The objective of this study is to explore relationships among neighborhood socioeconomic characteristics (for example, income and ethnicity), spatial access to health care, and emergency department (ED) visits for ambulatory care sensitive conditions (ACSC) for adults aged 65 years and over. ED visit data were from 15 counties in the Texas Coastal Bend from September 1, 2009 and August 1, 2012. ED visits for ACSC that were common for elderly were estimated based on Agency for Healthcare Research and Quality's (AHRQ's) ACSC and Prevention Quality Indicators. The U.S. Census American Community Service (ACS) data provided neighborhood socioeconomic characteristics. Spatial access to general practices and to hospitals, respectively at the zip code level were estimated using the enhanced two-step floating catchment area method. Using multivariable regression models, we estimated associations of elderly ACSC ED visits with neighborhood socioeconomic characteristics and spatial accessibility of healthcare. We found higher rates of elderly ACSC ED visits are significantly associated with higher rates of elderly Hispanic and poverty at the zip code level. Spatial access to general practices and hospitals play inverse roles in the rate of elderly ACSC ED visits. Poorer access to general practices but easier access to hospitals contributes to the higher elderly ACSC ED rate at the zip code level. Neighborhood socioeconomic characteristics and spatial access to healthcare affect the rate of elderly ACSC ED visits. Research informing policy action is needed to decrease racial/ethnic and economic disadvantage and increase equitable spatial access to primary care for the elderly.