title: Measuring disparities across the distribution of mental health care expenditures.
abstract: BACKGROUND
  Previous mental health care disparities studies predominantly compare mean mental health care use across racial/ethnic groups, leaving policymakers with little information on disparities among those with a higher level of expenditures.
  
  
  OBJECTIVE
  To identify racial/ethnic disparities among individuals at varying quantiles of mental health care expenditures. To assess whether disparities in the upper quantiles of expenditure differ by insurance status, income and education.
  
  
  METHODS
  Data were analyzed from a nationally representative sample of white, black and Latino adults 18 years and older (n=83,878). Our dependent variable was total mental health care expenditure. We measured disparities in any mental health care expenditures, disparities in mental health care expenditure at the 95th, 97.5 th, and 99 th expenditure quantiles of the full population using quantile regression, and at the 50 th, 75 th, and 95 th quantiles for positive users. In the full population, we tested interaction coefficients between race/ethnicity and income, insurance, and education levels to determine whether racial/ethnic disparities in the upper quantiles differed by income, insurance and education.
  
  
  RESULTS
  Significant Black-white and Latino-white disparities were identified in any mental health care expenditures. In the full population, moving up the quantiles of mental health care expenditures, Black-White and Latino-White disparities were reduced but remained statistically significant. No statistically significant disparities were found in analyses of positive users only. The magnitude of black-white disparities was smaller among those enrolled in public insurance programs compared to the privately insured and uninsured in the 97.5 th and 99 th quantiles. Disparities persist in the upper quantiles among those in higher income categories and after excluding psychiatric inpatient and emergency department (ED) visits.
  
  
  CONCLUSIONS
  Disparities exist in any mental health care and among those that use the most mental health care resources, but much of disparities seem to be driven by lack of access. The data do not allow us to disentangle whether disparities were related to white respondent's overuse or underuse as compared to minority groups. The cross-sectional data allow us to make only associational claims about the role of insurance, income, and education in disparities. With these limitations in mind, we identified a persistence of disparities in overall expenditures even among those in the highest income categories, after controlling for mental health status and observable sociodemographic characteristics.
  
  
  CONCLUSIONS
  Interventions are needed to equalize resource allocation to racial/ethnic minority patients regardless of their income, with emphasis on outreach interventions to address the disparities in access that are responsible for the no/low expenditures for even Latinos at higher levels of illness severity.
  
  
  CONCLUSIONS
  Increased policy efforts are needed to reduce the gap in health insurance for Latinos and improve outreach programs to enroll those in need into mental health care services.
  
  
  CONCLUSIONS
  Future studies that conclusively disentangle overuse and appropriate use in these populations are warranted.
authors.affiliation: Center for Multicultural Mental Health Research, Somerville, MA 02143, USA. bcook@cha.harvard.edu
authors.forename: Benjamin
authors.initials: B
authors.lastname: Le Cook
authors.forename: Willard
authors.initials: W
authors.lastname: Manning
authors.forename: Margarita
authors.initials: M
authors.lastname: Alegria
mesh_terms: D000293:Adolescent; D000328:Adult; D001741:Black or African American; D000368:Aged; D000369:Aged, 80 and over; D003430:Cross-Sectional Studies; D005006:Ethnicity; D005260:Female; D005102:Health Expenditures; D006297:Health Services Accessibility / Q000191:economics; D054625:Healthcare Disparities / Q000191:economics* / Q000208:ethnology; D006630:Hispanic or Latino; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000191:economics*; D008875:Middle Aged; D011795:Surveys and Questionnaires; D044465:White People; D055815:Young Adult