title: Geography and the Medicaid mental health care infrastructure: implications for health care reform.
abstract: OBJECTIVE
  Medicaid is the largest payer of mental health (MH) care in the United States, and this role will increase among states that opt into the Medicaid expansion. However, owing to the dearth of MH care providers who accept Medicaid, expanded coverage may not increase access to services. Facilities that provide specialty outpatient MH services and accept Medicaid compose the backbone of the community-based treatment infrastructure for Medicaid enrollees. For states that opt into the expansion, it is important to understand which local communities may face the greatest barriers to access these facilities.
  
  
  OBJECTIVE
  To examine the availability of outpatient MH facilities that accept Medicaid across US counties and whether specific types of communities are more likely to lack this infrastructure.
  
  
  METHODS
  Data from the 2008 National Survey of Mental Health Treatment Facilities and Area Resource File were merged. A generalized ordered logistic regression with state fixed effects was estimated to examine determinants of accessibility of these facilities. Covariates included the percentages of residents who are black, Hispanic, living in poverty, and living in a rural area.
  
  
  METHODS
  An ordered variable assessed whether a county had no access to outpatient MH facilities that accept Medicaid, intermediate access to these facilities (ie, ≥1 facility, but not top quintile of facility to Medicaid enrollee per capita ratio), or high access (ie, top quintile of facility to Medicaid enrollee per capita ratio).
  
  
  RESULTS
  More than one-third of counties do not have any outpatient MH facilities that accept Medicaid. Communities with a larger percentage of residents who are black (marginal effect [ME] = 3.9%; 95% CI, 1.2%-6.6%), Hispanic (ME = 4.8%; 95% CI, 2.3%-7.4%), or living in a rural area (ME = 27.9%; 95% CI, 25.3%-30.4%) are more likely to lack these facilities.
  
  
  CONCLUSIONS
  Many communities may face constraints on the MH safety-net system as Medicaid is expanded, especially rural communities and communities with a large percentage of black or Hispanic residents.
authors: Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors: Janet R
authors: JR
authors: Cummings
authors: Hefei
authors: H
authors: Wen
authors: Michelle
authors: M
authors: Ko
authors: Benjamin G
authors: BG
authors: Druss
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D018166:Health Care Reform; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006630:Hispanic or Latino / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008484:Medicaid; D012424:Rural Population / Q000706:statistics & numerical data; D019371:Topography, Medical; D014481:United States
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