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Democrats’ $3.5 trillion budget plan does have ‘long road to go’ with Medicare

Program has long marginalized mental health and substance use disorders. That needs to end

Senate Majority Leader Charles E. Schumer speaks at a news conference on mental health in New York in April. With the $3.5 trillion budget reconciliation package, Congress has an opportunity  to correct Medicare’s discriminatory coverage provisions for mental health and substance use disorders, Kennedy and Miller write.
Senate Majority Leader Charles E. Schumer speaks at a news conference on mental health in New York in April. With the $3.5 trillion budget reconciliation package, Congress has an opportunity to correct Medicare’s discriminatory coverage provisions for mental health and substance use disorders, Kennedy and Miller write. (Lev Radin/Pacific Press/LightRocket via Getty Images file photo)

After Senate Democrats and the White House reached agreement on a $3.5 trillion budget reconciliation package, Senate Majority Leader Chuck Schumer said, “We know we have a long road to go.”

Indeed, legislators do — particularly where the proposal’s Medicare modifications are concerned.

While adding hearing, vision and dental benefits to Medicare is a positive step, doing so without first correcting the program’s discriminatory mental health and substance use disorder, or SUD, coverage provisions is flat-out foolish, infuriating and just another example of how we marginalize mental health in policy.

Right now, there are approximately 60 million Americans over 65 or with long-term disabilities who stand to benefit greatly from Medicare providing them access to better mental health and SUD care. Pre-pandemic, one-third of U.S. adults with disabilities spent around half their month “mentally unhealthy,” and suicides were particularly high among men, especially those over 85. During the pandemic, nearly half of adults 65 and over polled by Kaiser Family Foundation said coronavirus-related worry and stress were taking a negative toll on their mental health. And this does not even take into account additional beneficiaries on Medicare’s roll as some have proposed.

Despite Medicare beneficiaries’ clear needs, the program currently has in place some of the most restrictive and exclusionary policies for mental health and SUDs. This only sustains our nation’s stigmatizing and ostracizing beliefs about individuals who struggle with their mental well-being. For example:

●      Medicare does not currently comply with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, or MHPAEA, which states that insurers may not treat mental health benefits as inferior to benefits provided for physical health care services.

●      Medicare does not cover mental health counselors, marriage and family therapists, and peer support specialists, nor evidence-based, multi-disciplinary team interventions for people with the most severe mental health and substance use conditions, such as Coordinated Specialty Care for early psychosis and Assertive Community Treatment teams, or for medical nutrition therapy for eating disorders.



●      Medicare does not cover services within each of the American Society of Addiction Medicine criteria’s five broad levels of substance use disorder care, nor residential care, intensive outpatient care or care provided in a free-standing community-based SUD treatment facilities. 

●      Medicare does not cover mental health crisis services, which will be increasingly problematic once the nationwide 988 mental health crisis system — which Congress has taken pains to set up through the National Suicide Hotline Designation Act of 2020 — comes into effect.



●      And Medicare does not cover services delivered in an inpatient psychiatric hospital if, over the course of their lifetime, a beneficiary needs more than 190 days of care.

Medicare does currently — and, we must emphasize, temporarily — cover some telemental health services because of the public health emergency. But this silver lining is not nearly enough to make up for Medicare’s mental health and SUD shortcomings.

Medicare’s temporary telehealth benefits can’t come close to overcoming its many downsides, in large part because of its influence on other health insurance plans. In the public health insurance market, TRICARE — the insurance program provided to servicemembers, veterans and their families — mirrors Medicare. And even in the private health insurance market, Medicare makes an impact because commercial insurance plans use the same Medicare codes — or in the case of mental health and SUD, lack thereof — for billable services.

Therefore, we encourage Congress right now to make every effort to modify as much of Medicare as it can. This means not only adding hearing, vision, and dental benefits, but saving lives by applying the MHPAEA to Medicare to help end Medicare’s long-standing discrimination against mental health and SUDs; and in those efforts, resisting separating coverage for mental health from coverage for SUDs — the two are intrinsically linked.

The road that inevitably lies ahead for this $3.5 trillion proposal will be long. And if we wish it to eventually be seen as a positive path forward for this nation, Congress cannot sidestep mental health and substance use disorders. It is a time to be bold and courageous and right a historical wrong in the Medicare program.

Patrick J. Kennedy represented Rhode Island in the House as a Democrat from 1995 to 2011. He is the founder of The Kennedy Forum, a mental health advocacy group, and co-chair of the Mental Health & Suicide Prevention National Response to COVID-19, an initiative of the National Action Alliance for Suicide Prevention.

Benjamin F. Miller, Psy.D., is a clinical psychologist and president of the Well Being Trust, a national foundation dedicated to advancing mental, social and spiritual health. He authors the weekly newsletter Mental: Fighting the fragmentation of mental health one policy at a time.


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