Medicaid,Race,Utilization of Crisis Services at Community Mental Health Agencies

Abstract

We compare African-American and White clients receiving services at 13 rural and semi-rural community mental health agencies (CMHAs) and the impact of Medicaid on the use of crisis and outpatient services. SEM was utilized to model the indirect effect of crisis services between the association of Medicaid and total hours of outpatient services. We modeled the moderating effects of race using mixture modeling and latent class. The base model showed a non-significant indirect effect between having Medicaid and total hours of services through the use of crisis services (Indirect effect = 0.01, p = .98). African-American clients who received Medicaid were more likely to use crisis services ( $β = .155, p < .05, a p a t h)$ , which was associated with increased hours of outpatient services ( $β = .224, p < .05, b p a t h)$ . In general, Medicaid was not related to increase service or crisis service usage. However, African-American clients access crisis services significantly more than White clients.

Keywords

African-American adults with serious mental illness crisis services community mental health agencies rural

Medicaid, Race, Utilization of Crisis Services at Community Mental Health Agencies

Access to community-based mental health services is a significant problem facing African-American adults with serious mental illness (SMI; Bruckner et al., 2014; Snowden, 2001; USHHS, 2001). Disparities in access experienced by African-American adults with SMI result in negative quality of life outcomes including decreased earnings, poor physical health, and housing insecurity (Snowden, 2001). Beyond day-to-day impacts, African-American adults with SMI are also at extraordinary risk of premature death and/or incarceration when access to services is limited (USHSS, 2001). These many negative structural factors result in African-American adults with SMI being at high risk for use of crisis services.

There has been growing interest over the past two decades in equalizing access to mental health services for African-American adults with SMI. One method is to increase enrollment in Medicaid, which decreases barriers associated with costs and provides access to a wide array of services provided by community mental health agencies (CMHAs). The role of Medicaid in decreasing racial disparities related to access to mental health services is fairly well understood (Buchmueller et al., 2016). Less understood is if decreasing payment barriers and improving service utilization results in decreasing the need for crisis services.

We compare African-American and White adult clients with SMI receiving services at 13 rural and semi-rural CMHAs and the impact of Medicaid on the use of crisis and outpatient services. Race, although measured at the individual measure is treated as a proxy for racism. We hypothesized that increased access created by Medicaid would decrease the racial disparities in the use of crisis services.

Crisis Services

Crisis services treat acute psychiatric episodes to decrease the need for inpatient services and involvement with the criminal justice system for adults with SMI (Dempsey et al., 2020; Hasselberg et al., 2011; Murphy et al., 2012). Crises are brief incidents in which an adult with SMI is experiencing an exacerbation of symptoms that may lead to self-harm or harm to others. Crises are also clinically defined as an “acute disruption of psychological homeostasis in which one's usual coping mechanisms fail and there exists evidence of distress and functional impairment” (Roberts, 2005). To address acute incidents of crisis, crisis services were created with the goal of decreasing symptoms and behaviors in the moment of crisis to levels that permit the adult with SMI to remain in their community.

Crisis interventions have taken on many forms including mobile crisis teams, crisis units in hospitals, residential programs, and crisis day treatment centers (Dempsey et al., 2020; Hogan & Goldman, 2021). Crisis interventions are a prominent method of treatment provided by many CMHAs across the country (Cutler et al., 2003; Hasselberg et al., 2011; Murphy et al., 2012; USHHS, 1999). The use of crisis interventions decreases hospital admission, is cost-effective, and reduces the stigma associated with institutionalization (Belkin & McCray, 2019; Dempsey et al., 2020; Hogan & Goldman, 2021).

Despite the noted effectiveness, the goals of CMHAs are to minimize the use of crisis services by providing appropriate and regular outpatient treatment (Hasselberg et al., 2011). One of the assumptions is that increasing usage of crisis services across the nation is driven by decreasing access to the types of outpatient services offered by CMHAs (Cutler et al., 2003). There is concern that with decreasing access in general, African-American adults with SMI, similar to other healthcare settings, will be hardest hit, resulting in increased usage of crisis services.

Racial Disparities

Reasons typically cited for racial disparity in mental health services tend to focus on service providers (Larrison et al., 2011; Larrison et al., 2008), clinical factors (Mackenzie et al., 2012), client level demographics (Hack et al., 2017; Hack et al., 2014), and attitudes toward seeking services (Diala et al., 2000, 2001; Hines-Martin et al., 2004; Shim et al., 2009). In the past two decades, there have been attempts to better understand how structural level factors related to institutional racism and poverty impact help seeking behaviors of African-American adults with SMI (Bruckner et al., 2014; French et al., 2020; Snowden et al., 2009a; Snowden et al., 2009b). In general, African-American adults, because of disparities in educational access and training opportunities disproportionately work in low-wage jobs that have inadequate employer base health insurance, unstable income, and limited retirement resources (Bruckner et al., 2014). Economic downturns disproportionally impact African-American adults with increased rates of unemployment and loss of housing (Bocian et al., 2010; Marazziti et al., 2021; Saegert et al., 2011). All of these significant societal and economic factors along with institutional racism are related to the increased stress that results in increased mental health vulnerabilities (French et al., 2020; Marazziti et al., 2021). The combination of institutional racism and numerous economic disadvantages leaves African-American adults with SMI particularly vulnerable to increased stress and isolation, which can magnify symptoms of mental illness including suicidality and psychosis in a manner that leads to an increased probability of needing crisis services (Catalano et al., 2011; French et al., 2020).

Objective

The objective of this study was to investigate if access to Medicaid and the use of outpatient services provided by CMHAs decreased the use of crisis services among African-American adults with SMI to similar rates experienced by White adults with SMI.

Methods

Clients from thirteen CMHAs were included in the present study. CMHAs are what remain of the federally funded community mental health centers created under the 1963 Community Mental Health Centers Act. CMHAs provide services that are selected from an array of services reimbursable by Medicaid. They provide services to a geographically defined catchment area and are expected to serve a wide range of individuals with an array of mental health problems. Approximately 45% of counties in the United States have access to a CMHA (Cutler et al., 2003), and the system provides outpatient mental health services to approximately 8% of the general adult population (USHHS, 1999).

Table 1.

Demographic Characteristics.

Variable	Mean (SD) or n (%) N = 801
Age	42.9 (10.4)
Race n(%)
White	600 (74.9)
African-American	201 (25.1)
Marital status n(%)
Married	129 (16.2)
Single	273 (34.2)
Divorced/separated	352 (44.1)
Employment n(%)
Unemployed	637 (79.6)
Part-time	114 (14.3)
Full-time	48 (6.00)
Psychotropic medication n(%)	462 (59.4)
Education n(%)
High school or less	478 (59.8)
College	322 (40.3)
Diagnosis n(%)
Schizophrenia	235 (30.0)
Bi-polar	139 (17.8)
Depression	291 (37.2)
Substance use disorder	50 (6.40)
Total service hours	41.4 (86.0)
Total crisis hours	1.14 (1.71)
Medicaid n(%)	610 (78.0)

Data Collection Methods

Data collection took place between 2007 and 2009. Staff at each CMHA introduced eligible clients to a member of the research team located on-site. The on-site researcher then described the study and obtained informed consent. Participants completed a face-to-face interview with the on-site researcher. All methods used in the project were approved by the Institutional Review Board at the University of Illinois at Champaign-Urbana.

Participants

Participants were 801 adults (ages 20–65) recruited from 13 rural and semi-rural CMHAs. On average participants were 42 (SD = 10.4) years old, identified primarily female (63%, n = 505), 75% characterized themselves as White (n = 600), and 25% identified as African-American or African-American and another race/ethnicity (n = 201). The majority of participants (60%, n = 478) had an education background of high school or less.

Most individuals in the sample were diagnosed with a serious mental illness including schizophrenia (30%, n = 235), bipolar disorder (17%, n = 139), and depression (36%, n = 291). A smaller proportion of individuals were diagnosed with drug or alcohol dependence (6%) and generalized anxiety disorder (5%). Detailed demographic characteristics can be found in Table 1.

Measures

Public Insurance. Our main independent variable, the participant's insurance status, was obtained from official client records. This variable was dichotomous. Participants either received Medicaid or had another form of payment not associated with Medicaid (i.e., other). Medicaid is the reference group.

Crisis Services

Crisis services were assessed by data obtained from official client records identifying how many hours of crisis intervention services were received in the past 90 days.

Total Service Hours

A count of the hours of outpatient services received in the past 90 days was used as our dependent variable. Data were obtained from official client records and included services such as case management, therapy, and medication reviews.

Demographics

Demographic characteristics included participant age, gender (female reference group) and if participants were currently taking any psychotropic medication (e.g., medication for schizophrenia, bipolar, or depression) were self-reported.

Analytic Plan

Data were analyzed using indirect effect modeling within a structural equation framework. We used indirect effects to assess the extent to which Medicaid was predictive of hours of outpatient services and if this effect was indirectly related through the use of crisis intervention services. Specifically, we were interested if differences existed in this model across races (African-American and White). We first modeled the indirect effects with the full sample and then used mixture modeling (e.g., latent class) to assess the effects of race across our indirect effect model. Because our dependent variable was a count of the number of hours clients received outpatient services, we utilized a negative binomial distribution to capture the functional form of the data. The dispersion parameter was used to determine if the negative binomial distribution was appropriate. When the dispersion parameter equals zero, the model reduces to the simpler Poisson model—however, when the dispersion parameter is greater than zero the dependent variable is over-dispersed and the negative binomial is appropriate. In each model, we controlled for participant age, gender, and use of psychotropic medication. As a post-hoc test, we evaluated the indirect effect model across races for individuals diagnosed with schizophrenia. All models were estimated using robust maximum likelihood. A statistically significant indirect effect can be interpreted as the amount that the outcome variable is expected to change as the independent variable changes by one unit as a result of the independent variable on the mediator. All analyses were conducted using Mplus version 7.4 (Muthén & Muthén, 1998–2015).

Results

Overall Model

In the overall model (Table 2, Model 1), the use of the negative binomial distribution was appropriate (α = 2.89 & α = 23.6, p's < .01). Further, we found significant direct effects on Medicaid on total hours of services (B = 0.870, 95% CI [0.527, 1.21]) and crisis hours on total hours or services (B = 0.387, 95% CI [0.292, 0.481]. We did not find a direct effect of Medicaid on crisis services. This resulted in a non-significant indirect effect (IND = − 0.023 95% CI [ − 0.307, 0.261]).

Table 2.

Direct, Indirect, Total Effects. Parameter Estimates (or Odds Ratio), 95% Confidence Intervals.

	Model 1	Model 2	Model 3
a path	−0.060 [ − 0.789, 0.669]
b path	0.387 [0.295, 0.481]
c path	0.870 [0.527, 1.21]
Indirect effect	−0.023 [ − 0.307, 0.261]
Total effect	0.847 [0.399, 1.30]
White
a path		−0.343 [ − 1.11, 0.425]
b path		0.428 [0.305, 0.550]
c path		0.425 [0.035, 0.814]
Indirect effect		−0.147 [ − 0.489, 0.196]
Total effect		0.278 [ − 0.235, 0.790]
African-American
a path		9.29 [8.63, 9.95]
b path		0.255 [0.124, 0.387]
c path		1.85 [1.08, 2.63]
Indirect effect		2.37 [1.14, 3.60]
Total effect		4.23 [2.83, 5.62]
White
a1 path (pub pay to tot hrs)			0.569 [0.214, 0.924]
a2 path (pub pay to schiz)OR			1.61 [1.08, 2.41]
a path (Schiz to crisis)			0.733 [0.057, 1.41]
b path			0.449 [0.309, 0.588]
c path			0.569 [0.214, 0.924]
Indirect effect			0.329 [0.016, 0.642]
Total effect			1.42 [0.984, 1.85]
African-American
a1 path (pub pay to tot hrs)			1.20 [0.289, 2.10]
a2 path (pub pay to schiz)OR			9.87 [3.45, 27.9]
a path (schiz to crisis)			2.22 [0.472, 3.97]
b path			0.146 [0.030, 0.263]
c path			1.24 [0.780, 1.70]
Indirect effect			0.325 [ − 0.110, 0.760]
Total effect			1.57 [0.969, 2.16]
Fit Statistics
AIC	7695.547	8493.479	9307.112
BIC	7751.257	8595.613	9437.102
−2 LL	−3835.774	−4224.739	−4625.556
Df	12	22	28

Note: OR = odds ratio; typical model fit parameters and standardized coefficients are not available when using negative binomial distributions. All parameters are unstandardized coefficients. Model 1 included only overall effects. Model 2 included mixture modeling by race. Model 3 included mixture modeling by race with diagnosis of schizophrenia as independent variable. All models controlled for gender, age, and use of psychotropic medications.

Mixture Modeling by Race

When using mixture modeling to test our indirect effects across races (i.e., African-American and White) we get a different story. The use of a negative binomial distribution was confirmed with our dispersion parameters (α = 2.72 & α = 23.4, p's < .01). For individuals identifying as White we found evidence of only one significant direct effect from crisis services to total hours of service (B = 0.428, 95% CI [0.305, 0.550]). It follows, that the indirect effect for this model was non-significant (IND = − 0.147, 95% CI [ − 0.489, 0.196]).

However, for individuals identifying as African-American, we found significant direct effects for all paths (Table 2, Model 2, and Figure 1). For example, we found Medicaid was associated with the use of more crisis services (B = 9.29, 95% CI [8.63, 9.95]), and the use of crisis services was associated with increased total hours of outpatient service (B = 0.255, 95% CI [0.124, 0.387]). While we did find a significant indirect effect (IND = 2.37, 95% CI [1.14, 3.60]), this can only be interpreted as a partial indirect effect as our main effect from Medicaid predicting total hours of services remained significant (B = 1.85, 95% CI [1.08, 2.63]).

Figure 1.

Direct effect mixture model by race. Parameter estimate and 95% confidence interval. Note. Dash line indicates non-significant path.

Post-Hoc Analysis

We chose to do a post-hoc analysis using the diagnosis of schizophrenia as our independent variable. Schizophrenia was chosen because the diagnosis is associated with the need for a wide variety of services ranging from case management to crisis services. Testing this model across races for individuals with schizophrenia would provide further evidence for our initial mixture model. In this model we allowed Medicaid to remain a predictor of both total hours of service as well as diagnosis of schizophrenia (odds ratio). Model results indicate using the negative binomial distribution was appropriate based on our dispersion parameters (α = 2.51 & α = 20.4, p's < .01). Figure 2 displays the results for our post-hoc analysis. Across both White and African-American participants, we find non-significant indirect effects for schizophrenia diagnosis and crisis services (Table 2, Model 3).

Figure 2.

Indirect effect mixture model by race. Parameter estimate and 95% confidence interval. Note. Dash line indicates non-significant path.

Discussion

We examine the use of crisis services and outpatient treatment by African-American and White clients at 13 rural and semi-rural CMHAs in the Midwest. SEM modeling was utilized to assess the impact of Medicaid versus other payment forms on hours of crisis service used and total hours of outpatient services accessed over a 90-day period. The moderating effects of race were estimated using mixture modeling and latent class analysis for a dichotomous moderator. The base model showed a non-significant indirect effect between having Medicaid and hours of services through the use of crisis services. Specifically, individuals who use Medicaid were not more likely to use crisis services. However, the use of crisis services was associated with increased hours of services, and individuals who had Medicaid were more likely to report increased outpatient service utilization.

When we examine the impact of race, African-American adult clients who received Medicaid were more likely to use crisis services and the utilization of crisis services was associated with increased hours of outpatient services. In contrast, for White clients, receiving Medicaid was not associated with increased utilization of crisis services or total treatment hours. However, indirect effects for White participants between the use of crisis services and increased service usage were trending toward significance.

By decreasing access barriers associated with costs for African-American adults with SMI and increasing outpatient service usage to rates comparable with White adults with SMI, we hypothesized that there would not be racial differences in crisis service usage between African-American and White clients receiving services at CMHAs. The hypothesis was based on findings that cost barriers are one of the substantial reasons African-American adults in general—more than any other race/ethnicity—rely on emergency psychiatric services for mental health care (Snowden et al., 2009a). The findings indicate that decreasing cost barriers and providing access to outpatient treatment does not decrease the use of crisis services for African-American adults with SMI. This racial difference concerns practitioners because the literature reports that care in the crisis setting undermines treatment continuity and sometimes negatively impacts the long-term outcomes of community-based outpatient services (Bruckner et al., 2014). This elevated incidence of crises among African-American adults with SMI who are receiving services from CMHAs represents a failure of the system of care (Bruckner et al., 2014; Stergiopoulos et al., 2016).

Although less often considered than individual and family characteristics, characteristics of the local environment including rates of employment, housing costs, health care access, and level of structural racism play a significant role in why African-American adults with SMI seek crisis services at a higher rate (French et al., 2020). Additional community-based mental health services and their sociopolitical environments vary greatly state-to-state, which can affect treatment opportunities (Bruckner et al., 2014). These variations impact help-seeking behaviors. African-American adults were found to have more positive attitudes than Whites toward seeking such mental health services (Diala et al., 2000, 2001). After assessing services, their attitudes were found to be less positive than those of Whites (Diala et al., 2000, 2001). Differences in attitudes toward seeking professional mental health care and in the utilization of mental health services remain important factors that influence when mental health services are accessed and are deeply affected by perceptions of institutional racism (Diala et al., 2000, 2001).

Conclusions

This paper explores the complex issue of racism and the effectiveness of public policy, in the form of Medicaid, at decreasing racial disparities in access to mental health services in a fashion that results in less reliance on crisis services by African-American adults with SMI. We hypothesized the impact of Medicaid, which addresses a substantial portion of costs that create access barriers for African-American adults with SMI, would decrease crisis service usage. Our findings did not support the hypothesis. Despite the evidence that Medicaid decreases cost barriers for African-American adults with SMI and increases outpatient service usage, these changes did not decrease the need for crisis services. The continued disproportional usage of crisis services by African-American adults with SMI results in an unacceptable increased risk of psychiatric hospitalization and/or involvement with the criminal justice system among other numerous negative impacts on overall quality of life.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute of Mental Health (grant number 1 R34 MH074640-02).

ORCID iD

Christopher R. Larrison

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