Health Disparities and Social Isolation in Major Black Cities

Sally Ayuk, MS

Equity Senior Research Fellow

Health Disparities and Social Isolation in Majority Black Cities

Introduction

The neighborhoods people live in influence whether they can see a doctor, afford care, find emotional support, and access opportunities that promote well-being. 1 Community conditions, including clean air, safe housing, public transportation, and access to healthy food, all play a crucial role in shaping health outcomes. 2 For many Black communities in urban areas, basic resources that support health care access are often out of reach. Gaps in insurance coverage, limited access to nearby providers, long travel times to care, and underinvestment in mental health services—including high out-of-pocket costs—make staying physically and mentally healthy far more difficult. 3 Structural health barriers are not only at the individual level; they are built into the way cities are designed and funded.

This brief examines how inequities in healthcare access manifest in three predominantly Black cities: Detroit, Philadelphia, and Houston. By examining local data on insurance, healthcare spending, mental health services, and provider availability, it demonstrates how geography and inequality are closely intertwined. Understanding how place-based healthcare disparities play out on the ground is key to shaping practical, community-driven solutions that bring care within reach.

1 Palmer, R. C., Ismond, D., Rodriquez, E. J., & Kaufman, J. S. (2019). Social determinants of health: future directions for health disparities research. American Journal of Public Health, 109(S1), S70-S71.

2 University of Wisconsin Population Health Institute. (2025). 2025 Report: Building power for health and equity. https://www.countyhealthrankings.org/findings-and-insights/2025-report

3 Rapfogel, N. (2022). The Behavioral Health Care Affordability Problem. Center for American Progress Action Fund (CAP). https://www.americanprogress.org/article/the-behavioral-health-care-affordability-problem.

Medical Spending

Insurance coverage is critical to making healthcare affordable. In 2022, the average amount spent on out-of-pocket healthcare in the U.S. was $1,424.60 per person.4 This spending comes from a significant portion of people’s income, with the yearly median household income at $74,580.

In Detroit, residents spent $840, or 1.13% of their income.

In Philadelphia, residents spent $940, or 1.26% of their income.

In Houston, residents spent $860 on healthcare, or 1.15% of their income.

Compared to the national average of 1.91%, all three cities spent a smaller share of their income on out-of-pocket healthcare costs. However, this figure represents only out-of-pocket spending, not the additional costs incurred through weekly, biweekly, or monthly insurance premiums and uncovered services. In addition to what you are charged by healthcare professionals and facilities, you may have personal costs involved in seeking and receiving medical treatment. These costs can include childcare, lodging if you need to travel for care, lost income from taking time off work, and transportation costs such as fares, gas, or parking fees. According to the U.S. Census Bureau, 92.1% of U.S. residents had health insurance at some point in 2022. However, even with insurance, many individuals still face significant out-of-pocket costs in addition to their monthly premiums. Others have incomes low enough to qualify for Medicaid but may still struggle to afford out-ofpocket expenses. A lower proportion of out-of-pocket spending does not necessarily imply equitable healthcare access, and attention should still be paid to lower-income groups who may experience a disproportionate burden relative to their income.

4 Vankar, P. (2024). U.S. per capita out-of-pocket health care payments 1970-2022. Statista. https://www.statista.com/statistics/484578/ us-per-capita-out-of-pocket-health-care-payments-since-1960/#:~:text=In%202022%2C%20U.S.%20out%2Dof,States%20from%20 1970%20to%202022

Insurance Coverage

Gaps in health insurance coverage across different age groups further shape these healthcare spending figures. For instance, young adults (ages 19–34) face the highest risk of being uninsured in all three cities, with 3% of both Detroit and Philadelphia residents uninsured and 7% in Houston. Many young adults rely on employer-provided insurance, so gaps in job-based coverage remain a significant issue. On the other hand, children under six and seniors over 75 have the highest rates of health insurance coverage, largely due to the strong reach and effectiveness of programs such as Medicaid, CHIP, and Medicare. Slight gaps in coverage in Houston suggest that some eligible individuals may not be enrolling in these programs. This highlights the need for improved outreach and accessibility to ensure that everyone who qualifies can fully participate in these essential healthcare programs, thereby addressing coverage gaps and promoting more equitable access. Notably, recent changes under H.R. 1, the One Big Beautiful Bill Act—including new Medicaid work requirements and stricter eligibility checks—could make closing these gaps more difficult, lead to increased Medicaid and the Affordable Care Act coverage losses, and have significant implications for state budgets and healthcare systems. Policymakers must closely monitor the rollout of these provisions, as an estimated 9.9 to 14.9 million people could lose Medicaid coverage by 2034 under the bill’s work requirements.

Depression, Social Isolation,

and Lack of Social and Emotional Support

Mental health challenges are a growing concern across the United States. Depression is a negative affective state, ranging from unhappiness and discontent to extreme feelings of sadness, pessimism, and despondency, that interferes with daily life.5 The 2020 National Data Benchmark reports a national average depression rate of 18.5%, meaning nearly one in five Americans experience symptoms of depression. At the state level, depression rates range from 12.7% to 27.5%, meaning that in some states, as few as one in eight people report experiencing depression, while in others it is closer to one in four residents.6 Social isolation refers to the absence of relationships, contact, or support from others.7 Approximately one in three adults in the U.S. report feeling lonely, and about one in four U.S. adults report lacking social and emotional support.8 Social isolation and a lack of social and emotional support are strongly linked to higher depression rates, which are evident in all three cities. In cities like Houston, Detroit, and Philadelphia, these rates are higher than the national and state averages:

Houston: 20.1% of residents report experiencing depression, above the national rate of 18.5%. The city also has a high social isolation rate of 37.8%, and 30.4% of residents report a lack of emotional support.

Detroit: Depression affects 21.5% of residents, well above the national average, and slightly higher than the typical state rate. Social isolation is also elevated at 33.7%, and 32.1% of residents report not having enough emotional support.

Philadelphia: This city has the highest rate of depression among the three at 21.7%, making it significantly higher than both national and statelevel averages. Data on social isolation and emotional support was not available for this city.

5 American Psychological Association (APA) Dictionary of Psychology. (2018). Depression. https://dictionary.apa.org/depression

6 Lee, B. (2023). National, state-level, and county-level prevalence estimates of adults aged≥ 18 years self-reporting a lifetime diagnosis of depression—United States, 2020. MMWR. Morbidity and Mortality Weekly Report, 72.

7 U.S Centers for Disease Control and Prevention. (2024). Health Effects of Social Isolation and Loneliness. https://www.cdc.gov/social-connectedness/risk-factors/index.html

8 Town, M. (2024). Racial and ethnic differences in social determinants of health and health-related social needs among adults— Behavioral Risk Factor Surveillance System, United States, 2022. MMWR. Morbidity and Mortality Weekly Report, 73.

Mental Health Professional Shortage Areas (MHPSAs)

Access to mental health care depends not just on the presence of facilities, but also on whether there are enough trained professionals to meet community needs. The federal designation of Mental Health Professional Shortage Areas (MHPSAs) highlights areas where the number of licensed mental health providers is insufficient relative to the population (Figure 1).

In Houston and Detroit, the situation is especially concerning: 96% of Houston and 98% of Detroit are classified as MHPSAs. This means nearly the entire geographic area of both cities faces a shortage of mental health professionals. Even when treatment centers exist, there may not be enough staff to meet demand, making it more difficult for people to receive timely care. Only 4% and 2%, respectively, are not classified as MHPSA shortage areas, highlighting the severity of the issue.

In contrast, none of Philadelphia’s census tracts are designated MHPSAs, indicating that the city is considered to have sufficient licensed mental health professionals to serve its population. While this does not eliminate all barriers to care, it does suggest that provider availability is less of a structural concern in Philadelphia than in Houston or Detroit.

Mental Health Staffing Shortages and Access to Care

Houston and Detroit both face serious challenges when it comes to mental health care, but the situation is more severe in Houston.

• Staffing Shortages: On average, 70.4% of Houston’s need for mental health professionals goes unmet, compared to just 7.6% in Detroit. This means that Houston has far fewer mental health workers available relative to its population and needs urgent investment in professional capacity.

• Who Gets Help? In Detroit, 95 out of every 100 people who need care are served, while in Houston, only 79 out of every 100 are. This means Detroit is close to a balanced system, while Houston leaves more people without support.

POPULATION SERVED VS. UNDERSERVED:

• In Houston, about 10,960 people receive mental health care, while 13,830 people remain underserved, representing less than 1% of the total population. This suggests that the vast majority of people who could benefit from mental health support remain unserved, highlighting a much larger unmet need.

• In Detroit, about 3,760 people are served and 3,960 underserved, less than 1% of the city’s total population, indicating significant gaps in identifying and meeting community mental health needs.

Both cities show substantial gaps in access to mental health care, but Detroit reaches a slightly larger share of residents in need of mental health care compared to Houston. Places with more people forgoing mental health care also tend to have the most severe staffing shortages. In other words, the fewer professionals there are, the harder it is for people to get help. This relationship is especially strong in Houston, where nearly every increase in unmet need is matched by an even greater shortage of providers. While this trend is also present in Detroit, the mismatch between demand and provider availability is less pronounced. This highlights the importance of investing in the mental health workforce to bridge these access gaps.

Access to Mental Health Facilities and the Role of Transportation in Disconnection

Getting help with mental health challenges is not just about whether services exist; it is about whether people can realistically reach them. In cities like Philadelphia, Detroit, and Houston, the number of mental health facilities, and the time it takes to get to them, vary widely, creating uneven access and deepening barriers to care.

Philadelphia has the best overall access. There are close to three mental health facilities for every 100,000 residents, and people generally live about 0.74 miles from the nearest facility. That is roughly fifteen minutes on foot, five minutes by bike, or two minutes by car, making it easier for residents to access care when needed.

Detroit has a similar facility density, with just over two facilities for every 100,000 people, and most residents are about 0.97 miles away from treatment. That is approximately a twenty-minute walk, six minutes by bike, or three minutes driving. Although Detroit still struggles with high depression rates and social isolation, physical access to care is not as large a barrier.

Houston, by contrast, has less than one facility for every 100,000 residents, significantly lower than both Detroit and Philadelphia. The average distance to a facility is nearly 2.92 miles, about fifty-eight minutes by walking, eighteen minutes by bike, and seven minutes by driving. For some residents, it can be as far as 14.6 miles, which could mean walking for over four hours and fifty-two minutes, biking for up to an hour and twenty-eight minutes, or driving for thirty-five minutes, depending on the location and traffic. For those without reliable transportation, that gap can make care feel out of reach altogether.

This mismatch between where care is located and how people can reach it leads to more than just inconvenience; it also reinforces isolation. When people are already struggling, long travel times, a shortage of mental health providers, and transportation barriers compound the challenge. This is especially true in Houston, where staffing shortages are the most severe, and the population served is the lowest.

Policy Recommendations

DETROIT: STRENGTHEN SOCIAL INFRASTRUCTURE TO REDUCE ISOLATION

• Local government agencies and community-based organizations should build on Detroit’s relatively high service reach (95 out of 100 residents served) by investing in community-based emotional support programs, particularly in neighborhoods with elevated rates of depression (21.5%) and social isolation (33.7%).

• Use trusted community anchors (e.g., schools, libraries, places of worship) to link residents to mental health care and insurance education.

PHILADELPHIA: MAINTAIN PROVIDER ACCESS AND MONITOR EMERGING GAPS

• City health departments and nonprofit providers should coordinate and leverage the city’s MHPSAfree status and short facility distances (~0.74 miles on average) by focusing on preventive care and emotional support outreach, particularly for young adults and marginalized populations.

• While no current professional shortage is designated, public health agencies and advocacy groups should monitor changes in coverage trends and increase awareness campaigns for Medicaid and CHIP enrollment in underrepresented communities.

HOUSTON: ADDRESS WORKFORCE AND TRANSPORTATION GAPS SIMULTANEOUSLY

• Local policymakers, health systems, and private partners should collaborate to fund mobile mental health units and telehealth programs in high-need neighborhoods, addressing the city’s dual challenges of long travel distances and high professional shortages (96% MHPSA designation; 70.4% unmet staffing need).

• Federal, state and local health agencies should expand Medicaid outreach and eligibility screenings for uninsured young adults, especially those aged 19–34, where the uninsured rate is 7%, more than double that of the other two cities.

Conclusion

Although out-of-pocket healthcare spending appears manageable in all three cities, access remains deeply unequal when considering provider availability, transportation barriers, and mental health needs. Houston shows the most severe disconnect between care availability and accessibility. Detroit faces ongoing challenges with emotional support and social isolation. Philadelphia, while stronger on structural indicators, still shows elevated depression rates, especially among younger adults. To close these gaps, it is not enough to expand services; we must also ensure people can afford to use them. Young adults, particularly those aged 19–34, continue to face the highest uninsured rates in all three cities. This reflects a broader need to offer affordable insurance options outside of employer-based coverage.

At the same time, Medicaid and CHIP must be expanded, not rolled back, as seen under current administrative trends. Provisions in the One Big Beautiful Bill Act, signed into law on July 4, 2025, will weaken Medicaid by introducing additional paperwork barriers; increasing out-of-pocket costs; and reducing enrollment for seniors, working adults, adults with disabilities, and immigrants. These cuts will reverse progress made in expanding coverage, reducing racial and economic disparities, and improving access to mental health care, further limiting services for those already underserved. These programs are crucial in ensuring that children, seniors, and vulnerable adults remain covered. Because mental health services often require insurance, any strategy to reduce depression, isolation, and staffing shortages must be paired with strong, equitable coverage systems. A comprehensive response to the mental health access crisis must include coordinated investment in insurance outreach, healthcare workforce development, transportation solutions, and neighborhood-based support networks, so that all residents, regardless of their location or income, can access the care they need.

Data Sources

Average annual dollars spent out of pocket per person on medical care in 2022. PolicyMap, https://www. policymap.com/newmaps/e/uta/s/5002/7c381a12fdf0b960c610c738e92249be (based on data from PolicyMap and Quantitative Innovations; Accessed 6 February 2025).

Crude percent of depression among adults in 2022. PolicyMap, https://www.policymap.com/newmaps/e/uta/s/501 2/039086e6da297368e960ad486b1c6ed8 (based on data from CDC_PLACES; Accessed 6 February 2025).

Crude percent of feeling socially isolated among adults in 2022. PolicyMap, https://www.policymap.com/ newmaps/e/uta/s/5014/f89939c831ba45276fb78d3e2a48993f (based on data from CDC_PLACES; Accessed 6 February 2025).

Crude percent of lack of social and emotional support among adults in 2022. PolicyMap, https://www.policymap. com/newmaps/e/uta/s/5015/3b081ab0e6b03e902ccceebf1db8bcce (based on data from CDC_PLACES; Accessed 6 February 2025).

Full Time Equivalent mental health professionals as of 2023. PolicyMap, https://plcy.mp/2WGWdCT2 (based on data from HRSA; Accessed 6 February 2025).

Mental Health Professional Shortage Area status as of 2023. PolicyMap, https://plcy.mp/2wnLR6jC (based on data from HRSA; Accessed 6 February 2025).

Mental health professional shortage as of 2023. PolicyMap, https://plcy.mp/2DhvK99g (based on data from HRSA; Accessed 6 February 2025).

Mental Health Treatment Facilities. PolicyMap, https://plcy.mp/2sNBNrNX (based on data from SAMHSA; Accessed 6 February 2025).

Population adequately served by mental health professionals as of 2023. PolicyMap, https://plcy.mp/21mLLPjQ (based on data from HRSA; Accessed 6 February 2025).

Population underserved by mental health professionals as of 2023. PolicyMap, https://plcy.mp/2P5wcYny (based on data from HRSA; Accessed 6 February 2025).