Factors Beyond Coverage Limit Mental Health Care Access

If you’re one of the nearly 44 million Americans estimated to have a mental health condition, the 2010 health law is supposed to help you get treatment.

Yet actually getting that help depends, new research suggests, on who you are and, to an extent, on your racial background. While more people overall are getting mental health care, it’s still harder to do if you are not white.

Researchers analyzed National Survey on Drug Use and Health data from 2005 to 2014 and predicted how many people were likely to face “serious psychological distress” — a severe mental health issue that the Centers for Disease Control and Prevention estimates affects about 3.3 percent of non-institutionalized Americans. They treated that as a proxy to evaluate how people with mental illness access care generally. Then, they measured how many people received mental health care treatment — at least one inpatient, outpatient or pharmacy visit — during those years, comparing whites, Hispanics, blacks and Asians.

The findings were published Monday in Health Affairs.

“There was some hope that with the [health law] boosting coverage for everyone — and in particular, minorities who have historically been left out of insurance coverage — you’d see a little more help for folks in those groups,” said Timothy Creedon, the study’s main author and a doctoral student at Brandeis University.

But the research finds that hope has not yet panned out.

The breakdown: Whites were still the only racial group in which a majority of people with severe psychological distress get treatment. They were also the only group whose access to mental health services grew by a statistically significant amount, from near 50 percent to about 55 percent, after the federal law was implemented.

Hispanics and Asians are now more likely to find care than they used to be. But the growth wasn’t significantly more than recent trends predating the Affordable Care Act would have suggested — implying the health law didn’t really make a difference, the authors argue. Blacks are no more likely to get mental health treatment than they used to be. And in all three of those groups, more than half of people facing severe mental illness still don’t get treatment.

Unequal access to mental health care isn’t a new problem.

Given how common mental illness is, that matters. For one thing, it’s a drain on the system, said Jeanne Miranda, a professor of psychiatry and biobehavioral sciences at the University of California, Los Angeles, who researches mental health and health disparities but was not involved with the study.

“People with mental health problems that go untreated do more poorly at work, and in health care can cost more. If you have heart disease and are depressed, you’re going to come out worse,” she said.

These findings suggest that, when it comes to mental health, the health law’s coverage expansions haven’t closed the care gap, said Benjamin Le Cook, the study’s coauthor and an assistant professor of psychiatry at Harvard Medical School.

But that said, the analysis stopped in 2014, one year after the health law took effect. “You’re not going to see an impact and major changes in terms of detecting racial and ethnic disparities this early. So we need more time to see how things work out,” said Charlene Le Fauve, deputy director for the National Institute of Mental Health’s Office for Research on Disparities and Global Mental Health. “One year is just not enough data.” La Fauve was not associated with the study.

Since then, factors have come into play that could make a difference. For instance, more states have expanded Medicaid, the insurance program for low-income people. And buying coverage on state or federal exchanges is easier than it was when the health law’s online marketplaces first launched. These changes could benefit historically underserved groups. Plus, since 2014, people have continued learning how to use their plans and what benefits they have that they might not have known about.

In addition, minorities are often more likely to be poor, less likely to be treated by doctors of their same race and, in many cases, less likely to know they have a condition that requires professional care, Miranda said. Those all build upon each other. Doctors also sometimes discriminate against which patients they’ll see, recent research suggests, declining minority patients more often. If people think their doctors don’t understand or empathize with their background, they’re less likely to come in for care, Cook added.

Unless such awareness issues and cultural gaps are addressed, too, getting more people covered — while a first step — isn’t enough, note the researchers.

Miranda echoed that concern. “If you walk into a place, and everybody looks white, and you’re not, or they don’t speak your language, that’s huge,” she said.

Cook said policymakers need to think creatively about ways to connect people with health care, not “let the mental health system off the hook.”

“There are some different ways that racial and ethnic groups think about mental illness. And that may be culturally driven, and the system should figure that out,” he said. “They should work with those communities to figure out how to manage that.”

Categories: Mental Health, The Health Law

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