Health Policy Journal Club, Health Policy, Health Care Administration, Social EM

Expanding Coverage, Saving Lives

Did Medicaid Expansion Avert Suicides?

Suicide is a leading cause of death in the United States in those aged 10-34, only second to unintentional injuries, and the 10th most common cause of death in the U.S. overall. As suicidal ideations are often a manifestation of underlying psychiatric illness, access to mental health services can help prevent these deaths. However, lack of insurance coverage is a significant barrier to care. The Affordable Care Act went into effect in 2014 and allowed states the opportunity to expand Medicaid access (including mental health coverage) to more low-income adults and enabled young adults (<26 years old) to remain on their parents' health plans as dependents. As of November 2022, 39 states and the District of Columbia had adopted Medicaid expansion.

A recent study in JAMA compared suicide rates from 2000 to 2018 among adults ages 20-64 in states that expanded Medicaid and those that did not. The study found that rates of suicide increased across all states over this 19-year period, with the highest incidence among males (77.6%) and White people (89.6%). However, expansion states showed a smaller increase in suicide rates by -0.40 per 100,000 people, resulting in 1,818 fewer suicides in the years 2015 to 2018 after Medicaid expansion. The most notable mitigation in suicide rates was in the age group of 20-29 (-0.52 suicides per 100,000). Expansion-associated changes in suicide rates among women, Black people, and those ages 45-64 were nonsignificant.

The results of this study signal the importance of expanded health care access in averting suicides by overcoming financial barriers to mental health care. Women and middle-age to older adults were less likely to experience coverage gains as the expansion targeted childless, non-disabled, non-elderly individuals, perhaps contributing to the fact that changes in suicide rates in these groups were not significant. As this study did not include patient-level data it is unclear if the blunting of suicide rates seen in this paper is due to Medicaid expansion itself, or other confounders and, of course, increased insurance access alone does not address the persistent socioeconomic and structural inequities that contribute to the poorer health status of minority groups despite insurance coverage. Further work is needed to investigate and address disparities in access and outcomes. Regardless, advocating for increased access to mental health care may be a place to start to reduce deaths from suicide.

Patel H, Barnes J, Osazuwa-Peters N, Bierut LJ. Association of state Medicaid expansion status with rates of suicide among U.S. adults. JAMA Netw Open. 2022;5(6):e2217228.

Importance: In the U.S., 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 U.S. individuals aged 20-64 years from Jan. 1, 2000, to Dec. 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 non-expansion 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 U.S. 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 non-expansion 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.

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 non-expansion 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.

EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA

As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care physicians, and the lack of mental health services - are universal problems. As EM residents and fellows,  we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill.  Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.  

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