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The Affordable Care Act and suicide incidence among adults with cancer

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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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Data availability

The data analyzed during the current study is a subset of the Surveillance, Epidemiology, and End Results (SEER) national database, which is available online. Note that a waiver/application is a prerequisite to utilizing SEER*Stat software and accessing the associated data.

Code availability

Analyses were performed in R. Documents containing code can be provided upon request.

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Author information

Authors and Affiliations

  1. Department of Radiation Oncology, Washington University School of Medicine, St. Louis, MO, USA

    Justin M. Barnes

  2. Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA

    Evan M. Graboyes

  3. Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA

    Evan M. Graboyes

  4. Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA

    Eric Adjei Boakye

  5. Simmons Cancer Institute, Southern Illinois University School of Medicine, Springfield, IL, USA

    Eric Adjei Boakye

  6. Departments of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Erin E. Kent

  7. Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA

    Erin E. Kent & Eliza M. Park

  8. Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA

    Jeffrey F. Scherrer

  9. Comprehensive Cancer Support Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Eliza M. Park & Donald L. Rosenstein

  10. Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

    Donald L. Rosenstein

  11. Department of Radiation Oncology, Duke University School of Medicine, Durham, NC, USA

    Yvonne M. Mowery, Junzo P. Chino & David M. Brizel

  12. Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC, USA

    Yvonne M. Mowery, David M. Brizel & Nosayaba Osazuwa-Peters

  13. Duke Cancer Institute, Durham, NC, USA

    Yvonne M. Mowery, Junzo P. Chino, David M. Brizel & Nosayaba Osazuwa-Peters

  14. Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA

    Nosayaba Osazuwa-Peters

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  1. Justin M. Barnes
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  2. Evan M. Graboyes
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Contributions

Study conception: Barnes, Osazuwa-Peters; data curation: Barnes; formal analysis and software: Barnes; methodology: Barnes, Graboyes, Osazuwa-Peters; writing–original draft: Barnes; writing–reviewing and editing the manuscript: all authors.

Corresponding author

Correspondence to Justin M. Barnes.

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Barnes, J.M., Graboyes, E.M., Adjei Boakye, E. et al. The Affordable Care Act and suicide incidence among adults with cancer. J Cancer Surviv 17, 449–459 (2023). https://doi.org/10.1007/s11764-022-01205-z

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