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Barriers to Financing Cultural Competence

An Opinion by Michael B. Friedman, CSW
First Published in Mental Health News, Fall 2004

Creating a culturally competent mental health system requires vast efforts:

To assure access to needed, state-of-the art services,
To organize services in ways which engage, and are effective with, cultural minorities,
To build a culturally competent workforce,
To set research priorities which will result in state-of-the-art practices relevant to cultural minorities, and
To establish a leadership structure through which minorities can have a strong enough voice to influence the systems through which they are served.

Meeting these challenges will take great inventiveness. It will take money. And ultimately it will also require the political will to create a mental health system that is socially just.

How will we finance the creation of a culturally competent mental health system?

Recently I was privileged to moderate a panel on barriers to financing state-of-the-art services for people of color at a wonderful conference organized by the Institute for Community Living in Brooklyn. Tara Sher from Citizen’s Committee for Children and Ed Smith from The Coalition of Voluntary Mental Health Agencies joined me on the panel. Tara focused on children, Ed focused on adults, and I focused on older adults.

I wish I could say that the discussion that took place revealed the answers to the question of how to finance cultural competence. It did not. But it did reveal a great deal about the difficulties that have to be confronted. Here are some of the major themes that emerged.

Financing Cultural Competence Is A Challenge That Must Be Taken On in the Private Sector As Well As The Public Sector

Lack of insurance coverage and the failure of health insurance to provide adequate coverage of mental health conditions and non-traditional services is a major problem for minorities who need mental health services. When we think about cultural minorities, there is a tendency to think first about the inadequacy of public health insurance—for example, of problems of eligibility for Medicaid or of lack of parity in Child Health Plus and Medicare. But most people of color are working people, who ought to have mental health insurance coverage through work. It is important, of course, to press for extending coverage provided by the public sector; but unless this nation moves to universal health coverage, it will also be important to press the private sector to provide adequate mental health insurance coverage.

Funding Structures Out of Alignment With Service Needs and Goals

Funding structures for mental health services are fundamentally out of alignment with the realities of providing good services for cultural minorities.

For example, funding for health and mental health services in the United States is built on the expectation that people who need services will go to sites where services are provided. Providers wait for people to come to them rather than reaching out to people in their homes and communities. This approach to service provision creates special problems for cultural minorities because, as Lloyd Rogler has observed, different cultures follow different pathways to help. Funding needs to be structured so that mental health providers can place themselves along these pathways, at sites where people from cultural minorities will naturally turn for help.

In addition, funding sources for mental health services tend to draw from medical models of service which leave out of account not only the need for outreach into indigenous communities but also the need for family support, case management, integrated cross-system services, and the like.

Fragmentation of Funding Sources Contributes to Failure to Provide Integrated Services

People who are poor—and in the United States people of color are disproportionately poor—tend to have multiple problems to confront. They are not likely to be just depressed.

Adults may also be struggling:

To hold onto, or to get, jobs
To make rent payments or find housing
To feed and clothe their families
To be available when their children need them
To protect themselves from domestic violence

Children may be struggling:

To get by in school
To handle peer pressures that steer them in dangerous directions
To find a bi-cultural identity
To survive child abuse

Older adults may:

Have lost touch with family and friends
Have nothing to do which gives them a sense of satisfaction and meaning
Be homebound
Be so financially strapped that they have to choose between food and medications.

Our society responds to people with multiple problems with categorical systems of service, which address one need at a time. As a result it becomes exceedingly difficult to create integrated systems of service such as school-based services, integrated treatment for people with co-occurring mental and addictive disorders, integrated health and mental health services among other things. It is important, I think, to understand that the bureaucratic obstacles to integrated service result from humane impulses that lead to categorical benefits and not from lack of societal concern or the incompetence of bureaucrats. Fragmentation is rooted in the basic structure of our nation’s system of health and human services and does not just reflect what is dismissively and simplistically referred to these days as a “silo mentality.”

Additional Funding Needed

The claim that we don’t need more money but only restructuring has become increasingly commonplace among public officials trying to figure out how to balance budgets and among advocates trying to persuade public officials that social transformation will reduce costs. The discussion during our panel provided little reason to believe that this is true.

How without additional funding will we be able to substantially increase the capacity of the service system, make it mobile, and disperse it into indigenous communities?
How will we pay for training and education to build clinical and cultural competence?
How will we expand research so that it produces findings applicable to cultural minorities?

Political Will Required to Address These Challenges

Barriers to financing a culturally competent mental health system will not be easy to overcome. Engaging the private sector as well as the public sector, substantial restructuring of financing mechanisms; and funding for increased service capacity, training, and research are all profoundly difficult to achieve. Does the political will exist to take on these challenges? Participants in the ICL conference expressed a fundamental cynicism about our society’s willingness to honestly confront the needs of cultural minorities.

Thus our panel and the conference overall ultimately became a call to action, a call to create the political will without which the challenges of creating and financing a culturally competent mental health system cannot be met.

(Michael B. Friedman is the Director of the Center for Policy and Advocacy of The Mental Health Associations of New York City and Westchester. He can be reached at center@mhaofnyc.org. The opinions in this article are his own and do not necessarily reflect the positions of The Mental Health Associations.)

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