The Mental Health Access Improvement Act and What it Means for Counselors

Guila Todd:

Welcome to the Voice of Counseling from the American Counseling Association. I'm Guila Todd from ACA's Government Affairs and Public Policy Team. Joining me today is Dr. Victoria Kress, and today we're talking about the recent passing of the Mental Health Access Improvement Act and what this means for counselors. Dr. Kress is a distinguished professor and the Director of the Clinical Mental health and Addictions Counseling programs at Youngstown State University. She has published over 130 articles and book chapters, and she has co-authored five books. She's the past president of Chi Sigma Iota International, the Association for Humanistic Counseling, the Ohio Counseling Association, and the North Central Association for Counseling Education and Supervision.

Guila Todd:

She is the past ACA Midwest region chair and she is a current member of the American Counseling Association's Governing Council. Welcome Dr. Kress. Thank you for being here today. As you know and as many as of the listeners know that getting the Mental Health Access Improvement Act signed into law has been a long journey. The original language for the bill was drafted 1999, if you can believe it. ACA, as well as their coalition partners have been working on this legislation for the better part of the decade, and the bill actually gets LPCs and marriage and family therapists reimbursed through Medicare while working with the Medicare population, which is older Americans and individuals with disabilities. Can you talk a bit about your experience of working with older Americans in the mental health space?

Dr. Victoria Kress:

Yes, yes. I'd love to talk about that, and thank you for the opportunity to bring voice to this important conversation. I appreciate you having me. There's so much that has gone into getting this Medicare legislation put into place. And I think it's really important that as a profession we take a moment to reflect on the history and all that has gone into this, and to pause on that. We can't move forward and advance our profession unless we really understand our history and all that has gotten us here. As you alluded to for decades now, counselors have been working on trying to get counselors Medicare reimbursements. I know that I first talked to a legislator about this in 1998-

Guila Todd:

Wow.

Dr. Victoria Kress:

Before there was even any formal policies and suggestions on the table. I think we've always all recognized that us not being included has been a tremendous oversight that has hurt our profession and has hurt those that we serve in the community.

Dr. Victoria Kress:

I just want to applaud ACA and all of our partners, and especially all of the counselors who have been boots on the ground, pounding on legislators' doors for so many years now to try to get this legislation put into place. Without ACA and its actions and leadership and without people reaching out to their legislators, none of this would've ever happened. So it's such an exciting time, and I hope that we can all take a moment to celebrate it. I think the most important part of advocacy is the last step of the advocacy model, which is celebrating. So I think we all have so much to be excited and grateful for.

Dr. Victoria Kress:

This really opens up an opportunity for us to provide desperately needed services to older Americans who have not had access to those services. It's estimated that about a third, 30, 40% even, of Americans, older adult Americans live in areas where they don't have access to mental health providers, and we know that older adults have many significant and important mental health needs that need to be addressed. So this legislation, while benefiting our profession tremendously, it is also going to provide access to care for people who desperately need it. I'm the director of a counseling clinic, and so many people reach out and tell me their stories about wanting to get counseling but not having access to counselors, and so this is going to really open that up to them.

Guila Todd:

Yeah. I know from a lot of our meetings with congressional leaders, and for those meetings, we bring a lot of ACA members who are their constituents, and we hear those stories about their clients who age out of receiving mental health services from their counselor or have to pay out of pocket. Can you talk a bit about how some of your clients, how this may save them financially from having to pay out of pocket for those services?

Dr. Victoria Kress:

Absolutely. So many people need the services and they've not been able to get access to them, and so as you alluded to, what happens is when they age out of say Medicaid, or then they go into Medicare or they no longer have private insurance and go into Medicare, they have been losing access. Maybe it's to providers that they've already had in addition to not being able to access providers that they need because there just aren't enough mental health providers out there. So it's exciting because they won't have to pay out of pocket for service and they'll also have much broader access to getting well-trained, qualified mental health providers who can give those services to them. Something else that's really important to acknowledge is that there are a significant number of people who receive Medicare who are not necessarily older adults. I believe about nine million people with disabilities under the age of 65 also receive Medicare.

Dr. Victoria Kress:

And so that has been a real issue as well. People don't realize counselors, mental health counselors are one of the primary providers of mental health services all over the country. Another issue related to this is when we think about the opioid epidemic and addiction counseling services, many people don't realize that about a third of addiction services and inpatient settings are paid for by Medicare. So here again, data shows that counselors are the primary provider of addiction services around the country, yet we, in the midst of this opioid epidemic, haven't been able to be reimbursed for providing these services.

Dr. Victoria Kress:

We know that most of the clients who counselors serve can't afford to pay out of pocket. Counselors, we're out there in the trenches working with people who have less resources and who are more disadvantaged. These are not people who can afford to pay out of pocket. So what this is going to do, broadly speaking, is provide people who desperately need services with the services that they need so that they can be well and live their best lives.

Guila Todd:

While you were talking, I was just thinking about some of the congressional meetings we've had had over the years, because a lot of times when we meet with members of Congress, we talk about how it's a workforce issue. It will provide more mental health providers, about 200,000, once the passage of the bill takes place. But one of the things that's most important to clients as well as LPCs, is about continuity of care and how once you have to stop seeing a client, how oftentimes they deteriorate because they can't receive that mental health treatment. Can you talk a bit about some of the experience you've had with clients who've had to stop receiving mental health services because they've aged out? And do they ever come back, or how does that work in your experience?

Dr. Victoria Kress:

Yes, it's such an important issue. When clients age into Medicare and they can no longer receive services from counselors, it creates a lot of problems for them in terms of the quality of care that they're receiving. It's really difficult to pick up and start over with a new provider. You've worked with someone, sometimes people may have worked with someone for a significant amount of time, and to have to, after having built such a strong therapeutic alliance to have to transfer them to somebody else. I've heard clients say things like, I feel like I have to start over again, or I feel as though I'm being abandoned. It can really be disruptive to clients to have to go and take their story and start all over again with someone else.

Dr. Victoria Kress:

And again, there's this assumption that there is someone else to start over with. As I've, I've already mentioned, there is such a shortage of providers all over the country, that that may not even be an option for some people. So here again, I think this legislation is so exciting because it's ethical in that it's going to help clients have that continuity of care that they require in order to work on and address the mental health issues that they're struggling with.

Guila Todd:

Okay. Can you talk a bit, I know you've been involved in this youth advocacy efforts for ACA for quite a long time, can you talk about how important it is for counselors to get involved in advocacy efforts on behalf of their profession?

Dr. Victoria Kress:

Yes. Thank you so much for asking such a great question. You probably feel me live and up with that. Yes, this is my passion. As counselors, we go into this profession and we become counselors because we want to advocate for populations of people who were so passionate about. So for me, for example, I became a counselor because I wanted to advocate for children, particularly traumatized children and children who have been abused. So if you talk to any counselor, they will light up when they talk about what inspired them to want to become a counselor and who they wanted to help. I find we're so good at advocating for our clients, but I always say we can't advocate for our clients if we don't advocate for ourselves.

Guila Todd:

Right.

Dr. Victoria Kress:

We can't be strong and healthy and robust and be recognized in the legislative arena as advocates for our clients if legislators don't know who we are and what we do and if we don't have recognition. So again, this Medicare bill is huge. I think it's one of the biggest things that's ever happened to our profession in terms of advancing us, because what it's going to do is put us on an equal playing field with the other helping professions. So when we communicate with legislators and we talk about our passion topics that we're so excited about, they're going to be taking us much more seriously because they know that we're broadly recognized. So that feels really exciting.

Dr. Victoria Kress:

I want to just encourage all of the listeners to be passionate about advocating for the profession and to be as passionate about advocating for the profession as we are advocating for our clients. This is a huge win for us. At the same time, there are still battles out there that need to be fought. This is a great milestone for us, but there's still so much more work to do. For example, we still have states where counselors cannot be reimbursed by Medicaid. That's an atrocity because here again, we have such a shortage of providers all over the country. There's issues with Indian Health Services and us being included. There are still states where counselors are not broadly included in some of the workforce areas in the state.

Dr. Victoria Kress:

So for example, counselors may not be able to be employed in the prison system in those states. And there's still ongoing opportunities for counselors to be included in legislation that is important in terms of promoting our profession, but also helping those that we serve. So I just really want to, again, encourage all listeners to take professional advocacy seriously and to be engaged. I say sign up for legislative alerts through ACA, through NBCC, through any of the counseling organizations that you're a part of.

Dr. Victoria Kress:

The legislative alerts are so easy to do. It populates, it remembers you. So all you have to do is go back and click and it automatically sends out alerts to the legislators in your area. While those alerts are important, reaching out, calling, setting up meetings with your legislators is also really, really important and can go such a long way to advocacy for the profession. I hear a lot of counselors tell me, "Well, I don't know the topics. I don't really feel like grounded and I can speak articulately to a lot of these legislative topics." And what I say is that doesn't really matter. You have to have the ask. And if your legislators ask you for more information about the cost of the bill, for example, you've got people like ACA who can give you that information and then you can follow up with an email to them.

Dr. Victoria Kress:

What matters is that you are showing up to your legislators and you haven't asked, you know what the ask is, and that you're passionate and that you're excited about it. Those relationships that we build with our legislators, those individual relationships are what helped tremendously to get this Medicare legislation passed. I know that over, in December, I was reaching out to my legislators and it was really serendipitous because the legislators I was reaching out to were people who I had built a relationship with over the last decade. So I had worked with these people in multiple capacities.

Dr. Victoria Kress:

As an example, one legislator, I helped him set up an opioid epidemic panel in his community and they knew me. They were familiar with me. And so when I reached out and said, "Hey, we really need co-sponsors for this. Can you get on board?," They knew me and had a relationship with me. And that's the kind of thing that legislators is when counselors show up and they see how you can help them, and then they think about how they can help you. So I just want to encourage all counselors to really build those relationships with your legislators because you never know when those relationships will come in handy and be helpful when you have an ask for them.

Guila Todd:

It is about building those relationships, but it's also about when you go into those congressional meetings, just think of it as a conversation. A lot of times counselors are so intimidated because they've never gone through the process before, and sometimes you have to just tell them, relax, think about it as a conversation. To your point, you don't need to have all the facts because ACA can provide the data and numbers. We just need you to tell your story. I'm sitting here thinking about the first time I had a congressional meeting, which didn't go as smoothly as I thought. Do you remember the first time you actually advocated for the profession, and how did that meeting go for you?

Dr. Victoria Kress:

What a great question. It was, in a word, awkward. Yes. It was 1998, and I had, probably like many of our listeners, I had no formal training around the legislative process. It was part of the Ohio Counseling Association, a kind of day on the Hill type of an event. And I didn't really know or fully understand what I was asking or what was needed. I think I probably came off as a bit robotic because I wasn't sure about that. But what I learned over the years is it's exactly like you said, what matters is the connection and the relationship and getting to know them.

Dr. Victoria Kress:

Something interesting too is typically you meet with staffers, and I find a lot the staffers don't often know or care about all of the details in those initial meetings either. Right? They're just trying to get to know you and who you are and who are counselors and what are counselors about. So I just want to validate that I think it's an awkward experience for many people, and that's really normal. And again, you don't have to get caught up in the details of things. You just have to know who you are as a counselor and what you do. And there's no one better suited to speak to that than counselors.

Guila Todd:

Awesome. Also, so the Mental Health Access Improvement Act as many of won't take effect until January 1st, 2024. Before that time, is there anything that you can let counselors know, like things they need to do to prepare for that? Or, best practices after the law's been implemented?

Dr. Victoria Kress:

Yes. So as I understand it will be going as you said, into effect January 1st, 2024. As I understand that the process will involve filling out an application to be considered as a provider. Counselors will have to get an NPI number, which many already have because of Medicaid, and then you will indicate a specialty area. The Center for Medicaid and Medicare Services is working right now on fleshing out the rules related to that and the processes related to that. And I know that ACA will be a part of educating them and working with them on getting this implemented so that it can be successfully ruled out in January of 2024.

Dr. Victoria Kress:

I think in terms of preparing, I think it's helpful for counselors to start to further educate themselves on the issues associated with counseling and working with older adults. All counselors have some training on this. However, because we haven't been able to be reimbursed by Medicare, there are counselors who haven't worked a lot with older adults, and older adults have unique counseling considerations that are important to consider.

Dr. Victoria Kress:

So for example, many older adults may struggle with chronic healthcare issues, physical health issues, things like chronic pain, for example. They may be dealing with a lot of grief and loss issues associated with maybe losing loved ones, grief and transition around moving out of, say, their career. What does that look like as they start to think about retirement? So there's these unique issues that we have to consider, and I would encourage us all to try to get further educated on what are some of these issues that are important.

Dr. Victoria Kress:

Related to that, I envision counselors working with more people who have chronic disabilities because as I mentioned earlier, there is a significant chunk, nine million people who receive Medicare who have chronic health issues. So thankfully many counselors already work with people with mental health disabilities. But thinking about this intersection of mental health disabilities and physical health disabilities and just learning more about physical and chronic disability and rehab counseling, I think is going to also be really important for counselors as we start to increasingly work with this population as well.

Guila Todd:

Going back to working with the Medicare population, whether it be individuals with disabilities or older Americans, like I said, I know you've been involved in advocacy for years. Have you ever done advocacy on behalf of that population outside of Medicare, meaning older Americans or those with disabilities?

Dr. Victoria Kress:

Yes. There are so many issues relative to this population. I mean, we've talked about access to care. There's also so many organizations out there that can be really helpful that I would encourage listeners to take a look at. These are organizations who are doing really great work around this topic. So organizations like the National Coalition on Mental Health and Aging, the National Council on Aging, Geriatric Mental Health Alliance. If you go to the websites of these organizations, you can learn about a lot of different advocacy issues that they're tackling that counselors can be a part of in terms of thinking about this population in terms of mental health, disability and physical health disabilities, I think the National Alliance for Mental Illness, NAMI, does a really great job with this. They're considered, I think, leaders in terms of advocacy for this population as well. So again, these might be really good resources for listeners to connect with as they think about advocating for these populations.

Guila Todd:

So moving forward, as far as next steps, now that it's been signed into law by President Biden, ACA is working hand in hand with CMS to kind of refine some of the language and the guidance surrounding the legislation. From your experience, can you talk about maybe some of the guidance or language that you'd like to see refined in the bill? If there's anything you'd like to change or your thoughts on that maybe?

Dr. Victoria Kress:

Yeah, I don't have a lot to offer there. I don't have a lot of thoughts on that in terms of the details of the rules and the language. I think it's important that it continues to be focused on counseling and counselors and those who are trained as professional counselors. I think a lot of it's going to fall back on the laws in each state. Each state is very unique in terms of how they define a counselor and who can practice as a counselor and who can be a counselor and who can't be a counselor. So I think it's probably going to continue to be generic and have it continue to fall back at the state level.

Guila Todd:

Well, thank you so much for your insight and your answering the questions. I appreciate you being here.

Dr. Victoria Kress:

Thank you for having me. Yeah. One thing I would like to say as we wrap up is I think that I always encourage counselors to think about the lower case or what I call little A advocacy opportunities. So we often think about advocacy as capital A, big A advocacy opportunities, so things like legislative advocacy, sitting with your legislators, writing legislation. But all counselors have an opportunity every single day in their work environments to engage in lower case advocacy opportunities. And what I mean by that is advocating in your work settings and within your communities.

Dr. Victoria Kress:

So that might be things like working with your employer as we start to transition into being reimbursed by Medicare. What opportunities are there and how can we make sure that in different settings we're being included? Maybe working with your state branch around working with your different departments, state agencies around the rollout with Medicare reimbursement, and also things within your community. So how do we as counselors, reach out to members of our community and educate them about who we are and what we do and make them aware of our presence and that we are a resource for them? How do we educate them just about mental health in general so that they might be able to better identify they have a mental health issue that they can seek services for? So I want to encourage counselors to just think about those lower case, little A, advocacy opportunities because the time is ripe for us to really seize those and be advocates.

Dr. Victoria Kress:

Look, when I first became a counselor in 1995 in Ohio, counselors could only be reimbursed by 20 to 30% of insurance panels. For the last decade at least, we've been able to be reimbursed by all insurance panels. And that didn't just happen randomly. That happened because counselors were reaching out to insurance companies and saying, "Here is who I am as a counselor. This is what I do. Include us." And so I just want to encourage all counselors to continue to do that. We can't advance our profession and serve people who need us if we're not actively engaging in advocacy opportunities and promoting ourselves in these different ways.

Guila Todd:

Dr. Kress, it's been a pleasure. Thank you so much for the information, and thank you all for listening.

Dr. Victoria Kress:

Thank you for having me.

Guila Todd:

Thank you, Dr. Kress, and thank you to our listeners for joining us. Check out the episode description for more information on Medicare reimbursement for counselors, and go to the government affairs tab on the ACA website to learn more about advocacy. Be sure to subscribe to the Voice of Counseling on Apple and Google Podcasts, and you can follow ACA on social media. To join the ACA and get exclusive access to all the member benefits, check out counseling.org.

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