Health Care and Gay Men in the United States

By Frank Spinelli, M D

Originally published on Advocate.com June 30 2010 7:10 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. FIVE MEDICAL LEGAL ISSUES EVERY GAY MAN SHOULD CONSIDER

This section is meant to be informative only. Individual situations are likely to vary. I strongly urge you to contact and obtain legal advice and assistance from an attorney when considering any of these options. It is important to note that, depending on the state in which you reside, laws may vary, particularly with respect to civil unions, marriage, and domestic partnerships as they relate to gay people.

1. DNR, or Do Not Resuscitute order. This is a document that provides your family and healthcareproviders with instructions to not place you on artifi cial life support in case of heart or lung failure, especially if you are unable to make a conscious decision at the time. The DNR is a written order from a doctor indicating that you do not wish to be “coded.” Such an order may be instituted on the basis of an advanced directive from a person that is entitled to make decisions on your behalf, such as a health care proxy. In situations where you do not have a health- care proxy then either your spouse, partner, or your closest living relative gets to make these decisions on your behalf as determined by the applicable state law. In the United States, a valid DNR will ensure that cardiopulmonary resuscitation, and advanced life support will not be performed. To ensure that your DNR is honored, be sure to instruct your partner, family, friends, and doctors of your wishes. A DNR order must be specific and the terms should be laid out. For example, some individuals are specific about not wanting CPR yet will allow mechanical ventilation, feeding tubes, and pain management. In any case, discuss the specifics with your doctor.

2. A living will. A type of advanced healthcare directive often accompanied by a specific type of power of attorney or health-care proxy. Generally speaking it has to be witnessed and notarized. A living will covers specifi c instructions as it pertains to your treatment, even if you are unable to give an informed consent at the time due to incapacity. A DNR can be part of a living will. A living will is a statement of your wishes regarding end- of-life care. Unlike a health- care proxy, a living will does not empower another person to make important medical decisions if you are incapacitated.Instead, a living will gives direction to your healthcare provider or representative regarding what mea sures you want taken to prolong life and can serve to help assure that your wishes are being followed.

It is recommended that you obtain both a health- care proxy and a living will to ensure that your preferences about medical treatment are honored. Remember once again this is crucial. Recall the recent case involving Theresa Schiavo, who was declared brain dead but remained alive with the help of a feeding tube. Her parents battled with her legal husband about maintaining her life with the aid of this feeding tube, despite the fact that her legally recognized husband thought otherwise. In the case of a gay husband the wishes of the parent would likely be upheld.

3. A health-care proxy. Another legal document used in the United States in order to empower someone you have appointed to make health-care decisions in the event that you are incapable of doing so. The proxy cannot make a health- care decision as long as you, the primary individual, have the capacity to do so. They allow the patient’s wishes to be followed when he is incapable of communicating them. Unless you have a documented proxy, decisions made on your behalf will be deferred to your next of kin, not your partner.

4. A power of attorney. They can be general or specific. Essentially, it is an individual appointed by you who will act on your behalf in legal and financial decisions should you be unable to do so. This will allow a designated person to sign certain documents on your behalf and make informed decisions depending upon what you have authorized this person to do.

5. A last will and testament. In the event of your death, a last will and testament will ensure proper distribution of your money, assets, and property to the desired individuals. Without a written will, your estate will be distributed to your legally recognized family. In the event of one of the deaths of a partnership, in the absence of a valid last will and testament, money, assets, and property would go to the closet legally recognized living relative, not his partner.