A Health Equity Approach: Addressing Gaps in the Affordable Care Act’s Medicaid Expansion Program on Mental Healthcare Among Racial-Ethnic Groups

From the 2023 HVPA National Conference

Colleen Frank BA (Wright State University School of Professional Psychology), Serena Kaul MPH (Wright State University Boonshoft School of Medicine), Kassie Prevost BA, Amanda Bell MD

Mental healthcare has historically posed a notable challenge regarding diagnosis and treatment due to lack of coverage, financial barriers, and stigma (Ortega, 2022; Breslau et al., 2020). In 2010, the Affordable Care Act (ACA) implemented the option for states to opt in or out of a Medicaid expansion program (Blazoski & Maio, 2021; Aggarwal et al., 2010). The purpose of the expansion program was to provide home and community-based services as an alternative to hospitalization, to increase payment reimbursement services, and to aid in the integration of primary care and mental health (Aggarwal et al., 2010). While these ACA insurance expansion provisions increased health coverage, 12.2% of adults with a mental health disorder remain uninsured (Lai et al., 2023). There is limited data available on the specific impacts of the expansion provisions and the implications surrounding access to mental healthcare appointments with follow-up, prescribed medication, and psychological treatment, particularly among racial-ethnic groups.Methods: A literature review was conducted of peer-reviewed articles from 2010 to 2023 on Google Scholar, PubMed, CINAHL and MEDLINE. Keywords utilized to stratify relevant articles include Affordable Care Act, mental health and mental health reform.

Evidence suggests that Medicaid expansion states saw an increase in the number of prescriptions to treat common mental illnesses, better rates in visits with providers, and better rates in follow up visits (Ortega, 2023; Blazoski et al., 2021). While these results are promising, the likelihood that a provider accepts Medicaid post-expansion only increased by less than 2% and improvements related to accessing and receiving care were solely noted for White recipients (Blunt et al., 2020; Breslau et al., 2020; Robertson-Preidler et al., 2020). Despite a marked increase in mental health diagnoses among the Black and Hispanic communities, fewer recipients of these minority backgrounds sought mental healthcare or prescription medication post-expansion (Lai et al., 2023; Blunt et al., 2020; Robertson-Preidler et al., 2020). Overall, patient visits for mental health were found to increase because of higher utilization for services among those who already had Medicaid, not due to an increase in Medicaid enrollment (Breslau et al., 2020).

Although Medicaid expansion was meant to aid in the accessibility of mental health care for underserved communities, there is a significant misunderstanding on the effect it has on racial-ethnic groups (Lai et al., 2023). By focusing on reducing racial-ethnic disparities, a health equity approach should be utilized to tailor mental healthcare efforts and reforms.

Clinical Implications:
Medicaid expansion decreased the rate of uninsurance among individuals with mental health disorders, increased access to mental health treatment, and overall improved mental health outcomes. However, 14 states did not have Medicaid expansion programs put in place by 2020 causing over 2.3 million eligible Americans to not have proper access to primary or mental healthcare (Blazoski & Maio, 2021). This gap in care may be attributed to the lack of attention on barriers faced by stigmatized racial-ethnic groups. Achieving equity of access to mental healthcare will require the acceptance and enactment of additional policy reforms that support training in psychoeducation and preventive mental health treatment, especially for those who experience stigma and for those who reside in non-expansion states.

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