Barriers to Health Care Access for Low and Moderate Income Fathers

ACA

Ronald B. Mincy, Ph.D.Maurice V. Russell Professor of Social Welfare Policy and

Practice andDirector, Center for Fathers, Families, and Child Well-Being

Columbia University School of Social Work

Health and Healthcare Challenges of Fathers and Other MenFathers face the same health and healthcare challenges as most

men and a few additional challenges. These are thoroughly summarized by Williams (2003)

Except for Alzheimer’s disease, men have higher death rates than women from the fifteen leading causes of death, includingaccidents, suicides, cirrhosis of the liver, and homicide.

While health risks are elevated for men at all SES levels men at lower levels of SES, who are the main potential beneficiaries of healthcare expansion, are especially vulnerable,

Elevated health risks are even higher for men of color.

Male Socialization Leads to Elevated Health RisksMen are socialized to project or avoid attributes that

lead to higher health risks: They project: strength, individuality, autonomy, dominance, stoicism, and physical aggression They avoid expressions of emotion and vulnerability,

Our culture assess men based on occupational status , but lower SES men are over-represented among groups with weak attachments to work, including the

homeless, unemployed, incarcerated, and the institutionalized (in drug , penal, and mental health facilities).

Labor market outcomes for low SES men have been particularly troubling in recent decades:

More adverse effects of recessions on male unemployment since the 1980s Declines in labor force participation, but growing female labor force for dissipation since the 1960s Greater deterioration of earnings among men since 1973

Poor men of color also employed disproportionally jobs with higher rates of layoffs and lower rates of reemployment after displacement.

Consequences of Employment Instability among MenEmployment instability, such as that faced by low

SES men, is associated with occupational health & safety risks due to :injuries, disease risk, and hazardous exposures

As compared with the employed, the unemployed have elevated levels of stress, illness, and disability

Consequences of Low Status Male Employment

Men tend to work in more dangerous occupations than women, (e.g., men account for 90% of job fatalities)

Men of color are concentrated in jobs where they are exposed to prions,  fungi, viruses, bacteria,  and parasites, in the environment (e.g., Hispanics in agriculture, which is exempted from many

workplace regulations that apply to other industries)African-Americans in jobs where they are exposed to

occupational hazards and carcinogens at higher rates than whites, with the same education and work experience.

Stress and Its Consequences Low SES men are concentrated in jobs with high levels

of stress caused by combinations of high demands and little control effort and low rewards

Along with social isolation and poor diet, these conditions can alter the way our bodies respond to stress in ways that have adverse health effects (e.g.

Stresses and negative emotional states created by stress reduce the efficacy of medicines can lead to adverse health behaviors (e.g., erratic sleep, decreased physical activity ,

substance abuse and over-eating) that increase the risks of chronic health problems

Individuals with high levels of stress neglect disease prevention and treatment of chronic diseases ( e.g., such as diabetes, liver disease, high disease and certain forms of cancer)

Responses to risk factors

Masculinity and manhood encourage men to engage in unhealthy behaviors or to avoid health protective behaviorMen are more likely than women to:

smoke consume at least five drinks per day , engage in risky behavior while denying its effects

on performance (e.g., driving while under the influence of alcohol or drugs)

Masculinity and Health Care BehaviorMen’s tendency to suppress expression of need and

pain may also lower use of preventive healthcare visits men are almost twice as likely as women not to have visited a doctor and are less likely to adhere to treatment regimens,. these gender differences are pronounced at lower levels of SES

Lower SES men have low levels of health informationHealthcare professionals also provide poorer service to

men than women: Spend less time with men than women Provide men

with fewer services Less information Less advice

Less likely to talk with men about the need to change behaviors that improve health More likely to hospitalize men with depressive symptoms Less likely to hospitalize men with antisocial behavior off substance abuse problems

than women

Cumulative effects on Health

Higher exposure to health risks and underutilization of healthcare have cumulative effects on men’s health over the lifecycle.

At the program level, BarriersFear

of discovering the health problems they might have and high cost of treatment.

Embarrassment about having to ask for help, especially from men

Anger mostly at themselves, but some at the system for being so difficult to access and for being insensitive to their needs

Frustration about their situation- how did I get here?

After Entering The Health Care System

False sense of confidence “I can handle whatever arises” can be shaken by a negative diagnosis, resulting in disillusionment or even depression. As a result, they become paralyzed; they fail to Complete their required tests, Follow treatment regimens inconsistently

Diagnose w/ diabetes Drink water Take medications Using hunger levels to determine when to eat Restrict consumption of refined sugar, carbohydrates, fatty foods Monitor their blood sugar smoking cessation, and regular eye, foot and dental examinations 

Additional Health Risks for FathersHaving low SES means that men suffer from stress due to

High demands and little controlHigh efforts low rewards, But also from provider role strain

Unlike low-SES mothers, low-SES fathers, especially non-custodial parents, get little relief from the federal EITC, which can provide up $3000-$5000 in income as compared w/ $400.

Put women and children first when they think about spending on health care spending

Do not have access to Medicaid through birth or maternal and child health in the way low SES mothers do.

Medicaid Expansion at State OptionSupreme Court Decision made Medicaid

Expansion a State OptionOnly 28 states are planning to expand

Medicaid coverageStates that opt out of Medicaid expansion have

high rates of rural poverty and are located in the South, the North West, and Midwest Poor and near poor fathers in opt out states will be

uncovered Working poor and median income fathers will be

covered by the “federal” exchange

Differential affects of Stigma and Penalties on Participation in States that Expand Medicaid

Poor and near poor may not apply for Medicaid because Stigma attached to receiving means-tested benefitsLess likely to face sanctions for failing to show health coverage

on their tax returns, if filed. Working poor and median income fathers are likely to

participate in the exchange becauseMany will be unaware of how much subsidy they receive to

participate in the exchangeOthers will receive their subsidy in the form a tax credit, for

which little stigma is attachedFailure to show health coverage on their tax returns results in a

penalty.Fluctuations in income may require shifting from Exchanges to

Medicaid to get coverage, which cause some to exit the system

Minimum Wage (MW)MW + Childless CreditMW + NCP_EITCMW + Fed EITC (1

Child)MW + Fed EITC (2

Children)

$7.25$7.84$8.48$9.72$10.36

Making Work Pay

WageFTFY Annual Earnings

MW $7.25 $15,080.00

MW + Fed EITC 1 Child $9.72 $20,217.60

MW + Fed EITC 2 Children $10.36 $21,548.80

Making Work Pay

Persons in family/household Poverty guideline

Near Poor 200 Pct of Poverty100 Percent of Poverty 138 200

1 $11,490 15856.20 22,980

2 15,51021403.80 31,020

3 19,53026951.40 39,060

4 23,550 32499.00 47,100 5 27,570 38046.60 55,140

Poverty, Near Poverty, and Working Poverty

Discretionary Monthly Income after 250% Federal Poverty Level (FPL)

$1,602$1,226

$1,032

$461

$109

$680

$1,250

-$2,000

-$1,500

-$1,000

-$500

$0

$500

$1,000

$1,500

100% 133% 150% 200% 250% 300% 350%

Portland-Vancouver (2007) 1 Parent + 1 ChildSource: Heidi Allen Columbia University Center for Population Research

Documentation Barriers

Low income fathers (especially ex-offenders and others with unstable living arrangements) may not know or have the documentation they need to apply for Medicaid.

Informal Earnings and child support obligations Many low income fathers provide financial support to their children

outside the formal child support system or not at all. This is typical among unmarried fathers

during the first 3 years of their children’s lives, regardless of residential status

who live with mothers who receive public benefits Work in the informal economy

Applying for Medicaid will require these fathers to come above ground, which may put the benefits received by mothers and children at risk.

Overcoming the BarriersRaise awareness about wellness, health and

improve knowledge about how to use the health care system, so that access becomes a means to a newly valued end

Build relationships among stakeholders:To whom low-SES fathers will reveal the

information required to apply for Medicaid and the exchange

Who can help fathers assemble the required information