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Race/Ethnicity and Geographic Access to Medicaid Substance Use Disorder Treatment Facilities in the United States

Janet R. Cummings, PhD1; Hefei Wen, BA1; Michelle Ko, MD, PhD2; Benjamin G. Druss, MD, MPH1
[+] Author Affiliations
1Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia
2Department of Medicine, University of California, San Francisco
JAMA Psychiatry. 2014;71(2):190-196. doi:10.1001/jamapsychiatry.2013.3575.
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Importance  Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees.

Objective  To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure.

Design, Setting, and Participants  We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population.

Main Outcomes and Measures  Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid.

Results  Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect [ME],  −3.1; 95% CI,  −5.2% to −0.9%), rural (−9.2%; −11.1% to −7.4%), and/or uninsured (−9.5%; −13.0% to −5.9%) residents are less likely to have one of these facilities.

Conclusions and Relevance  The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.

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Access to Outpatient Substance Use Treatment Facilities That Accept Medicaid Across US Counties

Data from the 2009 National Survey of Substance Abuse Treatment Services.21

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