State-Level Variation in the Availability of Spanish and Asian Language Public and Private Mental Health Services: The Role of Political Factors

Background and Purpose: Language concordance between mental health providers and clients with limited English proficiency (LEP) is critical for equitable access and effective care. However, the availability of language-specific mental health services varies significantly across the United States, and the systemic factors driving this variation are poorly understood, particularly for large LEP groups like Spanish speakers and diverse Asian language communities. This study examines the state-level geographic distribution and predictors of availability for both public/facility-based and private practitioner mental health services offered in Spanish and six major Asian languages (Chinese, Korean, Vietnamese, Tagalog, Japanese, Hindi). We specifically investigate the role of political factors alongside demographic and healthcare system characteristics.
Methods: We conducted a cross-sectional ecological study utilizing aggregated state-level data from national datasets. Service availability, representing potential access to language-concordant care, was measured via two distinct counts for each language: 1) facilities reporting language services in the comprehensive National Survey of Mental Health Treatment Services (N-SUMHSS 2023), proxying for public/organizational capacity, and 2) private practitioners self-reporting language proficiency in the widely used Psychology Today directory (January 2024), capturing the private sector. State-level predictors encompassed potential need (language-speaking population size), demographic context (median age, sex ratio, poverty rate), healthcare system factors (Medicaid spending per capita from CMS), and indicators of the political environment (Democratic-Republican vote difference in the presidential election, and the number of non-white US Congressional representatives). Negative binomial regression models were employed to assess associations.
Results: We identified substantial state-level disparities in terms of language availability for all language groups, with services concentrated in a few states (e.g., California, New York). Political factors emerged as strong predictors: a higher Democratic vote margin was significantly associated with increased availability of facilities for most languages, including Spanish (IRR=1.04, p<0.001), Chinese (IRR=1.04, p<0.01), Korean (IRR=1.04, p<0.05), Vietnamese (IRR=1.04, p<0.05), Tagalog (IRR=1.04, p<0.05), and Japanese (IRR=1.05, p<0.01). A higher number of non-white Congressional representatives was also associated with greater service availability, particularly demonstrating significant positive associations with therapist counts for Chinese (IRR=1.26, p<0.001), Vietnamese (IRR=1.19, p<0.01), Tagalog (IRR=1.22, p<0.05), and Korean (IRR=1.17, p<0.05) speaking populations. State language-speaking population size showed inconsistent associations, often significant for facilities (e.g., p<0.001 for Spanish, Korean, Japanese, Hindi) but generally not significant for therapist counts (p>0.05 for most Asian languages) after accounting for other factors. Poverty rates and Medicaid spending per capita were non-significant predictors of service availability (p>0.05) across most models.
Conclusions and Implications: Access to language-concordant mental health services for Spanish-speaking and major Asian language communities exhibits state-level disparities. This variation is strongly associated with state political environments (partisan lean) and legislative diversity (racial/ethnic representation). This misalignment underscores that service availability is shaped significantly by policy contexts, not just demographic demand. Strategies should include targeted service development and resource allocation in underserved regions, investing in multilingual provider training and recruitment pipelines, and advocating for state-level policies that prioritize and enforce language access standards.