Key Federal Reports on Disparities

By way of introduction to the topic of racial and ethnic disparities in mental health care, four seminal reports on this topic are reviewed below.

Agency                                                       Report Title                                                                                                    Year

Office of the US Surgeon General  Mental Health: Culture, Race and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General  2001 
President's New Freedom Comission on Mental Health Achieving the Promise: Transforming Mental Health CAre in America 2003
Institute of Medicine of the National Academies (IOM) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 2003
Agency for Healthcare Research and Quality (AHRQ) The National Healthcare Disparities Report

2008 (annual)

Each of these four seminal works are a culmination of the efforts of a wide range of experts in the field of health and mental health care. They offer general findings on the issue of racial and ethnic mental health care disparities as well as recommendations for eliminating these disparities. Taken as a whole, these reports echo similar themes both in their findings and recommendations.

While the IOM and AHRQ reports do not focus specifically on mental health care, they are considered important documents for understanding the issue of racial and ethnic health disparities in general and, therefore, are included in this review.

Findings from the Four Reports on Health and Mental Health Care Disparities:

1)     Racial and ethnic disparities in mental health care do exist and persist, and are not acceptable.

2)     Social conditions such as community violence, poverty, racism, and discrimination contribute to the perpetuation of mental health disparities.

3)     Culture matters: The culture of both patients and providers is important to the conceptualization of mental health problems as well as to their assessment and treatment.

4)     Barriers to mental health care for racial and ethnic minorities include the limited availability of services, lack of access to care, and appropriateness of services available. Barriers to care also include fear and mistrust of the mental health system as well as discrimination on the part of individuals or institutions.

Recommendations from the Four Reports on Health and Mental Health Care Disparities:

1)     Expand the science base; more and better research is needed.

2)     Educate and empower patients.

3)     Improve access, reduce barriers to care, and improve quality of care.

4)     Develop the capacity of providers in mental health care professions.

5)     Promote mental health and prevention efforts.

6)     Intervene in the legal, regulatory, and policy arenas.

“Mental Health: Culture, Race and Ethnicity, A Supplement to Mental Health: A Report of the Surgeon General”

The Surgeon General’s Report provides comprehensive coverage of the issues related to the mental health of racial and ethnic minorities. The report finds that significant disparities exist regarding the mental health services delivered to racial and ethnic minorities: Racial and ethnic minorities have less access to and availability of care, receive generally poorer quality mental health services, and experience a greater disability burden from unmet mental health needs.

The main message of the report is “Culture Counts.” The report includes discussions of the cultural and social factors that contribute to mental health; the social and economic environment of inequality, including racism, discrimination, violence, and poverty that leave minorities with greater exposure to mental health; the racism and discrimination that have an adverse effect on mental health; the mistrust of mental health services that deters minorities from seeking help; and the clinical environments that are often inadequate to accommodate the needs of racial and ethnic minorities.

The remainder of the report is devoted to issues relevant to each of the major racial and ethnic groups in America: African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics. Major issues discussed include availability of services, access to services, utilization of services, and appropriateness and outcomes of services. A review of these issues for each group is consistent with the main finding that access and availability of appropriate services to racial and ethnic minorities is lacking.

The report also makes several recommendations for eliminating mental health disparities.

1)     Expand the science base. This includes more research to assess the influence of variables such as acculturation, stigma, spirituality, socioeconomic status, education, and perceived discrimination on mental health outcomes. Further study is also needed on the efficacy of evidence-based treatments for racial and ethnic minorities, the differential response to medications by race and ethnicity, clinician bias and diagnostic accuracy, and the differences in stress, coping and resilience that will provide the groundwork for new prevention and treatment strategies.

2)     Improve access to treatment. Improving access to treatment includes improving geographic availability of mental health services, integrating mental health care and primary health care, improving language access, and coordinating care to vulnerable, high-need groups such as people who are incarcerated or homeless.

3)     Reduce barriers to mental health care. Reducing barriers to mental health care requires addressing the cost of services, the fragmented organization of these same services, and the stigma toward mental health.

4)     Improve quality of mental health services. To improve quality of care, the report encourages providers to deliver treatment based on evidence-based professional guidelines, with treatments being tailored to the individual according to the person’s age, gender, race, ethnicity, and culture. Of course, more research is needed on adapting evidence-based treatments for effectiveness with racial and ethnic minorities. Further study of “ethnic- specific” and “culturally competent” practice models may reveal how these models can contribute to important aspects of quality care for racial and ethnic minorities.

5)     Support capacity development. All mental health professionals should develop their skills in tailoring treatments to age, gender, race, ethnicity and culture. However, racial and ethnic minorities are encouraged to enter the field because they are underrepresented among providers, researchers, administrators, policy makers, and consumer and family organizations. Further, leadership from within the community is required to better facilitate the design, planning and implementation of mental health service systems.

6)     Promote mental health. The reduction of negative social conditions such as poverty, community violence, racism, and discrimination is likely vital to improving the mental health of racial and ethnic minorities. Efforts to prevent mental health and promote health should build on community strengths such as spirituality, educational attainment, local leadership, and focus on families.

The President’s New Freedom Commission on Mental Health Report “Achieving the Promise: Transforming Mental Health Care in America”

In addition to highlighting issues of access to mental health services in general, the President’s New Freedom Commission on Mental Health Report focused on the additional barriers to care that prevent racial and ethnic minorities from seeking services, including fear and mistrust of treatment, different cultural ideas about illness and health, differences in help-seeking behaviors, racism, differing rates of being uninsured, and discrimination by individuals and institutions.

This report also emphasized the importance of the culture of providers of mental health services as well as the culture of those seeking help. Because providers have their own culture of shared beliefs, norms, and values, they may view mental health, diagnosis, and treatment in ways that may differ from the culture of the patient or client. The report suggests that without adequate training of professionals to deliver culturally competent care, the burden of mental disorders on racial and ethnic minorities will only deepen and intensify.

The President’s New Freedom Commission Report recommends improving access to quality care that is culturally competent. According to the report, culturally competent services are “the delivery of services that are responsive to the cultural concerns of racial and ethnic minority groups, including their language, histories, traditions, beliefs, and values.”

The Commission recommends that States address disparities as part of their Comprehensive State Mental Health Plans, which could include: setting standards for culturally competent care; collecting data to identify points of disparity; evaluating services for effectiveness and consumer satisfaction; developing collaborative relationships with culturally driven, community based providers; and establishing benchmarks and performance measures.

Additionally, State plans should promote increased opportunities to include individuals from diverse cultural backgrounds in the mental health workforce. Similarly, the Commission also recommends efforts to recruit, retain, and enhance a diverse workforce throughout the country. These efforts should include: recruiting and retaining racial and ethnic minority and bilingual professionals; developing curricula that address the impact of culture, race, and ethnicity on mental health, on help-seeking behaviors, and on service use; training and research programs targeting services to multicultural populations; funding these programs; and engaging minority consumers and families in workforce development, training, and advocacy.

Institute of Medicine Report “Unequal Treatment: Confronting Racial and Ethnic Disparities in health Care”

 In response to the body of research revealing that racial and ethnic minorities have less access to and experience a lower quality of health care, even when variables such as insurance status, income, age, co-morbid conditions, and symptom expression are taken into account, the U.S. Congress requested the Institute of Medicine to assess the extent of racial and ethnic differences in healthcare, evaluate potential sources of racial and ethnic disparities in healthcare, and provide recommendations for eliminating healthcare disparities.

Key findings from the report are summarized as follows:

1)     Racial and ethnic disparities in health care exist, and because they are associated with worse outcomes in many cases, are unacceptable.

2)     Racial and ethnic disparities in health care occur in the context of broader social and economic inequality.

3)     Many sources may contribute to racial and ethnic disparities.

4)     Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care.

5)     Minority patient refusal rates do not fully explain health care disparities.

Recommendations from the report are summarized as follows:

1)     General Recommendations 
        a.     Increase awareness of racial and ethnic disparities in health care. 
        b.     Increase health care providers’ awareness of disparities.

2)     Legal, Regulatory, and Policy Interventions 
        a.     Avoid fragmentation of health plans along socioeconomic lines. 
        b.     Strengthen the stability of patient-provider relationships in publicly funded health plans. 
        c.     Increase representation of racial and ethnic minorities among health professionals. 
        d.     Apply the same managed care protections to publicly funded HMO enrollees that apply to private HMO enrollees. 
        e.     Provide greater resources to the U.S. Department of Health and Human Services Office of Civil Rights.

3)     Health Systems Interventions 
        a.     Promote consistency and equity through evidence-based guidelines. 
        b.     Structure payment systems to ensure an adequate supply of services to minority patients. 
        c.     Enhance patient-provider communication and trust by providing financial incentives to reduce barriers and encourage evidence-based practice. 
        d.     Support the use of interpretation services. 
        e.     Support the use of community health workers. 
         f.     Implement multidisciplinary treatment and preventive care teams.

4)     Patient Education and Empowerment. Implement patient education programs to increase knowledge of how to access care and participate in treatment decisions.

5)     Cross-Cultural Education in the Health Professions. Integrate cross-cultural
education into the training of current and future health professionals.

Data Collection and Monitoring

Include measures of disparities in performance measurement.

Monitor progress toward eliminating disparities.

Report racial and ethnic data by Office of Management and Budget categories, but use subpopulation groups where possible.

Research Needs 
        a.     Collect and report data on health care access and utilization by patient race, ethnicity, socioeconomic status, and primary language. 
        b.     Conduct further research to identify sources of disparities and promising intervention strategies. 
        c.     Conduct research on ethical issues and other barriers to eliminating disparities.

Agency for Healthcare Research and QUALITY “National Healthcare Disparities Report”

The 2003 National Healthcare Disparities Report was the first annual report on healthcare disparities at the ahrq. This report tracks disparities in healthcare delivery as they relate to racial and socioeconomic factors using nationally available data sets.

The report provides seven key findings for policy makers, clinicians, administrators, and community leaders.

1)     Inequality in quality persists. Racial, ethnic, and socioeconomic disparities are national, pervasive problems in our healthcare system.

2)     Disparities come at a personal and societal price. The personal costs include morbidity, disability, and lost productivity. Societal costs include missed opportunities to intervene, resulting in costly management of conditions that could have been prevented.

3)     Differential access may lead to disparities in quality. Access barriers, actual or perceived, can result in adverse health outcomes. Patients may delay seeking care, resulting in presenting at a later, less treatable stage of illness.

4)     Opportunities to provide preventive care are frequently missed. The current healthcare system emphasizes treatment rather than preventative services that could reduce the burden of illness or prevent disease altogether.
Moreover, significant disparities exist in the use of preventative services for racial and ethnic populations.

5)     Knowledge of why disparities exist is limited. While there may exist sufficient data about racial disparities by race and ethnicity, it is difficult to disaggregate research findings by race, income or education. The report cannot determine what factors have a causal relationship to healthcare disparities, only that certain factors may be related to disparities.

6)     Improvement is possible. Some findings suggest that targeted improvement efforts could significantly reduce disparities. For example, quality improvement can be enhanced when detailed data is available at the most actionable levels, such as population subgroups.

7)     Data limitations hinder targeted improvement efforts. Because the report uses national data, it may not be possible to extrapolate these findings to any one community. State and local level data collection may also provide
information on disparities. The report also raises questions about public reporting of data by race, ethnicity, and socioeconomic status. Should national data collection include these variables? Finally, there are significant gaps in the existing data, and more robust measures are needed better understand underlying mechanisms and causal paths that result in disparities.