ISSN 2691-7475 Health Policy Brief September 2020 Serious Psychological Distress on the Rise Among Adults in California D. Imelda Padilla-Frausto, Firooz Kabir, Blanche Wright, Safa Salem, Ann Crawford-Roberts, and Hin Wing Tse ‘‘ Mental health is as important as physical health for overall health and well-being. ’’ SUMMARY: Serious psychological distress (SPD), an indicator of mental illness, is on the rise in California. From 2014 to 2018, the percentage of adults in California with SPD increased by 41.6%, from 7.7% to 10.9%. To understand the upward trend of SPD in California, this brief evaluates the impact percentages of SPD across all years were found among those ages 18–24, female, unemployed and looking for work, with less formal education, low income, publicly insured, and identifying as LGB. These findings support the need for equity-based policies, programs, and services that reduce inequities in education, of the social determinants of mental health employment, income, and health insurance inequities across a five-year period. Upticks coverage. Investment in supports and services in SPD were largest among adults who were for young adults, the LGBTQ community, and ages 18–24, male, employed part-time, Asian, communities at risk for lower socioeconomic and identifying as LGB. Persistently high status are crucial. A ccording to the Centers for Disease Control and Prevention (CDC), mental health is as important as physical Serious psychological distress (SPD), based on the number and frequency of symptoms reported in the past year, is an health for overall health and well-being. Mental estimate of adults within a population health includes emotional, psychological, and who have serious, diagnosable mental social well-being at every stage of life, from health disorders that warrant mental health childhood through adulthood.1 Mental treatment.4 This policy brief reports on illnesses are among the most common causes data from the California Health Interview of disability and can lead to harmful and Survey (CHIS) to examine the trends in long-lasting psychosocial and economic costs. SPD among California adults ages 18 and These costs impact not only the individual older between 2014 and 2018. Descriptive with the illness, but also their families, schools, analyses and policy recommendations are workplaces, and communities.2 Although guided by the conceptual framework on greater efforts have been made toward the social determinants of health inequities prevention and early intervention, a recent (SDHI) by the World Health Organization national study found a statistically significant (WHO). SDHI is made up of the structural increase in mental illness among adults ages determinants of education, income, and 18 and over between 2008 and 2018, with employment and the resulting socioeconomic the percentage of those suffering from mental status of individuals.5 We examined illness during that time period rising from education, income, employment, and 17.7% to 19.1%.3 2 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 1 Percentage of California Adults Ages 18 and Over With Serious Psychological Distress, by Structural Determinants of Mental Health, 2014–2018 Percent Increase 2014 2015 2016 2017 2018 from 2014 to 2018 All Adults, Ages 18 7.7%* 8.6%* 8.0%* 10.0% 10.9% 41.6% and Over Education Less than high school 10.0% 9.9% 8.7% 9.4% 9.7% N/A High school 7.8%* 10.2% 8.9%* 11.2% 12.3% 57.7% Some college 9.7%* 10.7%* 10.5%* 13.7% 14.7% 51.5% College graduate 5.1%* 5.8%* 5.8%* 7.4% 8.4% 64.7% or higher Poverty 0%–99% FPL 12.1% 13.9% 12.5% 13.4% 15.8% N/A 100%–199% FPL 11.3% 10.6% 10.5% 12.3% 12.8% N/A 200%–299% FPL 6.8%* 8.8% 7.8% 11.5% 11.8% 73.5% 300% FPL and higher 4.8%* 5.9%* 5.7%* 7.9% 8.6% 79.2% Insurance Type Public 14.1% 15.3% 13.7% 15.2% 16.1% N/A Uninsured 7.9%* 8.3%* 7.8% 11.8% 12.7% 60.8% Private 6.4% 6.2%* 5.7%* 8.6% 9.6% N/A Medicare 2.5% 3.7% 4.1% 3.5% 3.7% N/A Notes: Difference from 2018 estimates is statistically significant Source: California Health Interview Survey (CHIS) 2014–2018 at *p<.05. Estimates without an * are similar to 2018. ‘‘ From 2014 to 2018, the percentage of adults in California with insurance status as structural determinants, while age groups, gender, gender identity, sexual orientation, and race and ethnicity were examined as populations at risk of a lower socioeconomic status and thus more susceptible to inequities in mental health outcomes. Education Adults ages 18 and over with a college education or higher had the largest increase in SPD (64.7%), from 5.1% in 2014 to 8.4% in 2018, followed by adults with a high school education (57.7%) and adults with some college education (51.5%) (Exhibit 1). SPD increased However, a persistently higher percentage of by 41.6%. ’’ SPD by Education, Poverty, Insurance Type, and Employment Status From 2014 to 2018, the percentage of adults adults with SPD was found among those with less than a college education.6 in California with serious psychological distress Poverty Level (SPD) increased by 41.6%, from 7.7% in Although adults with incomes less than 2014 to 10.9% in 2018 (Exhibit 1). Analyses 200% of the federal poverty level (FPL) had by structural determinants of mental health the highest percentage of SPD across all five show that there are some adult groups that years, adults whose incomes were 200% FPL reported a higher percentage of SPD across or greater had the largest increase in SPD all years, and others that had larger increases during that period. Adults with incomes of in SPD than other adult groups during this 300% FPL or greater had a 79.2% increase in five-year period. SPD, from 4.8% in 2014 to 8.6% in 2018, UCLA CENTER FOR HEALTH POLICY RESEARCH 3 Percentage of California Adults Ages 18 and Over With Serious Psychological Distress, by Exhibit 2 Employment Status and Year, 2014–2018 25.0% 23.5% 19.3% 20.0% 15.5%* 14.8%* 15.0% 14.0%* 13.5% 11.6% 12.2% 10.5% 9.3% 10.2% 10.0% 9.7% 8.4% 9.9% 9.3% 9.0% 6.0%* 6.0%* 7.0%* 6.5%* 5.0% 0.0% 2014 2015 2016 2017 2018 Full-time Part-time Unemployed and looking for work Unemployed and not looking for work Notes: Difference from 2018 estimates is statistically significant Source: California Health Interview Survey (CHIS) 2014–2018 at *p<.05. Estimates without an * are similar to 2018. followed by adults with incomes between 200% and 299% FPL (73.5%) (Exhibit 1). Insurance Type Adults with no insurance had the highest increase in SPD from 2014 to 2018 compared to adults with any health insurance coverage. Employment Status Unemployed adults had the highest percentage of SPD (varying from 14.0% to 23.5%) during this five-year period. The increase in the percentage of adults with SPD was highest (103.3%) among adults who work part time, with the figure rising from 6.0% in ‘‘ The increase in SPD among adults based on employment status was Uninsured adults showed a 60.8% increase 2014 to 12.2% in 2018 (Exhibit 2). Full-time highest among in SPD between 2014 and 2018 (7.9% to employed adults had a 70% increase, and adults part-time 12.7%, respectively) (Exhibit 1). Adults with private insurance had a 50% increase in SPD, from 6.4% in 2014 to 9.6% in 2018. Among who were unemployed and looking for work had a 67.9% increase. workers. ’’ adults covered by public insurance, the SPD by Age, Gender, Gender Identity, percentage with SPD was persistently high Sexual Orientation, and Race and Ethnicity across all five years. Analyses by populations at risk of having a lower socioeconomic status and inequities in mental health outcomes show that there were 4 UCLA CENTER FOR HEALTH POLICY RESEARCH Exhibit 3 Percentage of California Adults Ages 18 and Over With Serious Psychological Distress, by Age Group and Year, 2014–2018 25.0% 23.0% 21.1% 20.0% 14.6%* 14.2%* 15.0% 14.5% 12.7% 10.9%* 11.3%* 10.5%* 10.0% 10.9% 10.0% 8.6%* 8.0%* 8.3%* 7.7%* 8.0% 7.7% 7.4% 7.5% 5.0% 6.1%* 3.5% 3.5% 4.2% 3.7% 3.2% 0.0% 2014 2015 2016 2017 2018 All adults Ages 18–24 Ages 25–39 Ages 40–64 Ages 65 and older Notes: Difference from 2018 estimates is statistically significant Source: California Health Interview Survey (CHIS) 2014–2018 at *p<.05. Estimates without an * are similar to 2018. ‘‘ Adults who self-identified as transgender or gender nonconforming some adult groups with a higher percentage of SPD across all years, and others that had larger increases in SPD from 2014 to 2018. Age Young adults ages 18–24 had the largest increase in SPD from 2014 to 2018. The ages 18 and over showed a 26.0% increase in reported SPD. Gender Identity In 2018, adults who self-identified as transgender or gender nonconforming were almost five times more likely to report were almost five percentage of those with SPD in this age SPD than adults who did not self-identify times more likely group more than doubled, from 11.3% in as transgender (49.7% vs. 10.8%; data not 2014 to 23.0% in 2018 (Exhibit 3). Young shown). Estimates from 2015, 2016, and to report SPD adults also had a persistently high percentage 2017 were not stable, so changes in reported than adults who of SPD in each year. SPD across years could not be examined. did not self- However, the high percentage of SPD among ’’ Gender this population in 2018 warrants attention. identify as such. Among adults ages 18 and over, males experienced a large increase in SPD Sexual Orientation from 2014 to 2018, while females had a Adults who self-identified as gay, lesbian, persistently high percentage of SPD in every homosexual, or bisexual reported higher year. The percentage of adult males reporting overall proportions of SPD, and they had SPD increased by 68.4%, from 5.7% in 2014 the largest increase in SPD from 2015 to to 9.6% in 2018 (Exhibit 4). Adult females 2018 when compared with adults who UCLA CENTER FOR HEALTH POLICY RESEARCH 5 Percentage of California Adults Ages 18 and Over With Serious Psychological Distress, Exhibit 4 by Year and Groups Vulnerable to Structural Determinants of Mental Health Inequities, 2014–2018 Percent Increase 2014 2015 2016 2017 2018 from 2014 to 2018 All Adults, Ages 18 and Over 7.7%* 8.6%* 8.0%* 10.0% 10.9% 41.6% Gender Female 9.6%* 9.4%* 9.2%* 11.4% 12.1% 26.0% Male 5.7%* 7.8%* 6.8%* 8.4% 9.6% 68.4% Sexual Orientation† Gay, lesbian, homosexual, or bisexual N/A 21.5%* 19.2%* 29.0% 31.0% 44.2% Straight or heterosexual N/A 7.9%* 7.5%* 8.8% 9.4% 19.0% Race and Ethnicity Latino 9.8% 9.6% 7.0%* 11.2% 11.6% N/A African American (NL) 5.7% 9.1% 13.7% 8.9% 9.1% N/A White (NL) 7.2%* 8.3%* 8.5%* 9.4% 10.6% 47.2% Asian (NL) 3.4%* 6.6% 6.3% 7.1% 9.2% 170.6% †The two categories for “Sexual Orientation” show the percent Notes: Difference from 2018 estimates is statistically significant increase from 2015 to 2018; there were no data for 2014. at *p<.05. Estimates without an * indicates estimates are similar to 2018. Source: California Health Interview Survey (CHIS) 2014-2018 NL = Non-Latino self-identified as straight or heterosexual. Among adults who identified as gay, lesbian, homosexual, or bisexual, the percentage of reported SPD was 21.5% in 2015 and 31.0% in 2018, a 44.2% increase (Exhibit 4). Race and Ethnicity for addressing the social determinants of health inequities. This section provides a brief summary of the results and policy recommendations for each indicator examined. These indicators are separated into the structural determinants—that is, the interplay between the sociopolitical ‘‘ Asian adults had the largest increase in SPD compared with other Asian adults experienced the largest increase context and the structural and institutional racial and in SPD (170.6%) from 2014 to 2018, although they had the lowest percentages of SPD during this period (3.4%–9.2%) mechanisms that results in the socioeconomic status of individuals—and the populations at risk of lower socioeconomic status and of ’’ ethnic groups. (Exhibit 4). The percentage of non-Latino mental health inequities.6 White adults with SPD increased by 47.2%, from 7.2% in 2014 to 10.6% in 2018. Latino Support Equity-Based Policy Interventions adults showed persistently high percentages to Address the Social Determinants of of SPD across most years. Mental Health Inequities Equity-based policies seek to understand and Summary and Policy Recommendations address the root causes and intersection of Between 2014 and 2018, there were both inequities in education, employment, income, increases in serious psychological distress and health insurance coverage.7 It is imperative (SPD) and persistently high percentages of that policymakers take a multidisciplinary SPD for some populations in California. The approach to intervene in the social following section is framed around the World determinants of mental health inequities. Health Organization’s conceptual framework 6 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ Among age groups, young adults ages 18–24 had the largest increases Structural Determinants Education Adults with less than a college education had a persistently high percentage of SPD between 2014 and 2018. At the same time, adults with a college education or higher •Supporting policies that target services and access to services—in particular, therapeutic services and supports—to adults who are recently unemployed and looking for work Insurance Coverage and most had an increase in SPD larger than that of adults without a college education. Policy Adults with no health insurance had the persistently high recommendations include the following: largest increase in SPD from 2014 to 2018. levels of SPD. ’’ •Reduce inequities in higher education by reducing inequities in: Adults with public or no insurance had a persistently higher percentage of SPD in all years. Policy recommendations include: Quality primary and secondary education •Reducing inequities in: School and district funding Health care coverage High school graduation rates Quality and coverage of mental health College counseling for middle and high services8 school students Access to care and preventive care for The affordability of college and graduate adults with no health insurance school Access to care that is based on insurance Student loans type9 •Reduce inequities in access to mental Health care coverage due to job loss health care in colleges and universities. Populations at risk of lower socioeconomic •Reduce inequities in continuity of care status and mental health inequities or preventive care following college and Age Group graduate school. From 2014 to 2018, the largest increases Income and Employment in SPD were seen among young adults ages Adults with incomes less than 200% FPL 18–24. This group also had a persistently had a persistently higher percentage of SPD high percentage of SPD compared to all between 2014 and 2018, as did adults who other age groups across the five-year time were unemployed and working part time. period. Policy recommendations include the In addition, adults working part time had following: a large increase in SPD from 2014 to 2018. •Reduce socioeconomic inequities among Policy recommendations include: young adults by reducing inequities in •Reducing inequities in: access to higher education, affordable housing, and employment opportunities. Income •Reduce inequities in access to care, Unemployment and underemployment particularly preventive and early Living wages and salaries intervention care, for young adults. Access to care and preventive care for •Support policies that target services and adults who are unemployed, work part access to services, particularly therapeutic time, or have incomes less than 200% FPL services and supports, for young adults. UCLA CENTER FOR HEALTH POLICY RESEARCH 7 Gender While male adults had the largest increase in SPD from 2014 to 2018, female adults had a persistently high percentage of SPD in every year. Policy recommendations include: •Reduce inequities in socioeconomic status Race and Ethnicity Asian adults had the largest increase in SPD from 2014 to 2018. Latino adults had persistently high percentages of SPD in four of the five years. Policy recommendations include: ‘‘ Among racial and ethnic groups, Latino adults had persistently high among females by: •Reduce inequities in socioeconomic status percentages of Reducing inequities in wages and salaries (SES) for Latino and Asian populations. SPD in four of Creating policies that support family caregivers •Reduce discrimination and hate crimes against Latino and Asian populations. •Reduce inequities in access to care and ’’ the five years. Supporting policies that provide a living preventive services. wage for family caregivers •Support policies that target services Supporting policies that provide health and access to services—in particular, care and retirement benefits for family therapeutic services and supports—for caregivers Latinos and Asians. •Reduce inequities in access to care and preventive care for men. The data presented in this brief were collected before the COVID-19 pandemic, Sexual Orientation and Gender Identity but the pandemic has likely exacerbated both Between 2014 and 2018, a large increase in the proportion experiencing SPD as well as SPD was seen among adults who identified disparities in the social determinants of mental as lesbian, gay, homosexual, or bisexual. In health inequities. In a March 2020 study, 2018, nearly half of adults who identified 45% of adults reported that the pandemic had as transgender or gender nonconforming negatively affected their mental health.10 Even reported having SPD—almost five times before the pandemic, 3.3 million California the percentage of adults who identified as households—predominantly African American, cisgender. Policy recommendations include: Latino, single female households, and households with children—were economically •Reduce stigma and discrimination against insecure and unable to meet basic living Californians who identify as LGBTQ. expenses.11 Since the start of the COVID crisis •Reduce bullying and hate crimes against in mid-March, nearly one-third of California LGBTQ populations. workers have filed for unemployment, with claims higher among females, younger adults, •Reduce inequities in socioeconomic status and African Americans.12 Policymakers will need among LGBTQ Californians. to focus on equity-based economic recovery •Mandate services, supports, and safe spaces policies that will help to reduce the negative for LGBTQ Californians, especially youth. psychological and economic impacts of COVID. •Promote and support an LGBTQ mental The increases and persistently high health workforce and culturally competent percentages of SPD for various groups over care. the past few years warrant a closer look at •Support policies that provide therapeutic the economic, social, and environmental services and supports for LGBTQ groups. 8 UCLA CENTER FOR HEALTH POLICY RESEARCH ‘‘ Public policies and social norms intertwined with structural determinants conditions that can negatively impact population-level mental health. Policy is an important tool for intervening in the structural determinants and the resulting socioeconomic status of individuals that can lead to mental health inequities.5 Equity- based policies are needed that will reduce For analyses in this brief, serious psychological distress (SPD) in the past year was measured by using a cutoff score of 13 to 24 on the Kessler 6 (K6), a validated measure designed to estimate the prevalence of diagnosable mental disorders within a population.4 CHIS data is cross-sectional, so inferences in causation cannot be made. Descriptive analyses were conducted; result in inequities in the socioeconomic status of therefore, hypotheses testing informed by WHO’s socioeconomic Californians and invest in communities conceptual model on the social determinants of mental health inequities were not performed. In and mental at risk of lower educational attainment, addition, it is well documented that having lower ’’ underemployment or unemployment, having educational attainment, having a low income, and health inequities. low income or being employed in sectors being uninsured are social determinants of mental that do not provide a living wage to cover health inequities. However, this study found increases basic living expenses. Communities at risk of in SPD among adults with a college education or higher, with incomes of 200% FPL or greater, and these social determinants are predominantly with private insurance coverage. Further research is African American, Latino, Asian, and other needed to ascertain the extent to which these increases marginalized populations, such as women and are due to an actual increase in psychological distress adults who identify as LGBTQ. or to prevention efforts to reduce stigma and increase awareness, which have made more people aware of the Public policies and social norms are central symptoms of SPD and more willing to report these. elements intertwined with the structural determinants that result in socioeconomic Author Information and mental health inequities; these factors, D. Imelda Padilla-Frausto, PhD, MPH, is a research scientist at the UCLA Center for Health too, must be considered by policymakers so Policy Research. Firooz Kabir is a master’s student that mental health outcomes in California can at the UCLA Fielding School of Public Health. be improved.5 Blanche Wright, MA, is a doctoral candidate in clinical psychology at UCLA, an NRSA fellow Data Source and Methods from the National Institute of Mental Health, and This policy brief presents data from the 2014 through a Robert Wood Johnson Foundation health policy 2018 California Health Interview Survey (CHIS), research scholar. Safa Salem is a UCLA CDC Public conducted by the UCLA Center for Health Policy Health Scholar alumna and a Harvard graduate in Research. We used data collected in interviews history and science. Ann Crawford-Roberts, MD, with adults sampled from every county in the state. MPH, is a resident physician at UCLA’s Resnick Interviews were conducted in English, Spanish, Neuropsychiatric Hospital and the Semel Institute Chinese (both Mandarin and Cantonese), Vietnamese, for Neuroscience and Human Behavior and an APA/ Korean, and Tagalog. CHIS uses a dual-frame, APAF Leadership fellow. Hin Wing Tse is a CHIS multistage sample design using a random-digit-dial researcher and data dissemination coordinator at the (RDD) technique. The use of traditional landline UCLA Center for Health Policy Research. RDD and cellphone RDD sampling frames ensured that the respondents were representative of the state’s Funder Information population. CHIS is designed with complex survey This policy brief was funded by the California methods that require analysts to use complex survey Department of Health Care Services, Community weights in order to provide accurate variance estimates Services Division. This content is solely the and statistical testing. All analyses presented in this responsibility of the authors and does not necessarily brief include replicate weights to provide corrected represent the official views of the funder. confidence interval estimates and statistical tests. For more information on CHIS methods, see: http:// healthpolicy.ucla.edu/chis/design/Pages/methodology.aspx. UCLA CENTER FOR HEALTH POLICY RESEARCH 9 Acknowledgments 8 Weiner J. 2020. California Poised to Become National Leader on Mental Health and Addiction Coverage. Sacramento, The authors truly appreciate Tiffany Lopes, Venetia Calif.: CalMatters. https://calmatters.org/health/2020/08/ Lai, Elaiza Torralba, Celeste Peralta, Donna california-leader-mental-health/ Beilock, and Mary Nadler for all their support in 9 Weiner J. 2020. “Go on Medi-Cal to Get That”: Why Californians With Mental Illness Are Dropping copyediting, designing, and disseminating this Private Insurance to Get Taxpayer-Funded Treatment. policy brief. In addition, the authors would like to Sacramento, Calif.: CalMatters. https://calmatters.org/ thank the California Department of Health Care projects/california-mental-health-private-insurance-medi-cal/ Services, Community Services Division, and Susan 10 Panchal N, Kamal R, Orgera K, Cox C, Garfield R, Hamel L, Muñana C, Chidambaram P. 2020. The Babey and Riti Shimkhada of the UCLA Center for Implications of COVID-19 for Mental Health and Substance Health Policy Research for their thoughtful and Use. San Francisco, Calif.: Kaiser Family Foundation. thorough reviews. https://www.kff.org/coronavirus-covid-19/issue-brief/the- implications-of-covid-19-for-mental-health-and-substance-use/ 11 Bhattacharya J, Price A. 2018. The Cost of Being Suggested Citation Californian: A Look at the Economic Health of California Padilla-Frausto DI, Kabir F, Wright B, Salem Families. Oakland, Calif.: Insight Center for Community Economic Development. https://insightcced.org/wp-content/ S, Crawford-Roberts A, Tse HW. 2020. Serious uploads/2018/04/Cost_of_Being_Californian_April_2018_ Psychological Distress on the Rise Among Adults in final.pdf California. Los Angeles, Calif.: UCLA Center for 12 Hedin TJ, Schnorr G, and von Wachter T. 2020. Health Policy Research. California Unemployment Insurance Claims During the COVID-19 Pandemic. Policy Brief. Los Angeles and Berkeley, Calif.: California Policy Lab. https://www. Endnotes capolicylab.org/california-unemployment-insurance-claims- 1 Centers for Disease Control and Prevention (CDC): during-the-covid-19-pandemic/ Mental Health. Retrieved from https://www.cdc.gov/ mentalhealth/index.htm 2 Office of Disease Prevention and Health Promotion (ODPHP): Healthy People 2020 – Mental Health. Retrieved from https://www.healthypeople.gov/2020/leading- health-indicators/2020-lhi-topics/Mental-Health. 3 Substance Abuse and Mental Health Services Administration (SAMHSA). 2018. Key Substance Use and Mental Health Indicators in the United States: Results From the 2017 National Survey on Drug Use and Health. HHS Publication No. SMA 18-5068, NSDUH Series H-53. Rockville, Md.: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data. 4 Kessler RC, Green JG, Gruber MJ, Sampson NA, Bromet E, Cuitan M, Furukawa TA, Gureje O, Hinkov The California Health H, Hu CY, Lara C, Lee S, Mneimneh Z, Myer L, Oakley- Interview Survey (CHIS) Browne M, Posada-Villa J, Sagar R, Viana MC, Zaslavsky AM. 2010. Screening for Serious Mental Illness in the covers a wide array of General Population With the K6 Screening Scale: Results health-related topics, From the WHO World Mental Health (WMH) Survey including health insurance Initiative. International Journal of Methods in Psychiatric Research 19(S1): 4-22. Erratum in: International Journal of coverage, health status Methods in Psychiatric Research, Mar 2011, 20(1):62. https:// and behaviors, and access pubmed.ncbi.nlm.nih.gov/20527002/ to health care. It is based 5 Solar O, Irwin A. 2010. A Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of on interviews conducted Health Discussion Paper 2 (Policy and Practice). Geneva, continuously throughout Switzerland: World Health Organization. the year with respondents 6 After controlling for age, these trends remained the same. from more than 20,000 7 Hankivsky O, ed. 2012. An Intersectionality-Based California households. Policy Analysis Framework. Vancouver, B.C.: Institute for Intersectionality Research and Policy, Simon Fraser University. CHIS is a collaboration among the UCLA Center for Health Policy Research, California Department of Public Health, California Department of Health Care Services, and the Public Health Institute. For more information about CHIS, please visit chis.ucla.edu. UCLA CENTER FOR HEALTH POLICY RESEARCH 10960 Wilshire Blvd., Suite 1550 Los Angeles, California 90024 The UCLA Center for Health Policy Research is part of the UCLA Fielding School of Public Health. The analyses, interpretations, conclusions, and views expressed in this policy brief are those of the authors and do not necessarily represent the UCLA Center for Health Policy Research, the Regents of the University of California, or collaborating organizations or funders. PB2020-7 Copyright © 2020 by the Regents of the University of California. All Rights Reserved. Editor-in-Chief: Ninez A. Ponce, PhD Phone: 310-794-0909 Fax: 310-794-2686 Email: chpr@ucla.edu healthpolicy.ucla.edu Read this publication online