the impact of mental health insurance laws on state suicide rates

THE IMPACT OF MENTAL HEALTH INSURANCE LAWS ON STATESUICIDE RATES

MATTHEW LANG*

Department of Economics, Xavier University, Cincinnati, Ohio, USA

SUMMARYIn the 1990s and early 2000s, a number of states passed laws requiring mental health benefits to be included in healthinsurance coverage. The variation in the characteristics and enactment date of the laws provides an opportunity to measurethe impact of increasing access to mental health care on mental health outcomes, as evidenced by state suicide rates. In con-trast with previous research, results show that when states enact laws requiring insurance coverage to include mental healthbenefits at parity with physical health benefits, the suicide rate decreases significantly by 5%. The findings are robust to anumber of specifications and falsification tests. Copyright © 2011 John Wiley & Sons, Ltd.

Received 5 November 2010; Revised 25 August 2011; Accepted 26 October 2011

KEY WORDS: insurance laws; suicide; mental health

1. INTRODUCTION

In any given year, over five million individuals in the USA have a serious mental disorder,1 but a majority ofthese individuals do not receive adequate treatment.2 Individuals with a mental illness often experience a lowerquality of life and have lower productivity levels compared with mentally healthy individuals.3 Mental illnessalso is related to suicide. State level suicide rates are strongly correlated with general mental health measures,such as depression and self-reported poor mental health episodes.4 The suicide rate for those with major depres-sion can be as high as 17.7%,5 and approximately 90% of suicides come from individuals with a mentalillness.6 The relationship between mental illness and suicide suggests that policies that reduce the suicide ratemay provide a lower bound on improvements in overall mental health. This analysis explores the impact oflaws requiring employer provision of mental health insurance on state-level suicide rates.

States began enacting mental health insurance laws in the mid-1990s and early 2000s. The variation in theenactment dates allows for the identification of the effect that mental health insurance laws have on within-statechanges in the suicide rate. Main results show that when a law is enacted that requires mental health care to beat parity with physical health care,7 the state suicide rate falls by approximately 5%. The estimates are robust to

*Correspondence to: Department of Economics, Xavier University, 3800 Victory Parkway, Cincinnati, OH, 45207, USAE-mail: [email protected]

1See Kessler et al. (2005).2See Wang et al. (2002).3See Berndt et al. (1998).4See Cavanagh et al. (1999), Conwell et al. (1996), Foster et al. (1997) and Mark et al. (2007).5See Angst et al. (2005).6See Arsenault-Lapierre et al. (2004).7A common phrase used in the literature and throughout the paper is ‘at parity’. The phrase is meant to illustrate when healthcare plans havethe same terms and conditions for mental health coverage as for physical health coverage.

Copyright © 2011 John Wiley & Sons, Ltd.

HEALTH ECONOMICSHealth Econ. (2011)Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hec.1816

controls for within-state suicide trends, numerous specifications and falsification tests. The findings provideevidence that mental health, as proxied by suicide, responds positively to legal requirements that increase avail-ability and access to meaningful levels of mental health insurance.

Despite the seriousness of mental health problems, only one other paper in economics explores the rela-tionship between suicide rates and health insurance laws.8 Klick and Markowitz (2006) use data between1980 and 2000 and find that state-level mental health mandates are not effective in reducing suicides. Apotential reason for their insignificant results is that between 2000 and 2003, 20 states enacted mental healthlaws, and their data are unable to capture the effects of more recent laws.9 The variation in enactments avail-able today allows the classification of mental health insurance laws to be more precisely estimated than inprevious work, and the results in the current paper show that only mental health laws that require coverageat parity with physical health care are effective in improving severe mental health outcomes, whereas weakerlaws are not.

An analysis of the impact of mental health mandates is of first-order importance to policymakers whenone considers that on 3 October 2008, the federal ‘Paul Wellstone and Pete Domenici Mental HealthParity and Addiction Equity Act’ was signed into law as part of the Emergency Economic StabilizationAct. The federal mental health law went into effect in January of 2010, and in a number of states, thefederal law requires all group insurance plans to provide mental health benefits that are at parity withphysical health benefits. Using estimates from previous state mental health mandates, the potential effectof the 2010 federal law is explored. Results show that when states enact laws similar to the 2008 federalact, the suicide rate decreases significantly. Given suicide rates are strongly correlated with overall mentalhealth, the recently passed federal legislation has the potential to improve both suicidal and non-suicidaloutcomes.

2. MENTAL HEALTH INSURANCE LEGISLATION

In 1996, the Federal Mental Health Parity Act of 1996 (MHPA) was passed in the US Congress and signed intolaw by President Clinton on 26 September 1996. The law went into effect on 1 January 1998 and states that if ahealth insurance plan includes mental health benefits, the annual and lifetime limits of mental health care andmedical care must be the same. The act does not require health insurance plans to offer or cover mental healthcare, and there are no restrictions on the terms and conditions covered in mental health plans. The limitationsof the law caused many critics to argue that access to mental health care is not improved by the federal act.10

Following the 1996 MHPA, a number of states enacted their own mental health laws, many of which arestronger than the federal law.11 Prior to the 1996 federal law, 11 states had some type of mental health insur-ance law enacted. By 2002, mental health insurance legislation was enacted in 45 states, and currently, onlytwo states, Wyoming and Idaho, do not have mental health insurance laws. The federal act is not necessarilythe direct cause of the passing of state legislation; however, a managed behavior healthcare company exec-utive argues that the MHPA ‘legitimizes advocates at the state level’.12

8A number of studies in economics focus on suicide including the seminal work by Hamermesh and Soss (1974). Recent work by Ruhm(2000), Marcotte (2003), Ludwig and Marcotte (2005) and Ludwig et al. (2009) focus on the outcome of suicide but not in the context ofinsurance laws.

9This paper uses data between the years of 1990 and 2004. Going back to 1980 does not alter the direction and significance of results. Whenthe effects of the laws in this paper are used over the same time frame as Klick and Markowitz (2006), results are insignificant, and themagnitude of coefficients is statistically similar to Klick and Markowitz’s findings.

10See Maxfield et al. (2007).11Although a handful of states enacted mental health mandates in the 1970s and 1980s, it is generally accepted that mental health paritymandates began in the 1990s. Much of the medical literature on mental health mandates omits any discussion of these early mandateswhen examining mental health legislation. This is likely because of the limited requirements that early mandates placed on health insur-ance packages.

12See Otten (1998).

M. LANG

Copyright © 2011 John Wiley & Sons, Ltd. Health Econ. (2011)DOI: 10.1002/hec

Figure 1 shows the number of states that enacted mental health insurance laws (in black) and access to par-ity laws (in gray) each year between 1990 and 2004. The figure shows that between 1990 and 1996, only ninestates enacted any type of mental health insurance law. After 1996, the number of states enacting laws increasedsignificantly, with 14 states enacting laws in 2000 alone, seven of which were access to parity laws. The federallaw itself may not have had a significant impact on mental health care; however, it seems to have been a catalystfor states to pass their own laws.

2.1. Characteristics of mental health laws

State laws differ in how much mental health care they require insurance packages to cover.13 Although there isheterogeneity in the strength of state laws, a natural grouping can be made based on the requirements of thelaws.

2.1.1. Access to parity states. States that require insurance packages to include access to mental health care atthe same terms as physical health care are denoted as ‘access to parity’ states. Two specific mental health in-surance laws require mental health care to be provided under the same terms and conditions as physical healthcare. The strongest type of law is a ‘parity’ law, which requires health insurance packages to include mentalhealthcare coverage, and coverage must be at parity with physical health care.

‘Mandated offering’ laws require health insurance packages to offer mental healthcare coverage at paritywith physical health care. The decision to purchase mental healthcare coverage is left to the buyer. Both theparity and mandated offering laws require that healthcare packages provide access to mental healthcare cover-age at parity with physical health care. The only difference between mandated offering and parity laws is thatparity laws require mental health care to be included in the insurance package, whereas mandated offering lawsrequire insurance packages to offer mental health care coverage at parity.

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1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Number of States Enacting Access to Parity Laws Number of States Enacting Mental Health Laws

Figure 1. Number of states enacting mental health laws by year

13Laws also can differ in what types of mental disorders must be covered, whether substance abuse is covered, which insurance plans mustcomply with the law and which businesses are exempt from the law.

THE IMPACT OF MENTAL HEALTH INSURANCE LAWS


2.1.2. Non-parity states.When a state does not require mental health care to be offered at parity, it is defined asa ‘non-parity’ state. Two situations can lead a state to be considered a non-parity state. A ‘mandated if offered’law states that if an insurance package provides mental health care, it must meet the requirements set forth inthe law. An example of a ‘mandated if offered’ law is the Federal MHPA; if mental health care is part of ahealth insurance plan, the annual and lifetime limits of mental and physical care are required to be equal. Theselaws do not require mental health care to be part of an insurance package.

Laws that require health insurance to include or offer mental health benefits, but these benefits do not need tobe at the same terms and conditions as physical benefits, are classified as ‘minimum mandated benefit’ (MMB)laws. In three states in the dataset, minimum mental health benefits must be offered, whereas in 16 other states,the benefits must be included. All 19 states that require mental health benefits to be included or offered, but thebenefits are not at parity, are considered MMB states.

The characteristics of each of the law categories are represented in Table I. Reading the table from left toright shows that when a state enacts a parity law, mental healthcare coverage must be included in health insur-ance plans, the coverage must be at parity with physical health care, and the state is classified as an access toparity state. Details on the remaining three types of laws are found in the same way in Table I.

2.2. Expected effect of mental health laws

The difference between the access to parity and non-parity states is best illustrated by analyzing an access toparity state, Vermont, and a non-parity state, Tennessee. The Vermont parity law requires health insurancepackages to include mental health coverage, and plans cannot ‘establish any rate, term, or condition that placesa greater burden on an insured for access to treatment for a mental health condition than for access to treatmentfor other health conditions’ (Vermont Statute, 1998). Access to parity states, such as Vermont, provides indi-viduals with access to mental health care that is at parity with physical health care.

The Tennessee mandate does not require mental health care to be affordable relative to physical health care.The law states that health insurance packages must cover 20 mental health hospital inpatient days and 25 mentalhealth outpatient visits and ‘nothing in this (law) shall limit the amounts and terms of coinsurance, copayments,deductibles, or differentials required to be paid by the enrollee’ (see Tennessee Statute, 1999). Non-parity states,such as Tennessee, do not guarantee access to mental health care at parity because there is no requirement formental health care to be covered at the same co-insurance rate as physical health care, and there is a limit onthe number of days of treatment that must be covered by a policy.

The general consensus in psychiatric studies is that psychotherapy and prescription drugs are needed to effec-tively treat mental disorders related to suicide,14 both of which are costly, but becomemore accessible in states thatenact parity laws. Recent randomized controlled trial studies find that cognitive behavioral therapy15 and behav-ioral activation16 are effective in treating major depression. Furthermore, the American Psychological Associationsuggests that 6–12 weeks is needed to stabilize a patient withmajor depression, and then, an additional 4–9months

Table I. Mental health law characteristics

Type of law Mental health coverage Coverage characteristics General category

Parity law Is included At parity Access to parity stateMandated offering law Is offered At parity Access to parity stateMin. mandated benefit law Is included or offered Not at parity Non-parity stateMandated if offered law No requirement to include or offer At parity or not at parity Non-parity state

14See Clayton and Auster (2008).15See Brown et al. (2005).16See Dimidjian et al. (2006).

M. LANG


of therapy sessions are needed after stabilization. Maintenance of depression can potentially last for years,17 andcosts of treatment can quickly become expensive.18

Considering the long-term and intensive treatment needed to treat a mental illness like major depression,non-parity states, such as Tennessee, are not expected to guarantee enough access to mental health care forindividuals with a severe mental illness to be effectively treated. Non-parity laws can have a positiveimpact on mental illness; however, the limited effect that the laws have in treating severe, long-term mentalillnesses makes a reduction in state level suicide rates difficult to observe. Access to parity states, such asVermont, provide patients with significant enough mental health care to treat severe mental illnesses. Theexpected effect of the two types of mental health laws on suicide rates differ, and the empirical analysisin the next section estimates the impact of both access to parity laws and non-parity laws on state-levelsuicide rates.

3. DATA

3.1. Variable descriptions

The data used to test how suicide rates are impacted by mental health insurance laws come from a variety ofsources. Suicides in each state are from the Multiple Cause-of-Death Public-Use Files published annually by theNational Center for Health Statistics (CDC, 2008). Suicides are defined in the files using the International Clas-sification of Diseases codebook (Versions 9 and 10).19 Suicide rates for all 50 states and the District of Columbiaare compiled between the years 1990 and 2004. The total number of observations is 765 (51 states � 15 years).

Information on the state mental health laws comes from reading and interpreting the specific state statutes andbills.20 Some states require mental health insurance to be offered at parity with physical health, but they mayhave limits on the number of days that are covered. This is controlled for in the specifications below, and Appen-dix A provides specific details on the states that fall into each category along with their enactment date.

The time-varying characteristics considered in the analysis include the unemployment rate, bankruptcies per100 000 and the percentage of workers in large firms (500 or more workers). Unemployment rates are obtainedfrom the Bureau of Labor Statistics’ Current Population Survey (CPS, 2008). Bankruptcy data are found at theUS courts (US Courts, 2008), and they provide the number of bankruptcy filings per state since 1990. All chap-ters of bankruptcy are considered in the analysis. The percentage of workers in large firms is from the US SmallBusiness Administration (US Small Business Administration, 2008) and controls for the fact that large firms aremore likely to self-insure, and self-insured firms are exempt from state-level mandates under the EmployeeRetirement Income Security Act (1974).

To control for the possibility that states are reacting to a trend in the suicide rate when implementing a mentalhealth insurance law, timing controls are created. Similar to Gruber and Hanratty (1995), the year-to-year changein the suicide rate is constructed. Because most laws have a time lag between the time they are introduced andwhen they are enacted, the year-to-year change is lagged by 1 year. For example, the timing control in the year1990 is the change in the suicide rate between 1988 and 1989. The timing control is included in all regressionsbelow; however, the exclusion of the timing control does change the coefficient estimates.21

17See Gelenberg et al. (2010).18See Shute (2007).19Suicides in the International Classification of Diseases codebook (Versions 9) are defined as deaths that have the code 350 in the ‘34Recode’ cause-of-death classification. In the International Classification of Diseases codebook (Versions 10), suicides are code 040 inthe ‘39 Recode’ classification.

20The state bills and statutes are available upon request from the author.21In the fixed effects regression results, the coefficient on mental health parity is �0.0467 with the timing control and �0.0477 without thetiming control. The standard error of the coefficient in both specifications is 0.022. The first difference regressions also are unchanged bythe exclusion of the timing control variable.



3.2. Summary statistics

Table II presents summary statistics for all states and the subset of access to parity and non-parity states. Thenon-parity states column also includes states that do not enact any type of mental health insurance law in thedataset. The first column shows averages for all states in the dataset with standard deviations reported in paren-theses and within-state standard deviations reported in brackets. The suicide rate per 100 000 in the dataset is11.43, weighted by population. The unemployment rate in the data set is 5.59, the bankruptcy rate per100 000 is 444.38 and the percentage of workers in large firms is 46.97.

To begin to have a sense of how the suicide rate has changed over time in the access to parity states, the secondand third columns report the average in pre-parity and post-parity time frames. The average suicide rate in access toparity states is 10.89 per 100 000 prior to the enactment of access to parity laws and decreases to an average of 9.88per 100 000 in the years after the access to parity laws are enacted. In those two periods, the unemployment rate fell,and the bankruptcy rate and the percentage of workers in large firms increased. The final column of Table II reportsaverages for non-parity states in all years of the study, and a higher suicide rate is observed in non-parity states.

3.3. Difference-in-difference estimates

Table II shows that suicide rates are lower in years after parity laws are enacted, but it is possible that this findingis confounded by unobservables. A first step in exploring the validity of the relationship is to investigate how thesuicide rate in non-parity states change when the access to parity states enact laws by calculating a difference-in-difference (DD) estimate.

Because laws are enacted in different years across states, it is not possible to calculate average suicide rates innon-parity states in a pre-parity and post-parity period. To construct the DD estimate, Table III examines the av-erage suicide rate of access to parity and non-parity states22 in two periods, 1990–1997 and 1998–2004. The cutoffwas chosen based on the fact that of the 29 states that enact access to parity laws in the dataset, 22 of them occurredbetween 1998 and 2002. Furthermore, splitting the years into these two groups splits the data as equal as possible.

In panel A of Table III, the DD estimate using the suicide rate per 100 000 is reported. Each cell reports thepopulation-weighted average suicide rate for the specified group with standard errors reported in parenthesesand the sample size of the cell in brackets. The results show that the suicide rate in access to parity statesdecreased 0.58 per 100 000 more than non-parity states between the two periods. The coefficient is nearingmarginal significance with a p-value of 0.12.

In panel B, the DD estimates are reported using the log of the suicide rate per 100 000. The results show thatrelative to non-parity states, the suicide rate in access to parity states decreased 8% between the 1990–1997period and the 1998–2004 period. The coefficient is significant at the 5% level and provides a baseline estimateof the effect of access to parity laws on the suicide rate. To more precisely estimate the relationship, the nextsection explores the effect of the laws in a panel data framework.

4. THE IMPACT OF MENTAL HEALTH LAWS ON SUICIDE RATES

4.1. Empirical specification

A panel data approach is used to empirically test the impact that requiring access to mental health care at parityhas on suicide rates. A specification that isolates this effect is

Si;t ¼ aþ b1Accessi;t þ b2NonParityLawi;t þ dXi;t þ gi þ pt þ ei;t (1)

where Si, t is the natural log of the suicide rate per 100 000 individuals in state i at year t. The variable of interestis Accessi, t, which is equal to one if state i has a mental health insurance law that requires access to parity in

22Similar to the summary statistics, the non-parity state category also includes states that never enact laws in the dataset.

M. LANG


Table III. Difference-in-difference estimates of the impact of access to parity mandates on suicide rates

Panel A. Suicide rate

State type/period 1990–1997 1998–2004 Difference between periods

Access to parity states 11.15 9.84 �1.31(0.17) (0.18) (0.25)[232] [203]

Non-parity states and no-law states 13.12 12.39 �0.73(0.20) (0.18) (0.27)[176] [154]

Difference between types of states �1.97 �2.55(0.26) (0.26)

Difference-in-difference �0.58(0.37)

Panel B. Log suicide rate

State type/period 1990–1997 1999–2004 Difference between periods

Access to parity states 2.39 2.25 �0.14(0.02) (0.02) (0.02)[232] [203]

Non-parity states and no-law states 2.56 2.50 �0.06(0.01) (0.01) (0.02)[176] [154]

Difference between types of states �0.17 �0.25(0.02) (0.02)

Difference-in-difference �0.08**(0.03)

Each cell contains the average suicide rate/log suicide rate for the specified group that are weighted by yearly state population.Standard errors are reported in parentheses; sample sizes are reported in brackets.**Significant at the 5% level, ***significant at the 1% level.

Table II. Summary statistics

All statesAccess to parity states

Non-parity states

Variable 1990–2004 Pre-Parity Post-Parity 1990–2004

Suicide rate per 100 000 11.43 10.89 9.88 12.76(2.82) (2.60) (2.67) (2.49)[1.17] [1.02] [0.82] 1.31

Log suicide rate per 100 000 2.41 2.35 2.26 2.53(0.25) (0.24) (0.26) (0.18)[0.09] [0.09] [0.07] [0.09]

Unemployment rate 5.59 6.06 5.15 5.40(1.41) (1.57) (1.15) (1.29)[1.05] [1.10] [0.66] [0.97]

Bankruptcies per 100 000 444.38 416.46 483.55 448.47(181.19) (151.76) (207.85) (186.43)[167.14] [103.88] [244.22] [116.39]

Percentage of workers in large firms (+500) 46.97 45.95 48.92 45.85(5.45) (5.02) (4.08) (6.17)[4.67] [4.09] [3.36] [4.72]

Observations 765 265 170 330

Number of states 51 29 22

Reported averages are weighted by state population.Standard deviations are reported in parentheses.Within-state standard deviations are reported in brackets.



year t, and zero otherwise. The variable NonParityLawi, t is equal to one if a non-parity law (mandated if offeredor MMB law) exists in state i in year t. If the law is enacted midway through the year, the observation isdropped from the regression, although the results are not sensitive to alternative codings that do not eliminatethese observations.23 The matrix Xi, t is a set of time-varying state characteristics. The terms gi and pt capturestate and year fixed effects. A negative coefficient on b1 indicates that enacting a law that requires access tomental health care decreases state suicide rates.

4.2. Regression results

All regressions are weighted by yearly state populations and include state and year fixed effects. Table IVshows the results of enacting mental health laws on the natural log of the suicide rate. To control for autocor-relation within states over time, the standard errors are clustered at the state level in all regressions.24 Column(1) shows that the suicide rate is 5% lower in states where access to parity laws are enacted. When a state enactsa non-parity law, the suicide rate increases insignificantly by 2%.

One may argue that there is an inherent difference between access to parity and non-parity states. Access toparity states may care more in general about mental health care and those unobservables may be driving theresults in column (1). Column (2) addresses this potential concern and only considers states that eventually re-quire access to parity in the dataset. Identifying the impact of enacting a mental health access law comes fromthe fact that the 29 states with parity access have different enactment dates. In column (2), the coefficient onmental health access is �0.04 and is significant at the 5% level. When only the subset of access to parity statesare considered, the point estimate on the coefficient of interest remains stable relative to the regressions thatinclude all states in column (1).25

4.2.1. 2008 Mental Health Parity Act. In October 2008, Congress passed the Emergency Economic StabilizationAct, also known as the ‘Economic Bailout Bill’. Included in this act is the Mental Health Parity and AddictionEquity Act of 2008 (CBO, 2007). The federal mental health act strengthens the 1996MHPA and became effectivein January 2010. The data used in the previous sections are able to estimate how this act may potentially impactsuicide rates.

The 2008 Federal Act is a ‘mandated if offered’ law and requires healthcare plans that include mental healthcoverage to provide mental health care at parity with physical health care. This impacts all MMB states significantlybecause MMB states require mental health coverage, but the coverage does not need to be at parity. Because of the2008 Federal Act, all MMB states will become parity states or mandated offering states because they are requiredunder state law to provide or offer mental health benefits, and those benefits must be at parity under the federal law.

Using a similar econometric specification as in Section 4.1, the potential effect of the federal act on suiciderates is estimated. Instead of the variables of interest being access to parity and non-parity laws, the laws arebroken down into more detail using the categories discussed in Section 2.

The specification

Si;t ¼ aþ b1Parityi;t þ b2MandatedOfferingi;tþb3MandatedIfOfferi;t þ b4NoLawi;t þ dXi;t þ gi þ pi þ ei;t

(2)

regresses the log of the suicide rate in state i in year t on dummy variables that are equal to 1 if a state has aparity law, mandated offering law, ‘mandated if offered’ law or no law at time t. The omitted category is

23For example, California enacted their law in July of the year 2000. The California observation in the year 2000 is dropped from the re-gression and the California observation in the 2001 is coded as 1. The results do not change if the codings are fractionalized, and 0 ischanged to 0.5 for the year 2000. The results also are unchanged if the dropped observation is included in the regression and coded aszero. These results are available upon request.

24See Bertrand et al. (2004).25The results also are insensitive to the inclusion of state-specific time trends but are omitted for brevity purposes. These results are avail-able from the author upon request.

M. LANG


MMB states, and b1 is the change in the suicide rate that results from requiring MMB states to become paritystates, which is what the 2008 Federal Act requires MMB states to become.

Column (3) of Table IV reports the regression results using the detailed specification of state mental healthlaws from Equation (2). The parity coefficient is �0.06 and significant, implying that the suicide rate in stateswith a parity law are 6% less than in states with MMB laws. It is worth noting that the mandated offering co-efficient in column (3) is larger in absolute value than the parity law coefficient. What is likely driving this re-sult is the fact that only four states enacted mandated offering laws, and a large fluctuation in one state can sig-nificantly alter the coefficient. The same situation is evident in ‘mandated if offered’ states, as only five statesenacted a mandated if offered law between 1990 and 2004. In contrast, 25 states enacted parity laws, and 16states are minimum mandated benefit states at some point in the data (seven states change from MMB statesto parity states in between 1990 and 2004).

The regression in column (4) considers that the federal law will make all MMB states become access to par-ity states. Column (4) merges the parity and mandated offering categories into the access to parity variable. Incolumn (4), the results show that relative to a MMB, the suicide rate in parity states is 7% lower.

4.2.2. First-difference specification. Columns (1) through (4) of Table IV account for possible serial correlationin the error term within states by clustering standard errors at the state level in a fixed-effects specification. Analternative approach to dealing with the possibility of serial correlation within states is to first-difference the inde-pendent and dependent variables and estimate the effect of changes in mental health laws on changes in the suiciderate.26 Estimating the effect of the mental health laws on suicide rates using a first-difference specification allowsthe assumption that the error term is serially uncorrelated to be relaxed. The coefficient on the access to parity lawis then interpreted as the change in the state suicide rate that comes from a change in the access to parity law.

Table V reports the results of first-difference specification regressions. The results in columns (1) and(2) show that relative to the previous year, in the first full year after a state enacts an access to parity law,

26The author wishes to thank an anonymous referee for this suggestion.

Table IV. The impact of mental health laws on state suicide rates

Fixed effects specification

Dependent variable: log suicide rate

(1) (2) (3) (4)

Access to parity law �0.05 �0.04** �0.07(0.02) (0.02) (0.02)

Non-parity law 0.02(0.02)

Parity law �0.06***(0.02)

Mandated offering law �0.12***(0.03)

Mandated if offered law �0.04* �0.03*(0.02) (0.02)

No law �0.03 �0.02(0.02) (0.02)

R2

-Within 0.57 0.64 0.58 0.57-Between 0.04 0.01 0.03 0.03N 752 425 752 752Included states All Parity All All

Standard errors clustered at the state level are shown in parentheses.All regressions are weighted by yearly state population.All regressions include state and year fixed-effects and controls.*Significant at the 10% level, **significant at the 5% level, ***significant at the 1% level.



the suicide rate decreases significantly by 4%. These are nearly the same results found in columns (1) and(2) of Table IV and imply that suicide decreases significantly in the first full year of the law enactment.Enacting a non-parity law insignificantly increases the suicide rate by 1% in the first year it is enacted.Columns (1) and (2) in Table V support the findings in Table IV, providing further evidence that serialcorrelation across periods and within states is not driving the relationship between access to parity lawsand suicide rates.27

4.2.3. Event study analysis. In addition to only analyzing the subset of access states and first-differencing thespecification, an event study model can be used to further test for the presence of policy endogeneity andprovide insight on how the suicide rate responds to law enactments over time. This is performed by runningthe log of the suicide rate on dummy variables equal to one when the state-year observation is 1, 2, 3, 4 and5 or more years before and 1 and 2 or more years after the enactment of a law. The omitted category is the yearthe law is enacted. A significant upward trend in the state suicide rate prior to the enactment of the law impliesthat states respond to increases in the suicide rate with a mental health mandate, and likely other policies,causing the results above to overstate the effect of the law. A significant downward trend in the state suiciderate prior to the law enactment makes it uncertain as to whether the access to parity coefficient is capturing atrend in suicide, and this is driving the results.

Table VI shows the results of the event study regression. The coefficients represent the percentage differencein the suicide rate compared with the year the law is enacted. The suicide rate in years prior to the enactment ofthe law is not significantly different from the suicide rate in the year the law is enacted. This mitigates concernthat there is a pre-existing trend in the suicide rate that is potentially confounding the results above. In the yearafter the law is enacted, the suicide rate falls 6%, relative to the year before. Two years or more after the law isenacted, the suicide rate remains significantly lower than the suicide rate in the enactment year, but the magni-tude of the coefficient falls to 3%. A possible reason that the coefficient falls in half 2 or more years after theenactment is that there is a large decrease in suicide in the first year of an enactment as the most at-risk obtaintreatment, which then levels out to 3%. Because the effect of the mental health laws is not becoming strongerover time, it also may be that the laws affect those that become suicidal over a long period differently than thosethat are currently suicidal.

27The mandated offering and mandated if offered classifications only contain four and five states, respectively, and there is not enough var-iation to provide reliable information in a first difference setting using a detailed law classification.

Table V. The impact of mental health laws on state suicide rates

First-difference specification

Dependent variable: Δlog suicide rate

(1) (2)

Access to parity law �0.04** �0.04**(0.02) (0.02)

Non-parity law 0.01(0.01)

R2

-Within 0.26 0.27-Between 0.13 0.12N 701 396Included states All Parity

Standard errors clustered at the state level are shown in parentheses.All regressions are weighted by yearly state populations.All regressions include state and year fixed-effects and controls.*Significant at the 10% level, **significant at the 5% level, ***significant at the 1% level.

M. LANG


4.3. Robustness checks

4.3.1. Age-specific results. Columns (1) through (4) of Table VII show the impact of mental health insurancelaws on suicide in specific age ranges. Because the variable of interest is measuring the effect of access to paritywith physical health care, the suicide rate across age groups are expected to be impacted differently. Elderlyindividuals should be less impacted by a mental health policy because they are more likely to have retired thana younger individual and, more importantly, are likely receiving benefits from Medicare. Young individuals inentry level positions may not have strong healthcare benefits in their compensation package, and a mentalhealth parity requirement would be limited because of their weak healthcare plan. To isolate these groups,the suicide rate of an affected age group (18–64 years old), a young and entry level age group (18–34 yearsold), a working age group (35–64) and an elderly age group (65 and older) is used as dependent variables inTable VII.

In column (1), the log of the suicide rate of 18- to 64-year-olds is regressed on the access to parity law variableand demographic and timing controls, as well as state and year fixed effects. The coefficient on the mental healthaccess law is �0.05 and significant at the 1% level. The regression using the log of the suicide rate of 18- to34-year-olds as the dependent variable is shown in column (2) and produces a coefficient of�0.03 that is insignif-icant. The regression using the log of the suicide rate of 35- to 64-year-olds as the dependent variable in column(3) reports a coefficient of�0.05 for the access to parity variable that is significant at the 5% level. The coefficienton the mental health law variable in the 65 and older age group in column (4) is 0.01 and insignificant. Theseregressions show that the impact of access to parity laws are being driven by the population that is most likelyto be impacted by mental health insurance parity laws, primarily the 35- to 64-year-olds and, to a lesser degree,the 18- to 34-year-olds and not elderly individuals.28

4.3.2. Ruling out general mortality trends. To confirm that the change in the suicide rate is not part of a generaldecline in mortality, a regression is run using the log of the total death rate as the dependent variable. If mentalhealth insurance laws are being instituted as part of an overall effort by the state to improve all facets of healthcare, then the effect of the access to parity coefficient will be overstated because the law is then capturing thegeneral health policies in a state. Column (5) of Table VII shows that total death rates are unresponsive to theenactment of mental health laws. The result does not rule out the possibility that mental health insurance lawsoccurred as a result of statewide mental health reforms, but it does show that the decrease in suicides from men-tal health parity access is unlikely to be confounded with general health initiatives.

4.4. Discussion

To examine how plausible the results in the previous sections are, the number of citizens impacted by access toparity mandates must be compared with the estimated number of suicides prevented by the mandates. The num-ber of suicides prevented by the enactment of access to parity laws can be estimated using the results above.

Table VI. Event study analysis

Years before/after Years prior Years after

Enactment year 5+ 4 3 2 1 1 2+

Log difference in suicide rate 0.01 �0.004 �0.002 0.01 0.01 �0.06** �0.03**Relative to enactment year (0.03) (0.03) (0.02) (0.02) (0.02) (0.02) (0.02)

Standard errors clustered at the state level are shown in parentheses.Regression only contains access to parity states and includes state and year fixed-effects and demographic controls.*Significant at the 10% level, **significant at the 5% level.

28The implications of the findings in the previous tables do not change when the suicide rate of 18- to 64-year-olds are used as the depen-dent variable.



The year following the enactment of access to parity laws, the 29 access to parity states had a suicide rate of10.24 per 100 000 and a total population of 160 221 455. The results indicate that if laws had not been enacted,the suicide rate would have been 0.37 points higher at a rate of 10.61.29 This equates to approximately 592 sui-cides prevented per year as a result of the mental health laws.

The number of individuals impacted by parity laws cannot be accurately identified because of data con-straints. However, an estimate of the number of people impacted by parity laws is found by finding the fractionof individuals in parity states that are insured and do not work in a large firm (greater than 500 employees).Omitting individuals who work in large firms reduces the likelihood of factoring in individuals who workfor firms that self-insure in the estimation. The fraction of individuals who work for large firms in the datasetis approximately 47%. After removing the fraction of individuals in large firms, the remaining population ismultiplied by the fraction of individuals with insurance in the state, which is approximately 85%. After remov-ing those in large firms and the uninsured, it is estimated that approximately 70.5 million individuals, or about45% of the population, are impacted by access to parity laws the year after the mandates are enacted.30

Given these calculations, for the regression results to be plausible, approximately eight suicides must be pre-vented for every one million individuals impacted by the law. According to the summary statistics in Table II,there are roughly 114 suicides per one million individuals in a state. This simple calculation assumes that the70.5 million individuals did not have mental healthcare coverage at parity prior to the enactment of laws, al-though this may not be the case. However, if only half of the 70.5 million individuals significantly increasedtheir access to mental healthcare coverage because of the parity laws, the results are plausible if approximately17 suicides are prevented for every one million individuals impacted.

For mental health parity laws to directly cause a decrease in suicide, the parity laws must increase mentalhealthcare utilization, which in turn treats mental illnesses and eventually prevents suicide for some individuals.Measuring mental healthcare utilization is difficult, as there is limited data available prior to state law enact-ments, but there is some evidence that mental health parity laws increase mental health care utilization. Harriset al. (2006) use data from the National Survey of Drug Use and Health and find that 12 months after statesenact parity laws, self-reported mental healthcare usage significantly increases. This study provides evidencethat mental health laws increase mental health utilization, which presumably decreases the suicide rate, butthe analysis only covers the period from 2001 to 2003, and their results are based on a limited number of states.

Table VII. Age-specific regressions and falsification specifications

Dependent variable

(1) (2) (3) (4) (5)

18–64 Logsuicide rate



65+ Logsuicide rate

Logdeath rate

Access to parity law �0.05*** �0.03 �0.05** 0.01 �0.002(0.01) (0.02) (0.02) (0.03) (0.007)

R2

-Within 0.52 0.64 0.31 0.60 0.54-Between 0.001 0.004 0.01 0.001 0.02N 425 425 425 425 425

Standard errors clustered at the state level are shown in parentheses.All regressions only contain access to parity states and are weighted by yearly state populations. All regressions include state and year fixed-effects and demographic controls.*Significant at the 10% level, **significant at the 5% level.

29These results come from regression using the suicide rate opposed to the log suicide rate as the dependent variable. The results generallymirror the log suicide regressions and are available upon request.

30Buchmueller et al. (2007) find that approximately 50% of private sector employees are exempt from state mandates because of the factthat their firms self-insure. Marquis and Long (1999) find similar results. In the calculations above, it is estimated that 45% of the pop-ulation is impacted by mental health mandates.

M. LANG


4.5. The cost of saving a life through mental health mandates

To examine whether implementing mental health insurance laws are cost-effective, an estimate of the overall costof enacting mental health laws is made. When a mental health law is enacted, the primary cost that employers andemployees bear is an increase in health insurance premiums, which results in a decrease in wages. By comparingthe loss in wages to the number of lives saved by access to parity laws, it is possible to construct a rough estimate ofthe cost per life saved.31

According to the Annual Employer Health Benefits Survey (2008), the average health insurance premiumfor a family in 1999 was $5791. Kirschstein (2000) shows that mental health parity laws are estimated to haveincreased health premiums by 1.4–3.6%, or roughly $80–200 per year per family. If mandates do not change,the level of insurance coverage and employees pay for the entire increase in premiums, the total amount of lostwages is between $745 million and $1.8 billion per year, assuming 37.5 million individuals are impacted by thelaws. When these lost wages are compared with the 592 estimated suicides prevented, then the cost of each sui-cide prevented is approximately $1.3–3.1 million.

The cost of saving a life through access to parity laws is near previous estimates of life-saving policies.32

However, for every suicide prevented, there is likely a significant number of non-suicidal individuals whoexperience an overall improvement in mental health. This implies that $1.3–3.1 million per suicide is an upperbound, as it only considers suicides prevented, not improvements in labor force productivity and quality of lifethat are associated with increased mental health care (Berndt et al., 1998).

The estimation also assumes that the value of life of a suicidal individual is the same as someone that diesfrom another unnatural cause, such as an auto accident. If an individual is prevented from suicide but has a lowquality of life because of their mental illness, then the relative value of preventing a suicide will be lower.Given the limited data and strong assumptions made in the calculations, the cost of a suicide prevented mustbe interpreted with caution. Regardless of how much is spent on preventing a suicide, the robust impact of ac-cess to parity laws on suicide rates implies that policies aimed at increasing access to mental health effectivelyreduces suicide and potentially improves less severe mental health outcomes that are not as easily measured.

5. CONCLUSION

Access to mental health care remains limited for many individuals throughout the USA (Donohue and Pincus,2007). To increase access, a number of states have enacted mental health mandates, and unlike previous researchon the topic, this paper shows that increasing access to mental health care is associated with a significant decreasein the suicide rate. The results are robust to a number of specifications that include only analyzing the subset ofaccess to parity states and accounting for state-specific time trends. The robustness of the access to parity lawcoefficient provides evidence that mental health insurance laws have a significant impact on suicide rates.

The findings add to the existing literature that examines the impact that state-level health mandates have onhealth outcomes. Schmidt (2007) looks at the effect of states mandating care for fertility on the birth rates ofwomen over 35 and finds that fertility mandates significantly increase first birth rates of women over 35. Daveand Mukerjee (2011) show that states that require substance abuse care as part of health insurance coverageexperience an increase in total treatment admissions.33 These recent papers, along with the current paper, showthat health insurance mandates are an effective way to improve health outcomes.

31Levitt and Porter (2001) calculate the cost of saving a life in a similar way. They compare the number of lives saved by seat belts andairbags to the cost of installing them in cars. Here, the cost of giving individuals access to mental health care is shared by all individualsthrough increased premiums and compared with the number of suicides prevented.

32Viscusi and Aldy (2003) estimate the value of a statistical life at 7 million dollars. Lutter et al. (1999) argue that only policies that cost lessthan 15 million dollars per life saved should be implemented, and the mental health mandates fall well below this cutoff. Seat belts and airbags are estimated to cost 30 000 and 1.8 million dollars per life saved, respectively (Levitt and Porter, 2001), and measles vaccinations inPapau New Guinea only cost 30 dollars per life saved (Duke, 1999). Arguably the least cost-effective policy is the FAA’s Federal AirMarshal Service, which is estimated to spend $180 million per life saved (Stewart and Mueller, 2011).

33McGuire and Montgomery (1982) and Frank (1985) look at early mandates that only required that health insurance packages provide$500 of mental health coverage and find that these modest mandates do not impact the demand for mental healthcare workers.



The recent implementation of the Mental Health Parity and Addiction Equity Act of 2008 increases theimportance of this analysis. According to the results above, enacting the federal act will potentially decreasesuicides, as well as improve less extreme mental health outcomes that are more difficult to measure. Improvingthe mental health of individuals will likely be associated with improvements in productivity (Berndt et al.,1998) and employment (Bartel and Taubman, 1986), in addition to suicide. To better capture the overall effectof mental health parity laws, determining the impact of mental health laws on other outcomes such as workerscompensation, wages and education is an interesting and pertinent topic for future research.

APPENDIX A: STATE MENTAL HEALTH LAWS

Table A1 shows which states fall under each category of the state mental health law groupings. The columns onthe left side of the table, ‘parity’ and ‘mandated offering’ groupings, are the mental health access law catego-ries. The right side of the table includes the categories that have non-access laws.

The asterisk in the ‘parity’ and ‘mandated offering’ categories denotes states that are considered accessstates but places particular limits on aspects of mental health coverage. For example, Maryland has an asteriskbecause they cover all mental health care at parity except for outpatient care. In Maryland, healthcare plans areonly required to pay for 50% of outpatient visits when the number of visits in a year is over 30.

Some states are in both the minimum mandated benefits category and parity category. California, Hawaiiand Illinois in particular are noted as having early mandates. This fact does not impact the results in Section4 because minimum mandated benefit laws are considered non-parity laws. In Section 4, the results from theregression on the detailed laws are unresponsive to the inclusion of these early laws.

Table AI. Mental health law groupings

Access to parity states No access to parity states

Parity laws Minimum mandated benefit laws

State Enactment date State Enactment date

Arkansas Aug-97 California Jan-74California Jul-00 Colorado Jul-92Colorado Jan-98 District of Columbia Jan-99Connecticut Jan-00 Florida Jan-92Delaware Jan-99 Hawaii Jan-88Hawaii Jul-99 Illinois Jan-91Illinois* Jan-02 Kansas Jan-98Kansas* Jan-02 Massachusetts Jan-96Louisiana* Jan-01 Michigan Jul-00Maine Jan-96 Mississippi Jan-02Maryland* Jul-95 Nevada Jan-00Massachusetts Jan-02 Oregon Jan-00Minnesota Aug-95 Pennsylvania Apr-99Montana Jan-00 South Carolina Jan-95New Hampshire Jan-95 Tennessee Jul-99New Jersey Jan-00 Wisconsin Jan-98New Mexico Oct-00North Dakota* Jan-96Oklahoma Jan-00 Mandated if offered lawsRhode Island* Jan-95

State Enactment dateSouth Dakota Jul-98

Arizona Jan-98Texas* Jan-98

Indiana Jan-00Vermont Jan-98

Kentucky Jan-00Virginia Jan-00

Missouri Jan-00West Virginia Jul-02

Nebraska Jan-00Ohio Jan-85

M. LANG


Table AI. Continued

Mandated offering laws No law (As of 2004)

State Enactment date State

Alabama Jan-01 AlaskaGeorgia* Jul-98 IowaNew York Jan-99 IdahoUtah Jan-01 North Carolina

WashingtonWyoming

*Indicates that the state is an access to parity states but has limits on a particular aspect of mental health coverage.

ACKNOWLEDGEMENTS

The author wishes to thank Rod Garratt, Philip Babcock, Olivier Deschenes, Peter Kuhn and Kelly Bedard fortheir helpful comments. The paper also has benefited from comments received at the UCSB Labor Seminar, theSociety of Labor Economists Annual Meeting in Boston, MA, and the Canadian Health and Economics StudyGroup in Waterloo, ON. Lastly, the quality of the paper significantly improved as a result of comments fromtwo anonymous referees and the editor, and their comments are greatly appreciated.

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