Association of State Medicaid Expansion Status With Rates of Suicide Among US Adults.
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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.
SUBMITTER: Patel H
PROVIDER: S-EPMC9201676 | biostudies-literature |
REPOSITORIES: biostudies-literature
Similar Datasets
Project description:ObjectiveTo test whether Medicaid expansion is associated with (a) a greater number of naloxone prescriptions dispensed and (b) a higher proportion of naloxone prescriptions paid by Medicaid.Data sources/study settingWe used the IQVIA National Prescription Audit to obtain data on per state per quarter naloxone prescription dispensing for the period 2011-16.Study designIn this quasi-experimental design study, the impact of Medicaid expansion on naloxone prescription dispensing was examined using difference-in-difference estimation models. State-level covariates including pharmacy-based naloxone laws (standing/protocol orders and direct authority to dispense naloxone), third-party prescribing laws, opioid analgesic prescribing rates, opioid-involved overdose death rates, and population size were controlled for in the analysis.Principal findingsMedicaid expansion was associated with 38 additional naloxone prescriptions dispensed per state per quarter compared to nonexpansion controls, on average (P = .030). Also, Medicaid expansion resulted in an average increase of 9.86 percent in the share of naloxone prescriptions paid by Medicaid per state per quarter (P < .001).ConclusionsOur study found that Medicaid expansion increased naloxone availability. This finding suggests that it will be important to consider naloxone access when making federal- and state-level decisions affecting Medicaid coverage.
| S-EPMC7080392 | biostudies-literature
Project description:ImportanceLow birth weight and preterm birth are associated with adverse consequences including increased risk of infant mortality and chronic health conditions. Black infants are more likely than white infants to be born prematurely, which has been associated with disparities in infant mortality and other chronic conditions.ObjectiveTo evaluate whether Medicaid expansion was associated with changes in rates of low birth weight and preterm birth outcomes, both overall and by race/ethnicity.Design, setting, and participantsUsing US population-based data from the National Center for Health Statistics Birth Data Files (2011-2016), difference-in-differences (DID) and difference-in-difference-in-differences (DDD) models were estimated using multivariable linear probability regressions to compare birth outcomes among infants in Medicaid expansion states relative to non-Medicaid expansion states and changes in relative disparities among racial/ethnic minorities for singleton live births to women aged 19 years and older.ExposuresState Medicaid expansion status and racial/ethnic category.Main outcomes and measuresPreterm birth (<37 weeks' gestation), very preterm birth (<32 weeks' gestation), low birth weight (<2500 g), and very low birth weight (<1500 g).ResultsThe final sample of 15 631 174 births (white infants: 8 244 924, black infants: 2 201 658, and Hispanic infants: 3 944 665) came from the District of Columbia and 18 states that expanded Medicaid (n = 8 530 751) and 17 states that did not (n = 7 100 423). In the DID analyses, there were no significant changes in preterm birth in expansion relative to nonexpansion states (preexpansion to postexpansion period, 6.80% to 6.67% [difference: -0.12] vs 7.86% to 7.78% [difference: -0.08]; adjusted DID: 0.00 percentage points [95% CI, -0.14 to 0.15], P = .98), very preterm birth (0.87% to 0.83% [difference: -0.04] vs 1.02% to 1.03% [difference: 0.01]; adjusted DID: -0.02 percentage points [95% CI, -0.05 to 0.02], P = .37), low birth weight (5.41% to 5.36% [difference: -0.05] vs 6.06% to 6.18% [difference: 0.11]; adjusted DID: -0.08 percentage points [95% CI, -0.20 to 0.04], P = .20), or very low birth weight (0.76% to 0.72% [difference: -0.03] vs 0.88% to 0.90% [difference: 0.02]; adjusted DID: -0.03 percentage points [95% CI, -0.06 to 0.01], P = .14). Disparities for black infants relative to white infants in Medicaid expansion states compared with nonexpansion states declined for all 4 outcomes, indicated by a negative DDD coefficient for preterm birth (-0.43 percentage points [95% CI, -0.84 to -0.02], P = .05), very preterm birth (-0.14 percentage points [95% CI, -0.26 to -0.02], P = .03), low birth weight (-0.53 percentage points [95% CI, -0.96 to -0.10], P = .02), and very low birth weight (-0.13 percentage points [95% CI, -0.25 to -0.01], P = .04). There were no changes in relative disparities for Hispanic infants.Conclusions and relevanceBased on data from 2011-2016, state Medicaid expansion was not significantly associated with differences in rates of low birth weight or preterm birth outcomes overall, although there were significant improvements in relative disparities for black infants compared with white infants in states that expanded Medicaid vs those that did not.
| S-EPMC6487545 | biostudies-literature
Project description:BackgroundIncidence of hypertensive disorders of pregnancy is increasing in the United States. Early detection is important to prevent adverse maternal and offspring outcomes. This ecological study evaluated changes in rates of hypertensive disorders of pregnancy among states that expanded Medicaid compared with states that did not expand Medicaid.MethodsA quasi-experimental analysis using difference-in-differences models compared changes in rates of hypertensive disorders of pregnancy in Medicaid expansion states relative to non-Medicaid expansion states from 2012 to 2019. Maternal data from singleton first live births to individuals aged 20 to 39 years were obtained from the National Center for Health Statistics. Outcomes of interest included age-adjusted rates of de novo hypertension in pregnancy (gestational hypertension or preeclampsia) and prepregnancy hypertension.ResultsData from 7 764 965 individuals with a singleton first live birth were analyzed from 17 states and Washington, DC that expanded Medicaid and 15 states that did not. Rates of de novo hypertension in pregnancy increased over the study period in both expansion (54.34 [95% CI, 48.25-60.43] to 74.87 [95% CI, 71.20-78.55] per 1000 births) and nonexpansion states (68.32 [95% CI, 61.02-75.62] to 84.79 [95% CI, 80.67-88.91] per 1000 births). In adjusted difference-in-differences analyses, expansion status was associated with a greater increase in rates of de novo hypertension in pregnancy (difference-in-differences coefficient, +8.18 [95% CI, 4.00-12.36] per 1000 live births) but a decline in rates of de novo hypertension in pregnancy complicated by low birth weight (-7.20 [95% CI, -13.71 to -0.70] per 1000 births with hypertensive disorders of pregnancy). In adjusted difference-in-differences analyses, there were no significant changes in rates of prepregnancy hypertension in expansion relative to nonexpansion states (+1.13 [95% CI, -0.09 to +2.35] per 1000 live births).ConclusionsBetween 2012 and 2019, states that expanded Medicaid had a significantly greater increase in rates of de novo hypertension, with some evidence of better outcomes among those with de novo hypertension diagnosed in pregnancy.
| S-EPMC8820292 | biostudies-literature
Project description:Importance:Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. Objective:To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. Design, Setting, and Participants:This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. Exposures:State Medicaid expansion between 2011 and 2017. Main Outcomes and Measures:Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Results:Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P?<?.001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P?=?.04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P?=?.049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P?=.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P?=?.14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P?=?.70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P?=?.06). Conclusions and Relevance:In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.
| S-EPMC7260619 | biostudies-literature
Project description:Importance:Medicaid community engagement requirements (work, school, job searching, or community service) are being implemented by several states for the first time, but the association of Medicaid coverage with enrollees' employment and school attendance is unclear. Objective:To assess longitudinal changes in enrollees' employment or student status after Michigan's Medicaid expansion. Design, Setting, and Participants:This survey study included 4090 nonelderly, adult Healthy Michigan Plan enrollees from March 1, 2017, to January 31, 2018. Main Outcomes and Measures:Self-reported employment or student status. Proportionate sampling was stratified by income and geographic region. Mixed-effects regression models with time indicators were used to assess longitudinal changes in the proportion of enrollees who were employed or students. Results:The response rate for the initial survey was 53.7% and for the follow-up survey was 83.4%. Of the 3104 respondents to the 2017 follow-up survey (mean [SD] age in 2017, 42.2 [13.0] years; 1867 [53.0%] female), 54.3% were employed or students in 2016, and this number increased to 60.0% in 2017 (percentage point change, 5.7; P < .001). Non-Hispanic black enrollees had significantly larger gains in employment or student status compared with non-Hispanic white enrollees (percentage point change, 10.7 vs 3.5; P = .02). Changes in employment or student status were not associated with improved health status. Conclusions and Relevance:Employment or student status increased from 2016 to 2017 among Michigan Medicaid expansion enrollees. These findings provide information about whether Medicaid coverage or community engagement requirements are best to promote the desired outcomes of employment and student status.
| S-EPMC7042869 | biostudies-literature
Project description:Of the fourteen states that have not expanded eligibility for Medicaid, nine are in the southern census region, and two others border that region. Ongoing debate over the merits of Medicaid expansion in these states has focused, in part, on whether the safety net provides sufficient access for uninsured low-income Americans. We analyzed longitudinal survey and vital status data from the twelve-state Southern Community Cohort Study (SCCS) for 15,356 nonelderly adult participants with low incomes, 86 percent of whom were enrolled at community health centers. In difference-in-differences analyses, we compared changes in self-reported health between participants in four expansion and eight nonexpansion states before (2008-13) and after (2015-17) Medicaid expansion. We found that a higher proportion of SCCS participants in expansion states reported increases in Medicaid coverage (a differential change of 7.6 percentage points), a lower proportion experienced a health status decline (-1.8 percentage points), and a higher proportion maintained their baseline health status (1.4 percentage points). The magnitude of estimated reductions in health declines would meaningfully affect a nonexpansion state's health ranking in our sample if that state elected to expand Medicaid. Our results suggest that for low-income adults in the South, Medicaid expansion yielded health benefits-even for those with established access to safety-net care.
| S-EPMC7169046 | biostudies-literature
Project description:ImportancePhysical abuse and neglect affect a significant number of children in the United States. The 2014 Medicaid expansion, in which several states opted to expand their Medicaid programs, is associated with parental financial stability and access to mental health care.ObjectiveTo determine whether Medicaid expansion is associated with changes in physical abuse and neglect rates.Design, setting, and participantsThis ecological study used state-level National Child Abuse and Neglect Data Systems (NCANDS) data from January 1, 2010, through December 31, 2016, to compare the change in physical abuse and neglect rates in states that chose to expand Medicaid vs those that did not. All cases of physical abuse and neglect of children younger than 6 years during the study period that were referred to state-level Child Protective Services and screened in for further intervention after having met a maltreatment risk threshold were included. Cases with only documented sexual or emotional abuse were excluded. A difference-in-difference analysis was conducted from April 12, 2018, through March 26, 2019.ExposuresState-level Medicaid expansion status.Main outcomes and measuresIncidence rate of screened-in referrals for physical abuse or neglect per 100 000 children younger than 6 years per year by state.ResultsData were analyzed for 31 states and the District of Columbia that expanded Medicaid and 19 states that did not during the study period, with baseline neglect counts of 646 463 and 388 265, respectively. After Medicaid expansion, 422 fewer cases of neglect per 100 000 children younger than 6 years (95% CI, -753 to -91) were reported each year after adjusting for confounders for comparison of postexpansion and preexpansion rates in states that expanded Medicaid contrasting with the change during that time in nonexpansion states. From 2013 to 2016, Medicaid coverage for adults with dependent children increased a median 1.9% (interquartile range, 0.4% to 4.3%) in the states that did not expand Medicaid and 4.2% (interquartile range, 0.9% to 6.0%) in the states that did. No associations were found between Medicaid coverage or Medicaid eligibility criteria and physical abuse or neglect rates.Conclusions and relevanceMedicaid expansion was associated with a reduction in the reported child neglect rate, but not the physical abuse rate. These findings suggest that expanding Medicaid may help prevent child neglect.
| S-EPMC6575148 | biostudies-literature
Project description:OBJECTIVE:To determine the association of Medicaid expansion with health insurance coverage by marital status and sex. METHODS:A population-based, quasi-experimental policy analysis was undertaken of the implementation of the Patient Protection and Affordable Care Act's (ACA) Medicaid expansion provision on or after January 1, 2014. The 2010-16 American Community Survey provided data on 3,874,432 Medicaid-eligible adults aged 19-64 with incomes up to 138% of the federal poverty level. The outcome measures were no health insurance coverage and Medicaid coverage. The predictor variables were marital status and sex, with controls for family size, poverty status, race/ethnicity, education, employment status, immigration status, and metropolitan residence. RESULTS:In 2016, the uninsured rate for married men and women in a Medicaid expansion state was 21.2% and 17.1%, respectively, compared to 37.4% for married men and 35.8% for married women in a non-expansion state. The Medicaid coverage rate grew between 14.8% to 19.3% in Medicaid expansion states, which contrasts with less than a 5% growth in non-expansion states. Triple differences analysis suggests that, for women of all age groups, Medicaid expansion resulted in a 1.6 percentage point lower uninsured rate for married women compared to unmarried women. For men, there was not a statistically significant difference in the uninsured rate for married compared to unmarried men. For women of all age groups, there was a 2.6 percentage point higher Medicaid coverage rate for married compared to unmarried women. For men, there was a 1.8 percentage point higher Medicaid coverage rate for married compared to unmarried men. CONCLUSION:Medicaid expansion under the ACA differentially lowered uninsurance and improved Medicaid coverage for married persons, especially married women, more than unmarried persons.
| S-EPMC6808332 | biostudies-literature
Project description:ImportanceThe Patient Protection and Affordable Care Act broadened insurance coverage, partially through voluntary state-based Medicaid expansion.ObjectiveTo determine whether patients with higher-risk prostate cancer residing in Medicaid expansion states were more likely to receive treatment after expansion compared with patients in states electing not to pursue Medicaid expansion.Design, setting, and participantsThis population-based cohort study included 15 332 patients diagnosed with higher-risk prostate cancer (ie, grade group >2; grade group 2 with prostate-specific antigen levels >10 ng/mL; or grade group 1 with prostate-specific antigen levels >20 ng/mL) from January 2010 to December 2016 aged 50 to 64 years who were candidates for definitive treatment. Patients residing in states that partially expanded Medicaid coverage before 2010 (ie, California and Connecticut) and those with diagnosis not confirmed by histology were excluded. Data were collected from the Surveillance, Epidemiology, and End Results Program. Data were analyzed between August and December 2019.ExposureState-level Medicaid expansion status.Main outcomes and measuresInsurance status before and after expansion, treatment with prostatectomy or radiation therapy (including brachytherapy), treatment trends over time.ResultsOf 15 332 patients, 7811 (50.9%) lived in expansion states (mean [SD] age, 59.1 [3.8] years; 5532 [71.9%] non-Hispanic White), and 7521 (49.1%) lived in nonexpansion states (mean [SD] age, 59.0 [3.9] years; 3912 [52.1%] non-Hispanic White). Residence in an expansion state was associated with higher pre-expansion levels of Medicaid coverage (292 [8.1%] vs 161 [3.8%]; odds ratio [OR], 2.12; 95% CI, 1.78 to 2.53) and lower likelihood of being uninsured (136 [3.2%] vs 38 [1.1%]; OR, 0.28; 95% CI, 0.15 to 0.54). After expansion, there was no difference in trends in treatment receipt between expansion and nonexpansion states (change, -0.39%; 95% CI, -0.11% to 0.28%; P = .25). Patients with private or Medicare coverage were more likely to receive treatment vs those with Medicaid or no coverage across racial/ethnic groups (eg, Black patients with coverage: OR, 2.30; 95% CI, 1.68 to 3.10; Black patients with no coverage: OR, 1.48; 95% CI, 1.09 to 2.00; P < .001). Medicaid patients were not more likely to be treated compared with those without insurance (737 [78.8%] vs 435 [79.5%]; OR, 0.97; 95% CI, 0.76 to 1.25).Conclusions and relevanceIn this cohort study, state-level expansion of Medicaid was associated with increased Medicaid coverage for men with higher-risk prostate tumors but did not appear to affect treatment patterns at a population level. This may be related to the finding that Medicaid coverage was not associated with increased treatment rates compared with those without insurance.
| S-EPMC7542300 | biostudies-literature
Project description:BackgroundYoung adults (YAs) experience higher uninsurance rates and more advanced stage at cancer diagnosis than older counterparts. We examined the association of the Affordable Care Act Medicaid expansion with insurance coverage and stage at diagnosis among YAs newly diagnosed with cancer.MethodsUsing the National Cancer Database, we identified 309 413 YAs aged 18-39 years who received a first cancer diagnosis in 2011-2016. Outcomes included percentages of YAs without health insurance at diagnosis, with stage I (early-stage) diagnoses, and with stage IV (advanced-stage) diagnoses. We conducted difference-in-difference (DD) analyses to examine outcomes before and after states implemented Medicaid expansion compared with nonexpansion states. All statistical tests were 2-sided.ResultsThe percentage of uninsured YAs decreased more in expansion than nonexpansion states (adjusted DD = -1.0 percentage points [ppt], 95% confidence interval [CI] = -1.4 to -0.7 ppt, P < .001). The overall percentage of stage I diagnoses increased (adjusted DD = 1.4 ppt, 95% CI = 0.6 to 2.2 ppt, P < .001) in expansion compared with nonexpansion states, with greater improvement among YAs in rural areas (adjusted DD = 7.2 ppt, 95% CI = 0.2 to 14.3 ppt, P = .045) than metropolitan areas (adjusted DD = 1.3 ppt, 95% CI = 0.4 to 2.2 ppt, P = .004) and among non-Hispanic Black patients (adjusted DD = 2.2 ppt, 95% CI = -0.03 to 4.4 ppt, P = .05) than non-Hispanic White patients (adjusted DD = 1.4 ppt, 95% CI = 0.4 to 2.3 ppt, P = .008). Despite the non-statistically significant change in stage IV diagnoses overall, the percentage declined more (adjusted DD = -1.2 ppt, 95% CI = -2.2 to -0.2 ppt, P = .02) among melanoma patients in expansion relative to nonexpansion states.ConclusionsWe provide the first evidence, to our knowledge, on the association of Medicaid expansion with shifts to early-stage cancer at diagnosis and a narrowing of rural-urban and Black-White disparities in YA cancer patients.
| S-EPMC9989840 | biostudies-literature