How America’s broken healthcare system fails abuse survivors
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Welcome to Code WACK!, your podcast on America’s broken healthcare system and how Medicare for All could help. I’m your host, Brenda Gazzar.
How does our health insurance system meet the needs of domestic violence victims? What obstacles do survivors of abuse face when it comes to getting and keeping health care? We spoke to Michele Hamilton, who’s been a counselor, and advocate for survivors of domestic abuse and sexual violence since 2004. She’s also a board member of Health Care for All Pennsylvania. The views expressed are her own and do not represent her employer.
Welcome to Code WACK!, Michele!
Q: What have you learned about our health insurance system and how it affects those who have experienced abuse through your work as a counselor?
Hamilton: So, through working with people in shelter, I learned a whole bunch of different things about health care. The primary thing is that we’re a very siloed state in terms of different types of health insurance in different types of places. Our big three are Geisinger Health Insurance, UPMC, which started in the west of the state and is pretty much taking over the whole state. And I think there’s another one called AmeriHealth but they often look very different in different counties.
So often, for example, someone would flee into our county from another county for a variety of reasons. For example, the abuser might know where the safe house is in another county, or there might be friends or relatives that can help the person that lives in Centre County. Maybe they can’t permanently house the person because they’re on public housing, or because of how their lease looks but they’re able to provide other types of supports. So people sometimes come into different counties from different places. And there would be difficulties in obtaining health care. So we have what we call a base service unit and the base service unit is mental health, intellectual disabilities, early childhood intervention, but they’ve prioritized people who are considered “in county.”
So if you’re coming from other counties, that could be a barrier to those types of services, and not having those types of case management services set up can really hurt you with your goals, whatever your goals are. Another thing that would happen with survivors, is say that you are on your abuser’s insurance so when you decide to end that relationship, or they decide to end the relationship because sometimes when they want to move on, they will leave you with nothing. That also means that you don’t have health insurance because one of the first things that most abusers do is they turn off anything that they were helping you with. Your phone gets turned off, and your health care gets turned off, too.
Q: Wow. What other health and insurance challenges do survivors of abuse face?
Hamilton: A lot of survivors do have health problems. A lot of survivors have post traumatic stress because this may not be the first, second or even third abusive relationship they’ve been in. They might also be dealing with sexual trauma or with past trafficking issues, or with even what we call adverse childhood effects from things that they dealt with in childhood. PTSD is a big issue. Access to alternative sort of medicines is a big issue.
There’s also a lot of issues with setting up health care for younger kids if there are children who come in from another county or setting up new things, if you exit out of the county. So Centre County is an expensive county to live in and sometimes, our survivors realize that even though Centre County has a lot of great things, it’s financially, in terms of rent or mortgage, easier to try to find housing, in one of the six counties that surround us that may not have as many resources, but also have more public housing and lower rents, so then they have to think about getting all kinds of healthcare things for themselves and for their kids and then this doesn’t even count older survivors.
Q: Do you have a story you can share that illustrates some of these issues?
Hamilton: Once I worked with an older survivor who also had an intellectual disability and part of the thing that we had to think about in terms of a potential housing plan was the fact that even though she had family in a different county, it would be so difficult to set up all the supports that she had in this county. It’s not guaranteed. Money doesn’t follow the person, basically, except for I think one or two diagnoses that you can have. And so one of the things she had to realize is even though she had family in another county that can be emotionally supportive, she may not be able to set up all the supports that she needed in that county, at least in a time efficient way because there’s different carriers to different counties. And you don’t have a case open here and all this stuff.
There’s also a discussion of just the physical toll of domestic and sexual violence on people. So for example Pennsylvania Coalition Against Domestic Violence has recently been looking more at traumatic brain injury history. I don’t want to say domestic violence leads to it but there can be a correlation sometimes between domestic violence, and a possibility of getting a TBI, if you are in a physically abusive relationship where there is strangulation, where there has been choking, hitting around the head or the neck area, but also a lot of times survivors in the relationship really don’t have the time to take care of their health the way they should.
Q: Interesting. Why is that?
Hamilton: They are trying to take care of their children’s health or other family members’ health, and also to be honest, the perpetrator does not allow them the time to take care of their health. Perpetrators for example might be the ride to a doctor’s appointment and if they are in an abusive cycle, decide to control the person by, “I’m not going to take you to your appointment” or “I’m not going to take you to get your pills” or “I’m not going to get your pills for you if you can’t get them” as a way of sort of controlling the situation and showing dominance. And then how that plays out is that, at least in PA, if you are on certain assisted programs, and you miss a certain amount of appointments, you then can be kicked down the list, you know what I’m saying?
Q: Yeah.
Hamilton: So sometimes the abuser does that purposefully because that’s one less point of contact the survivor has that can point out, or see that there’s potential trauma going on. So sometimes it’s very purposeful. It might look like it’s out of control. But it’s not meant to be out of control. If the abuser suspects that a caseworker or a doctor is seeing signs of abuse, they may want to cut that point of contact off. Some of it is just to show that I can control certain aspects of your life, including your health care, but sometimes it’s just that a survivor might feel so worn down that they have not had the opportunity to make a dentist appointment or a health appointment for themselves, because they are just dealing with depression from being in an abusive relationship or feeling like it’s taking so much effort to just get through the day, go to work, take care of their kids, take care of other family members and communities and to constantly trying to see what’s going on in the abuser’s head.
Q: What about young adults or college students who get health insurance through their parents’ plan until age 26? Do they face special challenges when it comes to issues of domestic violence?
Hamilton: While a goodly amount of students are covered by their parent’s insurance, until they’re older, and that’s a positive part of the Affordable Care Act, the negative, is that if there is sexual assault or domestic violence than the parents might get that bill and that might not be something that survivors want their parents to know about. And I know that can be hard to hear because parents would want to know. But it can then keep them from getting some of the treatments that they need. Insurance, in and of itself for these young people, is so expensive, and that’s not even counting international students that have to come with their own everything, because they cannot, like if you’re an international student, you have to pay for your own everything pretty much because you do not have access to the assistance office the way a resident of PA does. I actually don’t even know how that is working out for them but it does sort of potentially keep survivors of demostic violence and sexual assault on college campuses from possibly getting some of the treatment that they need.
So, basically what’s needed is a system where people have their own insurance — insurance that is not tied to a partner, insurance that’s not tied to a parent. And even though I’m very fortunate to work in a job that pays for my insurance. It also means that we are sort of tied to our jobs. And sometimes when I talk to people about that, the reality is, if I wanted to leave, COBRA is about $600 to $700 in PA. COBRAs are an insured person sort of insurance thing and it’s $600 to $700.
So, you either need to be uninsured, unless you can get another job that’s paying for your insurance or you just pay that $600, or you’re uninsured and you just hope that nothing happens to you, like a pandemic. It’s just like a lot of things and the more that I’ve seen these things, the more that I’ve realized that really what we need is universal health care.
Thank you, Michele.
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