A Reimbursement Dream Realized

For America’s nearly 140,000 mental health counselors and 55,000 marriage and family therapists, as well as the countless clients in need of their services, this holiday season just took a very merry turn.

On the afternoon of December 23rd, 2022, President Biden signed into law the Consolidated Appropriations Act of 2023, providing nearly $1.7 trillion in funding for a slew of government agencies and initiatives, with a sizeable chunk—$120.7 billion—going toward the U.S. Department of Health and Human Services, and by extension, to Medicare, Medicaid, the National Institutes of Health, and the Centers for Disease Control and Prevention.

The bill was vast, but counselors and MFTs were fixated on a small but certainly not insignificant piece of legislation tucked inside, known as the Mental Health Access Improvement Act. Its crown jewel: finally permitting these clinicians to receive Medicare reimbursement for services provided to clients 65 and older, veterans, and those with disabilities. These therapists say the bill’s passage will now allow them to work unfettered with particularly vulnerable populations reeling from particularly dire times.

“Getting to this point is a historic achievement, the fruit of decades of hard work,” says Matthew Fullen, an associate professor at Virginia Tech who, in partnership with a handful of counselor organizations, has spent the last ten years heavily advocating for this change. “We’re really thrilled that it all came together.”

Although Medicare has covered psychologists, psychiatrists, and clinical social workers since 1989, when its mental health provider regulations were last updated, licensed professional counselors had not been covered. In the nearly 33 years since that update, the population of Medicare-eligible Americans has doubled, from nearly 30 million to 60 million adults. According to the National Rural Health Association, there’s also a shortage of psychiatrists, psychologists, and social workers in rural areas. But there are counselors who, thanks to the new law, can now step in and help serve the approximately 30 million Americans living in rural counties with no access to mental health treatment. The new law also clears them to help battle two epidemics deeply affecting Medicare-eligible populations: post-pandemic anxiety and depression, and the opioid crisis (Medicare is currently the single largest payer for opioid-related hospitalizations).

But if this bill was so important, then why did it take so long to pass? For one, member organizations like the American Psychological Association and American Psychiatric Association predate their counselor and MFT counterparts—the American Counseling Association and American Association for Marriage and Family Therapy—by almost a century, so at the time of the 1989 Medicare update, they had a more established professional history to draw upon. Budget constraints and early misconceptions about counselors’ roles and responsibilities have also been suggested as possible culprits.

But things have changed since then, Fullen says. “Counselors now make up a greater percentage of the overall workforce than we did in 1989, when we weren’t really at the table.” Sure enough, counselors and MFTs are among the fastest growing healthcare professions. According to the U.S. Bureau of Labor Statistics, the number of counselors and MFTs is expected to grow by 22 and 14 percent, respectively, over the next decade—much faster than the average growth rate of five percent.

“There’s been a little bit of educating lawmakers, explaining that this is about shoring up existing Medicare policy and not creating a brand-new line item, and making the case that Medicare beneficiaries needs access to care just like everybody else,” Fullen adds, “but now there are very few questions about what we do, and that wasn’t necessarily the case in the past.”

A Bill Becomes Law

The road to getting here wasn’t easy, to say the least. A version of the bill has been introduced in almost every congressional cycle since the early 2000s. The current version of the Act was introduced in the House and Senate in 2021, with bipartisan support. It was also backed by an impressive lineup of 11 high-profile mental health associations known as the Medicare Mental Health Workforce Coalition, which includes the American Counseling Association, American Association for Marriage and Family Therapy, American Mental Health Counselors Association, Association of Marriage and Family Therapists, and the National Council for Behavioral Health.

But despite this widespread support and a handful of close calls, the bill failed to pass in both the House and Senate together on several occasions, mainly due to budget concerns: according to the Congressional Budget Office, incorporating counselors and MFTs into Medicare reimbursement was estimated to cost nearly $900 million over a 10-year period.

“In my experience,” Fullen says, “the main deterrent has been the cost. To some politicians, that was a dealbreaker, and for others it was a worthy investment that would provide long-term cost savings because we’d have fewer people hospitalized or in the emergency department.”

But this time, the momentum was different, Fullen adds. Thanks to the tireless advocacy of the Coalition, counselors and MFTs, and even noncounselor organizations like the National Council on Aging, the National Alliance on Mental Illness, and disability groups like the Michael J. Fox Foundation, elected officials were presented with a sizeable body of research about the coverage gap, what was at stake, and how the law would impact their Medicare constituents. Awareness about mental health issues had also been building during the pandemic and last summer, when bills on firearm access were considered and funding was allocated for community mental health. “There seemed to be a new, emerging consensus that mental health needed more of an investment,” Fullen says. “Over the last couple years, a more diverse coalition was saying ‘This makes sense. We need to prioritize this.’”

The Act’s inclusion in the bill happened suddenly, when the proposed budget was released in the Senate on December 20th. “We knew we were up for consideration, but we didn’t know we were officially included in the proposal until that Tuesday,” Fullen says. “From there, we were white-knuckling it for a few days while the House haggled and voted.” Fullen spent days watching C-SPAN and listening to congresspeople argue over the budget package. Then, on December 23rd, the bill was passed and sent to Biden, essentially guaranteeing it would be signed into law. Ten years later, Fullen’s hard work had paid off.

“We were this little footnote in the larger budget document,” he says, “but a lot of groundwork had been done to build momentum, a lot of grassroots advocacy from counselors and other advocates. We put our best foot forward, and it worked.”

The News Spreads

For some therapists, like Tennessee-based counselor Courtney Armstrong, who’s currently training Veterans Affairs clinicians in clinical hypnosis for trauma and chronic pain, the passage of the bill opens up a world of possibility.

“This is great news for our VA and our veterans,” she says. “There are a lot of people in rural areas who don’t have access to metal health professionals, and since COVID, we’ve been seeing much higher levels of depression, suicide, and suicidal ideation in seniors.”

Armstrong, who’s been a counselor for nearly 25 years, says the inability to get reimbursement had been a thorn in her side for as long as she can remember. Earlier in her career, she worked at a geriatric psych unit in Louisiana. She loved working with seniors, but she also saw how hard it was for them to get help because of the Medicare barrier. When she moved to VA work, that barrier persisted. “The VA covers some services,” she says, “but they also bill Medicare, so for a long time only psychologists and social workers were hired at the VA.”

Over the years, Armstrong followed the Act’s journey in ACA bulletins, and wrote to her congressman on several occasions to offer support, but saw little progress until recently.

Now that the law has been passed, Armstrong says she’s looking forward to getting back to working more with seniors. It also opens up doors for counselors interested in working in integrated care settings, she adds. “The trend is moving toward integrated care, and primary care physicians have wanted to bring counselors on staff, but Medicare has been a barrier.”

For other therapists, the new legislation is both professional and personal. “The passage of this bill is great news,” says Rita Schulte, a licensed counselor and grief and loss specialist based in Virginia. “I wish it could have happened sooner, because we’re in a mental health crisis right now, and every person, especially the elderly, should have access to treatment.” The suicide rate has skyrocketed since the pandemic, she adds, and “as a suicide loss survivor, I can’t imagine not being able to get the help I so desperately needed after my husband’s death due to financial reasons.”

What Comes Next

Although the new law won’t go into effect until a year from now (the Centers for Medicare and Medicaid services will need time to fully implement the new policy), Fullen says the hard part is finished, and what’s left is to make sure the new system is properly set up so counselors and MFTs can get properly onboarded.

There’s plenty of work to be done, with ten thousand people turning 65 every day and approximately 60 million Americans currently on Medicare. But Fullen says it’s an exciting opportunity, and the counselor and MFT community is ready to get started. Plus, now that the career path for aspiring counselors and MFTs interested in working with older adults or people with long-term disabilities is much clearer, students can focus their training on health and aging without having to worry that this choice could limit their ability to make ends meet.

Like Armstrong, Fullen also expects this will change the landscape of integrated care, creating a more efficient pathway for referrals. Now, instead of long waitlists—even when there are plenty of capable counselors available to see waitlisted clients—he believes the healthcare system will become more efficient, and care will become more driven by clients’ personal preferences or the best fit for their therapy journey, and less by antiquated billing issues.

In short, he says, the change “is a win for clients and a win for professionals. We’re still riding the wave of excitement.”