“Making a Bill” in Search of Health

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The Poorest, Sickest State

Mississippi is the U.S.’s poorest state and has the lowest rates of insurance coverage. Mississippi also has very poor health outcomes including the highest or second highest rates of cardiovascular disease, diabetes, and age-adjusted death rate due to cancer (Mississippi State Department of Health 2014). These rates are nothing new and Mississippi has a history of health disparities that stretch back to the Depression and beyond. In spite of this, the Affordable Care Act has had little impact on the nation’s poorest, sickest state. Mississippi opted out of the Medicaid expansion, which left 138,000 Mississippians, most of whom are African American, without any insurance options (Kaiser Health News 2014). Refusing the federal subsidies has increased the burden on rural hospitals, forcing some to close entire departments and lay off staff.

During the course of my thesis research on health seeking behaviors of the working poor, I defined a cultural model that primarily included the usage of safety net providers, delaying treatment, or “making a bill,” which I will discuss more in a moment. Participants were particularly open about the competing demands for resources that have to be weighed before they decide to seek health care, like whether to pay for groceries or a doctor bill. Some participants were very frank about having to go without in order to go a doctor. One participant talked about sacrificing food so they could go see a dentist, in her words, “One thing has to take the place of the other.” When seeking health care requires making such sacrifices… it’s not really fair to characterize it as a choice, but, for lack of a better word, I will now discuss the “choice” between delaying treatment or making a bill, something that the working poor frequently brought up during interviews.

Delaying treatment or “Making a Bill”

With few good options for affordable health care the working poor openly discussed delaying treatment so they could avoid “making a bill.” By making a bill, what participants were literally referring to was the creation of a new monthly bill. For the working poor, seeking health care outside of the free clinics is almost synonymous with the creation of a new long-term payment commitment. Participants discussed waiting until it was unavoidable to go to the doctor’s office or the ER/ED and “make a bill.” While they were speaking literally, this language also indexes to others their place in society and the tough decisions that the poor are faced with every day including those concerning their health and those of their family members. money-256312_960_720“Making a bill” indexes a position in society that is deemed unworthy of access to affordable health care. During the entire course of fieldwork and interviewing, not one participant said that a doctor’s visit would mean emptying their savings or bank account. A few participants mentioned borrowing money from family or friends, but “making a bill” was the more likely outcome. When asked if some people without insurance don’t seek health care when they are sick, one participant said:

Yeah, cause they can’t afford it. Sometimes before you can be seen they need money and you don’t have it cause you need it for groceries or to pay a bill. They pray to get well. They try to do a home remedy, try to get better on they own. Get on their knees and pray to God to get better.

This was not an uncommon response. When another participant was asked what he did for health care, he said:

If I ain’t got no money, if it’s an emergency, then I just have to charge up a bill and make a payment. […] I do anything to not get sick. That’s one thing about being a small business owner, no insurance. […] I primarily use the free clinic. I have medical bills right now. I try to pay them off. I’m a small business owner. I want a good credit rating.

This participant ran a small food cart and needed a good credit rating so he might expand his business in the future. He was one of a handful of participants who brought up credit ratings. The very real possibility of not being able to make consistent payments was yet another consideration for the working poor when deciding whether to seek medical care. Treating even relatively minor acute illness episodes could turn into years of monthly payments making it increasingly difficult for the working poor to make ends meet and to afford future health care costs.

This intersection of culture and biology finds the working poor making decisions based on financial needs in the moment that have repercussions for their long term health. The participants and providers I worked with indicated that outside of the free clinics, health care for the working poor came at cost they were ill able to afford out of pocket. When delaying treatment became unavoidable, they reported that “making a bill” was the only option. A circumstance which has become so normalized in this community that there is an effective shorthand for simultaneously conveying the situation they found themselves in and the outcome of seeking care.

It is important to note that the link between delaying treatment and poor health outcomes was not lost on patients or providers, but no one knew how to break the cycle within the current health care system. Medical and non-medical participants alike discussed changing the system. They were frustrated with a system that seems to be working against the working poor at every level of health care. One doctor told me that the hardest part of his job was getting people the care they need but can’t afford. Affordable health care for the poor seems to be continually out of reach.


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Biocultural Systematics is written by members of the University of Alabama Biocultural Medical Anthropology program.

Avery McNeece is a doctoral student in the department who has conducted research in northeast Mississippi.

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