CHAPTER 7

A Vision for the Future

Reduce Barriers to Treatment

Organization and financing of services have impeded access and availability for racial and ethnic minorities. Therefore, reducing financial barriers and making services more accessible to minority communities should be aims within any effort to reduce mental health disparities. Shame, stigma, discrimination, and mistrust also keep racial and ethnic minorities from seeking treatment when it is needed. Therefore, effective efforts to increase utilization will target social factors as well as quality of services.

Racial and ethnic minorities do not use mental health services at rates comparable to those of whites or in pro-portion to the prevalence of mental illness in either minority populations or the general population. The reasons for lower rates of utilization are complex. Research suggests that cost and lack of health insurance, fragmentation of services, culturally mediated stigma or patterns of help-seeking, mistrust of specialty mental health services, and the insensitivity of many mental health care systems, all discourage racial and ethnic minorities’ use of mental health care. Opportunities exist to remove barriers and to promote consumers’ access to needed services.

Ensure Parity and Expand Public Health Insurance

Minorities are less likely than whites to have health insurance and to have the ability to pay for mental health services. Across racial and ethnic groups, lack of health insurance is a significant financial barrier to getting needed mental health care. Even for people with health insurance, whether public or private insurance, there are greater restrictions on coverage for mental disorders than for other illnesses. This inequity, known as lack of parity in mental health coverage, needs to be corrected. The original Surgeon General’s Report on Mental Health made clear that parity in mental health coverage is an affordable and effective objective for the Nation.

Another important step toward removing the financial barriers that contribute to unequal access to needed mental health care is the extension of publicly supported health care coverage to children who are poor and near poor. Federal legislation has created prospects for significantly expanding mental health coverage for the nation’s 10 million uninsured children. The State Children’s Health Insurance Program is a federally funded program enacted in 1997 that provides $24 billion over five years to ensure health care coverage for children in low-income families who are not eligible for Medicaid. If this program were modified to ensure adequate coverage for mental health and substance abuse disorders, it might substantially reduce the financial barriers to treatment and enhance access to health care for millions of children from all racial and ethnic back-grounds.

Extend Health Insurance for the Uninsured

Approximately 43 million Americans have no health insurance. Federal and State parity laws and steps to equalize health and mental health benefits in public insurance programs will do little to reduce barriers for the millions of working poor who do not qualify for public benefits, yet do not have private insurance. Today, the Nation’s patchwork of health insurance programs leaves more than one person in seven with no means to pay for health care other than by out-of-pocket and charity payments. The consequences of the patchwork are many holes in the health care system through which a disproportionately greater number of poor, sick, rural, and distressed minority families frequently fall.

Efforts are currently underway to create more systematic approaches for States and local communities to extend health and mental health care to their uninsured residents. In 2000 and 2001, HRSA awarded planning grants to communities in 20 States to develop strategies to extend health coverage to their uninsured. Recipients of the grants will receive technical assistance to ensure that mental health needs of their uninsured residents are met in equal measure with other health needs. The pro-gram is modeled on a Robert Wood Johnson Foundation program, Communities in Charge, which is assisting 20 cities to stretch a safety net of health care insurance for people who have no health coverage. This and other efforts will have a significant impact on many racial and ethnic minority individuals who are uninsured.

Examine the Costs and Benefits of Culturally Appropriate Services

The burden of untreated mental illness is costly for all Americans. As the Nation looks into ways to remove financial barriers to mental health and addictions treatment, it is also important to look at the long-term cost-effectiveness of offering culturally appropriate services. Engaging and treating racial and ethnic minority children, adults, or older adults by reaching out to family members and other social supports may require a greater initial investment of resources, but it may also result in substantial decreases in disability burden. In addition, undertaking other case management services that do not involve direct client contact, such as discussing a coordinated treatment plan with a traditional healer, may not be payable through insurance. Nevertheless, such “ancillary” services may be essential to ensuring that those in need of services will enter and stay in treatment long enough to get help that is effective.

Similarly, bilingual or bicultural community health workers may be needed to bridge the gap between the formal health care system and racial and ethnic minority communities. Funds to support these community workers are scarce, and in the bottom-line environment of man-aged care, often nonexistent. Yet studies across many areas of health have shown that community health workers— neighborhood workers, indigenous health workers, lay health advisers, consejera, promotora—can improve minorities’ access to and utilization of health care and preventive services (Krieger et al., 1999; Witmer et al., 1995). These community health workers can also bridge language differences that create communication barriers for a substantial proportion of racial and ethnic minority Americans receiving health care (Commonwealth Fund, 1995; President’s Advisory Commission on Asian Americans and Pacific Islanders, 2001).

Many Americans, including members of racial and ethnic minorities, use alternative or complementary health care. The findings from a study of American Indian veterans’ use of biomedical and alternative mental health care suggest that medical need drives service use, but the physical, financial, and cultural availability of services may influence the form that such service use assumes (Gurley et al., 2001). Research is needed to fully understand the effects of complementary care and their interactions with standard mental health interventions. In the meantime, it is important that mental health systems create avenues for working with complementary care providers to foster greater awareness, mutual understanding, and respect. Consumers and families may be more likely to take advantage of effective mental health treatments if both the formal mental health and complementary care systems work together to ensure that individuals with mental illness receive coordinated, and truly complementary, treatments.

Although providing services to meet the cultural and linguistic needs of more diverse populations may demand more of an initial investment than continuing services as usual, cost-effectiveness studies will help to examine the benefits of providing (or the costs of failing to provide) culturally appropriate services.

Reduce Barriers in Managed Care

Evidence cited in this Supplement suggests that managed mental health care is perceived by some racial and ethnic minorities as creating even greater barriers to treatment than fee-for-service plans. However, more systematic assessment of the treatment experiences, quality, and out-come of racial and ethnic minorities in managed care may help to identify opportunities for using this mechanism to improve access and quality of services. Because managed care organizations contract to provide all necessary services to beneficiaries at a fixed cost, managed care offers a potential means for increasing providers’ flexibility to reach out and engage minority populations. For example, a health maintenance organization (HMO) might be able to support more outreach and engagement to people of color living in rural communities by removing inflexible billing methods based on individual office visits.

Overcome Shame, Stigma, and Discrimination

Shame, stigma, and discrimination are major reasons why people with mental health problems avoid seeking treatment, regardless of their race or ethnicity. The effects of negative public attitudes and behaviors toward people with mental illness may be even more powerful for racial and ethnic minorities than for whites (Chapter 2). For example, in some Asian American communities, the shame and stigma associated with the mental illness of one family member can affect the marriage and employment potential of other relatives. More research is needed to develop effective methods of overcoming this powerful barrier to getting people with mental health problems the help they need. Public education efforts targeting shame, stigma, and discrimination are likely to be more effective if they are tailored to the languages, needs, and cultures of racial and ethnic minorities.

Build Trust in Mental Health Services

Mistrust of mental health services deters many individuals from seeking treatment for mental illness. Although there are undoubtedly myriad complex reasons for this lack of trust, one of its major sources for racial and ethnic minorities may be their past negative experiences with the mental health treatment system. Mistrust is understandable in light of research findings that minorities receive a higher proportion of misdiagnoses, experience greater clinician bias, and have lower access to effective treatments that are evidence-based, as compared with whites. As detailed in the next section, one of the most essential steps to building trust in mental health services is reducing racial and ethnic disparities in the quality of available services. Minority communities also need more information about the effectiveness of treatment and the possibility of recovery from mental illness.