Erick Guerrero¹, Jin Ye Yeo²

¹I-Lead Institute, Research to End Healthcare Disparities Corp, Santa Monica, CA, USA; ²JHMHP Editorial Office, AME Publishing Company

Correspondence to: Jin Ye Yeo. JHMHP Editorial Office, AME Publishing Company. Email: jhmhp@amegroups.com

Expert introduction

Dr. Erick Guerrero (Figure 1) completed his Ph.D. at University of Chicago in 2009 and was granted tenure at University of Southern California in 2016. His sub-fields and areas of research are implementation and organization science, healthcare disparities and delivery of culturally responsive and evidence-based practices. Since 2018, Dr. Guerrero has been serving as the Founder and Research Director at the I-LEAD Institute, Research to End Healthcare Disparities Corp. Dr. Guerrero has published more than 100 peer-review articles in management, cultural competence and evidence-based practices. He is currently leading research studies in effective drug prevention and treatment, as well as integration of primary and behavioral care in the United States, Mexico and some European countries.

Figure 1 Dr. Erick Guerrero

Interview

JHMHP: What drove you to pursue social work, and subsequently focus on implementation and organization science? Were there any key events that ignited your interest in the field?

Dr. Guerrero: My interest in social work was derived from social work’s focus on helping the most vulnerable members of our society. I have always wanted, as a personal goal, to help those who have little, but also those who are struggling with health issues. Growing up in Mexico City, I saw a lot of need for healthcare services. There were a lot of community and family members who were affected by different types of diseases, anywhere from diabetes, cancer, addictions, and mental health issues. Since I was young, I was sensitive to those issues, which motivated me to pursue a career in the helping profession, as a clinician and later, as an organizational researcher to understand the different macro-systems, policies, service delivery, as well as the community needs of those who struggle to get needed healthcare. I have pursued questions about healthcare access for the past 25 years. I thought that implementation science and organization science would give me the tools to understand how systems of care work and how to help improve them.

JHMHP: Could you provide a brief overview of the current landscape of healthcare disparities in the United States? How have healthcare disparities in the United States (US) evolved over the years?

Dr. Guerrero: Healthcare disparities have been around for a long time. But it is only about the last 30 years that we started paying attention to this issue in the United States. First, we have focused on White-Black differences across the healthcare system, and now we have recognized differences across different vulnerable populations, including Asian and Hispanic/Latinos. Neglecting the sources of disparities have led to the current opioid overdose and mental health epidemics. It is partially due to the under-resourced system of prevention that is unable to respond adequately to the healthcare needs of vulnerable populations. Even though there have been a significant amount of resources and research in healthcare services to respond to underserved groups including early detection of breast cancer and autoimmune diseases and identification of substance abuse and mental health issues for racial ethnic minorities often referred to as minoritized communities, that state of disparity continues. There has been more understanding of what these disparities are, and how their social determinants produce these disparities. These determinants generally include issues like poverty, unemployment, environments where there is high risk for substance abuse and mental health, and communities with limited access to nutritional food, recreational parks, and healthcare and social services.

All these factors create these social determinants that tend to exacerbate these disparities. We actually wrote a paper (1) on the disparities in access to opioid treatment and we identified how if you are a White and have insurance, you generally receive care faster and better. And how is that so? Whites are typically prescribed buprenorphine which is a medication that is more advanced and can be taken once a week or month which allows flexibility, versus methadone, which is a highly regulated medication that is delivered daily in treatment centers and usually limited to minority communities. Individuals have to receive the medication from these centers every day. This bifurcated system produces disparities in access to medication, as well as in response to treatment (1).

To conclude about the state of disparity now, I think we know a lot more about it but the interventions to address them have been very limited. Even though more financial support has been put into it, this has not addressed the problem of disparity as a whole, so we have a long way to go.

JHMHP: Are there any aspects of healthcare disparity research that you believe have been overlooked or received insufficient attention?

Dr. Guerrero: I think the areas of financing healthcare systems to improve access to care specially to reduce disparities in people coming into care have received insufficient attention. Policies in payment systems could be implemented to ensure that organizations in the healthcare system, in this case my specialty is in mental health and behavioral health, have ongoing funding. As a result, they can continue to not only serve people but be able to maintain the quality of care that makes a difference in health.

For instance, in the US, the Affordable Care Act (ACA) that included policies that allow Medicaid expansion, meaning public insurance for everyone helped a great deal to enhance access to care.  Those states that expanded public health insurance had higher access to opioid treatment, compared to those who did not have Medicaid expansion. This is one example of how financing could work. It has been under-explored because even though there has been some research that does show this, there have been missing opportunities to create interventions at the county and state level, where more people get covered, as well as treatment programs or healthcare providers with more resources to be able to continue serving populations that generally would not receive treatment. One of the top three reasons why somebody with an addiction or mental health issue does not receive care includes not being able to pay. Hence that is a critical piece that needs to be tackled.

JHMHP: In your recent research studying the effects of uncertainty in substance use treatment programs, findings showed that the program, staff, and clients have varying influences on the prediction and response to change (2). In your opinion, which of these stakeholders has the most significant impact in reducing the difficulty of predicting and responding to changes?

Dr. Guerrero: The healthcare system has been underfunded. The US has spent more resources on healthcare than any other country in the world, and yet we have significant disparities across diseases and healthcare services. Firstly, there is insufficient investment in providing preventive care. Secondly, effective interventions generally are limited for those who are vulnerable, such as hard-to-reach populations or those who face significant stigma, leading to an environment of uncertainty. Another critical uncertainty environment is the funding system. Most behavioral health treatment programs face financial crises, on and off, throughout the years because they have limited funding. This limits the programs from hiring and maintaining staff when grant funding ends. By losing valued staff who are trained to provide a good standard of care, the programs lose their capacity to serve the same if not increasing number of patients coming in. Quality of care immediately gets impacted. There is a lot of uncertainty in the funding system that trickles down to quality of care. Thirdly, the workforce in the US is facing a crisis. There are not enough numbers of individuals completing degrees to prepare themselves for service in the field of behavioral health, especially in rural and sub-urban regions. These regions do not attract professionals so the treatment systems that serve rural communities face the most significant struggles and barriers, which also contribute to uncertainty. It requires state interventions to create or develop resources and policies to promote the workforce, to provide more stable funding, and to provide prevention services so that there are fewer people coming into the treatment systems.

JHMHP: To improve care delivery and outcomes of such treatment programs, interventions that facilitate effective prediction and response are needed. What are some strategies that you think can better facilitate effective prediction and response?

Dr. Guerrero: In addition to improving the funding systems mentioned previously, some regions of the country have highlighted the importance of supporting the behavioral health system. Some strategies we can adopt are: 1) to initiate federal and state appropriations of funds to improve the behavioral health system nationwide; 2) to identify the most effective interventions that could improve prevention services and to increase the quality of behavioral health. What does that entail? It involves having a trained workforce, having appropriate facilities, having resources to deliver care in a timely manner, and reducing stigma around people who need behavioral health interventions. Those are issues that systemically could be addressed. There have been significant efforts made in that regard but greater coordination of those efforts is necessary, and they have to be transparent so the communities can understand what the federal, state, county, and private sectors are doing to respond to these issues and be able to deliver quality of care and reduce the uncertainty for healthcare providers by having funds that are stable. If the behavioral health providers respond well by maintaining the standards of care that they provide and improving the methods of payment for these services so that everyone can receive care regardless of their financial status, only then will we be able to narrow or diminish the significant disparities in the quality of care received.

JHMHP: In addition to researching on effective drug prevention and treatment, your team also studies the integration of primary and behavioral care. What are some challenges faced in the integration of primary and behavioral care? How can the relevant stakeholders better support this integration?

Dr. Guerrero: The challenges of coordination across different entities and institutions have been millennial and there has not been a clear solution on how to bring in different entities to work together when they have very different goals and priorities. In healthcare, there is the same issue. There has always been significant interest in integrating care. We know that a portion of people who report to substance abuse or mental health treatment also have a primary physical health issue, and yet there have been limited effective efforts to integrate care. The only ones that are able to respond to these issues are generally large healthcare centers. They facilitate integrated care in one site, yet the way they respond is not perfect. For example, patients who are treated with diabetes but who also have an alcohol use disorder may not attend alcohol disorder treatment when referred because of stigma, limited ability to pay, lack of an integrated care team, etc. Hence, we still have to explore ways to promote understanding of the importance of behavioral health and engage people effectively. 

We need to rethink our system of care and try to bring in more community navigators and family members in decisions about healthcare and in supporting our patients. We need to involve the community rather than just the healthcare professionals to better support the recovery of individuals who do not agree or abide by the recommendations.

JHMHP: How has your experience been as an Editorial Board Member of JHMHP?

Dr. Guerrero: The journal has been very professional and timely, and engaged the editorial board members. I have led a special series on “Organizational Approaches to Implement Rapid Change in Hospitals to Respond to Public Health Emergencies” and am planning another series on “System Level Interventions to Improve Access to Prevention and Treatment of Mental Health and Substance Use Disorders”. It has been a great experience and we always get great responses from the journal and the scientific community.

JHMHP: As an Editorial Board Member, what are your expectations for JHMHP?

Dr. Guerrero: To continue their level of presence in the field, their productivity, and having high standards in all aspects of the publication process, anywhere from the solicitation, engagement of authors, and the submission. All of the journals now have platforms online so I think as an Editorial Board Member and active author of articles, having a very effective and responsive submission platform is critical for authors. There is an increasing number of authors who want a timely response typically within a month for review, and being able to have a review that has quality shows that the journal has a pool of experts in that area that are able to be summoned to do quality reviews. As an Editorial Board Member, that is not only something I expect, but also something I can provide, such as being a reviewer that can provide timely response with a certain level of rigor. This way, everyone benefits. The author benefits such that their work is highly vetted and for the journal, we feel proud that we are helping authors move their work in the best light possible, and ultimately, this extends knowledge in the subject for the benefit of not only the scientific community, but also the society in healthcare.

Reference

1. Guerrero EG, Amaro H, Khachikian T, et al. A bifurcated opioid treatment system and widening insidious disparities. Addict Behav. 2022;130:107296.
2. Frimpong JA, Guerrero EG, Kong Y, et al. Predicting and responding to change: Perceived environmental uncertainty among substance use disorder treatment programs. J Subst Use Addict Treat. 2023;145:208947.