Policy and Practice Must Benefit Older Americans

The aging of the U.S. population presents unprecedented challenges and opportunities. Enhancing the mental and behavioral health of older adults helps all of us to live well and contribute as we age. For many older adults, later life can be a time of enhanced resilience and emotional well-being. However, older Americans have faced increasing mental health challenges, which were exacerbated by the COVID-19 pandemic and the continuing opioid epidemic.

Providers, caregivers, and older adults themselves tend to incorrectly view symptoms of mental health conditions as an expected part of the life changes that occur as an individual ages. Moreover, stigma, ageism, and lack of awareness about mental illness—and the effectiveness of treatment—can result in reluctance to seek or accept behavioral health services.   

Untreated mental health and substance use disorders among older adults exacerbate health conditions, decrease life expectancy, and increase overall health care costs. Key issues include:

• An Aging America: The number of people 65 years and older has been increasing dramatically and will nearly double between 2010 and 2030, from 40.3 million to 72.1 million (according to the U.S. Census).
• High Prevalence of Mental Health and Substance Use Disorders: One in four older adults live with a mental health or substance use disorder. Depression is the most common mental illness experienced by older adults. Use of illegal and recreational drugs by older adults is increasing, as is problematic opioid use.
• Disproportionate Impact of Suicide: Older White men have the highest suicide rate of any group.
• Impact of Mental Illness on Physical Health: Mental illness in older adults increases poor outcomes and mortality for common conditions such as heart disease, cancer, hip fractures, and diabetes. Medicare spending on necessary care for beneficiaries with mental illness is two to three times higher than spending for other Medicare beneficiaries.
• Shortened Life Span: Serious mental illness reduces life expectancy by 11 to 30 years, largely due to increased comorbid conditions such as heart disease and diabetes.
• Inadequate Access to Appropriate Treatment: Only 30%–40% of older adults with behavioral health disorders receive mental health and substance use services.
• Racial and Ethnic Disparities in Access to Care: Black and Latino older adults have less access to affordable, culturally competent mental health services than do their White peers.
• Impact of the COVID-19 Pandemic: Almost half of older adults reported COVID-19–related worry and stress during the pandemic that had a negative impact on their mental health. Older people were disproportionately affected by loneliness, social isolation, and bereavement as a result of the pandemic. 

 Medicare Reimbursement 

Increasing reimbursement for mental health and substance use services is critical to assure adequate provider enrollment. Medicare provides much-needed coverage for older adults and those with disabilities. Unfortunately, reimbursement rates for both mental health and physical health services are inadequate for engaging more providers. 

In fact, psychiatrists are the most frequent providers to opt out, leaving older adults with little or no service. In this situation, patients may go out of network for behavioral health services, but the reality is that if their insurance does not cover services—or providers who take their insurance are not available—beneficiaries more often do not receive services. 

In addition, Medicare Advantage plans are required to allow for coordinated care by not separating contracts for health systems that also have behavioral health services. Optimal care for all adults coordinates mental health and physical health care. This is particularly the case for older adults with conditions ranging from depression to serious mental illness to substance misuse. However, few older adults receive integrated mental health services.  

Some providers neglect to screen older adults for substance use disorders due to the beliefs that older adults do not use drugs and that they stop drinking alcohol while taking high-risk medications, despite SAMHSA recommendations for universal screening. This was particularly problematic during the COVID-19 pandemic, as alcohol consumption among older adults increased dramatically. 

Managing one illness at any age is challenging, but older adults with both physical and mental health or substance use issues, multiple medications, multiple providers, and often multiple systems providing services require assistance in coordinating care. In fact, a survey of recipients of long-term services and supports found that 81% reported unmet needs, including help with self-care or other daily activities (21%), services that meet needs and goals (30%), assistive technology (54%), home modifications (52%), and transportation (26%). Many of these services are not reimbursed by Medicare, yet these are exactly the services that allow older adults to remain in their homes and which will lower health care utilization.  

Network adequacy remains a significant problem for beneficiaries trying to access mental health services. To aid consumers in identifying plans with adequate networks, the Centers for Medicare & Medicaid Services (CMS) could incentivize plans to make comprehensive, up-to-date provider directories available by incorporating measures of directory adequacy in their star rating system. 

Other Medicare reforms include statutory changes to Medicare to remove policies that limit Medicare beneficiaries to 190 days of care at inpatient psychiatric facilities. Financial incentives and technical assistance are also needed to help primary care practices and clinics increase uptake of the annual wellness visit, including depression screening and behavioral health integration services. 

The data is striking: Millions of older Americans go undiagnosed. The National Academy of Medicine has found that less than 40% of older adults with mental health and/or substance use disorders receive treatment. 

Beginning this year, the inclusion of counselors and MFTs in the Medicare program substantially increases the Medicare mental health provider pool, as the two professions make up approximately 40% of the licensed behavioral health workforce in the United States. With these two professions shut out of the largest insurer in the country for so long, older Americans have not had sufficient access to mental health treatment. That changed as of Jan. 1, 2024.   

However, with the number of older adults expected to reach 80 million, or 26% of the U.S. population by 2040, it is critically important that Congress pass needed policies to raise awareness, reduce stigma, and provide support for older adult mental health. 

Looking Ahead 

Faced with the task of improving mental health care for older adults, the question we should ask ourselves is “if not now, when?” With the significant demographic shift over the next two decades, we cannot afford to stand still.  

Congress should provide more funding to support programs to address ageism, encourage healthy behaviors, reduce older adult suicide, integrate key services, and bolster the workforce of mental health treatment providers.   

Counselors can do their part by enrolling in the Medicare program today and expanding their client base to serve older adults, supporting anti-stigma campaigns through aging networks in the local community, participating in training programs and continuing education about the unique needs of older adults, and working closely with primary care clinics and physicians where older adults frequently have the first point of contact for their mental health issues. There are consultation opportunities in a variety of service systems where counselors can now receive reimbursement under Medicare. 

We know that a significant wave of Americans will be reaching Medicare eligibility age over the next two decades. If we promote key policies and efforts now and take direct actions, we can make substantial progress in addressing the needs of older Americans with mental health conditions in the near and long term.