With ACA up and running, we are repeatedly assured that health care is within reach for everyone now! No one need suffer, alone and cold, not in a world where everything is beautiful and nothing hurts. Everything is splendid — when someone wants to see the doctor, by golly, she can just nip right on over. This ignores the fact that of course Obamacare excludes many people, forces people to pay for expensive insurance plans that they may not necessarily be able to afford if they straddle any of the awkward financial divides in this society that no one really knows how to deal with, and doesn’t account for copays, deductibles, and shares of care — pop on over to the doctor’s and you might be paying, $10, or $20, or more for the privilege.
Mental health care in particular is complicated for anyone on plans under ACA. Though this insurance is supposed to be ‘comprehensive,’ it starts to fall apart when it comes to mental health, especially for hospitalisation. Even those who have platinum plans are still going to be left paying a hefty chunk of change if they need inpatient treatment, especially if they require treatment for a week or more. While that’s certainly better than having no insurance, it’s definitely not the easy peasy easily affordable health care that was pitched.
And for low-income people, cost isn’t the only issue. Setting aside the question of whether people can afford the copays and deductibles for mental health services — remember, low-income people are likely to have bronze plans or other options with lower premiums and higher costs on the other side — there are other barriers that don’t get factored into mental health care. Those same factors are also ignored by people who seem to think that if they insist long enough and hard enough, every crazy person will magically get treatment and no acts of violence will occur in the US again ever (because only crazy people are violent, you see).
Getting mental health services is a complicated matter. Many working class people are working multiple jobs that stretch across a variety of hours, which can make it extremely difficult to get into a doctor’s office, especially for things like regular therapy appointments, particularly for those who need to show up once a week or more. And no, before you ask, it’s not possible to take time off from work to go to the doctor. Employers are often highly resistant to this and aside from the loss of wages, employees may face retaliation for asking for time off to go to their psychiatrists and other mental health care providers. It doesn’t matter if such retaliation is illegal — even if someone could afford to retain an attorney, employers are adroit at finding reasons to explain why, for example, they cut an employee’s hours or moved her to a different shift with fewer tips, leaving her making less at the end of the week.
And let’s talk about transportation. Low-income people are more likely to rely on public transit, bicycles, and their own two feet rather than having cars, and if they have personal vehicles, they’re sometimes unreliable. In areas with limited public transit, getting to the doctor’s office may require significant walks to and from bus stops or train stations to get where you need to go — and even in areas with good transit, people need to factor in a trip that could take an hour or more depending on where they are and where they need to go. Suddenly, ‘an hour off’ turns into three hours between transit, checking in, and actually having a mental health appointment.
Medications can be costly. Pricing varies depending on insurance plan, and it becomes even more complicated if someone needs medications that are not covered under a plan. While a psychiatrist may submit a letter to an insurer arguing that a medication is necessary to support a request for coverage, the patient either needs to pay out of pocket (which may not be possible) or wait without the medication. This is a particularly risky endeavor with psychiatric medications that cause seizures, depression, and other substantial side effects when patients drop them cold turkey or taper too quickly. While waiting for insurance approval, a patient could experience serious complications.
Stigma can also be a serious operator for low-income people in the US. While stigma is a wide social issue and one that’s pervasive across all economic classes, the middle and lower classes tend to be hit by it harder. Among upper class people, there can be unease about mental health in addition to ostracisation, but there’s also a wider acceptance that some people need therapy and other mental health services. The old joke about everyone in New York City being in therapy is a classic example — the city is a place with an extremely wealthy population (served by low-income people in outlying boroughs and suburbs) and people can talk openly about being in therapy because they feel comfortable about it, even if they may keep their diagnoses private.
When you face stigma within your community and from external sources like employers, it can be a disincentive to get mental health services or to pursue the options you need to manage your health effectively. This can be a particular problem in some racial and ethnic minorities with a complicated relationship with both the medical system and mental health. Not everyone views mental health the same way white people in the US do, and, notably, people of colour are poorer overall than white people. People living and highly active in communities where discussions about mental health are discouraged and people are encouraged to deal with it on their own are facing barriers of their own — getting care may be functionally impossible, or they may need to seek it out secretly, without getting support from friends and family.
When people say that getting mental health care is easy, they overlook a number of problems with mental health services in the US — like stigma, like provider availability, like affordability — but they also specifically slam low-income people who face accessibility barriers that ACA can’t fix with the wave of a wand.
Image: Theen Moy