The United States population is rapidly becoming more diverse as evidenced by the 2000 Census. Already, Hawaii, New Mexico, and California have become states without an ethnic majority, and other states, including Texas, will soon follow. In Massachusetts, ethnic minorities now comprise 16% of the population, up from 10% a decade ago. In Boston, “non-Hispanic White” Americans now comprise less than 50% of the population.
The heterogeneity and diversity that exist within each race and ethnicity must also be acknowledged. Native American tribal customs and languages vary tremendously from region to region. African Americans are comprised of people who have been in the U.S for generations as well as immigrants from the Caribbean and Latin America and from the African continent. Hispanics and Latinos represent people from the 32 different countries of Central and South America and the Caribbean. Asia, with 3.6 billion people, represents more than half of the world’s population, and yet, Asian Americans are often seen as a homogeneous group of people.
In order to meet the health care needs of ethnically diverse people, health care providers have struggled to find ways to offer the highest level of care taking into account the patient’s culture and language. This concept is especially important to mental health because a provider’s understanding of the patients’ cultural beliefs and background is indispensable to proper diagnosis and treatment. There is data suggesting that African Americans are more than twice as likely to be admitted to an inpatient psychiatric unit due to misdiagnoses resulting from the lack of cultural awareness of the provider. Latinos and Asian Americans under-utilize mental health services due to mistrust and seek care only in crisis situations.
In order to address some of the mental health care needs of minority patients, House Bill 2536: “An Act Providing for Culturally Competent and Linguistically Appropriate Mental Health Services” was filed with the Massachusetts State Legislature in December 2000. This bill proposes to allow members/patients of private managed care organizations (MCO) in Massachusetts to seek care outside of their MCO network if the MCO cannot provide culturally competent and linguistically appropriate mental health services.
The bill is designed to help minorities in MCOs access needed mental health services by addressing some of the barriers currently present. Due to the under-representation of minorities in the mental health professions, ethnic minorities, especially those with limited English proficiency, have difficulty finding an appropriate provider. The managed care system with its closed network of providers increases this barrier by further limiting the provider pool. If this bill is passed, patients will have access to a larger pool of providers and have an increased chance of finding a culturally competent provider.
This project analyzes the issues that must be addressed in order to pass and implement HB2536. A review of the literature was conducted to collect relevant data and analyze prior research on cultural competency. Federal and state policies, regulations and statutes were reviewed for precedence and models. Although no other states have been able pass legislation focusing on private MCOs, several states, including California and Washington, have implemented cultural competency plans for mental health in the public sector. Interviews were conducted with representatives from MCOs, state and federal agencies, professional associations, and academic institutions to elicit different perspectives, questions and concerns. Many of these questions and concerns regarding the definition of cultural competency and the implementation of the bill surfaced during the bill hearing in front of the Joint Committee on Insurance at the Massachusetts State Legislature.
Strategy considerations are divided into steps that needs to be addressed in order to pass the bill and programs that need to be implemented once the bill is passed. Using John Kingdon’s model of political analysis, strategies to pass the bill are divided into interventions that reframe the problem, build political capital, and present policy alternatives. Reframing the problem allows different stakeholders and politicians to become engage in the issue. In order to build political capital, possible coalitions and partnerships are suggested. Policy alternatives are then presented to allow for flexibility and to explore policy priorities. Lastly, implementation of the bill/law will be addressed by listing minimum program requirements at the systems/state level and at the individual MCO level.
Ruth B. Balser, Ph.D., State Representative, 11th Middlesex District, MA House of Representative
Joan Y. Reede, MD. MPH, Associate Dean for Faculty Development and Diversity, HMS
Jean Lau Chin, Ed.D., CEO Services
Elena Eisman, Ed.D., Executive Director, Massachusetts Psychological Association
Kamala Greene, M.A., Psychology Intern, Boston Consortium in Clinical Psychology
John E. McDonough, Dr.P.H, Senior Associate, Associate Professor, Schneider Institute for Health Policy, Heller Graduate School, Brandeis University