Samuel H. Zuvekas

Explaining Racial and Ethnic Disparities in Health Care

Objectives:The substantial racial and ethnic disparities in access to and use of health services are well documented. A number of studies highlight factors such as health insurance coverage and socioeconomic differences that explain some of the differences between groups, but much remains unexplained. We build on this previous research by incorporating additional factors such as attitudes about health care and neighborhood characteristics, as well as separately analyzing different Hispanic subgroups. Methods:We use the Oaxaca-Blinder regression-based method to decompose differences among racial and ethnic groups in 3 measures related to access, quantifying the portion explained by each of a number of underlying characteristics and the differences that remain unexplained. We use data from the 2000 and 2001 Medical Expenditure Panel Survey (MEPS), a nationally representative survey of the noninstitutionalized U.S. population. We link these data to detailed neighborhood characteristics from the Census Bureau and local provider supply data from the Health Services Resource Administration (HRSA). Results:Consistent with earlier studies, we find insurance status and socioeconomic differences explain a significant part of the disparities. Additionally, neighborhood racial and ethnic composition account for a large portion of disparities in access, and language differences help explain observed disparities in the use-based access measure. However, much of the differences between racial and ethnic groups remain unexplained. We also found substantial variation in the level of disparities among different groups of Hispanics. Conclusions:Researchers and policymakers may need to broaden the scope of factors they consider as barriers to access if the goal of eliminating disparities in health care is to be achieved.

Self-Rated Mental Health and Racial/Ethnic Disparities in Mental Health Service Use

Background:Studies of health service use for emotional problems show that the majority of those with disorders do not seek professional help. In addition, mental health service use is lower among members of minority communities, compared with non-Hispanic whites. Objective:To examine the role of self-reported mental health as an indicator of awareness of mental conditions and as an influence in the process of seeking mental health care. Research Design:We conducted cross-sectional analyses of nationally representative data from the Medical Expenditure Panel Survey (MEPS) for 2000–2004. Measures:In-person interviews obtained data on self-rated mental health (SRMH), ambulatory mental health visits, and purchase of prescription medications to treat mental conditions. Respondents completed the SF-12 health status survey; analyses included the SF-12 mental component summary (MCS) as a measure of emotional symptoms. Analyses included only those who provided self-reports of MCS and SRMH. Results:SRMH was related to any ambulatory visit and any medication purchase for mental health treatment, controlling for MCS, and other sociodemographic and clinical variables. The association between SRMH and service use was weaker for black and Hispanic respondents than for whites. In addition, the magnitude of the association between SRMH and MCS was weaker for black and Hispanic respondents than for whites. Conclusions:Racial/ethnic differences in service use may arise in part from different propensities to interpret emotional symptoms as reflecting ones mental health and then to seek professional intervention for emotional problems. SRMH may be useful as an indicator of the extent to which people acknowledge the existence of emotional problems.

Global self-rated mental health : Associations with other mental health measures and with role functioning

Background:A large body of research shows that global self-rated health is related to important outcome variables. Increasingly, studies also obtain a single global self-rating of mental health, but understanding of what this item measures is limited. Objective:To clarify interpretation of self-reported mental health, we examine its associations with other validated measures of mental health and role functioning. Research Design:We conducted cross-sectional analyses of nationally representative data from the Medical Expenditure Panel Survey. Measures:In-person household interviews obtained data on global self-reported mental health and any limitations in work, school, or housekeeping activities. Adult respondents (N = 11,109) completed the SF-12 health status survey, the K6 scale of nonspecific psychologic distress, and the Patient Health Questionnaire (PHQ-2) depression screener in a self-administered questionnaire. We used the SF-12 Mental Component Summary and the mental health subscale. Analyses examined associations among mental health measures and regressed activity limitations, and the SF-12 physical and emotional role functioning scales on mental health measures, controlling for demographics and selected chronic conditions. Results:The 4 multi-item mental health measures were strongly correlated with each other (r > 0.69), but correlated less strongly with the self-reported mental health item (r ≈ 0.4). In an exploratory factor analysis, self-reported mental health loaded on both mental and physical health factors. In multivariate analyses, each mental health variable was significantly associated with activity limitations and with role functioning, but the association of self-reported mental health with emotional role functioning was relatively weak. Conclusions:Although global self-rated mental health is related to symptoms of psychologic distress, it cannot be considered to be a substitute for them.

Drug use, drug abuse, and labour market outcomes

This paper examines the relationship between illicit drug use and labour market success, and in doing so addresses two shortcomings of the previous literature. First, unlike many previous analyses, ours accounts for differences in intensity of use using clinically based diagnostic measures. Second, while recent studies focus only on young adults, we analyze a prime-age (30-45-year-olds) sample as well. Our results indicate that these differences are important. Similar to previous studies, we find evidence of a positive relationship between drug use and income for young workers. However, we also find some evidence of lower incomes for young workers reporting daily use of illicit drugs. For prime-age men, we find strong evidence that problematic drug use (as indicated by either a diagnosis of pathological use or dependence or by daily use) is negatively related to income. We also find a negative relationship between problematic use and employment among prime-age, but not younger, men.

Determinants of ambulatory treatment mode for mental illness

We estimate a reduced-form bivariate probit model to analyse jointly the choice of ambulatory treatment from the specialty mental health sector and/or the use of psychotropic drugs for a nationally representative sample of US household residents. We find significant differences in treatment choice by education, gender, race and ethnicity, while controlling for several aspects of self-reported mental health and treatment attitudes. For example, while women are more likely than men to use the specialty mental health sector and more likely to take psychotropic medications, this difference between men and women is much greater for psychotropic medications. The estimated differences may reflect patient preferences in a manner traditionally assumed when interpreting these coefficients in such equations, but we discuss how they may also reflect biases and misperceptions on the parts of patients and providers. We also discuss how our results relate to some findings and policies in the general health care sector.

State Variations In The Out-Of-Pocket Spending Burden For Outpatient Mental Health Treatment

We examine the potential of mental health/substance abuse (MH/SA) parity laws to reduce the out-of-pocket spending burden for outpatient treatment at the state level by exploring cross-state variations and their causes, as well as the provisions of MH/SA parity laws. We find modest (yet important) variation in out-of-pocket burden across states overall, but-because prescription medications account for two-thirds of out-of-pocket spending and are generally beyond the scope of recently enacted federal parity laws-evidence suggests that those laws will do little to reduce the observed burden or its variation. Other policy measures, designed to expand and improve health insurance coverage or reduce racial/ethnic disparities, could have a more profound impact.