Medicare Must Cover Mental Health
Ensuring more Americans have quality, affordable health coverage is an urgent national priority. Therefore, it is understandable that Medicare, one of America’s great public policy success stories, is being considered as a model to expand coverage. After all, Medicare currently provides more than 60 million older Americans — and younger adults who have long-term disabilities — reliable access to affordable care. Most conditions are covered, with one glaring omission: mental health and substance use disorders.
This is because Congress has repeatedly failed to update Medicare’s discriminatory mental health and addiction benefits to keep pace with rapidly evolving scientific knowledge and public perception around these illnesses. Consequently, Medicare lags decades behind, hindering access to mental health and addiction treatment services for all Americans who rely on the program. Thus, any proposal to expand Medicare — without fixing it first — will only serve to perpetuate discriminatory coverage.
By comparison, the Affordable Care Act (ACA) offers much more comprehensive protections. In fact, the ACA’s essential health benefits include mental health and addiction treatment services as required benefits. The ACA also has strong provisions to prevent discrimination against Americans with mental health and substance use disorders.
While there’s more the ACA can do to improve our worsening mental health crisis — and historic rates of overdoses and suicides — its protections should serve as a baseline against which we can measure all current and future health plans. It’s a simple way to tell whether any plan treats mental health as essential health.
In so doing, Medicare gets a failing grade for arbitrarily, and detrimentally, limiting much-needed care. For example, if a Medicare recipient experiences crises that necessitate inpatient psychiatric hospital visits, they are limited to 190 days of covered care — over the course of their lifetime. Medicare also does not cover mental health crisis services or team-based interventions such as Coordinated Specialty Care (CSC) or Assertive Community Treatment (ACT), nor psychiatric or substance use disorder Intensive Outpatient Programs or psychiatric Residential Treatment for persons over 20 years old. Additionally, medical nutrition therapy for eating disorders is not covered.
Alarmingly, discrimination against those with mental health and substance use disorders within Medicare — including Medicare Advantage plans — is considered legal because Medicare is not subject to the 2008 Mental Health Parity and Addiction Equity Act (Federal Parity Law), which requires insurers to cover treatment for mental health and substance use disorders no more restrictively than treatment for illnesses of the body, such as diabetes and cancer.
Some changes to Medicare have been made to temporarily expand telehealth coverage during the Covid-19 crisis, but this short-term win is greatly overshadowed by the other ways in which Medicare makes it difficult for people to access care. For instance, Licensed Professional Counselors (LPCs) and Marriage and Family Therapists (MFTs) are not allowed to bill Medicare. Peer services aren’t covered, nor are Certified Community Behavioral Health Clinics (CCBHCs). And for children, Medicare contains nothing equivalent to Medicaid’s guarantee of mental health services through the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) mandate.
With all of these deficiencies, it is easy to see that Medicare’s foundation is badly flawed, as would be the logic behind any new health care proposals based solely on Medicare in its current form.
As America’s mental health crisis continues to worsen due to the traumatic events of 2020, we can — and must — do better.
In April, three times as many adults reported psychological distress as they did two years prior. In August, 41% of adults and 75% of young adults reported experiencing mental health challenges stemming from COVID-19. And after a record high of 72,000 overdose deaths in 2019, over 40 states have reported a rise, and preliminary data for 2020 shows a national increase of 15 percent between May and August.
The data are clear: people need help. Spending precious time debating the merits of Medicare-based plans that do nothing to address the severity of our mental health crisis is doing a disservice to society.
American success stories have a place in our history books, but even the most prolific policies must be updated to reflect the times and challenges our nation faces.
Former U.S. Rep. Patrick J. Kennedy (D-R.I.) is founder of The Kennedy Forum and co-chair of the Mental Health & Suicide Prevention National Response to COVID-19, an initiative of the National Action Alliance for Suicide Prevention.
Dr. Kavita K. Patel is a primary care physician at Mary’s Center and a former Director of Policy in the Obama Administration.