Index of cardiometabolic health: a new method of measuring allostatic load using electronic health records

OBJECTIVE

We developed a measure of allostatic load from electronic medical records (EMRs), which we named "Index of Cardiometabolic Health" (ICMH).

METHODS

Data were collected from participants' EMRs and a written survey in 2005. We computed allostatic load scores using the ICMH score and two previously described approaches.

RESULTS

We included 1865 employed adults who were 25-59 years old. Although the magnitude of the association was small, all methods of were predictive of SF-12 physical component subscales (all p < 0.001).

CONCLUSION

We found that the ICMH had similar relationships with health-related quality of life as previously reported in the literature.

Rethinking funding priorities in mental health research

Mental health research funding priorities in high-income countries must balance longer-term investment in identifying neurobiological mechanisms of disease with shorter-term funding of novel prevention and treatment strategies to alleviate the current burden of mental illness. Prioritising one area of science over others risks reduced returns on the entire scientific portfolio.

Unpacking Collaborative Care for Depression: Examining Two Essential Tasks for Implementation

OBJECTIVE

This study examined how two key process-of-care tasks of the collaborative care model (CCM) predict patient depression outcomes.

METHODS

Registry data were from a large implementation of the CCM in Washington State and included 5,439 patient-episodes for patients age 18 or older with a baseline Patient Health Questionnaire-9 (PHQ-9) score of ≥10 and at least one follow-up contact with the CCM care manager within 24 weeks of initial contact. Key CCM tasks examined were at least one care manager follow-up contact within four weeks of initial contact and at least one psychiatric consultation between weeks 8 and 12 for patients not responding to treatment by week 8. Clinically significant improvement in depression symptoms was defined as achieving a PHQ-9 score of <10 or a 50% or more reduction in PHQ-9 score compared with baseline. Bivariate and multivariate (logistic and proportional hazard models) analyses were conducted to examine how fidelity with either task predicted outcomes. All analyses were conducted with the original sample and with a propensity score-matched sample.

RESULTS

Four-week follow-up was associated with a greater likelihood of achieving improvement in depression (odds ratio [OR]=1.63, 95% confidence interval [CI]=1.23-2.17) and a shorter time to improvement (hazard ratio=2.06, CI=1.67-2.54). Psychiatric consultation was also associated with a greater likelihood of improvement (OR=1.44, CI=1.13-1.84) but not with a shorter time to improvement. Propensity score-matched analysis yielded very similar results.

CONCLUSIONS

Findings support efforts to improve fidelity to the two process-of-care tasks and to include these tasks among quality measures for CCM implementation.

Excess mortality due to depression and anxiety in the United States: results from a nationally representative survey

OBJECTIVES

We compared the mortality of persons with and without anxiety and depression in a nationally representative survey and examined the role of socioeconomic factors, chronic diseases and health behaviors in explaining excess mortality.

METHODS

The 1999 National Health Interview Survey was linked with mortality data through 2011. We calculated the hazard ratio (HR) for mortality by presence or absence of anxiety/depression and evaluated potential mediators. We calculated the population attributable risk of mortality for anxiety/depression.

RESULTS

Persons with anxiety/depression died 7.9 years earlier than other persons. At a population level, 3.5% of deaths were attributable to anxiety/depression. Adjusting for demographic factors, anxiety/depression was associated with an elevated risk of mortality [HR=1.61, 95% confidence interval (CI)=1.40, 1.84]. Chronic diseases and health behaviors explained much of the elevated risk. Adjusting for demographic factors, people with past-year contact with a mental health professional did not demonstrate excess mortality associated with anxiety/depression while those without contact did.

CONCLUSIONS

Anxiety/depression presents a mortality burden at both individual and population levels. Our findings are consistent with targeting health behaviors and physical illnesses as strategies for reducing this excess mortality among people with anxiety/depression.

Opening Doors to Recovery: Recidivism and Recovery Among Persons With Serious Mental Illnesses and Repeated Hospitalizations

OBJECTIVE

Repeated hospitalizations and arrests or incarcerations diminish the ability of individuals with serious mental illnesses to pursue recovery. Community mental health systems need new models to address recidivism as well as service fragmentation, lack of engagement by local stakeholders, and poor communication between mental health providers and the police. This study examined the initial effects on institutional recidivism and measures of recovery among persons enrolled in Opening Doors to Recovery, an intensive, team-based community support program for persons with mental illness and a history of inpatient psychiatric recidivism. A randomized controlled trial of the model is underway.

METHODS

The number of hospitalizations, days hospitalized, and arrests (all from state administrative sources) in the year before enrollment and during the first 12 months of enrollment in the program were compared. Longitudinal trajectories of recovery-using three self-report and five clinician-rated measures-were examined. Analyses accounted for baseline symptom severity and intensity of involvement in the program.

RESULTS

One hundred participants were enrolled, and 72 were included in the analyses. Hospitalizations decreased, from 1.9±1.6 to .6±.9 (p<.001), as did hospital days, from 27.6±36.4 to 14.9±41.3 (p<.001), although number of arrests (which are rare events) did not. Significant linear trends were observed for recovery measures, and trajectories of improvement were apparent across the entire follow-up period.

CONCLUSIONS

Opening Doors to Recovery holds promise as a new service approach for reducing hospital recidivism and promoting recovery in community mental health systems and is deserving of further controlled testing.

Effect of Medicaid Expansions on Health Insurance Coverage and Access to Care among Low-Income Adults with Behavioral Health Conditions

OBJECTIVE

To examine the effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions.

DATA SOURCES/STUDY SETTING

Nine years (2004-2012) of individual-level cross-sectional data from a restricted-access version of National Survey on Drug Use and Health.

STUDY DESIGN

A quasi-experimental difference-in-differences design comparing outcomes among residents in 14 states that implemented Medicaid expansions for low-income adults under the Section §1115 waiver with those residing in the rest of the country.

DATA COLLECTION/EXTRACTION METHODS

The analytic sample includes low-income adult respondents with household incomes below 200 percent of the federal poverty level who have a behavioral health condition: approximately 28,400 low-income adults have past-year serious psychological distress and 24,900 low-income adults have a past-year substance use disorder (SUD).

PRINCIPAL FINDINGS

Among low-income adults with behavioral health conditions, Medicaid expansions were associated with a reduction in the rate of uninsurance (p < .05), a reduction in the probability of perceiving an unmet need for mental health (MH) treatment (p < .05) and for SUD treatment (p < .05), as well as an increase in the probability of receiving MH treatment (p < .01).

CONCLUSIONS

The ongoing implementation of Medicaid expansions has the potential to improve health insurance coverage and access to care for low-income adults with behavioral health conditions.

Impact of a Telepsychiatry Program at Emergency Departments Statewide on the Quality, Utilization, and Costs of Mental Health Services

OBJECTIVE

This study estimated the impact of a statewide, centralized telepsychiatry service provided in nonpsychiatric emergency departments (EDs) on use of mental health services.

METHODS

Individuals treated via telepsychiatry were compared with a matched control group of individuals with mental health diagnoses who were treated in nonparticipating hospitals. Bivariate and two-part and generalized linear regression models were used to assess differences between the two groups in outpatient follow-up, hospital admission following the ED visit, length of hospital stay if admitted, and inpatient and total costs.

RESULTS

Between March 2009 and June 2013, there were 9,066 patients with at least one telepsychiatry visit. Of these, 7,261 had index telepsychiatry visits that the authors were able to successfully match. Compared with the matched control group, telepsychiatry recipients were more likely to receive 30-day outpatient follow-up (46% versus 16%, p<.001) and 90-day outpatient follow-up (54% versus 20%, p<.001). Telepsychiatry recipients were less likely than the control group to be admitted to the hospital during the index ED visit (11% versus 22%, p<.001). The combined effect of having a telepsychiatry consult during the index ED visit was a reduction of .86 days in inpatient length of stay. Thirty-day inpatient costs were $2,336 (p=.04) lower for the telepsychiatry versus the control group, but 30-day total health care costs were not statistically different.

CONCLUSIONS

Telepsychiatry delivered in the ED through a centralized coordinated program has great promise for improving linkage with outpatient mental health services while reducing inpatient utilization and hospital costs.

Time Preferences, Mental Health and Treatment Utilization

BACKGROUND

In all countries of the world, fewer than half of people with mental disorders receive treatment. This treatment gap is commonly attributed to factors such as consumers' limited knowledge, negative attitudes, and financial constraints. In the context of other health behaviors, such as diet and exercise, behavioral economists have emphasized time preferences and procrastination as additional barriers. These factors might also be relevant to mental health.

AIMS

We examine conceptually and empirically how lack of help-seeking for mental health conditions might be related to time preferences and procrastination.

METHODS

Our conceptual discussion explores how the interrelationships between time preferences and mental health treatment utilization could fit into basic microeconomic theory. The empirical analysis uses survey data of student populations from 12 colleges and universities in 2011 (the Healthy Minds Study, N=8,806). Using standard brief measures of discounting, procrastination, and mental health (depression and anxiety symptoms), we examine the conditional correlations between indicators of present-orientation (discount rate and procrastination) and mental health symptoms.

RESULTS

The conceptual discussion reveals a number of potential relationships that would be useful to examine empirically. In the empirical analysis depression is significantly associated with procrastination and discounting. Treatment utilization is significantly associated with procrastination but not discounting.

DISCUSSION

The empirical results are generally consistent with the idea that depression increases present orientation (reduces future orientation), as measured by discounting and procrastination. These analyses have notable limitations that will require further examination in future research: the measures are simple and brief, and the estimates may be biased from true causal effects because of omitted variables and reverse causality. There are several possibilities for future research, including: (i) observational, longitudinal studies with detailed data on mental health, time preferences, and help-seeking; (ii) experimental studies that examine immediate or short-term responses and connections between these variables; (iii) randomized trials of mental health therapies that include outcome measures of time preferences and procrastination; and, (iv) intervention studies that test strategies to influence help-seeking by addressing time preferences and present orientation.

Insurance status, use of mental health services, and unmet need for mental health care in the United States

OBJECTIVE

The purpose of this study was to provide updated national estimates and correlates of service use, unmet need, and barriers to mental health treatment among adults with mental disorders.

METHODS

The sample included 36,647 adults ages 18-64 (9,723 with any mental illness and 2,608 with serious mental illness) from the 2011 National Survey on Drug Use and Health. Logistic regression models were used to examine predictors of mental health treatment and perceived unmet need.

RESULTS

Substantial numbers of adults with mental illness did not receive treatment (any mental illness, 62%; serious mental illness, 41%) and perceived an unmet need for treatment (any mental illness, 21%; serious mental illness, 41%). Having health insurance was a strong correlate of mental health treatment use (any mental illness: private insurance, adjusted odds ratio [AOR]=1.63, 95% confidence interval [CI]=1.29-2.06; Medicaid, AOR=2.66, CI=2.04-3.46; serious mental illness: private insurance, AOR=1.65, CI=1.12-2.45; Medicaid, AOR=3.37, CI=2.02-5.61) and of lower odds of perceived unmet need (any mental illness: private insurance, AOR=.78, CI=.65-.95; Medicaid, AOR=.70, CI=.54-.92). Among adults with any mental illness and perceived unmet need, 72% reported at least one structural barrier and 47% reported at least one attitudinal barrier. Compared with respondents with insurance, uninsured individuals reported significantly more structural barriers and fewer attitudinal barriers.

CONCLUSIONS

Low rates of treatment and high unmet need persist among adults with mental illness. Strategies to reduce both structural barriers, such as cost and insurance coverage, and attitudinal barriers are needed.

Trends in mental health care among children and adolescents

BACKGROUND

Increasing mental health treatment of young people and broadening conceptualizations of psychopathology have triggered concerns about a disproportionate increase in the treatment of youths with low levels of mental health impairment.

METHODS

We analyzed the 1996-1998, 2003-2005, and 2010-2012 Medical Expenditure Panel Surveys, which were nationally representative surveys of U.S. households, for trends in outpatient use of mental health services by persons 6 to 17 years of age; 53,622 persons were included in the analysis. Mental health impairment was measured with the use of the Columbia Impairment Scale (range, 0 to 52, with higher scores indicating more severe impairment); we classified youths with scores of 16 or higher as having more severe impairment and those with scores of less than 16 as having less severe impairment.

RESULTS

The percentage of youths receiving any outpatient mental health service increased from 9.2% in 1996-1998 to 13.3% in 2010-2012 (odds ratio, 1.52; 95% confidence interval, 1.35 to 1.72). The proportionate increase in the use of mental health services among youths with more severe impairment (from 26.2% to 43.9%) was larger than that among youths with less severe or no impairment (from 6.7% to 9.6%). However, the absolute increase in annual service use was larger among youths with less severe or no impairment (from 2.74 million to 4.19 million) than among those with more severe impairment (from 1.56 million to 2.28 million). Significant overall increases occurred in the use of psychotherapy (from 4.2% to 6.0%) and psychotropic medications (from 5.5% to 8.9%), including stimulants and related medications (from 4.0% to 6.6%), antidepressants (from 1.5% to 2.6%), and antipsychotic drugs (from 0.2% to 1.2%).

CONCLUSIONS

Outpatient mental health treatment and psychotropic-medication use in children and adolescents increased in the United States between 1996-1998 and 2010-2012. Although youths with less severe or no impairment accounted for most of the absolute increase in service use, youths with more severe impairment had the greatest relative increase in use, yet fewer than half accessed services in 2010-2012. (Funded by the Agency for Healthcare Research and Quality and the New York State Psychiatric Institute.).

Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis

IMPORTANCE

Despite the potential importance of understanding excess mortality among people with mental disorders, no comprehensive meta-analyses have been conducted quantifying mortality across mental disorders.

OBJECTIVE

To conduct a systematic review and meta-analysis of mortality among people with mental disorders and examine differences in mortality risks by type of death, diagnosis, and study characteristics.

DATA SOURCES

We searched EMBASE, MEDLINE, PsychINFO, and Web of Science from inception through May 7, 2014, including references of eligible articles. Our search strategy included terms for mental disorders (eg, mental disorders, serious mental illness, and severe mental illness), specific diagnoses (eg, schizophrenia, depression, anxiety, and bipolar disorder), and mortality. We also used Google Scholar to identify articles that cited eligible articles.

STUDY SELECTION

English-language cohort studies that reported a mortality estimate of mental disorders compared with a general population or controls from the same study setting without mental illness were included. Two reviewers independently reviewed the titles, abstracts, and articles. Of 2481 studies identified, 203 articles met the eligibility criteria and represented 29 countries in 6 continents.

DATA EXTRACTION AND SYNTHESIS

One reviewer conducted a full abstraction of all data, and 2 reviewers verified accuracy.

MAIN OUTCOMES AND MEASURES

Mortality estimates (eg, standardized mortality ratios, relative risks, hazard ratios, odds ratios, and years of potential life lost) comparing people with mental disorders and the general population or people without mental disorders. We used random-effects meta-analysis models to pool mortality ratios for all, natural, and unnatural causes of death. We also examined years of potential life lost and estimated the population attributable risk of mortality due to mental disorders.

RESULTS

For all-cause mortality, the pooled relative risk of mortality among those with mental disorders (from 148 studies) was 2.22 (95% CI, 2.12-2.33). Of these, 135 studies revealed that mortality was significantly higher among people with mental disorders than among the comparison population. A total of 67.3% of deaths among people with mental disorders were due to natural causes, 17.5% to unnatural causes, and the remainder to other or unknown causes. The median years of potential life lost was 10 years (n = 24 studies). We estimate that 14.3% of deaths worldwide, or approximately 8 million deaths each year, are attributable to mental disorders.

CONCLUSIONS AND RELEVANCE

These estimates suggest that mental disorders rank among the most substantial causes of death worldwide. Efforts to quantify and address the global burden of illness need to better consider the role of mental disorders in preventable mortality.

A meta-review of lifestyle interventions for cardiovascular risk factors in the general medical population: lessons for individuals with serious mental illness

OBJECTIVE

Individuals with serious mental illness die years younger than members of the general population, with cardiovascular disease and related risk factors accounting for the majority of deaths. Lifestyle interventions targeting these risk factors have begun to be developed for those with serious mental illness, but they have largely been created de novo rather than with information from work already done in the general population. This review aims to synthesize for a mental health audience the common factors for success in nonpharmacologic lifestyle interventions and identify specific considerations in adapting these models for those with serious mental illness.

DATA SOURCES

We searched the PubMed and Cochrane databases for English-language reviews from 2003 to 2013. The search employed combinations of the following terms: diabetes, diabetes mellitus, hypertension, hyperlipidemia, dyslipidemia, obesity, mental illness, schizophrenia, psychosis, bipolar disorder, lifestyle intervention, non-pharmacologic intervention, lifestyle modification, and weight gain.

STUDY SELECTION

We identified 8,147 review articles from the PubMed and Cochrane databases. 123 articles were selected. The selected articles were reviews of dietary, behavioral, or exercise interventions that focused on obesity and related cardiometabolic risk factors.

DATA EXTRACTION

We undertook a qualitative "review of reviews" focusing on nonpharmacologic interventions for obesity and related cardiometabolic risk factors.

RESULTS

Effects of interventions in the general population were meaningful but generally modest. Specific elements of diet, exercise, and behavioral therapy produced larger effects. Additionally, successful programs employed multiple components, personalization, longer duration, more frequent contact, and trained treatment providers. Interventions addressing these risk factors in people with serious mental illness typically incorporated some, but not all, of the elements demonstrated to be effective in general medical populations.

CONCLUSIONS

Studies from the general medical literature demonstrate considerable promise in addressing lifestyle risk factors. Existing programs will require tailoring to address the needs of those with serious mental illness and may be harder to implement given the challenges faced by this population. However, successful lifestyle interventions for those with serious mental illness can make a significant impact on the health and well-being of this vulnerable population and may inform future strategies for other underserved groups.

Psychiatric workforce needs and recommendations for the community mental health system: a state needs assessment

Similar to other states, Georgia is facing workforce challenges within its community mental health system. These issues may be exacerbated as implementation of the Affordable Care Act expands demand for behavioral health services. Georgia's Department of Behavioral Health and Developmental Disabilities commissioned a needs assessment to examine the shortage of prescribing providers (psychiatrists, advanced practice registered nurses, and physician assistants) in the state's public mental health system. A unique partnership of key stakeholders developed and conducted the mixed-methods needs assessment at six of Georgia's 27 community mental health centers serving more than 40,000 patients annually. The assessment documented challenges in recruiting and retaining psychiatrists and workforce shortages for all prescriber groups. The authors describe opportunities for optimizing the psychiatric workforce and training the next generation of community psychiatrists.

Using electronic health records to improve the physical healthcare of people with serious mental illnesses: a view from the front lines

Individuals with serious mental illnesses (SMI) treated in the public mental health sector die decades younger than the general population. Poor quality and fragmentation of care are risk factors underlying the poor health of this population. Integrated electronic health records (EHR) can play a vital role in efforts to improve quality and outcomes of care in patients with SMI. The objective of this paper is to describe the current state of efforts to integrate and improve the mental and physical care of individuals with SMI in the public sector, with an emphasis on the use of electronic health records (EHR). While a range of encouraging initiatives exists throughout the country, technological and medico-legal challenges are providing significant barriers for the successful integration of care and EHRs for many partnering organizations. Furthermore, there is a lack of rigorous research studying the effectiveness and sustainability of these programmes. Recommendations are made for the alleviation of policy barriers and future areas of inquiry.

The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma's adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

Racial/ethnic differences in perceived reasons for mental health treatment in US adolescents with major depression

OBJECTIVE

Racial/ethnic differences in the course of treatment for a major depressive episode (MDE) among adolescents may arise, in part, from variation in the perceived rationale for treatment. We examined racial/ethnic differences in the perceived reasons for receiving mental health (MH) treatment among adolescents with an MDE.

METHOD

A total of 2,789 adolescent participants who experienced an MDE and received MH treatment in the past year were drawn from the 2005 to 2008 National Survey on Drug Use and Health. Adolescents reported the settings in which they received care and reasons for their most recent visit to each setting. Distributions of specific depressive symptoms were compared across racial/ethnic groups. Racial/ethnic differences in endorsing each of 11 possible reasons for receiving treatment were examined using weighted probit regressions adjusted for sociodemographic characteristics, health and mental health status, treatment setting, and survey year.

RESULTS

Despite similar depressive symptom profiles, Hispanic adolescents were more likely than whites to endorse "breaking rules" or getting into physical fights as reasons for MH treatment. Black adolescents were more likely than white adolescents to endorse "problems at school" but less likely to endorse "felt very afraid or tense" or "eating problems" as reasons for treatment. Asian adolescents were more likely to endorse "problems with people other than friends or family" but less likely than whites to endorse "suicidal thoughts/attempt" and "felt depressed" as reasons for treatment.

CONCLUSION

Racial/ethnic minority participants were more likely than white participants to endorse externalizing or interpersonal problems and less likely to endorse internalizing problems as reasons for MH treatment. Understanding racial/ethnic differences in the patient's perceived treatment rationale can offer opportunities to enhance outcomes for depression among diverse populations.

Health insurance coverage and the receipt of specialty treatment for substance use disorders among U.S. adults

OBJECTIVE

The study examined the association between private health insurance and the receipt of specialty substance use disorder treatment.

METHODS

Weighted logistic regressions were estimated to examine the association between health insurance and the receipt of any specialty substance use disorder treatment in national samples of nonelderly adults with alcohol abuse or dependence (N=22,778), alcohol dependence (N=10,104), drug abuse or dependence (N=9,427), and drug dependence (N=6,736). Receipt of any specialty substance abuse treatment was compared among the uninsured and privately insured persons who reported known coverage, no coverage, or unknown coverage for alcohol and drug abuse treatment. Regressions adjusted for sociodemographic characteristics, treatment need, criminal justice involvement, and year of survey.

RESULTS

Compared with being uninsured, private insurance was associated with greater use of any specialty substance use disorder treatment only among those with alcohol dependence with known coverage for alcohol treatment (p<.05).

CONCLUSIONS

Private insurance was associated with increased use of specialty treatment among persons with severe alcohol use disorders who knew they had coverage for alcohol abuse treatment.

Randomized trial of an electronic personal health record for patients with serious mental illnesses

OBJECTIVE

The authors evaluated the effect of an electronic personal health record on the quality of medical care in a community mental health setting.

METHOD

A total of 170 individuals with a serious mental disorder and a comorbid medical condition treated in a community mental health center were randomly assigned to either a personal health record or usual care. One-year outcomes assessed quality of medical care, patient activation, service use, and health-related quality of life.

RESULTS

Patients used the personal health record a mean of 42.1 times during the 1-year intervention period. In the personal health record group, the total proportion of eligible preventive services received increased from 24% at baseline to 40% at the 12-month follow-up, whereas it declined in the usual care group, from 25% to 18%. In the subset of patients with one or more cardiometabolic conditions (N=118), the total proportion of eligible services received improved by 2 percentage points in the personal health record group and declined by 11 percentage points in the usual care group, resulting in a significant difference in change between the two groups. There was an increase in the number of outpatient medical visits, which appeared to explain many of the significant differences in the quality of medical care.

CONCLUSIONS

Having a personal health record resulted in significantly improved quality of medical care and increased use of medical services among patients. Personal health records could provide a relatively low-cost scalable strategy for improving medical care for patients with comorbid medical and serious mental illnesses.

Race/ethnicity and geographic access to Medicaid substance use disorder treatment facilities in the United States

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.