Hospitals in Rhode Island also all offer free care to everyone whose income is up to 200 percent of the federal poverty line, and a sliding fee scale for people between 200 and 300 percent of the poverty line. The details have to be posted at each hospital, and the forms to qualify are provided at discharge.

The policies apply to emergency care and are extended to care provided if the patient is admitted to the hospital, says Edward J. Quinlan, president of the Hospital Association of Rhode Island. For elective procedures, on the other hand, hospitals may not be so generous, although, Quinlan says, when patients need care, the main restriction of hospitals is to only offer charity care to patients from their service area.

Like the health centers, however, hospitals are struggling to meet the needs of a growing uninsured population, he says.

"The changes we've seen in this area significantly pre-date the Wall Street situation," Quinlan says. More and more patients are uninsured, more and more are getting charity care, and more and more are failing to pay their hospital bills, he says — hundreds and often thousands of dollars' worth each.

For a state that prides itself on its mental-health parity laws, and whose congressman — US Representative Patrick J. Kennedy — is a national leader in this field, Rhode Island falls really short when it comes to providing mental health care to the uninsured and the poor.

There's not a local therapist who won't take a cash-paying patient; in fact, some local psychiatrists won't take insurance, because the pay is too low. But paying out of pocket is expensive: $75 or more, typically, for an hour with a social worker, higher for a psychologist, and $250 or more for a psychiatrist.

Primary-care doctors, of course, can prescribe antidepressants and other psychotropic drugs, but mental health experts strongly recommend that anyone on medication also go for talk therapy, to learn coping skills, deal with traumatic experiences, etc.

Community mental health centers offer a safety net, but it's limited. Dale K. Klatzker, president and CEO of the Providence Center, the largest provider in the state, says his team can't serve all the uninsured, so they focus their resources on the neediest people, providing both mental health and substance abuse treatment for free or at a minimal cost.

The Providence Center alone provides about $2 million worth of charity care each year, he says, much of it to "people who literally have nothing," but both city and state support has been declining, Klatzker says. "It's kind of the worst-case scenario, because they're cutting us at precisely the same time that there's more and more need, which is perversely going to drive people to not get care when they need it and end up in the emergency room."

While Klatzker's biggest worry is what will happen to the poorest Rhode Islanders who need help, he acknowledges that the outlook for people with a bit more money — the self-employed, the newly unemployed, and those who can't get employer coverage — is bad, too.

Quite simply, there's nothing for that population. "If you have no resources at all," he says, "you're probably better off than someone who has some resources."

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