I n the wake of the GOP’s recent and unflagging attempts to repeal the Affordable Care Act — an unpopular move by multiple measures — a handful of Democrats are fighting back with a push in the opposite direction. Rather than try to tape the ACA back together, candidates and lawmakers are pushing for a health-care revolution in the form of a single-payer system. Last week, the idea got its most high-profile boost yet, when Sanders unveiled a Medicare-for-All bill with a record 15 Democratic co-sponsors in the Senate.

The legislation, of course, doesn’t stand a chance of passing in the current GOP-controlled political climate (Trump has even gone so far as to call the plan, ludicrously, a “a curse”) — but there’s reason to believe it has potential, especially if Democrats soon take back political power. A recent Pew poll, for instance, found that support for single-payer health care has grown 12 points since 2014.

This push for universal or single-payer health care — which aren’t exactly the same, but are similar enough that they’re largely used interchangeably — is undoubtedly promising. But there is also good reason to believe that a single-payer plan could potentially leave many pregnant people without a way to pay for a necessary medical procedure that hundreds of thousands seek each year.

A recent Pew poll found that support for single-payer health care has grown 12 points since 2014.

That’s because in the United States — a country where erectile dysfunction medication, cosmetic surgery, and numerous other pills and procedures are covered by insurance — abortion has largely been funded out of the pockets of the people who pursue it. Since the 1970s, Medicaid funds have been barred from paying for abortion services, and Targeted Regulation of Abortion Providers (TRAP) laws have restricted the ways in which even private insurance can pay for the procedure and aftercare. If restrictions like these aren’t expressly confronted and dismantled in a single-payer health-care plan, many reproductive-rights organizations believe that universal health care will not expand access to coverage for pregnant people in need, and could even further hinder access.

At a time when basic abortion services are in peril — when states are rolling back abortion rights with little resistance, and when Democratic organizations and lawmakers have made it clear that abortion is an area of potential compromise — how can we be sure that any attempt at single-payer health care will hold strong and ensure that everyone truly is covered?

Even as we fight back against the GOP’s latest last-gasp effort to get rid of Obamacare — and it’s crucial that we do — it’s also important that we open up a pro-choice dialogue around single-payer. Because no plan can be universal if it doesn’t support those seeking reproductive care.

The Power Of Hyde

It would be easy to assume that pro-choice advocates and single-payer advocates are one in the same — they are united in their interest in expanding health-care access, and both tend to come from more progressive camps. However, many reproductive-health organizers are skeptical that single-payer plans will truly be inclusive, while single-payer supporters view pro-choice groups as being too incremental.

The schism lies partially — but not entirely — in concerns over the budget appropriation known as the Hyde amendment, which bars most public money from paying for abortion services. Because of Hyde, for the 17% of non-elderly adult women who are on Medicaid (many of whom are members of marginalized populations), abortion services — which can run up to $1,500 — must be paid out of pocket except in very specific instances. That’s in addition to the cost of traveling over state lines and potential hotel stays in states that require 24-hour waiting periods, which only increase the chance that an unwanted pregnancy becomes financially ruinous.

Hillary Takes Crucial Stand Against Anti-Choice Hyde Amendment

However, there’s little political will to change the rule; since its passage in 1976, the Hyde amendment has been renewed every single year. And support has come not just from conservatives — but, in more subtle ways, from pro-choice organizations like Planned Parenthood.

This isn’t because Planned Parenthood is against reproductive justice for the less privileged, of course. But as the organization has clawed its way to remain funded in the wake of relentless GOP attacks, it’s often distanced itself rhetorically from abortion services. As a result, as Kylie Cheung wrote for Mediaite in July:

“Instead of fighting the Hyde amendment, which prevents thousands of low-income women from being able to access safe and legal abortion, [Planned Parenthood] routinely affirms the Hyde amendment’s legitimacy by reminding conservatives that they don’t use federal funding to pay for abortion.”

Still, there’s reason to be hopeful that getting rid of Hyde could be part of a push for universal health care. Despite Planned Parenthood’s rhetoric, the organization has in action fought the Hyde amendment in some key ways — it lobbied aggressively against HR 7 in January, which would have made Hyde permanent, and has supported numerous candidates who have listed rescinding Hyde as a major campaign promise. The organization also recently hosted a rally with Sanders, patron saint of single-payer, who has himself strongly backed repealing Hyde.

Rescinding Hyde as part of the push for single-payer is possible, then — but there’s also reason to believe it could be entirely ignored. And this would ensure many pregnant people would continue to struggle to access abortion services, even in the wake of “universal” care.

The Power Of State Control

Hyde isn’t the only thing standing in the way of universal health care covering abortion services. The United States prizes its ability to let states govern themselves in many ways, including how they distribute grant money and when and where they allow their medical professionals to practice. Without express federal protections for abortion that actively require states to expand access and coverage, the question remains: Even if we pass comprehensive universal health care, could it be whittled away by states looking to curb coverage and access?

There’s an example of precisely that just north. In Canada — where many in the United States look to see a shining example of single-payer at work — there’s a clear example of what happens when reproductive health is not at the center of the health-care conversation. In spite of the country’s reputation for progressive values, abortion rights have been whittled away, one province at a time.

Writing for Jacobin, Gerard Di Trolio explains what’s happening.

“Though there is no law regulating abortion in Canada, all provinces have varying restrictions on government-funded abortions. Women seeking an abortion have to meet a particularly high bar in New Brunswick. There, abortions are only covered when: performed before the 16-week mark, carried out by an obstetrician or gynecologist in a hospital, and after two doctors have signed off on the procedure.

Prince Edward Island (PEI) is even worse. The province doesn’t have a single medical facility that can perform abortions. This has led to instances in which women have harmed themselves because they didn’t have abortion access. Pro-choice activists have long argued these regional variations violate the Canada Health Act. Still, PEI Premier Robert Ghiz said this spring, ‘I believe the status quo is working.’ He can get away with such comments and policy positions because the federal government has never intervened to ensure equitable access.”

To see how state regulations could complicate abortion access under a single-payer system, one need look no further than Colorado. In 2016, voters from the state rejected a bill that would have achieved universal health care. And from the beginning, reproductive-rights organizations expressed concerns about one very specific legal hurdle: a state amendment passed in 1984 which prohibited public funds from being used to fund abortion services.

Even states like California — where health care access is greater than many others and abortion services are potentially more in-reach — still present significant barriers to accessing abortion. For instance, Medi-Cal, California’s Medicaid program, has a massive access problem; a 2011 report found that 45% of California counties don’t have a Medi-Cal abortion provider. Which means that even if the state were to pass a single-payer plan (without additional stipulations to provide more clinics or locations which offer abortion service), the coverage would still be just as limited, if not more so.

Sans federally mandated abortion protections within a single-payer plan, it’s easy to see how states could severely limit access to reproductive services.

The Power Of The Democratic Party

Perhaps the biggest threat to abortion services, though, is the current ideology of the Democratic party. Regardless of a person’s moral beliefs about abortion, there is an inalienable case to be made that abortion on demand is an economic imperative. Yet the party has made it clear in recent months that it views abortion services as an optional or superfluous part of the left’s agenda.

As such, the most important way to move forward on single-payer is to make this message crystal-clear: Interjecting mentions about Hyde and abortion and reproductive care into conversations about single-payer is not derailing — it is essential.

It’s possible to do, too — and when it’s done correctly, the desired effect of fewer abortions can be achieved. In Massachusetts, where statewide health care was used as a model (kind of) for the ACA, abortion rates declined significantly “despite public and private funding of abortion that is substantially more liberal than the provisions of the federal legislation currently under consideration by Congress,” according to a 2010 article by Patrick Whelan, M.D., Ph.D. in the New England Journal of Medicine.

Perhaps the biggest threat to abortion services is the current ideology of the Democratic party.

However, in the current climate, where the GOP seems more certain than ever that the only way to preserve their legacy to repeal the ACA, it seems exceedingly difficult to imagine that, as a nation, we could both a.) build and implement a functional universal health care system that truly works for everyone and b.) repeal the numerous state and federal bans on public dollars for abortions.

In the United States, where the GOP is so passionate about states’ rights, it’s easy to see how a situation like the one in Canada could unfold. States like Texas and Missouri are already attempting to reduce access at every turn. What happens if we do push so hard for single-payer that we forget how many in the country still desperately want to not only strengthen Hyde, but repeal Roe v. Wade?

What happens if we stop bringing up the existing barriers to abortion and as a result, they are never removed when new health-care policies are put into place?

What happens if the fervor for single-payer becomes so great that compromising on abortion becomes fair game?

There is a surging current of support for universal health care in some ways — perhaps even universal Medicaid or Medicare, as the Dem-backed new bill is pushing for. But if access to necessary medical procedures and reproductive health care aren’t part of the policy (if clinics aren’t added, waiting periods aren’t repealed, and requirements that trans-vaginal ultrasounds aren’t removed), it will necessarily be a half-measure achieved at the expense of millions.

What if the fervor for single-payer becomes so great that compromising on abortion becomes fair game?

Even if Hyde is repealed and universal health insurance can pay for abortions, if there’s nowhere to go, it’s not really a right.

Supporters of single-payer ought to be on the front lawn, in the streets, and on the phones with their representatives. They must be turning out at the ballots and holding town halls and pressing their lawmakers. But they also must do so with an eye on the very real, very scary potential that single-payer which doesn’t cover abortion is nowhere near universal.

The brownstone I lived in for eight months in 2009 and 2010 had few amenities — the building often smelled like leaking pipes, the carpets were threadbare in many places, and the steam heater in the corner was completely out of my control, resulting in quite a few freezing mornings and sweltering nights. It did, however, have a gas stove and oven which, the landlord had told me, was pretty new and “worked great.”

Unfortunately, everything else in the unit was electric, which meant that I’d need to set up separate utility accounts and pay for the gas every month just to run the stove and range.

“It’s like $10 to turn it on and then another $20-$30 per month depending on how much you use it,” she explained.

Yeah, I’m just not going to do that, then, I thought, doing the math in my head.

At that point, $30 was just a little bit less than my take-home after a day of making lattes, which is what I was doing every day that I wasn’t at my public radio internship. The rent on the apartment — which was the least expensive I could find in Seattle — was already going to cost well more than half of my monthly income. With student loan payments to top it off, I barely had living expenses to speak of, and the extra money I’d spend on the gas just didn’t seem worth it.

This wasn’t my first go-round with poverty: We grew up without much money, and I supported myself through college. But after graduation — when the student loan envelopes started showing up and I had to move out of my inexpensive college town to a city that actually had jobs — the situation was dire. But I knew how to handle it.

Every month, I’d scrutinize my budget, looking for things to trim or ways to increase my earnings.

I moonlit as a cocktail waitress. I considered selling plasma (again), but the bus ride to the clinic was too long to fit into my days. I didn’t have a car or health care (or a stove). I picked up odd jobs on Craigslist, receiving cash under the table for nights of cocktailing or working as a cater waiter. I visited food banks. I never bought clothing. I stopped shaving to save money on razors.

Eventually, I was able to get a slightly more lucrative job, began piling on freelance work, and basically never looked back.

I am very, very confident that I did everything in my power to provide myself the best life possible as a young adult, and that the choices I made were the correct choices. My life now would indicate that that’s the case. And still, without fail, when I tell someone or write about that time in my life, I’m met with a cascade of advice.

I am very, very confident that I did everything in my power to provide myself the best life possible as a young adult, and that the choices I made were the correct choices.

Well-meaning people who have never been poor are convinced that they know what I should have done. That subtle tweaks to my budget could somehow stretch my $9.50 per hour. I should have gotten a roommate. I should have lived somewhere cheaper. I should have found a better job.

Anyone who’s ever lived in poverty has probably had this experience.

In the U.S., we have become so accepting of the fact that poverty is not a symptom of a grossly unequal economy, or the result of numerous systemic failures, or the product of years of trickle-down economics, but instead, that the only thing standing between a poor person and the life of their dreams is their own decisions, their own choices, and their own failures.

This is why I would advise any person whose immediate reaction upon hearing about a friend, relative, or stranger on the Internet who is living in poverty is to offer unsolicited advice to hold their tongue (or fingers), at least long enough to consider what other forces contribute to poverty and how their “help” may actually be insulting, incorrect, and downright damaging.

In the U.S., we have become so accepting of the fact that poverty is not a symptom … but instead, that the only thing standing between a poor person and the life of their dreams is their own decisions, their own choices, and their own failures.

The Most Common Advice Doesn’t Add Up

The over-simplification of poverty is often apparent in the advice that gets disseminated by people who have money and companies who make money off of other people’s financial predicaments.

Earlier this year, an infographic circled around which underscored this fact. Created by a company called InvestmentZen, the infographic showed how to “build wealth on the minimum wage.”

Aside from the fact that it contained numerous logistical issues — it used the federal minimum wage, which isn’t accurate in most states, either because their wage is higher or lower due to tip-crediting — the graphic also seemed to be concerned about moralizing the decisions of poor people and less about actually helping anyone.

Advice from the graphic included “learning skills on YouTube,” only eating in-season produce, and remembering that “the best things in life are free.”

“You can make excuses, or you can do something about it,” the graphic chided. “It’s your choice to make.”

Twitter instantly took it to task; the response was so heated that it eventually led one of the men responsible for circulating to issue a retraction, calling many of the criticisms “fair.”

I suspect that the graphic was so easily mocked because the advice it selected was familiar. Despite the myriad systemic reasons that many people live in poverty, there are a handful of “tips” that well-meaning (most of the time) folks recycle with alarming regularity.

Despite the myriad systemic reasons that many people live in poverty, there are a handful of “tips” that well-meaning (most of the time) folks recycle with alarming regularity.

Move somewhere cheaper. Buy in bulk. Get rid of your car. Get a roommate. Eat out less.

These changes seem simple — if you just spent less money on groceries, you’d have more money! If you didn’t have a car, you could save hundreds on car insurance! — but they fail to take into account one crucial element of humanity and existence: The dollar amount of a thing doesn’t fully capture the value of it.

Most people who live in poverty are working jobs where their income is determined by how many hours they can spend on the job, which often don’t fall within typical commuting hours, and often run well over forty hours per week.

When you’re poor, your time — especially your free time — is extremely precious. And many of the prescribed tips for saving money cut into that free time, make it less enjoyable, or might even actively cost more money in the short term.

I’ve written before about the actual cost of moving — renting a truck, putting down a deposit, the financial hit of taking time off work to move — but recommending that someone relocate their entire life to save on rent also neglects to account for the real value of living in a place with a support system.

Whether it’s a family by birth or by choice, living near people you know offers a sense of responsibility and place — not to mention a couch to crash on if you get evicted and the potential for free childcare or other assistance.

Whether it’s a family by birth or by choice, living near people you know offers a sense of responsibility and place — not to mention a couch to crash on if you get evicted and the potential for free childcare or other assistance.

To illustrate this point, let’s use another common tip: giving up a car.

Access to transit is one of the single biggest investments that communities can make to help people get out of poverty. But overwhelmingly, transit systems are failing poor people. And for seniors or disabled people, taking the bus may be even more difficult if cities and transit authorities don’t accommodate for various mobility, vision, or hearing impairments.

Which means that the cost (both figurative and literal) of giving up a car might be steeper than keeping it. Which means that even if a person makes the choice to save money by riding the bus, the bus may not be there for them.

There’s also the issue of time and convenience, particularly if you live in a smaller city, which tend to have much spottier bus service.

We can look at it like this: Estimated cost of owning a car over a year: about $725 per month, according to AAA. That’s a lot, but compared to riding the bus (because let’s assume a person doesn’t have the upfront cash for a bike, a lock, and the gear they might need to commute in all weather), it’s not really.

Where I live, it costs about $5 per day to commute via bus, assuming I’m traveling inside the city and just going to work and back using a single method of transit. Multiply that by five days per week (though most people working minimum wage work more than that), and it’s about $100 per month. That’s still less than $725 — until you account for:

Two hours of commuting compared to thirty minutes of commuting (at $13/hour): $19.50/day in lost income, or $390 per month.

Cost of an extra hour of childcare to account for the commute time (at $13/hour, as well): $260 per month

The cost of using the bus for weekly grocery trips (which limit the choices a person has and reduces the ability to buy in bulk, another favorite piece of advice for people with means to give to poor people) and the occasional other appointment: about $50 per month.

Which equals $800 — and doesn’t take into account the fact that grocery shopping by bus is not ideal for someone with kids in tow. Additionally, taking the bus to get groceries makes it less likely that a person can comparison shop, visit multiple stores for ultimate savings, and purchase products that are less easy to carry, like fresh produce or bulk items.

You can also see from this example how interconnected so many of these pieces of advice are.

Get rid of your car” is a fine piece of advice in a vacuum, but when it’s coupled with “drive for Uber to make extra money,” you’ve now prescribed something that’s literally impossible. “Spend less on groceries” is fine on its own, but if you’re also recommending that someone switch to commuting by bike or bus and move to a less dense place with fewer food choices, you’ve now quadrupled the daily difficulty of their life.

And that has a real cost, even if it’s not tangible or numeric.

This, I think, is truly at the heart of the advice we tend to offer poor people: It implicitly says that we believe that they should be willing and able to exchange their own time on earth, comfort, happiness, and even physical health and safety just to scrape by.

Being Poor Is Really Expensive

The assumption that “simple advice” can dramatically change a person’s economic outlook assumes that a person’s poverty is solely the result of personal failings, rather than very real and costly systems of oppression, including legacy poverty, systemic racism, mass incarceration, punitive immigration policies, medical debt, and more.

Regardless of the personal choices a family might make to save money, there are some unavoidable costs that are baked into our financial and social systems.

Overdraft fees, late fees on missed bills, high-interest credit card fees, and payday lenders are just a few ways that poverty begets higher expenses. The average payday loan borrower — who is usually short just a few hundred dollars between paychecks — ends up paying more than 300% interest on their initial amount.

These companies make billions each year by offering people a necessary service that costs them an outrageously inflated price.

Banks also find ways to capitalize on people without money. Many checking accounts require that a person carry a minimum balance — and fine customers for every month that they don’t meet the requirement. And that’s assuming a person even uses a bank! An estimated 8% of Americans don’t use a bank, largely due to their low monthly income. As a result, they pay more money in fees at check cashing businesses or by using prepaid debit cards.

There are hundreds of small ways that being cash-poor can make it harder to save.

In addition to these fees and fines, a lack of funds in-hand can also mean paying more for services and products. Whether it’s putting charges on a credit card and paying interest or buying in smaller denominations (and thus paying more per unit), there are hundreds of small ways that being cash-poor can make it harder to save.

The Washington Post reported on a study on this subject:

When [researchers] compared households with similar consumption rates shopping at comparable stores — and controlling for two-ply TP — they found that the poor were less likely than wealthier households to buy bigger packages, or to time their purchases to take advantage of sales. By failing to do so, they paid about 5.9% more per sheet of toilet paper — a little less than what they saved by buying cheaper brands in the first place (8.8%).

Poor folks don’t buy single-use items because they never thought about buying in bulk — it’s often because they literally don’t have the money to do so, or don’t have a way to get bulk items home.

Our broken immigration system is also responsible for trapping new Americans (and their children) in low-income jobs, substandard housing, and legitimately dangerous transportation and work situations — all of which have a compounding effect on poverty.

Each year, immigrants pay billions into our tax coffers, only to get the short end of the economic stick.

New Americans are less likely to report wage theft, may experience housing discrimination, and of course, often have to pay massive sums of money to travel, bring relatives to the county, and send money back to their nation of origin.

And if you want to begin the process of obtaining citizenship? Expect to cough it up. Just becoming a US citizen can cost up to $900.

Mass incarceration also has a stark economic impact, specifically on the Black community — a population that already sees lower lifetime earnings and increased rates and instances of poverty.

Poor People Deserve To Taste Something Other Than Shame

One in four Black children born in the era of mass incarceration will have a parent who is incarcerated, which will limit that parent’s earning by an average of 40% over their lifetime. The cycle of incarceration is expensive at every single step — from the cost of arrests, legal fees, and fines, parole, and lost jobs and hours on the clock, evictions, and so much more — and effectively traps people in a feedback loop of poverty that’s nearly impossible to break.

Even those who aren’t themselves incarcerated pay for incarceration, though. The cost of visiting a spouse in prison (both in lost time and expenses), inflated commissary bills, prohibitively expensive phone bills, the cost of lost time due to traveling, court dates, and meetings, and legal fees make it impossible for some families to dig out.

Having poor parents also puts in motion a cycle of disadvantage (and not because poor people are just worse at raising their children). The vast majority of people who grow up poor stay poor for a variety of complex reasons — which means no amount of coupon-cutting or Costco shopping can dig some families out of poverty, and to suggest otherwise is just disrespectful.

Personal Choices Don’t Fix a Broken System

The InvestmentZen infographic was roundly mocked because it was a symptom of a larger problem, which is that people with means love to give advice to poor people. This serves two distinct purposes:

1. It makes people with means feel better about their means because they feel like they have wealth as a direct result of their own effort — and not systems and structures that helped them along the way; and
2. It makes people with means feel better about those systems, rather than being forced to confront them or work to dismantle them.

When the infographic said that a person “can’t earn minimum wage and live in an expensive city and be wealthy,” they weren’t telling a lie — but they were accepting implicitly that it’s okay for people who work full-time to live in poverty if they live in large cities.

Imagine if everyone took that advice — if every person working minimum wage up and fled all of the major cities to go live and work in smaller markets with less expensive rent. Cities literally could not function.

Despite the commonly held belief that only teens should or do work for the minimum wage, the fact of the matter is that millions of Americans of all ages, a/genders, and educational levels support their families on hourly low-wage jobs. That includes seniors, disabled people, and women of color.

Millions of Americans of all ages, a/genders, and educational levels support their families on hourly low-wage jobs. That includes seniors, disabled people, and women of color.

The answer, then, is not that poor people live differently, but instead, that we create a society and an economy where people who work full time can live in the community where they work.

No amount of cutting back on luxury spending or driving extra hours for Uber can change the fact that there is literally nowhere in the country where a minimum wage job can support a family, that good union jobs have been in decline for decades, or that housing costs have priced people out of their homes. Cutting coupons, commuting by bike, and enjoying outdoor activities can’t really fix that.

So, instead of telling poor people what they should do to work around a system that’s leaving more and more people behind every year, we need to consider how the system can bend and change to better fit the needs of all people.

The ACA Has Been A Lifesaver For Those With Eating Disorders — What Happens If It Goes Away?

Millions could be hurt by the GOP’s health-care plans. But one group in particular is often overlooked.

flickr / daniellehelm

This week, the United States Senate again failed to collect enough votes to complete one of President Donald Trump’s cornerstone campaign promises: repealing and replacing the Affordable Care Act. Senate Majority Leader Mitch McConnell has since proposed a vote to simply repeal the ACA without a plan for replacement (he promised a two-year “pause” without more specifics), though that plan doesn’t appear to have the votes required to pass, either. Meanwhile, the President stated that he’d be more inclined to just “let Obamacare fail,” an ominous threat without much substance or policy behind it.

This constant changing of the currents — an uncertain future that has left insurers skittish, local governments scrambling, and patients in fear — is largely due to political disagreements and power struggles between wealthy white men, but its impact is much greater and more deadly than they seem to realize.

The constant changing of the currents on health care is largely due to power struggles between wealthy white men.

Justly, more visible diseases, like diabetes and cancer, receive the lion’s share of the attention in discussions about the devastating impacts of the ACA. But there’s another, less talked-about group who may also die as a result of this politicking — those who are struggling with, and unable to get help for, their eating disorders.

The National Eating Disorder Association (NEDA) estimates that about 30 million people in the United States live with an eating disorder at some point in their life. Eating disorders are not fatal for the majority of those who get help — about 97% of patients who are treated survive — but when treatment is not available, the mortality rate jumps as high as 20%.

The fact is, despite targeted rhetoric about its costliness and general failure, the ACA has substantially increased access to treatment for many patients — and without it, many people with eating disorders would die.

Eating Disorders Before The Affordable Care Act

Though Netflix’s To The Bone made it look easy to get into a cushy in-patient program and stay for months at a time, the reality of eating-disorder treatment is much more bleak for many patients — and was even moreso prior to the adoption of the ACA.

In 2011, a court case in California pushed back on the idea that insurers don’t need to cover in-patient treatment, one of the most aggressive methods of treating eating disorders. The case stemmed from a perception that mental-health issues and physical ailments weren’t being treated equally, a violation of the state’s mental-health parity law and its federal counterpart, The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008.

For years, insurers would cover only a limited number of days — a week, a month — in residential treatment, typically citing the cost; a week at Renfrew, the gold standard of eating disorder treatment, costs over $8,000 per week out-of-pocket. Other insurers flat-out wouldn’t cover any kind of residential treatment, despite recommendations from health-care providers.

Whether residential treatment is the most effective method is up for dispute — and there’s plenty of debate on that exact subject — the fact remains that in-patient treatment is still highly recommended by many doctors and therapists, and can be a lifeline for families who need help.

When You Include Your Eating Disorder On A Medical Intake Form

The ruling, which stated that insurers must strive toward parity of care between mental and physical ailments and thus, provide coverage for residential treatment programs, came down in 2012. NEDA CEO Lynn Grefe called it “a significant victory in the battle against eating disorders that we hope will have repercussions throughout the health insurance industries.”

It did not, however, help establish how patients would be able to access these resources if they couldn’t afford or obtain insurance in the first place. Crucially, despite the significance of the ruling, insurers could still find ways to avoid picking up the tab. Prior to the passage of the Affordable Care Act, they had one very handy tool: pre-existing conditions.

Though “being a woman” is not, in fact, a pre-existing condition, being a woman (or a person of any gender) with an eating disorder is — which means even if a person got coverage once, they could be denied it in the future. That’s challenging when dealing with a disease which tends to take multiple attempts at treatment (and many years) to fully recover from.

Thanks to Obamacare, insurers could no longer turn people away for trying again, and accessing health care was easier than ever.

Eating Disorders Are Expensive For Everyone

Even after the passage of the ACA, though, treatment for eating disorders was difficult to access — making the President’s threat of just “letting it fail” even more frightening.

At the time of the law’s passage, treatment of eating disorders had not qualified as an “essential health benefit” under the new law, despite lobbying from industry professionals. In a letter to then-Secretary of Health and Human Services Kathleen Sebelius, an organization of “more than 35 organizations in the eating disorders education, prevention, and treatment communities” stated their case:

“People with eating disorders experience discrimination in accessing proper treatment and this is a serious obstacle to recovery…According to a 2003 epidemiological study of more than 2000 women, only 1 in 4 white women and 1 in 20 black women who had a diagnosable eating disorder ever received any treatment for their eating disorder.”

Protecting benefits and Medicaid coverage is a matter of social justice. A lack of treatment options and funding methods means that the lethality of eating disorders can be extremely discriminating; if only one in 20 Black women receives treatment, the other 19 are at a much higher risk of death.

Protecting benefits and Medicaid coverage is a matter of social justice.

Reducing access to treatment may also skew research and perpetuate the myriad stereotypes about eating disorders — what they look like, who gets them, and how old they are. One of the most comprehensive ways to collect data about who suffers from eating disorders is to survey those who are getting help. However, when people from marginalized groups — LGBTQ individuals (particularly trans youths), people of color, immigrants, and the very poor, to name a few — don’t have access to treatment, they can’t be counted. The prevalence of eating disorders in poor, rural, and immigrant communities is fairly unknown because they just aren’t getting treatment. Additionally, because these stereotypes persist, primary-care physicians working with these populations may not know the signs or know when to refer someone to care.

The common perception is that eating disorders are private battles fought by thin white women (again, thanks a bundle, To the Bone), but the truth is that they frequently intersect with a whole lot of other issues.

Many eating disorders have nothing to do with restricting and may be masked by other behaviors, substance abuse issues, or trauma. It’s impossible to have conversations about obesity, diabetes, the opiate crisis, or the cost of health care in the United States without mentioning the fact that many of these issues impact and are impacted by the millions of Americans who are living with some kind of eating disorder.

Why We Need More ‘Hunger’ And Less ‘To The Bone’

Offering treatment, then, has far-reaching effects. But the case for offering it goes beyond being the right thing to do. Footing the bill for treatment also does what conservatives have claimed as their goal: saving money.

The sticker shock of a $30,000 per month tab for residential treatment may seem like a lot to a lawmaker looking to make cuts, but consider the cost of not treating those struggling. Again, from the provider letter sent to Secretary Sebelius:

“Consequences of not receiving necessary health insurance coverage include financial ruin for families paying out of pocket, a lack of life saving care, which leads to the worsening of symptoms and in some cases death. Anorexia has the highest mortality rate of all mental illnesses, upwards of 20%. Individuals with anorexia nervosa are 11 times more likely to die than their peers and they are 57 times more likely to die of suicide. Mortality rates are also higher for people with bulimia nervosa (3.9%), and eating disorder not otherwise specified (5.2%).”

Unlike many other ailments, which land sufferers in the emergency room for a round of antibiotics if they’re uninsured, eating disorders are an ongoing, deeply damaging experience that impacts both a person’s physical and mental health. It hinders lifetime productivity, can reduce earning power, and generally perpetuates the gender wage gap. Mental-health issues, particularly those with physical impacts, cost billions in unearned income, creating a cycle of economic despair and expense. They literally make people more poor, thus making them more reliant on social services.

The absence of a functional health-care system — whether that’s single-payer, an improved Obamacare, or something else — is also necessary for the ever-increasing number of children who develop eating disorders.

Yes, many eating-disorder patients are children — between 1999 and 2006, the number of children under 12 who were hospitalized for eating disorders increased 119%. These kids are unable to “go get jobs,” and may be reliant on their parents’ Medicaid, which is also in peril under the GOP’s health-care plan.

The Medicaid expansion portion of the ACA has been monumental for families; in some states, children are the single largest dependents on Medicaid. Meanwhile, children as young as 4 years old report disordered eating patterns that often go undiagnosed because they don’t have access to competent care. The younger these patterns are caught, the better a child’s chance of recovering early.

Repeal, Replace, Fail

There are necessary improvements to the ACA that must be made, but none of them are contained in the proposals coming from Republicans in the House, Senate, or Executive branches.

Each plan put forth by the GOP — from the AHCA to the BRCA to the plan to just plain old repeal — would put people with eating disorders at risk. Cuts to Medicaid spending, reduced coverage for pre-existing conditions, and trimmed mental-health-care coverage would all directly impact the millions of Americans seeking help.

They won’t help bring down the cost of treatment, either; with less insurance or Medicaid funding for eating disorder centers and recovery options, the patients will be expected to pony up. And in the absence of funding, many, many patients will opt not to get help, deferring the cost of treatment to a later date, and potentially dying while they do.

Each health-care plan put forth by the GOP would put people with eating disorders at risk.

McConnell’s two-year pause could also be lethal for patients; recovery is a long road, and many patients who are fortunate enough to be able to afford residential treatment, either through insurance or their own financial stockpile, will need ongoing aftercare. Putting a pause on coverage or temporarily cutting Medicaid will ensure that the long-term care is not an option — significantly increasing a patient’s risk of death.

And as for the President’s promise to “let it fail,” he may be waiting for a while. The ACA is far from perfect and there are still many reasons why treatment is just beyond reach for a lot of individuals, but it is not, as claimed, collapsing — despite concerted efforts from the President to make it so.

Regardless, this is a fight that’s being waged in Washington but fought with the weaponized bodies of people who are disproportionately young, disproportionately marginalized, and disproportionately struggling with other issues. Though the men in ties in the Beltway may view this as a high-level game of chess, the fact of the matter is that the future of the ACA is intimately tied to the future of many Americans who’ve only just got some semblance of hope.

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]]> https://theestablishment.co/the-establishment-i-dont-want-to-be-the-troubled-girl-anymore-373459f0be71/ Thu, 06 Apr 2017 15:31:22 +0000 https://theestablishment.co/?p=2334 Read more]]> Turns out, you can’t get healthy and hold on to all your bullshit ideas about sexy tragedy.

Content note: There’s some talk of mental health, suicidal ideations, and eating disorders in here so please be kind to yourself and make a decision that’s good for you.

“You do remind me a bit of tragedy,” read the AOL Instant Message on my computer screen. I was in my college dorm, about to go out for yet another Lucky Strike on the back steps with the other bad kids. “With your, like, big sunglasses and your scarves and stuff.”

It was, at the time, the greatest compliment he could have paid me.

I was listening to a lot of Bob Dylan then and like any number of girls in the last four decades, I identified closely with the character (because truly, it could not have been an accurate portrayal of a complete human) described in “Just Like a Woman.”

You know the details of this kind of character. TVTropes.com refers to her most closely as the Broken Bird, but even if you’ve never heard her referred to in that way, you’re certainly familiar with her traits.

She’s a kind of young, sorrowful Femme Fatale who, perhaps later in life, will turn her toughness into strength and power but for right now is just kind of…dark. She’s a Chill Girl with No Feelings (unless those feelings are sad, but she largely keeps the real emotions to herself). Like a Manic Pixie Dream Girl but much more sorrowful and dark and serious, she exudes sexuality and desire through her brokenness. She is brooding and fierce and somehow inspirational despite being deeply fucked up. She’s Penny Lane, she’s Marla, she’s Sam in The Perks of Being a Wallflower, she’s the woman in Chelsea Hotel №2, she’s the literal girl next door in Breaking Bad.

But perhaps the best name for this trope (for this lifestyle, really) is the Sexy Tragic Muse, who Anne Thériault described beautifully in this 2015 essay.

“She’s damaged, often as a result of sexual assault or other abuse by men. Her life carries with it some kind of Deep Lesson, usually a lesson that a male protagonist needs to learn…The Sexy Tragic Muse fetishizes women’s pain by portraying debilitating mental health disorders filtered dreamily through the male gaze. The trope glamourizes addiction and illnesses like depression, bipolar disorder, and schizophrenia — diseases that are distinctly unglamorous for those of us who live with them. The Sexy Tragic Muse is vulnerable, and her vulnerability is sexualized. Her inability to properly care for herself or make decisions on her own behalf is presented as being part of her appeal.”

And she was exactly who, in my teens and early twenties, I thought I wanted to be. And that has made it, as I approach 30, all the more difficult to get better.

When you’ve spent most of your life identifying with and even clinging to the worst of you, the most painful of you, it makes being well and healthy feel an awful lot like giving up.

There were, in the ‘80s and ‘90s, and still are to some degree, a limited number of role models for girls and young women to look to. In my most impressionable days, they seemed to me to be neatly deliniated into categories. Smart Girls, Good Girls, Rich Girls, Plucky Girls, and of course, Bad Girls. Troubled Girls. For a while there, it was Emo Girls, though that’s its own essay.

Poor, white, and pretty rural, I saw myself a bit in several, but never fit quite comfortably in any one. I was smart (though numerous outside forces attempted to tell me I wasn’t, or at least, that I wasn’t the kind of smart that counted), I was plucky, I was good…but I was also emotionally treading water, beating my stout legs against a then-undiagnosed mental illness.

The Dangers Of The ‘Cool Girl’ Ideal
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Going to college has a kind of sharpening effect on a person’s characteristics, or at least, the ones they make the most visible. You come into clearer focus when hundreds of new eyes set upon you and decide who you are and what you’re like.

It was when I moved away that I really found myself identifying with the Troubled Girl. After all, she is always kind of the best character if we’re being honest with ourselves. The Troubled Girl taps into the centuries-old idealization of the Starving Artist; she’s a kind of new beat poet. In the bulk of teen lit and media, the girl who has it going on in the traditional sense is nearly always cast as dull and one-dimensional; the (still hot) Troubled Girl likes cool music and does cool things and attracts cool boys.

See: Vanessa in Gossip Girl. See: Ramona Flowers in the Scott Pilgrimuniverse. See: Mimi in Rent.

Unfortunately, the Sexy Tragic Muse must also look a certain way to be fully realized. The specific traits of such a character are rote and easy to identify. This character is:

— Thin (always and in the extreme; it is very necessary that she be thin)
— White (always except in the very rare occasion when she is a hyper sexualized, exoticized non-Black woman of color)
— A user of something (coffee, cigarettes, alcohol, drugs, all of the above, especially if it fuels the aforementioned thinness)
— Hot (necessarily)
— Modified in some way (tattoos, piercing, unnatural hair color)
— Unwell in some way (that must be somewhat sexualized, as well, like depression, bipolar, a restrictive eating disorder, addiction, or cutting; more on this later)

This was, in essence, a trap for every single thing I prized the most as a teen. I wanted to be smart. I wanted to be desired. I wanted to be thin. And I wanted my chaotic inner life to make sense among all of it.

This is the ultimate, dangerous trap of the Sexy Tragic Muse or Troubled Girl ideal — it creates space for people in pain where there’s no other space and allows them to hang on to it with both hands. It’s a map for depression and eating disorders and anxiety and substance abuse and hurting.

The Sexy Tragic Muse must also look a certain way to be fully realized.
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When the currents of overwhelming emotions that beat inside of you like a second pulse are sexualized and made to match with other cultural values—attractiveness, the ability for a woman to be a kind of Swiss Army knife, the impacts of rape culture as Not That Bad—that are difficult and toxic, you may find yourself bound up in your pain like the shell of a moth affixed to a web.

It’s not only understandable that a young person would identify this trope, it’s practically a given.

Unfortunately, we have yet to develop a way to grow out of it or beyond it. Sexy Tragic Muses aren’t depicted with a path to a healthy life. They tend to fade away, or live Sadly Ever After, or die.

Here’s the honest truth about life as a Troubled Girl: It’s not really a way that a fully-realized human being can be, and it’s certainly not a way that a person who is loving and caring and helpful and effective can be. But when you identify so thoroughly with a one-dimensional idea of a person, you begin to fear than your other dimensions are boring or undesirable or otherwise repellent in some way.

My body and I have been at odds for some time now, and like a lot of people who have lived with an eating disorder, I’ve gone through fits and starts when it comes to getting better. I’m a pretty firm believer that, a lot like living with mental illness, there’s no such thing as being “cured” entirely. However, there is the possibility to get better.

In the last few months, I’ve been taking a hardcore stab at it. Again. And it’s going well—I’ve got my meds and my mental health apps and my exercise routine and my healthy diet all hammered out—except for the fact that every single day, I still have to remind myself that I don’t want to be the Troubled Girl anymore.

The Sexy Tragic Muse represents a lot of things we collectively covet (thin, hot) but her traits are also specifically, systematically designed to keep her from becoming anything more than human. When we sexualize and revel in emotional pain, we all but ensure that the people who live with it can never experience anything else.

Here’s the honest truth about life as a Troubled Girl: It’s not really a way that a fully-realized human being can be.
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The Sexy Tragic Muse is not a good friend or partner. She’s not good at her job. She’s not a productive community member. She can’t be, because, by definition, she’s unwell and able to do anything but emote and maybe fix a sad boy’s heart or give a nice boy a chance to redeem himself.

Though I hit the peak of my Troubled Girl status a decade ago, it’s still evident that these ideals are pervasive. A recent series of advertisements for the startup Fiverr make it clear that the idea of being unhealthy as a point of pride is still alive and well, even if it looks a little less emo than it used to.

This is the pernicious nature of tropes like the Sexy Tragic Muse, which all but demand a certain kind of weakness (hunger, exhaustion, reduced lung capacity due to cigarette smoking) to portray strength or beauty or desirability. The Sexy Tragic Muse might look a little different in Silicon Valley—call her the Sexy Tragic CEO or the Sexy Tragic Founder or the Sexy Tragic Gig Economist—than she does on a college campus, but the idea is the same and it’s one that is designed to be limiting.

These tropes are seductive; they create thought patterns that are difficult to shed and easy to take advantage of. But this is a choice that I’m making (and in part, I’m writing it for accountability, so welcome to my process).

In order for me to be my healthiest self, I have to be okay with shedding the trope that has kept me from getting better by encouraging me to stay within dangerous parameters.

And I suspect I’m not alone.

There’s too much tragedy in the world to create more for the sake of sexiness.There’s plenty of sadness in the air to wear it like perfume. There’s too much trouble in me already to cultivate more for the sake of an imaginary ideal meant to keep me simple.