Rural and Urban Differences in Access to Mental Health Care Among Medicaid Enrolled Children

Purpose: One of the primary goals of health care reform is to ensure equitable access to healthcare and eliminate geographic disparities. Studies suggest that rural populations are particularly vulnerable to access problems due to the demographic composition of individuals residing in these areas and contextual characteristics (Reschovsky & Staiti, 2005). The purpose of this study was to examine rural and urban differences in access to mental health care (defined as the utilization of inpatient, outpatient, or emergency room services) for children enrolled in Ohio's Medicaid program.

Methods: The study population (N=100,985) included all youths under age 18 who had: 1) a primary mental health diagnosis; 2) at least one service claim for an outpatient, inpatient, or emergency room visit associated with a mental health disorder; and 3) were continuously enrolled in Medicaid during fiscal year 2008. Data on individual (age, race/ethnicity, gender), clinical (primary psychiatric diagnosis, comorbidities, prior service use) and contextual (provider supply, health care facilities, socio-demographics) characteristics of Ohio's counties were abstracted from Medicaid eligibility and claims files, the Area Resource File, and the Ohio State Psychology and Social Work Licensure Boards. The primary explanatory variable, urban/rural status, was derived from the individual's county of residence and classified into three categories based on the Urban Influence Codes: metro (UIC categories 1, 2; population ≥ 50,000), micro (UIC categories 3, 5, and 8; population ≥ 10,000 and < 50,000 ), and rural (UIC categories 4, 6, 7, 9-12; population < 10,000) (ERS, 2003). Multivariate negative binomial regression and logistic regression analyses were used to examine rural and urban differences in utilization of mental health services. Results: The results indicated significant differences in the utilization of outpatient mental health services χ² = 87.8, df = 2, p < 0.001), inpatient (χ² = 98.5, df = 2, p < 0.0001), and emergency room services (χ² = 26.0, df = 2, p < 0.0001) for youths living in rural areas compared to those living in metro or micro areas. Controlling for individual and contextual-level variables, youths who lived in rural areas had a 14% decrease in the number of outpatient visits (Incident Rate Ratio [IRR] = 0.86, p < 0.001), a 37% decrease in the odds of being admitted to a psychiatric hospital (Odds Ratio [OR] = 0.63, p < 0.001), and a 36% decrease in the odds of being admitted to an emergency room (OR = 0.64, p = 0.006).

Discussion: Study findings highlight geographic disparities in access to mental health services for children in Medicaid. Policy efforts directed towards improving access should address inadequate provider supply and social/structural factors (e.g., poverty) that contribute to poor access for rural residents. Further research is warranted to identify other potential access barriers for youths living in rural areas.