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Unchanged a Decade After Landmark IOM Report

More than a decade after the Institute of Medicine's landmark Unequal Treatment report documented dramatic racial disparities in the access to and the
Benjamin Cook
Photo: Hoag Levins

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Benjamin Cook, PhD, MPH, is an Assistant Professor in the Harvard Medical School Department of Psychiatry and a Senior Scientist at the Cambridge Health Alliance Center for Multicultural Mental Health Research.
quality of mental health care across the U.S., little has improved says Harvard researcher Benjamin Cook.

Speaking at a health policy seminar at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI) co-sponsored by the Robert Wood Johnson Foundation, Cook also predicted that, rather than helping to narrow those disparity levels, the Affordable Care Act might actually exacerbate them by adding so many new patients to an already-inadequate system.

'Plagued by disparities'
The historic 2002 IOM report noted that "more so than in other areas of health and medicine, mental health services are plagued by disparities in the availability and access to its services and these disparities are viewed readily through the lenses of racial and cultural diversity, age, and gender."

Cook, an Assistant Professor at Harvard Medical School and a senior scientist at the Center for Multicultural Mental Health Research, says that despite IOM's recommendation for a "comprehensive, multi-level strategy to eliminate these disparities," minorities continue to suffer higher rates of persistence of mental disorders, significantly lower rates of initiation of treatment, and much lower rates of per capita spending on mental health care than their white counterparts.

He pointed out that ten percent of the U.S. population has "quite severe" mental health problems. Among those with serious mental disorders, there are low rates of access to mental health
Unequal Treatment
The 2002 IOM report, 'Unequal Treatment: Confronting Racial and Ethnic Disparities in health care,' reported that 'more so than in other areas of health and medicine, mental health services are plagued by disparities.' Ten years later, little has been done to either confront or alter those disparities.
care across the board. According to the 2011 Medical Expenditures Panel Survey (MEPS), only half of whites get care, and that number falls to 1 in 3 among Hispanics, 1 in 4 among Blacks, and 1 in 5 among Asians.

These differences can be attributed to a wide range of factors, which the IOM broke down into three general categories: clinical appropriateness and need and patient preference; health care systems and legal and regulatory climate; and discrimination.

Potential causes
Cook highlighted several potential causes. Personal experience of discrimination can dissuade minorities from seeking care, while institutional racism in both medical and nonmedical arenas leads to stress, which can contribute to the persistence of mental disorders.

For example, a 2012 report by the Center for Constitutional Rights explored the human toll of New York City's stop and frisk policy, finding that it contributed to hypervigilance among African Americans.

Neighborhood segregation likewise leads to unequal access to mental health care. The shortage of specialists in minority communities means that finding a mental health practitioner may be a challenge. Furthermore, among Asians and Hispanics, the lack of providers who speak their language can be an additional barrier to mental health care.

Insurance, education, income
Even when providers are present, lack of insurance, lower levels of education, and lower income can also decrease minorities' likelihood of utilizing mental health services.

racial disparity hot spots

While the ACA has been touted as an equalizing force, Cook is doubtful that it will help close the access and outcomes gaps in mental health care.

"In a way, there's a train wreck coming," he told the audience.

The latest estimate, he said, has the ACA increasing the number of people who get insurance by millions, with as many as 1.5 million of them seeking care for mental health issues.

Crush of new patients
"The crush of this new crowd could ultimately create problems of unmet need and actually exacerbate the disparity between whites and blacks," he said.

One possibility is that access will increase for everyone, but will rise disproportionately for whites compared to blacks and Hispanics -- because minorities will be more likely to run into supply contraints than whites. This scenario "is likely without interventions to deal with both insurance expansion and addressing the greater barriers to care that racial and ethnic minorities face," Cook said.

Another possibility that both Cook and other health services researchers at the seminar pointed to is a situation in which disparities would decrease but not for the reasons one might expect. If the number of patients greatly increases at the same time the supply of mental health care providers contracts, it could raise significant new access barriers for whites -- creating the illusion that the disparity gap between whites and blacks has narrowed because, actually, access has gotten worse for whites.

On the brighter side, Cook suggested that patient-centered medical homes (PCMHs) may hold promise for increasing access to care. "We know that greater exposure to primary care physicians increases the chances of detecting mental illness and reducing disparities in access," he said. "The PCMH provides that same potential -- of increasing the exposure to primary care in a way that is consistent over time and, thus, improves the detection of mental illness and referrals to treatment for racial and ethnic minorities."

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Lauren Reed-Guy is a University of Pennsylvania senior majoring in English and a free-lance writer.

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