Does Race and Ethnicity Influence the Relationship between Community-Level Characteristics and Healthcare Access and Utilization Among Individuals with Mental Illness?

Background and Purpose: Health disparities based on race and ethnicity have long been documented in the United States, with people of color disproportionately bearing the burden of chronic conditions such obesity, diabetes, and heart disease. These disparities are further amplified for people of color who have mental illness (MI). The social determinants of health suggest that community-level characteristics, such as area-level deprivation and residential stability, contribute to health outcomes and disparities. Community-level characteristics might be particularly salient drivers of health and healthcare outcomes among racial and ethnic minorities with MI who face disproportionately high rates of exposure to neighborhood stressors. However, there is a paucity of research examining how the impact of community-level factors on healthcare access and utilization among individuals with MI varies based on an individual’s race and ethnicity.

Methods: A national sample of people with MI (N=5,444) was established using data from the Medical Expenditure Panel Survey (MEPS; 2013-2017). Mental health (MH) diagnoses included schizophrenia and psychotic disorder, bipolar disorder, and depressive disorders. Community-level independent variables (IV) included the Area Deprivation Index (ADI) and an indicator of Residential Stability. The moderating effect of race and ethnicity on the relationship between community-level IVs and healthcare access and utilization was examined using logical regression models. A healthcare visit was considered “mental health focused” (MH-focused) if it included a mental health provider, diagnosis, or medication. All other visits were considered "general" healthcare.

Results: Moderation analysis revealed that community-level residential stability significantly reduced delaying needed care (OR = 0.73, p < .05) and delaying prescription medication (OR = 0.79, p < .05) among Black individuals, but not among White individuals. Increased community-level residential stability decreased the odds of forgoing needed care among Latinx individuals (OR = 0.72, p < .01), but not among White individuals.

Higher area-level deprivation was associated with decreased MH-focused office-based care among White individuals (OR = 0.96, p < .05), but this relationship was not found to be significant among Latinx individuals. Finally, residential stability was found to significantly decrease general outpatient care and emergency room use among Latinx individuals (ORs = 0.82 and 0.84, p < .05), but this relationship was not found among White individuals in the sample.

Conclusion and Implications: Area-level deprivation was negatively associated with using MH-focused care for White individuals but not for Latinx individuals. This might be indicative of a range of barriers that impede Latinx individuals with MI from engaging in mental healthcare regardless of community-level SES. Community-level residential stability appeared to be a protective factor against delaying and forgoing needed care among Black and Latinx individuals. Previous studies have shown that social networks and social support systems, particularly among Black and Latinx communities, can influence the perceived need for care, the willingness of individuals to initiate care, and serve as informal sources of care. Narrowing disparities in health and healthcare outcomes will require programs and policies that are responsive to community contexts.