Is a sliding fee scale unethical?

Ambox scalesBack in 2008, the American Counseling Association not only advised against using a sliding fee scale, it went so far as to call sliding fee scales “discriminatory.” As David Kaplan, the ACA’s Chief Professional Officer, put it in this 2008 article:

“You aren’t charged according to income in a physician’s office, at the grocery store, at the gas pump or at the dentist. […] A sliding fee scale charges people with larger incomes more for the exact same service that is being provided to clients with lesser incomes. Along those lines, it has been argued that a sliding scale can come across as gouging — that you are looking to squeeze as much money as you can out of an individual.”

While there are some problems with the specifics of that statement (we have a complex healthcare bureaucracy that ultimately does leave individuals paying vastly different amounts at the physician’s or dentist’s office for the exact same service), it’s hard to argue with the underlying principle. If you use a sliding fee scale, you’re taking more money from people who can better afford it, when providing the same service.

Calling this discriminatory makes sense in the context of ethical codes that prohibit discrimination based on income. It would be blatantly unethical to charge clients differently based on their race or sexual orientation, for example. Income (or, more broadly, socioeconomic status) is one of those areas protected in most non-discrimination clauses, so charging clients differently based on income does appear to put a therapist at risk of being accused of discrimination.

At the same time, this is the kind of issue where we need to zoom the lens out a bit and consider what the whole point is of having a professional code of ethics. It codifies (and thus makes enforceable) a shared set of values for those in a profession. One of the core values we seek to uphold as therapists is that of Justice. Reducing fees for those less able to afford them certainly can be in keeping with this value. While a sliding fee scale risks being exploitive of those with wealth if the scale slides too far on the high end (“Oh, you make $250,000 a year? Your fee, let’s check the chart here… is one thousand dollars an hour”), a scale that comes down on the low end of client incomes does not exploit the wealth of better-off clients or otherwise seem morally problematic.

The ACA acknowledged as much when it updated the ACA Code of Ethics in 2014, adding in standard A.10.c:

“In establishing fees for professional counseling services, counselors consider the financial status of clients and locality. If a counselor’s usual fees create undue hardship for the client, the counselor may adjust fees, when legally permissible, or assist the client in locating comparable, affordable services.”

Interestingly, the APA and AAMFT codes of ethics don’t include similar provisions, meaning that psychologists or MFTs using a sliding fee scale still might technically be discriminating. But that’s an imperfection in how we’ve set up the codes, and I can’t imagine any of these organizations intend to prohibit sliding fee scales. To do so would miss the forest for the trees. Sliding fee scales uphold the values we aim to uphold as mental health professionals.

(The NASW code doesn’t include socioeconomic status or income in its non-discrimination clause, making the argument moot for social workers. Even if a sliding fee scale is discriminatory, that form of discrimination is not prohibited.)