If you want to reduce suicide, Medicaid expansion is a good place to start

Researchers from the Centers for Disease Control and Prevention released results this week to document that suicide rates have increased by 24% since 1999. The increase has been especially rapidly among women and among middle-aged people of both genders between the ages of 45 and 64. This is just a huge problem. Quite properly, the story has gotten much play. This morning’s New York Times includes a front-page story: “U.S. Suicide rate surges to a 30-year high.”

I’m glad that the story has gotten so much attention. Yet the generalized calls to action seem oddly divorced from the actual policy levers through which we might reduce this problem. Here for example is my friend (and Twitter sparring partner) Ron Fournier:

Ron asked the right question, but left things oddly hanging when the most obvious answer was staring him in the face: States could adopt the ACA’s Medicaid expansion, which expands access to mental health services, supports the ecology of safety-net mental health care, and protects many people against burdensome medical debt, which is often referred to collection agencies. All of these issues plausibly matter for people at risk of self-harm and suicide.

More here, at healthinsurance.org.

PS–Yeah, guns matter, too. An essay for another day.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

17 thoughts on “If you want to reduce suicide, Medicaid expansion is a good place to start”

  1. Expanding access to mental health services and cutting medical debt are worth doing even if they have no demonstrable impact on the suicide rate. Common sense suggests they might reduce it, and will certainly not make matters worse. This is not a case where calling for more research before doing anything is reasonable.

    1. If my best friend's daughter had been able to get help when she sought it out, they might both still be alive today.

  2. Harold, can you point the way to finding correlations between Medicaid expansion and suicide rates? Or maybe to a tutorial on navigating the CDC WONDER database? I could find the link for state level data but had trouble finding cause of death by state. I had some luck selecting on Region, but these are broken down into Northeast, Midwest, South, and West only.

    For example, intentional self-harm with handgun (E Code X72), the regional rates in 2014 per 100,000 were: Northeast 0.5, Midwest 1.4, South 1.5, and West 3.0. For intentional self-harm with rifle (E Code X73), the rates per 100,000 were Northeast 0.6, Midwest 1.2, South 0.9, and West 1.0.

    Getting Medicaid-level data is no doubt easy for an experienced navigator; basically what I would like to find is a web tutorial on drilling down further into the database. Any help is appreciated.

  3. I have no statistical evidence connecting economic insecurity and lack of professional opportunity to suicide, but I'm not sure your friend DID ask the right question. The availability of mental health services addresses the symptoms, not the cause. Is it not possible, or even probable, that suicide rates have risen among middle-aged Americans because over the past 25 years of neoliberal and Libertarian predation on the American commonweal, a vast swath of middle-aged Americans are not looking at the next 15 years in senior management, making more than they ever have before, being the revered elder statespersons of their companies and unions, vesting 100 percent in their pensions, paying off their 30-year mortgages and owning their homes free and clear, and in ten years they'll be fishing and playing golf and hosting their grandkids at the cottage by the lake every summer? And instead they'll be taking a second shift to pay off their spouse's medical bills, and having adult children move back in with them because they've been downsized or outsourced out of a job, and looking at higher and higher co-pays and deductibles, and they certainly can't afford to pay for college for their youngest kid, and they've recently been demoted and are now reporting to a snot-nosed 27-year-old MBA from Wharton….and everything looks really shitty to a 58-year-old Average Joe, compared to how it looked in 1965, or 1978?

    I mean, not to belittle the need for better mental health services — but I'm not sure everyone had Prozac and a therapist in 1985. I think what they had was job security and decent healthcare and a public education system that worked.

  4. If only half of all suicides occurred among a small, easily identifiable group of people, during a fairly narrow time window, so that it would be easy to direct help where it was most needed. Such as, say, men going through divorce.

    But, alas, we don't have a cause for divorce that's that easily identified, so I guess we're reduced to indirect measures like expanding controversial programs opposed by most members of Congress, such as the ACA and gun control.

    Darn it!

    1. Did you read the same abstract I did? The one I read says nothing – nothing – about men "going through divorce." It talks about divorced men, but the time window you imagine is not mentioned.

      Nor does it say anything about overall rates for men and women, merely the relative rates for married and divorced individuals.

      For the entire sample, higher risks of suicide were found in divorced than in married persons. Divorced and separated persons were over twice as likely to commit suicide as married persons (RR=2.08, 95% confidence intervals (95% CI) 1.58, 2.72). Being single or widowed had no significant effect on suicide risk. When data were stratified by sex, it was observed that the risk of suicide among divorced men was over twice that of married men (RR=2.38, CI 1.77, 3.20). Among women, however, there were no statistically significant differentials in the risk of suicide by marital status categories.

      Can you show just a smidge of integrity, please?

      1. Yes, it's difficult to find something closely on point, (This is not a topic that get addressed much, which is kind of the point I was making.) and I was in a bit of a hurry, so I went with the closest link I could find in a couple of minutes. Sorry if it didn't meet your standards.

        It's true, it conflates men after divorce, and women after divorce. This dilutes the actual affect, as women after divorce actually do not show any heightened tendency towards suicide at all. It's all due to the men killing themselves.

        Perhaps you'd find this more on point. Men after divorce are over nine times more likely to suicide than the women. OVER NINE TIMES! Yes, if you run the numbers, it turns out that about half of all suicides in the US are men either going through divorce, or recently divorced. A VERY easy to identify risk group!

        Imagine the explosion of colored ribbons, and urgent efforts at doing something about it, if the numbers were reversed.

        1. Well, if you don't have evidence "on point" why are you trying to make that point?

          I accept that divorced men have a much higher suicide rate than divorced women. It's the "going through" and "narrow time window" part I don't see supported.

          As for Medicaid expansion and other approaches, if they reduce suicides neutrally, wouldn't they reduce divorced men's rates by nine times as much as divorced women's?

          As for guns, well, I wonder what the numbers say about respective gun ownership and use in suicide. Of course, your complaint notwithstanding, that issue has been forced off the table.

  5. From the OP: The increase has been especially rapidly among women and among middle-aged people of both genders between the ages of 45 and 64.

    So, when you say "men going through divorce", do you mean women?

    1. No, because the risk of suicide among women has increased more rapidly, but from a much lower baseline. Women's risk of suicide has "shot up" from 22% of the male suicide risk, to a whole 28%. A mere 3 1/2 times lower than the male rate. And women who go through divorce are more than 9 times less likely to suicide than men. Basically, divorce has no influence on women's suicide rates, it makes men's rates skyrocket. (Shouldn't we be asking why?)

      Making it clear we should focus all our efforts on reducing the rate of women's suicide back to 4 1/2 times lower than the male rate, where it belongs, and just ignore those guys. After all, if we totally eliminated women's suicide, we could knock down the overall rate by several percent!

      If I sound mad, it's because I am. There are very few public health issues where we have such incredibly good information about exactly who is at risk, and where the at risk group is so easily identified. Practically no others, as a matter of fact.

      And yet, here's Harold suggesting what are, at best, highly general and indirect measures. More realistically, just using suicide as an excuse to do things almost totally unrelated, that he just happened to want to do anyway.

      The OP is, to put it simply, a joke, thanks to this. A freaking black joke.

      1. This isn't an either/or. Sure we should look hard at divorce as a threat to mental health and happiness. As a social institution, it's not working very well.

        One line could be whether the stresses and conflicts of a failing relationship are amplified by the adversarial paradign of common law civil justice. It's not just the incentives on divorce lawyers to go for blood, but the role of judges as arbitrators between two "sides", rather than mediators seeking the least bad exit strategy, and guardians of the interests of any minor children. Is suicide connected to divorce less common in civil law jurisdictions?

        Though I very fortunately have no personal experience of the current process, I made on this blog a modest proposal for changing it with a civil divorce ceremony. In this the two parties would publicly consent to the conditions of the divorce decree, and reaffirm their ongoing joint responsibility for the care and education of any children. Would it work? I'm not sure. But some new thinking is called for.

        1. No, not "either/or", more a question of allocation of scarce resources. Say you find out that you can trace half of all new AIDS cases to tattoo parlors in lower Manhattan. Do you expend your limited resources trying to get tattoo parlors in lower Manhattan to use proper sterile procedure, or do you blow off doing anything about the parlors, and concentrate on distributing condoms nation-wide?

          Maybe the latter, if you've got a predisposition to think distributing condoms is important, and AIDS looks like an excuse to distribute them. Your goal is distributing condoms, if this improves the AIDS situation, that's a bonus. If it doesn't, no big deal, since distributing condoms is "worth doing even if they have no demonstrable impact" on AIDS.

          IOW, the measures proposed in the OP are not proposed because they're the best way to deal with suicide. Suicide is just an excuse for doing them. In the very first comment you as much as admitted it.

          But, setting that aside, I've got a bone to pick with you concerning how you described the situation in regards to suicide and divorce.

          The relationship between suicide and divorce is not *gender neutral*. Divorce does not make *people* more likely to suicide. It makes *men* more likely to suicide. This is not a gender symmetric problem, we should not pretend it is a gender neutral problem, with a gender neutral solution. Doing so is just a way of deliberately not coming to grips with what the problem really is.

          The problem with divorce and suicide is that American law is systematically biased against men in this context, and to an enormous extent. Theoretically, no. Facially, no. In reality? Absolutely, and to the point that it drives men who come in contact with our divorce system to suicidal despair.

          And nobody who is committed to pretending this isn't so, is going to be able to do much about a suicide problem where half of all suicides are men involved with divorce.

          1. "I've got a bone to pick with you concerning how you described the situation in regards to suicide and divorce."
            You must be thinking of some other commenter.

            I suspect where we differ is the feasibility of finely targeted as against to general health programmes. If you have a childhood whooping cough epidemic (here I have skin in the game – it almost killed me as an infant), there's a vaccine. Do you set up a specific vaccine programme, or make sure that all children have access to preventive health services that will automatically include the service? The USA can easily afford this, like other OECD countries. The same goes for Medicaid expansion.

          2. Skin in the game here, too: The only reason I'm still around is that I didn't drink enough before trying to slit my wrists, after my divorce. Remarkable how pain can temporarily clear up depression, and give you a chance to think clearly about things before you resume wanting to die.

            This is a case where fine targeting is perfectly feasible, because divorce is a *legal* proceeding, the government knows who's going through it. We KNOW who is at risk.

            Honestly, the legal system ought to know who is at risk. It's largely responsible in the first place, by making the divorce process so utterly one-sided. We were both gainfully employed, no children. I had savings, she had massive debts. A year and a divorce later, she had savings, and I had debts. Funny how the legal system thought that was reasonable…

          3. I'm sorry to hear this.
            One of the demands of Muslim fundamentalists in say Britain is to settle divorce by shariah law. They have half a point, in that Islam has always seen easy and simple divorce as the necessary counterpart of a strong ban on adultery. Ibn Battuta travelled the Muslim world as an itinerant legal expert, setting up a new household wherever he stayed for a while, with a wife or two, divorcing them tidily before he moved on. The objection is less to shariah as such than to the built-in gender inequality.

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