Monday, August 28, 2023

By Rob Waters

Good morning MindSite News readers. Don Sapatkin, who writes our Monday newsletter, has hung up the “gone canoeing” sign for the next three weeks and is probably now paddling on the Muskoka River in Ontario’s Algonquin Provincial Park. Don covers health insurance issues for us and before he left, he filed a story on the latest machinations of a key case. We published it on Thursday but are including it in today’s newsletter for those of you who missed it.

We also have an interview I did with two researchers who looked at an interesting question: How do wealth and race intersect to affect the worsening mental health crisis among American teens? Read on for today’s edition of MindSite News Daily.

Courtney Wise will continue to roll with her editions of the newsletter in the coming weeks, but we’ll be taking off the next couple of Mondays to allow Don to exercise his portaging and J-stroke skills.

MindSite News Interview:
Unique study finds big impact of race and poverty on the mental health of teens

As rates of depression and suicide continue to rise among American youth, a new study by Kaiser Permanente researchers has found that teenagers living in “less economically and racially privileged neighborhoods” are far more likely to grapple with these conditions.

Drawn from data on nearly 35,000 teens served by Kaiser clinics in Northern California, the study employed an unusual research strategy. It looked at the results of screenings for depression and suicide conducted during routine medical visits of 12-to-16-year-old patients, then charted the impact of where these teenagers lived.

The Kaiser team, led by Ai Kubo, a Kaiser Permanente research scientist, and Julia Acker, a PhD student at UC Berkeley, used a measure that quantifies the relative concentration of white, high-income residents to Black, low-income residents in a neighborhood. This tool – called the Ice measure, which is short for the Index of Concentration at the Extremes – helps chart extremes of privilege and deprivation and had previously been developed as a proxy – a way to quantify structural racism.

Results, published in JAMA Network Open, showed that living in neighborhoods with the most extreme concentrations of racial and economic disadvantage further magnified the high rates of depression and suicidal behavior already known to affect Black and Latino youth.

I spoke with Kubo and Acker about their findings. Their responses have been edited for brevity and clarity.

Rob Waters: Where did the idea of this study come from?

Ai Kubo:

Ai Kubo. Photo courtesy Kaiser Permanente

I’m interested in adolescent health and health disparities and have been looking at early puberty. The timing of puberty has gone down drastically over the past few decades, with huge disparities by ethnicity. Black and Latina girls go through puberty much earlier than whites or Asians. I’m trying to understand why.

Early puberty is also related to mental health – girls and even boys who go through early puberty have a much higher risk of depression, bullying, body image, teen pregnancy, and so on. I was interested in understanding whether the timing of puberty will widen the disparities in mental health.

I created this big cohort of children that we follow from birth to adolescence, and I was able to do this because Kaiser Permanente realizes the importance of assessing puberty as a marker for different outcomes. Every time kids come in for well-child checkups, the pediatricians assess their puberty, their development, and they enter it in their health record. As researchers, we have access to thousands and thousands of these records.

We know that the rate of depression and suicidality have gone up so much, especially since COVID, and I wanted to see how teen mental health was going. I was interested in early-life risk factors – maternal factors, the impact of in-utero exposure to different things, including stress. And I was interested in neighborhood-level factors because we can tease apart individual factors and the place that you’re living in. Do you live in a very safe place with lots of green space where you can exercise easily? Or do you live in a dangerous place, an unsafe space where they don’t have parks for kids to play and there’s no healthy food? I wanted to know how neighborhoods affected kids’ health. And Julia is very interested in neighborhood-level factors, especially of structural racism.

In this study you were trying to examine the impacts of structural racism on teens. How do you define structural racism, and how does the proxy you’re using measure or predict it?

Julia Acker:

Julia Acker. Photo courtesy Kaiser Permanente

Structural racism refers to ways that laws, policies, institutional practices, and entrenched norms and beliefs produce and maintain racial inequalities – things like historical and contemporary practices in education, banks, voting, healthcare, the labor market, policing, and courts, as well as acts of discrimination such as laws mandating residential and school segregation by race.

The effects can be seen in racial disparities in wealth accumulation, educational attainment, neighborhood conditions, healthcare, incarceration. All of this affects health and life expectancy and is a root cause of health inequities. Another important point: While structural racism marginalizes and harms racialized communities, it simultaneously bestows advantages and increased opportunities upon the dominant group. These privileges are usually invisible to those who benefit from them.

The ICE measure is designed to capture the concentration of economic and racial privilege and disadvantage in a particular geographic area. Like all measures, ICE has its strengths and limitations. It provides a framework to highlight neighborhoods with extreme racial and economic inequality – high-income white residents and low-income Black residents. At the same time, the ICE is quite reductive since it can only compare the concentration of two social groups in a neighborhood. Its binary nature might not capture the complexities and nuances of multi-racial and multi-ethnic communities. So it is essential to accompany the ICE with other quantitative measures of structural racism, as well as qualitative research focused on individuals’ lived experiences.

How does the Northern California area served by Kaiser that you examined for this study fit into these models?

Acker: California has a long history of racially exclusionary policies and practices. Significant portions of the state remaining highly segregated by race and ethnicity. The state also grapples with profound wealth and income inequalities. A strength of our study is the racial/ethnic, socioeconomic, and geographic diversity of the population.

What has previous research revealed about the effects of income, race and privilege on mental health? What’s unique about your study?

Acker: My expertise is not in mental health, but when I was reviewing the literature, it became apparent that children of color were underrepresented in mental health research despite evidence of disparities in depression, suicide and other mental health outcomes. The number of studies on structural racism and physical health outcomes has skyrocketed in recent years, but mental health research is lagging. There is good evidence that racial discrimination is associated with worse mental health. Relatively little research has focused on upstream, structural inequities that contribute.

Were you able to tease out the effects of living in an impoverished, low-resource area? Do kids from middle-income families living in under-resourced neighborhoods do any better than the lower-income kids around them?

Acker: Unfortunately, the electronic health records don’t contain data on income. We used maternal education level and age at delivery as proxies for household socioeconomic status. These preliminary findings suggest that even more affluent teens living in disadvantaged neighborhoods may not be insulated from the broader mental health effects associated with residing in a disinvested neighborhood. Also, the sample was restricted to individuals with health insurance. Kaiser membership also underrepresents individuals at the extremes of the income distribution (people with very low or very high incomes), so the effect sizes we are reporting may be more conservative than what we would find in a community-based sample.

There is a great deal of concern right now about rising rates of mental illness and suicide among young people. From your research, what do policy makers need to understand and how should they address this crisis?

Acker: Our research adds to a growing body of evidence that mental health is not evenly distributed across places. It’s essential for policymakers and advocates to understand that mental health can be influenced by structural factors. Investment in community resources might have ripple effects on residents’ wellbeing. Targeted mental health resources or early intervention programs in disinvested neighborhoods are also worth exploring further. Addressing structural racism demands concerted, long-term efforts across virtually all sectors. 

Kubo: People of color have higher risk of mental health issues but lower access to mental health care. My hope would be that clinicians become more aware of this, so they do more screening, and give children and teens more access to treatment.

At a policy level, how we can draw more funding, more equality in distribution of wealth from certain places to other places, so there is a minimum standard in all neighborhoods of safety, green space and healthy food options? Right now, the disparity is huge – rich neighborhoods have everything, while other neighborhoods have nothing. In Japan, we don’t have bad neighborhoods and good neighborhoods – it’s all the same no matter where you go. It’s all the same. There are very rich people, but very few. Everybody’s middle class. In the U.S., we could create more evenness – less extreme disparities of privilege – and then see how much healthier people are.
–Rob Waters

Federal Appeals Court revives legal battle for health insurance parity

A roller-coaster of a federal court case that initially produced a landmark ruling in favor of mental health patients against the nation’s largest health insurer – only to be gutted on appeal – moved back in the plaintiffs’ favor this week, at least a bit. The closely watched class-action case, Wit v. United Behavioral Health, is considered among the most significant to date in the fight for mental health parity – the effort, supported by federal and state law, to require insurers to cover behavioral health treatment on par with what they provide for physical health.

In 2019, Federal District Judge Joseph Spero invalidated the denial of hundreds of thousands of mental health claims by UnitedHealthcare’s behavioral health unit. He ruled that the company had abused its discretion by using its own, more restrictive internal guidelines to determine whether coverage for mental health conditions was “medically necessary,” rather than adhering to generally accepted standards of care adopted by medical societies.

Then, in March 2022, a three-judge panel of the 9th Circuit Court of Appeals reversed virtually the entire ruling, a devastating setback to the movement for mental health parity that also upended assumptions by patients, providers and insurers nationwide. Although not all insurers were as restrictive as United, the reversal appeared to give insurance companies carte blanche.

But the legal wrangling continued, and this week, the appeals court took the unusual step of vacating its own opinion for the second time and issued a new decision that affirmed parts of the lower court’s original ruling, reversed others, and sent a key issue back to the district court for reconsideration. In doing so, the appeals court “resurrected a generationally important mental health ruling,” said Caroline Reynolds, an attorney for the plaintiffs, in a press release from lead counsel Zuckerman Spaeder. “The fight is far from over, but this decision unquestionably offers new hope for millions of Americans in need of mental health and addiction treatment.

Spero was scathing in his 2020 decision against United, finding that the company had intentionally designed its guidelines to save money and violated its fiduciary responsibility to the health plans it administered. He ordered United to switch to widely recognized medical society guidelines and reprocess more than 50,000 claims.

This week’s decision came after 15 states, plus Washington, D.C., the Department of Labor and multiple medical and advocacy groups, filed amicus briefs detailing the potential harm to patients if the appellate court’s previous ruling remained in place. The panel’s latest decision again reversed the lower court’s ruling that United could not use its own guidelines for determining medical necessity, but it affirmed other parts and, crucially, remanded a key issue to the district court that, plaintiffs’ attorney say, could yet result in an order to reprocess some of the rejected claims.

It “opens the door for us,” said D. Brian Hufford, another plaintiffs’ attorney. “We are in a strong position” to get another ruling that many of the denied claims be reprocessed – the meat of the original decision. Still, the law firm Miller & Chevalier wrote in a blog post for employee benefits managers that the ruling is “largely a win for United Behavioral Health,” while also predicting that “this will almost certainly not be the last we hear” of the Wit case.

“I am heartened on behalf of the millions of Americans who need mental health and addiction care,” former Rep. Patrick J. Kennedy, an author of the 2008 Mental Health Parity and Addiction Equity Act, said in a statement. “The case continues to demonstrate the need to enforce existing laws so people receive the timely care they need.” Kennedy is the founder of the Kennedy Forum, which advocates for better mental health coverage. (He is also a member of the MindSite News Editorial Advisory Board.)

Asked for comment, UnitedHealthcare released a statement that did not directly address the ruling. “We are committed to ensuring all our members have access to mental health care consistent with the terms of members’ health plan and in compliance with state and federal rules,” the company said.   
–Don Sapatkin

If you or someone you know is in crisis or experiencing suicidal thoughts, call or text 988 to reach the 988 Suicide & Crisis Lifeline and connect in English or Spanish. If you’re a veteran press 1. If you’re deaf or hard of hearing dial 711, then 988. Services are free and available 24/7.

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Type of work:

Rob Waters, the founding editor of MindSite News, is an award-winning health and mental health journalist. He was a contributing writer to Health Affairs and has worked as a staff reporter or editor at...