This weekend the New York Times reported on a new study which finds that kids on Medicaid are four times more likely to be prescribed antipsychotic drugs than their privately insured counterparts, and often for conditions for which the drugs are not FDA approved such as A.D.H.D. and conduct disorders. These drugs may not only have significant psychological impacts on the children who take them, but they also cause long-term physical harm. This is terrible no matter what, of course, but let us be very clear about what we are talking about here. In places like New York City, where African-Americans and Latinos are 3.5 times more likely to be on Medicaid than whites, the kids we are talking about are black and brown.
The children who are being systematically over-medicated and denied high quality mental and behavioral health services are disproportionately young people of color. What we are talking about, then, is race even if all but the most oblique reference to it has been scrubbed from the lines of the mainstream media coverage.
Let us also be clear about how this may be happening. The Times piece implies that certain problems with the Medicaid program, such as low reimbursement rates for therapy, contribute to the over-medication of children by creating incentives for doctors to prescribe antipsychotics or by reducing the availability of psychiatrists who accept Medicaid, thus funneling low-income kids to non-specialists who are more likely to provide treatment through drugs. This may very well be true, but let us unpack these dynamics as well from the racial justice tip.
In New York City, where I work, there are large, well-respected institutions providing high quality mental health services for children that refuse to accept Medicaid patients ostensibly because they don't pay that well. This can be viewed as a rational dollars-and-cents reaction to an inadequate Medicaid system, but when you consider the close relationship between insurance and race, it starts to look like a modern version of Whites Only. Such policies become all the more difficult to swallow when you compare them to the approach of some community-based health care providers that also exist in the city and manage to make mental health services available effectively and equitably.
The directors of clinical services at these community health centers will tell you about how they've figured out their administrative and billing infrastructure so they can work around some of Medicaid's challenges to provide high quality mental health care to all patients, regardless of their insurance. Providers like these fight alongside consumer advocates to preserve Medicaid and make it better because they recognize how critical it is to the lives of their patients. They don't retreat from the system or take shortcuts, hoping that poor kids of color and their mental health problems will just go somewhere else. Indeed, they bear responsibility for their colleagues at other institutions, who disguise their discrimination in the form of a "rational" economic calculus.
You can expect to hear more about the doping of America's children in the coming year, as more studies are released and blue-ribbon policy panels convened to address the problem. What you probably won't see are many efforts to write race into the story or the solution. That is our job as racial justice advocates: to read between the lines and move in from the margins.
Nisha Agarwal is the Director of the Health Justice Program at New York Lawyers for the Public Interest, where she began her legal career as a Skadden Public Interest Fellow. Ms. Agarwal's work at NYLPI focuses on bringing a racial justice and immigrant rights perspective to health care advocacy. In collaboration with community-based organizations and coalitions across New York City, Ms. Agarwal is working on campaigns on language rights in pharmacies, racial discrimination in hospitals, medical deportation, and the closure of community hospitals and clinics in medically under-served areas. Nisha is also active in the South Asian Bar Association of New York, where she serves as Vice President for Public Interest, and is the co-founder of the Harvard Law School Summer Theory Institute for public interest law students. Ms. Agarwal earned her BA, summa cum laude, from Harvard College in 2000 and received a British Marshall Scholarship for graduate studies at Oxford University. She received her JD from Harvard Law School in 2006.