Issue Category: Substance Misuse and Mental Health

In 1966, Dr. Martin Luther King, Jr. famously condemned injustice in health as the most shocking of all forms of inequality.  As TFAH recognizes Mental Health Awareness Month almost 60 years later, populations of color and other underserved groups in the United States continue to experience disparities in behavioral health outcomes and the availability and quality of care.  By supporting and promoting culturally and linguistically appropriate services (or CLAS), however, policymakers can reduce these disparities and promote well-being for all Americans.

The Office of Minority Health at the U.S. Department of Health and Human Services (HHS) defines CLAS as services that are respectful of and responsive to cultural and communication needs, including through consideration of cultural health beliefs, health literacy levels, and preferred languages.  By incorporating CLAS, providers can ensure individuals and families receive respectful, understandable, effective, and equitable care.  Among other features, CLAS can involve recruiting and supporting a culturally and linguistically diverse workforce, offering language assistance to individuals with limited English proficiency, and collecting and maintaining accurate data to evaluate impacts on health equity and outcomes.

The U.S. mental health care system, specifically, has struggled to address the needs of culturally and linguistically diverse populations; as a result, racial and ethnic minority populations have historically been less likely to receive necessary mental health care and more likely to receive low-quality care.  In addition, these groups are more likely to use hospitals and inpatient facilities to address mental health needs instead of community-based services.  Across the healthcare system, non-white patients report lower quality patient-physician interactions, less participation in medical decision making, and lower overall satisfaction with care. Other social and economic factors like lack of health insurance, limited income, transportation barriers, and experiences of racism and bias also contribute to these outcomes. In addition, a recent report found that 50 percent of LGBTQ+ young people who wanted mental healthcare could not get it due, in part, to a lack of affordable options and fears of negative reactions or other consequences.

Racial and ethnic health disparities impose a high burden in the United States—one study found $451 billion in costs, including medical expenses, lost productivity, and premature death, for 2018 alone—but CLAS can significantly improve quality of care and advance equity.  One study found that the single most important factor for increasing use of mental health services for individuals with limited English language proficiency was access to providers speaking their native languages.  In addition, the use of peer support specialists and other lay health workers with community-specific experience can promote access to care and help to reduce dropout rates and boost attendance rates for patients during mental health treatment.  In Native communities, for example, these workers can help overcome practical barriers to mental healthcare like lack of transportation and reduce symptoms of depression and suicide-related outcomes.  An integrated care approach that coordinates a variety of services can also improve mental health outcomes for patients from racially and ethnically diverse populations.

The Biden-Harris Administration has undertaken significant efforts to support and enhance CLAS across the spectrum of behavioral healthcare.  The 988 Suicide and Crisis Lifeline, which launched in July 2022, for example, has implemented specialized services for the LGBTQ+ population, and the Substance Abuse and Mental Health Services Administration announced the addition of Spanish language text and chat services in July 2023.  In November 2023, the White House also released the U.S. Playbook to Address Social Determinants of Health.  This document outlines strategies to “support equitable health outcomes by improving the social circumstances of individuals and communities,” including the structural inequities that “often disproportionately impact historically underserved individuals.” The 2023 HHS Equity Action Plan similarly outlined measures to improve access to behavioral healthcare coverage for underserved populations, including by developing an inclusive workforce, promoting behavioral health integration, and enhancing language services.  Relatedly, in January 2024, the Centers for Medicare & Medicaid Services (CMS) announced the Innovation in Behavioral Health (IBH) Model, which will comprehensively address health-related social needs of Medicaid and Medicare populations with moderate to severe mental health conditions and substance use disorder.  Importantly, this model requires participating Medicaid agencies to develop a health equity plan to address disparities in the populations they serve.

Several recent Congressional initiatives have also focused on promoting CLAS in the behavioral health system.  The PEER Support Act, for example, would strengthen the peer support specialist workforce by ensuring accurate data reporting on the profession, supporting best practices on training and supervision, and addressing barriers to certification and practice.  In addition, the Pursuing Equity in Mental Health Act would help establish behavioral healthcare teams in areas with underserved populations, improve training and best practices for addressing mental health disparities, and enhance outreach to populations of color to promote mental health and reduce stigma.  Finally, the Health Equity and Accountability Act would help reduce health disparities by improving data reporting, supporting workforce diversity, and increasing access to CLAS.

TFAH encourages Administration officials and Congressional leaders to continue to bolster CLAS to improve behavioral health outcomes for populations of color and other underserved groups. These improvements will not only help address the high cost of health disparities in the United States but will also support foundational changes to improve access and outcomes in the future.