The number of people diagnosed with mental health issues, such as depression and anxiety, has risen to new highs during the COVID-19 pandemic. That’s inevitably increased the demand for treatment in a health care system that already falls short — particularly when it comes to the mental health of our country’s older adults, according to a new report from the Commonwealth Fund, a New York-based foundation supporting efforts to provide better access to high-quality health care in the U.S.
The report, “Comparing Older Adults’ Mental Health Needs and Access to Treatment in the U.S. and Other High-Income Countries,” analyzed results from a survey or more than 18,000 adults age 65 and older in 11 high-income countries, between March and June 2021. Researchers compared Medicare beneficiaries in the United States with older adults in places like the United Kingdom, France and Germany for their mental health and ability to access and afford treatment.
While nearly all U.S. adults over age 65 have some mental health coverage through their enrollment in Medicare, the report suggests that it’s inadequate.
In the U.S., “Medicare beneficiaries are more likely to report emotional distress or be diagnosed with a mental health need, compared to older adults in other high-income countries,” says Munira Gunja, lead report author and senior researcher for the Commonwealth Fund’s International Program in Health Policy and Practice Innovations.
More than a quarter of older adults in the U.S. said they have mental health needs, defined as either a diagnosed condition, such as anxiety or depression, or self-reported emotional distress.
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The survey also found that Medicare beneficiaries (26 percent of them) were most likely to report skipping or putting off needed mental health care because of costs, while fewer than 1 in 10 older adults in the U.K., France, Germany and Sweden reported doing so.
“This is a problem that we don’t see in other countries,” Gunja says.
Also concerning: stark disparities in mental health needs and treatment access between ethnic and racial groups. Hispanic Americans are the most likely to be diagnosed with a mental health condition and to report emotional distress, with 42 percent of the Hispanics surveyed reporting a need for mental health services.
Despite having some coverage, “it’s still too expensive for older adults to get the proper care they need,” Gunja says. “Medicare covers basic preventive services, such as substance abuse screenings and depression screenings. But beyond that, once you’re actually diagnosed with a mental need, whether or not you’ll be covered or be able to afford the actual care that you need — for example, getting psychiatric care or getting the proper drugs — is really up in the air.”
And supplemental plans may not help, says Dan Adcock, director of government relations and policy for the National Committee to Preserve Social Security & Medicare: “Depending on what kind of Medigap insurance that you couple with traditional Medicare, there can be some pretty big cost sharing that’s involved.”
Not only are there too few mental health professionals to meet the growing need for services in the U.S., “there’s a diminishing number of providers who accept Medicare insurance,” says Lauren Gerlach, a geriatric psychiatrist and health services researcher at the University of Michigan.
The numbers back her up. An analysis of physician networks in Medicare Advantage health maintenance organizations (HMOs) and local preferred provider organizations (PPOs) offered in 20 counties across the U.S. in 2015 found that, on average, Medicare Advantage networks included only 23 percent of psychiatrists in a county. “That’s a pretty small number for a profession that is underrepresented to begin with,” Adcock says.
Part of the problem is the reimbursement rates, says Adam C. Powell, president of Payer+Provider Syndicate, a management advisory and operational consulting firm that focuses on managed care and other organizations in the health care sector. “A large portion of the mental health workforce is not willing to accept Medicare and Medicaid coverage [because] the amount they get from Medicare and Medicaid isn’t enough to make them want to take on these patients,” he notes. “Many providers would prefer to be seeing patients on a cash-only basis or only accept commercial health plans. As a result, simply being insured does not guarantee that one has ready access to care.”
What’s more, it can be overwhelming for independent practices to handle billing. “It’s the sheer bureaucracy of having to deal with this,” says Daniel Enrique Jimenez, associate professor of psychiatry and behavioral sciences at the University of Miami Miller School of Medicine. He notes that the University of Miami maintains a team of people just to deal with insurance, Medicare included. Those with smaller practices aren’t as fortunate. “Say I’m an independent provider who charges $200 for an hour of psychotherapy,” Jimenez says. “If the patient pays out of pocket, boom, perfect. If not, I have to then spend time trying to get reimbursed. … It may become not worth it to take insurance.”
Time for change
The good news: The past two years have brought a push to get better mental health coverage for those on Medicare. During the COVID-19 crisis, the federal government temporarily relaxed restrictions on receiving mental health care via telehealth. In December 2020, Congress did one better, making access to telehealth permanent. “It has been a significant achievement as far as increasing access to mental health professionals,” says Adcock, “particularly in rural areas where there are even fewer mental health providers.”
Under the new law, those eligible under Medicare will be able to use telehealth for diagnosis, treatment or evaluation of mental health disorders. This includes counseling, psychotherapy and psychiatric evaluations. It also removes geographic restrictions, allowing Medicare beneficiaries to receive services via telehealth without having to leave their homes. There are some restrictions: For example, under some circumstances, patients must have an existing in-person relationship with the provider prior to the telehealth session — such as at least one in-person visit with a provider in the previous six months.
In addition, in November 2021, the Centers for Medicare & Medicaid Services (CMS) announced that “for the first time outside of the COVID-19 public health emergency (PHE), Medicare will pay for mental health visits furnished by Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology, including audio-only telephone calls, expanding access for rural and other vulnerable populations.”
And the proposed Mental Health Access Improvement Act of 2021, introduced in the Senate, would widen the pool of providers that can deliver mental and behavioral mental health services to Medicare beneficiaries. Currently, psychiatrists, psychologists, clinical social workers and psychiatric nurses can do so; mental health counselors and marriage and family therapists cannot be reimbursed by Medicare for their services. The legislation would add an estimated 225,000 licensed behavioral health providers to those available to Medicare beneficiaries.
Congress is taking a closer look at mental and behavioral health issues, holding several hearings in recent months to discuss barriers and improvements. According to Andrew Scholnick, senior legislative representative for AARP, “policymakers realize that the lack of access and coverage for mental health services is an ongoing problem, and the COVID-19 pandemic has exacerbated unmet mental health needs and highlighted the continuing struggle that individuals face in accessing timely, quality mental health care services.”
President Biden has vowed to make mental health a priority, presenting a strategy that would build upon changes in progress. As part of his proposal, the president pledged to expand the availability of community-based mental health services — for example, extending funding to expand Certified Community Behavioral Health Clinics (CCBHCs), which deliver mental health and substance use care regardless of patients’ ability to pay. And, in an effort alleviate the shortage of mental health care providers, the president’s proposal includes nearly $700 million to provide training, including access to scholarships and loans, to mental health and substance use disorder clinicians who practice in underserved communities.
The proposal needs to be passed as actual legislation, but mental health advocates are buoyed by this high-profile acknowledgment that the country is facing a mental health crisis — and that the system to address it needs fixing. “Physical health needs have been prioritized,” Gunja notes. “Now it’s time for mental health.”
Barbara Stepko is a longtime health and lifestyle writer, and a former editor at Women’s Health and InStyle. Her work has appeared in The Wall Street Journal and Parade and other national magazines.