Introduction
There is a history in the United States health care system of discrimination against minority populations based on race. These disparities have significantly increased over the last three decades. In particular, mental health has traced sizable disparity in treatment in areas of access to care, quality of care and access to evidenced-based treatment (Primm et al., 2010).
The American Psychology Association (2020) has recognized the existence of health disparities among vulnerable minority groups, and has organized to support policies aimed at reducing health disparities for disadvantaged populations. African American and Afro-Caribbean communities in particular, have been heavily impacted by health equity issues. These impacts have been further exacerbated, in part, due to a systemic failure by public health institutions to broadly address specific underlying social determinants (such as immigration, housing, living location, etcetera) that affect the well-being of minority populations, as well as this population’s lived experiences of economic and social marginalization.
The goal of this paper is to propose health equity-focused policies that reduce or eliminate disparities among the underserved Black and Caribbean American communities due to social and/or economic disadvantages. More specifically, I hope to close the gaps in health disparities in Treatment Access, and Quality of Care for minorities, as a means to disparity reduction. According to US Surgeon General Report (General, U.S. 2001) Black minority populations had less than equal access to mental health treatment and evidenced-based quality care than White Americans. Additionally, Black people utilized emergency care services, primary care physicians, and alternative treatments more than their White counterparts, who more frequently used specialists for diagnosis and treatment of mental health concerns. The report also cited that an overrepresentation of inpatient treatment for Black Americans and, an underrepresentation in outpatient care.
Finally, I will discuss how my proposed policy changes align with the American Psychology Association’s (APA) ethical principles of Justice and Respect for People’s Rights and Dignity, and the Standards of Competence, Unfair Discrimination, Ethics and, Mental Health Assessments, as outlined by the APA.
The African American and Afro-Caribbean Populations
According to The Pew Research Center, America is undergoing a steady increase in racial and ethnic diversity, and by 2042, the U.S. will become a minority-majority nation (Passel & D’Vera Cohn, 2008). Notwithstanding these statics, Black American and Caribbean populations remain vulnerable to disparities.
Today, more than 25% of the Black population of the largest U.S. north-eastern cities from Boston to New York and Miami, consist of Caribbean immigrants who comprise of 4.4% of the entire U.S. Black population (Jackson et al., 2004). Based on these statics, it is easy to understand why several noted scholars and respected researchers have made international migration a new area of interest in mental health, and it has become a major tenant of the burgeoning global “health equity” movement concerned with the social determinants of health (Gómez et al., 2021). Both scholars and practitioners agree that it is critical to understand the manner in which social and institutional contexts mold individuals’ lives, including such factors as immigration, access to food, housing, employment, and living conditions. As migration increases around the world, the social determinants that impact immigrants as they leave their homelands and settle in foreign lands are overwhelming. Studies have confirmed that there is a nexus between the social and economic impacts of immigration and mental health wellness (Castaneda et al., 2015).
In a report analyzing the National Survey of American Life (NSAL) which is the largest, most in-depth investigation of serious mental disorders and mental health ever conducted on a national household sample of the Black American population, Jackson et al., (2014) asserted that this was the first-time, previously lumped together data regarding the Black population in America, now included a nationally representative sample of Caribbean Blacks. This differentiation allowed for a closer examination of the data and permitted the identification of mental health differences among the native Black American population and Black Caribbean born immigrants. The results showed that the level of unmet need for mental health care, was substantially higher for African-Americans and Afro-Caribbeans than it was for white Americans (Snowden, 2001). The NSAL’s results affirmed a conclusion from the Supplement (DHHS, 2001) that has also been reported elsewhere: that Black Americans’ untreated mental illness is significantly more untreated than mental illness suffered by White Americans, and that Black Americans’ psychiatric hospitalization rates are also higher than those of White Americans.
Policy Recommendations
In addition to the policy recommendations alluded to in other parts of this paper, such as economic incentives such as rewarding appropriate screening, evidence-based clinical care for minority populations, and recruiting more minorities as providers as a critically element for reducing health inequities. According to both the American Psychiatric Association and the APA, of the 13.2% of the American population who identify as Black, only 2% are psychiatrists and 4% are psychologists, making it difficult for Black Americans to find service professionals who look like them. While the above recommended policy changes are easily implemented, and may even be considered “low hanging fruit,” psychologists who are committed to the APA principles of justice and respect for people’s rights and dignity should standup and advocate in favor of policy reforms aimed at ending all forms of health disparities experienced by marginalized minority communities.
It is likewise important that mental health educational institutions, schools, treatment centers and facilities recruit minority clinical professionals, particularly in urban areas where ethnic minorities are poorly represented. A diverse and inclusive clinical force tends to be more culturally sensitive and have better insight into how to treat patients with whom they are culturally related, in addition, to being able to speak the same language of their patients. Health care scholars suggest that a national government initiative to provide education and community outreach to create a more racially inclusive mental health workforce is an essential step forward to shrink inequities (McGuire & Miranda, 2008).
The research team of Primm et al., (2010) postulated that the health care disparity gap will not close if the public health system does not determine the prevalent inequities that exist within vulnerable groups and take the following actions: Set measurable improvement goals, engage in local grassroots studies, and address essential local population needs. In taking a local community-centered approach, I believe that Primm and his colleagues have identified practical recommendations to a vexing problem. By offering community-based public health interventions, Primm’s research team is making the community part of the solution (Primm et al., 2010).
Kessler et al., (2005) research team found that community-based informal social support networks help to decrease emotional distress within neighborhoods and families. These imbedded grassroots type networks are known to help communities address concerns which reduce the need for treatment and produce better outcomes (Kessler et al., 2005). Similarly, more community-based surveillance and research needs to be done within these minority populations, to provide relevant mental health care access data. Ultimately, these specific data points may be used to assess and navigate better access to treatment (Colpe et al., 2010). When armed with this specific type of information, psychologists will be better able to provide more culturally competent services to their patients, with ethics, and based on accurate, reliable mental health assessments as described by the APA.
In many Black Caribbean communities English is not the primary language spoken (For Example: Haitians, Arubans, Martinique). It is a core necessity for a patient to be able to articulate their health concerns to their treatment professional, and equally important for the clinician to be able to communicate with their patients in a culturally competent manner. Additionally, public education by means of social media and other forms of digital audiovisual marketing would aid in combating the stigmatization of mental illness within the Black community. Finally, national policies must provide more resources to fund the effort of reducing health care disparities among Black Americans. The DHHS Office of Civil Rights should be funded specifically in areas of improving more access to mental health care and better quality of care for Black people, in addition to investigating and enforce public mental health care civil rights violations (Snowden & Yamada 2005).
Current Policies
The original 2001 NSAL report represented a seismic shift in how government and health authorities viewed mental health in the Black community. In an acknowledgement of the health inequities facing minority populations Congress asked the Institute of Medicine (IOM) to determine whether there was a problem in American society with health disparities (Nelson, 2002). The IOM was asked to evaluate the relationship between bias, discrimination, and stereotyping, and health care disparities, and to recommend steps needed to eliminate them. Their response was long and affirming; and concluded that there were very real and problematic disparities existing within health care for minority communities that did not exist in the White population (Nelson, 2002). Although no one single cause could be identified as the problem, the report assessed that the disparities were complex and “are rooted in historic and contemporary inequities, and involve many participants at several levels, including health systems, their administrative and bureaucratic processes, utilization managers, healthcare professionals, and patients” (Smedley et al., 2003, p. 1).
Unfortunately, the policy gaps unearthed 20 years ago by the IOM still exists today. Two central policy issues cited are among the main offenders of health inequities:
1. The “lower-end” health care plans have a fragmentation of services along socioeconomic lines which allows for disparities in the relationships between patients and providers in publicly-funded health plans such as Obama-Care; and
2. The managed care protections provided by the more expensive private HMO enrollees have a “better patients’ bill of rights,” than those publicly funded HMO enrollees.
Such disproportionate policies should be eradicated, even outlawed. Economically induced discrimination that allows psychologists’ service providers to treat patients different along socioeconomic lines are an affront to equal access in health care, and violates APA’s principles of Justice and Respect for People’s Rights and Dignity. Psychologists are obligated to recognize that fairness and justice is a right of all persons seeking access to and benefit from the contributions of psychology. It is a psychologist’s duty to respect the dignity and worth of all people, and where necessary, to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making (American Psychological Association, 2010a).
Social Determinants
Social science research has supported the view that many social determinants are a result of an unequal distribution of resources, that can be reduced through targeted social and economic policies and programs. As researchers better understand the causalities of health inequalities, they suggest that more insights should be placed on social determinants in order to appreciate the effects of social experiences on mental health. According to research done by Allen et al., (2014) poor and marginalized populations are most vulnerable to mental health disorders; and individuals at the lower end of the socioeconomic ladder feel a greater impact on their mental health, including stress from negotiating everyday circumstances, anxiety about immigration status, insecurity and unpredictable living conditions.
The APA standards of professional competence in patient care, avoidance of discrimination, ethics and, researched based mental health assessments, all come into view for practitioners as they assess social determinants. A successful treatment and intervention methodology should always consider racial/ethnic culture of the patient health results. Social determinant frameworks rest on the concept of the “social gradient” where people of lower social status experience greater health risks and lower life expectancy than those with higher status (Marmot & Bell, 2016). This is a flawed systemic problem. Health care policy approaches should not have baked-in biases that affect treatment protocols. For example, A clinician who uses social determinants to assess treatment interventions without any consideration of a Caribbean American patient’s migration status, time in the U.S., acculturation, culture, living conditions, household situation, along with the other “normative factors” such as economic status etc., fail to provide competent, ethical, researched based care in a manner that respects the dignity and rights of that person, according to the APA, (2010a).
For several years, there have been national calls for the American mental health system to consider social determinants as a means of eliminating mental health care diagnosis and treatment inequities. Immigrants often function under circumstances where society and its institutions are either ambiguous or hostile in response to their needs. In either situation, individuals are directly impacted and significantly affected by society’s rejections due to their immigration status and general powerlessness (Castañeda et al., 2015). As a result, researchers and practitioners recommend that in order to achieve significant improvements in health outcomes, immigration must be understood as a key social determinant of health in its own right (Castañeda et al., 2015).
“Solid Facts” is a concept primarily concerned with the roles of public policy in creating the desired social environment in which individuals achieve better health. Unfortunately, when it comes to reducing health inequities, recommended strategies overlook the importance of immigration. For example, the World Health Organization (WHO) booklet on social determinants of health highlights the lifelong importance of social determinants in early childhood, and the negatives of poverty, drugs, poor working conditions, unemployment, and the positives of social support, good food, and transport policy, but nothing related to immigration status. Consequently, there is a policy of social determinants “Soft Factors” (which does not mean unimportant factors) but not “Solid Facts” that health workers can target interventions that can improve by giving people practical guides for living their daily lives (Wilkinson & Marmot, 2003). Adoption of a Solid Facts approach, allows psychologists to tailor interventions ethically and competently, and within the meaning of respect for people’s rights and dignity.
Health Equity Advocacy for African Americans and Afro-Caribbean Minority Populations
Mental health care disparity is about the discrimination in making equal good quality health care available to all people regardless of race or ethnicity (Nelson, 2002). Most scholarly studies agree with this consensus, and the overwhelming weight of the evidence supports the findings that there are serious and persistent mental health care disparities in America between White Americans and minority populations, particularly African Americans and Afro-Caribbean. Most times, health discrimination is clearly demonstrated by disparities in insurance coverage, availability of quality care, evidenced-based treatment, and the unconscious bias of service providers. The Agency for Healthcare Research and Quality (AHRQ) is a lead federal agency for tracking and monitoring health disparities (Kelley et al., 2005). The AHRQ has responded to a federal congressional mandate to review “prevailing disparities in health care delivery as they relate to racial factors and socioeconomic factors” (Moy et al., 2005, p. 376), including such factors as emergency room use, and other care quality when outcomes were associated with improved health.
Years of research studies confirm that Black Americans continue to be overrepresented in emergency room use and inpatient services. These inequities can be linked to a systemic characteristic of mental health treatment which does not afford opportunities for minority outpatient care (Snowden et al., 2009) due to multiple factors, such as the lack of insurance coverage or the quality of their plans. The fact that explanations for these racial inequities outlined in the AHRQ’s report had been met with little objection, is evidence in itself, why these health care inequities continue to persist. Often times, many health disparities are socially conditioned and much of the conditions are brought about by circumstances we as a society should not accept.
African Americans and Afro-Caribbeans with mental illness experience more disabling forms of mental illness and experience them for longer periods of time than do other populations. As previously cited in the results from NSAL data, mentally illness within the Black U.S. populations is mostly unlikely to be treated. According to the data, over half of the persons experiencing significant mental health disorders were Black, compared with one-third White Americans (Neighbors et al., 2007), yet the treatment rates for the Black populations were significantly lower. These lower treatment rates translated into greater exposure to adverse life circumstances which resulted in more severe and disabling mental illness and related disabilities.
National Mental Health Care Policies
Generally, whenever the issue of health care policy is being discussed the concept of “mental health exceptionalism” arises. This concept asserts that mental health varies from the general physical health care, and therefore deserves special policy considerations – an exception to the rule. When it comes to mental health inequities however, the argument of exceptionalism does nothing to ameliorate disparity concerns. According to the IOM report cited earlier, availability of mental health care, guaranteeing unrestricted access to minority patients, as well as improving access by offering interpreter services, economic incentives, evidence-based treatment and rewarding appropriate screening (Nelson, 2002). Many of these policies are now in effect and work to improve disparities, but major barriers to inequities continue.
The Federal Government highlighted health disparities as early as 1985 when the DHHS issued its 1985 Secretary’s Task Force Report on Black & Minority Health (DHHS, 1985). Fifteen years later, the federal Healthy People 2010: Understanding and Improving Health (DHHS, 2000) addressed racial and ethnic disparities in health status. Since the 1980s there have been several federal initiatives signaling an interest in addressing American mental health treatment racial inequities in treatment access and care quality, searching for ways to reduce treatment inequities. These policy proposals involved institutions which engaged in: (a) disparity studies; (b) disparities monitoring; (c) NSAL data compilation; and (d) the WHO studies in disease burden among African Americans. Most recently on a national scale, the Patient Protection and Affordable Care Act (commonly known as Obama Care) attempted to build a bridge for unprecedented opportunities to improve national U.S. health care treatment access and quality care for minorities (Snowden, 2012), however, even these legislative policy initiatives were flawed.
To further elucidate on two national policies mentioned earlier, lower-level health plans that provide fragmentations of services perpetuates disparity in access to care, and is compounded by the lower quality of care Black Americans receive, even if or when they are treated. Low quality health plans are created in part, to avoid a full complement of quality health care. Survey studies conducted by Wang et al., 2005 concluded that Black minority populations only received “minimally adequate treatment” from service providers. These indicators refer to receiving (a) pharmacotherapy with minimal medication; or (b) attending minimal sessions of psychotherapy with specialty mental health, or human services. According to nationwide estimates, one-third of the individuals treated had the minimum care required, and approximately one-fifth of Black participants received below the required standard of minimum care (Neighbors et al., 2007).
Improving Black Americans’ treatment access via Obama Care by legally requiring insurance coverage and mandating Medicaid expansion as a means of extending insurance coverage to over 30 million Americans, was indeed a worthy goal. But the legislation still fell short by failing to legislate an “equal bill of rights” across the board on par with the more expensive private insurance policies. As a consequence, Obama care was better than nothing but still left gaps in disparities that will be explored. Regrettably the drive toward Universal Coverage for all Americans, including minorities, was assessed to not being able to close health care disparities, and may very well increase them. The fact is that Universal Coverage as conceived for Obama Care could only be accomplished via a national expansion of the Medicaid program and still would only cover persons earning above the current poverty line. What that means is that it would leave behind all those with incomes below the poverty line, which includes more than twice the number of Blacks than Whites (Newhouse, 2010).
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