, where he was diagnosed with a nervous system disorder and prescribed medication to lower his heart rate.

Wendling hasn’t returned to the health center and is concerned that the school cannot manage an outbreak of the coronavirus this fall.

“It would be absurd to even think that place is capable of treating someone with coronavirus,” Wendling said. “I don’t trust it.”

Officials with Ohio University and OhioHealth said they could not comment on individual cases because of privacy restrictions. The school has partnered with OhioHealth to provide services on campus and receives high patient satisfaction scores each year, said Carly Leatherwood, an Ohio University spokeswoman.

“The health and safety of our students, faculty and staff is Ohio University’s highest priority,” Leatherwood said. “We take every complaint very seriously.”

Dozens of college students from around the nation told The Post that campus health clinics dismissed their medical problems as anxiety or downplayed the severity of their symptoms.

Chloe Shriber said she felt a sharp pain in her abdomen during her sophomore year at Kansas State University in 2018. She said she left class to visit the Lafene Health Center.

At the clinic, Shriber told a nurse and a doctor that she worried she had appendicitis. After pressing down on Shriber’s abdomen, a doctor claimed that she would have been “screaming in agony” if she had appendicitis, Shriber recalled.

Shriber’s mother, Joni Scobee, urged her daughter to go to Ascension Via Christi Hospital about 1.5 miles away. There, doctors discovered the 20-year-old had appendicitis. She had emergency surgery to remove her appendix that day.

Scobee blasted off angry emails to school officials: “The fact that a LAZY doctor ignored the signs and sent her home is ridiculous. … Your clinic could have cost my child her life.”

Kansas State, located in Manhattan, declined to comment on Shriber’s case, but a university spokesman said the center was ranked second in the nation for best health services by the Princeton Review, a student ratings publication. He said the university was making “thorough plans” for students to return in August.

The college halted workouts for football players after 14 of 130 tested positive for the coronavirus. The school is testing all athletes for the virus but has not committed to free testing for all students when they come back to campus.

Shriber, who has transferred to another university, said it’s “dangerous and reckless” to have students return to campus, “especially when you don’t have the health-care center that can provide even basic things.”

‘Sometimes we have to sacrifice our health’

In recent years, budget cuts and efforts to limit student fees have strained resources available for campus clinics, resulting in smaller staffs, fewer services and longer wait times, according to interviews with college health officials and a survey of about 200 schools. The Post conducted the survey using a random sample of public and private colleges to be representative of enrollment, location, religious affiliation, and historically black colleges and universities.

Almost three-quarters of these colleges closed their health centers on weekends, and two-thirds provided no evening clinic hours during the week.

Now, the pandemic has set off a new financial crisis. Some institutions have furloughed medical staffers. Oregon State University closed its pharmacy in June, and the University of North Dakota is planning to cut a physician assistant and shutter its pharmacy at the student health center.

About 250 residential colleges have no campus medical clinics or provide services only to athletes, according to a Post analysis of about 1,500 four-year schools with at least 500 students enrolled. Some offer students telemedicine or partner with off-campus providers.

Hardin-Simmons University, a private school in Texas with roughly 2,000 students, has three medical clinics for athletes but had only one nurse to treat other students. She retired in 2016 after 25 years of service.

When asked why the nurse wasn’t replaced, a university spokesman said Hardin-Simmons made “a variety of adjustments to our campus organizational structure” to build “long-term financial sustainability.”

The college added two mental health professionals for students and opened a $7 million fitness center. A student who worked at the fitness center said she had stocked up on disinfectant before the pandemic to avoid getting sick because there was no nurse on campus.

The university recently contracted with a local medical provider to conduct free coronavirus testing for all sports teams as they return to school — and at least five students have already tested positive. But other students have to go off campus for testing and medical care.

As the demand for mental health services has soared, some institutions have had to make hard choices. In 2019, Minnesota State University Moorhead converted its medical clinic into a counseling center because it couldn’t afford to operate both.

The University of Central Florida, which has a comprehensive health center offering dental care, physical therapy and other specialty services, has had to find ways to contain costs, such as reducing evening hours, according to Michael Deichen, the associate vice president of UCF Student Health Services in Orlando. The clinic also has hired more affordable nurse practitioners instead of physicians, a trend at many health-care institutions across the country.

Deichen, who sits on the American College Health Association’s covid-19 task force, said student health centers face many challenges — from external threats like the coronavirus to internal budget pressures.

“There’s always an opportunity for improvement,” Deichen said. “There are limitations everywhere, too.”

Talisha Bowe, a 21-year-old junior at the University of Central Florida, said she appreciates the convenience of having a campus clinic and is mostly satisfied with the care she has received over the years.

Bowe said it’s extremely important for colleges to make sure campus health centers are accessible and ready to handle sick students during the pandemic.

College health officials and public health experts worry about the consequences of reopening without adequate access to testing, contact tracing and general medical care, especially at historically black colleges and universities, or HBCUs.

Many of these institutions have less funding and smaller endowments to invest in critical health-care infrastructure compared with other schools, and their students and faculty are more at risk, as the coronavirus has disproportionately affected the black community.

About 12 percent of HBCUs that offer bachelor’s degrees have no campus clinics, according to a Post review of the roughly 80 institutions. Of those that provide health services, about 70 percent do not have a full-time physician on staff.

“Your dollars are smaller, so you have to do the best, but with the small pool of money that you have,” said Reginald Fennell, an emeritus professor of public health at Miami University in Ohio who now works as a nurse practitioner at a historically black college in North Carolina. “Here we are trying to bring students back on campuses across the United States when all schools are not on the same level of trying to get prepared.”

Several students at Howard University, a historically black college in the District of Columbia, said they routinely have trouble getting medical care at the campus clinic because staff members rarely answer the phone to schedule appointments and because the center shuts down for lunch and closes at 5 p.m.

After calling several times with no answer, Elyssa Sanderson said, she walked to the health center to get treatment for severe vaginal pain in April 2019. The staff informed her no appointment was available for two days and recommended she visit the emergency room around the corner, at Howard University Hospital.

Sanderson said she ended up with a $900 hospital bill for a condition that she said could have been treated at the campus clinic.

“They are always so quick to send us to the ER,” Sanderson said. “We’re really not ready to go back to school without a functioning health center.”

Howard, which has roughly 9,000 students enrolled, declined to comment. A spokeswoman referred to the college’s reopening plan, which requires students to get tested for the coronavirus before returning to campus. The university will test a limited number of students who arrive without testing documentation.

“I am pleading with you to be understanding, patient and flexible,” President Wayne A.I. Frederick wrote in a June 25 letter to students.

Before the pandemic, many students across the country had trouble affording care on campus because they were uninsured or their plans weren’t accepted at the health clinic. More than 2.5 million college students are on government insurance, such as Medicaid, and at least 95 percent of campus health services that bill insurance do not accept these plans, according to Beckley, the health consultant.

Since Trisa Chakraborty began attending Indiana University in 2017, she has made the same calculation every time she gets sick: Is it worth going to the student health center?

Chakraborty, who has asthma, is on Medicaid, and the on-campus clinic in Bloomington doesn’t accept her insurance. That means she has to pay entirely out of pocket. A 2018 ankle fracture resulted in more than $400 in medical bills.

Now, the 21-year-old said she avoids seeking medical care or travels 2.5 miles to IU Health Bloomington Hospital, where she has a small co-pay. She still is required to pay Indiana University the roughly $100 student health fee for a clinic she can’t afford to visit. Chakraborty, an incoming senior, is dreading the choices she will have to make if she gets sick during the pandemic.

“Sometimes we have to sacrifice our health because financially we may not be able to afford it,” she said.

Indiana University, with more than 43,000 students enrolled last fall, charges some of the highest prices for such medical services as Pap smears, contraceptive implants and HIV testing, according to a Post analysis of fees from about 150 universities.

Just a year ago, Chakraborty and other students petitioned the university to make the health clinic more accessible. Students protested on campus, holding “Prove That IU Cares” signs, and met with college officials to discuss their proposal, which called for the university to accept all health insurance and offer more care for students with chronic illnesses.

Zoe Layton, one of the students who met with the director of student health and other university leaders, said they dismissed the petition, claiming it cost too much money and wasn’t necessary.

Peter Grogg, executive director of IU Health Center, said no student is ever turned away and the college has emergency funds to help those who need financial assistance to cover the cost of services. He said medical health-care financing is complex, but the university is “actively pursuing how to accept Medicaid and other insurance.”

Layton, who said the health center could not provide treatment for her autoimmune disease, is working with students to renew their demands.

“We need to guarantee that the people who are going to be putting their lives on the line going back in the fall are protected and feel safe and that we have the health care and the resources we need to be students right now,” Layton said.

‘You have to be held responsible’

Students and parents have flagged problems at campus health clinics through letters, social media campaigns and court battles, but colleges have resisted scrutiny of their health operations.

Earlier this year, Liberty University in Virginia sought criminal trespassing charges against two reporters who visited the campus to write a story about the college’s response to the coronavirus pandemic.

About 80 of the roughly 280 colleges contacted by The Post refused to answer questions about budgets and staffing at their campus clinics.

In an email last year, the chief executive of the American College Health Association cautioned members about sharing information with The Post and referenced its reporting about a viral outbreak at the University of Maryland. The association later said the message was sent to inform colleges and took no position on whether universities should comply with the requests.

Olivia Paregol, who had a compromised immune system, was among dozens of students sickened by an adenovirus in the fall of 2018 at the University of Maryland. When the 18-year-old freshman fell ill and went to the campus clinic in College Park, no one informed her about the virus.

By the time officials disclosed it publicly, 18 days had passed, and Paregol had died.

Paregol’s father, Ian, fears that campus health centers across the country are woefully unprepared to handle the pandemic.

“How are they even going to possibly protect those kids?” he questioned. “They could barely function when there is no crisis.”

Gracie Engelkes said she is still looking for her college to accept responsibility after she nearly died in 2016 because a nurse practitioner missed signs of meningitis during two separate visits to the University of Arkansas health center in Fayetteville.

The 19-year-old freshman was hospitalized for several weeks and said she never received an apology from anyone at the health clinic — only a bill for several hundred dollars.

Engelkes and her family explored filing a lawsuit but decided not to after learning that Arkansas state laws made it difficult to do so because of immunity given to government entities. Colleges in many states are covered by immunity laws and liability caps that limit the damages plaintiffs can receive.

Engelkes was furious after she heard from friends that the University of Arkansas waited weeks to disclose multiple cases of mumps on campus that eventually sickened nearly 40 people last fall.

Rebecca Morrison, a university spokeswoman, said the college “communicated fully” with Engelkes and her family in 2016, but Morrison declined to comment further on her care, citing privacy laws. She added that the college followed directives from the Arkansas Department of Health on communicating to the campus community about the mumps outbreak.

“I understand that people make mistakes,” Engelkes said. “But when you’re dealing with people’s lives, you have to be held responsible.”

Millsop, the Ohio University student who had her arm amputated, fought the college for five years in court before agreeing to a $250,000 settlement — the maximum allowed under state law at the time.

Millsop never returned to Ohio University and dropped her dreams of becoming a journalist.

“Had I gone to any other doctor that wasn’t employed by the state, this would have been handled differently,” she said.

Plans to reopen university campuses have led many educational institutions to lobby for state and federal legal protections from potential coronavirus lawsuits.

During a recent Senate hearing on liability during the pandemic, Lee Tyner, general counsel for Texas Christian University, questioned whether all campuses would be expected to conduct massive testing like the University of California at San Diego and the University of Arizona have planned for the fall.

“What if an institution does not have access to or cannot afford that kind of testing?” Tyner asked. “This will certainly be the case for hundreds of institutions across the country — small, tuition-dependent private colleges, under-resourced, public two-year community colleges and four-year regional universities.”

At a different Senate hearing on reopening colleges amid the pandemic, Sen. Elizabeth Warren (D-Mass.) in June asked what message gets sent to families and students when colleges are trying to avoid being held responsible for possible illnesses.

“Would it make you more comfortable or less comfortable as the parent of an incoming student?” Warren asked Christina Paxson, Brown University’s president.

“I am in favor of very carefully crafted liability protection that in no way, shape or form permits us to be careless with people’s lives,” Paxson responded.

Michael Sorrell, president of Paul Quinn College, a historically black institution in Dallas, is taking a different approach to the risk: He announced on Thursday that students would not be returning to campus in the fall.

“When I’m dealing with the health and safety of other people, I refuse to take chances,” Sorrell said. “I worry about a scenario where we bring people back to school and people are sick and they continue to become sick, and then we struggle to care for them. And then we have betrayed the public trust.”

Steven Rich, Austin Riley Ramsey, Verónica Del Valle, Jacob Wallace, Lucas Smolcic Larson, Julie Tate, Alice Crites, Scott Clement and Circe Granholm contributed to this report.

Ramsey has been the IRW Graduate Fellow in 2019-2020;  Larson was an intern at IRW;  Del Valle and Wallace were students at American University working on this project through our graduate practicum.

Co-author Meryl Kornfield was an IRW intern and now works at the Post.

For The Washington Post: Editing by David Fallis and Jeff Leen. Photo editing by Nick Kirkpatrick. Production by Julie Vitkovskaya. Copy editing by Frances Moody. Design by Victoria Adams Fogg.

More from the Washington Post:

• Coronavirus is spreading in fraternity houses, raising concerns for campuses opening this fall.
• This college is tiny and isolated. For some students during the pandemic, that sounds perfect.
• Five takeaways from The Washington Post’s investigation of college health centers.

Methodology

The Washington Post surveyed 280 schools that were selected based on a random sample of four-year public and private nonprofit schools in the U.S. Education Department’s postsecondary schools database. The sample was designed to be representative of enrollment, location, religious affiliation, historically black colleges and institutions, and other characteristics. The Post filed public records requests when schools did not voluntarily provide the information. About 80 schools refused to share information.