Universal health coverage has been viewed as an important factor in reducing disparities in access to behavioral health services. However, ethnic/racial groups might benefit differently from this access-expanding policy. Expansion of insurance coverage could increase access for Latinos and non-Latino whites, but it may have modest effects for African Americans, implying that policy making might need to look beyond health coverage alone to effectively increase access. We found considerable service disparities for African Americans, even among those with insurance coverage, which confirms the findings of the 2009 National Healthcare Disparities Report from Agency for Health Research and Quality (AHRQ) (2009
). Furthermore, service disparities were more pronounced among African Americans with Medicaid as compared with non-Latino whites with the same insurance coverage. We conclude that caution should be exercised in generalizing the effect that expansion of insurance coverage could have on increased use of services for racial/ethnic vsubgroups, since insurance coverage without adequate providers to offer behavioral health services is unlikely to decrease service disparities. Highlighting this issue is the finding that only one-third of primary care physicians (PCPs) report that they were able to successfully obtain outpatient mental health services for their primary care patients (Cunningham and Hadley 2008
). This lack of providers might be especially severe in areas where African Americans reside (Waidmann and Rajan 2000
). Given the importance of provider supply on treatment, referral, and engagement (Lindrooth, LoSasso, and Lurie 2006
), having a sufficient workforce of service providers must be addressed in order to truly implement the Affordable Health Care Act. In addition, attention to the effect of socio-cultural factors and patient preferences for service delivery is particularly important for ethnic/racial minority populations (Mulvaney-Day et al. 2011
) and must be considered if we are to close the disparities gap.
Contrary to the AHRQ's Report (2009
), our results provide no evidence of service disparities for Latinos when examined in the aggregate. This inconsistency may be due to how we adjust for differences in need for care. Since there were a significant number of immigrants in the Latino sample, and immigrant Latinos tend to have lower levels of behavioral health needs (Alegría et al. 2008
), results may differ from other studies that only include English-proficient minority populations. In some subgroup analyses, we found estimates of behavioral health services access that are suggestive of potential disparities between Latinos and non-Latino whites but not statistically significant. Although not statistically significant, the notable disparity estimates are still of practical interest and warrant further investigation.
These results also suggest potential mechanisms through which ethnic/racial disparities in access could increase, given the limited focus on disparities reduction in the Affordable Care Act (Weinick and Hasnain-Wynia 2011
). Assuming that use of services is widely similar to the patterns observed here, our estimation of disparities suggests that with full insurance coverage, African Americans would see access to services improved, but they may nonetheless encounter service disparities in comparison to non-Latino whites with insurance coverage. In other words, universal insurance coverage could increase access across populations, but it would have only a modest effect in decreasing service disparities. One potential explanation may be that the emphasis in behavioral health care on psychopharmacological treatments is not aligned with treatment preferences of African Americans (Cooper-Patrick et al. 1997
). Another potential reason is that the South, with a greater concentration of African Americans, might have fewer options for care in public insurance programs than the West, where many Latinos reside (Waidmann and Rajan 2000
; Chow, Jaffee, and Snowden 2003
). Federal stimulus funds devoted to community health centers may counteract these factors and facilitate access to behavioral health care for minorities (Felland et al. 2010
Neighborhood clinics, combined with universal coverage, appear to be able to reduce access disparities. Community clinics may reach out to minorities who may have limited transportation or offer culturally sensitive care to marginalized populations. Both Latinos and African Americans utilize community health centers at rates much higher than that of non-Latino whites (Smedley, Stith, and Nelson 2003
However, access problems would not be completely resolved even if all our findings are substantiated and all remedial solutions are implemented. Even in the presence of universal insurance coverage and the resolution of barriers like stigma, 50 percent or more of people with significant behavioral health needs will not access any behavioral health care, independent of race/ethnicity. The treatment system may be failing racial/ethnic minorities as currently configured.
Also relevant is the absence of a significant difference in access to behavioral health care for Latinos or African Americans (as compared to non-Latino whites) who did not complete high school and had no insurance. A parallel pattern is observed for poor Latinos who are not insured. For disadvantaged individuals, regardless of racial/ethnic group, there might be few service options beyond public insurance. This suggests the importance of monitoring states that raise eligibility thresholds for Medicaid in the presence of poverty, with no alternative low-cost options, making everyone, independent of race/ethnicity, vulnerable for unmet needs.
There are limitations to the present study. The cross-sectional nature of the study design does not permit identification of causal effects, so that the findings are suggestive of potential mechanisms to be tested in future studies. Both diagnostic and use of service data are based on self-report that may be subject to incomplete information, particularly if respondents who have accessed services do not know they are being treated for behavioral health problems, as could be the case in primary care settings when providers might not specify they are prescribing antidepressants. Another limitation is the exclusion of other racial/ethnic groups (e.g., Asians) and geographical areas given the small sample sizes. The precision of disparity estimates was limited in that confidence bounds in suggest that lack of significant findings do not rule out important disparities. Our disparity estimates are dependent on the ratios constructed from the estimated propensity scores that enable us to adjust minority mental health need characteristics so they are similar to those of non-Latino whites. Therefore, the disparity estimates may be sensitive to the assumed propensity score models. However, we emphasize that the propensity score model does not involve the use of services as an outcome variable, but only the race/ethnic group membership, behavioral health needs, and sociodemographic covariates. Thus, our reweighting method may actually provide more robust disparity estimates than other methods that require parametric assumptions of the relationship between use of services and other covariates.
Our findings stress that universal coverage alone may not be sufficient for eliminating disparities, especially when targeted approaches may be needed for specific racial/ethnic groups. Certain interventions, including increasing the community health clinic availability, augmenting patient education, and addressing stigma, should be tested. Furthermore, health system interventions may be needed to better align services to needs, including substantially improving geographical shortages of behavioral health professionals in certain African American communities (Merwin 2003
), particularly for those who prefer counseling and psychotherapeutic interventions or voluntary support networks (Snowden 2001
), not necessarily available in community health clinics. Similarly, we might need community interventions to help minority patients with behavioral disorders advocate for services not covered by typical insurance plans (Garfield, Lave, and Donohue 2010
). Although insurance provides coverage for services, it is not sufficient to eliminate disparities. The system must attend to individual, family, and socio-cultural factors that weigh on accessing care. Additional interventions beyond extending insurance coverage will be needed to eliminate racial and ethnic disparities in access to behavioral health services.