Use of Medicaid Data to Explore Community Characteristics Associated with HIV Prevalence Among Beneficiaries with Schizophrenia

A 2006 report of the National Association of State Mental Health Program Directors (NASMHPD) called on the federal government to designate the population with serious mental illness as a health disparities group as part of an effort to slow an accelerating “epidemic of premature death” and morbidity among people with serious mental illness.1 The NASMHPD based these conclusions partly on estimates that in the public mental health system in eight states, patients die an average of 25 years earlier than their general population counterparts. Suicide and injury are estimated to account for about one-third of excess mortality, with most of the excess associated with chronic medical illnesses,2 particularly for diseases whose etiology implicates behavioral and environmental contributions, including cardiovascular and metabolic conditions, as well as infectious diseases.3–5 The report concluded that the elevated rates of disease and death in this population should be made a policy priority, requiring significant efforts to develop data sources necessary for meaningful surveillance, and that cooperative efforts between Medicaid and public health agencies could provide one important source for these efforts.1 The rarity with which the elevated morbidity and mortality among people with severe mental illness (SMI) has been described as evidence of health disparities is striking, both because many of the social structural processes that produce the disadvantages commonly tied to health disparities are associated with SMI and because the medical risks faced by people with SMI are arguably a paradigm case of “falling through the cracks” in a poorly configured public health and health-care system. Despite mention of definitions that include disabilities (presumably including those associated with psychiatric illness) as a disparities category alongside race/ethnicity, socioeconomic status, and others, neither of two recent reviews of health disparities does more than mention the drastic differences in disease burden found in this population.66,7