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Cited by 29Suicide and Self-Harm StudiesHealthcare Policy and ManagementOpioid Use Disorder Treatment

Association of State Medicaid Expansion Status With Rates of Suicide Among US Adults

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Patel, Hetal, Barnes, Justin, Osazuwa-Peters, Nosayaba, Bierut, Laura Jean·2022·JAMA Network Open
DOI 10.1001/jamanetworkopen.2022.17228PMC PMC9201676
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Abstract

Importance: In the US, suicide is the 10th leading cause of death and a serious mental health emergency. National programs that address suicide list access to mental health care as key in prevention, and more large-scale policies are needed to improve access to mental health care and address this crisis. The Patient Protection and Affordable Care Act (ACA) Medicaid Expansion Program was implemented in several states with the goal of increasing access to the health care system. Objective: To compare changes in suicide rates in states that expanded Medicaid under the ACA vs states that did not. Design, Setting, and Participants: In this cross-sectional study, state-level mortality rates were obtained from the National Center for Health Statistics for US individuals aged 20 to 64 years from January 1, 2000, to December 31, 2018. Data analysis was performed from April 18, 2021, to April 15, 2022. Exposures: Changes in suicide mortality rates among nonelderly adults before and after Medicaid expansion in expansion and nonexpansion states were compared using adjusted difference-in-differences analyses via hierarchical bayesian linear regression. Main Outcomes and Measures: Suicide rates using death by suicide as the primary measure. Results: Of the total population at risk for suicide, 50.4% were female, 13.3% were Black, 79.5% were White, and 7.2% were of other races. The analytic data set contained suicide mortality data for 2907 state-age-year units covering the general US population. A total of 553 912 deaths by suicide occurred during the study period, with most occurring in White (496 219 [89.6%]) and male (429 580 [77.6%]) individuals. There were smaller increases in the suicide rate after 2014 in Medicaid expansion (2.56 per 100 000 increase) compared with nonexpansion states (3.10 per 100 000 increase). In adjusted difference-in-differences analysis, a significant decrease of -0.40 (95% credible interval, -0.66 to -0.14) suicides per 100 000 individuals was found, translating to 1818 suicides that were averted in 2015 to 2018. Conclusions and Relevance: In this cross-sectional study, although suicide rates increased in both groups, blunting of these rates occurred among nonelderly adults in the Medicaid expansion states compared with nonexpansion states. Because this difference may be linked to increased access to mental health care, policy makers should consider suicide prevention as a benefit of expanding access to health care.

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  • Medicaid expansion has potential benefits including reduction of suicide rates and improving access to inpatient rehabilitation after acute hospitalization among those injured by firearms.

    “While Missouri expanded Medicaid in 2021, the high percentage of firearm injured patients without insurance is of great concern given the potential benefits of Medicaid expansion that include reduction of suicide rates and improving access to inpatient rehabilitation after acute hospitalization among those who are injured by firearms [20, 21].”

    From Firearm injuries in Missouri (2023) · cites this paper as [20]

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  1. [2]Hedegaard H, Curtin SC, Warner M. Increase in suicide mortality in the United States, 1999-2018. NCHS Data Brief. 2020;(362): 1- 8. 32487287
  2. [5]US Department of Health and Human Services, Office of the Surgeon General; National Action Alliance for Suicide Prevention. 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. US Dept of Health and Human Services; 2012. 23136686
  3. [6]US Department of Health and Human Services, Office of the Surgeon General; National Action Alliance for Suicide Prevention. Strategic direction 3: treatment and support services. In: 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. US Dept of Health and Human Services; 2012:50-59. 23136686
  4. [7]US Department of Health and Human Services, Office of the Surgeon General; National Action Alliance for Suicide Prevention. Strategic direction 2: clinical and community preventive services. In: 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action. US Dept of Health and Human Services; 2012:40-49. 23136686
  5. [9]Cunningham PJ. Beyond parity: primary care physicians’ perspectives on access to mental health care. Health Aff (Millwood). 2009; 28(3): w490- w501. doi: 10.1377/hlthaff.28.3.w490 19366722 · DOI · Paper page
  6. [10]Simon K, Soni A, Cawley J. The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions. J Policy Anal Manage. 2017; 36(2): 390- 417. doi: 10.1002/pam.21972 28378959 · DOI
  7. [11]Saloner B, Bandara S, Bacchuber M, Barry CL. An update on “insurance coverage and treatment use under the Affordable Care Act among adults with mental and substance use disorders.” Psychiatr Serv. 2017; 68(3): 310- 311. doi: 10.1176/appi.ps.201600566 28240146 · DOI
  8. [12]Creedon TB, Cook BL. Access to mental health care increased but not for substance use, while disparities remain. Health Aff (Millwood). 2016; 35(6): 1017- 1021. doi: 10.1377/hlthaff.2016.0098 27269017 PMC7033262 · DOI · Paper page
  9. [13]Winkelman TNA, Chang VW. Medicaid expansion, mental health, and access to care among childless adults with and without chronic conditions. J Gen Intern Med. 2018; 33(3): 376- 383. doi: 10.1007/s11606-017-4217-5 29181792 PMC5834959 · DOI
  10. [14]Miller S, Wherry LR. Health and access to care during the first 2 years of the ACA Medicaid expansions. N Engl J Med. 2017; 376(10): 947- 956. doi: 10.1056/NEJMsa1612890 28273021 · DOI
  11. [15]Sommers BD, Blendon RJ, Orav EJ, Epstein AM. Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance. JAMA Intern Med. 2016; 176(10): 1501- 1509. doi: 10.1001/jamainternmed.2016.4419 27532694 · DOI
  12. [16]Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after state Medicaid expansions. N Engl J Med. 2012; 367(11): 1025- 1034. doi: 10.1056/NEJMsa1202099 22830435 · DOI
  13. [17]Bhatt CB, Beck-Sagué CM. Medicaid expansion and infant mortality in the United States. Am J Public Health. 2018; 108(4): 565- 567. doi: 10.2105/AJPH.2017.304218 29346003 PMC5844390 · DOI
  14. [18]Eliason EL. Adoption of Medicaid expansion is associated with lower maternal mortality. Womens Health Issues. 2020; 30(3): 147- 152. doi: 10.1016/j.whi.2020.01.005 32111417 · DOI
  15. [19]Barnes JM, Johnson KJ, Boakye EA,. Early Medicaid expansion and cancer mortality. J Natl Cancer Inst. 2021; djab135. doi: 10.1093/jnci/djab135 34259321 PMC8634305 · DOI
  16. [20]Khan SS, Lloyd-Jones DM, Carnethon M, Pool LR. Medicaid expansion and state-level differences in premature cardiovascular mortality by subtype, 2010-2017. Hypertension. 2020; 76(5): e37- e38. doi: 10.1161/HYPERTENSIONAHA.120.15968 32951471 PMC7544679 · DOI
  17. [21]Kumar SR, Khatana SAM, Goldberg D. Impact of Medicaid expansion on liver-related mortality. Clin Gastroenterol Hepatol. 2022; 20(2): 419- 426.e1. doi: 10.1016/j.cgh.2020.11.042 33278572 PMC8672394 · DOI
  18. [22]Miller S, Johnson N, Wherry LR. Medicaid and mortality: new evidence from linked survey and administrative data. Q J Econ. 2021; 136(3): 1783- 1829. doi: 10.1093/qje/qjab004 · DOI
  19. [23]Austin AE, Naumann RB, Short NA. Association between Medicaid expansion and suicide mortality among nonelderly US adults. Am J Epidemiol. 2021; 190(9): 1760- 1769. doi: 10.1093/aje/kwab130 34467410 PMC12931419 · DOI · Paper page
  20. [25]Fry CE, Hatfield LA. Birds of a feather flock together: Comparing controlled pre-post designs. Health Serv Res. 2021; 56(5): 942- 952. doi: 10.1111/1475-6773.13697 34212387 PMC8522572 · DOI
  21. [26]Case A, Deaton A. Deaths of Despair and the Future of Capitalism. Princeton University Press; 2020.
  22. [27]Olfson M, Cosgrove C, Altekruse SF, Wall MM, Blanco C. Deaths of despair: adults at high risk for death by suicide, poisoning, or chronic liver disease in the US. Health Aff (Millwood). 2021; 40(3): 505- 512. doi: 10.1377/hlthaff.2020.01573 33646867 · DOI
  23. [29]Huskamp HA. Mental health insurance parity: how full is the glass? In: Goldman H, Frank R, Morrissey J, eds. The Palgrave Handbook of American Mental Health Policy. Palgrove Macmillan; 2020: 367- 387. doi: 10.1007/978-3-030-11908-9_13 · DOI
  24. [30]Robertson-Preidler J, Trachsel M, Johnson T, Biller-Andorno N. The Affordable Care Act and recent reforms: policy implications for equitable mental health care delivery. Health Care Anal. 2020; 28(3): 228- 248. doi: 10.1007/s10728-020-00391-0 32103383 · DOI
  25. [31]Stewart MT, Horgan CM, Hodgkin D,. Behavioral health coverage under the Affordable Care Act: what can we learn from marketplace products? Psychiatr Serv. 2018; 69(3): 315- 321. doi: 10.1176/appi.ps.201700098 29241429 PMC5832546 · DOI
  26. [32]Maxwell J, Bourgoin A, Lindenfeld Z. Battling the mental health crisis among the underserved through State Medicaid reforms. Accessed April 17, 2022. https://www.healthaffairs.org/do/10.1377/forefront.20200205.346125/full/ · DOI
  27. [33]Frank RG, Beronio K, Glied SA. Behavioral health parity and the Affordable Care Act. J Soc Work Disabil Rehabil. 2014; 13(1-2): 31- 43. doi: 10.1080/1536710X.2013.870512 24483783 PMC4334111 · DOI
  28. [34]Wisk LE, Peltz A, Galbraith AA. Changes in health care–related financial burden for US families with children associated with the Affordable Care Act. JAMA Pediatr. 2020; 174(11): 1032- 1040. doi: 10.1001/jamapediatrics.2020.3973 32986093 PMC7522777 · DOI
  29. [35]Griffith K, Evans L, Bor J. The Affordable Care Act reduced socioeconomic disparities in health care access. Health Aff (Millwood). 2017; 36(8): 1503- 1510. doi: 10.1377/hlthaff.2017.0083 28747321 PMC8087201 · DOI
  30. [37]Guy GP Jr, Zhang K, Bohm MK,. Vital signs: changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; 66(26): 697- 704. doi: 10.15585/mmwr.mm6626a4 28683056 PMC5726238 · DOI · Paper page
  31. [38]Barnes JM, Graboyes EM, Adjei Boakye E,. The Affordable Care Act and suicide incidence among adults with cancer. J Cancer Surviv. Published online April 4, 2022. doi: 10.1007/s11764-022-01205-z 35368225 · DOI
  32. [39]Buchmueller TC, Levinson ZM, Levy HG, Wolfe BL. Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage. Am J Public Health. 2016; 106(8): 1416- 1421. doi: 10.2105/AJPH.2016.303155 27196653 PMC4940635 · DOI
  33. [43]Johnston KJ, Hammond G, Meyers DJ, Joynt Maddox KE. Association of race and ethnicity and Medicare program type with ambulatory care access and quality measures. JAMA. 2021; 326(7): 628- 636. doi: 10.1001/jama.2021.10413 34402828 PMC8371568 · DOI
  34. [44]Churchwell K, Elkind MSV, Benjamin RM,; American Heart Association. Call to action: structural racism as a fundamental driver of health disparities: a Presidential Advisory from the American Heart Association. Circulation. 2020; 142(24): e454- e468. doi: 10.1161/CIR.0000000000000936 33170755 · DOI · Paper page
  35. [45]Bailey ZD, Krieger N, Agénor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017; 389(10077): 1453- 1463. doi: 10.1016/S0140-6736(17)30569-X 28402827 · DOI · Paper page
  36. [48]Hill SC, Abdus S, Hudson JL, Selden TM. Adults in the income range for the Affordable Care Act’s Medicaid expansion are healthier than pre-ACA enrollees. Health Aff (Millwood). 2014; 33(4): 691- 699. doi: 10.1377/hlthaff.2013.0743 24670269 · DOI

Cited by

Sorted by citations

Authors
Patel, H., Barnes, J., Osazuwa-Peters, N., & Bierut, L. J.
Affiliations
  • Washington University in St. Louis (US)
  • Deputy Editor, Diversity, Equity, and Inclusion, JAMA Otolaryngology–Head and Neck Surgery
Corresponding author
Bierut, Laura Jean
ORCID
Venue
JAMA Network Open
Publisher
American Medical Association (AMA)
Published
2022-06-15
Volume
5
Issue
6
Pages
e2217228
ISSN
2574-3805 (ISSN-L)
DOI
10.1001/jamanetworkopen.2022.17228
PMC
PMC9201676
OpenAlex
W4282960532
Cited by
29
References
4
Citations by year
2026: 5 · 2025: 12 · 2024: 6 · 2023: 6
FWCI
5.48
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • JAMA Network Open (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Digital Commons@Becker (Washington University School of Medicine) (submittedVersion, cc-by)
Funders
  • National Institute of Mental Health (MH112473, R25MH112473)
  • National Institute on Drug Abuse (K12DA041449)
  • National Institute of Dental and Craniofacial Research (K01DE030916)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Keywords
Medicaid expansion, suicide rates, suicide mortality, Affordable Care Act, access to mental health care, mental health policy, non-elderly adults, state health policy, suicide prevention, health insurance
MeSH terms
Adult, Bayes Theorem, Cross-Sectional Studies, Female, Humans, Male, Medicaid, Suicide, United States, Patient Protection and Affordable Care Act

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