Tag Archives: Medicare

Changing the conversation about aging

By Lindsey Phillips January 10, 2018

Picture a grandson trying to help his grandfather adjust the tracking on his VCR. In the corner, the grandson’s friend jokes that they are ignoring the larger issue — that no one uses VCRs anymore. When the grandfather starts talking about his life, the young men make up an excuse to leave, but the grandfather captures their attention with a story about his experience during the war. By the end, the young men are eager to spend more time with him.

This is the opening scene from an episode of the Netflix comedy series Master of None. The episode, titled “Old People,” effectively exposes and challenges ageist stereotypes.

For some people, even the phrase older adult conjures up negative images of physical and cognitive impairment. But ageist stereotypes, such as older people being out of touch, do not reflect the typical experiences of older adults. Aging is a natural part of life, and many people age well. In fact, only approximately 5 percent of older Americans live in nursing homes at any given time, according to the American Psychological Association.

AARP is attempting to reverse this negative narrative with its #DisruptAging campaign, which provides a space for changing the story about aging and embracing life throughout the life span. In a recent post, AARP used the phrase gray-cial profiling to call out companies guilty of age discrimination. These offenses range from identifying older adults as potential shoplifters to excluding older adults from certain career opportunities.

Unfortunately, the issue of thinking negatively about aging often extends to health care professionals, many of whom view aging as a problem to be solved rather than a normal part of the life span. In addition, they often focus on the physiological aspects of aging rather than the psychological, social and spiritual needs of older adults.

Many interventions across disciplines focus on deficits, observes Sara Bailey, a doctoral candidate at the University of North Carolina at Greensboro (UNCG). For example, some gerontology, nursing and medical programs use an aging suit — a suit that simulates the physical impairments of older adults, such as strength and sensory loss — to expose students to the impairments of older people. “That basically conditions the student to understand that age and impairment are the same thing,” argues Bailey, a member of the American Counseling Association.

In his work in long-term care facilities, Matthew Fullen, an assistant professor of counselor education at Virginia Tech, noticed that conversations between older adults and health care providers often focused on physiological deficits. From his perspective, this scenario contributes to the medicalization of aging and tells only a narrow piece of the overall story. “If we assume that [physiological changes] are only going to be moving in a deficit direction, then we sort of get the self-fulfilling prophecy where we see those problems and we don’t see the rest of the person in front of us,” Fullen explains.

Most older adults don’t develop dementia or lose their ability to walk, be funny or engage with others, so “it’s important to expose [counseling] students to the reality of [aging] instead of pathologizing it,” Bailey says. To assist with this process of introspection, she challenges counseling students to find a birthday card for someone beyond the age of 18 that doesn’t rely on disparagement humor. Bailey refers to this type of humor as future-focused self-loathing: “When we laugh at getting older, we’re really laughing at ourselves, and we’re not laughing in a kind and loving way. We’re laughing in a way that others our future selves, and that’s not OK.”

The forgotten population

The level of importance placed on gerontology in counseling has not been clear or consistent. In 1975 in the Personnel and Guidance Journal, Richard Blake called attention to counseling older adults, a population he deemed “forgotten and ignored.” Then, gerontological counseling gained forward momentum. In 1986, the Association for Adult Development and Aging (AADA) became a division of ACA. Between 1990 and 1992, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) adopted gerontological counseling standards for community counseling programs, and the National Board for Certified Counselors (NBCC) created a specialty certification in gerontological counseling. However, because of declining interest, NBCC retired this certification by 1999 and CACREP removed the gerontological counseling standards by 2009.

This de-emphasis on later adulthood in counseling education motivated Bailey to pursue a doctorate in counseling and become part of the solution by specializing in later adulthood. At her first counseling education and supervision conference, she discovered that the gerontological counseling certification no longer existed. She says this led her to wonder, “What does this say about the focus of counselor educators? What does it say about the value of our clients and who we value more?”

In the United States, the older adult population is projected to more than double from 46 million to over 98 million by 2060, according to the Population Reference Bureau, and the Institute of Medicine notes that nearly 1 in 5 older adults has one or more mental health or substance use disorders. This raises a question: Why isn’t the counseling profession doing more to prepare counselors to care for this rapidly growing and vulnerable population?

Fullen, an ACA member who also serves as secretary of AADA, argues that counselors lack awareness about aging issues. This lack of awareness may stem from a range of factors, including the fact that older adults are a segmented part of the population, he says. Fullen also posits terror management theory as a possible explanation: Counselors fear the aging process because it reminds them of their own mortality.

In a course on life span development, Amber Randolph, an assistant professor and program director of the clinical mental health counseling program at Judson University in Illinois, discovered that her entire class of 25 students was terrified to discuss the end of life. “We’re turning out counselors who are going to be dealing with grief and loss issues who are very uncomfortable with the idea of death and, in particular, the idea that they too will age and die,” notes Randolph, a member of ACA.

This anxiety over aging can lead to the avoidance of older adults’ needs. Humans are the only species aware of their own mortality, so avoiding working with older adults is often not a conscious decision but rather an aversion to fear, Bailey adds.

Bailey is directly addressing counselors’ resistance to incorporating later adulthood within counselor education. Her research focuses on reintegrating gerontological competencies into existing coursework, which she believes will be a less objectionable approach. “I think it’s going to take a sea change in the way we view culture to start to include age in our developmental courses, in our career courses, in our theories courses, in our diversity courses,” she says. That might mean really integrating “the competencies that used to exist … in a subtle, gentle, very fluid … way so that every counseling course covers the age span,” she adds.

Bailey thinks that emotionally connecting counselors with aging issues is key. “You can talk about issues of late adulthood, but until you connect emotionally with the student around those issues … it just doesn’t click.”

To improve empathy and attitudes toward older adults, Bailey developed a perspective-taking intervention that includes three parts. First, in a journaling activity, counseling students describe their future 75-year-old selves. The second part is a game in which the students read prompts describing ageist events and then immediately reflect on the emotional reactions they would have if they were the older adult. In the third part (a reflective journaling activity), the counseling students consider their feelings and reactions toward counseling a 90-year-old client who shows symptoms of depression.

Age as an intersecting identity

Intersectionality is often discussed in terms of the interconnections between a person’s identities of race/ethnicity, gender, sexual orientation and class, but age typically gets overlooked. “Age is the only one of these marginalized identities that every single person will experience granted that they live long enough,” Fullen says. Even so, he points out that little research exists within the counseling profession on intersectionality that includes aging. “The client’s age just becomes another intersection piece that fits in very appropriately with all of those other constructs. So I’m more concerned with the ability of counselors to consider age as another intersection.”

Christian Chan, an assistant professor of counseling at Idaho State University and an ACA member, also encourages counselors to discuss intersectional identity with clients. “There are microaggressions that exist because of those intersections,” he says. For example, an older adult may refuse to socialize with someone who is gay. Thus, diversity exists between and within identity categories, and the way people navigate their overlapping forms of privilege and oppression provides them with their unique experience, he explains. By putting these identities into conversation, counselors can help clients understand what is happening to them.

This conversation about intersectionality is crucial because the growing population of older adults is also becoming more diverse. According to the Centers for Disease Control and Prevention, between 2014 and 2060, the percentage of adults age 65 and older who identify as white non-Hispanic is expected to drop from 78 percent to 55 percent. In addition, according to the University of Washington’s School of Social Work, approximately 2.7 million U.S. adults age 50 and older identify as lesbian, gay, bisexual or transgender, but that number is expected to increase to more than 5 million by 2060.

Counselors should avoid speaking about diversity in a broad sense, cautions Chan, who serves on the AADA executive board. He explains that when counselors focus on the centrality of one type of identity, they lose sight of the other identities and the way these intersections affect experiences, which can lead to the rank order of identities. For example, counselors often talk about LGBTQ+ (lesbian, gay, bisexual, transgender, queer/questioning and others) communities and older adult communities in isolation rather than discussing the overlap between these identities.

Instead of asking broad questions (e.g., “How do you identify culturally?”), Chan advises counselors to use specific questions (e.g., “How would you identify in terms of your racial/ethnic identity?”) to engage in a richer conversation with clients. The simple act of including open-ended space for identity on preliminary assessments and intake interviews — for instance, by replacing check boxes with fill in the blanks — can help counselors understand a client’s multiple identities and possible intersections, he adds.

Mijin Chung, an ACA member and licensed professional counselor (LPC) with a private practice in the greater Atlanta area, also sees a danger in discussing diversity broadly. When working with older adult immigrants, for example, counselors should examine the home country and family culture of clients and avoid making broad generalizations based on age or culture, she says, because a significant number of within-group differences exist. Therefore, it is crucial for counselors to understand the environmental context of older adult clients. For example, immigrant older adults who came to the United States when they were young may have a different view of aging and U.S. culture compared with immigrant older adults who recently came to the country and perhaps live with their adult children.

Chung finds the narrative approach helpful when working with older adults, and especially with older adult immigrants, to uncover clients’ unique experiences. Often, Chung says, this population does not receive many opportunities to share their life or immigrant stories. With a narrative approach, counselors can glean the obstacles and challenges older adults have overcome, and clients’ stories can provide counselors with a frame of reference for how to proceed in session.

Counselors must also remember that intersectionality is more than just multiple identities, Chan says. “You can’t have intersectionality if you’re not talking about power; you can’t have intersectionality if you’re not talking about social context; you can’t have intersectionality if you’re not talking about social justice,” he explains.

Fullen agrees that intersectionality is about the way that multiple identities lead to power differences or marginalization. In fact, disparities often emerge when marginalized identities such as race and sexual orientation are combined with an older adult experience. For example, an older LGBTQ+ individual may face barriers to finding safe housing options, such as denial from entry or a higher probability of eviction. These barriers are further complicated if this older individual has a disability that limits mobility or a lower income because of decreased access to income opportunities, Chan says.

Counselors should think about how they can help to make systemic changes to ensure that multiple marginalized communities are visible and have rights and access to opportunities and basic care, Chan argues.

A hidden reserve of resilience

Resilience — an individual’s ability to recover from adversity — is often a coping skill that we attempt to teach to children, but research shows that resilience can have a positive effect in later adulthood as well. According to an article by Tara Parker-Pope in The New York Times this past summer, scientists claim that resilience operates like an emotional muscle that can and should be strengthened with techniques such as being optimistic, reframing your personal narrative and remembering challenges that you have overcome.

Of course, building resilience isn’t easy and takes practice. To further complicate matters, resilience is a contested term among gerontological scholars, who debate whether it is something that only certain people possess. Fullen rejects this all-or-nothing view and instead assumes that every person possesses some degree of resilience.

With this core assumption, Fullen and Sean Gorby, a doctoral candidate in counselor education at Ohio State University, piloted a Resilient Aging program, which they believe holds the potential to enhance participants’ perceptions of resilience and wellness. In their pilot study, Fullen and Gorby helped marginalized older adults identify connections between their histories and the ways they had already shown resilience throughout their lives, with the hope that participants could apply this resilience to their present situations.

After Fullen and Gorby introduced the term resilience and allowed the participants to generate their own definitions, the older adults easily identified moments of resilience in their own stories or the lives of others. “Those resilience examples became … counternarratives to the larger societal narratives about aging being only a time of decay and decrement,” Fullen says.

In his prior research, Fullen had noticed that people who are marginalized seemed to possess a hidden reserve of resilience. The pilot study for the Resilient Aging program served as a lightbulb moment for him because he was able to see it in action. “It was a chance for us to better understand the way that people who have been overlooked at various points throughout their lives develop this sort of reserve of resilience that perhaps better equips them to handle some of the challenges associated with aging because this isn’t the first time the deck had been stacked against them,” he explains.

Thus, rather than discussing a marginalized identity such as age only in terms of oppression and deficits, counselors also need to highlight resilience and make it a part of the conversation, says Chan, a past president of the Maryland Counseling Association. “What is so beautiful about working with older adults is that they have such rich narratives [in] their lives. … They have found ways to navigate and make sense of not only their identities but their experiences,” he points out.

Empathizing and reframing clients’ stories

Fullen realizes that using a resilience-based approach requires counselors to walk a tightrope between empathizing with clients’ lived experiences of the difficulties of aging and pointing out an alternative viewpoint. “It’s important not to lose [the] client by jumping too quickly into strength and resilience,” he warns. “[Counselors should] spend some time … building rapport in regard to their grief or their sense of lament related to the aging process but then start to integrate this alternative narrative, alternative conceptualization, that is more strengths oriented or resilience orientated.”

Fullen provides an example of how counselors can navigate this delicate balance in a counseling session. Suppose a client says, “I’m just fed up with this friction between me and my kids. I remember when I was the one calling the shots for them, and now all of a sudden, the tables have turned and I’m not happy about that.” First, the counselor needs to be empathetic, Fullen says. For example, the counselor could say, “Wow, that must be really difficult. It can’t be easy to spend so much of your life being the one who’s providing and now all of a sudden having your kids try to provide for you.” This is not the time to correct the client’s perception of what he or she is going through; instead, the counselor should join the client in understanding how difficult the transition is for the individual, Fullen advises.

As the session unfolds, the counselor can begin a more formal assessment of the client’s perception of how he or she is doing across the wellness domains (emotional, physical, occupational, social, spiritual and intellectual wellness) and how the client views the aging process, which will elicit any age-related bias that the client has internalized, Fullen notes. This is also the time to ask broad questions about resilience, he advises. For example, the counselor could say, “It sounds like things are so challenging right now. I can’t imagine this is the first time that you’ve been through a really challenging situation. So, tell me about how you have shown resilience over the course of your life when it comes to facing really difficult situations like the one you are talking about.”

Fullen notes a broad question that is particularly helpful for counselors to ask when working with marginalized clients: “How have you survived? You’ve been through so much. You continue to go through so much.” This question allows clients to talk about resilience — even if they don’t use that language, Fullen says. Then the counselor can introduce the term resilience by saying, “That is so fascinating to hear about all the ways that you have survived over the years. In my profession, we have a word for that, and the word is resilience. Are you familiar with that concept? What do you make of that concept?” This process subtly introduces a counternarrative to the dominant ageism narrative for both the client and counselor, Fullen says.

If clients begin talking about their history of resilience, then the counselor can incorporate resilience language and help them reframe their stories as resilient ones, Fullen suggests. However, if a client pushes back and says, “I don’t know what resilience has to do with anything,” that indicates the client needs more time to unpack the situation and vent, he says.

The future of gerontological counseling

Despite the obvious need to work with older adults, the counseling profession has slowly de-emphasized gerontology. This has left Fullen to wonder whether gerontology and Medicare reimbursement are priorities for the counseling profession or whether gerontological counseling will survive only as a niche in the future. Currently, Medicare, the federal health care insurance program for people 65 and older, does not cover LPCs.

There seems to be a sense that once Medicare reimbursement for LPCs is achieved, counselors will make gerontological counseling a priority, but that is problematic, Fullen says. He questions whether counselors would be as complacent if an insurance issue hindered their ability to work with another population group, such as children. “We would find ways to innovate. We would find ways to bang that door down,” he asserts.

Fullen points out that although approximately half of older adults’ mental health services are paid for by Medicare, that leaves another 50 percent of mental health care dollars tied to this client population that the counseling profession isn’t tapping into regularly. Counselors need to explore alternative strategies such as private pay, grant opportunities and supplemental insurance, which haven’t received as much attention, he says.

Bailey has heard similar arguments indicating that the counseling profession’s relative lack of interest in serving the older adult population stems from the lack of progress in securing Medicare reimbursement. From her perspective, that makes gerontological counseling a social justice issue. “If we are simply discounting an entire population of people because we can’t make money off of them, that’s a problem that goes well beyond counselor education and CACREP Standards,” she says. “That goes to the heart of the counseling profession.”

“Across the entirety of the profession, there have been inconsistent commitments to the needs of this population,” Fullen asserts. This inconsistency directly affects counseling students, who may struggle to find gerontology-related courses and internships or even counseling professors who are truly knowledgeable in that area.

With the discontinuation of both NBCC’s specialty certification for gerontological counseling and CACREP’s gerontological counseling standards, counselors often must go outside the profession and counseling education departments to receive gerontological training. After developing an interest in working with older adults during her master’s program, Randolph noticed the lack of a gerontology specialization or certification within the counseling profession when she was applying for doctoral programs. To address this, she earned a certificate in gerontology through the continuing education department at the University of Wisconsin–La Crosse.

Bailey is also taking an interdisciplinary approach to gerontological training. She is in the process of finishing a post-baccalaureate certificate in gerontology from the gerontology program at UNCG.

There is a silver lining, however. Namely, the counseling profession already teaches and embraces qualities essential to working with older adults. For instance, counselors focus on using wellness and strength-based approaches, being client oriented and building meaningful relationships. The fact that wellness is vital to the work that counselors do is significant, Fullen says, because wellness can be the antidote against the tendency to view aging through a medicalized lens.

In addition, AADA provides resources and support for counselors who want to work with older adults but do not feel adequately trained. “[AADA’s] overarching goal is to make sure that there are counselors out there who feel prepared to meet the needs of our rapidly aging population,” says Randolph, who serves on AADA’s executive board. In addition, the AADA Older Adult Task Force is focused on expanding and promoting research, advocacy and practice related to older adulthood so that full-time practitioners do not feel alone in working with the older adult population, Fullen says.

Avoiding gray-cial profiling

Earlier this year, Allure magazine made a bold move to stop using the word anti-aging. Acknowledging that language about aging matters, editor-in-chief Michelle Lee challenged readers to consider how the simple act of removing the qualifier “for her age” from a statement such as “She looks great for her age” changes the meaning. Jo Ann Jenkins, CEO of AARP, praised the decision and stated that AARP would follow suit and avoid falling prey to the “anti-aging” trap.

This action highlights the power and danger of ageist language. Counselors steeped in societal ageism and ageist language may incorrectly assume that counseling won’t work with older adult clients, or they may focus only on the physiological aspects of aging. However, as Bailey points out, all people, regardless of age, are still developing. “People can learn throughout the life span. … People can develop new habits and change old habits. … As long as there is air in the lungs, there is potential for change.”

Even though the counseling profession is well-positioned to serve the growing, diverse population of older adults, it often leaves them out of the conversation, committing its own gray-cial profiling. “It’s an open question of whether or not [counselors] will rise to the occasion and start to think in a more sophisticated way about these issues,” Fullen says, “or whether [they’ll] want to continue to keep [their] heads in the sand.”

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia. She has a decade of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

ACA advocates for Medicare bill on Capitol Hill

By Bethany Bray July 20, 2017

ACA leaders gather for a day of advocacy on Capitol Hill on July 18. (Photo by Paul Sakuma)

A bill that would allow professional counselors to be reimbursed for the treatment of clients under Medicare has been introduced in the House of Representatives, and more than 100 counseling professionals added to its momentum by advocating in person on Capitol Hill earlier this week in an event organized by the American Counseling Association (ACA).

Currently, Medicare does not reimburse licensed professional counselors (LPCs) for the treatment they provide for older adults who carry this federal insurance coverage. However, ACA is advocating for a bill that would add LPCs to the list of providers who can be reimbursed under Medicare – a list that already includes clinical social workers and marriage and family therapists. H.R. 3032 was introduced last month by Rep. John Katko (R-N.Y.) in the House of Representatives, and a companion Senate bill is expected to be introduced shortly by Sen. John Barrasso (R-Wyo.) and co-sponsored by Sen. Debbie Stabenow (D-Mich.).

H.R. 3032 currently has three co-sponsors: Reps. Mike Thompson (D-Calif.), Elise Stefanik (R-N.Y.) and Zoe Lofgren (D-Calif.). If passed, the measure would add an estimated 165,000 mental health providers to the Medicare network, providing much-needed access to care for older adults in the United States.

On July 18, 125 ACA members from across the United States visited the Capitol Hill offices of their senators and House representatives to ask for support for the Medicare bill. The counselors were gathered in Washington, D.C., for ACA’s annual Institute for Leadership Training (ILT), a four-day conference of education sessions, trainings and business meetings for leaders in the counseling profession.

“In the United States, exercising our First Amendment rights under the Constitution is vitally important to ensure that we have a strong and responsive government,” said ACA Director of Government Affairs Art Terrazas. “I am so happy that we were able to help ACA leaders from across the country meet and speak with their federal lawmakers about the needs of the counseling profession.”

Amanda DeDiego, an ACA member from Casper, Wyoming, talks with Sen. John Barrasso (R-Wyo.) in his Capitol Hill office. (Photo by Bethany Bray)

Amanda DeDiego, an ACA member from Casper, Wyoming, met with Sen. Barrasso to thank him for his upcoming sponsorship of the Medicare bill. Barrasso expressed his support for the issue, saying “the needs are great” in Wyoming. For example, the average life expectancy on Native American reservations is 47 years – decades below that of Wyoming’s general population – and issues related to mental health are part of the cause, Barrasso said.

A delegation from the American Counseling Association of New York (ACA-NY) met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for co-sponsorship of the bill that Barrasso soon will introduce in the Senate.

ACA-NY leaders Summer Reiner, Allison Parry-Gurak and Tiphanie Gonzalez (ACA-NY president) explained that LPCs have training and graduate coursework that is equal to or exceeding that of the social workers and other mental health practitioners currently covered under Medicare. In the rural parts of New York, a dearth of mental health providers already exists, and that number shrinks further for people who rely on Medicare coverage for treatment, Reiner explained.

“There’s a huge need,” said Reiner, an associate professor at the State University of New York (SUNY) in Brockport and ACA-NY past president. “There are more than enough clients to go around, and we all have a different perspective for a reason.”

“We’re very much cousins in the exact same family, with different specialties,” agreed Gonzalez, an assistant professor at SUNY Oswego.

ACA members who visited legislative offices on July 18 also advocated for full funding of the Title Four block grant as part of the Every Student Succeeds Act (ESSA). The grants, some of which goes to support school counseling programs, were funded at $400 million, or just 25 percent of the $1.6 billion that was authorized this year. President Trump’s proposed budget for 2018 recommends no funding for the block grant at all.

Terrazas, in a training session held prior to the Day on the Hill event, urged the assembled ACA leaders to follow up with their legislators, stay informed and continue pushing for issues that are vital to the counseling profession.

“Advocacy doesn’t start and end with just this day [on Capitol Hill] tomorrow; it is year-round,” said Terrazas.

 

ACA members from Louisiana speak with staff in the office of Congressman Steve Scalise (R-La.) on July 18. (Photo by Bethany Bray)

 

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By the numbers: ACA Day on the Hill 2017

125 ACA members from 37 states, plus the District of Columbia, U.S. Virgin Islands and Puerto Rico, visited 74 Senate offices and 95 House offices

ACA President Gerard Lawson also met with

  • James Paluskiewicz, staff, House Committee on Energy and Commerce
  • Nick Uehlecke, staff, House Committee on Ways and Means
  • Allison Steil, deputy chief of staff, U.S. House Speaker Paul Ryan (R-Wis.)
  • Wendell Primus, office of House Minority Leader Nancy Pelosi (D-Calif.)

 

Cynthia Goehring and Sarah Shortbull, ACA members from South Dakota, met with Sen. John Thune (R-S.D.) on July 18. (Photo by Paul Sakuma)

 

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ACA awards Murray, Lieu

ACA has recognized Rep. Ted Lieu (D-Calif.) and Sen. Patty Murray (D-Wash.) with an Illumination Award for their work against harmful conversion therapy. Lieu and Murray have introduced bills in the House and Senate, respectively, that would classify commercial conversion therapy and advertising that claims to change sexual orientation and gender identity as fraud.

An ACA delegation met Murray on July 18 to recognize her on Capitol Hill; Lieu was previously honored at last month’s Illuminate symposium, a three-day conference in Washington, D.C., focused on the intersection of counseling and lesbian, gay, bisexual, transgender, questioning or queer (LGBTQ) issues.

Sen. Patty Murray (center left, in grey suit) is given an ACA Illumination Award on July 18 by ACA Past President Catherine Roland, current ACA President Gerard Lawson and ACA President-elect Simone Lambert, along with ACA members from Washington state. (Photo by Paul Sakuma)

 

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To stay up-to-date on the Medicare bill and other current issues, sign up for updates from ACA Government Affairs at counseling.org/news/aca-blogs/aca-government-affairs-blog

 

Search for the hashtag #ACAILT2017 for social media posts from ILT and the Day on the Hill

 

See more photos on the ACA flickr page: flickr.com/photos/23682700@N04/albums/72157686345016025

 

A delegation from the American Counseling Association of New York (left to right) Tiphanie Gonzalez (ACA-NY president), Summer Reiner and Allison Parry-Gurak met with staff in the office of Sen. Kirsten Gillibrand (D-N.Y.) to ask for cosponsorship of the Medicare bill that Sen. Barrasso will soon introduce in the Senate. (Photo by Bethany Bray)

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

 

Have you gone gray?

By Matthew Fullen June 27, 2016

The United States is going through a rapid demographic shift unlike anything it has ever experienced. Approximately 10,000 Americans are turning 65 every day. Meanwhile, the average life span in the United States has increased to approximately 81 years for women and 76 years for men, with a significant number of people living well beyond those ages.

By 2030, demographers project that 70 million people, or about 20 percent of the U.S. population, will be 65 or older. Industries ranging from health care to technology to real estate have taken note of this emerging trend and are identifying how best to respond to the needs of an older population. Although a great deal has been written about how an aging population will affect the need for biomedical services, the story of how older people maintain optimal mental health throughout the life span has received far less attention.

First, the good news. Research indicates that older adults report the highest levels of life satisfaction when compared with young and middle-aged adults. Older adults are more likely to report a satisfying marriage, and they outperform younger individuals when it comes to remaining calm during times of stress. Subjective well-being is particularly high when older people perceive that they have adequate social support; have a sense of control and mastery, opportunities to derive meaning through paid or unpaid work and a positive perception of their age; and when they participate in spiritual or religious practices. Therefore, for many people, older adulthood can be a very fulfilling phase of life.

On the other hand, a large number of people 65 and older need mental health care but do not have adequate access to it. Approximately 20 percent of adults 65 and older meet the criteria for a mental disorder. Older adults with mental disorders experience higher rates of functional disability than those with a physical illness alone. They also experience poorer overall health outcomes and higher rates of hospitalization. Economically, these factors result in medical costs that are 47 percent to 200 percent higher for older adults with a mental disorder than for other older adults. Furthermore, older Americans are disproportionately likely to die by suicide, with older white males in particular having one of the highest rates of suicide.

Access to mental health services

Why is there such a discrepancy between the preponderance of older adults who experience increased life satisfaction in old age versus those who are at risk for depression, anxiety and suicide? One factor often cited in the research is older adults’ lack of access to mental health care.

In a recent study of older Americans, only 3 percent reported seeing a mental health professional, the smallest percentage of any age group. It is likely that stigma related to aging and mental health is at least partially to blame. For instance, previous cohorts of older adults came of age in an era when mental health services were far more stigmatized. Instead of seeking services from mental health professionals, older people are more likely to share their complaints with primary care providers, family members or friends. It is worth noting, however, that the current generation of individuals turning 65, known as the boomer generation, is likely to be more open to discussions about mental health.

Stigma also exists in the form of cultural myths about aging that create barriers to older adults seeking help for mental health concerns. For instance, despite the previously cited research about older adults’ high levels of life satisfaction, many people mistakenly believe that depression is a normal feature of growing older. A myth that may influence clinicians is the notion that certain problems associated with aging — including the increased likelihood of one or more chronic health conditions, the loss of a loved one and existential concerns related to meaning and life purpose — will not be responsive to counseling treatment.

Practical skills for counseling older adults

In reality, older adults are excellent candidates for counseling services. They respond to treatment as well as or better than members of other age groups. The counseling profession is particularly well-situated to provide effective services to older adults because of its emphasis on life span development, wellness and attention to diversity. Three practical strategies can promote the work of counselors with this population.

First, it is important for counselors to consider the developmental needs of older adults. Historically, human development theorists, including Sigmund Freud, suggested that development stopped around age 40. Although this seems laughable today, the assumption that most growth and change occurs early in life is still reflected in sayings such as “You can’t teach an old dog new tricks.”

In fact, in a 2000 study, Paula Danzinger and Elizabeth Welfel found that despite identical symptom profiles, mental health professionals rated older clients as having a more negative prognosis when compared with younger clients. Therefore, when working with older clients, it is imperative for counselors to challenge this myth, first in their own minds, but also potentially with clients who do not believe in their capacity to make changes at this point in their lives. For instance, recent findings in neuroplasticity suggest that humans are capable of making changes to their attitudes and behaviors across the life span. When counselors reflect this viewpoint in session, they provide hope to clients who may have otherwise resigned themselves to a particular problem or mindset.

Next, counselors should consider the use of a wellness perspective when assessing and treating older adults. Although the wellness paradigm is increasing in popularity, its use with older adults has lagged behind, both in research and clinical applications. However, older adults are prime candidates for the use of a wellness approach for multiple reasons.

First, a great deal of research indicates that a broad range of variables influence older adults’ longevity and quality of life. These variables include strong mental and emotional health, reciprocal social relationships that are perceived as supportive, participation in preferred spiritual or religious practices that provide meaning and purpose, a belief that one has at least some control over circumstances and a positive perception of aging. A recent example of the multidimensionality of older adults’ needs was demonstrated in a 2015 study by Kelley Strout and Elizabeth Howard. The researchers found that emotional wellness was the highest predictor of cognitive health, followed by physical and spiritual wellness as additional significant variables. Therefore, counseling interventions that bolster emotional wellness may influence brain health in later life.

Similarly, there is growing interest in the concept of resilience among older people. Given the wide range of challenges that may accompany older adulthood, some gerontologists suggest that resilience should be used as a primary measure of what it means to age well.

In research supported by the Association for Adult Development and Aging (AADA), a division of the American Counseling Association, Sean Gorby and I recently piloted a program in which older adults participated in a counseling group focused on how participants had demonstrated resilience in various domains over the course of their lives. Group members identified adversities they had experienced, including physical and functional setbacks, emotional distress, changes in social relationships and spiritual and existential hardships. Participants then shared personal stories about resilience, either in their own lives or in the lives of others, and discussed how this could be manifested once again with the current challenges they were facing.

At the conclusion of the group, we found that participants perceived themselves as more resilient. This indicates that counselors may be able to tap into the reserves of resilience that older clients possess, using discussions of resilience to help these clients restructure their self-concepts around adversity and their ability to bounce back.

Finally, in spite of cultural assumptions to the contrary, older adulthood is an extremely heterogeneous phase of life. Cultural diversity and vast individual differences related to the aging process shape how older adulthood is experienced. For instance, a person’s chronological age, by itself, does not communicate a great deal of information about how one perceives life, nor does it directly correlate with overall health and wellness.

Most broad definitions of older adulthood use age 65 and up; however, there have been efforts within gerontological research to subdivide older adulthood into two segments, with the “young-old” representing individuals 65–80, and the “old-old” reflecting those who are older than 80. Although some research supports differing health and life experiences for individuals in these two groups, the division is still limited by the assumption that chronological age is aBranding-Images_gone-gray helpful descriptor. For instance, one’s health, holistic wellness and functional status may provide better information about what life is like than simply stating how many years one has lived. For this reason, some have argued for the use of biological or functional age as a more descriptive demographic than chronological age.

How one perceives his or her age can also be a telling indicator for quality of life and longevity. In fact, research by Becca Levy shows that older people with a positive age perception live significantly longer than those older adults who have a negative perception of their age, even after controlling for other health and demographic variables.

The older adult population is also rapidly becoming more diverse. In fact, ethnic minorities, particularly Latino and Asian/Pacific Islander elders, make up the fastest-growing subset of the older adult population. Furthermore, more than 2 million American older adults currently identify as lesbian, gay or bisexual.

In terms of socioeconomic diversity, a wide gap exists between older adults who have accumulated sufficient financial resources and the vast number of older adults who have either experienced poverty throughout their lifetimes or who are now on the edge of poverty because of recent changes to their health, relationships or work status. Therefore, counselors interested in working with older adults should anticipate that their clients will possess a diverse range of backgrounds and perspectives, and differing levels of health, wellness and functional abilities. Some counselors may encounter older adult clients who can afford to pay out of pocket for mental health services, whereas other counselors are likely to interact with older adults whose low income levels qualify them for subsidized housing or health care.

Counselors should recognize that growing older in America is not a monolithic experience. In fact, the diversity of perspectives related to the aging process is one of the most compelling features of working with older adults. Rather than older adults all being alike and resistant to change — as the cultural myth might suggest — older people possess a diversity of backgrounds and life experiences that can make the counseling experience particularly invigorating for client and counselor alike.

Strategies for including older adults in your practice

Counselors interested in working with older adults should be proactive about seeking opportunities to market their services to these clients. Counselors cannot currently bill Medicare. However, there are other ways to make a difference in the lives of older adults.

For instance, a 2012 report by the Institute of Medicine (now the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine) found that 47.5 percent of older adults’ mental health services were not paid for through Medicare. Non-Medicare payment sources included paying out of pocket (18.3 percent), supplemental private insurance (11.7 percent), Medicaid (11.4 percent) and other state and community programs (6.1 percent). Therefore, in addition to offering services directly to older clients, counselors can also market their services to local agencies on aging, community and neighborhood clinics with local service grants and capitated health service providers.

For some older people, seeking mental health treatment within a private practice or standalone mental health clinic may be appealing. However, I have found that linking mental health services to older adults’ housing, medical care and social services is an excellent strategy for providing integrated care and making mental health services more accessible to older clients. For instance, forming partnerships with primary care providers who view mental health treatment as a necessary and value-added component of integrated treatment can be an effective strategy for connecting with older clients. Counselors accustomed to the use of a wellness paradigm are familiar with the challenges of providing prevention and holistic wellness services to clients in a world of managed care and disjointed services. Therefore, instead of focusing solely on the need for Medicare reimbursement, entrepreneurial counselors may wish to consider how to extend the integrated wellness work that is already being done with younger clients to an older population.

Ongoing education and training are helpful to ensure that your counseling services are well-suited for older clients. Members of the counseling profession should look for continuing education or postgraduate training opportunities that will expand their understanding of the impacts that adult development and aging have on their clients. This could include:

  • Attending educational sessions at state or national counseling conferences
  • Joining AADA
  • Networking with other professionals in the aging sector by getting involved with a local area agency on aging
  • Seeking formal education in the form of a certificate program in gerontology at a local university

Counselor advocacy 

Given the rapid growth of the older adult population in the United States, there is a need for more mental health professionals who are both willing and able to work effectively with these clients. Although it is not the only means of access for mental health services, Medicare covers the majority of these services (52.5 percent) for older adults. Recently, there have been several critiques of the Medicare program for not doing more to address the growing number of older adults who need mental health treatment. According to the 2012 Institute of Medicine report, only 1 percent of the total Medicare budget was spent on mental health services (with a total budget estimated at $505 billion in 2014).

Advocacy for Medicare reimbursement of counselors is vital to expanding the mental health workforce. Two bills were introduced in Congress in 2015 calling for mental health counselors to be included as recognized Medicare providers: the Seniors Mental Health Access Improvement Act of 2015 (S. 1830) and the Mental Health Access Improvement Act of 2015 (H.R. 2759). Both bills have received bipartisan support in the past. However, it is common for legislative efforts to go through many iterations before becoming law.

Due in large part to the advocacy efforts of the counseling profession, there are currently numerous bipartisan co-sponsors for both of these bills. Recently, counselor advocacy efforts resulted in AARP writing a letter that supported passage of congressional bills calling for inclusion of counselors as Medicare providers.

To continue this momentum, it is imperative for all members of the counseling profession to raise awareness of Medicare’s lack of attention to mental health and the current restrictions that deny older adults the freedom to choose their mental health providers. Counselors should consider contacting their congressional representatives to provide awareness about the counseling profession and how it is uniquely situated to provide mental health care to older adults that is grounded in wellness, life span development and awareness of the diversity of older adults. Please consider contacting your senators and representative with a brief statement that advocates for S. 1830 and H.R. 2759. Contact information can be found at congress.gov/members, where you can sort by state to locate your senators or search by ZIP code to find your representative. (If you are interested in learning more about specific Medicare advocacy strategies, consider reading my April 2016 article in Adultspan Journal on this topic.)

Members of the counseling profession must also consider whether the current state of counselor training provides adequate exposure to the possibility of working with older adults. A 2009 study by Thomas Foster, Val Kreider and Jennifer Waugh found that counseling students had a high degree of interest in topics related to older adulthood, including the transition to retirement, helping families navigate the aging of a family member, providing support to caregivers and discussing issues such as dying and grief with clients. However, the authors suggest that counselors and counseling students lack opportunities to follow through with these interests.

At the programmatic level, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) specialization in gerontological counseling was discontinued in 2008 because of a lack of counselor training programs applying for accreditation in this area. Although the lack of Medicare reimbursement for counselors may influence the viability of a gerontology specialization, it is worth asking whether more could be done to promote work with older adults within counselor education programs. For instance, in reviewing the 2016 CACREP Standards, I found zero references to the words older, age or ageism, and only one reference to the word aging.

Anecdotally, I have had numerous conversations with counselors and students who express a great deal of interest in focusing more of their work on older adulthood but do not think they have adequate opportunities or knowledge to do so. Therefore, it is important for counselor training programs to assess their students’ interest level in working with older adults, identify practicum and internship sites that provide access to these individuals and participate in professional advocacy efforts to expand the role of counselors to meet the mental health needs of older adults. In addition, members of the counseling profession should work with their state counseling associations to coordinate state and local efforts to raise awareness within the community, as well as within the political arena, about the current state of older adults’ mental health access and the need for Medicare reform.

Conclusion

In summary, the “graying” of America is making its mark across a wide range of industries, including mental health. As more attention and public dollars shift toward the national challenge of promoting the health and wellness of an older population, members of the counseling profession will find themselves impacted in myriad ways.

Families will be affected by the growing number of older people living with chronic health conditions. Paid and unpaid caregivers will have greater responsibility for providing support to older adults. Topics such as retirement and lifelong vocation will be reconsidered as individuals work longer to make ends meet and spend their post-retirement years continuing to seek avenues for purpose and meaning.

In spite of the hurdles that remain, members of the counseling profession can support the growing number of older adults by providing mental health services that are developmentally appropriate, grounded in wellness and suited for a diverse range of older individuals. With that in mind, why don’t you go gray?

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

FullenMatthew Fullen is a licensed professional clinical counselor in Ohio. He has worked with older adults in a variety of contexts since 2005. He currently serves on the board of the Association for Adult Development and Aging and is completing a doctorate in counselor education with a specialization in aging at Ohio State University. Contact him at fullen.33@osu.edu.

Letters to the editor: ct@counseling.org

 

 

 

Medicare bill gains critical co-sponsor

By Bethany Bray November 23, 2015

U.S. Sen. Michael Bennet has agreed to co-sponsor a bill that would allow professional counselors to be reimbursed for care of clients who have Medicare health insurance, an issue the American Counseling Association has long advocated for.

The Colorado Democrat’s endorsement of the bill carries significant weight because he sits on the U.S. Senate Committee on Finance.

Bennet’s decision to co-sponsor the bill came after months of advocacy by American Counseling Association members in the Denver area. He is now one of 11 bipartisan lawmakers who co-sponsor the bill.

[Editor’s note: Soon after this article was posted, the bill gained another co-sponsor: Sen. Sherrod Brown (D-Ohio). As of December 2015, the bill has 12 co-sponsors.]

Senate bill 1830, or the Seniors Mental Health Access Improvement Act of 2015, would establish reimbursement of licensed professional counselors (LPCs) and licensed marriage and family counselors (LMFTs) for the treatment of clients whose primary coverage is Medicare, the federal

ACA member and LPCC Denise Magoto (on left) and LPC and licensed addictions counselor Katherine Bujak-Phillips are pictured at an advocacy to Sen. Michael Bennet's office this spring. Bujak-Phillips leads the LPC peer supervision group at the Medical Health Center of Denver, where Magoto works.

LPCC Denise Magoto (on left) and LPC and licensed addictions counselor (LAC) Katherine Bujak-Phillips are pictured at an advocacy visit to Sen. Michael Bennet’s office this spring. Bujak-Phillips leads the LPC peer supervision group at the Medical Health Center of Denver, where Magoto works.

health insurance program for citizens who are age 65 or older. Medicare has covered psychologists and licensed clinical social workers (LCSWs) since 1989, but does not cover LPCs.

“For years now we’ve ben hearing about the baby boomer generation coming onto Medicare. They’re already predicting shortfalls in healthcare, and mental health is no exception,” says Denise Magoto, an ACA member who has advocated for Bennet’s support of S.1830. “There’s not enough licensed clinical social workers to go around. We’re already seeing that shortfall.”

Magoto, a licensed professional counselor candidate (LPCC) at the Mental Health Center of Denver, is all too familiar with the headaches that counselors face over the Medicare reimbursement issue.

Every time a new client comes to the Mental Health Center of Denver, the intake department works to match the client with a clinician based on what insurance they have and whether or not the center would be reimbursed for their care.

“It really complicates the process,” says Magoto, who handles a caseload of clients with serious or persistent mental illness, often coupled with substance abuse.

The crux of the problem is that it keeps professional counselors from helping an entire slice of the U.S. population — more than 40 million people. Senior citizens are far from immune to depression, suicide and other mental health issues, Magoto notes.

Magoto has worked with the ACA government affairs team through the spring and summer to draw Sen. Bennet’s attention to the need for counselor reimbursement through Medicare. She has met with Priscilla Resendiz, a constituent advocate in Bennet’s office, twice; last month, Magoto gave Resendiz a tour of the center where she works.

Resendiz was “incredibly receptive,” Magoto says. When they met for the first time in May, what Magoto expected to be a 10-minute session stretched to an hour and a half.

Dillon Harp, grassroots organizer in ACA’s Department of Government Affairs, says local advocacy, like Magoto’s efforts, is critical for S.1830 to gain momentum and support.

“(Resendiz’s) visit and the tour were a huge success and it was instrumental in Senator Bennet co-sponsoring this important piece of legislation. Denise was able to highlight the important work that LPCs do and show the staff member why this bill must be passed,” says Harp, who attended Magoto’s meeting with Resendiz in October. “Getting Senator Bennet’s co-sponsorship was a major milestone in ACA’s efforts to get this bill passed. Obtaining Senator Bennet’s support was a crucial because of his seniority in the Senate and because he is a senior member who sits on the all-important Senate Finance Committee, which has jurisdiction over the Medicare program. ACA could not have secured Senator Bennet’s support without all the advocacy work that ACA members in Colorado performed.”

Bill S.1830 was introduced into the Senate on July 22 by Sen. John Barrasso (R-Wyo.) and co-sponsored by Sen. Debbie Stabenow (D-Mich.). After its introduction, the bill was referred to the finance committee; It won’t go for a full Senate vote until more co-sponsors support the bill, says Harp.

One lesson Magoto says she’s learned through this process is to never think that your hands are tied, or that you can’t do advocacy work if you aren’t politically savvy. She admits she’s a novice when it comes to the intricacies of government. Magoto simply knew there was a problem that was affecting her daily work as a counselor and contacted ACA to see what could be done.

“Initially I had some fear … The biggest thing that I’ve learned is that it (advocacy) is a learning process and that’s OK. It doesn’t mean you shouldn’t (advocate or get involved),” she says. “Even though I had no idea what I was doing, I had a resource [ACA] to reach out to and walk me through it.”

(Left to right) Katherine Bujak-Phillips, Priscilla Resendiz (constituent advocate in Sen. Bennet's office) and Denise Magoto.

(Left to right) Katherine Bujak-Phillips, Priscilla Resendiz (constituent advocate in Sen. Bennet’s office) and Denise Magoto.

 

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To get involved in ACA’s advocacy for the Medicare bill, and other issues that affect professional counselors, email Dillon Harp at dharp@counseling.org or visit counseling.org/government-affairs

 

To receive ACA’s Government Affairs newsletter and action alerts, email dharp@counseling.org

 

 

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Seniors Mental Health Access Improvement Act of 2015

Follow the bill’s progress at congress.gov: 1.usa.gov/1QysDjy

 

S.1830 co-sponsors (As of December 2015; listed in the order in which they agreed to co-sponsor)

Sen. Debbie Stabenow, D-Mich. (original co-sponsor)

Sen. Al Franken, D-Minn.

Sen. Kelly Ayotte, R-N.H.

Sen. Jon Tester, D-Mont.

Sen. Thomas Carper, D-Del.

Sen. Kristen Gillibrand, D-N.Y.

Sen. Charles Schumer, D-N.Y.

Sen. Susan Collins, R-Maine

Sen. Angus King, Jr., I-Maine

Sen. Richard Blumenthal, D-Conn.

Sen. Michael Bennet, D-Colo.

Sen. Sherrod Brown, D-Ohio

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook: facebook.com/CounselingToday

Medicare and counselors: Frequently asked questions

Scott Barstow, Christopher Campbell and Brian Altman January 7, 2006

At presstime, Congress was still considering budget reconciliation legislation that included language establishing Medicare coverage of state-licensed professional counselors. American Counseling Association members are strongly encouraged to check www.counseling.org/publicpolicy for updates on the status of this legislation and the possible need for grass-roots support for this provision. This website and the related website at http://capwiz.com/

counseling will include information regarding members of Congress to contact and suggested messages for discussing the issue.

To help familiarize counselors with both Medicare and the legislative process involved in working to gain recognition of counselors under this program, ACA’s Office of Public Policy and Legislation offers a list of “frequently asked questions” (and answers!).

 

Q: What is Medicare? Who are Medicare’s beneficiaries?

A: Medicare is the federally run and financed health insurance program covering an estimated 40 million older Americans (age 65 and older) and Americans with disabilities. Medicare is the single largest health insurance program in the country. It should not be confused with Medicaid, the health insurance program for low-income uninsured children and families funded jointly by states and the federal government. States control their Medicaid programs, including eligibility and benefits criteria, within certain basic federal guidelines. Congress controls Medicare, although the program is administered in each state by one or more intermediaries.

Q: How do I get a Medicare provider number?

A: Right now, you can’t. Currently, psychologists and clinical social workers are the only nonphysician mental health professionals covered under the program. Congress writes Medicare’s benefit package. At presstime, Congress had yet to pass (and the president had yet to sign) legislation establishing Medicare coverage of licensed professional counselors.

The Senate has passed legislation establishing Medicare coverage of state-licensed professional counselors and state-licensed marriage and family therapists, but this is only the first step in the legislative process. Before any legislation can be enacted, it must be approved in exactly the same text and format by three separate entities: the House of Representatives, the Senate and the president. (The House and Senate can enact legislation by overriding the president’s veto, but this is a rare occurrence.)

Q: Since Medicare coverage of counselors has passed the Senate, does this mean it’s going to become law in a certain amount of time?

A: No. The Senate has passed legislative language establishing Medicare coverage of counselors before, but without subsequent House approval of the same language. Each chamber (the Senate and the House of Representatives) routinely passes legislation that the other chamber chooses not to approve. Simply because the Senate has passed something doesn’t automatically mean it’s going to become law.

In this case, the Senate included a counselor coverage provision in its broad budget reconciliation bill, S. 1932. The House budget reconciliation bill does not include this provision. At presstime, a group of House and Senate members was working together to reconcile differences between the two bills. As mentioned previously, before a bill becomes law, the same exact language must be passed by both the House and the Senate and then be signed by the president. The House and Senate conferees on the budget reconciliation legislation are working through a long list of contentious issues.

ACA is working alongside the American Mental Health Counselors Association and the American Association for Marriage and Family Therapy to see that the counselor/MFT coverage provision is retained in the conference report (the name for the compromise version of the legislation written by the House-Senate conferees) developed on the budget reconciliation legislation.

Q: If the Medicare language passed by the Senate on counselor coverage is enacted, which counselors would be covered?

A: The provision passed by the Senate would establish Medicare coverage of state-licensed professional counselors who have obtained the highest level of licensure. Thus, the provision would not apply to any mental health counselors in states without licensure (California and Nevada). School counselors would receive reimbursement for services provided to Medicare beneficiaries only if they were licensed in their state as independently practicing mental health counselors.

Q: What groups are opposing this provision?

A: The only groups we know of opposing Medicare coverage of licensed professional counselors and marriage and family therapists are the American Psychiatric Association and the National Association of Social Workers. The opposition of these two groups is disappointing, if not surprising.

The American Psychiatric Association has a long history of opposing efforts to expand direct access to nonphysician providers (including psychologists, clinical social workers and licensed professional counselors) under Medicare and other public health programs.

The National Association of Social Workers appears to share the American Psychiatric Association’s desire to protect its members’ “turf” at the expense of patient access to services. This is despite the strong similarities in counselor and social work training standards and the fact that clinical social workers are routinely licensed with significantly less actual graduate coursework than licensed professional counselors. Many — if not most — graduate programs in social work give students as much as a full year of credit for bachelor’s level coursework.

Q: If counselor coverage is enacted, when would it go into effect?

A: Most likely sometime in 2007. Under the legislation passed by the Senate, coverage of state-licensed professional counselors would begin Jan. 1, 2007. However, House and Senate conferees on the measure could change this date. In addition, the U.S. Department of Health and Human Services and its Centers for Medicare and Medicaid Services will need time to develop regulations implementing this and any other changes in Medicare law. The regulatory process is sometimes painfully slow.

Q: Would getting Medicare coverage affect reimbursement under Medicaid?

A: Only indirectly. As noted above, states control their Medicaid programs and have free reign to cover (or not cover) many services and populations. Under federal law, state Medicaid programs must cover physicians’ services, but they are not required to cover psychologists’ services or those of other nonphysician mental health professionals. Recent budget shortfalls have forced nearly all states to cut back on their Medicaid programs.

However, Medicare coverage will help demonstrate to state officials that counseling is a legitimate mental health profession. This, combined with counselors’ cost-effectiveness, may cause more states to establish or expand coverage of counselors for their Medicaid beneficiaries.

Q: How would this affect private health plans?

A: Again, only indirectly. Changing the benefit package of one of the primary public health insurance programs doesn’t mean that private sector plans have to change anything. However, they will likely be more inclined to recognize and reimburse licensed professional counselors if they know we’re covered under Medicare. Medicare law prohibits “Medicare+ Choice” managed care plans from discriminating against providers on the basis of their type of license.

Q: How much does Medicare pay?

A: Medicare is not known for its generous reimbursement rates, and one of the major policy discussions taking place is the extent to which Medicare’s small payments to providers are leading them to stop seeing Medicare clients. Medicare pays for services through a complex fee schedule that takes into account the difficulty of the service provided, the resources necessary to provide the service and geographic cost factors.

Medicare generally pays 80 percent of the cost of outpatient treatment, with the beneficiary responsible for the remaining 20 percent. However, for outpatient mental health treatment, Medicare only pays 50 percent of the cost, with the beneficiary responsible for the other half. This inequitable copayment requirement remains unchanged in both the House- and Senate-passed bills.

The Senate’s bill would pay state-licensed professional counselors and marriage and family therapists at the same rates as clinical social workers. If and when this provision is enacted into law, counselors can find out what Medicare payment rates are for outpatient mental health services in their area by contacting their state’s Medicare carrier.

Q: Can I do anything to help Medicare coverage of counselors become law?

A: We think so! As stated previously, either check the ACA website at www.counseling.org/publicpolicy or contact Brian Altman with ACA’s Office of Public Policy and Legislation at 800.347.6647 ext. 242 or via e-mail at baltman@counseling.org to get an update on the status of this legislation.

If Congress hasn’t already decided on this issue by the time you receive this issue of Counseling Today, we may need you to contact your Representative to ask him or her to contact the respective chairs of the House Ways and Means Committee (Rep. Bill Thomas) and Energy and Commerce Committee (Rep. Joe Barton) to express support for Medicare coverage of licensed professional counselors.

You can find your Representative through the ACA Internet Legislative Action Center at http://capwiz.com/counseling. Since the Senate has already approved our provision, we need to focus on getting House members to support this as well.