Mental Health Care Coverage for Adults on Medicare Falls Short

Nearly all U.S. adults over the age of 65 have some mental health coverage through Medicare. But a recent Commonwealth Fund survey shows that it’s not enough.

Munira Gunja, MPH, senior researcher in the Commonwealth Fund’s International Program in Health Policy and Practice Innovations, and her colleagues compared mental health needs and treatment of older adults in the U.S. to those of 10 other nations. They found that of all 11 countries, older adults with Medicare in the U.S. were the most likely to report being diagnosed with a mental health condition.

At the same time, they were the most likely to seek care for mental health, but skip care due to cost and financial insecurity.

“What the study found is that just because you have health insurance doesn’t mean it’s adequate,” Gunja, the lead study author, told Verywell.

“We really need to prioritize mental health,” Gunja added, especially by reducing financial barriers and promoting healthcare reform. “I think that is going to hopefully become more of the shift.”

The survey was published in late January.

U.S. Care Compared

For mental health care, Medicare covers services including annual depression and substance use screenings, outpatient therapy, and counseling. But the question is: How well does this coverage address need, which has become dire during the pandemic?

To answer this question, Gunja and colleagues analyzed the findings from the 2021 Commonwealth Fund International Health Policy Survey of Older Adults. They specifically looked at self-reported diagnosed mental health problems, mental health burden, and financial hardship for adults 65 and over in the U.S. And they compared U.S. findings with similar data in 10 other high-income countries, including Canada, Norway, and New Zealand.

In total, their data included more than 18,000 adults 65 and over across these 11 countries.

Overall, the U.S. showed the highest rates of mental health need across the board. Twenty-one percent of Medicare beneficiaries 65 and over reported having been diagnosed with mental health problems, compared to 13% in New Zealand, Canada, and France, and 5-7% in Germany, the Netherlands, and Norway.

Older adults in the U.S. were also the most likely to seek mental health care for anxiety and/or depression. Sixty-six percent of U.S. Medicare beneficiaries with a mental health need sought help, compared to 49% in Australia, 37% in Switzerland, and 22% in the U.K. The greater likelihood of U.S. adults seeking care may be due to culture and stigma related to such care in other countries.

At the same time, the authors wrote, not all people in the U.S. who could benefit from care may be accessing it due to the low supply of mental health workers and challenges accessing care in rural areas.

Costs Pose a Barrier

Gunja and colleagues found that out of all 11 countries, U.S. adults with mental health needs were the most likely to report cost-related difficulties getting care—even though they had Medicare.

“Every person above the age of 65 is enrolled in Medicare, yet there are serious financial barriers that really prohibit people from actually seeking the care that they need,” Gunja said. “That’s something that other countries don’t really have to deal with.”

To gauge financial hardship under Medicare, the survey asked about times when cost prevented them from accessing health care in the past year, including:

• When they had a medical problem but did not visit a doctor
• Skipped a needed test, treatment, or follow-up
• Did not fill a prescription for medicine
• Skipped medication doses

Even with Medicare, they found that 26% of U.S. adults had participated in one of these, compared to 6–14% in the other countries studied. In addition, 27% of U.S. respondents 65 and over reported being always or usually worried or stressed about economic hardship. This hardship was defined as worries regarding being able to buy a nutritious meal, meet rent or mortgage payments, or pay monthly utility bills (including necessities like electricity, heat, or telephone).

On the flip side, only 4–5% of older adults in Germany, the Netherlands, and the U.K. reported this economic hardship.

“When you have Medicare, you do have access to your annual screenings and preventative services, and that’s all great,” Gunja said. “But as soon as you’re diagnosed with a mental health condition, whether or not you’ll be able to afford actual treatment is up in the air.”

And compared to the 10 other countries studied, the U.S. is the only country without universal health care.

Latinx Older Adults Expressed More Need

When Gunja and colleagues looked closely at the data, they found that Latinx Medicare beneficiaries stood out.

A much greater share of Hispanic/Latinx adults 65 and over said they were diagnosed with a mental health condition, compared to White or Black beneficiaries in the U.S. Also, 42%, compared to the U.S. total of 28%, reported needing mental health care.

Hispanic/Latinx older adults were also more likely to report emotional distress, defined as “anxiety or great sadness which the respondents found difficult to cope with by themselves in the past 12 months.” Thirty-one percent of Hispanic/Latinx adults reported this, compared to 18% of all U.S. older adults combined.

Entrenched healthcare bias and stigma might be influencing differences between racial groups, the authors wrote. For example, although Black older adults were the least likely to report mental health diagnoses, studies have found that providers are more likely to underdiagnose Black adults for mood disorders than they are for other adults.

At the same time, the authors wrote, job loss due to COVID-19, as well as fears around changes in immigration policies, disproportionately impact the mental health of older Latinx adults. To better address this group’s mental health need, further investigation and policy reforms are needed.

Accessibility of Care

These data confirmed previous findings: Both mental health diagnoses and economic hardship tend to be higher among older adults in the U.S. compared to those in other industrialized countries. These two factors, the authors wrote, work in tandem, leading to a negative cycle.

“Studies show that unmet economic and social needs, which tend to be more prevalent in the U.S. than in other high-income countries, may contribute to the high rate of mental health needs,” they wrote. This may be even more true for low-income adults since the pandemic began in early 2020.

To break this cycle, Gunja and colleagues stressed that we need to address policy as well as the underlying forces at play.

Although Medicare has made it easier for adults to get care, the authors wrote, other systemic factors complicate access. For example, not all psychiatric care services accept Medicare, likely due to administrative burdens and lower financial incentives. On average, Medicare pays healthcare providers only 80% of what private health insurance pay, and often with significant delay.

High drug prices and care limits baked into Medicare also make coverage the least helpful for those who need care most. A 2021 study found that Medicare beneficiaries who self-reported a history of depression also reported more unmet needs and financial hardship.

For Gunja, solutions lie in reducing all financial barriers to health care and expanding telehealth. Additionally, better integrating mental health care within health systems, as other countries surveyed have done, could benefit all.

“Other countries have really made it so that most general practitioners have at least one mental health provider within their practice,” Gunja said. But right now the U.S. is a very siloed system. You go to a healthcare provider and they refer you to another one, who may or may not be within your network or accept your insurance. They may also be far or take more time to get to.

“We really need to connect it all together,” she said. “Until we can agree that everyone should have a right to health care, we’ll continue to have an uphill battle.”