Article Abstract

Article Abstract

Online ISSN: 1099-176X Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 16, Issue 1, 2013. Pages: 3-12
Published Online: 1 March 2013

Measuring Disparities across the Distribution of Mental Health Care Expenditures

Benjamin Lê Cook,¹ Willard Manning,² Margarita Alegría³

¹Ph.D. MPH, Assistant Professor, Department of Psychiatry, Harvard Medical School Senior Scientist, Center for Multicultural Mental Health Research
²Ph.D., Professor, Harris School and the Department of Health Studies of the Biological Sciences Division, University of Chicago
³Ph.D., Professor of Psychology, Department of Psychiatry, Harvard Medical School, Director, Center for Multicultural Mental Health Research

* Correspondence to: Benjamin Cook, Center for Multicultural Mental Health Research, 120 Beacon Street, 4^th Floor, Somerville, MA 02143, USA
Tel.: +1-617-503 8449
Fax: +1-617-503 8430
E-mail: bcook@cha.harvard.edu

Source of Funding: This study was supported by grants from the National Institute of Mental Health (R01 MH091042: PI Cook, and P50 MHO 73469: PI Alegría). This study was approved by the Cambridge Health Alliance Institutional Review Board.

Abstract

Previous mental health care disparities studies predominantly compare mean mental health care use across racial/ethnic groups. Using nationally representative U.S. data, we estimated quantile regression models to measure mental health care expenditure disparities at the 95th, 97.5th, and 99th expenditure quantiles and examined whether disparities in the upper quantiles differed by income, insurance and education. Significant Black-white and Latino-white disparities were identified in any mental health care expenditures. Moving up quantiles of mental health care expenditures, Black-White and Latino-White disparities were reduced but remained significant, even after controlling for mental health status and observable sociodemographic characteristics. Disparities persisted in the upper quantiles among those in higher income categories. Interventions are needed to equalize resource allocation to racial/ethnic minority patients regardless of their income, with emphasis on outreach interventions to address disparities in access that are largely responsible for the no/low expenditures for even Latinos at higher levels of illness severity.

Background: Previous mental health care disparities studies predominantly compare mean mental health care use across racial/ethnic groups, leaving policymakers with little information on disparities among those with a higher level of expenditures.

Aims of the Study: To identify racial/ethnic disparities among individuals at varying quantiles of mental health care expenditures. To assess whether disparities in the upper quantiles of expenditure differ by insurance status, income and education.

Methods: Data were analyzed from a nationally representative sample of white, black and Latino adults 18 years and older (n=83,878). Our dependent variable was total mental health care expenditure. We measured disparities in any mental health care expenditures, disparities in mental health care expenditure at the 95^th, 97.5^th, and 99^th expenditure quantiles of the full population using quantile regression, and at the 50^th, 75^th, and 95^th quantiles for positive users. In the full population, we tested interaction coefficients between race/ethnicity and income, insurance, and education levels to determine whether racial/ethnic disparities in the upper quantiles differed by income, insurance and education.

Results: Significant Black-white and Latino-white disparities were identified in any mental health care expenditures. In the full population, moving up the quantiles of mental health care expenditures, Black-White and Latino-White disparities were reduced but remained statistically significant. No statistically significant disparities were found in analyses of positive users only. The magnitude of black-white disparities was smaller among those enrolled in public insurance programs compared to the privately insured and uninsured in the 97.5^th and 99^th quantiles. Disparities persist in the upper quantiles among those in higher income categories and after excluding psychiatric inpatient and emergency department (ED) visits.

Discussion: Disparities exist in any mental health care and among those that use the most mental health care resources, but much of disparities seem to be driven by lack of access. The data do not allow us to disentangle whether disparities were related to white respondent's overuse or underuse as compared to minority groups. The cross-sectional data allow us to make only associational claims about the role of insurance, income, and education in disparities. With these limitations in mind, we identified a persistence of disparities in overall expenditures even among those in the highest income categories, after controlling for mental health status and observable sociodemographic characteristics.

Implications for Health Care Provision and Use: Interventions are needed to equalize resource allocation to racial/ethnic minority patients regardless of their income, with emphasis on outreach interventions to address the disparities in access that are responsible for the no/low expenditures for even Latinos at higher levels of illness severity.

Implications for Health Policies: Increased policy efforts are needed to reduce the gap in health insurance for Latinos and improve outreach programs to enroll those in need into mental health care services.

Implications for Further Research: Future studies that conclusively disentangle overuse and appropriate use in these populations are warranted.

Received 19 March 2012; accepted 17 February 2013