Two of the groups that stood to gain the most from the passage of the Affordable Care Act were people of color, and people with mental, behavioral, and substance-abuse issues. The law was intended to expand affordable coverage to minorities who’d historically lacked it, but the ACA also contained provisions requiring that the new insurance plans and expanded coverage that popped up under its auspices cover a range of behavioral-health services, including some substance-abuse treatments.
A recent study from Timothy Creedon at Brandeis University and Benjamin Lê Cook at the Health Equity Research Lab at Cambridge Health Alliance shows that the ACA has actually achieved gains for both groups, despite some real setbacks over its first few years. The ACA has not yet, however, helped ease racial disparities within behavioral health, with most of the significant gains in treatment coming for white patients. In other words, while white patients with behavioral-health issues and minorities with behavioral health-issues gained insurance coverage at similar rates, only white patients saw that increased coverage resulted in significantly better behavioral- and mental-health treatment.
Creedon and Cook’s work uses data from the National Survey on Drug Use and Health and examines coverage, mental-health treatment, substance-abuse treatment, insurance coverage, and barriers to access among people with substance-abuse disorders or serious psychological distress. What they found on the insurance coverage front was similar to what other analyses have found among the general population. Overall coverage in this group rose to a 10-year high of 81.5 percent in 2014, with the highest rates among whites, but with blacks, Hispanics, and Asian Americans all seeing signifiant increases in coverage after the ACA’s passage, as well. Although the research does not show any shift in the racial-coverage disparity between whites and people of color, the overall coverage gains for this underserved group of people with behavioral-health issues should result in better treatment across races.
Except, by the end of 2014, they hadn’t. Creedon and Cook’s paper shows no significant change in substance-abuse treatment for any race. Only whites enjoyed significant across-the-board increases in mental-health treatment in 2014. Their data does show a significant increase for Hispanics treated for behavioral-health disorders relative to 2005, but according to the authors “these increases were not significantly greater than what was to be expected given prior trends in mental health treatment.” Insurance-coverage increases only led to increases in treatment among white patients.
There are a few limitations here, and the authors discuss them at length. For one thing, 2014 was a long time ago in terms of health policy, so the data may be picking up an unrepresentative blip. 2014 was the first year of the ACA’s coverage expansions, and there were several setbacks that held back early enrollment. Also, even people who enrolled in Medicaid or exchange coverage may not have been aware of the behavioral-health benefits of their new plans. The National Survey on Drug Use and Health asks respondents about treatment over the year prior to the date of their interview, so people interviewed earlier in the year may mostly have been reporting experiences before the coverage expansions came into effect.
The existing data does fit with other evidence on mental-health coverage, however. Tellingly, Creedon and Cook’s analysis shows that whites in 2014 were actually more likely to cite cost or insurance-coverage barriers as reasons for not receiving needed treatment than people of color. That data point is consistent with other research identifying race and socioeconomic status as major barriers to mental-health care. My colleague Olga Khazan writes:
A new study suggests there might be another problem at play when low-income and black people attempt to schedule psychotherapy appointments: They never make it past the first voicemail. The study, published in the June issue of the Journal of Health and Social Behavior, suggests psychotherapists are more likely to offer appointments to middle-class white people than to middle-class African Americans or to working-class people of any race.
Essentially, white patients found their biggest barriers to be poverty and the constellation of factors that come with it—time, availability, and familiarity—while black patients had an added layer of race that barred them from needed care. Granted, that study focused on outpatient psychotherapy appointments among all patients while Creedon and Cook’s study focused on those with inpatient, outpatient, or pharmaceutical treatment for serious psychological disorders or substance abuse, but the overall conclusions may hold. Patients of color have additional barriers to mental-health care that extend beyond finance or insurance coverage.
The ACA is still a critical tool for providing necessary services for people with behavioral-health disorders and for helping close the racial disparities within that group. It removes the first and most obvious barriers for many potential patients, setting the stage for what Creedon and Cook characterize as “further attention on the unique access barriers confronting racial/ethnic minorities.” But these results are perhaps another reminder that making health care more equitable is a continuing process.