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In an article published on May 3 in the Chicago Tribune, I laid out a controversial case for why Certificate of Need (CON) laws, state regulations of the health care industry, may contribute to higher suicide rates. The argument essentially this: CON laws deliberately restrict access to many health care services, including mental health services, and lower access to mental health services leads to higher suicide rates. Thus, CON laws contribute to higher suicide rates.
It has been proven by numerous studies CON laws do create environments in which there is reduced access to care. As I wrote in the Tribune piece:
Research published by Thomas Stratmann and Jacob Russ at the Mercatus Center shows CON regulations across the country make accessing health care services more difficult. According to their findings, CON law states, compared to states without them, have on average “99 fewer hospital beds per 100,000 people.”
It has also been proven by multiple studies that reduced access to mental health care is connected to suicide. In one such study, authored by Tondo, et al. and published in The Journal of Clinical Psychiatry in 2006, the authors concluded, “In multivariate models of associations between suicide rates and indices of access to health care, the state rate of federal aid for mental health was the strongest indicator, followed by the rate of uninsured persons and population density of psychiatrists and physicians and by population density.”
Federal aid, health insurance rates, and population density of health care providers are all related to what I call “access” in my piece and elsewhere. The argument is logical and clear: When people have less access to mental health care, suicide rates go up.
In the Tribune article, I attempted to explain this problem in a number of ways, but one such way, looking back on it now, would have benefited from additional information. In the article, I wrote, “Of the 25 states with the highest suicide rates, 17 have CON laws or a variation on CON laws. Out of the 28 states with the largest number of health professional shortage areas related to mental health — as determined by the U.S. Department of Health and Human Services — 20 states have CON laws.”
Sounds pretty convincing, right? But as one close friend of mine, who caught on to a fairly obvious point many other experts in the field missed, the correlation displayed above is not dramatic enough to show any sort of a real connection between suicide rates and CON laws. While it’s true many states with high suicide rates have CON laws, it’s also true many states have CON laws. So, when I wrote the piece, what exactly did I have in mind?
Of the 25 states with the highest suicide rates, 17 have CON laws. The remaining eight states are: Colorado, Idaho, Kansas, New Mexico, North Dakota, South Dakota, Utah, and Wyoming. If these states don’t have CON laws and have high suicide rates, doesn’t this undermine my primary argument?
If you haven’t noticed by now, all eight states have one characteristic in common: They all would be classified as exceptionally rural and have very low population densitities. In fact, of the eight states mentioned, only Colorado falls below 40th on rankings of state population densities, and it sits at 37th overall.
Why does this matter? If you go back to the original argument presented at the top of the page, you’ll notice the argument is not: “CON laws equate to more suicides.” The argument is actually: “Lower access to mental health care causes more suicides, and CON laws cause lower access than there would otherwise be. Thus, CON laws contribute to higher suicide rates.”
Research has proven over and over that rural populations have less access to mental health services compared to more urban populations. It’s also been a well-known fact that rural populations have higher suicide rates. Nothing here contradicts my argument. Less access to health care has proven to lead to higher suicide rates, regardless of the reason for the lower level of access. In the case of the eight states mentioned above, one of the primary reasons for high suicide rates is low access to care that results from low population density.
If you remove the exceptionally rural states from the top 25 states with the highest suicide rates, nearly all remaining states have CON laws. Rather than undermine my point, these data actually reinforce it: When there is less access to care, suicide rates go up, which is why every state on the list of the top 25 suicide rates are either very rural or have CON laws.
Some might argue that while this data doesn’t disprove the argument, it doesn’t prove it either. While I don’t think the data prove my point as well as I initially thought, there are some states with CON laws in the top 25 that don’t have extremely low population densities, and I think a strong case could be made CON laws play a significant role in at least several of them. Just some of those states are: Kentucky, Louisiana, Missouri, New Hampshire, Vermont, Washington, and West Virginia.
The thing to remember, however, is not that CON laws equate to high suicide rates, but rather that they contribute to higher suicide rates than would otherwise exist without them. By including the connection between higher suicide rates and CON laws into my article, I may have erred — not because what I said disproves my point, but because it’s a weaker argument than simply hammering home the idea statistics show lower access to mental health care leads to higher suicide rates, and statistics show CON laws lower access to care.