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Cam Montgomery was a bartender at a hotel in Seattle when the sky fell. As Covid-19 swept through the city, King County purchased her employer’s hotel to accommodate hospital overflow, and Montgomery lost her job. It was a twofold blow: Like millions of other newly unemployed Americans, she lost her health insurance, too.
She endured a mind-numbing gauntlet of phone calls with insurance companies and state agencies only to receive contradictory information. The Medicaid system listed Montgomery as enrolled in insurance through a prior employer. She had to get a formal letter from her former insurance provider to prove that her position and benefits had been terminated, which led to a five-week coverage gap. Without insulin for her Type 1 Diabetes, she was forced to take out a $550 loan for a month’s worth of medication.
Making matters worse, she also ran out of her psychiatric medication. “This pandemic is a traumatic experience in and of itself,” Montgomery told me. “But to add the imbalance of an unmedicated person struggling with anxiety, depression, and panic disorder is something else entirely. It takes trauma, hooks it up with some jumper cables, and shocks your system beyond its limits.”
Once Medicaid coverage took effect, she could start taking her Wellbutrin and Zoloft again: “I’m back on my meds now, but I’m still feeling the effects of those five weeks.”
Montgomery isn’t alone. Since Covid-19 hit the United States, roughly 16.2 million workers have lost their employer-sponsored health insurance, according to an estimate published by the Economic Policy Institute. And like other impacts of the pandemic, the cost hasn’t been borne equally: Black women have been twice as likely to lose their jobs or income as white men.
Right now, an estimated one in 10 Americans is struggling to afford coverage and medications, and about 16 percent of Americans take a psychiatric medication. That means somewhere between 2.5 to 5 million people are having trouble accessing the psychiatric medications they need.
Even under normal circumstances, such a sudden lack would be a public health crisis. But the pandemic, as Montgomery pointed out, is triggering in itself. During March, the Disaster Distress Helpline, a government-run counseling hotline, witnessed a 338 percent increase in call volume compared to February. Researchers in the UK recently published a review article that examined how quarantined people exhibit post-traumatic stress symptoms, sometimes for years after lockdown. They reported that after a long period of isolation, individuals often have difficulty securing medical care and medication and suffer financial losses that contribute to suicides, insomnia, fear, confusion, anger, frustration, boredom, and stigma. (The authors are clear to note, however, that their review is not intended as a critique of quarantine as a necessary tactic to slow the spread of a lethal disease.)
Some, like 24-year-old Caitlin Damm in Wilmington, N.C., are anticipating calamity. Damm’s mother was abruptly fired prior to the pandemic after receiving her first disciplinary infraction in seven years. Then Damm lost her job at a family-owned restaurant that closed during the shutdown.
With her insurance, Damm’s four prescriptions for depression and anxiety cost about $30 a month, but without it they would cost hundreds. “When we lose our insurance—boom. No more medication,” Damm told me. “We need these medications, and even if we didn’t, detox or withdrawal from medication is essentially hell and will last no less than two weeks.”
Damm described her stress level as “sky high,” but said her mother is suffering more. “She has never been diagnosed with any mental illness, but is getting more and more depressed every day,” Damm said. “She feels no one wants her, because she can’t get a job. It’s affecting her so much, and I can’t seem to help her at all.”
Damm and her mother live in a $900 a month one-bedroom apartment, which Damm said was already a financial strain. They’re enrolled in North Carolina’s Health Choice program, a government assistance plan. Two-person households qualify if they have an annual income roughly between $23,000 and $36,000. Once Damm and her mother report their new, lower annual income, they will have a salary below that threshold, and as Damm put it, they will be “too poor for government help.”
Before Covid-19 hit, 500,000 North Carolinians fell into the coverage gap Damm describes, earning too little for Health Choice but being ineligible for Medicaid. In North Carolina, only dependents or people who are blind, disabled, or pregnant can access Medicaid. Lower-income mothers, for example, can enroll their children but not themselves into Medicaid. The Republican-controlled legislature in North Carolina could have easily closed this chasm: For a decade, the state rejected billions of federal dollars to expand Medicaid coverage under the Affordable Care Act.
In January, a coalition of self-described conservatives drove six hours to a legislative mini-session in Raleigh to urge Republican congressional leaders to adopt expansion measures, but Republicans had already left by the time their constituents had arrived. In a press conference, Senate majority leader Phil Berger told reporters that none of the Republicans in his chamber would be willing to vote for a Medicaid expansion bill. Thirteen other red states—including Alabama, Texas, Florida, and Georgia—have yet to expand coverage to include its working poor.
Although decent health coverage has been an eternal problem in the United States, the government and medical professionals’ mental health care recommendations assume people have unbroken access. Kaiser Permanente, a health care conglomerate, says, “No one should ever stop taking antidepressants suddenly. An antidepressant should be tapered off slowly and only under the supervision of a health professional. Abruptly stopping antidepressant medicines can cause side effects or a relapse into another depressive episode.”
Withdrawal symptoms can be serious: They can include depression, dread, shock-like sensations, visual trails, anorexia, flu-like symptoms, gait instability, vomiting, insomnia, rushing noises, numbness, and dizziness, and typically last up to six weeks with a subset lasting 12 weeks. Abrupt discontinuation and dosing changes significantly increases the risk of suicide.
To maintain dosing consistency, some have relied on GoodRX, a company that boasts “saving” Americans $14 billion by selling generic medications at a lower price than insurance companies. Why is GoodRX able to offer such prices? In part, according to Consumer Reports, because the company has been sharing consumers’ personal data, including the name of medications searched and whose laptop or phone was used for searches to Google, Facebook, and marketing companies. (The company has since said it will provide users with an option to delete their data.)
A 25-year-old woman living in Florida, who prefers anonymity, told me that she relied on GoodRx for anxiety and depression medications that she has taken since her teenage years: “I truly need this medication to help me function.” Prior to finding a healthy balance with medication, she was self-injurious, nearly anorexic and hospitalized.
After she left a job she described as “emotionally draining and borderline abusive” this winter, her health care coverage was precarious. Her former employer was supposed to provide information related to the Consolidation Omnibus Budget Reconciliation Act, known as COBRA—a law that allows people to keep their health insurance after a job loss but only if they pay for it, which makes it notoriously unaffordable. Her old company, however, failed to send the paperwork until the day her insurance expired. “I was very anxious and a little panicked when they didn’t send the COBRA info until the last moment,” she told me. “I was worried about affording my medication, and [as I have anxiety] I was going through the ‘what-if’s’ like what if I got into an accident and had no insurance, what if I got sick, what if I broke a bone. The company kept telling me to stop worrying about it and that they’d get to it.” She wound up paying for short-term insurance that barely covered the necessities.
In January, she landed a job as a speech therapist for children with disabilities at a private practice and was set to receive health care after three months. Phone appointments with her psychiatrist during lunch, necessary for obtaining prescriptions, cost $120. For a 30-day supply, her anxiety medications cost $142 and antidepressants $28. Through GoodRx, the cost reduced to $44 and $26 respectively.
These payments weren’t ideal, she acknowledged, but she had assumed her coverage would begin once she hit her three-month mark in early April. Then the coronavirus hit, and she was furloughed on March 20. Around the same time, her landlord informed her that she would increase her rent in July. She had to move. Since Florida’s unemployment website was overloaded and inaccessible, she couldn’t afford the cost of therapy or medications, so without supervision, she decreased her doses from three times a day to one or two.
“There are some nights where my anxiety keeps me up, and some days that I don’t want to get out of bed,” she said. “However, I’d rather have a little bit harder time everyday than have several miserable days or weeks without any medication.” Without her medication, she told me, “it’s harder to reframe my thoughts and gain control of my anxiety.”
The impact of the virus and subsequent lockdown on our mental health is not entirely avoidable. But the domino effect of sub-crises—the abysmal health care system in the United States, financial hardship, and even the root causes behind why many of us are so miserable—are often socially and politically constructed.
For many people, jobs are the main source of misery in their lives. One woman who takes antidepressants described how corporate America left her feeling like an “unfulfilled pawn.” Another attributed her anxiety disorder to her work. There’s a cruel irony in America: People are trapped in miserable jobs to maintain health care coverage needed to treat the depression caused or exacerbated by their employment. And without work, financial hardship—also a source of depression—sets in.
With a suicide rate that increased 33 percent from 1999 to 2017 and skyrocketing rates of depression, universal health coverage is a crucial step in transforming a society wracked by crises.