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Jack A. Meyer, PhD

Correspondence: Requests for reprints should be sent to Jack A. Meyer, PhD, Economic and Social Research Institute, 1015 18th St, NW, Suite 210, Washington, DC 20036 (e-mail: jmeyer{at}esresearch.org).

	INTRODUCTION

TOP INTRODUCTION REASONS FOR DISPARITIES THE HIDDEN COSTS OF... TOWARD A SOLUTION References

 
The subject of men’s health is frequently neglected in public health discussions. Yet neglecting men’s health generates considerable pain and suffering, along with sizeable and avoidable health care costs.

The United States today is paying for men’s health, but as with the health care system generally, the payments are heavily tilted toward costly, high-tech interventions to address serious and neglected health conditions that, in many cases, could have been treated more effectively and efficiently at an earlier stage. By paying too little at the front end of the health delivery system, we end up wasting money later on.

The dimensions of the problem are the subject of this issue of the Journal and will therefore be noted only briefly here. The life expectancy of men in the United States is about 6 years less than that of women. African American men can expect to live 7 fewer years than White men (67.6 vs 74.5 years). Latino male life expectancy is 69.6 years, while Native American men have the lowest figure of any demographic group—66.1 years.¹ African American men are more likely to die of serious chronic illness than are White men. For example, 40% of African American men with heart disease die prematurely, nearly double the rate for White men (21%), and the situation is nearly as bad for Latino men (37%).² Another study revealed that 35% of African American males aged 20 to 74 years had hypertension, compared with 25% of all men. African American men also have a higher incidence of several types of cancer than other groups of men. The death rate from homicide for African American males aged 15 through 24 years has been measured at 17 times the rate for White males in this age group.³

	REASONS FOR DISPARITIES

TOP INTRODUCTION REASONS FOR DISPARITIES THE HIDDEN COSTS OF... TOWARD A SOLUTION References

 
A confluence of factors drives these problems, and all must be addressed. First, low-income men are more likely to be uninsured than low-income women, and men of color are particularly vulnerable. A recent study found that while 17% of non-Latino White men were uninsured, the corresponding figures for Latinos and African Americans were 46% and 28%, respectively.⁴ This situation reflects the systematic exclusion of low-income adult men without dependent children from government health insurance programs. In several states, childless adults cannot enroll in Medicaid even if they have absolutely no income; most other states require them to have incomes well below the federal poverty line. The problem also reflects the fact that many lower-income men work in jobs without employer-sponsored health insurance. These include part-time, temporary, and contract jobs, as well as retail sales work and nonunion laborer jobs. These men fall into the deep chasm between public and employer-sponsored health coverage, and they frequently lack the resources to buy coverage on their own.

A variety of access barriers beyond the lack of insurance also block men from receiving the health care they need. These include perceived hostility, racial stereotyping, and discrimination in the health care delivery system; fear of adverse consequences with regard to immigration status; language barriers; a shortage of primary care facilities and medical personnel in lower-income neighborhoods; an inadequate number of minority physicians; and a lack of cultural competence across the health care provider community. For men who have been incarcerated, many of these factors are exacerbated by the difficulty of gaining employment or qualifying for government assistance.

	THE HIDDEN COSTS OF NEGLECT

TOP INTRODUCTION REASONS FOR DISPARITIES THE HIDDEN COSTS OF... TOWARD A SOLUTION References

 
The net result of the isolation of these men from the mixed public/private health insurance system and the steep barriers to access to care is a large pile of costs that are, for the most part, kept "off the books" of the US health care system. The hidden costs of neglecting men’s health emerge in the health care provided to men who are incarcerated and in outlays by federal, state, and local governments for treating mental health problems, substance abuse, sexually transmitted diseases, and other chronic conditions.

Public and private payers frequently fail to account for this extra categorical spending when they cut back on insurance coverage. For example, some states have put in place (or are considering) cutbacks in optional Medicaid coverage for adults. According to a new report from the State Coverage Initiatives program, removing 10 000 adults from Medicaid might save a state about $12 million annually. But applying prevalence data, the author assumes that approximately 22% of these adults have a mental illness, 20% have a disability, and 25% have cardiovascular disease. Many of these people will delay getting the care they need until their conditions become serious. When these people need health care, they will use local public or private hospitals, state university medical schools, local mental health authorities, local health departments, and state-only services and programs. The result will be expensive—perhaps $25 000 for a heart attack, $13 600 for a schizophreniarelated psychotic episode, $7300 for a severe asthma attack. The state will pick up many of these costs—for example, when newly uninsured adults with serious mental illness use state mental health institutions.⁵

With these price tags per episode and incidence data, one can estimate the total costs involved, and they may very well approach or exceed the projected "savings" from reducing coverage. But the costs will be in some other budget, not the Medicaid budget, so the effort will be "scored" as a gain for the state. Likewise, states may log large apparent gains from moving people with severe mental illness out of mental hospitals, or worse yet, reducing funds for outpatient mental health services, only to see these costs, and others as well, show up in their prison budgets. The federal Bureau of Justice Statistics found that 238 800 mentally ill individuals were incarcerated in US jails and prisons in 1998. In Florida, mentally ill individuals in jails and prisons outnumber those in state mental hospitals by nearly 5 to 1. Minimum care for one mentally ill person for a year in a Florida jail costs $40 000 and one year in a state prison cell costs more than $60 000 per mentally ill inmate, while intensive community mental health treatment for an individual costs approximately $20 000 per year. Some savings!⁶

Indirect costs of neglecting men’s health can also be found in bad debt and charity accounts among US hospitals and other health care providers, as well as in Disproportionate Share Hospital payments. Neglected oral health creates hidden costs within the health care system, as the lack of dental care leads to disease and illness. Even further outside the ledgers of the US health care system is the hidden cost of absenteeism in the workplace and lost productivity associated with delayed or neglected health care.

	TOWARD A SOLUTION

TOP INTRODUCTION REASONS FOR DISPARITIES THE HIDDEN COSTS OF... TOWARD A SOLUTION References

 
To help men gain access to timely, affordable, and appropriate health care, we need to develop both short-term and longer-term strategies. In the short term, we must acknowledge the limitations of our current health care system even as we work to reform it. This system is rife with both inefficiency and inequities. Widespread inappropriate and unnecessary care exists side by side with substantial "undercare." Our current patchwork system forces us to take each target group—men, older women, minorities, children—and fashion separate strategies to fill the gaps and address the special needs of each group. But we must recognize that such strategies are ineffective in the face of the flaws in our present system, which ultimately must be fundamentally overhauled. We stitch over here while the system unravels over there. This will never lead to a truly protective garment.

Neglecting men’s health is not only inefficient, but also takes a terrible toll on the quality of life, generates human suffering, and leads to premature deaths. Controllable chronic illnesses, such as hypertension, diabetes, and asthma, go unchecked, generating serious adverse health effects. Sexually transmitted diseases lead to pain and suffering and, too frequently, to premature death. Substance abuse and crime waste and cut short lives. The incidence of all these problems is much higher among men of color, creating a deep national health crisis that is generally obscured from public view. Men of color are too frequently shunned and feared; they often do not evoke much sympathy from the general public, politicians, or private-sector leaders.

An important short-term strategy could involve redeploying some of the funding currently used to finance men’s health in a piecemeal and fragmented fashion toward primary and preventive health care services for men linked in a coordinated way to an array of social support services.

The first step in this process is for local communities to take a full inventory of the sources and uses of funds now allocated to men’s health. This would include federal grants, state programs, and local initiatives. This accounting of funds is likely to reveal that much of the money is being spent to address the adverse effects of neglecting men’s health in the first place. Funding streams may include Disproportionate Share Hospital funds and Substance Abuse and Mental Health Services Administration programs, along with funding targeted toward HIV/AIDS.

While these and other programs will still be needed, a creative and forward-looking financing strategy could reallocate a portion of this money toward the formation and operation of men’s health clinics; staffing of hospitals and clinics serving vulnerable men of color with culturally competent workers; provision of health insurance and referrals to health care systems to inmates before they are freed from incarceration; and development of prevention programs focusing on nutrition, mental health, and physical fitness.⁷ A somewhat bolder step could entail subsidies provided by state and local governments or private foundations to make private health coverage more affordable for both small employers and their employees. Such programs are under way in Sacramento, Calif, and Muskegon, Mich. Another option would be for states to use existing program authority (e.g., Section 1931) or obtain waivers to cover some currently uninsured adult men (and women) under Medicaid.

An effective strategy must recognize the diversity of health care needs among men. Many young adult men (18–24 years old) are uninsured. Among African American and Latino men in this age group, about 1 in 4 is uninsured.⁸ The key issue for this group is ensuring at least basic health coverage for emergencies and educating these men about avoiding behavior that poses serious risks to health. Many middle-aged men are experiencing long-term chronic conditions such as hypertension, diabetes, and asthma. They need an effective care management/disease management program stressing medication management, healthy lifestyle, and regular monitoring of their conditions. Ex-offenders need job opportunities and access to men’s health clinics. Older men not yet eligible for Medicare need to be able to buy into affordable group coverage, control and manage disabilities, and gain access to affordable prescriptions.

A longer-term strategy involves moving toward a universal health care system. This would transcend the focus on separate incremental strategies for each and every demographic group and ensure access to timely, affordable, and medically appropriate care for all Americans, regardless of age, race, family status, or job status. Ultimately, we must pay for such coverage, and the price will not be trivial. But when we properly account for the offsetting savings (e.g., much of the piecemeal funding mentioned above could be scaled back, and productivity would be enhanced), the front-end cost will prove to be a good investment.

With health coverage for all, we can move toward a public health strategy to supplement insurance with a wide array of health care management and social services that are differentiated by group. Men do have different health care needs than women, and there are variations as well with characteristics other than sex. Insurance creates the foundation. But we must build on this foundation to address the social determinants of poor health, including inadequate nutrition, dangerous air quality, unsafe working conditions, and hazardous housing conditions. Lifestyle and behavior must also be a part of the picture, including smoking, substance abuse, violence, and "Russian roulette" sexual behavior. With both insurance and direct outreach strategies, we can improve men’s health, and, indeed, the health of all Americans.

Accepted for publication October 20, 2002.

	References

TOP INTRODUCTION REASONS FOR DISPARITIES THE HIDDEN COSTS OF... TOWARD A SOLUTION References

 
1. Hoyert DL, Arias E, Smith BL, Murphy SL, Kochanek KD. Deaths: final data for 1999. Natl Vital Stat Rep. September 21, 2001;49(8).

2. Barnett E, Casper ML, Halverson JA, et al. Men and Heart Disease: An Atlas of Racial and Ethnic Disparities in Mortality. Morgantown, WV: Office for Social Environment and Health Research, West Virginia University; June, 2001. Also available at: http://oseahr.hsc.wvu.edu/hdm.html (PDF file). Accessed March 17, 2003.

3. Rich JA, Ro M. A Poor Man’s Plight: Uncovering the Disparity in Men’s Health. Battle Creek, Mich: The W. K. Kellogg Foundation; 2002.

4. Brown ER, Ojeda VD, Wyn R, Levan R. Racial and Ethnic Disparities in Access to Health Insurance and Health Care. Los Angeles, Calif: UCLA Center for Health Policy Research and The Henry J. Kaiser Family Foundation; 2000.

5. Fenz C. State health care spending: a systems perspective. State Coverage Initiatives Issue Brief. May 2002;3(1).

6. From prisons to hospitals and back: the criminalization of mental illness. Kentucky Cabinet for Health Services Dept for Mental Health and Mental Retardation, March 28, 2002. Available at: http://dmhmrs.chr.state.ky.us/mh/gnu/files/Criminalization%20of20Mentally%20Ill.htm. Accessed July 30, 2002.

7. What About Men? Exploring the Inequities in Minority Men’s Health. Battle Creek, Mich: The W. K. Kellogg Foundation; 2001.

8. Hoffman, Catherine. Uninsured in America: A Chart Book. Menlo Park, Calif: The Kaiser Family Foundation; 1998.

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This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (6) Citing Articles via Google Scholar Google Scholar Articles by Meyer, J. A. Search for Related Content PubMed PubMed Citation Articles by Meyer, J. A. Related Collections Gender Access to Care Quality of Care Other Race/Ethnicity Men's Health