April 6, 2016
By Imaz Athar

Read part 1 here.

As a volunteer counselor at APPRISE—an agency that provides free one-on-one health insurance counseling to individuals—I spent the day helping advise our clients, with a team of other counselors. Many of our clients had just turned 65, and were exploring their Medicare options. It was up to us to help them decide whether or not it was better for them to enroll in an all-encompassing, yet expensive Medigap or a more affordable advantage plan that limits individuals to a certain health network. Other clients wanted to find out what the prices of their prescription drugs would be under a new plan, and whether or not they reached the coverage gap, otherwise known as the ‘donut hole.’ Another client, who was under the age of 65, was trying to find how to enroll in Medical Assistance for Workers with Disabilities, or MAWD.

As you see more clients, each with a different set of needs, your brain starts to melt—you lose yourself in a sea of healthcare jargon, even after spending hours and hours learning it during counselor training. Then, you look at the client, and you begin to realize how laboring it must be for them to navigate through such an unfamiliar and complicated system that seems to want to detach itself from its own beneficiaries.

While most days are pretty routine, others are more unusual than others. One day near the end of my shift, one of our clients came in for some basic health insurance counseling. She was in her 60s, and she seemed very joyful, cracking a couple jokes as I walked with her from the waiting room to our office. We sat down and after we talked briefly about the services we provide, she pulled out what looked like a petition with a list of names. She began to explain that she was pregnant, but she wasn’t able to find a doctor who would deliver her baby; the petition was to be used to help her find doctors. Right away, none of this clicked. First off, the client was in her 60s, so there was no way she could be pregnant. Also, it was unusual that she was carrying a petition around to seek medical care—don’t see that too often, if at all. We asked if she needed help with anything health insurance related, but she insisted that we sign her petition. She brought some paperwork with her, and we began to look through it. After a few minutes of digging, we discovered that she had been admitted to a psychiatric hospital in the past. Some more digging, and we found out why: she had schizophrenia.

We weren’t entirely sure how to address the situation from there. So, we pivoted, and called one of the more experienced counselors to help us out. It turns out the client did have a few issues with her health insurance that she needed help with, and she was able to speak with one of the experienced counselors about it. But, after the client left, we were still caught up by the whole ordeal. A couple of big questions stood out to me. First off, why wasn’t she receiving treatment for her psychiatric disorder? It seemed that she had to have slipped through the cracks somewhere—there had to be a reason she was sitting at APPRISE, a health insurance counseling center, rather than in front of a mental health professional. Another question—how would she be able to consider her health insurance options while her schizophrenic symptoms were still very clearly present?

It’s hard to answer these questions without knowing more about our client’s background. When we asked her about her stay at the psychiatric facility, she told us she didn’t like it and that her dissatisfaction was a reason why she was no longer there. This raises a number of concerns.  First, it’s widely known that schizophrenia can be an extremely debilitating illness, if not treated. During our visit, she was convinced that she was pregnant—it was so believable, in fact, that I was almost convinced myself. Clearly, she wasn’t pregnant, but who knows how much worse her symptoms could get without treatment, considering how driven she was by her pregnancy delusion. I don’t doubt that whoever treated her had the best intentions, but clearly it didn’t work. There must be ways to improve treatment so that patients, especially those with serious illnesses, are able to comply with it. For instance, studies have shown that culturally aware mental health treatment is very effective. Some patients may view mental illness differently than practitioners, based on their own personal beliefs. Perhaps if psychiatrists, or other mental health professionals, better understood their patient’s view of illness, they’d be able to better treat it.

But, then again, this kind of culturally-sensitive, patient-centered treatment is very difficult to provide in our current healthcare environment—where physicians are expected to see patient after patient after patient in a short amount of time. How are physicians able to build relationships with patients when they’re only able to see them for minutes at a time? Rather than establishing a deep connection with a patient that informs effective treatment, psychiatrists are forced to rely more heavily on just prescribing medicine so that they can see their next patient in a day full of them—psychotherapy is dying. Providing more ‘aware’ treatment requires a great shift in patient care, a change can be very difficult to realize.

On to my other question—how would our client be able to consider her health insurance options while her schizophrenic symptoms were still very clearly present? As I mentioned earlier, our health insurance system can be very difficult to navigate. I, myself, had trouble remembering all of the eligibility requirements, policies, and intricate terminology, even though I went through a training course before I became a counselor. For many of our clients, it was almost like learning a new language. With that said, I can’t even imagine how challenging it would be for someone with a severe mental illness to understand all of their health insurance options. It turns out our client did have issues with her health insurance, but she was so caught up with her petition and pregnancy, that she wasn’t able to discuss it. This is where mental health competency is incredibly important. Training physicians, counselors, and others to communicate effectively and sensitively with individuals with a mental illness could go a long way. I certainly would’ve benefitted from it—I feel like I would’ve been better able to help our client if I just knew where she was coming from.

Like culturally sensitive treatment, providing mental health competency is by no means easy to implement. It requires a shift in how patient care and effective treatment is viewed and understood. These are things for aspiring clinicians, counselors, social workers, etc. to think about and consider—it’s up to us to help shape a health care system that maximizes the well-being of all patients, including our client at APPRISE.