Suicide and Organ Donors: Spillover effects of Mental Health Insurance Mandates. Jose Fernandez, University of Louisville

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1 Suicide and Organ Donors: Spillover effects of Mental Health Insurance Mandates Jose Fernandez, University of Louisville Matthew Lang, Xavier University Abstract: This paper considers the effect of mental health insurance mandates on the supply of cadaveric donors. We find that enacting a mental health mandate decreases the count of organ donors from suicides and results are driven by female donors. Using a number of empirical specifications, we calculate that the mental health parity laws are responsible for an approximately 0.52% decrease in cadaveric donors. Additional regression results show that the mandates are not related to other types of organ donations, ruling out the possibility that the mandates are related to an overall trend in the supply of organ donations. The findings suggest that future policies aimed at reducing suicide in a large and significant way can potentially increase the inefficiency that currently exists in the organ donor market. JEL Classification: I18 Keywords: Organ Donations, Suicide, Insurance Mandate, Mental Health

2 I. Introduction Several studies have shown that economic and public policies are related to mental health outcomes. 1 In particular, increases in state spending on public health (Minoiu and Andres, 2008) and public assistance (Flavin and Radcliff, 2009) are correlated with reductions in state suicide rates. Since 1994, nearly all states in the US have enacted mental health mandates aimed at increasing access to mental health care. The Mental Health Parity and Addiction Equity Act has created a federal mandate starting in These mandates are shown to increase substance abuse treatment (Dave and Mukerjee, 2011) and reduce suicide (Lang, 2013). Suicide is positively correlated with psychiatric disorders (Mann et al, 2005) and the reduction in suicide may represent an overall improvement in mental health. 2 The reduction in suicides caused by these mandates may also reduce the number of organs donated. Suicide deaths tend to provide fewer damaged organs than other causes of death (Figueiredo et al., 2007) and account for approximately 9.7% of organ donations. If fluctuations in the suicide rate impact the supply of organ donors in a significant way, enacting mental health mandates may reduce the supply of organ donations. This paper explores whether suicide reducing mental health laws decrease the supply of organ donors. Between 1994 and 2009, every state but Idaho enacted a mental health parity law aimed at providing health insurance coverage for mental health treatment. Although there is variation between state laws, a natural grouping can be made based on attributes of the mandates. The 1 The seminal work on suicide by Durkheim (1897), finds a strong relationship between financial crises and suicide rates in 19th century Europe. Henry and Short (1954) find that suicide rates in higher status groups reacted strongly to business cycle fluctuations. See Lester and Yang (1997) for a detailed discussion of historical suicide research. 2 There is a strand of literature in economics that studies the decision making process of suicidal individuals in a theoretical context. See Chen et al., (2012) for a thorough review of recent suicide work.

3 strongest mandates require health insurance packages to cover or offer mental health care coverage at the same terms and conditions as physical health care. Weaker laws require mental health care coverage, but the coinsurance rates and number of days covered do not need to be at parity. 3 We use state level variation in adoption year of the required mental health parity laws to explore how increased access to mental health care impacts organ donations. Currently, over 100,000 individuals are on the US waiting list for an organ transplant. As advocates attempt to correct the market inefficiency by increasing the supply of donors, 4 policies that save and extend lives may offset increases in the cadaveric donation rate. State motorcycle helmet laws, for example, decrease fatal motorcycle accidents, but also decrease the supply of cadaveric organ donors (Dickert-Conlin et al., 2011). Our paper aims to increase understanding of the organ donation market and aid policy makers attempting to eliminate the inefficiencies in the market. II. Data and Empirical Results A number of data sources are used to isolate the relationship between mental health parity laws, suicide rates and organ donations. The Organ Procurement Transportation Network reports the count of cadaveric donors originating from suicide by sex and state for Suicide data are from CDC WISQARS and are merged with state level demographic variables from the Behavioral Risk Factor Surveillance System and the Association of Religion Data Archives: United States Decennial survey. A state is considered a parity state in a particular year if it has enacted a law requiring mental health care to be provided or offered at parity with physical 3 See Lang (2013) for a detailed description of the specific state laws. 4 Facebook recently urged members to add their organ donor status (Richtel and Sack, NY Times, May 1, 2012).

4 health care. If a state enacts a law in the middle of the year, it is not considered a parity state until the following year. The average US suicide rate is 11.3 suicides per 100,000 people. 5 Males account for approximately 80% of all US suicides and use firearms in 55% of suicides, while females attempt suicide three times as often as males (Krug et al., 2002) and use poison more often than any other method (CDC, 2010). Descriptive statistics of suicide and suicide donors are found in Table 1. Male suicides account for 80% of all suicides and 81% of all suicide donors. On average, 1.7% of suicides become organ donors. This result is consistent across gender, but female suicide donors have a larger variance in their donation rate. The average number of suicide donors for females is 2.83 and for males is The following regression isolates the relationship between donors, suicide rates, and mental health parity laws,. (1) In equation (1), is the natural log of the suicide or donor rate per 100,000 in state i at time t. The variable of interest is, which is equal to one if a state has enacted a mental health parity mandate in the previous year and zero otherwise. The matrix contains state level control variables: unemployment rate, percent white, percent female, percent married, income/capita, percent Medicaid coverage, percent Medicare coverage, percent private insurance, percent military insurance, percent catholic, state population, and population age 5 CDC:

5 grouping. 6 State and year fixed effects are captured by and respectively. Table 2 reports the mean, standard deviation and range of the variables. The parameter of interest,, represents the percent change in suicides or donors associated with an adoption of the mental health parity mandate. The first column of table 3 reports the regression results from equation (1). Enacting a mental health mandate decreases the suicide rate by approximately 2.5% and the coefficient estimate is not impacted by covariates, consistent with previous findings (Lang, 2013). The suicide data are reported as count values and may be non-normally distributed causing OLS estimates to be biased. We adopt a fixed effects Poisson regression to account for the count nature and the estimated coefficients are consistent even if the underlying data generating process is not Poisson (Gourieroux, et al., 1984). We account for potential overdispersion of the count data by estimating robust standard errors clustered by state (Cameron and Trivedi, 2005). 7 We define the conditional suicide donor mean, of the fixed effects Poisson model as. (2) We restrict the coefficient of the state population variable to unity, which converts the count model into a rate model [ ]. However, state population is allowed to affect the rate by including ln(population) in the X as well. 8 6 We use seven age groups: 0 17, 18 24, 25 34, 34-35, 45 54, 55 64, and greater than Similar estimates are obtained using the quasi-maximum likelihood estimator with robust standard errors suggested by Wooldridge (1999). 8 This restriction only affects the coefficient of population in the regression and allows easy comparison with the OLS estimates.

6 Column (2) of Table 3 shows the results of the Poisson specification for the suicide rate. The mandate is associated with a significant 3.84% decrease in the suicide rate without covariates, and a 2.89% decrease with covariates included. The results in columns (1) and (2) suggest that enacting a mental health parity mandate is associated with a significant decrease in state suicide rates. Almost 10% of organ donations are from suicide deaths. Therefore, it is possible that the decrease in suicides from mental health mandates will reduce cadaveric organ donors. Columns (3) and (4) of Table 3 begin to address this relationship. Column (3) reports OLS regression results where the dependent variable is the suicide donor rate. When a mandate is enacted, donor rates decrease, but the effect is only marginally significant when covariates are included. The coefficient estimates become insignificant using the Poisson specification, suggesting that mandates do not significantly impact the overall organ donation rate. To better understand the relationship between parity mandates, suicide and donation rates, Table 4 presents the coefficient estimate of the parity mandate for males and females. Each cell represents a unique regression for a specific sex. Standard errors are reported in parentheses and the R 2 is reported in italics. All regressions include the covariates reported in Table 3. According to Table 4, male suicide rates decrease significantly by 2.92% (OLS) to 3.03% (Poisson) after the parity mandate is enacted. Female suicide rates decrease in both specifications, but the effect is only significant at the 10% level in Poisson specification. The point estimate of the mandate is larger for females at 3.82% compared to males. The third and fourth columns of Table 4 use the suicide donors as the dependent variable. Male suicide donor rates are not significantly impacted by the parity mandates,

7 however, female suicide donor rates decrease by 17.8% (OLS) and 28.4% (Poisson). A 28.4% reduction in the suicide donor rate reduces the number of female suicide donors by 0.8. If the male points estimates are taken at face value, the mandate decreases the average number of male suicide donors by 0.4. The point estimate on the mandate variable in column (2) of Table 4 suggests that female suicides will decrease by 0.18 per 100,000. Given that the mean ratio of female suicide donors to female suicides is 0.017, if no selection issue existed, the mandate is expected to decrease the number of female donors by per 100,000. Instead, column (4) shows that female suicide donors decrease by approximately per 100,000 when evaluated at the mean. The suicide rate for females decreased after the mandate, but the donations per suicide fell by more. Because female donor rates are impacted by mental health parity laws, but males are not, it is possible that the mandate has affected the production function of organ donors from suicide by gender. The mandate can reduce the number of suicide donors through two potential pathways: (1) by preventing the suicide or (2) by damaging the organs of a potential donor. 9 If the mandate decreases suicides by more than it decreases suicide donors then the ratio of suicide donors to suicides will increase. Columns (5) and (6) of Table 4 report the mandate coefficients when the ratio of suicide donors to suicides is the dependent variable. In the Poisson specification, the mandate decreases the ratio of suicide donors to suicide for females significantly, but insignificantly increases the ratio for males. Consistent with the findings in columns (2) and (4), the marginal female suicide 9 Some Mental Health Medications can damage kidney and liver functions (see National Institute of Mental Health, Mental Health Medications, US Dept. of Health and Human Services

8 donor is more sensitive to the mandate change than the marginal male donor. 10 Overall, the results in Table 4 suggest there is a disproportionate share of female organ donors that are impacted by the mental health mandate. We consider a falsification test to rule out the potential that the mandate is correlated with other modes of organ donations. The count of organ donors from motor vehicle accidents are used as a test group. In addition to the previous controls, we include motorcycle helmet laws and seat belt laws as controls. The estimates are reported in Table 5. The effect of the mandate is close to zero and not significant at conventional levels. 11 The results above are consistent with previous work showing that state level mental health parity mandates are related to decreases in the suicide rate. The mandates do not have an observable effect on the overall suicide donation rate, but the mandate decreases female suicide donor rates significantly. Male suicide donor rates are insignificantly affected by the mandates. III. Discussion and Conclusion In the past two decades, most states enacted mandates that increase access to mental health care and improve mental health outcomes. These measures have now been adopted at the federal level as well. Because a significant fraction of organ donations come from suicide deaths, mental health laws can potentially affect the supply of organ donors. We explore the relationship between mental health parity laws and organ donors and find that parity mandates are associated with modest decreases in female suicide donors, but not male suicide donors. The results suggest 10 Not reported in the Tables, we find the mandate decreases the probability of a suicide donor from drug intoxication by (p-value =.07). These estimates are found using the full set of controls and robust standard errors clustered by state. We do not find a statistically significant relationship for gunshot wounds and the mandate. We are unable to disaggregate this effect by gender with the publicly available data. 11 In unreported regressions (available upon request), we use a negative binomial specification to directly account for over-dispersion, but the results are qualitatively unchanged.

9 that females who benefit from mental health intervention differ from those who do not. Why this difference manifests itself in the organ donation market is unable to be answered currently, however, is a relevant topic for future research. Mental health mandates decrease female suicide donors by 28.4%, but the impact on the overall organ donor supply is less, since females account for 19% of suicide donors, and 10% of organ donations are from suicides. These point estimates suggest that mental health laws decrease the organ supply by approximately 0.52%; Dickert-Conlin et al. (2011) find that motorcycle helmet laws decrease the supply by 0.98%. Mental health parity laws have a small, but significant, impact on the overall organ supply. As policy makers and advocates continue to push for policies aimed specifically at suicide prevention, the supply of organ donors will have to increase through other sources in order to keep the inefficiency of the organ market from growing. References Cameron, Colin and Pravin Trivedi Microeconometrics: Methods and Applications Cambridge University Press Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics Query and Reporting System (WISQARS) (2010). National Center for Injury Prevention and Control, CDC (producer). Chen, J., Choi, Y.J., Mori, K., Sawada, Y., Sugano, S. (2012). Socio-economic studies on suicide: A survey. Journal of Economic Surveys, 26, Dave, D. and S. Mukerjee. "Mental health parity legislation, cost-sharing and substance-abuse treatment admissions," Health Economics Vol. 20, No. 2 (February 2011), pp Dickert-Conlin, S., Elder, T., and B. Moore. Donorcycles: Do Motorcycle Helmet Laws Contribute to the Shortage of Organ Donors? Journal of Law and Economics Vol. 54, No. 4 (November 2011), pp Durkheim, E. (1897). Le suicide [suicide]. Paris, France: Alcan.

10 Figueiredo, F., Capaverde, F., Londero, G., Costa, M., Leaes, P., Oliveira, D., Garcia, C. and V. Garcia. "Organ donation in suicides," Transplant Proc Vol. 39, No. 2 (March 2007), Flavin, P., and Radcliff, B. (2009). Public policies and suicide rates in the American states. Social Indicators Research, 90, Gourieroux, Christian, A. Monfort, and A. Trognon, "Pseudo Maximum Likelihood Methods: Theory," Econometrica Vol. 52, No. 3 (1984), pp Henry, A. F., & Short, J. F. (1954). Suicide and homicide: some economic, sociological and psychological aspects of aggression (Vol ). New York: Free Press. Krug, B.G. (ed.). World report on violence and health, Geneva, World Health Organization (2002) Lang, M. (2013) "The Impact of Mental Health Laws on State Suicide Rates," Health Economics, 22 (1), Lester, D., & Yang, B. (1997). The Economy and Suicide: Economic perspectives on suicide. Nova Science Pub Incorporated. Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A.,... & Hendin, H. (2005). Suicide prevention strategies. JAMA: the journal of the American Medical Association, 294(16), Minoiu, C., and Andrés, A.R. (2008). The effect of public spending on suicide: Evidence from U.S. state data. The Journal of Socio-Economics, 37(1), National Institute of Mental Health. "Mental Health Medication," US Department of Health and Human Services (2010). Accessed at: Organ Procurement Transportation Network. Accessed at: Richtel, M. and K. Sack. "Facebook is Urging Members to Add Organ Donor Status," New York Times, May 1st, 2012 Wooldridge, Jeffrey M., Distribution-free estimation of some nonlinear panel data models, Journal of Econometrics, Volume 90, Issue 1, May 1999, Pages 77-97

11 Table 1: State Level Suicide and Donors from Variables Mean STD Min Max N Suicide All Suicide Female Suicide Male Suicide Rate per 100,000 - All Suicide Rate per 100,000 Female Suicide Rate per 100,000 Male Suicide Donor All Suicide Donor Female Suicide Donor Male Suicide Donor Rate per 100,000 - All Suicide Donor Rate per 100,000 Female Suicide Donor Rate per 100,000 Male Ratio of Suicide Donor to Suicide All Ratio of Suicide Donor to Suicide Female Ratio of Suicide Donor to Suicide Male Source: Organ Procurement and Transplant Network (OPTN.org) and CDC's WISQARS website, "Fatal Injury Reports," (http://www.cdc.gov/inhttp://www.cdc.gov/injury/wisqars/) Note: Organ Donation data are missing for Delaware, Idaho, Maine, New Hampshire, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming. Suicide data are missing for state-year observations less than 5.

12 Table 2: State Level Demographic Variables from Variables Mean STD Min Max N Mental Parity Health Insurance Mandate Unemployment Rate Percent years old Percent years old Percent years old Percent years old Percent years old Percent + 64 years old State Population (in millions) State Income Per Capita (in 2000 $ s) Percent White Percent Female Percent Married Percent Private Health Insurance Percent Medicaid Percent Medicare Percent Military Health Insurance Percent Catholic Sources: Age, Population, and Health Insurance Status data from US Census (census.gov). State Income per capita from Bureau of Economic Analysis (http://www.bea.gov/regional/). Unemployment rate from the Bureau of Labor and Statistics (www.bls.gov). State Demographics from CDC Behavioral Risk Factor Surveillance System (www.cdc.gov/brfss/). Religion Data from the Association of Religion Data Archives in the United States Decennial survey

13 Table 3: The Effect of Mental Health Mandates on Suicide and Donor Rates ln( Suicide Rates ) ln( Suicide Donor Rates) Variables OLS Poisson FE OLS Poisson FE No Covariates Mandate * *** (0.0154) (0.0132) (0.0512) (0.0474) R 2 /McFadden R Mandate ** ** * (0.0125) (0.0143) (0.0491) (0.0484) Unemployment rate 1.671*** 1.592*** (0.575) (0.442) (1.862) (1.634) Pct years old * 30.07** (4.196) (2.589) (19.78) (14.70) Pct years old ** (4.210) (2.581) (20.24) (15.03) Pct years old ** (4.179) (2.566) (19.92) (14.79) Pct years old * (4.133) (2.633) (20.02) (14.62) Pct years old * 35.44* 32.20** (4.058) (2.630) (19.61) (14.82) Pct + 64 years old * 29.00** (4.125) (2.711) (19.13) (14.46) ln(state Inc. Per Capita) * *** (0.0197) (0.0177) (0.389) (0.0710) Pct White (0.344) (0.190) (0.684) (0.694) Pct Female ** (3.405) (2.733) (13.70) (9.851) Pct Married * (0.219) (0.138) (1.114) (0.987) Pct Private Insurance (0.223) (0.179) (1.247) (1.050) Pct Medicaid (0.215) (0.185) (1.272) (1.124) Pct Medicare * (0.322) (0.375) (2.511) (1.517) % Military ** (0.317) (0.291) (2.526) (2.419) % Catholic ** * (0.214) (0.158) (0.859) (1.073) ln(population) *** *** *** (0.134) (0.0933) (0.0959) (0.417) Observations R 2 /McFadden R Robust standard errors clustered at the state level are reported in parentheses. All regressions include state and year fixed effects. *** p<0.01, ** p<0.05, *p<0.1.

14 Table 4: The Effect of Mental Health Mandates on Suicide and Donor Rates, by Sex Dependent Variables ln (Suicide Rate) ln(suicide Donors Rate) ln(suicide Donors / Suicides) (1) (2) (3) (4) (5) (6) Sex OLS Poisson FE OLS Poisson FE OLS Poisson FE ** *** Males (0.0123) (0.0104) (0.0486) (0.0484) (0.0503) (0.0548) * * *** ** Females (0.0231) (0.0223) (0.0895) (0.0869) (0.0856) (0.108) *** p<0.01, ** p<0.05, *p<0.1. R 2 and McFadden R 2 are reported in italics. Robust standard errors clustered at the state level are reported in parentheses. All regressions include all covariates reported in table 3 including state and year fixed effects.

15 Table 5: The Effect of Mental Health Mandates on MVA Donor Rates, by Sex ln(mva Donor Rate) All Male Female Variables Poisson FE Poisson FE Poisson FE Mandate (0.0354) (0.0393) (0.0460) Universal Helmet Law ** (0.0331) (0.0321) (0.0522) Partial Helmet Law ** * (0.0399) (0.0481) (0.0464) Seat Belt Law Secondary 0.182*** 0.252*** 0.127* (0.0474) (0.0631) (0.0688) Seat Belt Law Primary 0.197*** 0.250*** 0.160** (0.0378) (0.0507) (0.0657) Observations McFadden R *** p<0.01, ** p<0.05, *p<0.1. Robust standard errors clustered at the state level are reported in parentheses. All regressions include all covariates reported in table 3 including state and year fixed effects.

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