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US Mental Healthcare Access Trails Other Nations’ Due to Cost

For adults over 65, costs deter mental healthcare access, exposing gaps in Medicare coverage for this type of medical care.

Adults over age 65 in the US have more cost-related mental healthcare access challenges than seniors in other similarly developed nations, according to a recent assessment from the Commonwealth Fund.

This comes even as health payer coverage under Medicare promises at least some degree of mental health coverage, the report pointed out.

“Nearly all U.S. adults over age 65 have some mental health coverage through their enrollment in Medicare, which covers annual depression and substance use screenings, outpatient therapy, and counseling services, among other services,” the Commonwealth Fund authors, supported by research firm SSRS, wrote in the report’s introduction.

“But is that coverage enough to ensure older Americans’ mental health needs are being met, especially as cases of depression and other mental health disorders have risen during the pandemic?”

Using survey data from the 2021 Commonwealth Fund International Health Policy Survey About Older Adults, the researchers found that adults in the US were more likely than those in other nations included in the survey to have a mental health diagnosis.

Overall, about one in five older adults in the US have a mental health diagnosis, with diagnoses being more common among Hispanic people. Thirty-two percent of Hispanic people over age 65 have a mental health diagnosis.

Other nations don’t see nearly as high a rate of mental health diagnoses. In New Zealand, Canada, and France—the three nations which tie for the second-highest rate of mental health issues—only 13 percent of adults over 65 have a diagnosis. In Germany, as little as 5 percent of adults over 65 reported a mental health diagnosis.

About three in 10 older Hispanic adults in the US said they experience emotion distress, while that was true for 18 percent of the older US population as a whole. Meanwhile, 42 percent of older Hispanic adults in the US self-reported a mental health need, and 28 percent of the senior population as a whole reported the same. Comparatively, only 9 percent of older Germans self-reported a mental health need.

And to be clear, older adult in the US are far more likely to access mental health treatment than those in other affluent nations, something the Commonwealth Fund researchers posited toward cultural norms. Although stigma still exists in the United States, other nations have far more rigid cultural norms barring mental health access.

Overall, 66 percent of US Medicare beneficiaries have visited a healthcare provider to manage their depression or anxiety. In Australia, the nation that sees the second-highest mental healthcare access rate, 49 percent of people accessed a provider for depression or anxiety symptoms.

In some nations, like France, self-reported mental health needs and actual access were mismatched, again likely because of social norms. Only about a quarter of older adults in France have visited a healthcare professional for depression or anxiety.

That all said, older adults in the US are significantly more likely to have to forgo mental healthcare access because they can’t afford it. Going without needed mental healthcare may not be a choice for these patients, the report suggested, or the result of cultural norms. Rather, it could be the result of lapses in health payer coverage for mental health services.

Just over a quarter (26 percent) of US adults over age 65 said they did not access mental healthcare that they needed because of high patient financial responsibility.

“Despite the financial protections Medicare offers, its coverage leaves many U.S. older adults exposed to high health care costs,” the researchers reported. “This is particularly true for beneficiaries with serious mental health needs who are likely to spend more on health services. High out-of-pocket health costs can lead beneficiaries to postpone care or forgo it entirely, which can produce poorer health outcomes and raise overall health care spending.”

This isn’t the case in other developed nations. In the United Kingdom, France, Sweden, and Germany, fewer than 10 percent of older adults with mental health needs skipped or delayed care due to cost.

Adding insult to injury, it is those with the greatest mental health need who are also reporting financial need in the US. Just over a quarter of older adults in the US with mental health needs also reported economic struggles.

In Switzerland, the nation which has the second highest rate of dual mental health and economic hardship, that rate is only 20 percent. In the Netherlands, those conflicting issues affected only 4 percent of older adults.

These findings underscore some serious shortcomings in Medicare’s mental healthcare coverage, the researchers asserted. For one thing, programmatic barriers are keeping seniors from getting the mental health help they need. The Commonwealth Fund said there is a dearth of mental health providers willing to accept Medicare insurance, causing a provider shortage for older populations.

What’s more, Medicare has its own limits on how it will cover mental health. For example, Medicare will only cover up to 190 of inpatient psychiatric treatment. There are also barriers to telehealth for mental healthcare, the researchers reported.

Finally, Medicare beneficiaries are set back by the high cost of prescription mental health drugs. The high net cost for those drugs has translated into high out-of-pocket costs for beneficiaries, creating another treatment hurdle.

The Commonwealth Fund researchers posited the US could borrow some mental healthcare access programs from other similarly affluent nations. In the United Kingdom, Germany, Canada, and the Netherlands, free primary care access has helped connect more seniors to affordable mental healthcare.

Additionally, some countries subsidize mental health medications for seniors. France, for example, waives all copayments for medications treating chronic psychiatric conditions. Canada offers free phone- and text message-based mental health check-ins with seniors, while Australia offers subsidize therapy sessions with certain providers.

In the US, it will also be essential for policy design to consider health equity, as the researchers observed a number of mental health disparities particularly affecting Hispanic and Black people. In the Hispanic population, the researchers observed higher reported mental health need, while the inverse was observed for Black people.

The former could be the result of economic differences further perpetuated by job loss and hardship during the COVID-19 pandemic. Additionally, so-called public charge rules and fears of immigration enforcement caused healthcare access problems across the care continuum, potentially including mental health, the researchers said.

The latter trend regarding Black populations could be attributed to social stigma, they team posited.

“Stigma, lack of trust in the medical system, and systemic barriers are all possible factors as to why Black adults report lower rates of both mental health illness and seeking treatment,” the researchers concluded. “Understanding the cultural differences that may be associated with the mental health burden should be an aim of future research.”

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