Twenty-one-year-old Albert is a self-described transient who picks up odd jobs whenever possible. On this day in mid-July, he’s waiting to be picked up for day labor in Santa Ana.
Albert has a black spot on his foot that he knows could signal diabetes, an illness that runs in his family and forced his uncle to lose a leg.
He has read about the condition and switched to a plant-based diet as a result. But he doesn’t intend to see a doctor. Albert, who declined to give his last name because of the health details he shared, doesn’t lack medical insurance — he recently signed up for California’s low-income program, Medi-Cal, while applying for public assistance.
He just doesn’t seek preventive health care.
One reason is the fear of getting stuck with bills he can’t pay. He watched a sister lose her job and insurance and incur substantial medical debt. He also grew up not going to doctors except when he was injured, so medical care is not an obvious recourse for him.
In a number of ways, Albert’s perspective on health care taps into key barriers that seem to conspire against young men getting regular medical attention: poverty, chronic disease and mistrust of the medical system.
But public health advocates are banking on the Affordable Care Act to break this pattern. Under the federal reform, Medi-Cal has been expanded to include single people instead of only parents of young children.
Anthony Wright, executive director of Health Access, a statewide health advocacy group, argues that young adults want more access to care, despite conventional thinking to the contrary.
“There’s a myth of young invincibles,” he said, adding that when offered health benefits, young people sign up in proportion to the rest of the population. He said the elimination of co-pays on some screenings under health care reform encourage more young, low-income men to seek preventative care.
But some health professionals and outreach workers on the front lines are not so sure.
Statistics bear out the longstanding disconnect between young men and preventive health care, according to Will Courtenay, a psychotherapist, author and men’s health researcher in Berkeley. For example, he said over half of men aged 18 to 29 do not have a regular physician compared with a third of women in this age group.
Among adults aged 20 to 29, women make more than four times as many physician visits as men.
“In fact, on average, young men see a doctor less than once in nine years,” Courtenay said. Boys and young men of color are much less likely than white boys and young men to have a usual source of health care.
Unmet health needs among young men are linked in the long term to higher rates of death from heart and respiratory diseases and cancer. This contributes to a shorter lifespan than that of women.
In the short term, the biggest health challenges facing young men are mental health, HIV care, STDs, physical labor accidents and chronic injuries, according to doctors and researchers.
Obstacles: access and beyond
Some of the barriers to care are well known, including being an undocumented immigrant, which prevents people from signing up for Medi-Cal in many situations.
Dr. Ryan Choi in Garden Grove offered an example of a patient with a hernia resulting from his work moving furniture. He ignored the problem for as long as possible and by the time he made it to Choi’s office, he needed surgery.
Since the patient was undocumented, Choi’s best option was to refer him to a surgeon with a long waiting list of patients needing pro-bono services. But even when young workers have coverage, Choi said, they can’t afford to take time off work and frequently lack transportation to get to appointments.
In other cases, the barrier is not always access but rather reluctance to see doctors, according to Choi.
“For a majority of younger male patients, it’s more behavioral and cultural — these are more of a factor than insurance,” he said.
One behavioral factor is a lack of familiarity: not visiting doctors while growing up, or not being exposed to the routine of yearly check-ups, as young women regularly are.
Another behavioral factor cited by experts is an aversion to the vulnerability that goes along with visiting a doctor.
“Being vulnerable is not considered manly,” said Nina Harawa, an epidemiologist affiliated with Charles Drew University and UCLA who has researched HIV among African-American men, including men having sex with men while not being part of the gay community. “With this group of men who were not out [of the closet], it was even more important not to feel effeminate.”
Compounding these issues is a tendency to wait to see doctors until a condition is aggravated.
“We’ve seen kids walking around with VD (venereal diseases) and they will walk around with it for a month,” said Jeffrey King, an HIV activist who promotes health among African-American gay men in Los Angeles. In another example, a young man he knows with HIV recently had to be hospitalized without warning due to a low T-cell count, which occurred because he hadn’t sought prior treatment.
While many low-income men with HIV have some options for care — for example, the federal Ryan White Program covers doctor visits and medicines, even among the undocumented — King says many men forgo treatment out of concern of being discovered.
“When I talk to young, black, gay men, I say, ‘You need to tell the doctor you had anal sex and oral sex with a man,’” King said. “What we find with most of these guys is because of homophobia and fear of exposing themselves as a gay person, they will not talk about it with a doctor.”
Philip Yaeger, executive director and CEO of the AIDS Services Foundation Orange County, said a study of local doctors showed they were uncomfortable discussing sexual health matters with patients and didn’t routinely test for HIV on the assumption that the procedure wasn’t covered, though state law requires coverage.
“There’s a lot of education we still need to do with health providers,” Yaeger said.
Young men speak
Gabriel Maldonado of Riverside, 25, is openly HIV-positive and works with young men in AIDS awareness, prevention and care. He said it’s particularly hard for young low-income men of color to follow HIV-AIDS treatment regimens that require a pill a day at a certain time and physician follow-up.
“Even when people do receive care and get medication, adherence can be a challenge,” he said.
When young men are staying on friends’ couches without a regular home base, relying on public transportation and have in-flux schedules of part-time work and part-time classes, it’s difficult for them to create a structured environment, he said.
Meanwhile, at the Home Depot in Santa Ana, the men who stand outside the store’s parking lot approaching cars on their way in and out say that injuries are rare.
Though, upon second thought, day laborer Raul Chopin remembers that one time he cut his hand while operating a drill on an assignment. His boss gave him cash that he used at a corner clinic, where he got stitches and went back to work the next day.
Hearing his story, another day laborer who was standing nearby weighed in on the discussion. He walked by and confidently announced that, “We’re strong young men. We don’t get injuries.”