How Do You Set Your Rates?
Shared wisdom on the Sliding Fee Scale
& Business Practices for Economic Justice
Why research the sliding fee scale?
Under a newly warmed sun, two healing justice practitioners from the People’s Movement Center - Ihotu Ali and Griffen Jeffries – met on a spring afternoon in New York City, chatting about the joys and pitfalls of the Sliding Fee Scale. We personally knew the difficulties of this “Pay What You Can” model - the risk and reality of burnout, of feeling abused and growing resentful, of subtly, unintentionally even, offering lower quality care to lower income clients. We also knew of practitioners across the country who had developed, borrowed, and tweaked their sliding fee scale language and policies to serve both clients and practitioners sustainably and abundantly – each in their own unique ways.
And so, we thought it could be helpful to crowdsource our collective experiences, share lessons learned, and merge our spring afternoon conversation into existing and public conversations about the sliding scale and economic justice – and in context with indigenous economic philosophy, the Black Panthers, community acupuncture, radical herbalists and beyond. But let’s start with some background.
Whose practices and voices are we looking at?
This report stands on the shoulders of the work of elders, visionaries for justice who have come before us, and is itself the collective experience of over 50 practitioners surveyed or verbally interviewed over several weeks. We sent a 10 question survey to colleagues mostly in Minnesota and New York (where Ihotu and Griffen are based), many sent it on to others across the United States and Canada, and we were blown away by the response and enthusiasm for this project.
Not all, but most of the practitioners surveyed had an active sliding scale, and spanned healing justice practices including educators and organizers, writers and artists, doulas and midwives, massage therapists, herbalists and acupuncturists, family therapists and spiritual healers. Roughly 65% of practitioners identified as women or femmes, 25% as cisgender, 20% as transgender, 20% as non-gender binary, and many others as queer or two spirit. Other identities were mentioned such as mother, trauma survivor, disabled, chronically ill, artist, Christian, pagan, and liberal progressive Democratic socialist.
60% of practitioners were white, 10% black, and others mentioned identities including Indigenous, Native, Latinx/Xincanx, African-born, Mixed, Jewish, and Appalachian. 30% identified as being in the middle economic class, 30% in the lower class, and a handful in upper class, though many related to a mixed, cross-class identity – feeling in between lower, middle and upper class – many as first generation college students who had experienced upward mobility.
What is a sliding fee scale, exactly?
It seems simple, right? And most practitioners mentioned similar values and concepts of “pay what you can”, “pay it forward” or “no one turned away.” But as far as what exactly this looks like in practice – we broke this down into a few main camps:
Most of these sliding fee scales were public, mentioned on websites and new client forms, and accessible by any client, with no proof of income required. A few practitioners chose to make their sliding scale private, by request only, for indigenous and people of color only, and a few others requested some proof of income or asked for budget totals or budget lines before offering their scale prices.
For some, their sliding scale was simple, with no additional structure or limits - an open discount off of their market rate - “Choose your price between $0 and $100” - for example, for a product valued at $100.
For others, lower limits were set such as “Choose your price between $75 and $100,” or specific suggested rates were given for tiers of income level or budget size - “Chose your price among these options: $75, $100, or $125” or according to a worksheet where rates are mapped to ranges of income.
Many practitioners mentioned using a sliding scale as a way to “discount” their services, while another handful insisted it is not a discount! Rather, if you are able to tap partially into a wealthy market, you can receive more income than needed, which subsidizes your lower income clients. These few placed the market value of their product at the middle of their scale, with upper and lower limits well above and well below, for example “Choose your price between $175 and $25” for a product valued at $100.
*A note here, that each of these models asks both practitioner and client to stretch the limits of their generosity and humility to different lengths. Practitioners suggested checking in FIRST with their own budget, any anxieties or hangups around money, and honest feelings toward clients based on how much or little they chose to pay. Identity and privilege also shaped their access to different income markets – practitioners with more access to privilege or additional income streams mentioned an easier time sustaining and feeling financially comfortable with flexible, and especially higher pricing.
Are our models rooted in indigenous practice & relational economies?
No matter which model we choose, the goal for many of us is to create systems that move us away from a market economy of haves and have nots, to what author and scientist Dr. Robin Wall Kimmerer calls a Gift Economy - where common wealth is shared, and we give and take based on need and on relationships and a sense of abundance, rather than a number and sense of scarcity:
“I dreamed not long ago of [a] market with all its vivid textures. I walked through the stalls with a basket over my arm as always and went right to Edita for a bunch of fresh cilantro. We chatted and laughed and when I held out my coins she waved them off, patting my arm and sending me away. A gift, she said. Muchas gracias, senora, I replied. There was my favorite panadera, with clean cloths laid over the round loaves. I chose a few rolls, opened my purse, and this vendor too gestured away my money as if I were impolite to suggest paying. I looked around in bewilderment; this was my familiar market and yet everything had changed. It wasn’t just for me - no shopper was paying. I floated through the market with a sense of euphoria. Gratitude was the only currency accepted here. It was all a gift. It was like picking strawberries in my field: the merchants were just intermediaries passing on gifts from the earth.
I looked in my basket: two zucchinis, an onion, tomatoes, bread, and a bunch of cilantro. It was still half empty, but it felt full. I had everything I needed. I glanced over at the cheese stall, thinking to get some, but knowing it would be given, not sold, I decided I could do without. It’s funny: Had all the things in the market merely been a very low price, I probably would have scooped up as much as I could. But when everything became a gift, I felt self-restraint. I didn’t want to take too much. And I began thinking of what small presents I might bring to the vendors tomorrow… The relationships became as nourishing as the food I was getting. Across the market stalls and blankets, warmth and compassion were exchanging hands. There was a shared celebration of abundance for all we’d been given. And since every market basket contained a meal, there was justice.”
- Braiding Sweetgrass, 2013
There is also immense wisdom and academic theory around solidarity economies, worker-owned cooperatives, and alternative systems and structures for equity. We didn’t directly ask practitioners’ political views, but it may be helpful to consider the role of our practice in a larger economic context.
Are we in any leadership positions in our community to promote, explain, or reinterpret broader equity practices such as land trusts, community gardens, credit unions, collective houses and more?
How could being in a more equitable economy support our business as well as our sliding fee scale?
Solidarity NYC, 2019
What prep work is helpful to create a sliding scale practice?
Most practitioners did research for their sliding scale model, through books on progressive or class politics, videos, documentaries, talking to mentors in their communities, visiting other practitioners’ websites to compare rates and sliding scale policies, and more. Acupuncturists in particular mentioned the radical history, connections to the Black Panther and Young Lords, and sliding scale model provided by the People’s Organization of Community Acupuncture (POCA) and its hundreds of clinics across the country. Feel free to check out the Resource List at the end of this article with dozens of resources shared from the practitioners.
Some set their rates based on what they found was the most common rate already offered in the market for that service. Others started with the concept of not just a bottom line or break even number, but an “Enough Number” - how much is needed to have basic needs met (including health insurance, caretaking work, mental health support, exercise and healthy eating, vacations, sabbaticals, but without moving into greed and excess) - and set their rates based on what they require as a basic minimum wage.
Some mentioned it helpful to reflect on one’s own “Money Stories” - family and ancestral history, experiences, and feelings toward money, abundance, and scarcity. Some found it supportive to practice talking about money with friends and strangers while staying confident, grounded, and humble – especially given that in the United States we can be easily triggered, embarrassed, defensive or judgmental around having too little, or too much money.
What are common ways to structure rates and ranges?
As we mentioned earlier, many practitioners use an open “pay what you can” structure, where the product value is stated - i.e. $1000 - but clients can choose any price to pay, down to $0. Many also mentioned over time, adding bottom limits, suggested prices per income or budget size in order to guarantee a minimum amount of profits. Some pricing ranges were on the wider side - i.e. $500-$1200 for birth doula services - while others stayed fairly narrow - i.e. $175 to $200 for a therapy session.
A couple practitioners mentioned the game-changing value of having access to an outside fund that could pay practitioners and make up the difference for very low income clients who couldn’t afford even the bottom limit of their sliding scale.
People spoke to the financial unpredictability and trust required for this work. Entrepreneurship always involves risk, and business owners tend to know when are their high profit and low profit seasons throughout the year - for example, the holidays are a high profit season for retail, as opposed to the dead of winter. So having a backup plan for that month when all your clients are very low paying clients is helpful. One common strategy mentioned for this was diversifying income streams - “mixed income marketing” specifically to both low and high income communities, or offering additional services (not sliding scale) that have reliable profits. Some practitioners had a spouse or partner who could support them financially during seasons when their sliding scale business
One practitioner shared that “all salaried full time work is an illusion of security” and that having “side hustles” - even unpredictable flows of income - ultimately gives you more security. She added - “I also believe in the law of attraction, and that God wouldn’t do me like that.”
How can I communicate my vision to clients, and handle challenges along the way?
Most practices did not ask for proof of income, and many shared powerful and creative language and images to assess one’s place along the sliding scale and determine between nuances such as fear of vs. actual hardship, or perceived, relative or chosen low income vs. poverty. Check out the Green Bottle by the brilliant Herbalist Alexis J. Cunningfolk (feel free to use this image and credit Alexis!), or language and imagery below from a bodywork practitioner, from Third Root Community Health Center in New York City (also see their worksheet), and Ride Free Fearless Money Blog:
Please thoughtfully consider the value of this service to you, your current level of income (no proof required), and your ability to support a fair price for fellow community members in need.
Are you in a place of abundance where you can hold and nurture others today? Do you deeply need to lean on others today and recharge your batteries? The amount you pay may change at each appointment. This sliding fee system follows the principles of health insurance, where the healthy help to subsidize costs for the sick, and this allows both equal access to services and sustainable pay for the practitioner. Thank you for making the countercultural choice to support this practice!
Sliding scale $75 – 175. Suggested payment for financially stable households with a total income at or above $50,000, including tax and tip: $140 + 11 (8.025%) sales tax + $23 (15%) tip = $174
Some also mentioned the difficulties of identity, privilege, and catering to a mixed income
customer base, via lessons from the Panera Bread Company’s food justice nonprofit, “Panera Cares” and pay what you can cafes around the country:
GONZALEZ: Pretty early on, Cares cafes started telling customers that if they didn't have enough money to pay, they could volunteer for an hour in exchange for a meal, clean under the counters. But in the end, they were not attracting enough generous customers for Panera to break even.
ECKHARDT: What ended up happening is the people who were not food insecure did not want to eat lunch with people who were food insecure.
GONZALEZ: Almost nine years into the experiment, every Panera Cares cafe closed except for the one in Boston. But Ron Shaich still considers the experiment a success.
SHAICH: You've served millions of people over many, many years.
GONZALEZ: The one remaining pay-what-you-want Cares cafe is still losing money. The manager says they cover about 85 percent of their cost. Panera makes up the rest. But Eckhardt says there are more successful pay-what-you-want models, like the ones that make people feel like they're getting a gift.
ECKHARDT: So you think, oh, I've received a gift from someone that I don't even know, and this I-should-repay-that-gift is a very strong instinct inside people, I think.
GONZALEZ: Another thing that would work better - no prices. If you see even a suggested price, Eckhardt says that's the amount you think you should pay. With no price, people actually give more.
Many practitioners mentioned challenging experiences, of course. Some lower income clients repeatedly cancelled or no-showed, and some clients had paid very little or chosen not to tip, and then are found out later on to be extremely wealthy. Practitioners expressed varying levels of frustruation and disappointment that customers were “abusing” the system and in some cases, wealthy customers were more savvy at accessing lower prices, discounts, and packages than low income folks.
Some practitioners felt these were ultimately issues that could be overlooked or improved over time and chose to persist through this - some made changes to their models such as requiring proof of income, raising the top end of their scale, or introducing worksheets to specify payment over income ranges, or more in-depth conversations about relational gift economies or abundance vs. scarcity, sending text reminders to avoid no-shows, or charging a late cancel fee (which could also be waived as needed).
Others chose to remove their sliding scale altogether because of such experiences, or moved into a private sliding scale by request or for certain populations, or offering discounts or packages instead of an open scale.
A few folks mentioned the importance of tracking one’s “Resentment Rate” - or the moment at which you begin to resent a client, either for how little they choose to pay, how late they arrive, their style of dress or level of hygiene, and that it is helpful to ask questions and understand context, notice your tone and body language, raise the bottom limit of your pricing or even refer out to another practitioner, to avoid providing lower quality or toxic care. All clients, regardless of what they pay, deserve equal treatment (and in some cases, particularly in health and healing, practitioners found that those with lower resources may actually require more time or attention to reach the same outcomes as others).
There are also ongoing discussions about the role of money in healing work, whether healers especially in traditional therapies should only accept donations rather than charging a rate, and if it is appropriate to market to higher paying clientele in order to subsidize low income clientele. For those seeking access to wealthier clients, advanced training in modalities with niche markets and referrals from established or well known practitioners seem to be helpful, though runs the risk of over time, subtly catering to and handing power over to high paying clients than to lower income clients, and shifting the focus and style of the practitioner, if not held grounded through community and open dialogue:
"Our keeper of the Gate was known throughout Africa and parts of Europe as a man deeply connected with dimensional beings. People came from all over the world to meet him and to be healed by the spirits through the Gate he was in charge of. Europeans, whose needs were met, gave him lots of money. Error number one – he took it. Soon, he started charging them money for his services – error number two. In the end, only foreigners went to him. Village people, knowing that he had transgressed the law of the spirit world, would go somewhere else for their healing needs. Eventually the spirit abandoned him. He could not open the Gate anymore, nor could he effectively heal anyone… Would-be healers, and sometimes true healers, medicine men and shamanas, have slipped away enveloped by the huge wave of money, making people aware that, in fact, they have lost their power to strangers who want to buy them off."
--- Malidoma Patrice Somé, Ritual: Power, Healing, and Community, 1993
Thanks for reading and exploring this wide range of perspectives and experiences on money, economies, and sliding fee scales with us, in all their colors! We hope this has been helpful to you, your practice, and your clients. Please feel free to share this wisdom with colleagues and friends, add to it by sharing comments, and discover more in the Collective Resource List.
Gratitude to all who have elevated this conversation to this point. Let’s keep it going, and hopefully, generate more abundance for all of us to be nourishing and nourished by our work.
In Solidarity. Ase.
COLLECTIVE RESOURCE LIST
(In addition to what is listed below, people reported being highly influenced by specific individuals, relationships, life experiences, political ideologies and communities, and religions and spirituality)
Books & Articles:
Braiding Sweetgrass: Indigenous wisdom, scientific knowledge and the teachings of plants, by Robin Wall Kimmerer
Ritual: Power, Healing, and Community by Malidoma Patrice Somé
The Healing Wisdom of Africa: Finding Life Purpose Through Nature, Ritual and Community by Malidoma Patrice Somé
The Spirit of Intimacy: Ancient African Teachings in the Ways of Relationships by Sobonfu Somé
My Grandmother's Hands: Racialized Trauma and the Pathway to Mending Our Hearts and Bodies, by Resmaa Menakem
Queerly Classed: Gay Man and Lesbians Write About Class, Edited by Susan Raffo
Thinking Class: Sketches from a Cultural Worker, by Joe Kadi
Emergent Strategy, by Adrienne Maree Brown
Care Work: Dreaming Disability Justice, by Leah Lakshmi Piepzna-Samarasinha
Parable of the Sower, by Octavia Butler
Acupuncture is like Noodles, by Lisa.Rohleder
The Remedy now Fractal, by Lisa Rohleder
Banker to the Poor, by Muhammad Yunus
Where We Stand: Class Matters, by bell hooks
Leadership and the New Science: Discovering order in a chaotic world, by Margaret Wheatley
The Revolution Will Not Be Funded: Beyond the non-profit industrial complex, by INCITE!
White Fragility: Why it’s so hard for white people to talk about racism, by Robin DiAngelo
Freedom Is a Constant Struggle: Ferguson, Palestine, and the foundations of a movement, Angela Davis
Sacred Economics: Money, gift and society in the age of transition, by Charles Eisenstein
Liberation Theology, and Pedagogy of the Oppressed by Paulo Freire
A Radical History of Acupuncture in America, prepared by St. Paul Community Acupuncture
Organizations, Websites & Links:
Third Root Community Health Center and Example Sliding Scale Worksheet
Hadassah's Ride Free Fearless Money
Work by the Black Panthers and Young Lords at the Lincoln Hospital Detox clinic in the 70's http://mutulushakur.com/site/2018/11/acupuncture-interview/
Reclaiming Tradition language on sliding scale:
The People's Movement Center & People’s Fund
Community Acupuncture Network, now People's Organization of Community Acupuncture www.pocacoop.com
Cultural Wellness Center Philosophy
Allied Media Conference Healers
Karma Doula Collaborative and Everyday Miracles
New York City Solidarity Economy
National Public Radio Planet Money: The Pay What You Want Experiment
Reproductive Justice Principles
Design Justice Principles
Queer Birth Project - for gender-inclusive language and trans-aware care
Ahava Birth Works - Cultural Competency and Privilege in Birth Work
Circles of Change - for activists in movement building, exercises on class and our multiple identities
Maternal Mental Health Now - Transgenerational Trauma & Resilience Among Black Mothers
Headwaters Foundation Giving Project - racial and economic justice, fundraising and philanthropy
Social Justice Leadership
SPIRAL Collective Abortion Doula Training - for reproductive justice and self-care / community-care