October Blog 1: Action Toward Health Equity

October 1, 2018

Submitted by Institute for Public Health 2018 Annual Conference Speaker:  Jorge Riopedre, President & CEO, Casa de Salud

No sooner is there yet another school shooting, or for that matter a mass shooting of any kind, than the mantra of access to mental health services starts pouring forth from the mouth of politicians and activists. Paul Ryan, Speaker of the House of Representatives, summed this up when he opined that, “Mental health is often a big problem underlying these tragedies.” And yet mass shootings by people with serious mental illness represent one percent of all gun homicides each year, according to the American Psychiatric Association.

Not only, then, does this mindset misrepresent the facts, it also conceals the real impact of access disparities, including homelessness, incarceration, job and family instability, and clinical health issues. In fact, the Patient-Centered Primary Care Collaborative reported that two-thirds of all primary care physicians are not able to access outpatient behavioral health for their patients.

There is also enormous inequity. According to the National Institute of Mental Health, “Members of racial and ethnic minority groups in the U.S. are less likely to have access to mental health services, less likely to use community mental health services, more likely to use inpatient hospitalization and emergency rooms, and more likely to receive lower quality care.”

One issue is discrimination, which is especially disheartening since people who perceive that they have been discriminated against have higher rates of PTSD, major depressive disorder, and generalized anxiety disorder than those that report having experienced lower levels of or no discrimination.

Less insidious reasons also exist. There is a shortage of providers, a factor often cited by America’s Health Insurance Plans, a national trade association representing companies that sell health insurance coverage. Cost is also a major factor. A national survey report by the U.S. Substance Abuse and Mental Health Services Administration showed that unaffordability was the most common reason for not receiving mental health services among adults who needed it. A separate study revealed that consumers pay 10 percent—or nearly $20 billion—of mental health care bills out of pocket.

Insurance should be able to help, but a National Alliance on Mental Illness report found that more than a third of privately insured mental health patients said they had difficulty finding any therapist who would accept their plan, and 28% said they had to use an out-of-network mental health provider, which of course resulted in higher out-of-pocket costs. This issue is exacerbated by the fact that about half of psychiatrists in the U.S. don’t accept insurance.

Another contributing factor is the mixed results, at least thus far, of the Mental Health Parity and Addiction Equity Act. The law mandates equity in insurance coverage, including both treatment limits (caps on inpatient days and out-patient visits) and financial requirements (cost sharing, deductibles, and out-of-pocket limits), for behavioral health and medical/surgical services. However, compliance is an issue. For instance, a California plan was cited for refusing to cover mental health and substance abuse services unless there was a written treatment plan for a condition that could be favorably changed, but there was no comparable requirement for medical and surgical benefits.

So, lots of problems. What about solutions? A major step in the right direction is ongoing healthcare reform that ensures meaningful standards of care and that actually achieves parity with clinical care. Loan forgiveness programs for those new to the mental health field could help increase the availability of providers. The integration of clinical and behavioral health is also something to strive for. One study in particular showed that patients at team-based medical practices that integrate mental health experience a 23% reduction in emergency room visits, a 10.6% reduction in hospital admissions, a 7% reduction in primary care physician encounters and 3.3% lower costs for care.
Many mental health problems that materialize later in life begin at an early age, so placing social workers and therapists on the staff at schools with high risk populations would also be a great step. Meredith Rataj, Site Director for St. Francis Community Services, says that collaborating with educators can empower them to be the first line of identification and prevention while also reducing stigma associated with treatment. Also helpful would be increasing access to accredited early childhood programming so that children get a healthy start in life.

Ideas like these may seem far afield from mental health, but as the non-profit industry writer Vu Le has observed, “Mental health will affect employment will affect housing will affect early learning will affect youth development will affect safety.”

As Le’s reflection implies, any meaningful efforts will require collaboration, accompanied by a mindset that will not accept inequity. Policy makers, educators, housing advocates, clinicians and a host of others must break out of their silos and work in partnership to improve systems for health and well-being, knowing that as long as inequities exist, our entire community is diminished.

Jorge Riopedre will be a speaker at the Institute for Public Health Annual Conference on Oct. 31. 

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