Black, Indigenous, and people of color (BIPOC) experience greater barriers to accessing mental health and substance use services than their white counterparts, and the COVID-19 pandemic has not only made disparities more evident, but also worsened them. As members of Congress measure possible solutions to improve behavioral health care access, it is critical they consider the benefits of integrating behavioral health services with primary care and the impacts of doing so on health equity.
The need for mental health and substance use services has soared since the beginning of the pandemic, and even before that the treatment gaps were significant. Recent data for 2020 show rising drug overdose deaths, worsening of existing mental health problems, and increasing incidence of anxiety and depression. Before the pandemic in 2019, less than half of all adults with mental health conditions were receiving services. For BIPOC, the gap was significant. Research shows that in the same year, only 34% of Latino Americans, 33% of Black Americans, and 23% of Asian Americans in need of mental health services received treatment, compared to approximately 50% of white Americans. In reality, the disparity may even be bigger as these numbers do not reflect those who are undiagnosed.
A major contributor to the equity gap is the lack of diversity among behavioral health providers. The current makeup of the behavioral health workforce is predominantly white. The lack of racial, ethnic, and linguistic diversity in providers makes it more difficult for BIPOC patients to access a doctor or other provider who speaks their language or who they feel understands their culture. In addition, many providers lack the training for cultural competency necessary to connect in a meaningful way with their BIPOC patients and understand their unique needs, which can lead to underdiagnosed and misdiagnosed mental illness, or deter these patients from seeking care.
BIPOC with limited English proficiency tend to turn more to primary care physicians to access health care services, making this a crucial entry point to our country’s health care system. One review found that culturally-tailored integrated care in Indigenous communities improved access to care and retention and reduced depression symptoms. Integrated care teams can add providers who attend to certain socio-cultural factors, such as care managers who engage family members in treatment plans, and non-clinicians who help overcome language barriers and encourage patients to continue their treatments.
The situation is particularly troubling in rural areas, where there is a greater shortage of culturally competent providers. More than 60% of nonmetropolitan counties do not have a psychiatrist—regardless of cultural competency—and almost half do not have a psychologist, compared to 27% of urban counties without a psychiatrist and 19% without a psychologist.
To make matters worse, BIPOC are more likely to be uninsured. According to the Kaiser Family Foundation, 11% of Black adults and 14% of Native Hawaiian or Other Pacific Islander populations are uninsured, as well as a staggering 26% of Hispanic adults and 25% of Indigenous people, compared to only 9% of white adults.
Even for those who do have coverage, it is hard to find providers. There is limited participation of behavioral health providers in insurance networks, requiring patients to pay for services out-of-network and placing care out of reach for many. This is a significant burden for lower income populations. Studies show the average white family has eight times the wealth of the average Black family and five times the wealth of the average Hispanic family.
Integrating behavioral health and primary care services would help reduce these barriers for BIPOC communities. In 2020, the Bipartisan Policy Center convened the Behavioral Health Integration Task Force to address the mental health and substance use crisis and offer solutions to the growing issue. The task force released an in-depth report in March 2021 with recommendations to successfully integrate care.
Increase the pool of behavioral health providers by reducing barriers to reimbursement.
While there is an overall behavioral health provider shortage, the need is even greater for diverse behavioral health providers. Another roadblock is that in areas where there is an adequate supply of behavioral health providers, many do not accept insurance.
The task force recommended increasing the behavioral health provider types covered under Medicare and requiring the Centers for Medicare & Medicaid Services to adopt measures that would facilitate behavioral health provider placement in integrated care settings. It is particularly important for Medicare to cover peer support specialists because they have personal experience with mental health and substance use conditions and are certified and trained at the state level. They can be essential assets to integrated teams because they can: effectively extend treatment beyond the clinical setting, reach into shortage areas, and provide cultural competency patients need.
Improve integrated care education for new primary care and behavioral health providers and expand and diversify the behavioral health workforce.
To expand the workforce, Congress should increase financial support for continuing education programs, which would prepare providers to work in integrated settings, meet the needs of diverse and underserved populations, and improve health disparities. Post-degree training programs can increase primary care providers’ knowledge of behavioral health and core competencies necessary to understand and respond to the unique needs of diverse populations. In addition, the task force supported increasing financial support for programs that recruit diverse students into primary care and behavioral health professions and improving access to and affordability of health care education.
While these recommendations are essential in addressing equity issues, telehealth can also help expand culturally competent care. Telehealth services can connect more people with a wider range of providers and extend access for some patients to providers who speak their language. During the pandemic, Congress and the Trump administration increased flexibilities for telehealth utilization under Medicare. For example, they increased payments for virtual care, whether through video or telephone; allowed patients to receive virtual care in their homes; and loosened state licensing restrictions.
These flexibilities are scheduled to end when the public health emergency does, and policymakers are considering whether to keep these services for the long term. As they deliberate, they should consider options that reduce disparities for underserved communities without further increasing the digital divide. It will be important to allow time to collect evidence about the cost effectiveness and outcomes of various forms of virtual care, and for which conditions, before making important decisions that could seriously impact BIPOC.
The task force’s report offers a comprehensive look at the current state of behavioral health in our nation and offers a wide range of recommendations on how to integrate behavioral health with primary care. As the COVID-19 pandemic carries on and members of Congress continue to introduce legislation, they should make the unique needs of BIPOC a priority.
Read BPC’s Behavioral Health Integration report here.