Health Insurance and Mental Health Treatment Use Among Adults With Criminal Legal Involvement After Medicaid Expansion.

OBJECTIVE: Individuals with criminal legal involvement have high rates of substance use and other mental disorders. Before implementation of the Affordable Care Act's Medicaid expansion, they also had low health insurance coverage. The objective of this study was to assess the impact of Medicaid expansion on health insurance coverage and use of treatment for substance use or other mental disorders in this population. METHODS: The authors used restricted data (2010-2017) from the National Survey on Drug Use and Health (NSDUH). Using a difference-in-differences approach, the authors estimated the impact of Medicaid expansion on health insurance coverage and treatment for substance use or other mental disorders among individuals with recent criminal legal involvement. RESULTS: The sample consisted of 9,910 NSDUH respondents who were ages 18-64 years, had a household income ≤138% of the federal poverty level, and reported past-year criminal legal involvement. Medicaid expansion was associated with an 18 percentage-point increase in insurance coverage but no change in receipt of substance use treatment among individuals with substance use disorder. Individuals with any other mental illness had a 16 percentage-point increase in insurance coverage but no change in receipt of mental health treatment. CONCLUSIONS: Despite a large increase in health insurance coverage among individuals with criminal legal involvement and substance use or other mental disorders, Medicaid expansion was not associated with a significant change in treatment use for these conditions. Insurance access alone appears to be insufficient to increase treatment for substance use or other mental disorders in this population.

Perspectives of Historically Black College and University Advisors to Premedical Students During the COVID-19 Pandemic: A Qualitative Study.

Importance: Black students remain underrepresented in medicine despite national efforts to increase diversity in the physician workforce. Historically Black College and University (HBCU) students play a vital role in increasing representation in the workforce. Currently, there is a paucity of literature understanding the impact of COVID-19 on premedical students from HBCUs. Understanding the adverse impact of the pandemic on HBCU students is essential to inform strategies that promote holistic medical school admissions and increased diversity, equity, and inclusion in the medical workforce. Objective: To explore premedical advisors' perspectives on the impact of the COVID-19 pandemic on HBCU premedical students pursuing admission to medical school. Design, Setting, and Participants: In this qualitative study, semistructured interviews of HBCU premedical advisors were performed from March 2020 to March 2021. One-on-one interviews were conducted with 21 advisors with a depth of experience as advisors, varied educational backgrounds, and diverse geographic representation. Data analysis was performed from March 2021 to December 2021. Main Outcomes and Measures: The experiences of HBCU premedical students during the COVID-19 pandemic from the perspective of the premedical advisor. Results: Among the 21 participants, 13 (62%) were female, 15 (71%) were Black or African American, 11 (52%) had a doctorate degree, and 7 (33%) had more than 10 years of experience as advisors. Participants described 3 major themes: (1) balancing academic responsibilities with family demands; (2) distraction, disruption, and isolation in the virtual learning environment; and (3) harmful impact of new stressors for HBCU applicants in the medical school admissions process. Conclusions and Relevance: In this qualitative study of HBCU advisors to premedical students, advisors described how the COVID-19 pandemic adversely affected undergraduate HBCU premedical students; students faced family hardships, challenges with virtual learning, and uncertainty in the medical school admissions process. These findings suggest that medical schools should continue to create direct interventions to address the challenges that HBCU students faced during the height of the pandemic and as longitudinal consequences of the pandemic. Addressing these issues may improve physician workforce representation and promote more equitable patient care for underserved communities disproportionately affected by COVID-19 and other health disparities.

Building Bridges Between Evidence and Policy in Mental Health Services Research: Introducing the Policy Review Article Type.

Although it is widely accepted that patients do better when evidence-based health care practices are used, there is less acknowledgment of the positive outcomes associated with evidence-based policy making. To address the need for high-quality evidence to inform mental health policies, Psychiatric Services has recently launched a new article format: the Policy Review. This review type defines a specific policy-relevant issue affecting behavioral health systems, describes current knowledge and limitations, and discusses policy implications. Reviews can focus on mental health policies or examine how other health or social policies affect people with mental illness or substance use disorders. This brief overview of the need for a policy review article type describes differences between evidence-based policy making and practices and looks at research approaches focused on evidence-based policy making, as well as legislative and other efforts to support it. Broad guidelines for potential submissions are also provided.

Striving for Equity in Community Mental Health: Opportunities and Challenges for Integrating Care for BIPOC Youth.

Supporting the mental health of youth who identify as Black, Indigenous, or Persons of Color (BIPOC) continues to be a challenge for clinicians and policymakers alike. Children and adolescents are a vulnerable population, and for BIPOC youth, these vulnerabilities are magnified by the effects of structural, interpersonal, and internalized racism. Integration of psychiatric care into other medical settings has emerged as an evidence-based method to improve access to psychiatric care, but to bridge the gap experienced by BIPOC youth, care must extend beyond medical settings to other child-focused sectors, including local governments, education, child welfare, juvenile legal systems, and beyond. Intentional policy decisions are needed to incentivize and support these systems, which typically rely on coordination and collaboration between clinicians and other stakeholders. Clinicians must be trauma-informed and strive for structural competency to successfully navigate and advocate for collaborative systems that benefit BIPOC youth.

Association of Psychiatric Diagnoses and Medicaid Coverage with Length of Stay Among Inpatients Discharged to Skilled Nursing Facilities.

BACKGROUND: Inpatients with psychiatric diagnoses often require higher levels of care in skilled nursing facilities (SNFs) and are more likely to be covered by Medicaid, which reimburses SNFs at significantly lower rates than Medicare and commercial payors. OBJECTIVE: To characterize factors affecting length of stay in inpatients discharged to SNFs. DESIGN: A retrospective cross-sectional study design using 2016-2018 data from National Inpatient Sample. PARTICIPANTS: Inpatients aged ≥ 40 who were discharged to SNFs. EXPOSURES: Primary discharge diagnosis (medical, psychiatric, or substance use) and primary payor. MAIN OUTCOMES AND MEASURES: Length of stay, categorized non-exclusively as >3 days, >7 days, or > 14 days. RESULTS: Among 9,821,155 inpatient discharges to SNFs between 2016 and 2018, 95.7% had medical primary discharge diagnoses, 3.3% psychiatric diagnoses, and 1.0% substance use diagnoses; Medicare was the most common primary payor (83.3%), followed by private insurance (7.9%), Medicaid (6.6%), and others (2.2%). Median length of stay for all patients was 5.0 days (interquartile range [IQR], 3.0-8.0), 5.0 (IQR, 3.0-8.0) for those with medical diagnoses, 8.0 (IQR, 4.0-15.0) for psychiatric diagnoses, and 5.0 (IQR, 3.0-8.0) for substance use diagnoses. After multivariable adjustment, compared to patients with medical diagnoses, patients with psychiatric diagnoses were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to Medicare patients, Medicaid patients were more likely to have hospital stays > 3, > 7, and > 14 days, respectively (p < 0.001). Compared to patients with medical diagnoses, those with psychiatric diagnoses were also more likely to have lengths of stay 1 times, 1.5 times, and 2 times greater than the national geometric mean length of stay for that diagnosis-related group (p < 0.001). CONCLUSIONS: Patients discharged to SNFs after inpatient hospitalization for psychiatric diagnoses and with Medicaid coverage were more likely to have longer lengths of stay than patients with medical diagnoses and those with Medicare coverage, respectively.

COVID-19 Vaccine Acceptance and Access Among Black and Latinx Communities.

Importance: Black and Latinx communities have faced disproportionate harm from the COVID-19 pandemic. Increasing COVID-19 vaccine acceptance and access has the potential to mitigate mortality and morbidity from COVID-19 for all communities, including those most impacted by the pandemic. Objective: To investigate and understand factors associated with facilitating and obstructing COVID-19 vaccine access and acceptance among Black and Latinx communities. Design, Setting, and Participants: This community-partnered qualitative study conducted semistructured, in-depth focus groups with Black and Latinx participants from March 17 to March 29, 2021, using a secure video conferencing platform. Participants were recruited through emails from local community-based organizations, federally qualified health centers, social service agencies, the New Haven, Connecticut, Health Department, and in-person distribution of study information from community health workers. A total of 8 focus groups were conducted, including 4 in Spanish and 4 in English, with 72 participants from a diverse range of community roles, including teachers, custodial service workers, and health care employees, in New Haven, Connecticut. Data were analyzed from March 17 to July 30, 2021. Main Outcomes and Measures: Interviews were audio-recorded, transcribed, translated, and analyzed using an inductive content analysis approach. Themes and subthemes were identified on the acceptability and accessibility of the COVID-19 vaccine among participants who identified as Black and/or Latinx. Results: Among 72 participants, 36 (50%) identified as Black, 28 (39%) as Latinx, and 8 (11%) as Black and Latinx and 56 (78%) identified as women and 16 (22%) identified as men. Participants described 3 major themes that may represent facilitators and barriers to COVID-19 vaccinations: pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access. Conclusions and Relevance: The findings of this qualitative study may impact what health care systems, public health officials, policy makers, health care practitioners, and community leaders can do to facilitate equitable uptake of the COVID-19 vaccine. Community-informed insights are imperative to facilitating COVID-19 vaccine access and acceptance among communities hardest hit by the pandemic. Preventing the further widening of inequities and addressing structural barriers to vaccination access are vital to protecting all communities, especially Black and Latinx individuals who have experienced disproportionate death and loss from COVID-19.

The Association Between History of Depression and Access to Care Among Medicare Beneficiaries During the COVID-19 Pandemic.

BACKGROUND: Depression is associated with a higher risk for experiencing barriers to care, unmet social needs, and poorer economic and mental health outcomes. OBJECTIVE: To determine the impact of COVID-19 on ability to access care, social and economic needs, and mental health among Medicare beneficiaries with and without depression. DESIGN AND PARTICIPANTS: Cross-sectional study using data from the 2020 Medicare Current Beneficiary Survey COVID-19 Summer Supplement Public Use File. MAIN MEASURES: Access to medical care, inability to access food, medications, household supplies, pay rent or mortgage, feelings of economic security, and mental health effects since COVID-19, risk-adjusted for sociodemographic and clinical characteristics. KEY RESULTS: Participants were 11,080 Medicare beneficiaries (nationally representative of 55,960,783 beneficiaries), 27.0% with and 73.0% without a self-reported history of depression. As compared to those without a history of depression, Medicare beneficiaries with a self-reported history of depression were more likely to report inability to get care because of COVID-19 (aOR = 1.28, 95% CI, 1.09, 1.51; P = 0.003), to get household supplies such as toilet paper (aOR = 1.32, 95% CI, 1.10, 1.58; P = 0.003), and to pay rent or mortgage (aOR = 1.64, 95% CI, 1.07, 2.52; P = 0.02). Medicare beneficiaries with a self-reported history of depression were more likely to report feeling less financially secure (aOR = 1.43, 95% CI, 1.22, 1.68; P < 0.001), more stressed or anxious (aOR = 1.68, 95% CI, 1.49, 1.90; P < 0.001), more lonely or sad (aOR = 1.97, 95% CI, 1.68, 2.31; P < 0.001), and less socially connected (aOR = 1.27, 95% CI, 1.10, 1.47; P = 0.001). CONCLUSION: A self-reported history of depression was associated with greater inability to access care, more unmet social needs, and poorer economic and mental health outcomes, suggesting greater risk for adverse health outcomes during COVID-19.

Medical Students' Demographic Characteristics and Their Perceptions of Faculty Role Modeling of Respect for Diversity.

Importance: Faculty role modeling is critical to medical students' professional development to provide culturally adept, patient-centered care. However, little is known about students' perceptions of faculty role modeling of respect for diversity. Objective: To examine whether variation exists in medical students' perceptions of faculty role modeling of respect for diversity by student demographic characteristics. Design, Setting, and Participants: This cross-sectional study analyzed data from the Association of American Medical Colleges' 2016 and 2017 Medical School Graduation Questionnaire, which was administered to graduating students at 140 accredited allopathic US medical schools. Data were analyzed from January 1 to November 1, 2020. Main Outcomes and Measures: Students' perceptions of faculty role modeling of respect for diversity by the independent variables sex, race/ethnicity, sexual orientation, and age. Multivariable logistic regression was used to examine the extent to which student-reported perceptions of faculty respect for diversity varied by demographic characteristics, and logistic regression models were sequentially adjusted first for demographic characteristics and then for marital status and financial variables. Results: Of 30 651 students who completed the survey, the final study sample consisted of 28 778 respondents, representing 75.4% of the 38 160 total US medical school graduates in 2016 and 2017. Of the respondents, 14 804 (51.4%) were male participants and 1506 (5.2%) identified as lesbian, gay, or bisexual (LGB); a total of 11 926 respondents (41.4%) were 26 years or younger. A total of 17 159 respondents (59.6%) identified as White, 5958 (20.7%) as Asian, 1469 (5.1%) as Black/African American, 2431 (8.4%) as Hispanic/Latinx, and 87 (0.3%) as American Indian/Alaska Native/Native Hawaiian/Pacific Islander individuals. Overall, 5101 students (17.7%) reported perceiving that faculty showed a lack of respect for diversity. Of those who identified as Black/African American students, 540 (36.8%) reported perceiving a lack of faculty respect for diversity compared with 2468 White students (14.4%), with an OR of perceived lack of respect of 3.24 (95% CI, 2.86-3.66) after adjusting for other demographic characteristics and covariates. American Indian/Alaska Native/Native Hawaiian/Pacific Islander (OR, 1.73; 95% CI, 1.03-2.92), Asian (OR, 1.62; 95% CI, 1.49-1.75), or Hispanic/Latinx (OR, 1.43; 95% CI, 1.26-1.75) students also had greater odds of perceiving a lack of faculty respect for diversity compared with White students. Female students had greater odds compared with male students (OR, 1.17; 95% CI, 1.10-1.25), and students who identified as LGB (OR, 1.96; 95% CI, 1.74-2.22) or unknown sexual orientation (OR, 1.79; 95% CI, 1.29-2.47) had greater odds compared with heterosexual students. Students aged 33 years or older had greater odds of reporting a perceived lack of respect compared with students aged 26 years or younger (OR, 1.81; 95% CI, 1.58-2.08). Conclusions and Relevance: In this cross-sectional study, female students, students belonging to racial/ethnic minority groups, and LGB students disproportionately reported perceiving a lack of respect for diversity among faculty, which has important implications for patient care, the learning environment, and the well-being of medical trainees.

Implementing the Street Psychiatry Model in New Haven, CT: Community-Based Care for People Experiencing Unsheltered Homelessness.

"Street psychiatry" is an innovative model that serves people experiencing unsheltered homelessness, a vulnerable population with increased rates of mental illness and substance use disorders. Through community-based delivery of mental health and addiction treatment, street psychiatry helps the street-dwelling population overcome barriers to accessing care through traditional routes. Throughout the United States, street psychiatry programs have arisen in multiple cities, often in partnership with street medicine programs. We discuss the philosophy of street psychiatry, document operational highlights involved in the development of a street psychiatry program in New Haven, CT, suggest key ingredients to implementing a street psychiatry program, and explore challenges and future frontiers. Street psychiatry is an effective person-centered model of service delivery with the potential to be applied in a variety of urban settings to serve people experiencing street homelessness.

Perspectives of Internal Medicine Residency Program Directors on the Accreditation Council for Graduate Medical Education (ACGME) Diversity Standards.

BACKGROUND: To increase diversity and inclusion in graduate medical education, the Accreditation Council for Graduate Medical Education (ACGME) issued a revision to their Common Program Requirements during the 2019-2020 academic year mandating that all residency programs must have policies and practices to achieve appropriate diversity among trainees and faculty. OBJECTIVE: To explore the perspectives of internal medicine program directors (PDs) and associate program directors (APDs) on the ACGME diversity standard. DESIGN: Qualitative study of internal medicine residency program leadership from academic and community programs across the USA. PARTICIPANTS: Current PDs (n = 12) and APDs (n = 8) of accredited US internal medicine residency programs. APPROACH: We conducted semi-structured, in-depth qualitative interviews. Data was analyzed using the constant comparative method to extract recurrent themes. KEY RESULTS: Three main themes, described by participants, were identified: (1) internal medicine PDs and APDs had limited knowledge of the new Common Program Requirement relating to diversity; (2) program leaders expressed concern that the diversity standard reaches beyond the PDs' scope of influence and lack of institutional commitment to the successful implementation of diversity standards; (3) participants described narrow view of diversity and inclusion efforts focusing on recruitment strategies during the interview season. CONCLUSIONS: Our findings of lack of familiarity with the new diversity standards, and limited institutional investment in diversity and inclusion efforts raise a concern about successful implementation across GME programs. Nevertheless, our finding suggests that structured implementation in the form of education, guideposts, and financial allocation can alleviate some of the concerns of program leadership in meeting the new ACGME diversity standard in a meaningful way.