As a child, my family did not have a lot of money. In fact, we regularly struggled. I know there were periods of time that we went without health insurance. While we had some major medical problems during that time (we sought care at the University Hospital), we were, for the most part, mentally and physically healthy.

I did, however, have some friends who were not able to seek mental health treatment due to not having health insurance. Sure, they could go to the hospital, but routine care was not in the cards. In the state where I lived, only pregnant women and children were eligible for state Medicaid—regardless of income.

I was very angry with how that system worked and was excited to go to graduate school in Missouri because I had been told that Missouri had more options, including Medicaid for those who were disabled or had serious mental and/or physical health diagnoses and some DMH (Department of Mental Health) funding.

Through my internship (and into my residency), I got to see how many problems there still are with state funded/assisted healthcare, even in states that have guidelines to include larger groups of people.

Problems with the Application Process

One of the problems is the time it takes for Medicaid applications to be approved or denied.

We often have clients who apply for Medicaid, wait several months, and get a denial letter because they forgot to send in one thing with their application. This leads to an even longer wait.

I understand that the Medicaid office gets massive amounts of applications each day, and I also appreciate the hard work that those employees do trying to process those applications. However, this is a broken system because it may result in a delay of treatment, and rejections can often cause the client to be frustrated and decide that treatment is not worth the pain of the application process.

Clients who Earn “Too Much” Money

The bigger problem is caring for clients who earn “too much” money.

I am currently finishing my post-doctoral residency in a community mental health clinic. A large number of clients who seek services at these offices receive state funded/assisted healthcare. When we have a client come through the walk-in intake process who has very little (or zero) income and no assets in addition to a qualifying mental health diagnosis, we know that they are likely to receive Medicaid.

We also know that if the client is granted Medicaid, we can back bill the insurance (up to 90 days or the date they apply) in order to receive compensation for services such as the CPRC program. Therefore, we may attempt to use General Revenue (GR) funding (largely supplied by DMH) for a specified short time period to see if they get Medicaid and start them in treatment as quickly as possible (as the GR funding is often reimbursed when we back bill).

That works out well for those clients. That being said, it is important to be aware that GR funding eventually runs out and once it runs out, it is not available for the remainder of the year.

However, a chunk of our clients earn “too much” money to qualify for Medicaid. At this time, in Missouri, residents who are disabled (not necessarily as declared by Social Security Disability but by the state of Missouri) and single, must earn less than $9,920 per year (or, less than 85% of the federal poverty level) in order to qualify for Medicaid. Let’s break that down—the person must earn less than $826 per month in order to qualify.

Even if you have a job that pays minimum wage ($7.65/hour in Missouri), to be safe, you should not work more than about 24 hours per week.

I have seen many clients come through during the walk-in intake hours that are trying very hard to make ends meet and are often not able to do so. They want very badly to improve their mental health. Many of these clients are feeling desperate by the time they “resort” to seeking treatment for mental health.

When I am doing the intake, I will ask them if they have Medicaid, and they will tell me that they do not. Once I ask them about their income, I’ll find out that their low income is still above the cutoff for Medicaid yet still low enough that they cannot pay their bills. So I’ll ask them about other health insurance. They then tell me that they are unable to afford that—after all, they are barely paying their bills.

So they feel stuck. These groups of people who work so hard to become fully functional in life are not able to seek treatment because they earn too much money to qualify for Medicaid yet earn too little money to afford health insurance. In the end, these patients either have to self-pay for treatment (which many of them cannot afford just as they cannot afford health insurance) or go without treatment.

This is when I get frustrated. One of the goals of our comprehensive outpatient program (CPRC) is to work toward independent functional daily living. This involves working with a Community Support Specialist (CSS) and may involve medication management services with the psychiatrist, individual therapy, or group therapy and/or education.

One of the individual treatment goals our clients work toward is a stable environment. This often involves housing assistance and help in finding employment.

But if these clients earn too much money, they risk not being able to have Medicaid anymore, then not having treatment, and spiraling downward from there. We promote independent functioning, but there is an underlying fear that the client may risk earning “too much” to qualify for Medicaid anymore and, subsequently, cannot pay for treatment.

This feels much like a never-ending cycle. I do not have an answer for this, nor do the people I vent my frustrations to. It is simply an issue that we face daily in community mental health that we need to begin raising awareness about.

Options Outside of Medicaid

For those who earn too much to qualify for Medicaid, there are a few options outside of Medicaid – though not many. Here are some of the options we encourage clients to consider when they do not have Medicaid and cannot afford private health insurance:

Self-Pay Sliding Scale Fees based on Income

  • Single individuals who earn less than $11,770 (federal poverty level) qualify for an 80% discount (slide A) which leads to the following costs: $30-$36 for an individual therapy session, $56 for a first psychiatrist appointment, approximately $21 for follow-up psychiatry appointments, and $9 for group therapy appointments.
  • However, if you work full time at minimum wage, you fall above the poverty level because you will earn around $1,224 per month before taxes. This places you in the Slide B level, a 75% discount, leading to the following costs: $37-$45 for individual therapy, $70 for a first psychiatrist appointment, approximately $26 for follow-up psychiatry appointments, and $11 for group therapy appointments.
  • Many of our clients, even on these lower scales, cannot afford services or have to choose between services and other necessary expenses like paying bills or buying gas.

Requesting a Student

  • Some community mental health programs offer lower rates if you are willing to be seen by a student who is closely supervised by a licensed professional.

Other Options

  • Finding out if their employer has an employee assistance program.
  • Working with churches or other local agencies to get assistance for their sliding scale fees.
  • If in-person services are not deemed feasible, it may be beneficial to explore local support groups.
  • Additionally, online assistance in the form of mental health forums and supportive websites such as 7 Cups of Tea may be beneficial.

Moving Forward

While none of these solutions are perfect, I feel that they are better than doing nothing. However, as a profession, we need to continue working on contacting those who are in leadership roles across our state and making them aware that there are a large number of clients who cannot afford treatment because they earn “too much” to get state funded/assisted healthcare services yet earn too little to pay their bills.

We can make change….but we have to start by being vocal about the problems!

Amelia Winsby, PsyD