Katherine Hempstead

Rising suicide among adults aged 40-64 years: the role of job and financial circumstances

INTRODUCTION Suicide rates among middle-aged men and women in the U.S. have been increasing since 1999, with a sharp escalation since 2007. PURPOSE To examine whether suicides with circumstances related to economic crises increased disproportionately among the middle-aged between 2005 and 2010. METHODS This study used the National Violent Death Reporting System (NVDRS) in 2014 to explore trends and patterns in circumstance and method among adults aged 40-64 years. RESULTS Suicide circumstances varied considerably by age, with those related to job, financial, and legal problems most common among individuals aged 40-64 years. Between 2005 and 2010, the proportion of suicides where these circumstances were present increased among this age group, from 32.9% to 37.5% of completed suicides (p<0.05). Further, suffocation is a method more likely to be used in suicides related to job, economic, or legal factors, and its use increased disproportionately among the middle-aged. The number of suicides using suffocation increased 59.5% among those aged 40-64 years between 2005 and 2010, compared with 18.0% for those aged 15-39 years and 27.2% for those aged >65 years (p<0.05). CONCLUSIONS The growth in the importance of external circumstances and increased use of suffocation jointly pose a challenge for prevention efforts designed for middle-aged adults. Suffocation is a suicide method that is highly lethal, requires relatively little planning, and is readily available. Efforts that target employers and workplaces as important stakeholders in the prevention of suicide and link the unemployed to mental health resources are warranted.

Price Transparency in Primary Care: Can Patients Learn About Costs When Scheduling an Appointment?

BackgroundCost-sharing in health insurance plans creates incentives for patients to shop for lower prices, but it is unknown what price information patients can obtain when scheduling office visits.ObjectiveTo determine whether new patients can obtain price information for a primary care visit and identify variation across insurance types, offices, and geographic areas.DesignSimulated patient methodology in which trained interviewers posed as non-elderly adults seeking new patient primary care appointments. Caller insurance type (employer-sponsored insurance [ESI], Marketplace, or uninsured) and plan were experimentally manipulated. Callers who were offered a visit asked for price information. Unadjusted means and regression-adjusted differences by insurance, office types, and geography were calculated.ParticipantsCalls to a representative sample of primary care offices in ten states in 2014: Arkansas, Georgia, Iowa, Illinois, Massachusetts, Montana, New Jersey, Oregon, Pennsylvania, and Texas (N = 7865).Main MeasuresCallers recorded whether they were able to obtain a price. If not, they recorded whether they were referred to other sources for price information.Key ResultsOverall, 61.8% of callers with ESI were able to obtain a price, versus 89.2% of uninsured and 47.3% of Marketplace callers (P < 0.001 for differences). Price information was also more readily available in small offices and in counties with high uninsured rates. Among callers not receiving a price, 72.1% of callers with ESI were referred to other sources (billing office or insurance company), versus 25.8% of uninsured and 50.9% of Marketplace callers (P < 0.001). A small fraction of insured callers were told their visit would be free. If not free, mean visit prices ranged from

Differences in U.S. Suicide Rates by Educational Attainment, 2000–2014

157 for uninsured to

The Need for State Health Services and Policy Research

165 for ESI (P < 0.05). Prices were significantly lower at federally qualified health centers (FQHCs), smaller offices, and in counties with high uninsured and low-income rates.ConclusionsPrice information is often unavailable for privately insured patients seeking primary care visits at the time a visit is scheduled.

Community Characteristics and Qualified Health Plan Selection during the First Open Enrollment Period

INTRODUCTION The purpose of this study was to document the association between education and suicide risk, in light of rising suicide rates and socioeconomic differentials in mortality in the U.S. METHODS Differentials and trends in U.S. suicide rates by education were examined from 2000 to 2014 using death certificate data on 442,135 suicides from the National Center for Health Statistics and Census data. Differences in the circumstances and characteristics of suicide deaths by education were investigated using 2013 data from the National Violent Death Reporting System for nine states. Analyses were conducted in 2016. RESULTS Between 2000 and 2014, men and women aged ≥25 years with at least a college degree exhibited the lowest suicide rates; those with a high school degree displayed the highest rates. Men with a high school education were twice as likely to die by suicide compared with those with a college degree in 2014. The education gradient in suicide mortality generally remained constant over the study period. Interpersonal/relationship problems and substance abuse were more common circumstances for less educated decedents. Mental health issues and job problems were more prevalent among college-educated decedents. CONCLUSIONS The findings highlight the importance of social determinants in suicide risk, with important prevention implications.

The Health Reform Monitoring Survey: Addressing Data Gaps To Provide Timely Insights Into The Affordable Care Act

Many provisions of the Affordable Care Act of 2010 (ACA) are being implemented at the state level, and state decisions will play a significant role in the successful implementation of the law. Effective evaluation of the ACA will depend on rigorous health services research conducted at the state level. The Supreme Court decision of 2012 rejected the requirement that states must expand their Medicaid programs to include individuals with incomes up to 133 percent of the federal poverty level (FPL). This decision made the Medicaid expansion optional for states and guaranteed variability in ACA implementation. To date, 28 states including the District of Columbia are moving ahead with the Medicaid expansions, 21 states are not moving forward, and 2 states are considering the expansion option (The Henry J. Kaiser Family Foundation, Status 2014). The ACA also included provisions for the development and implementation of Health Insurance Marketplaces across the states. The Marketplace is an online resource for comparing, selecting, and enrolling in competing private health plans. The Marketplace also provides the opportunity, if income eligible, to apply for and receive tax credits to help applicants with purchasing coverage. States have the option of implementing a State-Based Marketplace, partnering with the federal government to implement a Marketplace, or defaulting to a Federally Facilitated Marketplace. As of this writing, 17 states had initiated State-Based Marketplaces, 7 had established State-Federal Partnership Marketplaces, and 27 states had defaulted to the Federally Facilitated Marketplace (The Henry J. Kaiser Family Foundation, State 2014). To further muddy the waters, in July 2014, the U.S. Court of Appeals for the District of Columbia Circuit ruled that the ACA, as written, “unambiguously” restricts the tax credits provided to help subsidize the purchase of health plans sold through the Marketplace to State-Based Marketplaces (Jacqueline Halbig v. Sylvia Burwell 2014). The Obama administration has appealed this decision, but the implementation of the ACA has certainly not gone as smoothly or as uniformly as initially envisioned. The rollout of the ACA has been complex and varied across states. Researchers and policy makers are eagerly awaiting data and research to answer many questions about the impact of health reform. What impact did the ACA have on reducing the uninsured? What were the relative roles played by Medicaid expansion and the Marketplaces in expanding coverage? Do federal and state Marketplaces appear to differ in terms of important market characteristics such as premium prices? What are the characteristics of the remaining uninsured?

Changes in primary care access between 2012 and 2016 for new patients with medicaid and private coverage

OBJECTIVE To examine state and community factors that contributed to geographic variation in qualified health plan selection during the first open enrollment period. DATA SOURCES/STUDY SETTING Administrative data on qualified health plan selections at the ZIP code area merged with survey estimates from the American Community Survey. STUDY DESIGN Descriptive and regression analyses. DATA COLLECTION/EXTRACTION METHODS Data were generated by healthcare.gov and from a household survey. PRINCIPAL FINDINGS Thirty-one percent of the variation in qualified health plan selection ratios resulted from between-state differences, and the rest was driven by local area differences. Education, language, age, gender, and the ethnic composition of communities contributed to disparate levels of plan selection. Medicaid expansion states had a qualified health plan selection ratio that was 4.4 points lower than non-Medicaid expansion states, controlling for covariates. CONCLUSIONS Our results suggest community-level differences in the intensity or receptiveness to outreach and enrollment activities during the first open enrollment period.