Health Insurance - Financing Health Care

Excerpted from
The Black Woman's Guide to Black Men's Health
By Andrea King Collier, Willarda V. Edwards, M.D.

Self-care and commitment to that care are key if we want to build a community of really well and healthy black men and women. But there is no denying that access to care is a huge issue for people of color. Of course, one of the biggest issues of access is health insurance or lack of health insurance and ability to pay. According to data from the Institute of Medicine, blacks are less likely to work at jobs that offer them health care coverage. They are also less likely to take it, if offered, probably because of the premiums and the co-pays for office visits that still must be paid. This chapter will show you how to maximize health care opportunities, despite these obstacles.

Is Insurance Essential?

People who go without health insurance or health subsidies are often sicker than other people by the time they seek health care, probably because they have put off treatment. They get caught in a downward spiral of illness and debt, which can lead to or worsen poverty. Of course, those of us who do have insurance could easily lose it if we get an illness that makes us too sick to work. In fact, according to the United States Census report on health coverage, in 2001, nearly a million people who make over $75,000 a year lost their health insurance. Millions of people of all income levels go without health insurance each year, due to loss of jobs, cutbacks of benefits, changes in marital status, and self-employment.

If the man in your life finds himself without health insurance, it is important to research alternatives for receiving care. It may mean purchasing short-term coverage, or it could mean signing up for a federally or state subsidized limited coverage program that may be available in the area where he lives. But it is important to find some way to stay in the loop of health care. The more men ignore their health, the more problems develop in the long run.

While there is limited access to care in some urban and rural areas, it is important to know what is available in terms of community-based clinics, community mental health centers, mobile care vans, and free and low cost services available at many churches. Some stores are even starting to offer free blood pressure screenings on a periodic basis.

You can find out about these services by reading the local newspapers, visiting community centers, watching the local news, checking the church bulletins, and making a call to the local health department. Many organizations post updates on community health events on their Web sites.

Of course, the man in your life would rather have the health care choices and options that having insurance affords him, but many of the free and low-cost clinics in your community are providing solid care. Some health care is always better than none. And there are other insurance coverage options, such as working part-time for an organization that offers all its employees, including those who work less than thirty-five hours a week, health benefits. It could be a good bridge while he secures more stable benefits.

Myths of Insurance

Most people think that all jobs come with health insurance benefits. But not every working person has health insurance. In fact, eight of every ten people with no health insurance come from working families. Half of them live in low-wage families. Even if a man has insurance, that coverage may still fall short if he faces a long and debilitating illness such as cancer. Mounting medical bills are one of the major reasons that many middle-income families file for bankruptcy.

As many men who have worked in what used to be considered stable industries like steel mills and automobile manufacturing will tell you, health insurance coverage isn't what it used to be. As every industry struggles with cost reductions, one of the first things on the chopping block is health insurance. If he works in one of these industries he has probably been forced to pay a bigger portion of his employer-sponsored insurance and may be getting fewer benefits from his program. Prescription dings may not be covered anymore. They may now cost several hundred dollars a month if they are not covered by a co-pay. He may have lost his dental coverage. As a retiree, he may be at risk of losing the health benefits he always relied on in the past.

What Are the Different Types of Medical Insurance?

If his employer offers health insurance, part of his benefits for working there may be paid or partially paid health insurance. His employer collects a premium (payment) from him to purchase medical insurance. The money goes into a fund that pays for medical care for employees who are included in the plan. It is a pool of sorts. Everybody may pay the same amount but some are bigger users of the system and cost it more money. The older a man is and the more chronic conditions he has, the more it costs to cover him. Every company is different in what they offer and how much they charge individuals. The basic types of insurance are as follows:

Fee-for-Service Plan

In a fee-for-service plan, such as some offered by Blue Cross/Blue Shield, or Humana, an individual pays a higher premium because he can use any doctor or hospital he chooses. The provider sends the bill for the office visit to the insurance company, who pays part of it after the deductible has been met. The deductible is the amount that you pay out of pocket for your health care expenses before the insurance kicks in. The deductible is set by the employer or the carrier.

Usually the insurance company pays 80 percent of the customary charges. The employee pays 20 percent. As an example, say your deductible as set by your employer is $200 in a calendar year. You will have to pay out of pocket to your doctor $200 before your insurance pays your provider. After you meet the deductible, your provider will pay $80 of your $100 medical bill, and you are responsible for the other $20. There are no co-pays in fee-for-service health insurance coverage. Make sure you understand your health care coverage premiums and deductibles before you sign on. Also be aware that many insurers set a limit on how much you can spend in health care in a calendar year for certain services.

HMOs (Health Maintenance Organizations)

HMOs offer members of the plan a set of medical services, including preventative care, for a set monthly premium and a co-pay. The HMO plans give members a list of doctors from which they must chose a primary care provider. This doctor then becomes the health care gatekeeper for all tests, screenings, and referrals to specialists. He or she manages and coordinates all other care. An HMO covers the costs of physicians and services inside the HMO group. Without a referral from your primary care provider, any costs you incur for treatment out of the HMO network will not be covered. The patient is responsible for paying the cost of services. You will pay a co-pay for each doctor visit and prescription that is covered within that plan. If you require a prescription that is outside of the list of approved medicines, you will have to pay for it out of your own pocket.