Beyond Access and Representation: Building the Next Phase of Health Equity

We have spent years working toward access.

More providers.
More programs.
More representation.
More conversations about mental health than ever before.

And yet, something still does not fully add up.

Because access does not automatically lead to utilization. And representation alone does not guarantee care that feels safe, responsive, or deeply aligned with the lived experience of the person sitting in front of us.

This is not a failure of progress. Many of the changes we have fought for were necessary. Reducing stigma matters. Seeing providers who look like you matters. Expanding telehealth has removed barriers that once felt immovable.

But if we are honest, these were foundation building efforts. They were never meant to be the final destination.

We are now entering a new phase of health equity work. And it requires us to ask harder questions.

Access does not equal utilization

We often talk about increasing access as if it automatically leads to better outcomes. But anyone working closely with communities knows that access alone is not enough.

Many people who recognize their mental health needs still do not seek care. Others start services but do not stay engaged. Programs with strong funding struggle with participation despite clear community need.

Why?

Because utilization is deeply tied to trust.

When people believe that systems have historically dismissed, harmed, or misunderstood them, they do not naturally run toward those same systems when they need support. Even when services are technically available.

Trust is built through experience, not availability.

Representation is important. Attunement is essential.

Over the last decade, we have made meaningful strides toward increasing representation in healthcare. There are more visible Black clinicians, more diverse providers, and more conversations about culturally responsive care.

This matters deeply.

But representation alone does not ensure that care feels culturally attuned.

Cultural competence often focuses on learning about groups. Cultural attunement focuses on learning how to be present with people.

Attunement means recognizing that survival strategies are not automatically pathology. It means understanding historical context without requiring clients to educate us about it. It means seeing identity not as a demographic checkbox but as part of the nervous system, relationships, and lived reality.

Representation can open the door. Attunement determines whether someone feels safe enough to stay.

The paradox of modern access

We are living in a moment where more people than ever are openly discussing mental health. Young adults are naming patterns in their families. People are identifying symptoms and language through social media. Psychological literacy is expanding.

At the same time, healthcare remains one of the few systems where people often do not know what something will cost until after they receive it.

Virtual care means you may not need an office. But affordability, insurance complexity, and fragmented systems still create invisible barriers.

And many of the current gains disproportionately benefit individuals with strong employer sponsored insurance or higher economic stability.

For others, the reality often feels like this: mediocre quality care at a high cost.

Programs are multiplying. Engagement is not.

Across the country, new initiatives are constantly being launched. Funding streams encourage innovation, pilot programs, and rapid expansion.

Yet many mobilizers quietly share the same challenge. Utilization is lower than expected. Sustainability becomes fragile.

This is not because communities do not care about their health.

It is because many services do not fully account for the complexity of life outside the appointment.

Care that does not integrate social context, stress load, caregiving roles, cultural meaning making, and systemic realities often feels incomplete.

When care feels incomplete, people disengage.

The shift from quantity to quality

The next era of health equity must move beyond expanding services toward refining them.

Quality must take priority over quantity.

This might look like fewer overlapping programs and more integrated initiatives. It might mean funding completion of care cycles rather than rewarding volume alone.

It may require us to rethink what counts as legitimate treatment.

Somatic work, embodied practices, and integrative approaches should not exist at the margins of care. They belong alongside traditional medical and psychological interventions when supported by evidence and clinical wisdom.

And integration cannot depend on everyone working within the same hospital system. Coordination must become easier, more fluid, and less constrained by institutional boundaries.

Building systems that can actually hold people

Social determinants of health are widely acknowledged, but often poorly integrated into practice.

We know that health outcomes are shaped by more than biology. Stress exposure, economic pressure, caregiving roles, cultural expectations, and historical harm all live alongside physical symptoms.

The systems we build must be capable of holding this full context.

That means moving away from fragmented models where patients are expected to carry the burden of coordination themselves.

It also means creating environments where providers are supported to focus on healing rather than navigating administrative complexity that pulls them away from meaningful care.

A call forward

We know how to rally people around change. History shows that transformation often begins with a relatively small group willing to engage deeply.

The question now is not whether we know what needs to shift.

The question is whether we are ready to move beyond legacy models that focused on access alone and step into a deeper commitment to quality, attunement, and integration.

What would it look like if we stopped asking only how many services exist and started asking whether those services actually meet the full reality of people’s lives?

What would change if trust became the primary outcome we measured?

The next phase of health equity will not come from simply spreading existing services wider and farther. It will come from building on the strong foundation of access and representation and shifting our focus from who provides care to how care is practiced and coordinated.

CONTRIBUTED BY:
Dr. Bri Beverly, PhD, LPC
Founder, Lotus Life Total Wellness
Supporting whole person healing through integrated, culturally attuned care and systems transformation.

Evidence map

1. Black people experience excess deaths and years of potential life lost

   • Large national analysis using CDC mortality data found 1.63 million excess deaths and more than 80 million excess years of potential life lost for the US Black population compared with the White population from 1999 to 2020.  

2. Social determinants of health matter and “health care access and quality” is a core domain

   • Healthy People 2030 explicitly defines SDOH domains, including Health Care Access and Quality.  

   • CDC also frames SDOH domains similarly and links them to national objectives.  

3. Access does not automatically translate into utilization and unmet need remains high

   • National data show large treatment gaps. In 2023, among adults with any mental illness, a substantial share did not receive treatment.  

   • Among young adults specifically, national survey analysis documents symptoms, service use, and unmet need during the COVID period.  

4. Trust and medical mistrust are tied to lower engagement or delayed care

   • Medical mistrust and racism were associated with delays in preventive health screening among African American men.  

   • Recent work continues to document medical mistrust as a barrier and examines how Black patients mitigate mistrust in care settings.  

5. Representation alone does not guarantee culturally attuned care and the field is moving beyond “competence”

   • Cultural humility was proposed as a critical distinction from cultural competence in clinician training, emphasizing lifelong self evaluation and power awareness.  

   • “Cultural attunement” is used in the intervention adaptation literature as an engagement and retention strategy that improves fit without changing core components.  

6. Healthcare pricing is opaque and policy efforts exist because patients often cannot anticipate costs

   • CMS created and enforces hospital price transparency requirements intended to help people see prices before care.  

   • Ethics and policy analysis describes why price transparency is sought and what it can and cannot solve in the US system.  

7. Cost barriers remain even with insurance and disproportionately affect Black adults and uninsured adults

   • KFF reports affordability difficulty and highlights disproportionate burden for Black adults and the uninsured.  

   • Peterson KFF Health System Tracker summarizes differences in delaying or foregoing care due to cost by insurance status.  

8. Young people increasingly use social media for mental health information and self diagnosis trends exist

   • Peer reviewed paper specifically examines TikTok inspired self diagnosis and implications.  

   • Content quality study of ADHD TikTok videos evaluates misleading versus useful content and quality metrics.  

   • Pilot research on social media and self diagnosis in youth entering treatment supports that social media is used in diagnosis beliefs.  

9. Telehealth reduces some access barriers but digital divide issues and disparities persist

   • Evidence documents disparities in telehealth access and participation, including underparticipation patterns and structural barriers.  

   • Digital connectivity constraints are linked to no show risk in telehealth.  

10. Somatic and body oriented interventions have a growing evidence base and are discussed as viable modalities

• • Scoping review finds preliminary evidence for Somatic Experiencing and improvements across PTSD related outcomes.  

  • Updated systematic review and meta analysis suggests body and movement oriented interventions may reduce PTSD symptoms and related secondary symptoms.  

11. The “3.5%” participation heuristic for major political change

    • The underlying empirical work is commonly attributed to Chenoweth and Stephan’s large campaign dataset and later synthesis.  

    • Note: the strong claim “never failed” is widely repeated but also frequently described as a descriptive pattern, not a guarantee.