Justin M Barnes1, Evan M Graboyes2,3, Eric Adjei Boakye4,5, Erin E Kent6,7, Jeffrey F Scherrer8, Eliza M Park7,9, Donald L Rosenstein9,10, Yvonne M Mowery11,12,13, Junzo P Chino11,13, David M Brizel11,12,13, Nosayaba Osazuwa-Peters12,13,14. 1. Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA. justinbarnes@wustl.edu. 2. Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA. 3. Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA. 4. Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA. 5. Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, USA. 6. Departments of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. 7. Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA. 8. Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA. 9. Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. 10. Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. 11. Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA. 12. Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA. 13. Duke Cancer Institute, Durham, NC, USA. 14. Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
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.
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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