By Breanna Lathrop

At the clinic, we are regularly asked by patients to complete paperwork to assist with social supports. Paperwork for handicap stickers, half-fare public transportation cards, rent relief, affordable housing eligibility, and the list goes on. Sometimes we know the patient well and other times we are just meeting. However, it always feels odd to me, as the health care provider, to be gatekeeper between a person and a needed social service. The paperwork always contains long definitions and criteria along with message about all the consequences I will face (fines, jail, loss of license) if I give false report. The more I fill out these types of things the more bazar and frustrating the entire operation feels.

            Let’s start with the half-fare public transportation card. This card enables a person to get a bus or train ride for $1.75 instead of $2.50. It eases the financial burden of public transit slightly, increasing their ability to get where they need to go. The form provides a list of medical conditions from which I can choose that would qualify the person to receive this coveted card. The form clearly states that the criteria for qualification is based on diagnosis NOT income. In other words, you can make a million dollars a year and have heart failure and you can get a half-fare card. You can be working multiple part-time minimum wage jobs on opposite sides of the city and living in severe poverty but if you are not sick, no half-fare card. It seems to me that people suffering from severe poverty are in the most need of transportation assistance. In addition, activities that help people get out of poverty such as furthering their education, obtaining consistent employment, and securing childcare so they can work, are all heavily dependent on having transportation. The form is missing the box where I can say, “my patient doesn’t have a qualifying diagnosis yet if he can’t get to the health center to manage his diabetes or the store to buy food, he will have heart disease or kidney disease in another year.” Or maybe a box that says, “employment providing a livable wage is essential to good health and my patient can’t start a job because she has no transportation to get to the job.” I keep checking but these boxes aren’t on there yet. You just have to get sick enough so you can get some help with transportation.

            The housing forms are even worse. Here we are asked to certify that the patient has a mental health diagnosis that precludes them from employment. After a paragraph of threats, which I’m pretty sure includes torture, providers are asked to make a judgment call about whether or not a patient deserves housing assistance based on the severity of their diagnosis. What!? I need a box that says, “It’s hard to know whether this person suffers from chronic depression or if she is depressed because she has been sleeping outside for the last three months.” Or maybe, “This person can probably work again someday but right now he has been in five different shelters over the last six months, been in the ER three times for violent assaults, and doesn’t know how he is going to eat tomorrow. Could you work in these conditions?”

            These forms also like to remind me that substance abuse disorder is not a qualifying mental health disorder. If they are going to get assistance they are going to need another mental health condition along with substance abuse disorder. Here I want to write, “do you have any idea how I can accurately diagnosis someone with bipolar disorder or schizophrenia when they are actively using drugs? It’s not possible. In fact, the DSM-5 diagnostic criteria for schizophrenia actually states the diagnosis can only be made when the individual is not under the influence of substances.” Despite our growing understanding of addiction as a disease, it’s still not a disease worthy of housing assistance.

            I certainly understand the need for appropriate documentation and the correct allocation of limited funds. Yet, as I sit with patients and hear their stories, I often wonder if our policies are designed with real people in mind. It feels like help, whether with transportation, housing, or even health care, often comes with a long list of conditions and expectations. Is there ever a place and time when someone deserves help simply because life is really hard?

            The work I do is often described as part of the “safety-net,” a collection of health and social serves designed for those who are vulnerable and plummeting toward rock bottom. I often find that our nation’s policies around “safety-net” structures function more like a mattress. They will soften the landing and give you a few inches boost if you are going to try to climb back up, but you’re going to have to fall a long way to reach it.

2 thoughts on “The Missing Box

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