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FOR IMMEDIATE RELEASE, Aug. 12, 2016
Contact: Mark Almberg, PNHP communications director, 312-782-6006, mark@pnhp.org

Black children and young adults are about half as likely as their white counterparts to get mental health care despite having similar rates of mental health problems, according to a study published today [Friday, Aug. 12] in the International Journal of Health Services. Hispanic youth also get only half as much mental health care as whites.

The study used data on children under 18 and young adults 18-34 from the Medical Expenditure Panel Survey covering all 50 states for the years 2006-2012. It found that minorities received much less of virtually all types of mental health care, including visits to psychiatrists, social workers and psychologists, as well as substance abuse counseling and mental health counseling by pediatricians and other doctors.

The research was led by Dr. Lyndonna Marrast, who was a fellow at Harvard Medical School and Cambridge Health Alliance when she initiated the study. Marrast is currently assistant professor of medicine at the Hofstra Northwell School of Medicine in New York. The study’s co-authors are Drs. Steffie Woolhandler and David Himmelstein, professors at the City University of New York at Hunter College and lecturers at Harvard Medical School.

Their findings include the following:

• Black and Latino children made, respectively, 37 percent and 49 percent fewer visits to psychiatrists, and 47 percent and 58 percent fewer visits to any mental health professional, than white children.

• Black children’s low use of services was not due to lesser need. Black and white children had similar rates of mental health problems, and similar rates of severe episodes that resulted in psychiatric hospitalization or emergency visits.

• Hispanic parents reported less mental health impairment among their children, but analyses that controlled for this lesser need for care continued to show underuse compared to non-Hispanic whites.

• Racial/ethnic disparities were even larger among young adults. Whites received about three times more outpatient mental health services than blacks and Hispanics in this age group. The substance abuse counseling rate for black young adults was strikingly low, about one-seventh that for whites.

• While poor children and young adults had lower rates of care, differences in income and insurance did not account for the racial/ethnic disparities in care.

• Among children, girls got less mental health care than boys. The gender difference was reversed among young adults, with women having more visits.

• Groups at highest risk for incarceration – black and Hispanic young men – had particularly low mental health visit rates. According to Department of Justice data, at least half of inmates suffer from mental illness, most of which had been untreated when they were arrested.

The authors write: “The under-provision of mental health care for minority children contrasts starkly with the high frequency of punitive sanctions that their behaviors elicit. Black children suffer excessive rates of school discipline such as suspensions and expulsions starting at preschool ages. Minority teens also have disproportionate contact with the juvenile justice system, with higher arrest rates for nonviolent, low-level offenses such as drug possession, as well as for non-criminal misbehaviors such as truancy and curfew violations. Youthful transgressions that might result in referral for treatment among non-minority children more often incur criminal sanctions for minorities.”

The authors also observe that minorities’ very low substance abuse treatment rates contrast with their high rates of arrest for substance abuse.

Dr. Marrast commented: “It has become increasingly clear that minorities are overrepresented in the criminal justice system and underrepresented in the receipt of mental health care. We need to look closely at how equitably our health care institutions are serving all segments of society.”

According to Dr. Woolhandler: “Minority kids don’t get help when they’re in trouble. Instead they get expelled or jailed. But punishing people for mental illness or addiction is both inhumane and ineffective. The lack of care for minority youth is the real crime.”

Drs. Woolhandler and Himmelstein co-founded Physicians for a National Health Program, a nonprofit group that advocates for universal, comprehensive health coverage through a single-payer plan. PNHP played no role in financing or otherwise supporting the study.“Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study,” by Lyndonna Marrast, M.D., M.P.H., David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H. International Journal of Health Services, published Online First, Aug. 12, 2016. doi: 10.1177/0020731416662736

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

FOR IMMEDIATE RELEASE, July 6, 2016
Contact: Mark Almberg, PNHP, mark@pnhp.org, (312) 782-6006

Inequality in the use of health care has increased dramatically in recent years, with wealthier Americans, who tend to be healthier, now consuming the most care, according to a studypublished today [Wednesday, July 6] in the July issue of Health Affairs.

In 2012, the wealthiest fifth of Americans got 43 percent more health care ($1,743 more per person) than the poorest fifth of Americans, and 23 percent more care ($1,082 per person) than middle-income people.  (These figures are adjusted for the higher burden of illness among poor and middle-class people as compared to the wealthy.)

According to the study’s authors, who analyzed 22 national surveys conducted over the past five decades, these numbers reflect a striking reversal of a long-term trend toward greater equality in health care use by all income groups. They marshal data showing that the turning point came in the mid-2000s.

Prior to the passage of Medicare and Medicaid in 1965, the wealthy got about twice as much care as the poor. Subsequently, care became more equal, with lower-income Americans using more care than the wealthy (although analyses adjusting for the greater burden of illness among lower-income people showed that the gap was never fully erased).

But between 2004 and 2012, as the growth in medical spending slowed overall, the use of care by the wealthiest fifth of Americans grew by 19.7 percent, outpacing growth for middle-income groups by 57 percent. Meanwhile, care for the poorest fifth of Americans actually fell by 3.7 percent.

No upswing in health care inequality occurred among the elderly, virtually all of whom are covered by Medicare.

The researchers, who conducted their work at Harvard Medical School, the City University of New York at Hunter College, and Boston University, determined individuals’ health care use based on the total costs of their care, whether paid by insurers, the patients themselves, or government programs. Results were similar when they looked at the use of specific services such as the number of doctor visits, which were 40 percent higher for the wealthy than for all other Americans by 2012.

In their study, the income threshold for the wealthiest fifth in 2012 was $101,094 for a family of three, while those in the poorest fifth had family incomes below $22,689. The 60 percent of Americans with incomes between these thresholds were considered middle-income.

The authors attribute their findings to the synergistic impact of widening U.S. income inequality, the 2007-2009 recession and the slow recovery for the poor and middle class, and a sharp rise in health insurance co-payments and deductibles that discourage non-wealthy Americans from seeking care.

According to lead author Dr. Samuel Dickman, who conducted his research at Harvard Medical School and who is now at San Francisco General Hospital: “We spend more on medical care than in any other country, and those dollars are increasingly concentrated on the wealthy, who have good insurance and enough cash to afford skyrocketing deductibles and co-payments. In recent years economists have celebrated a slowdown in health care cost growth. But the slowdown seems to have been achieved by forcing poor and middle-class Americans to choose between paying rent, buying groceries, or going to the doctor when they’re sick.”

Dr. David Himmelstein, a professor at the City University of New York at Hunter College and lecturer at Harvard Medical School who was the senior author of the study, commented: “While poor and middle-class patients are skipping vital care, the wealthy are getting unnecessary and even harmful care. And the widening inequalities in health care are reflected in rising inequality in death rates. Meanwhile, our overall life expectancy is falling further and further behind nations that distribute care based on need, not wealth. Our findings dramatize the urgent need for national health insurance – a single-payer reform with first-dollar coverage – that would assure that all Americans can get the care they need.”

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“Health Spending For Low-, Middle-, and High-Income Americans, 1963-2012,” by Samuel L. Dickman, Steffie Woolhandler, Jacob Bor, Danny McCormick, David H. Bor, and David U. Himmelstein. Health Affairs, July 2016.

The full text of the article is available to media professionals upon request from Mark Almberg (mark@pnhp.org) at Physicians for a National Health Program.

Physicians for a National Health Program is a nonprofit research and educational organization of more than 20,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

FOR IMMEDIATE RELEASE, March 11, 2016
Contact: Mark Almberg, PNHP communications director, 312-782-6006, mark@pnhp.org

Although both liberal and conservative economists have denounced the longstanding exemption of employment-based health benefits from taxes as tantamount to a “regressive” tax subsidy that unfairly favors the rich, and have lauded a provision of Affordable Care Act that will impose a hefty tax on costlier (“Cadillac”) benefit packages, those who stand to be hit hardest by the new provision are middle-income families.

That’s the chief finding of a new study by Drs. Steffie Woolhandler and David U. Himmelstein, professors of health policy and management at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School. Their article was published this week in the International Journal of Health Services.

“Taxpayers should be paying directly for health care through Medicare-for-All, not indirectly through tax subsidies to private insurance,” said Woolhandler. “However, removing the tax subsidies – as Obamacare will do – without setting Medicare-for-All in place is a step backwards. It’s shameful that economists have provided cover for this tax that will hit middle-class families and largely spare the wealthy.”

“Most Americans are covered by employment-based health insurance,” Woolhandler and Himmelstein write in their study. “Both employers’ and employees’ payments for such coverage are exempt from income and payroll taxes, an exemption that provided a tax subsidy of $326.2 billion in 2015.

“For years, economists and health policy analysts have criticized these subsidies on two grounds, claiming they (1) encourage over-insurance, resulting in the frivolous use of unneeded care, and (2) that the subsidies are regressive, that is, disproportionately benefiting the rich.”

These claims, they say, lay behind the so-called Cadillac tax provision of the ACA, which would impose a 40 percent, nondeductible excise tax on employment-based plans that exceed $10,200 for individuals or $27,500 for family coverage in 2018 (now set to take effect in 2020).

Because the upper limit on the cost of such plans “will be indexed to overall inflation rather than to health care inflation (which is almost always faster), over time more and more employee groups will be hit by the tax, or by a cut in benefits to avoid it.”

The authors note that the new tax provision has been sharply criticized by labor groups and some businesses.

To calculate the impact of the Cadillac tax on various segments of the U.S. population, the authors drew upon a key 2009 study by economist Jonathan Gruber, who helped design the tax, and data from the U.S. Census Bureau, the Robert Wood Johnson Foundation and the World Top Incomes Database. They break out the bulk of their findings by family income quintiles, with an accompanying table and chart.

As to the claim that new levy will make the tax subsidy less “regressive,” the authors flatly deny it. They say that while it’s true that the wealthiest segment of the U.S. population, e.g. the richest fifth, is currently receiving the largest subsidies in terms of absolute dollars (hence the claim that the subsidies are regressive), if one uses the standard definition of regressivity – based on share of income – it’s clear that middle-income Americans stand to sustain the greatest financial harm.

“The tax subsidy is a big help for people with (2009) family incomes of $38,550 to $100,000, but not for those with lower or higher incomes,” they write. As a result, the new tax on benefits “will hit the middle class hardest and spare the wealthy.”

They add that eliminating the subsidies (and “over-insurance”), as the Cadillac tax aims to do, “has ripple effects that will disproportionately harm lower-income workers.”

“Employers seeking to avoid the tax will probably increase copayments and deductibles. Even if most of the employers’ premium savings were eventually passed on to workers as higher wages, the higher out-of-pocket costs would discourage most low-income families from seeking care – exacerbating inequalities in health and health care.”

The authors also criticize other inequities that are built in to the Cadillac tax provision, and note “the glaring unfairness of levying the Cadillac tax based on the cost of benefits, rather than their richness.”

In addition to their academic posts, Woolhandler and Himmelstein are co-founders of Physicians for a National Health Program, which advocates for single-payer national health insurance. PNHP had no role in funding or otherwise supporting their study.

“The ‘Cadillac Tax’ on Health Benefits in the United States Will Hit the Middle Class Hardest: Refuting the Myth that Health Benefit Tax Subsidies Are Regressive,” by Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D. International Journal of Health Services, OnlineFirst ahead of print, first published on March 9, 2016, as doi:10.1177/0020731416637163.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

FOR IMMEDIATE RELEASE, January 21, 2016
Contact: Mark Almberg, PNHP communications director, (312) 782-6006, mark@pnhp.org

Tax-funded expenditures accounted for 64.3 percent of U.S. health spending – about $1.9 trillion – in 2013, according to new data published today [Thursday, Jan. 21] in the American Journal of Public Health. The Affordable Care Act will push that figure even higher by 2024, when government’s share of U.S. health spending is expected to rise to 67.3 percent.

At $5,960 per capita, government spending on health care costs in the U.S. was the highest of any nation in 2013, including countries with universal health programs such as Canada, Sweden and the United Kingdom. (Estimated total U.S. health spending for 2013 was $9,267 per capita, with government’s share being $5,960.) Indeed, government health spending in the United States exceeded total health spending (government plus private) in every other country except Switzerland.

The finding that Americans pay the world’s highest health-related taxes conflicts with popular perceptions that the U.S. health care financing system is predominantly private, write Drs. David U. Himmelstein and Steffie Woolhandler, the authors of the study. Himmelstein and Woolhandler are professors at the City University of New York School of Public Health and lecturers in medicine at Harvard Medical School.

Direct government payments for such programs as Medicare, Medicaid and the Veterans Administration accounted for 47.8 percent of overall health spending. The analysis also identified two commonly overlooked tax-funded health expenditures – government outlays for public employees’ private health insurance coverage ($188 billion, or 6.4 percent of total spending) and tax subsidies to health care ($294.9 billion, or 10.1 percent of the total). Together, these public expenditures put the U.S. in first place for health care taxes.

Using another yardstick, the researchers note that tax-funded health expenditures in the U.S. accounted for a larger share of the gross domestic product (11.2 percent in 2013) than did the total health expenditures of any other nation.

The researchers drew upon data from the Centers for Medicare and Medicaid Services, the Office of Management and Budget, the U.S. Census Bureau and the Internal Revenue Service to analyze government outlays for health care costs. They utilized data from the Organization for Economic Co-operation and Development to compare the U.S. data with that of other nations.

“We pay the world’s highest health care taxes. But patients are still saddled with unaffordable premiums and deductibles,” said Dr. Steffie Woolhandler. “Meanwhile, billions are squandered on paperwork, and insurers and drug companies pocket huge profits at taxpayer expense.”

Dr. David Himmelstein commented: “Our study shows that universal coverage is affordable – without a big tax increase. In fact, we already pay for national health insurance, but we don’t get it. It’s an outrage that the American people pay sky-high health care taxes, but 33 million are still uninsured.”

In addition to their academic posts and clinical work as internists, Himmelstein and Woolhandler are co-founders and leaders of Physicians for a National Health Program, a nonprofit organization that advocates for a single-payer health system. PNHP had no role in funding their study.

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“The current and projected taxpayer shares of U.S. health costs.” David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H. American Journal of Public Health, online ahead of print, Jan. 21, 2016. doi: 10.2105/AJPH.2015.302997

A PDF of the article is available to media professionals upon request from Mark Almberg at mark@pnhp.org. The abstract of the article is available here: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302997

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Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 20,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.