Mass violence takes toll on Americans’ psyches

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When the American Psychological Association surveyed more than 2,000 people about their stress levels just days after back-to-back mass shootings in El Paso and Dayton, Ohio, in 2019, the findings laid out the toll of seemingly ceaseless, random violence.

A third of the respondents said they would no longer go to certain public places for fear of becoming a casualty of a mass shooting. Almost as many said they could not go anywhere without worrying about being shot. Twenty-four percent said they had made changes in their lives due to their fear of a mass shooting.

Sixty-two percent of parents said they lived in fear of their children becoming victims of a mass shooting, and 71 percent said the possibility of mass violence was adding stress to their lives.

The assaults on Americans’ psyches have only intensified since then, with a two-year-plus pandemic that has taken 1 million U.S. lives; street battles in the struggle for racial justice; a war in Ukraine that has renewed fears of a nuclear conflict; a roller-coaster economy; an insurrectionist riot at the U.S. Capitol; visibly worsening effects of climate change and many more mass shootings. Those culminated in the massacre Tuesday of 19 children and two adults in a Uvalde, Tex. elementary school, just 10 days after the slaughter of 10 African Americans in a Buffalo supermarket

Experts say the unrelenting developments are taking a toll on our mental and physical health and how we interact as a society. The targeting of churches and schools has been particularly distressing to many people who have long regarded them as safe spaces from the tumult of the world.

“People are emotionally exhausted,” said Roxane Cohen Silver, a University of California at Irvine psychologist who has studied trauma for decades. “We cannot see any one of these events in isolation. We are seeing a cascade of collective traumas. … I don’t think that many people could have conceived of this degree of loss.”

The impact is felt most deeply by communities already under stress. “It takes a toll on the country as a whole and an even higher toll on people of color, who are largely the victims of these last two incidents,” said the Rev. Ray Hammond, pastor at Bethel AME Church in Boston, who has worked on anti-violence initiatives for decades.

“Even though intellectually you know this is a rare thing, the sense of insecurity is cumulative, and I think for a lot of people extremely unsettling.”

America’s new norm: ‘Why are we willing to live with this carnage?’

The notion that people of color feel more vulnerable is supported by the APA survey, which was incorporated into the organization’s annual Stress in America report. Hispanics, Blacks, Asians and Native Americans all reported more stress from mass shootings than Whites.

A Quinnipiac University poll and a Pew Research Center survey, both taken in 2018 after the mass shooting at Marjory Stoneman Douglas High School in Parkland, Fla., showed the same results, with Blacks and Hispanics more fearful of mass violence than Whites, and younger people more worried than older respondents.

Tuesday’s rampage brought an extra measure of anguish to a nation that saw the faces of children such as 10-year-old Amerie Jo Garza, smiling proudly with her Honor Roll certificate just hours before she was murdered by a gunman with an assault rifle.

The surveys, experts said, affirm their belief that repeated exposure to shocking acts of violence that happen with horrific regularity in this country, alone among its peers, is affecting people’s health.

“It’s clearly having a significant negative impact, and particularly on our mental and our physical health,” said Vaile Wright, senior director for health-care innovation at the APA, who works on the Stress in America surveys that have been conducted each year since 2007.

When acts of mass violence “are repeated in this way, they start to feel more and more overwhelming, and a sense of hopelessness starts to set in,” she said.

Human bodies are not meant to be so frequently in a state of agitation, she said. The result is hyper-vigilance, anxiety and an inability “to be in the moment.” Some people may become desensitized to violence as a defense, she said.

“People feel so overwhelmed by the stress and worry that they have to compartmentalize it to a certain extent,” Wright said.

Joshua Morganstein, a psychiatrist and chair of the American Psychiatric Association’s Committee on Psychiatric Dimensions of Disaster, noted that schools are considered safe places, as are houses of worship — both of which have been attacked in mass shootings in recent years.

When these places are struck by violence it is particularly distressing, he said. And the deaths of children in violent acts adds another layer of horror: “It also challenges our perception and belief about the natural order of life in the world, which is that parents are supposed to precede their children in death, not the other way around,” he said.

Morganstein suggested that people monitor their consumption of news about horrific events such as the Uvalde shooting. It is not being callous to turn off the news, he said — it can be necessary for mental health.

“The media is such an important source of information for us, but we know that exposure to disaster-related media is consistently associated with feelings of anxiety, depression, post-traumatic stress symptoms, trouble sleeping, increased use of alcohol and tobacco,” he said.

Silver, the California psychologist, studied the health consequences of exposure to news about the 9/ 11 attacks and the Iraq War, and found evidence that suggests some people developed new cardiovascular illnesses as a result. She is now studying the psychological and physical health consequences of this “ongoing onslaught” of bad news on our sense of safety.

Previous research on collective trauma shows that some people can develop conditions that include short-term anxiety, depression, post-traumatic stress disorder (PTSD) and other mental health issues.

And those exposed to multiple tragedies tend to have “greater distress, functional impairment and lower life satisfaction,” according to a 2020 commentary Silver published in Nature Human Behavior, based on numerous studies. The bad news is amplified by rapid dissemination on social media and repetition through the 24-hour news cycle.

“We are not only seeing or hearing the news of these tragedies, but we are seeing that in graphic color,” she said.

In addition to reducing news consumption, experts advised focusing on what you can control rather than worrying about what might happen, and to put upsetting information into a broader context.

Mass shootings that kill four or more people account for less than 1 percent of the roughly 20,000 firearm homicides in the United States each year, according to Jillian Peterson, an associate professor of criminology and criminal justice at Hamline University in St. Paul, Minn. Suicides by firearms make up about 60 percent of all gun deaths each year.

“The most dangerous thing you will do today is ride in a car,” said Joel Dvoskin, a clinical assistant professor of psychiatry at the University of Arizona College of Medicine. “And in fact we’ve made that safer.”

But Beverly Kingston, director of the Center for the Study and Prevention of Violence at the University of Colorado, said society is only now beginning to ask “how do we heal collective trauma? How do we acknowledge our society is built on top of layers of trauma?”

“I worry about our collective trauma getting in the way of what we could be doing to create a better society,” she said.


The Behavioral Health Care Affordability Problem

Introduction and summary

For far too long, people—especially people of color, people with low incomes, and people with disabilities—have struggled to access behavioral health care services in the United States. Reports of individuals endlessly navigating inaccurate provider directories,1 insurance denials,2 and expensive treatment3 have proliferated in recent years.

The coronavirus pandemic has further highlighted and exacerbated the behavioral health crisis and barriers to access care.4 Self-reported anxiety and depression disorder symptoms have increased 400 percent during the pandemic.5 Moreover, the same historically oppressed communities that have faced the brunt of the COVID-19 crisis—Black, Native, and low-income communities, in particular—have also experienced heightened levels of mental health needs and have disproportionately struggled to access much-needed services.

Despite advancements toward mental health parity and state initiatives, mental health and substance use services remain inaccessible for millions of Americans who need them.

In recent decades, policymakers have created frameworks to improve behavioral health care affordability and access. While these guidelines are imperfect, they provide an important baseline on which policymakers can and should build. In particular, lawmakers and regulators should strengthen existing parity frameworks, leverage the Affordable Care Act’s (ACA) no cost sharing for preventive service provision for behavioral health, and develop enforcement mechanisms that operate without depending on consumer complaints.

The key framework: Mental health parity

Prior to 1996, there were no national laws in the United States to govern behavioral health coverage in the private insurance market. While there were regulations that mandated psychiatric coverage for federal employees in the 1960s and 1970s, behavioral health regulations were largely focused on mandated benefit laws, rather than parity, and these regulations were set by state legislatures.6

In 1996, Congress passed the Mental Health Parity Act (MHPA), which prohibited large-group employer-sponsored health plans that provided mental health benefits from imposing more restrictive annual or lifetime limits on mental health benefits than those imposed on medical or surgical benefits.7 While the MHPA was an important leap toward mental health parity, it contained many gaps by which insurers could evade compliance. For example, health plans could receive a waiver if they demonstrated that their costs increased as little as 1 percent as a result of compliance. Additionally, the law’s requirements were limited: It allowed treatment limits, insufficient numbers of covered facilities, differences in cost sharing, and restrictive medical management techniques to remain.8

During the next decade, several states implemented behavioral health parity policies with varying scopes in an attempt to close some of the remaining gaps of the MHPA. Then, in 2008, Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA). In addition to reaffirming the MHPA requirements, the MHPAEA expanded these guidelines to apply to both substance use disorder and mental health services, while also instituting more comprehensive guidelines to promote behavioral health parity. Specifically, the MHPAEA extended the requirement that large-group health coverage for behavioral health services be no more restrictive than coverage for medical or surgical conditions to Medicare Advantage, Medicaid managed plans, and state Children’s Health Insurance Plans.9 The law also has more sweeping protections that prohibit treatment and visit limits, cost sharing, and network limitations from being more stringent than those for medical and surgical benefits.

The Affordable Care Act (ACA) was the first in this series of the parity laws to mandate behavioral health coverage, rather than require parity only if coverage is offered; it added mental health and substance use disorders (SUDs) to its list of essential health benefits (EHBs) required in small-group and individual market insurance plans.10 The ACA also extended parity regulations from group plans to the individual health insurance market, requiring parity for an additional 11 million individuals.

Read more on how the ACA has improved health care

Limitations of parity laws

Dr. Richard Frank, the Margaret T. Morris professor of health economics in the Department of Health Policy at Harvard Medical School, has noted that many of these policies constitute “parity in law” rather than “parity in principle.”11 Parity in principle extends beyond parity in law to mean that “people with mental illnesses and SUDs should have access to high-quality treatments for their illnesses and protection against the costs of care that meets their health care needs in the same way that any other health needs are addressed.”12

People with mental illnesses and SUDs should have access to high-quality treatments for their illnesses and protection against the costs of care that meets their health care needs in the same way that any other health needs are addressed. Dr. Richard Frank

For example, while insurers cannot charge patients more in cost sharing for behavioral health services or set annual limits on treatment, insurers often manage care or create networks in ways that prevent equal access to behavioral health services.

Generally, quantitative treatment limits (QTLs), such as annual and treatment limitations, are more straightforward to assess and enforce than nonquantitative treatment limits (NQTLs), such as network adequacy, prior authorization, and step-therapy.13 It is challenging to ensure compliance with NQTL parity; yet there are clear opportunities for policy intervention to enforce NQTL parity and ensure broader behavioral health access.

Network adequacy is included in the existing NQTL parity requirements—which means health plans must have a sufficient number of in-network primary care and specialty providers and included benefits to offer reasonable access to services. However, insurers often offer providers low payment rates, limiting willingness of an already insufficient workforce to join networks and impeding compliance with network adequacy standards.14 Insurers can also set treatment limits to manage care; these plans often do not offer as much treatment as a patient or provider may find beneficial or clinically significant. Moreover, insurance companies may require prior authorization or medical necessity forms that can slow or prevent access to care.

While these limitations impede parity in principle, they are often more challenging to enforce and may proceed undetected by regulating bodies.

Insufficient enforcement of parity

In addition to these gaps, few standards exist to adequately and regularly monitor potential violations of parity. Currently, state agencies, the U.S. Department of Labor (DOL), and the U.S. Department of Health and Human Services (HHS) share the responsibility of overseeing compliance with mental health and SUD parity requirements.15 A 2019 Government Accountability Office (GAO) report assessed oversight of the MHPAEA and other parity requirements, finding that while nearly all states reviewed group and individual insurance plans for parity before they were approved for sale to consumers, only 12 states reported conducting at least one targeted review of specific parity concerns in 2017 and 2018.16 The DOL and HHS conduct reviews only when they receive information, such as consumer complaints, about possible noncompliance with parity regulations. Yet because many beneficiaries who have trouble accessing behavioral health services are also experiencing behavioral health crises and struggling with a variety of social determinants of health, relying on consumer complaints places an undue burden on struggling beneficiaries and is bound to miss violations. Unlike state agencies, these federal agencies only conduct these reviews after the plans have been sold to consumers.

The GAO report identified some instances of noncompliance but was unable to determine the extent of noncompliance with parity requirements. It recommended that the assistant secretary of labor for the Employee Benefits Security Administration and the administrator of the Centers for Medicare and Medicaid Services (CMS) evaluate whether targeted oversight in response to information about possible noncompliance was sufficient. The Biden administration should direct these agencies to conduct these analyses expeditiously. And if they find that current practices pose significant risks, the GAO suggests that these agencies develop plans to more effectively enforce parity requirements and seek additional oversight authority as needed.

The current parity laws and state-level enforcement mechanisms do not adequately consider network adequacy standards appropriately as an inhibitor to parity. Even if parity were enforced such that a patient seeking in-network behavioral health care owed the same amount in cost sharing as for primary care, networks for behavioral health care providers are so restrictive that many patients would still struggle to find in-network providers. Equal coverage must therefore factor in the availability of providers that accept insurance and contract in network.

With proper oversight and enforcement, the existing parity laws could be used to expand coverage and access. However, due in part to the issues described above, many behavioral health care providers refuse to accept public or private insurance; insurers make it difficult for patients and providers to prove the medical necessity of the services; and a shortage of mental health providers leaves many people with no access to care.

Network adequacy remains a problem

A 2013 final rule intended to clarify implementation of the MHPAEA and extend consumer protections affirmed that parity laws apply to nonquantitative treatment limits—specifically naming geographic limits, facility type limits, and network adequacy. While parity laws do not adequately address dollar reimbursement to providers directly, low reimbursement rates to providers are tied to insufficient network adequacy.17 For example, a 2017 study that analyzed private insurance claims data for thousands of patients found major disparities in payment to psychiatrists and nonpsychiatrist medical doctors performing the same services: Psychiatrists were paid a median of 13 to 20 percent less than nonpsychiatrist medical doctors for the same in-network evaluation and management services, depending on severity of the diagnosis.18 However, for the same services out of network, psychiatrists were paid 28 percent and 6 percent more than nonpsychiatrist doctors for services for patients presenting problems of low to moderate and moderate to high severity, respectively.

These low in-network payments may discourage psychiatrists from joining networks, as the higher out-of-network payments incentivize providers not to contract with insurers, narrowing networks and reducing access for patients. Primary care physicians (PCPs) are already underpaid for their services, and mental health providers are paid even less—despite the legal mandate for parity compared with substantially all other medical and surgical services.19

With so much dependence on out-of-pocket costs, in many cases, mental health care may only be accessible for those with higher incomes.

According to an analysis by health care consulting company Milliman, for every $1 that insurance companies reimbursed primary care physicians in preferred provider organizations (PPOs) in 2017, they reimbursed behavioral health professionals only 76.2 cents.20 Milliman also found that primary care providers and medical and surgical specialists were paid 14.7 percent and 11.1 percent higher, respectively, than Medicare-allowed amounts, while behavioral providers were paid 5 percent less than Medicare-allowed amounts for in-network services.

Network adequacy: By the numbers

Low payment rates to behavioral health providers often inhibit the creation of adequate networks:

  • For every $1 reimbursed to primary care physicians in certain plans, behavioral health providers only made 76 cents.
  • For the same in-network services, behavioral health providers were paid 17 percent less than medical specialists and 14.5 percent less than surgical specialists.
  • In a study of the individual market, only 43 percent of psychiatrists and 19 percent of nonphysician mental health care providers participated in any network. These rates were 27 percent and 67 percent lower, respectively, than insurance participation among primary care providers.
  • In the same study, private insurers paid behavioral health providers between 164 and 178 percent more for out-out-network services than in-network services.

Given reimbursement rates that are lower than other specialties and have not increased in decades, as well as shortages in the mental health workforce, it is no surprise that network participation among behavioral health providers is low.21 In a 2017 study of more than 500 ACA marketplace networks, only 42.7 percent of psychiatrists and 19.3 percent of nonphysician mental health care providers were found to participate in any network, compared with 58.4 percent of PCPs.22 The study noted, “On average, plan networks included 24.3 percent of all primary care providers and 11.3 percent of all mental health care providers practicing in a given state-level market.”23 The authors suggested that given relatively recent standards of parity and behavioral health benefit inclusion, insurers have turned to other tactics, such as restricting networks to avoid paying for potentially costly behavioral health care needs.

Even a vigilant consumer who knows their behavioral health needs and makes a concerted effort to ensure in-network coverage may face additional barriers. In a 2015 study, researchers called 360 psychiatrists on Blue Cross Blue Shield’s in-network provider list in three large cities and were unable to make appointments with nearly three-fourths of the listed providers.24 The database listed wrong numbers and providers that refused to accept insurance or new patients. Yet these inaccuracies are not limited to behavioral health care or the private market: A 2016 CMS review found similar inaccuracies in nearly half of the entries reviewed in Medicare Advantage directories.25 Furthermore, the behavioral health provider industry can be volatile, with providers entering and leaving insurance networks often and those with time-limited coverage, such as short-term Medicaid and Medicaid pregnancy coverage, struggling to receive continuous care.26 These types of barriers to accessing in-network services reduce the likelihood that an insurer will pay for a beneficiary’s care.27

With a demand for behavioral health providers that greatly surpasses the supply, coupled with low reimbursement rates, many behavioral health providers can obtain a sufficient client base without accepting insurance. Indeed, insurance acceptance rates were about 30 percentage points lower among psychiatrists than among physicians with other specialties for private insurance, Medicare, and Medicaid. (see Table 1)

Table 1

While private insurers pay physicians and hospitals more than Medicare and Medicaid does for nearly all services, the landscape of behavioral health payments is a bit more complicated.28 In 2014, for in-network behavioral health services—which are difficult to access in many regions and on many plans—private insurers, including commercial and Medicare Advantage plans, actually paid 13 to 14 percent less than Medicare fee-for-service (FFS) rates for identical services.29 However, these lower reimbursement payments from private insurers did not reduce average cost sharing for patients, possibly because so many patients resorted to seeking out-of-network behavioral health services.30


Additional likelihood that patients with commercial insurance used out-of-network services for mental health services versus other services

Comparatively, private insurers reimbursed beneficiaries at higher rates for out-of-network mental health needs than did FFS Medicare, but 1 in 3 out-of-network payments was paid completely out of pocket by the patient.31 Meanwhile, private insurers paid 43 to 53 percent more for out-of-network mental health services than did Medicare FFS.32 And out-of-network service use by patients with commercial insurance was six times more common for mental health services than for other services.33 Privately insured patients spent twice as much in cost sharing for out-of-network services than for in-network services.34

With so much dependence on out-of-pocket costs, in many cases, mental health care may only be accessible for those with higher incomes.

Mental health care is unaffordable and inaccessible without insurance

As the pandemic and related economic crisis continue, loss of employer-sponsored coverage and inability to afford insurance may drive more people to experience periods of uninsurance. Uninsured patients typically must bear the entire cost of behavioral health services, which can very quickly add up to thousands of dollars in treatment and make these services unattainable for many.

There are some limited programs at low or no cost, such as sliding-scale services at federally funded health centers, low-cost services with training graduate students at colleges and universities, and patient assistance programs for prescription drugs. In addition, reforms to expand affordable coverage—including Medicaid expansion and universal health care proposals as well as more providers being encouraged to practice in federally qualified health centers—would help people who are currently uninsured access behavioral health care. Likewise, permanently increasing marketplace subsidies across income ranges, as done temporarily by the American Rescue Plan Act until the end of 2022, would help more low-income people gain insurance.35

The true cost of mental health care

MNHealthScores, a website managed by the nonprofit organization MN Community Measurement, publishes average costs of various health services across payers in Minnesota.36 In this report, the Center for American Progress uses these data to estimate the out-of-pocket financial burden for patients responsible for some or all of the cost of services, including insured patients seeking in-network care before meeting their deductible, insured patients seeking out-of-network care with limited out-of-network coverage, and uninsured patients seeking care out of pocket.

Imagine an adult patient in Minnesota who exhibits symptoms of depression, as experienced by nearly 1 in 3 adults during the COVID-19 pandemic in 2021.37 The patient is insured but contacts the providers listed in network and finds that they are not taking new patients, no longer contract with their insurer, or have long wait times. Instead, the patient seeks care from an out-of-network psychologist for an initial intake visit, which costs $241 on average, and is diagnosed with major depressive disorder. A provider may suggest weekly cognitive behavioral therapy for 45 minutes weekly for 8 to 16 sessions.38 Yet the cost of a 45-minute psychotherapy session averages $160, which comes to an additional $480 for the first month, followed by $640 each month for the next one to three months. Assuming the patient needs 12 sessions, in addition to the diagnostic session, to see results, they might pay $2,161 out of pocket for all services with the psychologist before even considering longer-term maintenance treatment.

Over the course of psychotherapy, the therapist believes the patient may benefit from pharmacotherapy and refers the patient to a psychiatrist, who is also out of the patient’s insurance network. The initial diagnostic evaluation costs $346. Of course, treatment varies by a person’s diagnosis and situation, and rates differ by location and degree of provider. Assuming there are no additional evaluation and management services, this dual-pronged course of treatment for a depressive episode would cost $2,507, without accounting for the costs of prescription drugs.

Insurance limitations foster a crisis-response mental health system

Patients with insurance coverage often face restrictions and limitations that inhibit access to behavioral health care. Insurers may limit treatment and only cover services they deem medically necessary. Indeed, a National Alliance on Mental Illness (NAMI) online survey of people with mental illness who had private insurance, along with their families, found that respondents were more than twice as likely to be denied by their private insurer for mental health care on the basis of medical necessity, compared with other medical care.39 These kinds of designations may violate the nonquantitative treatment limits of the MHPAEA.

To qualify for medical necessity and service coverage, a patient must receive a mental illness or behavioral health diagnosis, even if their symptoms may not fit into the biomedical diagnosis categories. Furthermore, “medical necessity” remains undefined and unpinned to clinical standards. According to Meiram Bendat, founder of the mental health law firm Psych-Appeal, in a testimony before the U.S. House Subcommittee on Health, Employment, Labor, and Pensions, “Health plans are free to create and operationalize self-serving, overly restrictive medical necessity definitions that undermine access to essential health benefits, including mental health and substance use treatment.”40 If a patient bills to their insurer, the insurer can set treatment plans and limitations and determine how many sessions are needed to treat the diagnosis. While insurance companies claim to consider clinical guidance, medical necessity determinations, treatment plans, and limits on the duration of covered treatments are at the discretion of the insurer.

There is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions. Judge Joseph C. Spero

These limitations set by insurers foster a crisis-response behavioral health care system, rather than allowing for prevention and maintenance. For instance, a federal court judge in Northern California recently ruled that a unit of UnitedHealth Group had created internal policies to cut costs by effectively discriminating against patients with mental health and substance use disorders.41 U.S. Chief Magistrate Judge Joseph C. Spero, who decided the case, said, “There is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.”42 Patients reported denials for care as soon as they appeared stable.

When insurers deny coverage for treatment prematurely, patients can relapse or continue to struggle in between acute crises when treatment is inaccessible. Prevention and treatment for conditions is more efficient for payers and often more helpful for patients than treating an acute crisis. In primary care preventive appointments, for example, a person exhibiting symptoms of depression might have to self-identify these symptoms and bring them to a PCP’s attention. Just as a PCP might screen for signs of cancer, an infection, or a heart problem; act as the first line of defense; and refer out for conditions that may be beyond their scope of expertise, PCPs have the clinical capacity to screen for common mental health disorders and treat more basic cases.

However, PCPs should be careful not to overprescribe mental health medications as initial treatment and should ensure that they have the resources and capacity to follow up with referrals and treatments. Nonetheless, behavioral health care can be overlooked in primary care settings and, despite a recommendation from the U.S. Preventive Services Task Force in 2016, there is no standard obligation or requirement for PCPs to inquire about the behavioral health of their patients.43

Disparate experiences of behavioral health care

People experience challenges to accessing behavioral health access differently. In particular, low-income, uninsured, and underinsured individuals face heightened barriers to affording behavioral health services. Forms of marginalization and the lived experiences of intersecting identities contribute to additional challenges that may compound behavioral health issues. Indeed, stigmas toward behavioral health, combined with other forms of shame and discrimination imposed on people with marginalized identities, can affect treatment rates, access, and affordability of treatment.

Income disparities

Of the 11.8 million Americans who reported an unmet need for behavioral health care in 2016, 38 percent could not afford the cost of treatment.44 Furthermore, 2.5 million adults with serious mental illness (SMI) have incomes below the federal poverty line (FPL), and adults over the age of 26 with incomes below the FPL are more likely to experience SMI than those with incomes above it.45 In addition to the many challenges faced by lower-income individuals when searching for and seeking health care more generally, having lower incomes can make services with out-of-pocket costs or cost sharing inaccessible. Moreover, lack of transparency or confusion about insurance coverage for behavioral health services, as well as fears that insurers can limit care or determine medical necessity and threaten coverage, can make the process of initiating treatment even more daunting.

For these reasons, the experiences of having both a mental illness and a lower income can intersect in complicated ways and exacerbate both experiences.

Disparities among people involved in the justice system

Notably, people incarcerated in prisons and jails were three and five times more likely, respectively, to experience severe psychological distress than the general adult population in 2011 and 2012.46 The overutilization of 911 emergency services disproportionately harms communities of color, and people with serious mental illness are “16 times more likely than the general public to be killed during a police encounter.”47 Nearly 37 percent of those incarcerated in prisons and more than 44 percent of those incarcerated in jails have a history of mental health disorders.48

Importantly, these data do not indicate that people with mental illnesses are more likely to be violent or break the law; rather, they point to the criminalization of mental illness; the failure of courts, police, and incarceration facilities to direct people with mental health crises to the appropriate services; and the overall lack of access to these mental health services. Indeed, in a study of New York City jails, Black and Hispanic people were less likely to access mental health services than their peers but more likely to experience solitary confinement—which those with a mental health diagnosis are already 3.3 times more likely to experience than people without mental illness diagnoses.49 Overall, the experience of being incarcerated can significantly worsen mental health problems.

Furthermore, people with criminal records face additional challenges obtaining access to supports, highlighting the need to reduce barriers to eligibility.50

Disparities among unhoused people

Some criminalized activities stem from not having basic needs met. Poverty and homelessness are risk factors for both mental illness and incarceration. People in poverty are more likely to forgo mental health treatment due to high levels of stressors involved with meeting basic needs and having the financial stability to afford treatment options.51 Individuals who struggle with housing and financial insecurity also struggle to access mental health services: Nearly half of unhoused people in 2015 had a mental illness,52 and unhoused people have 10 times more contacts with the justice systems than does the general population.53

Access to quality, affordable, and affirming mental health services is necessary to address the disproportionate impact of unmet behavioral health needs for vulnerable populations. Additionally, policies and programs that address basic needs and the social determinants of health—including racism, housing, and neighborhood safety, as well as access to jobs and economic opportunity—are necessary to break the incarceration cycle and help individuals and communities live prosperous, healthy, and fulfilling lives.

Racial and ethnic disparities

Given the lack of culturally competent care and the shortage of providers able to treat unique issues such as displacement, racism, xenophobia, and culture loss, there are significant racial and ethnic disparities in behavioral illness treatment and access to that treatment.54 While more than 1 in 2 non-Hispanic white people with mental illness access treatment, only slightly more than 1 in 3 non-Hispanic Black or African American and Hispanic or Latino people with mental illness, as well as 1 in 5 non-Hispanic Asian people with mental illness, access treatment.55 Moreover, whereas mental health treatment rates increased among white and Hispanic people following implementation of the ACA’s major coverage provisions in 2014, no other racial or ethnic groups received significantly more mental health treatment than their same-minority-group counterparts pre-ACA implementation.56 However, in the same study, treatment rates for substance use disorder did not improve significantly for any racial or ethnic group after 2014.

Gender disparities

In 2020, women were more likely to access mental health treatment (51.2 percent) than men (37.4 percent).57 Yet these numbers do not reveal the full story: When race was factored in, Black women were half as likely to receive mental health treatment as white women.58 While up to 1 in 7 women experience postpartum depression, rates are significantly higher for new mothers of color—reaching nearly 38 percent.59 Despite their clear need for mental health services, women of color are less likely than white women to access mental health care during pregnancy and the postpartum period.60

There are a number of systemic reasons for this, including many mentioned above, such as lack of adequate insurance and high treatment costs. In addition, a study of low-income women—55 percent of whom were Black—found that the lack of affordable, accessible child care and transportation was a barrier to accessing mental health and SUD treatment.61 Many women of color face systemic and structural barriers to accessing mental health services beyond the postpartum period as well.62

LGBTQI+ disparities

Likewise, LGBT communities are at higher risk than non-LGBT communities of experiencing mental health problems, and severe mental illness may occur at higher rates among LGBT populations.63 Furthermore, transgender adults are nearly nine times and intersex youth are more than four times more likely than the overall U.S. population to have attempted suicide.64 Transgender youth and LGBQ teens, in particular, experience depression or depression symptoms at higher rates than their cisgender and heterosexual peers, respectively.65 Yet according to a nationally representative 2020 CAP survey, approximately 3 in 10 LGBTQ Americans reported cost barriers to accessing necessary medical care, including more than 1 in 2 transgender Americans and 60 percent of transgender individuals of color.66

It is important to note than disparities in mental illness rates reflect treatment accessibility, discrimination, and additional challenges faced by marginalized communities, rather than innate differences. Indeed, 84 percent of LGBTQ youth reported wanting mental health counseling, but 54 percent of those who wanted treatment did not receive it.67 High rates of mental health conditions may be part of a “minority stress model,” in which stigma, prejudice, and discrimination faced by minority communities create a hostile and stressful social environment that contributes to poorer health, often compounded by intersecting identities such as race and ethnicity.68

Disparities among disabled people

Disabled people, whose identities and experiences may also intersect with other disparate experiences described above, face particular mental health access challenges. One in 3 disabled adults experience frequent mental distress, nearly five times as often as nondisabled people.69 Yet many behavioral health provider offices remain inaccessible for people with physical disabilities.70 Few clinicians are able to identify unique risks faced by disabled people, including ulcers and other chronic conditions; consider ableism as a significant stressor; and avoid reinforcing ableism by dehumanizing disabled people as needing to be “fixed.”71

Even with the increased uptake of telemental health treatments, many disabled people still face communication barriers and, with disproportionally high rates of poverty among disabled people, access concerns such as lack of broadband.72 For example, in one 2012 study, only 17 percent of deaf patients received an interpreter for health care visits.73

Disparities in rural settings

A person’s location also affects their ability to access care. While there is a national shortage of behavioral health providers, rural community members struggle more greatly to access care. Indeed, nearly half of all nonmetropolitan U.S. counties lack a psychologist, and more than 65 percent lack a psychiatrist—more than double the rate in metropolitan counties.74 Additionally, in smaller, close-knit communities, stigma can be greater, as people seeking behavioral health care may fear being seen by someone they know at a treatment center.75 Together, limited access and fear of seeking treatment may drive behavioral health care to be a last resort to address an acute crisis, rather than preventive, ongoing care.76 The crisis-response approach is not limited to rural communities and reflects a larger cultural and clinical trend.

This report does not seek to provide recommendations that address the structural roots of these disparities, but rather proposes policy changes to increase access and affordability, which would benefit vulnerable populations to a greater extent. Further research that highlights and addresses these differential experiences would be a valuable addition to the discourse.

See also


State and federal policymakers have the tools at their disposal to improve behavioral health access and affordability. By leveraging and enforcing existing programs and legislation, policymakers can both ensure that people experiencing behavioral health struggles can access care and save lives.

Improve initial affordability

Policymakers should make initial behavioral health services more affordable to help patients get in the door and access care. The behavioral health care model prioritizes acute response to crisis and short-term solutions to complex behavioral health needs. Policymakers should incentivize prevention, early intervention, and maintenance of chronic behavioral health disorders. The Primary and Behavioral Health Care Act of 2021 (H.R. 3550), introduced by Rep. Lauren Underwood (D-IL), and President Joe Biden’s State of the Union mental health strategy would require health insurers offering individual or group plans to cover three behavioral health care visits with no cost sharing each year.77 Paired with network adequacy provisions to ensure that beneficiaries can find providers who accept their insurance, these provisions could greatly increase access to behavioral health care.

Primary care providers can conduct annual screenings for common behavioral health ailments. However, behavioral health specialists should also be able—with insurance coverage—to see patients in the early stages of complications that may precede diagnosis before the conditions become more complicated, decrease quality of life, and become more expensive to treat. In the same way that a patient can be screened for complications by their primary care provider—as well as specialists such as gynecologists, ophthalmologists, and cardiologists—patients should be able to see behavioral health providers for early treatment or maintenance of concerns or complications even if those sessions do not result in diagnoses. As required by the ACA, if these visits are redefined as preventive care, there should be no cost sharing. HHS has yet to codify this categorization with a rule.

According to existing parity requirements, maintenance treatment for behavioral health care after a patient is stabilized can be no more restrictive than for medical or surgical care. Following existing regulations, managing chronic behavioral health needs should be covered on par with managing a chronic illness such as diabetes. States and DOL and HHS regulatory agencies should monitor compliance of insurers with parity requirements for ongoing care. In addition, the Biden administration should issue an executive order to ensure federal agencies proceed with these reviews as a priority.

Limit patient cost sharing

Many people seeking behavioral health care must pay out of pocket until they reach their deductible. For plans offered in the federal marketplace for 2021, someone with a silver plan and no cost-sharing reductions has an average medical deductible of $4,500.78 In an analysis of deductibles in open enrollment on the federally facilitated marketplace, a person would have an average deductible of $2,825 after cost-sharing reductions.79 Meanwhile, the average deductible for an employer sponsored plan in 2021 was $1,434.

Two in 5 Americans are unable to afford an unexpected $1,000 expense.80 Therefore, many individuals faced with urgent behavioral health needs may forego care or accrue medical debt to do so. There are several ways to address cost-sharing requirements for behavioral health services that are too high for average Americans.

2 in 5

Share of Americans who can’t afford an unexpected $1,000 expense, while behavioral health treatment can cost thousands

One option is for states or the federal government to implement standard benefit plans that limit cost sharing in the ACA marketplaces. In the Notice of Benefits and Payment Parameters Final Rule of 2023, issuers offering non-standardized qualified health plans on the federal marketplace will be required to offer standardized plan options at every network type, metal tier (referring to plans categorized by the share of costs covered by a health plan), and service area in which they offer non-standardized plans.81

On the state level, Covered California, the state’s marketplace established under the ACA, initiated a standard benefit design for their marketplace plans that limits copays for primary care and specialist visits even when a deductible has not been met.82 For a standard silver plan in California, a primary care visit would cost $40 and a specialist visit would cost $80 out of pocket, rather than the full cost of treatment until the deductible has been met. For those with family incomes below 250 percent of the federal poverty level, rates decrease incrementally from $35 to $5 for a primary care visit and $75 to $8 for a specialist visit. Mental health care visits could be standardized to primary care levels, with reduced cost sharing for those with low incomes, although even an out-of-pocket limit at specialist rates would be a significant improvement. While the details of the federal standardized plans required by the 2023 final rule remain to be seen, this move could be an opportunity to improve mental health access, in alignment with the Biden administration’s other priorities.83

Another option is a separate, lower deductible for behavioral health care in ACA marketplace plans for those who have not yet met their deductible, modeled like separate prescription drug deductibles. Spending toward the behavioral health deductible would still count toward meeting the general medical deductible. The current parity regulations under the MHPAEA require equal or better coverage for behavioral health care; a lower threshold for insurers to begin covering behavioral health services would constitute better coverage and be permissible under the law.

Enforce network adequacy as parity

As an NQTL within the parity framework, network adequacy for behavioral health is often lacking and prevents insured patients from accessing care. The ACA requires insurers with plans on the individual marketplace to maintain networks that are sufficient in number and type of provider and do not lead to unreasonable wait times.84 The ACA, however, did little to define regulation and enforcement of these metrics, and in practice, patients often struggle to find an in-network provider for behavioral health care. While held to the same standards as all other medical and surgical specialties covered by ACA marketplace plans, behavioral health coverage is governed by additional consumer protections that have also largely evaded enforcement.

While held to the same standards as all other medical and surgical specialties covered by ACA marketplace plans, behavioral health coverage is governed by additional consumer protections that have also largely evaded enforcement.

On the federal level, legislators have proposed several bills to better enforce parity requirements. For example, the Parity Enforcement Act of 2021, introduced in the House of Representatives, would give the DOL authority “to enforce the parity requirements for group health plans with respect to the coverage of mental health and substance use disorder benefits.”85 Meanwhile, the Parity Implementation Assistance Act of 2021, introduced in the Senate, would provide states with grant funding to implement mental health and substance use disorder parity provisions.86

Many states have created more stringent requirements and accountability metrics for network adequacy, with some specifically in the context of behavioral health. For example, Illinois recently amended the Network Adequacy and Transparency Act of 2017, which required insurers to charge a beneficiary no more for out-of-network services than for in-network services if the beneficiary made a “good faith effort” to access in-network care, to account for “timely and proximate access to treatment” for behavioral health—a minimum standard state and federal governments should implement.87

Additionally, California, Tennessee, and Nebraska set travel time and distance standards for obtaining mental health services in order to promote network adequacy.88 New York, for its part, has created a behavioral health ombudsperson and its attorney general’s office has reached several settlements with carriers and created a hotline for consumer complaints.89 While indicators besides consumer reports would better inform parity, states should follow the lead of New York in creating pathways for consumers to report their struggles accessing care and make these channels easily accessible to consumers.

The MHPAEA parity regulations must be paired with robust enforcement of consumer protections. Regulators should investigate insurance plans that do not comply with the full scope of parity and penalize them where appropriate. This includes preventive care with no cost sharing, annual behavioral health checkups, adequate networks, and no difference between behavioral health and other health services in terms of nonquantitative and quantitative treatment limits.

The aforementioned GAO report questioned whether targeted parity reviews, in which the DOL and HHS only investigate plans for violations of parity if they receive a consumer complaint or other information, were sufficient in determining parity.90 An alternative approach would be for these agencies to set several standards and investigate insurance plans that do not meet these standards. For example, reviewers could monitor the ratio of out-of-network payments to in-network payments for behavioral health providers compared with those of other specialty providers. If the ratios differ beyond a certain threshold, an investigation into the parity of a plan would be warranted. Additionally, regulators could determine a band within which utilization rates should fall for behavioral health services. Utilization rates below the band would trigger an investigation into parity violations.

If an investigation triggered by failing to meet these standards found a plan in violation of parity, the plan would have to correct these parity violations and could face additional financial penalties. For example, the Pennsylvania Insurance Department found UnitedHealthcare to be in violation of several elements of the MHPAEA.91 As a result, it imposed $1 million in civil penalties and agreed to fund a $800,000 public outreach campaign. As a state government agency ramping up efforts to oversee and enforce the MHPAEA, the Pennsylvania Insurance Department should serve as a model for other state governments looking to hold insurers accountable.

Increase payments to providers

In theory, adequately enforcing parity regulations and network adequacy standards should drive insurers to more fairly calculate their provider payment rates to encourage providers to join networks. Medicare sets payment rates based on complexity, which disadvantages nonprocedural services, including many behavioral health services.92 Increased behavioral health payment rates for Medicare, Medicaid, and private payers are needed to incentivize network and workforce participation.

Increased behavioral health payment rates for Medicare, Medicaid, and private payers are needed to incentivize network and workforce participation.

States should increase their Medicaid rates to mental health providers. The ACA temporarily set primary care rates for Medicaid equal to those of Medicare. In recent years, states have begun to codify these changes in the long term and increase their Medicaid payment rates to providers for services that treat substance use disorders. A GAO report found that 80 percent of states increased payment rates for at least one SUD service from 2014 to 2019.93 State officials reported that these rate increases contributed to greater SUD provider participation in Medicaid.

For example, in 2017, Virginia increased its reimbursement rates for SUD services for Medicaid recipients to encourage providers to accept Medicaid for people affected by the opioid epidemic.94 This strategy was quite successful: There was a 69 percent increase in Medicaid recipients accessing opioid use disorder treatment and a 25 percent decrease in opioid-related emergency department visits.95 In fact, the program worked so well that the Virginia government decided to expand Medicaid reimbursement rate increases to 80 percent of Medicare rates for other services, such as primary and pediatric care.96


Despite advancements toward mental health parity and state initiatives, mental health and substance use services remain inaccessible for millions of Americans who need them.

Policymakers have key tools at their disposal to promote timely and accessible mental health treatment options. By creating pathways for affordable initial treatment, limiting patient cost sharing, enforcing network adequacy provisions, and increasing payments to providers, policymakers and regulating bodies can take steps toward ensuring behavioral health care access and affordability.


The author would like to thank Richard Frank, Maura Calsyn, Emily Gee, Jill Rosenthal, and Azza Altiraifi for their input and guidance, as well as the Criminal Justice Reform, Disability Justice Initiative, LGBTQI+ Research and Communications Project, Poverty to Prosperity, and Women’s Initiative teams at the Center for American Progress for their thoughtful feedback.

Balls and beautillions, long a tradition of the marrying Black middle class in Maryland, carry on with a new purpose

Dr. Camille Hammond beamed with pride as she watched her 17-year-old sons in the throng at the ballroom of the Marriott Baltimore Waterfront. This spring day was when Kai and Aaron completed their “beautillion” process. That’s when, for her, they became men.

“I feel like they got a little older that evening. I heard them say, ‘I’m a man now,’” said Hammond, a physician who lives in Reisterstown.


A beautillion for young men, like a cotillion or a debutante ball for young women, is a rite of passage that formally presents teenagers to society as adults. While many teens mark that milestone on a graduation stage or at a school prom, a group of Black Marylanders has its own traditions.

These events have been carried on for generations, particularly among middle-class and affluent Black families. They began as a way to introduce young people to potential spouses. They have evolved into building professional networks and long-lasting social circles, and they’ve provided ways to connect Black students who can feel isolated in suburban and private schools with one another.


The process usually involves months of mentorship, dance lessons, etiquette classes and service projects. For instance, the beautillion that the Hammonds took part in cost $1,000 per participant and the process began in September.

Although some students participate grudgingly, almost all tout the benefits of the system. Aaron Hammond, a junior at Gerstell Academy in Finksburg, was apprehensive about the process — particularly regarding learning some of the formal dances performed during the beautillion.

“I was kind of passive-aggressive. To think that I was acting like that — and the dances were the most memorable part of the night,” he said. “I guess it was kind of worth it to go through all the pain, if you will, to learn the dances and be annoyed, to dance with family and friends.”

While rooted in the South, Black cotillions and debutante balls can be found throughout the country — especially in places with active Black fraternities, sororities and other service-based social clubs.

For example, the April 23 beautillion the Hammonds participated in was hosted by Jack and Jill of America Inc., a group founded in 1938 by Black American mothers with the goal of bringing together their children for social and cultural enrichment. A June debutante ball will be hosted by the Baltimore County chapter of Alpha Kappa Alpha Inc., the nation’s first Black sorority.

Jack and Jill children typically attend private or suburban schools, which often lack diversity, making these activities and traditions necessary, according to Camille Hammond.

“I wanted them to connect with other kids of a similar background,” she said.

Hammond, who went through the debutante process growing up in Richmond, Virginia, wanted her children to experience it. She also wanted to make sure her offspring — who were enrolled in Jack and Jill at age 4 — were exposed to like-minded children who valued Black excellence.


Beautillions and cotillions remain an important part of Black society, according to Lynn M. Selby, a lifestyle expert and executive director of the Caroline Center, an education and career skills training program in Baltimore. She also teaches etiquette classes to Black high school students and is a member of several Black social and service organizations, such as Delta Sigma Theta and The Links, Incorporated.

“It allows young people early on to prepare for the corporate environment, how to learn proper etiquette, how do you network, meet and make small talk,” she said.

“I know some people will say these are ‘bourgeoisie Black people.’ But there is more value than that,” Selby said. “It has evolved some beyond arranged marriages.”

Although the origin of debutante balls was to foster future marriages, current organizers and participants say the mission has evolved. Now, these events prepare people for the realities of the world — from how to safely interact with police officers to how to play golf.

“Now, in African American culture, the goal of debutante cotillions is to prepare you for [higher] education and pushing you in that direction,” said Alana Younger, 17, a senior at George Washington Carver Center for Arts and Technology in Towson.

Alana will make her debut in early June at the Precious Pearls Debutante Cotillion, thrown by the Upsilon Epsilon Omega chapter of Alpha Kappa Alpha Sorority.


“I am glad it has changed. As a young lady, having the idea of marriage pushed on you sends the wrong message,” Alana said. “Education is one of the most important things that young women should be taught.”

Alana has been impressed with the workshops and community service requirements.

“They taught us a lot about navigating life after high school — realizing that we will be in the real world after this,” she said.

Alana, who plans to study nursing at Coppin State University, also values professional connections she made at the workshops and remains in contact with the health care professionals she met.

Kai Hammond, a junior at the Carver Center, said the beautillion “went above my expectations.”

“It’s important because all around you is just Black excellence. Everyone had scholarships to college, whether it was athletics or academic,” he said.


Aaron Hammond said he would recommend the process to other students.

“Honestly, I would, so that they can have the experience about being around other African Americans who are doing great things,” he said.

Aaron’s most memorable part of the process was a “Millionaire Manners” etiquette workshop.

“It was a great refresher from what our parents taught us,” he recalled.

Selby knows that some might criticize the training as encouraging students to play the game of respectability politics and conform to white cultural practices.

“I think there is something to be said for authenticity. They are not asking them not to be their authentic selves,” Selby said. “But there are still societal norms. If you don’t believe in that, you will be sadly mistaken. You can’t go to the law firm dinner having your elbows on the table or slurping soup.”


Alana enjoyed the process of meeting the other debutantes, none of who went to her school.

“I feel like I have built a sisterhood and a bond,” she said. “It has opened me up to other lifestyles and other people — people who are interested in some of the same things I am. Hearing their stories pushes me harder.”

Thinking of the future, Alana added: “I would want all of my children to be a part of something like this. It has changed my perspective on a lot [of things]. These are all things that teenagers need.”

Kai and Aaron’s father, Dr. Jason Hammond, valued the interaction that his sons have had with the other beaus.

“We’ve been able to see their growth,” he said. “They’ve matured.”

Hammond, who did not go through a beautillion process growing up, now sees its value.


“It has been really illuminating,” said Hammond, who is a physician like his wife.

Kai and Aaron’s sister, Simone Hammond, will participate in a cotillion in the fall. “The beautillion made me a lot more excited for the cotillion. That community and environment is one I’m not part of as much as I would like,” Simone said.

Simone, also a junior at Gerstell Academy, said she plans to expose any future sons and daughters to the process.

“It was a fantastic experience,” she said. “I hope a lot more Black kids get to hear about it and experience it. It does take up a lot of time, but it’s worth it.”

Kelly Mason’s two sons, Jordan and Cole, went through the beautillion process. At the beginning, she was more excited than they were, but by the end, they realized the benefits.

“I knew it was the last time I had time with that child before they went to college,” the Columbia resident said. “They did it willingly, but begrudgingly. By the end, you could see the group becoming more accepting.”


The night of the beautillion, she knew her elder son, Jordan, was hooked.

“He looked like he was having so much fun. I had never seen my son dance before,” she said.

For Mason, Jack and Jill and the balls reinforced a sense of self for her children — particularly as they felt isolated in predominantly white spaces, such as suburban schools.

“I just think it is a great place for your kids. We all want to expose them to the best they can do. I remember my daughter wanted her hair to be blond at 5; there weren’t other Black girls around,” Mason said. Daughter Brooke was later an escort at a beautillion, and now attends Spelman College, a historically Black institution in Atlanta.

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The tradition of the beautillion ultimately carried over to Mason’s children attending historically Black colleges and universities.

“Once they applied and visited, it was a done deal. Having them be in that type of group, it was a camaraderie that they felt when they went to an HBCU, as well,” she explained.


Three of Cynthia Bell’s four children have participated in a beautillion, whether as a beau or a dance escort. Her youngest son will participate next year, according to Bell, the president of the Columbia chapter of Jack and Jill. The chapter has hosted biannual beautillions since 1983, and 300 male teens have gone through the process.

“It’s an outstanding program that focuses on leadership, life and cultural exposure, and philanthropic giving,” said the Clarksville resident.

Bell added: “It just gives you so much hope for the future. You hear so much bad in the African American community. This shines a positive light on what our men are doing in the community.”

Camille Hammond pointed out the ultimate results of the debutante process: guests throughout the ballroom who are politicians, doctors, judges and college presidents.

“These are the people of our community,” she said. “These kids are all going to college. Their biggest worry is getting a C on a test. Regardless of what everyone else is doing, this is our reality. This is to be celebrated.”

St. Anselm’s senior travels to serve people in the Congo

For Walter Heiser, a graduating senior at St. Anselm’s Abbey School in Washington, D.C., a recent trip to the Democratic Republic of the Congo gave him the opportunity to live out his faith and practice what he has learned at his school.

The visit to the Central African nation to work with a non-profit organization providing accessible health care in remote areas, Heiser said, was “a memorable service opportunity… (where) I exhibited love through my actions.”

“I love rendering service to others in my community and in the world because I know that service is a form of love of neighbor, and that when I am in the service of my fellow man, I am in the service of my God,” he said. “My St. Anselm’s education has reinforced the importance of serving others in my life.”

St. Anselm’s is a Benedictine-sponsored, all-boys school for students in the sixth through 12th grades. Heiser is the son of Marie-Stella Heiser and is a member of St. John Neumann Parish in Gaithersburg, Maryland. At his parish, he is active in St. Vincent de Paul Society, distributing food to the less fortunate.

An American of Congolese origin, Heiser said he felt called to serve there because “the people of the Congo are my brothers and sisters, and giving back to the people in need is the least that I can do to pay homage to my motherland.”

While in the Congo, Heiser helped to paint a health care center, and gave a demonstration about environmental safety to children. One of the children in the village touched his heart and Heiser helped that young man with his education.

Heiser recalled that one day in the village of Kinzau, he saw a young boy about 13 years old walking back from the school building by himself. Since it was the middle of the day, all the other children were at school.

“I asked him why he was not with the rest of his peers, and he said because he could not pay his last trimester’s tuition,” Heiser said. “I asked him how much it was, and he told me 6,000 Congolese Francs, which converts to a mere $2 U.S. dollars. I had spare pocket change and decided to pay for the boy’s tuition.”

That experience not only changed the young boy’s life, but Heiser’s as well.

“I had a much-needed epiphany that revealed how valuable the little money we waste on mundane futilities here in the western world is to communities in rural, impoverished communities,” he said. “I believe that everyone deserves to pursue their dreams, attain their goals, and live comfortably.”

He said he wanted to make sure the young boy continued his schooling because “knowledge is power and sets us free. With a solid education, anyone can teach others the crucial values needed to improve the world.”

When he returned to St. Anselm’s, he shared his experiences with his fellow students.

“I explained to them how my perception on life shifted when I was in the midst of the rural villages as one American teenager. I explained the story of the schoolboy and how his tuition is something that here in the U.S.A. we take for granted,” Heiser said.

He said that in addition to telling the students and faculty about the poverty he encountered in the Congo, he also made them aware of “the beauty of the country – the landscape, food and culture.”

“I also made sure to emphasize that in the Congo even though they do not wield much material wealth, they have the wealth of humanity. They do not have much, but at least they have each other,” he said, adding that he “reinforced the notion of loving our neighbor.”

After the talk, Heiser said, “multiple students and faculty members approached me asking how they could contribute to the efforts in the Congo. It brought me great joy to see how eager they were willing to serve a people not of their own and of a distant land.”

Among his favorite classes during his four years at St. Anselm’s, Heiser includes Arabic language classes, Christian ethics, and African-American literature.  Outside of the classroom, he was a trumpeter in the Jazz Club, spirit director of the InterHouse Council, and a member of the Model UN, the history and chess club and the Arabic Honor Society. He was also a junior varsity member of the school’s soccer, basketball, track and lacrosse teams.

In the fall, Heiser will attend New York University on a Liberal Studies Scholarship and Global Pathways Scholarship. He plans to eventually major in international relations and public policy.

Speaking of how his faith influences his life and his future career, Heiser said, “The second greatest commandment that God gives us is to love our neighbors as we love ourselves. Service and charity are both forms of loving thy neighbor. I see all humans as equal no matter their ethnicity or socioeconomic status. We are one family under God.”

Walter Heiser holds a baby at a health care clinic in a remote village in the Congo. The St. Anselm’s graduating senior traveled to that nation to “give back to the people in need.” (Photo courtesy of Walter Heiser)

Anti-fatness in the Surgical Setting

It was 6:30 A.M., and I was getting ready to head down to the operating room (OR) for the first case of the day: an abdominal wall hernia repair. In preparation for the case, I logged on to the electronic health record portal and read through the patient’s medical history and the preoperative notes written by the surgical team. In many of the physician notes, the first line noted the patient’s body mass index (BMI) of 41. The patient’s ventral hernia was estimated to be 30 centimeters by 20 cm, one of the largest hernias ever repaired by the surgeon I was working with. The CT scan showed sections of the large intestine protruding through the hernia, which posed a high risk for bowel twisting, which can lead to perforation and sepsis or tissue deoxygenation and necrosis. The patient’s condition had reached a critical point.

I ventured down to the OR and located the CT and MRI images, as part of my medical student role of assisting the nursing and scrub technicians in prepping the OR prior to surgery. I projected the scans onto the large screen TVs hanging in the OR to help the surgeons better visualize the anatomy and their approach. As I pulled up the images, the team in the room erupted in shock. How could someone let a hernia get this bad before seeking medical consultation, they wondered. And others couldn’t believe that someone could live with such a large defect and not want it fixed for cosmetic purposes. After rolling the patient into the OR and moving her onto the operating table, the team began to prep the surgical site. As she drifted off into a state of sedation, medical staff in the room could not stop talking about her BMI. The comments were unrelenting throughout the five-hour procedure, as people took turns gawking at the gaping hole in the patient’s abdomen. Two of the largest pieces of Strattice biologic mesh made by the supplier were sewn together to repair the hernia. The estimated cost of the mesh alone was $30,000.

As the surgery ended, I couldn’t stop thinking about the obvious, yet ironic, connection between the weight comments from the health care team and why the patient procrastinated before getting the surgery. Why would anyone want to interact with a medical system that looked at them in such a derogatory way?

Anti-fatness is socially ingrained and virtually inescapable. Pop culture idolizes thinness. The Centers for Disease Control and Prevention created an alarmist “obesity epidemic” based on exaggerated data that haven’t held up. Like everyone else in society who is socially conditioned to this bias, clinicians are not exempt from harboring anti-fatness. In a recent study, 24 percent of physicians stated they were uncomfortable having friends in larger bodies, and 18 percent admitted they felt disgusted when treating a patient with a high BMI. This is upsetting, yet unsurprising considering that few programs actively train health care providers against this cognitive bias.

Abundant research demonstrates that “obesity” is not really a choice and is often a product of systemic inequity. The crux of this research explores the multiple systems that underpin weight: food insecurity, housing insecurity, poverty-induced scarcity mindset, medications, diseases, lack of education, mental health issues and chronic stress among them.

Many researchers and scholars have exposed the pervasiveness of anti-fatness culture, but some of the most prominent actors in maintaining this culture have not been discussed. Surgeons are central to dismantling the problems of anti-fat bias in health care, and that requires addressing aspects of surgeons’ training and day-to-day tasks that may make them more prone to this cognitive bias.

Weight bias is heightened and reinforced in the surgical setting, where surgeries on higher BMI individuals take more time, cost more money and have an increased risk of complications. Anti-fatness attitudes and behaviors may be higher among surgeons partly as a result of the lack of filter people may have when the patient is sedated. The increased time and care required in these cases can be difficult for surgeons, whose time and care are already strained given staff shortages. Together, these factors may lead surgeons to express their frustration through comments about the patient’s body.

In addition, professional culture and training are different for surgeons. Primary care physicians’ training may focus more on upstream factors contributing to care, including being taught about social determinants of health and multifactorial causes of the patients’ conditions. In contrast, surgeons—who on average spend 3,963 hours of training honing a complex motor and visuospatial skill may naturally focus more on the procedural task at hand rather than the factors contributing to their patient’s condition. Ultimately, the everyday demands of a surgeon’s job may make them less likely to think critically about anti-fatness when providing their day-to-day care. Yet, to provide optimal patient care, it is equally important for surgeons to work against weight stigma.

Surgeons are often the physicians who spend the most time in the hospital. As such, they play a vital role in forming the culture in the OR and hospital at large, and their understanding of weight bias and its associated behaviors is critical to counteracting pervasive weight stigma among health care providers. Post-surgery, many higher-weight patients will require intensive care, continual follow-up and long-term treatment adherence. Patients with a higher weight are also 12 times more likely to have a complication requiring extended hospitalization and continued interface with their surgical team. Surgeons must confront their own weight bias to build positive ongoing partnerships with patients.

A culture of anti-fatness among surgeons leads to compounding negative impacts on individual patients and the health system. Studies show weight bias from providers is palpable for patients. Patients can sense the lack of dignity and respect in providers’ attitudes and, in turn, may choose not to interact with the system that degrades them. Many clinicians turn weight loss into an ultimatum for patients rather than focusing on building their trust, understanding contributing factors and partnering with them to make incremental lifestyle modifications possible. Altogether this can harm patients’ self-worth and rapport with providers.

When providers alienate patients who first touch the health care system, through poor care or rapport, these patients are more likely to not resurface until reaching a critical health point, as with the hernia repair case discussed above. Research suggests that providers spend less time with larger patients, provide a lower quality of care and misdiagnose larger patients more frequently.

Anti-fatness is often a more socially acceptable masquerade for anti-Blackness. The Department of Health and Human Services reports that about four out of five African American women are overweight or obese, and Black Americans were 1.3 times more likely to be obese compared to white Americans. This intersection allows covert ways to harm Black and brown bodies.

Ultimately, the biases and behaviors that maintain anti-fatness need to change. Potential avenues for change include creating systemwide education, amending medical documentation, reframing patient conversations and advocating for upstream policies that increase access. A health provider’s goal should be health—vital statistics, lab results, symptom reduction, time spent exercising, mental health—not thinness. There are health consequences to obesity, but the current BMI-focused approach is not the best way to capture a person’s current health status. Lack of education among medical professionals is perpetuating anti-fatness. A health systemwide training should be developed to educate health care providers and shift conscious and unconscious attitudes.

Providers should also make a habit of noting diet and exercise in social history, as opposed to collapsing these factors into BMI. They could partner with patients and connect them with community resources to enable them to meet their health goals of lower blood pressure or better cardiovascular health. Providers can also focus on evidence-based methods, such as educating patients about nutrition, increasing access to food or exercise, discussing weight-loss surgery or medication and employing motivational interviewing. Understanding the multifactorial nature of weight and taking a patient-centered approach early on can ensure patients feel supported and empowered to achieve optimal health outcomes. This affirmative type of partnership will encourage patients to return to the health care system and invest in the provider-patient relationship and health goals. Providers must internalize the complexity of weight, learn how to utilize alternative health markers and even advocate for policies that reduce food deserts. Surgeons may read the above action items and write them off as tasks reserved for primary care physicians. But practicing unbiased medicine is possible. In one promising model, hospitals in Canada have recently launched a surgical prehabilitation program and toolkit that helps surgeons and their patients work on hypertension, hyperglycemia, hyperlipidemia and cardiovascular health.

Recent movements around self-love and body acceptance are important, but they cannot replace the work that needs to be done by the people who manifest anti-fatness bias. America does not have an obesity epidemic; it has an unhealthiness epidemic. Yet the worse health outcomes compared to countries with similar economies are just as much a product of anti-fatness as they are of fatness. Through shame and blame, anti-fatness may be contributing to obesity and exacerbating poor health. Until surgeons and other health care providers choose to be a part of the solution to anti-fatness, then they will be part of the problem.

How Black-owned private equity firm Red Arts Capital spreads the wealth from supply chain investments

  • Nicholas Antoine and Chad Strader founded Red Arts Capital in 2015.
  • The Black-owned private equity firm targets supply-chain investments in trucking and logistics.
  • In October, the firm set out to raise its first institutional fund, worth up to $225 million.

When Nicholas Antoine and Chad Strader first met at the Starbucks on Michigan Avenue in Chicago, they dissected the book ‘Why Should White Guys Have All the Fun?’

The book — by Reginald Lewis, the first Black man to execute a $1 billion leveraged buyout in the US — had a firm hold on Antoine and Strader, who hatched a plan together to do something few Black people have done in the US. They would start a private-equity firm.

“There really aren’t that many Black-owned investment businesses period. And 100% Black-owned private equity firms? You can count on two hands,” Antoine told Insider in an interview.

The pair founded Red Arts Capital in 2015, and is currently raising a new fund of up to $225 million, adding dollars to what is currently an extremely small pot.

Women and minority-owned private-equity firms accounted for just 6% of the total capital raised in the US in 2021, according to Fairview Capital’s annual Market Review of Woman and Minority-Owned Private Equity and Venture Capital Firms. That may be changing: Fairview reported a 25% uptick in the number of women and minority-owned private-equity firms from 2020 to 2021, with the number now totaling 627 firms in the US.

African-American investment firms are growing in number too, albeit from a relatively low starting point. The number of Black-led US venture capital and private-equity firms raising money in 2021 rose 25% from the previous year, reaching 84 firms, according to Fairview.

But just 15% of those Black-led investment firms execute buyout strategies like Red Arts — a fraction of the private-equity pie dominated by outfits helmed by white men. These figures also only include firms led by Black people, not necessarily Black-owned firms. Antoine told Insider he wants to expand that very small club.

“Diversity is so important in finance, and there’s so little of it,” he said.

Antoine has spent time with top Chicago investment luminaries like John Rogers, Chairman of Chicago’s Ariel Investments. But the first business role model he brings up is his father.

“He was being entrepreneurial just for coming here. But he was also an entrepreneur,” Antoine said about his father, an immigrant from Trinidad and Tobago, who built and sold a restaurant business in New Jersey. “I always wanted to be like him.”

Strader similarly grew up with a family auto-repair business in Augusta, Georgia. He ended up planning Pepsi’s supply chain, a position that exposed him to the transportation industry and formed the basis of Red Arts’ investment thesis.

Niche players by design

Specializing was part of the plan from that first meeting, and Strader told Insider his supply chain background helped the pair identify transportation and logistics as an investment area with plenty of opportunity and relatively few dedicated players.

“I think we’re kind of hardwired to be contrarians in terms of our thinking and there’s a lot of focus right now on technology and health care,” said Antoine. “We were looking at businesses and thinking about industries where there was an under-appreciation for the value they were providing to the economy and to society.”

A bench of advisors also contribute subject matter expertise, including former Universal Logistics CEO Jeff Rogers and Herb Shear, former President of Genco, which was acquired by FedEx in 2014.

Rogers, a long-time operator in the trucking industry, said Antoine and Strader take an unusual approach to buyouts, in that they want both sides to come out satisfied.

“There’s not a lot of win-win with PE in my mind sometimes. So that’s why I like those guys,” Rogers told Insider. 

Riding the supply chain wave

Red Arts has made five acquisitions with two exits so far. Its investments are in the third-party logistics and less-than-truckload spaces, both of which have benefited from the pandemic-driven boost in e-commerce.

“We always had an idea about e-commerce and LTL but I would say the last two years have accelerated that tremendously. LTL freight volumes have increased. The size of the average shipment, the average weight, all of those dimensions have increased. And that’s a big part of the strategy,” Strader said. Red Arts sold LTL firm Midwest Motor Express to Knight Swift Transportation for $150 million in December in what Strader said was a nearly 8X return for investors. The sale was the firm’s second exit in 2021.

Supply chain buyouts have reached a turning point recently, according to Antoine. Smart transportation investors are less likely to buy a company simply to strip it for parts.

“The industry has become a lot more efficient, a lot more competitive,” Antoine said. “That means that financial engineering is less of a tool to create value for investors. It requires more expertise, more planning, and thoughtfulness,” he said.

A mission of wealth creation

On top of financial returns, Antoine and Strader look to spread wealth among demographics that are often left out of private equity deals, by maintaining a keen awareness of the diversity of a management team at the moment of acquisition, and attempting to improve it before exit.

Current investment Sunset Pacific Transportation, an specialty logistics firm based in California, had a nearly all white and male management team when Red Arts took over in March 2021. Today four of the five-person management team could be considered diverse, considering race and gender.

“Four women are going to receive significant proceeds when we exit the deal. That’s very different than what it was prior to our ownership,” Strader said.

NEWS GLEAMS: Last Call for Our Reader Survey, 72-Hour Parking Rule Resumes, & More

curated by Emerald Editors

A round-up of news and announcements we don’t want to get lost in the fast-churning news cycle!

✨Gleaming This Week✨

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Annual Community BBQ

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Mohammed Ahmed smiles as he receives his COVID-19 vaccine at an ICHS pop-up vaccine clinic at the Redmond Islamic Center on March 30, 2021. Photo courtesy of ICHS.

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Mohammed Ahmed smiles as he receives his COVID-19 vaccine at an ICHS pop-up vaccine clinic at the Redmond Islamic Center on March 30, 2021. Photo courtesy of ICHS.

HealthierHere and Public Health – Seattle & King County Award $2 Million to 28 Organizations to Advance Health Literacy

On May 27, HealthierHere and Public Health – Seattle & King County (Public Health) announced 28 local organizations that will receive a total of $2 million in funding as part of the King County Health Literacy Project. The partnership between HealthierHere and Public Health aims to improve public health messaging developed by and for communities most affected by the COVID-19 pandemic.

The Health Literacy Project is funded through a financial assistance award from the federal Health and Human Services Office of Minority Health. Recipients include 26 community-based organizations and two Federally Qualified Health Centers. Over the next 14 months, partners will improve the systems for developing and disseminating culturally and linguistically responsive information about COVID-19.

In King County, rates of COVID-19 have been two to five times higher among American Indian/Alaska Native, Black/African American, Latinx, and Native Hawaiian/Pacific Islander residents compared to non-Hispanic white residents. The Health Literacy Project focuses on South Seattle and south King County — areas with high proportions of People of Color and low-income residents disproportionately impacted by COVID-19.

Recipients will work closely with HealthierHere and Public Health to codesign a Health Literacy Training curriculum, Health Literacy and Sustainability Plan, participate in project evaluation, and co-facilitate health literacy training sessions at Public Health and in health care settings. The project is currently funded through July of 2023.

The Health Literacy Project plans to partner with:

*Twelve organizations will also serve as “Advisory Group Participants,” helping to steer the project’s design, implementation, evaluation, and accountability.

More information can be found on

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New King County Study Shows Imported Aluminum Cookpots May Pose Serious Risk for Lead Poisoning

The Hazardous Waste Management Program (Haz Waste Program) works with local partners to reduce exposures to prevent lead poisoning. They provide in-home environmental assessments to newly arrived refugee families to identify sources of possible lead exposure. Through working with the Afghan Health Initiative, the Haz Waste Program Research Team discovered that aluminum cookpots and pressure cookers often brought to the U.S. from Afghanistan may be a source of lead exposure.

The study, done in collaboration with the Department of Environmental and Occupational Health Sciences at the University of Washington, revealed that several aluminum cookpots released enough lead under simulated cooking and storage conditions to present a significant risk for lead poisoning. The findings, which may have a negative impact on brain development for children and people who are pregnant or breastfeeding, were published this month in the Journal of Exposure Science and Environmental Epidemiology.

Researchers found in further tests that stainless steel cookpots and pressure cookers contain much lower lead levels and are safer alternatives. Aluminum cookware that is certified by NSF International also contains low levels of lead and other toxic chemicals.

Further details around potential no-cost or low-cost solutions can be found on Haz Waste Program’s website and press release.

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Parking Enforcement

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Image is attributed to Mack Male (under a Creative Commons, CC BY-SA 2.0 license).

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Image is attributed to Mack Male (under a Creative Commons, CC BY-SA 2.0 license).

Seattle Resumes Full Enforcement of 72-Hour Parking Rule for Vehicle Owners

As of May 13, the City of Seattle has begun resuming full parking enforcement for all vehicles that have remained unmoved for longer than 72 hours, as Seattle Municipal Code does not allow a person to park a vehicle on the same block of a city street for longer than that period of time.

This change is a return to the prior standards which were temporarily paused in March 2020 due to COVID-19 public health guidelines. While full enforcement is resuming now, parking enforcement officers will continue to provide official warning notifications on vehicles, allowing owners and occupants to move them before enforcement occurs. If it appears that people may be living in one of the vehicles, they will receive information about assistance, support services, and resources.

To avoid possible warnings and citations, vehicle owners are encouraged to regularly move their vehicles, as well as check their blocks for temporary parking restriction signs.

If a car is towed from a public street, instructions to locate the vehicle and documents required to release your vehicle will be available online. Vehicle owners should find and reclaim their vehicles by calling Lincoln Towing at 206-364-2000 or search for the vehicle on Lincoln Towing’s website.

If a car was towed from a private parking lot, vehicle owners are encouraged to look for posted signs and phone numbers for the tow companies which may operate the lot. Those who cannot locate their vehicles should call the Community Safety and Communications Center at 206-625-5011.

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Image created by Henry Behrens.

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Image created by Henry Behrens.

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Keeping Score: Spain to Offer Paid Menstrual Leave; U.S. Soccer Teams Score Pay Equity; Taliban Dissolves Human Rights Commission

In every issue of Ms., we track research on our progress in the fight for equality, catalogue can’t-miss quotes from feminist voices and keep tabs on the feminist movement’s many milestones. We’re Keeping Score online, too—in in this biweekly round-up.

Lest We Forget

As a nation, we have to ask: When in God’s name are we going to stand up to the gun lobby? When in God’s name will we do what we all know in our gut needs to be done?

—President Biden on the school shooting in Uvalde, Texas

Community members gather at the Uvalde Town Square for a prayer vigil in the wake of a mass shooting at Robb Elementary School on May 24, 2022 in Uvalde, Texas. (Jordan Vonderhaar / Getty Images)

“What are we doing? Days after a shooter walked into a grocery store to gun down African American patrons, we have another Sandy Hook on our hands. What are we doing?”

—Sen. Chris Murphy, a Democrat from Connecticut representing the district of Sandy Hook Elementary

We know that the state of Oklahoma is keen on punishing and criminalizing people for their pregnancy outcomes, specifically people from communities who are always under the white supremacist scrutiny of the state: Black people, Indigenous people, and people of color. …

Today I’m thinking about all of the Oklahomans I’ve provided abortion care for over the last many months. I’m thinking about how they were making decisions with their communities, families, and futures in mind. I’m thinking about everyone like them who will now be forced to either leave their community or have a forced pregnancy and forced birth. This is not freedom.”

—Planned Parenthood abortion care provider and fellow with Physicians for Reproductive Health Dr. Iman Alsaden on the Oklahoma legislature’s recent passage of a total abortion ban starting at fertilization. It was modeled on Texas’s S.B. 8, and is the strictest abortion restriction in the nation.

“Once again—as fundamental rights are at risk at the Supreme Court—Senate Republicans have blocked passage of the Women’s Health Protection Act, a bill that affirmatively protects access to reproductive health care. This failure to act comes at a time when women’s constitutional rights are under unprecedented attack—and it runs counter to the will of the majority of American people.

Republicans in Congress—not one of whom voted for this bill—have chosen to stand in the way of Americans’ rights to make the most personal decisions about their own bodies, families and lives.”

—President Joe Biden in a statement on the Women’s Health Protection Act, which would have enshrined federal abortion protections in the absence of Roe v. Wade.

A rally in support of abortion rights outside the Oklahoma state legislature in April 2012. (Serena Blaiz / Flickr)

“The horrific and despicable act of terror committed by a white supremacist this past weekend in Buffalo showed that we as a country are facing an intersection of two crises: the mainstreaming of hate speech—including white nationalism, racism and white supremacy—and the easy access to military-style weapons and magazines. This is a wake-up call and here in New York we are taking strong steps to directly address this deadly threat. … This is white supremacy in this nation at its worst. It’s infecting our society, it’s infecting our nation and now it’s taken members of our family away.”

—New York governor Kathy Hochul (D) in a public response to the racist shooting at a grocery store in Buffalo, New York, which resulted in ten deaths. Two executive orders signed by Hochul call for the creation of a new government unit to prevent domestic terrorism, and require New York police to flag and prevent individuals that may pose a threat from acquiring firearms.

“I am frightened by the course our country seems to be willfully taking. White supremacy is alive and well and it is becoming ever more aggressive, violent, and deadly. Yet, we seem unprepared or unwilling to name, confront, and destroy it once and for all. … I fear that in a week or so, we may return to ‘normal.’ We will rebuke Trumpists and conservatives who embrace Making America Great Again as backwards and uncivil, without confronting that this is no longer about politics. It is about life and death.”

—Rakim H.D. Brooks, president of the Alliance for Justice, in a statement on the Buffalo, N.Y., shooting fueled by racism and prejudice.


+ A bill passed by the Spanish Cabinet would make Spain the first European country to offer paid sick leave to employees with severe menstrual pain, if approved by the Parliament. Workers would have to visit a physician to determine the approximate length of the leave.

+ Economist Lisa Cook was confirmed by the Senate on Tuesday, May 10, becoming the first Black woman to join the Federal Reserve’s board of governors. An initial 50–50 Senate vote required Vice President Kamala Harris to step in as tie-breaker.

+ As a result of pandemic supply-chain interruptions and a major product recall by Abbott Nutrition, parents in the U.S. have struggled to track down available baby formula. The national out-of-stock rate hit 31 percent in April and continued to increase to 40 percent by the end of the month. In some states—includes Texas and Missouri—out-of-stock rates exceeded 50 percent.

On Wednesday, May 18, Biden ordered Defense Department planes to collect formula shipments from abroad, and boosted production by invoking the Defense Production Act.

+ In Louisiana, state legislators proposed a bill that would make abortion an act of homicide, prosecutable in criminal court. It was approved by a House committee, and shares similarities with Oklahoma’s proposed abortion restriction, which considers human life to begin at fertilization.

+ New York, however, is considering a law that would provide financial support to abortion providers to protect reproductive rights for low-income residents and travelers from more restrictive states.

The bill, which would establish the Reproductive Freedom and Equity Program Act, was introduced by state assembly member Jessica González-Rojas (D-East Elmhurst) and state senator Cordell Cleare (D-Harlem).

+ A Texas Supreme Court ruling will allow the state child welfare agency to resume investigating families who pursue gender-affirming care for their transgender children. The Court is entirely Republican, and overturned a prior decision by a lower court to halt the investigations ordered by Governor Greg Abbott (D) after being sued by the ACLU and Lambda Legal on behalf of the family of a transgender teenager.

2021 saw a record-breaking amount of anti-LGBTQ and particularly anti-trans bills. (Ted Eytan / Creative Commons)

+ Since the release of the Supreme Court’s draft decision overturning Roe v. Wade, companies including Starbucks, Amazon, Apple and Microsoft have pledged to cover some costs for their employees who must travel to obtain an abortion. Starbucks employees enrolled in the company’s insurance will be eligible for reimbursement if an abortion is not available within 100 miles.

+ Following a lawsuit by the national women’s soccer team against the U.S. Soccer Federation, the men’s and women’s teams successfully bargained for equal salaries and bonuses. They will even equally split all World Cup bonuses granted by FIFA.

“It’s going to be game-changing for what women’s football looks like in general,” women’s national team forward Margaret Purce told The Washington Post. “It’s historic, and I think it’s going to trigger a lot of other things in the sport, not just in the United States but globally.”

+ After Alabama successfully criminalized gender-affirming care—deeming it a felony punishable by imprisonment for up to 10 years—a federal judge in the state blocked the ban’s enforcement on Friday, May 13, less than a week after its initial passage.

+ “Because these departments were not deemed necessary and were not included in the budget, they have been dissolved,” the Taliban’s deputy spokesperson Innamullah Samangani said of the human rights commission and four other departments established under the nation’s former government.

How We’re Doing

+ A report by the U.S. Interior Department confirmed the deaths of at least 500 Indigenous children in over 400 government-run boarding schools. Officials expect to find even more gravesites in addition to the 50+ gravesites already identified.

“Many children like them never made it back to their homes. Each of those children is a missing family member, a person who was not able to live out their purpose on this Earth because they lost their lives as part of this terrible system,” Interior Secretary Deb Haaland—a grandchild of boarding school survivors—said at a news conference following the report’s release.

+ Public health experts predict an increase of 75,000 births next year due to the Supreme Court’s decision to strike down Roe v. Wade. The spike would exacerbate the U.S.’s already abysmal maternal mortality rate, which increased by 14 percent between 2019 and 2020.

+ The Marshall Plan for Moms released a report which concluded “expanded child care benefits can help companies attract, retain and advance women in the workforce.” By surveying mothers of children ages 0–5, the report found a 69 percent higher likelihood of choosing an employer that offer child care benefits, and 53 percent identified child care as one reason for leaving the workplace or taking on fewer hours.

+ According to a poll of 1,236 voters by Data for Progress, 58 percent wanted the Supreme Court to uphold Roe v. Wade. That statistic increased to 62 percent among women voters, and 78 percent among Democrats.

+ A spike in Google searches for terms like “IUD,” “Plan B,” and other contraceptives was attributed to fear associated with the Supreme Court’s leaked draft opinion that would overturn Roe v. Wade. “Protecting myself by getting an IUD and doing what I can to prevent myself from getting pregnant is at the forefront of my mind right now because of where I live,” said Sydney Phillip, a 26-year-old living in Alabama.

+ Five years after transgender youths’ initial transitions—although 7.3 re-transitioned once or more—only 2.5 percent of youth identified as cisgender. The vast majority—94 percent—identified as binary transgender youth, and 3.5 percent identified as non-binary. Re-transitions following social transitions in childhood are rare, as was concluded by Princeton University researchers as part of the Trans Youth Project.

+ By interviewing 851 people with uteruses—including 35.7 percent between ages 12 and 17—researchers found medication abortion instructions to be highly comprehensible, warranting the pills’ use without medical supervision.

Sign and share Ms.’s relaunched “We Have Had Abortions” petition—whether you yourself have had an abortion, or simply stand in solidarity with those who have—to let the Supreme Court, Congress and the White House know: We will not give up the right to safe, legal, accessible abortion.

Texas governor blames ‘mental health’ for mass shooting murder of at least 19 children and two teachers

This article contains references to family violence.
Texas Governor Greg Abbott has avoided the issue of whether tougher gun laws are needed after at least 19 children and two teachers were murdered by a shooter at a primary school in his state, instead saying it’s a case of improving mental health care.
“We as a state, we as a society, need to do a better job with mental health,” he said at a news conference.


The National Rifle Association (NRA) – a powerful lobby that has been instrumental in thwarting efforts to tighten US gun laws – took a similar tack, saying the shooting was the work of a “lone, deranged criminal.”


Mr Abbott had noted the shooter, identified as 18-year-old Salvador Ramos, did not appear to have any criminal record or history of mental health problems.
Ramos posted on social media that he was going to shoot up a primary school about 15 minutes before his rampage, Mr Abbott said, as harrowing details about the attack continued to emerge.
The high school dropout also wrote a message saying he was going to shoot his grandmother and another one confirming he had done so, Mr Abbott said. His grandmother, whom Ramos shot in the face shortly before attacking the school, survived and called the police.
Ramos fled the home he shared with his grandmother and crashed his car near Robb Elementary School in Uvalde, Texas. He entered the school through a back door carrying an AR-15 assault-style rifle and wearing tactical gear.

He barricaded himself in a fourth-grade classroom, authorities said, and killed students and teachers before he was fatally shot by a US Border Patrol officer, Mr Abbott said. An additional 17 people suffered non-life-threatening injuries.

Texas school shooting mourners carrying flowers.Texas school shooting mourners carrying flowers.

People walk carrying flowers to honour the victims of the shooting at Robb Elementary School in Uvalde in Texas. Source: AP / Jae C. Hong/AP

The online messages were the only advance warning, Mr Abbott said.

Mr Abbott said the posts were made on Facebook, but spokespeople for Facebook’s parent company, Meta Platforms, said they were private messages discovered after the shooting.
The company declined to say who received the messages or which of Meta’s platforms, such as Messenger or Instagram, was used to send them.
Ramos purchased two rifles and 375 rounds of ammunition in March, according to authorities.

The attack, which came 10 days after an avowed white supremacist shot 13 people at a supermarket in a mostly African-American neighbourhood of Buffalo, has reignited a national debate over US gun laws.

In a sign of the charged political atmosphere, Beto O’Rourke, the Democratic gubernatorial candidate challenging Mr Abbott in a November election, interrupted the news conference to confront Abbott for loosening, rather than restricting, the state’s gun laws.
Several officials yelled at Mr O’Rourke, with one calling him a “sick son of a bitch” for allegedly politicising the shooting, though it was not clear who.
Mr O’Rourke was escorted out of the building and spoke to reporters outside, calling it “insane” that an 18-year-old was legally permitted to acquire an AR-15 and vowed to pursue gun limits.
“We can get that done if we had a governor that cared more about the people of Texas than he does this own political career or his fealty to the NRA,” he said, referring to the National Rifle Association, a gun-rights advocacy organisation.

Texas has some of the country’s most permissive firearm laws.

In a prime-time address on Tuesday evening, US President Joe Biden called for new gun safety restrictions.
“As a nation, we have to ask when in God’s name we’re going to stand up to the gun lobby,” he said, his voice rising.
But new legislation appeared unlikely to pass in Washington. Virtually all Republicans in Congress oppose new gun restrictions, citing the US constitution’s guarantee of a right to bear arms, and there was no sign the massacre would alter that position.
White House officials were planning a trip to Texas for Mr Biden, a senior administration official said.
World leaders expressed shock and sympathy. Pope Francis on Wednesday said he was “heartbroken” and called for an end to “the indiscriminate trafficking of weapons.”

The Texas rampage stands as the deadliest US school shooting since a gunman killed 26 people, including 20 children, at Sandy Hook Elementary School in Connecticut in December 2012.

‘I will miss your laugh forever’

Uvalde, a community deep in the state’s Hill Country region about 130 km west of San Antonio, has about 16,000 residents, nearly 80 per cent of them Hispanic or Latino, according to US Census data.
Community members set up fundraisers for the families of the victims to cover funeral costs, while some relatives mourned their losses on social media.
“My little love is now flying high with the angels above,” Angel Garza, whose daughter, Amerie Jo Garza, was killed, wrote on Facebook. “Please don’t take a second for granted. Hug your family. Tell them you love them.”
The two staff members killed were identified as Eva Mireles and Irma Garcia, fourth-grade teachers trapped in the classroom with their students when the shooting began.

“My best friend, my twin was taken from me,” Ms Mireles’ daughter, Adalynn Ruiz, wrote on Facebook. “Everyone who knows you knows how outgoing and funny you were and I will miss your laugh forever.”

Democrats in Washington renewed calls for stronger gun safety laws. US Senator Chris Murphy of Connecticut, a leading advocate on the issue, told reporters: “You know, guns flow in this country like water. And that’s why we have mass shooting after mass shooting.”
The Democratic-controlled US House of Representatives last year passed two bills expanding background checks on firearm purchases. But the legislation has not advanced in the Senate, where at least 10 Republican votes are needed.
Mr Abbott said stricter laws would not prevent violence, citing states such as California and New York that have stringent limits. Instead, he said, the focus should be on mental health treatment and prevention.
If you or someone you know is impacted by family violence, call 1800RESPECT on 1800 737 732 or visit . In an emergency, call 000.
Readers seeking support can contact Lifeline crisis support on 13 11 14, visit  or find an . Resources for young Aboriginal and Torres Strait Islanders can be found at .

The Men’s Referral Service provides advice for men on domestic violence and can be contacted on 1300 766 491. 

Our View: Putting more guns on the street was a choice

In the wake of two more mass shootings, many of us are asking the same anguished questions.

Is it possible that we learned nothing from the 2012 Sandy Hook school massacre, which killed 20 5- and 6-year olds?

Why didn’t the government do anything to protect children from this uniquely American nightmare? How could we let this happen again?

It’s the right reaction, but these are the wrong questions.

It’s not true that we didn’t “do anything”: By choosing not to modernize firearm regulations, Congress accepted the gun lobby’s answer to these tragedies. The only response to gun violence that is acceptable to groups like the National Rifle Association is more guns. And that’s exactly what our government has done.

Over the last decade, federal policy has allowed the number of guns in this country to explode. Annual sales have gone from 19.6 million in 2012 to 39.6 in 2020. Domestic gun manufacturing has nearly tripled since 2000, going from 3.9 million guns a year to 11.3 million.


There are an estimated 400 million civilian-owned guns in America, maybe twice as many as there were on the morning that the Sandy Hook parents dropped their children off at school for the last time.

Congress and state legislators have conducted a massive natural experiment to test the hypothesis that guns protect us from danger. What have we learned?

Simply put, they were wrong. If guns made us safer, we would be safer. But we are not.

We lead the world in gun ownership, but we lead high-income countries in gun murders and suicides.

Mental illness is a problem everywhere. So are substance use disorder and the illegal drug trade that supplies it. Extremist groups spread racist lies wherever they can.

But if you are looking for American exceptionalism, it’s our love of guns.


Every moment of despair has the potential to end in suicide when a person has access to a firearm. Every argument has the potential to end in death when one or more of the participants has a gun. A toddler in Wells was shot to death last weekend when her 19-year-old uncle brought a gun into a dispute with his brother over a T-shirt.

We don’t have more crime than our economic peer nations, but the crimes here are much more likely to end in death.

When it comes to “active shooter” mass murders, like this week’s killings of 19 fourth-graders and two teachers in Ulvade, Texas, or the racist massacre in Buffalo, where a self-radicalized young man targeted African Americans, killing 10, the United States has a near monopoly.

These events make up a small percentage of the total number of gun deaths, but they terrorize millions who have to think twice about shopping for groceries, going to church or dropping their kids off at school. This simply is not a problem anywhere else.

Some will argue that the United States is different because our Constitution expressly protects the right to keep and bear arms from government interference. But the same sentence says the use of weapons should be “well regulated.” You cannot look at multiple murders of schoolchildren and believe that anything about this is “well regulated.”

As we start to see the school pictures of the children who were killed in Uvalde, we should remember that doing nothing after Sandy Hook was a choice.


We could have made it impossible for a teenager to buy a semiautomatic military-style rifle. We could have stopped him from getting high-capacity magazines, body armor (like the Buffalo shooter) or hundreds of rounds of ammunition without raising any questions from authorities.

We could have required a waiting period for gun sales. We could have toughened up the background check system, aligning the mental health prohibition with the reality of today’s health care system.

We could do that now, in the wake of two sickening mass shootings in less than a month.

We could also choose to put more guns in more hands of people who shouldn’t have them, which we know that’s what will happen if we do nothing. That should not be our choice.

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