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Austin AE, DePadilla L, Niolon P, Stone D, Bacon S. Intersection of adverse childhood experiences, suicide and overdose prevention. Inj Prev 2024:ip-2024-045295. [PMID: 39053926 DOI: 10.1136/ip-2024-045295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 07/11/2024] [Indexed: 07/27/2024]
Abstract
Adverse childhood experiences (ACEs), suicide and overdose are linked across the life course and across generations and share common individual-, interpersonal-, community- and societal-level risk factors. The purpose of this review is to summarise the shared aetiology of these public health issues, synthesise evidence regarding potential community- and societal-level prevention strategies and discuss future research and practice directions.Growing evidence shows the potential for community- and societal-level programmes and policies, including higher minimum wage; expanded Medicaid eligibility; increased earned income tax credits, child tax credits and temporary assistance for needy families benefits; Paid Family Leave; greater availability of affordable housing and rental assistance; and increased participation in the Supplemental Nutrition Assistance Program (SNAP), to contribute to ACEs, suicide and overdose prevention. Considerations for future prevention efforts include (1) expanding the evidence base through rigorous research and evaluation; (2) assessing the implications of prevention strategies for equity; (3) incorporating a relational health perspective; (4) enhancing community capacity to implement, scale and sustain evidenced-informed prevention strategies; and (5) acknowledging that community- and societal-level prevention strategies are longer-term strategies.
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Affiliation(s)
- Anna E Austin
- Centers for Disease Control and Prevention National Center for Injury Prevention and Control, Atlanta, Georgia, USA
| | | | - Phyllis Niolon
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Sarah Bacon
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Mueller JT, Baker RS, Brooks MM. The uneven impact of Medicaid expansion on rural and urban Black, Latino/a, and White mortality. J Rural Health 2024. [PMID: 38987990 DOI: 10.1111/jrh.12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 05/09/2024] [Accepted: 06/06/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE To determine the differential impact of Medicaid expansion on all-cause mortality between Black, Latino/a, and White populations in rural and urban areas, and assess how expansion impacted mortality disparities between these groups. METHODS We employ a county-level time-varying heterogenous treatment effects difference-in-difference analysis of Medicaid expansion on all-cause age-adjusted mortality for those 64 years of age or younger from 2009 to 2019. For all counties within the 50 US States and the District of Columbia, we use restricted-access vital statistics data to estimate Average Treatment Effect on the Treated (ATET) for all combinations of racial and ethnic group (Black, Latino/a, White), rurality (rural, urban), and sex. We then assess aggregate ATET, as well as how the ATET changed as time from expansion increased. FINDINGS Medicaid expansion led to a reduction in all-cause age-adjusted mortality for urban Black populations, but not rural Black populations. Urban White populations experienced mixed effects dependent on years after expansion. Latino/a populations saw no appreciable impact. While no effect was observed for rural Black and Latino/a populations, rural White all-cause age-adjusted mortality unexpectedly increased due to Medicaid expansion. These effects reduced rural- and urban-specific Black-White mortality disparities but did not shrink the rural-urban mortality gap. CONCLUSIONS The mortality-reducing impact of Medicaid expansion has been uneven across racial and ethnic groups and rural-urban status; suggesting that many populations-particularly rural individuals-are not seeing the same benefits as others. It is imperative that states work to ensure Medicaid expansion is being appropriately implemented in rural areas.
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Affiliation(s)
- J Tom Mueller
- Department of Population Health, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Regina S Baker
- Department of Sociology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Matthew M Brooks
- Department of Sociology, Florida State University, Tallahassee, Florida, USA
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Han GI, Jeong S, Kim I, Yuh MA, Woo SH, Hong S. Association of Medicaid coverage with emergency department utilization after self-harm in Korea: A nationwide registry-based study. PLoS One 2024; 19:e0306047. [PMID: 38917201 PMCID: PMC11198744 DOI: 10.1371/journal.pone.0306047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Self-harm presents an important public health challenge. It imposes a notable burden on the utilization of emergency department (ED) services and medical expenses from patients and family. The Medicaid system is vital in providing financial support for individuals who struggle with medical expenses. This study explored the association of Medicaid coverage with ED visits following incidents of self-harm, utilizing nationwide ED surveillance data in Korea. METHODS Data of all patients older than 14 years who presented to EDs following incidents of self-harm irrespective of intention to end their life, including cases of self-poisoning, were gathered from the National ED Information System (NEDIS). The annual self-harm visit rate (SHVR) per 100,000 people was calculated for each province and a generalized linear model analysis was conducted, with SHVR as a dependent variable and factors related to Medicaid coverage as independent variables. RESULTS A 1% increase in Medicaid enrollment rate was linked to a significant decrease of 14% in SHVR. Each additional 1,000 Korean Won of Medicaid spending per enrollee was correlated with a 1% reduction in SHVR. However, an increase in Medicaid visits per enrollee and an extension of Medicaid coverage days were associated with an increase in SHVR. SHVR exhibited a stronger associated with parameters of Medicaid coverage in adolescents and young adults than in older adult population. CONCLUSION Expansion of Medicaid coverage coupled with careful monitoring of shifts in Medicaid utilization patterns can mitigate ED overloading by reducing visits related to self-harm.
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Affiliation(s)
- Ga In Han
- Department of Emergency Medicine, Daejeon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sikyoung Jeong
- Department of Emergency Medicine, Daejeon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Insoo Kim
- Department of Emergency Medicine, Daejeon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Ah Yuh
- Department of Emergency Medicine, Daejeon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seon Hee Woo
- Department of Emergency Medicine, Incheon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sungyoup Hong
- Department of Emergency Medicine, Daejeon St Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Naumann RB, Frank M, Shanahan ME, Reyes HLM, Ammerman AS, Corbie G, Austin AE. State Supplemental Nutrition Assistance Program Policies and Substance Use Rates. Am J Prev Med 2024; 66:526-533. [PMID: 37918458 DOI: 10.1016/j.amepre.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION Food insecurity is associated with the development of substance misuse and use disorders (SUD). This study sought to estimate associations between state Supplemental Nutrition Assistance Program (SNAP) eligibility policies and substance-related outcomes. METHODS 2014-2017 SNAP Policy Database and 2015-2019 National Survey on Drug Use and Health state-level estimates were used to estimate associations between state SNAP eligibility policies and alcohol use disorder (AUD), opioid misuse, illicit drug use disorder (IDUD), SUD, and needing but not receiving SUD treatment. State SNAP policies included those that (1) do not disqualify individuals with a felony drug conviction from SNAP and/or (2) expand SNAP eligibility by increasing the income limit or removing the asset test. Analyses were conducted January-May 2023. RESULTS States that adopted both SNAP eligibility policies had reduced rates of AUD (adjusted rate ratio (aRR): 0.92; 95% CI 0.86, 0.99), opioid misuse (aRR: 0.94; 95% CI 0.89, 0.98), IDUD (aRR: 0.91; 95% CI 0.85, 0.98), SUD (aRR: 0.91; 95% CI 0.85, 0.97), and needing but not receiving SUD treatment (aRR: 0.92; 95% CI 0.87, 0.98) compared to states with neither policy. Among states that did not adopt increases to the income limit or removal of the asset test, those that removed the felony drug disqualification had lower rates of IDUD, SUD, and needing but not receiving SUD treatment, compared to those that maintained a disqualification. CONCLUSIONS Expanded SNAP eligibility could help reduce rates of substance misuse and SUD. Opting out of the federal disqualification on SNAP participation for those with felony drug convictions may be particularly beneficial.
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Affiliation(s)
- Rebecca B Naumann
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Madeline Frank
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Meghan E Shanahan
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - H Luz McNaughton Reyes
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alice S Ammerman
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Giselle Corbie
- Department of Social Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anna E Austin
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
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Cho S, Lee K. Association between insurance type and suicide-related behavior among US adults: The impact of the Affordable Care Act. Psychiatry Res 2024; 333:115714. [PMID: 38219348 DOI: 10.1016/j.psychres.2024.115714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 01/16/2024]
Abstract
This study examined the association between insurance type and suicidal ideation and attempts among adults in the United States, incorporating a comparative analysis of the pre- and post-Affordable Care Act (ACA) periods. We used a nationally representative, cross-sectional, population-based survey of individuals aged 18 years and older from the 2010-2019 National Survey on Drug Use and Health. The higher rates of suicidal ideation and attempts among Medicaid and uninsured groups compared with those with private insurance. After implementation of the ACA policy, the difference-in-differences analysis showed a significantly reduced risk of suicide in the Medicare group compared with the privately insured group, with no significant differences observed in the other groups. These findings highlight the importance of improving access to mental health services, particularly for those with lower levels of insurance coverage, such as Medicaid and Medicare.
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Affiliation(s)
- Seungwon Cho
- Department of Psychiatry, Hanyang Universtiy Medical Center, Seoul, Republic of Korea; Department of Health Policy and Management, Graduate School of Public Health, Hanyang University, Seoul, Republic of Korea
| | - Kounseok Lee
- Department of Psychiatry, Hanyang Universtiy Medical Center, Seoul, Republic of Korea; Department of Psychiatry, College of Medicine, Hanyang University, Seoul, Republic of Korea.
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Sokol RL, Austin AE. State expansion of Supplemental Nutrition Assistance Program eligibility and rates of firearm-involved deaths in the United States. Inj Prev 2024:ip-2023-045035. [PMID: 38365447 DOI: 10.1136/ip-2023-045035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/02/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Poverty is a consistent correlate of firearm-involved mortality, yet little work has considered the effects of social and economic policies on these deaths. This study examined associations of state elimination of the asset test and increases in the income limit for Supplemental Nutrition Assistance Program (SNAP) eligibility with rates of firearm-involved suicide and homicide deaths in the United States. METHODS This ecological repeated cross-sectional study used 2015-2019 data from the SNAP Policy Database and death certificate data from the National Vital Statistics System. The exposures were (1) state elimination of the asset test for SNAP eligibility and (2) state elimination of the asset test and increases in the income limit for SNAP eligibility, compared with (3) state adoption of neither policy. The outcomes were firearm-involved suicide deaths and firearm-involved homicide deaths. The research team conducted mixed-effects regressions to estimate associations. RESULTS State elimination of the asset test for SNAP eligibility (incidence rate ratio (IRR), 0.67; 95% CI, 0.48 to 0.91) and state adoption of both eliminating the asset test and increasing the income limit for SNAP eligibility (IRR, 0.68; 95% CI, 0.49 to 0.92) were associated with decreased rates of firearm-involved suicide deaths compared with state adoption of neither policy. There were no associations with state firearm-involved homicide rates. CONCLUSIONS SNAP is an important social safety net programme that addresses food insecurity, and the present results suggest it may also contribute to reducing firearm-involved suicide.
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Affiliation(s)
- Rebeccah Lyn Sokol
- School of Social Work, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Firearm Injury Prevention, University of Michigan, Ann Arbor, Michigan, USA
| | - Anna E Austin
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Swilley-Martinez ME, Coles SA, Miller VE, Alam IZ, Fitch KV, Cruz TH, Hohl B, Murray R, Ranapurwala SI. "We adjusted for race": now what? A systematic review of utilization and reporting of race in American Journal of Epidemiology and Epidemiology, 2020-2021. Epidemiol Rev 2023; 45:15-31. [PMID: 37789703 DOI: 10.1093/epirev/mxad010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/31/2023] [Accepted: 09/28/2023] [Indexed: 10/05/2023] Open
Abstract
Race is a social construct, commonly used in epidemiologic research to adjust for confounding. However, adjustment of race may mask racial disparities, thereby perpetuating structural racism. We conducted a systematic review of articles published in Epidemiology and American Journal of Epidemiology between 2020 and 2021 to (1) understand how race, ethnicity, and similar social constructs were operationalized, used, and reported; and (2) characterize good and poor practices of utilization and reporting of race data on the basis of the extent to which they reveal or mask systemic racism. Original research articles were considered for full review and data extraction if race data were used in the study analysis. We extracted how race was categorized, used-as a descriptor, confounder, or for effect measure modification (EMM)-and reported if the authors discussed racial disparities and systemic bias-related mechanisms responsible for perpetuating the disparities. Of the 561 articles, 299 had race data available and 192 (34.2%) used race data in analyses. Among the 160 US-based studies, 81 different racial categorizations were used. Race was most often used as a confounder (52%), followed by effect measure modifier (33%), and descriptive variable (12%). Fewer than 1 in 4 articles (22.9%) exhibited good practices (EMM along with discussing disparities and mechanisms), 63.5% of the articles exhibited poor practices (confounding only or not discussing mechanisms), and 13.5% were considered neither poor nor good practices. We discuss implications and provide 13 recommendations for operationalization, utilization, and reporting of race in epidemiologic and public health research.
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Affiliation(s)
- Monica E Swilley-Martinez
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599-7435, United States
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Serita A Coles
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599-7440, United States
| | - Vanessa E Miller
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Ishrat Z Alam
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599-7435, United States
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Kate Vinita Fitch
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599-7435, United States
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Theresa H Cruz
- Prevention Research Center, Department of Pediatrics, Health Sciences Center, University of New Mexico, Albuquerque, NM 87131, United States
| | - Bernadette Hohl
- Penn Injury Science Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104-6021, United States
| | - Regan Murray
- Center for Public Health and Technology, Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR 72701, United States
| | - Shabbar I Ranapurwala
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599-7435, United States
- Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC 27599, United States
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Barnes JM, Graboyes EM, Adjei Boakye E, Kent EE, Scherrer JF, Park EM, Rosenstein DL, Mowery YM, Chino JP, Brizel DM, Osazuwa-Peters N. The Affordable Care Act and suicide incidence among adults with cancer. J Cancer Surviv 2023; 17:449-459. [PMID: 35368225 DOI: 10.1007/s11764-022-01205-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/23/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer. METHODS We identified US patients with cancer aged 18-74 years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions. RESULTS We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64 years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39 years) (- 64.36 per 100,000, 95% CI = - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer. CONCLUSIONS We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicide among cancer survivors.
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Affiliation(s)
- Justin M Barnes
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Eric Adjei Boakye
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
- Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Erin E Kent
- Departments of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Eliza M Park
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
- Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yvonne M Mowery
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Junzo P Chino
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - David M Brizel
- Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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9
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Ortega A. Medicaid Expansion and mental health treatment: Evidence from the Affordable Care Act. HEALTH ECONOMICS 2023; 32:755-806. [PMID: 36480355 DOI: 10.1002/hec.4633] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 06/17/2023]
Abstract
This study uses a difference-in-differences design within an event-study framework to examine how state decisions to expand Medicaid following the passage of the Affordable Care Act (ACA) affected mental health treatment. The findings suggest that expansion states experienced increased admissions to mental health treatment facilities and Medicaid-reimbursed prescriptions for medications used to treat common forms of mental illness. The results also indicate an increase in admissions with trauma, anxiety, conduct, and depression disorders. There is also suggestive evidence of an increase in the number of mental health treatment facilities accepting Medicaid as a form of payment. Lastly, as with previous studies, I find weak evidence of a decrease in suicides in Medicaid expansion states. These findings highlight the vital role of the ACA in providing access to mental health treatment for low-income Americans.
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Affiliation(s)
- Alberto Ortega
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
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Austin AE, Shanahan ME, Frank M, Naumann RB, McNaughton Reyes HL, Corbie G, Ammerman AS. Association of State Expansion of Supplemental Nutrition Assistance Program Eligibility With Rates of Child Protective Services-Investigated Reports. JAMA Pediatr 2023; 177:294-302. [PMID: 36689239 PMCID: PMC9871943 DOI: 10.1001/jamapediatrics.2022.5348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/26/2022] [Indexed: 01/24/2023]
Abstract
Importance States in the US have the option to eliminate the asset test and/or increase the income limit for Supplemental Nutrition Assistance Program (SNAP) eligibility under a policy called broad-based categorical eligibility (BBCE). Given associations of economic hardships, including food insecurity, with child protective services (CPS) involvement, state adoption of these policies may be associated with changes in rates of CPS-investigated reports. Objective To examine the association of state elimination of the asset test and increases in the income limit for SNAP eligibility under BBCE with rates of CPS-investigated reports. Design, Setting, and Participants This cross-sectional ecologic study used data from 2006 to 2019 obtained from the SNAP Policy Database and the National Child Abuse and Neglect Data System Child Files and difference-in-differences analyses. The data were analyzed from March to September 2022. The study used CPS-investigated reports for suspected child abuse and neglect from 37 US states to examine elimination of the asset test, from 36 states to examine increases in the income limit, and from 26 states to examine adoption of both policies. Exposures State elimination of the asset test, increases in the income limit, and adoption of both policies to expand SNAP eligibility. Main Outcomes and Measures Number of CPS-investigated reports, overall and specifically for neglect and physical abuse, per 1000 child population. Results From 2006 to 2019 for all 50 states and the District of Columbia, there were a total of 29 213 245 CPS-investigated reports. By race and ethnicity, 19.8% of CPS-investigated reports were among non-Hispanic Black children and 45.7% among non-Hispanic White children (hereafter referred to as Black and White children). On average, there were 8.2 fewer CPS-investigated reports (95% CI, -12.6 to -4.0) per 1000 child population per year in states that eliminated the asset test, 5.0 fewer CPS-investigated reports (95% CI, -10.8 to 0.7) per 1000 child population per year in states that increased the income limit, and 9.3 fewer CPS-investigated reports (95% CI, -15.6 to -3.1) per 1000 child population per year in states that adopted both SNAP policies than there would have been if these states had not adopted these policies. There were decreases in CPS-investigated reports for neglect in states that adopted either or both policies, and small decreases in CPS-investigated reports for physical abuse in states that increased the income limit or adopted both policies. There were decreases in CPS-investigated reports among both Black and White children. For example, there were 6.5 fewer CPS-investigated reports among Black children (95% CI, -14.6 to 1.6) and 8.7 fewer CPS-investigated reports among White children (95% CI, -15.8 to -1.6) in states that adopted both SNAP policies than there would have been if these states had not adopted these policies. Conclusions and Relevance Results from this cross-sectional study suggest that state expansion of SNAP eligibility through elimination of the asset test and increases in the income limit may contribute to decreases in rates of CPS-investigated reports. These results can inform ongoing debates regarding SNAP policy options, specifically BBCE, and prevention efforts for child abuse and neglect.
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Affiliation(s)
- Anna E. Austin
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
| | - Meghan E. Shanahan
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
| | - Madeline Frank
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
- School of Social Work, University of North Carolina at Chapel Hill
| | - Rebecca B. Naumann
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - H. Luz McNaughton Reyes
- Injury Prevention Research Center, University of North Carolina at Chapel Hill
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Giselle Corbie
- Center for Health Equity Research, School of Medicine, University of North Carolina at Chapel Hill
| | - Alice S. Ammerman
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill
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Weldeslase TA, Akinyemi OA, Silvestre J, Li S, Green KM, Hughes K, Williams M, Cornwell EE. Predictors of Completed Suicides Among Emergency Department Visits for Attempted Suicides. Am Surg 2023:31348231161671. [PMID: 36853915 DOI: 10.1177/00031348231161671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND The objective of this study was to identify predictors of mortality among patients presenting to the emergency department (ED) with attempted suicides. METHODS We analyzed data on emergency department (ED) visits for attempted suicides from the Nationwide Emergency Department Sample (NEDS) database from January 2010 to December 2017. The predictors of mortality were determined in multivariate analysis including age, sex, insurance, annual income, region of the country, mechanism of injury, mental health conditions (schizophrenia; depression; and anxiety, bipolar, and personality disorders), chronic illnesses (hypertension, diabetes, obesity, and dementia), and social risk factors such as alcohol addiction, smoking, and substance abuse. RESULTS From 2010 to 2017, there were 979,383 ED visits for attempted suicides in the NEDS database. Among these patients, 10,301 (1.1%) died. Of these completed suicides, 73.9% were male with the median age of 43 years (IQR, 30) while the unsuccessful suicide attempt group had a median age of 30 years (IQR, 24) and were 42.7% male. The most common mechanisms of suicide attempt were poisoning (58.8%) and cut injury (25.6%). Gunshot was the most lethal mechanism accounting 40.3% of the completed suicides despite representing 1.3% of the attempts who came to ED. After controlling for common risk factors for attempted suicide, significant predictors of completed suicide include higher income status, uninsured status, male sex, and higher age. DISCUSSION Among US patients presenting to the ED following attempted suicide, factors associated with suicide completion include increasing age, male sex, higher income, gunshot injuries, and uninsured status.
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Affiliation(s)
- Terhas A Weldeslase
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
| | - Oluwasegun A Akinyemi
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
| | - Jason Silvestre
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
| | - Sandy Li
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
| | - Kelsey M Green
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
| | - Kakra Hughes
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
| | - Mallory Williams
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
| | - Edward E Cornwell
- Department of Surgery, 12232Howard University College of Medicine, Washington, DC, USA
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Weiss SJ, Simeonova DI, Koleva H, Muzik M, Clark KD, Ozerdem A, Cooper B, Ammerman RT. Potential paths to suicidal ideation and suicide attempts among high-risk women. J Psychiatr Res 2022; 155:493-500. [PMID: 36183603 DOI: 10.1016/j.jpsychires.2022.09.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 08/22/2022] [Accepted: 09/16/2022] [Indexed: 10/31/2022]
Abstract
Although men are more likely to die by suicide, women experience a greater and more rapidly increasing rate of suicidal ideation (SI) and are 3 times more likely to attempt suicide than men. Despite this increased risk, little is known about factors that contribute to SI or suicide attempts (SA) among women. We examined factors associated with SI and SA among women and identified mood-related symptoms that differentiate women who reported attempting suicide from those who did not. Women at elevated risk for depression from across the U.S. (N = 3372; age 18 to 90) completed a survey regarding depression, anxiety, sociodemographic and reproductive status, behavioral/mental health history, and exposure to adversity. Structural equation modeling and logistic regression were used to analyze the data. Variables with the most significant relationships to SI were severity of depression (OR = 5.2, p = 0.000) and perceived stress (OR = 1.18, p = 0.000) while frequency of suicidal thoughts (OR = 3.3, p = 0.000), family history of a depression diagnosis (OR = 1.6, p = 0.000) and exposure to violence (OR = 1.9, p = 0.000) had the strongest association with SA. Childhood abuse/trauma was associated with SA (OR = 1.13, p = 0.000) but not SI. 'Feeling bad about themselves, a failure, or having let themselves or their family down' was the symptom that most clearly differentiated women who attempted suicide from women who reported suicidal ideation but no SA. The salience of childhood abuse and domestic/community violence to women's risk for a suicide attempt reinforces previous findings that these adversities may differentiate suicide risk for women versus men. Continued research is essential to understand varied paths that may lead to suicidal behavior among women, some which appear unrelated to the frequency or intensity of their suicidal thoughts.
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Affiliation(s)
- Sandra J Weiss
- University of California, 2 Koret Way, Box 0608, San Francisco, CA, 94143, USA.
| | - Diana I Simeonova
- Emory University, 12 Executive Park Drive NE, Atlanta, GA, 30329, USA.
| | - Hristina Koleva
- University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| | - Maria Muzik
- University of Michigan, 4250 Plymouth Road, Ann Arbor, MI, 48109, USA.
| | - Kristen D Clark
- University of New Hampshire, 4 Library Way, Hewitt Hall, Durham, NH, 03824, USA.
| | - Aysegul Ozerdem
- Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Bruce Cooper
- University of California, 2 Koret Way, Box 0610, San Francisco, CA, 94143, USA.
| | - Robert T Ammerman
- University of Cincinnati, Cincinnati Children's Hospital, 333 Burnet Avenue, ML7039, Cincinnati, OH, 45229, USA.
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Fung V, Yang Z, Cook BL, Hsu J, Newhouse JP. Changes in Insurance Coverage Continuity After Affordable Care Act Expansion of Medicaid Eligibility for Young Adults With Low Income in Massachusetts. JAMA HEALTH FORUM 2022; 3:e221996. [PMID: 35977216 PMCID: PMC9287752 DOI: 10.1001/jamahealthforum.2022.1996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/17/2022] [Indexed: 11/14/2022] Open
Abstract
Question Did Medicaid expansion in Massachusetts change coverage continuity for child Medicaid enrollees entering young adulthood? Findings In this cohort study of 41 247 young adults, Medicaid enrollees who turned 19 after vs before Medicaid expansion were significantly less likely to have 3 or more months without insurance coverage at ages 18 to 19 and 19 to 20 years and more likely to have continuous Medicaid coverage for 24 or more months. Meaning Federal and state Medicaid expansions were associated with reductions in insurance disruptions and coverage gaps among child Medicaid enrollees entering young adulthood. Importance Young adults historically have had the highest uninsured rates among all age groups. In 2014, in addition to Medicaid expansion for adults with low income (≤133% of the federal poverty level [FPL]) through the Patient Protection and Affordable Care Act, Massachusetts also extended eligibility for children (≤150% FPL) to beneficiaries aged 19 to 20 years. Objective To examine changes in insurance coverage continuity for Medicaid enrollees who turned age 19 years before and after eligibility policy changes. Design, Setting, and Participants This cohort study used data from the Massachusetts All-Payer Claims Database (2012 to 2016) to compare coverage for Medicaid beneficiaries turning age 19 years before and after Medicaid expansion. Monthly coverage was examined for each cohort for 3 years as beneficiaries aged from 18 and 19 years to 19 and 20 years to 20 and 21 years. Analyses were performed between November 1, 2020, and May 12, 2022. Main Outcomes and Measures In each year, the likelihood of being uninsured or having Medicaid, employer-sponsored insurance, or individual commercial coverage for 3 or more months was examined along with the likelihood of having continuous Medicaid enrollment for 12 or more and 24 or more months. Multivariable linear probability models were used to compare the likelihood of these outcomes for those in the postexpansion vs preexpansion cohorts, adjusting for sex, comorbidity levels, neighborhood socioeconomic status, and neighborhood race and ethnicity. Results A total of 41 247 young adults turning age 18 to 19 years in the baseline year (20 876 [50.6%] men) were included in the study, with 20 777 in the preexpansion cohort and 20 470 in the postexpansion cohort. Enrollees who turned age 19 years after vs before the Medicaid eligibility expansion were less likely to have 3 or more uninsured months at ages 18 to 19 years (4.4% [n = 891] vs 22.9% [n = 4750]; adjusted difference, −18.4 [95% CI, −19.0 to −17.7] percentage points) and 19 to 20 years (13.2% [n = 2702] vs 35.8% [n = 7447]; adjusted difference, −22.4 [95% CI, −23.2 to −21.6] percentage points) and more likely to have continuous insurance coverage for 12 or more months (94.1% [n = 19 272] vs 63.7% [n = 13 234]; adjusted difference, 30.5 [95% CI, 29.7-31.2] percentage points) or 24 or more months (77.5% [n = 15 868] vs 44.4% [n = 9221]; adjusted difference, 33.0 [95% CI, 32.1-33.9] percentage points). Differences in the likelihood of having 3 or more uninsured months diminished at ages 20 to 21 years, when both groups had access to Medicaid (ie, in calendar years 2014 for the preexpansion cohort and 2016 for the postexpansion cohort). Conclusions and Relevance In this cohort study of young adults in Massachusetts, the combination of expanding Medicaid to lower-income adults and increasing the age threshold for child Medicaid eligibility was associated with reduced likelihood of becoming uninsured among Medicaid enrollees entering adulthood.
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Affiliation(s)
- Vicki Fung
- Mongan Institute, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Zhiyou Yang
- Mongan Institute, Massachusetts General Hospital, Boston
| | - Benjamin L. Cook
- Health Equity Research Lab, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - John Hsu
- Mongan Institute, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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Patel H, Barnes J, Osazuwa-Peters N, Bierut LJ. Association of State Medicaid Expansion Status With Rates of Suicide Among US Adults. JAMA Netw Open 2022; 5:e2217228. [PMID: 35704315 PMCID: PMC9201676 DOI: 10.1001/jamanetworkopen.2022.17228] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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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Affiliation(s)
- Hetal Patel
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Justin Barnes
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Nosayaba Osazuwa-Peters
- Deputy Editor, Diversity, Equity, and Inclusion, JAMA Otolaryngology–Head and Neck Surgery
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Laura Jean Bierut
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
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Medicaid expansion and opioid overdose mortality among socioeconomically disadvantaged populations in the US: A difference in differences analysis. Drug Alcohol Depend 2022; 233:109381. [PMID: 35259679 PMCID: PMC8971012 DOI: 10.1016/j.drugalcdep.2022.109381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 02/20/2022] [Accepted: 02/24/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Opioid-related overdoses are a major cause of mortality in the US. Medicaid Expansion is posited to reduce opioid overdose-related mortality (OORM), and may have a particularly strong effect among people of lower socioeconomic status. This study assessed the association between state Medicaid Expansion and county-level OORM rates among individuals with low educational attainment. METHODS This quasi-experimental study used lagged multilevel difference-in-difference models to test the relationship of state Medicaid Expansion to county-level OORM rates among people with a high-school diploma or less. Longitudinal (2008-2018) OORM data on 2978 counties nested in 48 states and the District of Columbia (DC) were drawn from the National Center for Health Statistics. The state-level exposure was a time-varying binary-coded variable capturing pre- and post-Medicaid Expansion under the Affordable Care Act (an "on switch"-type variable). The main outcome was annual county-level OORM rates among low-education adults adjusted for potential underreporting of OORM. FINDINGS The adjusted county-level OORM rates per 100,000 among the study population rose on average from 10.26 (SD = 13.56) in 2008-14.51 (SD = 18.20) in 2018. In the 1-year lagged multivariable model that controlled for policy and sociodemographic covariates, the association between state Medicaid Expansion and county-level OORM rates was statistically insignificant. CONCLUSIONS We found no evidence that expanding Medicaid eligibility reduced OORM rates among adults with lower educational attainment. Future work should seek to corroborate our findings and also identify - and repair - breakdowns in mechanisms that should link Medicaid Expansion to reduced overdoses.
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The influence of poverty attribution on attitudes toward suicide and suicidal thought: A cross-national comparison between South Korean, Japanese, and American populations. Compr Psychiatry 2021; 109:152259. [PMID: 34273607 DOI: 10.1016/j.comppsych.2021.152259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/22/2021] [Accepted: 06/15/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Previous studies report that income inequality is an important risk factor for depression and suicide, and an increasing income gap appears inevitable. However, little study to date has investigated associations between the attribution of poverty and suicide. Though we previously reported associations between socio-cultural factors, including income, and suicide, we tried to explore more focused associations between income, attribution of poverty (individualistic, societal), permissive attitude toward suicide, and suicidal thought using a structural equation model. METHODS A total of 2213 participants from each of three nations (South Korea, Japan, and the United States) completed an online survey. Participants without a history of psychological disorders or suicide attempts completed scales measuring attributions of poverty, attitudes toward suicide, and severity of suicidal thoughts. RESULTS We established a structural equation model, which exhibited a good fit for all nations, and compared significant path coefficients by country. South Korea had the highest severity of suicidal thought and societal attribution of poverty, followed by Japan and America. In all nations, a permissive attitude was positively related to the severity of suicidal thought and individualistic attribution of poverty was positively related to a permissive attitude toward suicide. Societal attribution of poverty was positively associated with a permissive attitude in Japan and the United States. Income was negatively associated with the severity of suicide in South Korea and the United States. CONCLUSION Through an established structural equation model, we found the influence of poverty on suicide and identify the common and distinctive factors associated with suicide in each country.
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