Rural-Urban and Racial-Ethnic Differences in Tele-Behavioral Health Access for Medicaid Beneficiaries

Tele-behavioral health (TBH) expanded significantly during the COVID-19 pandemic, but the extent to which this addressed or reinforced existing rural-urban disparities remains unclear, especially in states with diverse and underserved populations. This study investigates the role of rurality and broadband access in TBH utilization among adult Medicaid beneficiaries in New Mexico-a highly rural and racially diverse state.

We analyzed New Mexico Medicaid claims data from March 2019 to March 2021 for outpatient behavioral health visits. Using logistic regression models, we assessed differences in TBH use by rurality, race/ethnicity, and broadband connectivity across pre- and post-public health emergency (PHE) periods. Visits were categorized by modality (in-person, audio-only, video) and linked with county-level data on broadband access and provider availability.

Our study included 2,934,451 behavioral health visits among 216,898 unique Medicaid members. Total patient visits for BH increased by 19.2% from 1,326,473 (72.7% urban, 27.3% rural) to 1,607,978 (72.3% urban, 27.7% rural) across the study period. Urban patients had greater odds of TBH use (specifically audio-only visits) compared to rural patients, even in rural counties with high broadband access. Modeling results demonstrated that urban patients had greater odds of a TBH visit as compared to rural patients, which was more pronounced in high versus low connectivity counties (OR 2.20; 95% CI 2.21, 2.27 vs. OR 1.53; 95% CI 1.51, 1.56). Native American patients had the greatest odds of TBH visits, which may reflect established telehealth infrastructure within the Indian Health Service.

TBH expanded behavioral health access for Medicaid beneficiaries, but rural disparities persist and are not mitigated by broadband access alone. Rather, existing telehealth infrastructure appears to be related to improved rural TBH access. These findings underscore the need for policy efforts beyond broadband expansion to achieve equitable TBH access across diverse and rural populations.