Our Bodies, Ourselves (145 page)

These considerations make choosing an insurance policy a complicated task even when competing plans are clearly presented. It's tempting to choose what looks to be a less expensive insurance plan (that is, a plan with lower up-front premiums). However, those plans often have higher co-pays, coinsurance, and annual deductibles that can quickly add up to more money than the difference between a lower and a higher premium. As a result, those of us who opt for what looks to be a cheaper plan may find that we end up actually spending more on our health care.

It's impossible to predict future medical needs, so choosing an insurance plan is always a matter of guesswork. However, try to make the best possible guess by drawing up a comprehensive list of all of the health care services and products that you are likely to use and then checking whether they are completely or partially covered on a variety of lower-premium and higher-premium plans. This information should be available through your employer's human resources department and through the state insurance exchanges. It is particularly important to find out whether any medication you use regularly is covered, whether alternative and complementary methods you use are covered (fully, partially, or not at all), and whether you need to go through your primary care provider (which means a co-pay or coinsurance) in order to see a specialist. Once you have made your list—being sure to add in one or two unexpected health problems—you can try to calculate
how much you actually would have to pay out-of-pocket on various plans.

Here are some additional ways to control the cost of health care.

Negotiate for the lowest price:
Hospitals and health care providers (including labs) often quote higher fees to uninsured patients than the insurance companies have negotiated. You can call the billing department of the institution or provider and ask what its best rate is. Then (in a separate conversation) tell the person billing you that you are willing to pay only that rate. Or, offer cash, on the spot, for an amount that is half what the billing cost is.

Don't be afraid to ask if there are less expensive options available:
Lower-cost treatments or tests are often just as effective as, and sometimes more effective than, the option your care provider recommends.

Go to a Planned Parenthood clinic:
Planned Parenthood offers low-cost or free reproductive health care to uninsured women in many communities throughout the United States. Services include family planning, breast and cervical cancer screening, mammograms, and sexually transmitted infection testing, counseling, and treatment. To find a Planned Parenthood clinic near you, go to plannedparenthood.org and enter your zip code under “Find a Health Center.”

Go to a community health center (CHC):
There are CHCs in all fifty states. These centers are federally funded and provide care to all individuals; fees are set on a sliding-scale basis. Search for the nearest center at the Health Resources and Services Administration website (findahealth center.hrsa.gov). CHCs do not provide abortion care, owing to federal funding restrictions. Other low-cost options may include city/county public health clinics, community clinics, or clinics provided through medical, nursing, or dental schools.

Consult your care provider by phone or email:
You may be able to get prescription refills, orders for lab tests, or referrals to specialists without having a visit with your primary care provider.
Find out if your care provider works in more than one facility:
Costs may be lower at another location.

See a nurse-practitioner, physician assistant, or nurse-midwife:
In some settings, these professionals may provide the same services as a doctor but at a lower cost.

Keep copies of your test results:
You may be able to avoid repeating blood and other laboratory tests if there is a record showing they have been done recently.

If you are hospitalized, ask to see a social worker:
A social worker can help you navigate the system and discuss options for paying the hospital bill and the cost of follow-up care or rehabilitation.

Look into the cost of obtaining care in another country:
Some people find that it is more economical to travel abroad to receive health care. Unfortunately, it may be more difficult to assess the safety of overseas health care options, and you may not have recourse (e.g., the ability to sue or file a formal complaint) if you are harmed as a result of services you receive in another country.

Medicaid is a government program that provides health insurance to people with low incomes.

Eligibility for Medicaid depends primarily on your income but also on other factors, such as whether you are pregnant. There are also other special situations that may extend your Medicaid coverage.

Contact your caseworker or congressperson if you are about to lose public assistance because you have become employed:
If you are receiving Medicaid or other public assistance (financial
assistance from a government program) and get a job, you may no longer qualify for these benefits, but in some cases your eligibility can be extended.

If you are pregnant, find out if you qualify for Medicaid at a higher income level than if you weren't pregnant:
The Kaiser Family Foundation offers a table showing eligibility by state: statehealthfacts.org/comparemapreport.jsp?rep=43&cat=17.

If you need family planning services, find out if your state has special Medicaid eligibility that will provide coverage:
In many states, family planning services are available through Medicaid for women (and sometimes men) at the same income level as pregnant women. The Guttmacher Institute offers a list of family planning eligibility by state (guttmacher.org/state center/spibs/spib_SMFPE.pdf).

Find out if the company that makes your medication has a patient assistance program:
These programs distribute a limited amount of free and discounted medication to patients who cannot afford the drugs or do not have insurance. The downside is that the application may be too complex and jargon-filled. In many communities, charitable organizations (such as Catholic Charities) employ someone to help people fill out and submit this kind of application. Hospital case or social workers may also be able to help.

Call around to pharmacies before filling your prescription:
The cost to fill a prescription may vary among pharmacies, especially when you are paying out of pocket. Some pharmacies have a list of specific drugs that they provide at very low cost as a way to attract patients.

Ask your health care provider or pharmacist about economical ways to manage your medication:
In some cases medicine can be ordered at a higher dose for the same cost and the pills can be cut in half to provide the desired dose. This is a much better alternative than taking partial doses or skipping days or weeks, which can be more dangerous than not taking the medication at all.

Ask your provider if a generic or over-the-counter drug may be a cheaper but equally effective alternative to a brand-name prescription drug
. There's no reason to pay more, assuming the options are equally safe and effective.
Look into options for obtaining prescription drugs more cheaply
. Some medications can be ordered online from other countries, such as Canada. Be aware, however, that drug regulations vary from country to country, and some websites that sell drugs are not reliable.

Access to health care is far from equal. Women of color are less likely than white women to receive regular mammograms, and they are more likely than white women to report not having had a Pap test in the past three years.
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Black and Latina women are more likely than white women to receive no prenatal care or to receive care later in their pregnancy.
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Women of color are less likely to get prompt, adequate follow-up for abnormal cancer screening tests such as mammograms. This may contribute to the higher rates of death from breast cancer among black women compared with white women. Similarly, even though women of color are more likely than white women to report being in fair or poor health, they are less likely to have a regular health care provider, less likely to have health care insurance, and less likely to see a health care provider when ill.
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(For more detailed information and discussion, see “Disparities in
Women's Health”
).

Low-income women are more likely to receive care from medical and nursing students and residents (physicians training in a particular
area of medicine), who are learning and refining their skills. The same treatment options that may be available to women with insurance and/or higher incomes may not be discussed, and instead, more emphasis may be placed on disease management.

The recently adopted national health care reform law takes steps to increase access by offering continuing education support for providers who work in underserved communities and grants to increase retention and representation of minority faculty members and health professionals.

Women who have current drug and alcohol problems and women who have histories of such problems also sometimes experience discrimination. For example, women who are believed to be drug users may be denied pain medication during labor or in the course of painful illnesses, because of misinformation and prejudice about drug use, or experience hostile comments from medical staff members. Some women have been turned over to the police rather than offered appropriate medical care. Despite laws prohibiting discrimination, drug-using women often face extensive barriers to accessing appropriate drug treatment:
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I can't go into a doctor's office and say, “Look, I'm a heroin addict,” to tell them everything that I need to tell them about what I've done to my body and health. I don't think there is a doctor in this city that I can go to and be comfortable with and they can be comfortable with me and treat me totally equal as anybody else, you know?
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Sometimes health care providers set up narcotics contracts with former or current substance abusers if they are in true pain or recovering from surgery. The contract usually requires regular check-ins and a very limited supply of the medication. Ask your doctor about such a contract so you can obtain the pain-relief or other medications you need.

Many providers do not understand the beliefs and practices of each specific culture, including issues such as women's physical and sexual modesty around male health care providers. This puts some of us, especially immigrants, at a disadvantage. Even though Title VI of the Civil Rights Act of 1964 states that individuals cannot be discriminated against based on language, and every individual with limited English skills is entitled to care in her language, an interpreter may not always be available. It is helpful to request an interpreter in advance, when you make an appointment, if it is not an emergency visit. Sometimes an interpreter can be scheduled to be available by phone.

Most states offer health assessments to refugees soon after arrival, but the assessment sites vary in the type of services available and the quality of care, and time frames vary among states. Refugees are eligible for Refugee Medical Assistance, a federally funded, state-administered program with benefits similar to Medicaid, for their first eight months in the United States. Families with minor children are eligible for Medicaid. After eight months, refugees are subject to the same access limitations to health care as U.S. citizens. Finding or maintaining employment is a priority for refugees, but the employment available may not carry health benefits and may also lead to loss of eligibility for Medicaid benefits. Mental health and reproductive health services are increasingly recognized as essential to refugees, but traditionally, there has been an emphasis on screening refugees
only for infectious diseases such as tuberculosis.

Those of us with chronic illnesses and/or physical and developmental disabilities often experience barriers to receiving comprehensive health care, including lack of accessible transportation, limited income and insurance coverage, and inaccessible practitioners' offices and/or equipment such as examination tables that do not adjust. The recently adopted national health care reform law begins to address this problem by establishing standards for medical diagnostic equipment so people with disabilities can access vital preventive care.

Providers are not always knowledgeable about particular disabilities or conditions, so the responsibility is on us to provide medical information and educate them about our disability or illness and appropriate care. It is often difficult to be a teacher while also being an advocate for ourselves at a time when we need medical care. Another problem is dealing with providers who see only the disability and fail to address our reproductive and sexual health needs.

Some hospitals and health care systems have patient advocates who can provide help (see
“Patient Advocates”
).

To find providers who are capable and sensitive, contact a national advocacy organization for your specific disability or illness. Many keep lists of recommended providers or can direct you to a local organization for referrals. For more information and resources, check out the links section at the Center for Research on Women with Disabilities at Baylor College of Medicine (bcm.edu/crowd). There are also sections on reproductive health, sexuality, and access to health care.

Many lesbian, gay, bisexual, and/or transgender people experience financial, personal, and cultural barriers to getting appropriate health care.
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Obstacles can include the following.