Insurance Type: One Barrier to Care for Minority and Low-Income Patients

Insurance is just one of many hurdles

Diversity and equitable healthcare receive a lot of attention, and for good reasons. While access to early mental health treatment is a necessary first step toward health equity, results of a recent study showed that race/ethnicity and type of insurance were significantly associated with failure to receive care for eating disorders.

When pediatrician Ruby Moreno and her colleagues at the University of California, San Francisco, did a retrospective chart review of 1060 patients 11 to 25 years of age of diverse backgrounds, who presented to an urban adolescent medicine specialty program, they discovered that the type of insurance, public or private, strongly influenced the patient’s access to further care (J Eat Disord. 2023. 11:10).

The study population included patients with a mean age of 16; 86% were girls or women, 55% were White, 17.7% were Latinx, and 22.2% had a prior hospitalization. The most common diagnosis was AN (38.4%), followed by unspecified feeding or eating disorder (27.6%), atypical AN (13.3%), avoidant restrictive food intake disorder (6.1%), bulimia nervosa (BN) (6.1%), other specified eating disorders (5.5%), and BED (1.6%).

The charts revealed that the assessing clinicians, all specialists in mental health or in adolescent medicine, recommended further treatment. Patients diagnosed with restrictive eating disorders nearly always were referred for family-based treatment (FBT), except when this was contraindicated by a family history of abuse or borderline personality disorder. For the young adults, cognitive behavioral therapy (CBT) was often the first recommendation, except when the patient was living at home and preferred FBT, or when a higher degree of care was needed.

Compared with patients who had public insurance, such as Medicaid, those with private insurance were 3 times more likely to receive recommended treatment than were those with public insurance. Compared with White youth, racial and minority youth were about half as likely to receive the recommended treatment.

Patients with a history of hospitalization were nearly twice as likely to receive recommended treatment as those without. In contrast, patients with a diagnosis of “other eating disorders” were half as likely to receive recommended treatment as those with AN. Remarkably, those with a diagnosis of AN were 14 times more likely to receive recommended treatment than those with atypical AN (AAN); this is a striking finding, given that in many settings AAN appears to be the most commonly encountered eating disorder.

Other obstacles to treatment

What barriers other than insurance interfered with treatment? The authors reported that many publicly insured patients in their program were not able to access FBT at their institution or in the community; instead, these patients relied on therapists with limited experience with eating disorders and on nonspecialized individual therapy.

Minority youth often live in communities with fewer specialized medical mental health providers. The authors call for more research to identity the factors that may interfere with access to appropriate care for these youths with eating disorders. Thus, according to the authors’ results, minority patients are less likely to be screened for or to receive recommended treatment for eating disorders. Insurance coverage alone cannot guarantee equity to treatment of eating disorders.

Stigma and cultural beliefs about mental health care may act as additional barriers. The possible stigma of “mental disorders” may also be at work. Data are lacking due to the historic under-recognition of eating disorders in the population of people of color. Among Latinx patients with public insurance, for example, those with AAN were significantly less likely to receive recommended treatment than patients with AN.

Provider bias may be another barrier, according to the authors. Although eating disorders occur in people of color, males and non-binary individuals are also affected, and this is being more increasingly recognized. For many years eating disorders were believed to occur predominately in White females; this, of course, has changed with time. This study also indicates that youth of color are less likely to receive recommended treatment. These findings reflect the need to examine the role of structural racism in treatment of eating disorders.

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