Health Care and Gay Men in the United States

BY Frank Spinelli, M D

June 30 2010 6:10 PM ET

 If you happen to be one of the privileged Americans who have private health insurance, then consider yourself lucky. According to the U.S. Census Bureau, approximately 85 percent of Americans have some form of health insurance and 60 percent obtain insurance through their employment. Having health care in America is about as vital as having a place to go home to at night; however, uninsured Americans make up over 16 percent of the population, or over 48 million people. This number rose substantially between 2003 and 2006, and even more worrisome is that the percentage of people with employment-based health insurance has dropped from 70 percent in 1987 to 59 percent in 2004. This issue is particularly problematic for gays, as the ratio of uninsured individuals is 2:1 compared to heterosexuals. Even with the rising number of domestic partnership benefits, most homosexuals are excluded from the same benefits afforded to married heterosexual couples. Additionally, even with domestic partnership benefits, some gay men still refuse to come out at work due to the threat of homophobia. Complicating matters further is the issue of insurance carriers delaying benefits or refusing to take on individuals with pre existing conditions such as HIV. The dilemma of health care and gay men is complex and disheartening for all these reasons and more. The American Cancer Society recently published data showing that since gay men are less likely to have health insurance and seek out medical attention for reasons concerning homophobia, they are more likely to suffer from lung cancer, especially since gay men tend to smoke more (41 percent) than the general population. Incidentally, smoking is known to accelerate the progression of HIV disease.

As we age, our dependence on health care increases and the rising costs of medicine, hospitalizations, and doctors’ fees can make choosing an insurance carrier a difficult decision. Businesses that provide health insurance often offer a choice. The options may vary from indemnity plans to managed care plans and the difference between the two is as follows:

Managed care options require you to choose a doctor who participates in their plan. Plans such as HMOs (health maintenance or ga ni za tion) are prepaid health plans in which you pay a monthly premium and the HMO covers your office visits, hospital stays, emergency care, surgery, checkups, lab tests, X-rays, and therapy. You also pay a pre determined co-payment for each service and must choose a primary- care physician who coordinates all of your care and makes referrals to any specialists you might need. In an HMO, you must use the doctors, hospitals, and clinics that participate in your plan’s network. PPOs (preferred provider organization) are a network of health- care providers in which a health insurer has negotiated contracts for its members to receive health services at discounted costs. Health- care decisions generally remain with the patient as he selects physicians, and patients are given incentives to select providers within the PPO network.

Indemnity plans consist of picking your own doctor and then paying him up front. Then after submitting the claim, you will be reimbursed by the insurance company.

The Consolidated Omnibus Bud get Reconciliation Act of 1985, commonly referred to as COBRA, requires group health plans to be offered to you for eigh teen months after you leave your job. Longer durations are available under certain circumstances if you wish to continue coverage; however, you must pay the entire premium, plus an administration charge.

Men over the age of 65 are all automatically covered by Medicare in the United States. This is a federally sponsored health insurance program for hospital and medical coverage. Medicaid is a joint federal- state health insurance program that is run by individual states and covers low- income and disabled people. Men with HIV are eligible for the AIDS Drug Assistance Program, or ADAP, for people with limited income and assets. ADAP is unique to each state and they decide which medications will be included in its formulary and how those medications will be distributed. Criteria for enrollment are established by each individual state, but all such enrollments require a positive HIV test.

ADAP pays for many HIV prescription drugs, while ADAP- Plus covers the cost for doctor visits and labs. It is important for you to know that ADAP does not cover inpatient hospitalizations or any bills incurred before ADAP was instituted. Also emergency room visits are not covered by ADAP and many prescription drugs, not related to HIV, are also not covered by ADAP. Treatment for alcoholism and drug addiction, physical rehabilitation services such as physical therapy and speech therapy, counseling related to HIV testing, and case management are also not covered.











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