Even as psychiatry advances and develops new clinical techniques and as behavioral health systems seek the means to be able to serve all people needing care, disparities in service persist. The causative and associated factors affecting people who suffer from mental illnesses and substance misuse are numerous and include social stigmatization of illness, poverty, race, and geographic and social isolation. Such disparities are frequently the result of choices in how resources are allocated.
Understanding this from the perspective of health care systems is particularly important today because we are in the midst of rapidly evolving service reform, primarily initiated by passage of the 2010 federal Patient Protection and Affordable Care Act (PPACA). Through provisions in the PPACA, more people than ever will have access to health care through both public and commercially financed health insurance. Paradoxically, however, it may also diminish access for some patients: there may not be enough providers for the many additional people who will now be able to access health care. Moreover, public policymakers are clearly seeking to spend less on health care. Psychiatric services might feel the greatest impact and some systems will focus on more easily remedial, less expensive conditions—particularly in circumstances in which measurable outcomes are more readily attainable.
Two aspects of health care disparity may become more prominent. The first regards relatively straightforward epidemiology: chronic conditions and illnesses whose treatment is complex, with outcomes that are more difficult to measure, may be more difficult to effectively finance. The second, and the focus of this Special Report, concerns demographically hard-to-reach populations.
These underserved populations may not have particularly higher rates of illness but are more expensive to treat by virtue of needing more outreach and engagement. Thus, they are not necessarily the expensive “high utilizers” of acute services typically identified as responsible for high costs, and now receiving intense policy attention. Instead, they are marginalized populations that suffer disparities because of challenges in actually getting to and continuing care. They tend to be forgotten, and clinicians less frequently have the skills to be able to work with them.
The articles in this Special Report examine these underserved populations—the socially marginalized who require special outreach techniques. The authors offer clinical approaches to outreach and engagement; they also describe a necessary understanding of local culture to identify strengths and to meet special needs.
Our health care system continues transforming within a challenging fiscal environment. The authors of these articles are advocates. They are helping to make underserved populations more visible to all of us, thereby signaling to policymakers the need to allocate necessary funding, sometimes in nontraditional forms, to advance access to mental health care to all populations.
Dr McQuistion is Associate Clinical Professor of Psychiatry at the New York State Psychiatric Institute; Director, division of outpatient & community psychiatry, department of psychiatry and behavioral health, St Luke’s and Roosevelt Hospitals, New York; and Adjunct Associate Clinical Professor of Psychiatry, Mount Sinai School of Medicine, New York. He reports no conflicts of interest concerning the subject matter of this Special Report.