More Medicaid coverage hasn’t curbed increased firearm suicides among most men

By Jaymie Baxley

CONTENT WARNING: This article references suicide. Please take caution when reading. If you need mental health support, please consult this page for resources.

From better access to health care to lower financial barriers to treatment, the benefits of Medicaid expansion have been well documented: reduced mortality rates for recipients, improved economies in expansion states and more people getting access to treatment for opioid use disorder.

One thing, though, has not improved consistently in states that opened the government-funded health insurance coverage to more people under the Affordable Care Act: the firearm suicide rate among men.

A study published on July 15 in the American Journal of Public Health found that male firearm suicide rates in many of those states  climbed, continuing trends that began before Medicaid expansion.

Black men, whose firearm suicide rates were once far lower than those of white men, have seen the steepest rate increases of all, according to researchers.

The findings were surprising to Emily Rippey, a doctoral student in the Department of Public Policy at the University of North Carolina at Chapel Hill who led the study.

“We had originally anticipated a greater protective effect of the Affordable Care Act, given that it did increase access to behavioral health services,” she said.

A widening gap

Rippey said the study grew out of a broader observation: Firearm suicide rates have been rising for years, but the increases have been uneven. 

“We had been observing that firearm suicide rates had been increasing over time, and particularly that this was a gendered and racial phenomenon as well,” she said.

White men have historically died by firearm suicide at far higher rates than any other group, driven in part by higher rates of gun ownership, combined with continued stigma around mental health treatment among many men. But starting around 2015, researchers saw firearm suicide rates among Black men start to rise.

Using mortality data from the federal Centers for Disease Control and Prevention, Rippey’s research team conducted a state-level analysis of firearm suicide from 2000 to 2023 among men age 18 to 64. They then compared data from 21 states that expanded Medicaid in 2014 with data from a dozen states that had not expanded the program by January 2023.

(North Carolina expanded Medicaid in December 2023 and was not included in the analysis.)

Rippey said the numbers showed firearm suicide rising across groups, regardless of a state’s Medicaid status.

Among white men, firearm suicide rates in non-expansion states climbed from an average of 20.5 deaths per 100,000 residents before 2014 to 25.1 deaths afterward — a 22.4 percent increase. In expansion states, the rate rose, too, from 16.2 to 19.4 deaths per 100,000 residents — a smaller jump, but still a statistically significant increase of 19.8 percent.

Among Black men, the pattern was more dramatic. Firearm suicide rates rose by 78.3 percent in expansion states, which went from 6 to 10.7 deaths per 100,000 people — a larger increase than than in non-expansion states, which went from 7.2 to 11.1 deaths, a 54.2 percent increase.

By the end of the study period, in several states — including Illinois, Iowa, Kentucky, Ohio and Wisconsin — Black men’s firearm suicide rates had caught up with, or even surpassed, those of white men, who had historically far surpassed the firearm suicide rate for Black men.

Using statistical models designed to isolate the effect of Medicaid expansion from other trends, the researchers found only one group for whom expansion appeared to make a measurable difference: white men ages 35 to 49.

In that group, Medicaid expansion was associated with roughly 1.4 fewer firearm suicide deaths per 100,000 people.

“I don’t want to make assumptions over why this specific demographic [saw a reduction], but culturally, maybe they have a spouse that’s encouraging them to seek care versus older groups where people might feel like, ‘Well, I’ve gone 50-plus years without care, why start now?’” Rippey said. “There are a lot of different hypotheses that could go into why the Affordable Care Act was protective for this specific demographic.”

What Medicaid can’t fix

Rippey and her co-authors argue that the study’s central message is about the limits of health insurance as a single lever for suicide prevention.

“What our findings are saying is that Medicaid can help, but it’s not enough alone,” she said. “We need to focus on some of the broader social policies and the broader, cultural systemic issues as well.”

She noted that states with both Medicaid expansion and a waiting period for gun purchases had the lowest firearm suicide rates of any group the researchers examined. States without expansion and without a waiting period had the highest rates.

“Health insurance is a really important part of the conversation, but we want policymakers to also be prioritizing common-sense gun regulations,” Rippey said.

Another issue, she said, is a culture of masculinity that discourages men from seeking mental health care in the first place — regardless of whether they have Medicaid.

“Certain people have adopted stronger masculine norms than others, but we do kind of want to recognize that there is this culture of self-reliance and difficulty in reaching out,” she said.

Even when someone is willing to seek treatment, she said, finding a provider who is a good fit, getting an appointment and making time to attend therapy can all stand between a person and any care their insurance might make available.

The study’s authors acknowledge that there are gaps in their analysis. Rippey said data-privacy rules that suppress small case counts make it difficult to study firearm suicide among smaller racial and ethnic groups, including Native American men, with the same statistical precision used for Black and white men.

She added that future research digging into people’s experiences with the health system and with firearms could help fill in what the numbers can’t show.

Rippey said she’s interested in revisiting North Carolina data in a few years, once the state has accumulated enough post-expansion data to study on its own. For now, she said, there isn’t enough evidence to know whether North Carolina will follow the patterns seen in other states.

“We would have to see the data to make that conclusion,” she said. “Hopefully in North Carolina we can continue to break down some of these barriers, culturally and practically as well.”

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