Association of State Medicaid Expansion Status with Rates of Suicide among US Adults

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 553912 deaths by suicide occurred during the study period, with most occurring in White (496219 [89.6%]) and male (429580 [77.6%]) individuals. There were smaller increases in the suicide rate after 2014 in Medicaid expansion (2.56 per 100000 increase) compared with nonexpansion states (3.10 per 100000 increase). In adjusted difference-in-differences analysis, a significant decrease of -0.40 (95% credible interval, -0.66 to -0.14) suicides per 100000 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.