Abstract
In an equitable mental health system, the only factor determining use of services would be need, as indicated by impairment and disability. Once need was taken into account, service use would not be affected by factors such as income, education, location of residence, gender, or age.
In Australia, how well do mental health services live up to this ideal? On the positive side, there is evidence that need is the major driver of mental health service use (Parslow and Jorm, 2000). On the other hand, it is well known that people living in remote areas have worse access, and that men are less likely to seek professional help than women. Policy makers can attempt to reduce such inequalities by funding special services to people in these groups (e.g. providing remote area services) or promoting greater use of existing services by these groups (e.g. promoting help-seeking by men).
Socioeconomic factors, like low income and low level of education, are important potential sources of inequality. Such factors are associated with worse mental health (Slade, 2007), so in an equitable system, people who are socioeconomically disadvantaged should also receive more mental health services. However, there has long been concern in Australia that this is not the case. Data from as far back as the 1980s showed that receiving psychiatric services tended to be associated with socioeconomic advantage rather than disadvantage (Jorm et al., 1993). Data from the 1990s also showed that, after adjusting for need, better-educated Australians were more likely to receive mental health services (Parslow and Jorm, 2000).
How does this disjunction between need and service provision arise? Australia has a universal national insurance scheme, Medicare, which aims to promote equality of access. On the other hand, this scheme has been tinkered with by governments over the years to require co-payments and to encourage individuals to take additional private insurance. These factors will tend to bias services to the socioeconomically advantaged.
A study published in the current issue of the journal examines whether private health insurance is a source of inequality for people with mental health problems. This study by Leach and colleagues (2012) used data from a large national longitudinal study, The Household Income Labour and Dynamics in Australia (HILDA) survey. As its name suggests, the focus of this study is economic, but it does include some basic health measures, including of mental health. The study found that people with mental health problems do indeed have a much lower rate of private health insurance. It might be expected that this difference would affect access to mental health services. However, the findings are reassuring. Among people with mental health problems, there was no difference in access to psychologist/psychiatrist services between those with and without private insurance. By contrast, people with mental health problems who had private insurance were more likely to get services from chiropractors, physiotherapists, and optometrists.
The conclusion is that private health insurance is not a contributor to socioeconomic inequality in access to mental health services. Why is this so? The authors of the study speculate that major reforms in the provision of mental health services over recent years may have had a role. Australia saw the introduction of the Better Outcomes in Mental Health Care programme in 2001 and the Better Access initiative in 2006, both of which increased the availability of general practitioner mental health services and specialized psychological services (Jorm, 2011; Pirkis et al., 2011a, 2011b, 2011c). The uptake from the more recent Better Access scheme has been spectacular, with one in 19 Australians receiving a service under this scheme in 2009 (Pirkis et al., 2011c). While there has been concern that the Better Access scheme might increase socioeconomic inequalities by hitting patients with out-of-pocket expenses and allowing private practitioners to favour practice in affluent urban areas, the socioeconomic differentials have been less than might have been expected (Jorm, 2011; Pirkis et al., 2011c). Uptake rates of Better Access services have been only 10% lower in the most disadvantaged areas compared to the most advantaged. Furthermore, the scheme has greatly increased access to mental health services to all sections of the population, including those in socioeconomically disadvantaged areas (Pirkis et al., 2011c) and has produced equally good outcomes for socioeconomically disadvantages patients (Pirkis et al., 2011b).
Arguably, the greatest concern from the Leach et al. (2012) study is that people with mental health problems who do not have private insurance have lower rates of allied health services for physical health problems. There is considerable evidence that people with mental health problems have high rates of physical comorbidity (Teesson et al., 2011) and higher mortality from all causes (Lawrence et al., 2000), which supports their need for greater physical health services.
See Research by Leach et al., 2012 46(5): 468-475