Mental Illness, Aging, and the Failure of Public Policy

In the next twenty years, more than 3 million people over the age of 65 will likely experience serious mental illness.  Are we prepared to treat them?

The answer is no, according to a new Institute of Medicine report. 

The report was released in July, and it contains some striking evidence of the challenges we face as we confront the growing behavioral health care needs of our aging population.  We don’t have nearly enough trained providers.

And when states cut their existing state Medicaid programs or refuse to adopt the ACA Medicaid expansion, these decisions have devastating consequences for the providers we do have – and, of course, their patients. 

Today, between 5.6 and 8 million adults over the age of 65 are believed to have mental illnesses.  These numbers could nearly double over the next twenty years. 

There’s a reason that the range is so big.  We’ve given so little attention to this challenge in the past that we don’t even have an accurate count.

We do know a lot, however.  As the IOM report documents:

• At least 14-20% of the elderly population has a mental illness.
• Up to 1.9 million have a mental illness described as “serious” – a number that could grow to over 3 million by 2030.
• 57% of nursing home residents, or 675,000 people, have one or more mental health conditions.
• Dementia is not the same as mental illness.  However, 57% of adults with dementia, or approximately 2.5 million people, also have symptoms of mental illness.
• Older women are more likely than older men to have every type of behavioral health condition except two – alcohol abuse and drug abuse.  In fact, the prevalence rates of mental illnesses among elderly women are 50% higher than they are among elderly men.

Publicly funded programs – like Medicare and Medicaid – are essential to treating all these people. 

The 2009 AHRQ MEPS data determined that the cost of the mental health services alone for the over-65 population exceeded $17 billion.  Affecting 7.4 million individuals, behavioral illness was the 8^th most costly condition for the over-65 group. 

Medicare paid just over half the bill all by itself and the combined Medicare, Medicaid, and other public share was 70%.  Private insurance, on the other hand, paid under 12%, far less than patients paid out-of-pocket.

These costs don’t occur in isolation from other health care costs.

This is because elders with mental illness are also likely to have chronic physical conditions.

In one representative study cited in the IOM report, this group had an average of 3.8 co-occurring physical conditions:

• 58% had hypertension
• 57% had chronic pain
• 56% had arthritis
• 55% had hearing or vision loss
• 39% had urinary tract or prostate disease
• 28% had heart disease
• 23% had chronic lung disease
• 23% had diabetes
• 21% had gastrointestinal disease
• 11% had cancer  
• 8% had neurological disease

This puts pressure on providers, who must manage multiple chronic conditions at the same time. 

What’s the most cost-effective way to do this?  We already know the answer.

“What works for many older adults who need MH/SU services is a patient centered, team-based, primary care-centered model that is proactive and employs a coordinated team of personnel with specific roles and special training,” the IOM report concludes.

In other words, the same primary and behavioral health care integration initiatives that work for the non-elderly population work for elders, too.

But unless policymakers change the course of their current thinking dramatically, we may not get close to what we need.

• The report identified “a conspicuous lack of national attention” to developing an appropriate workforce – including mental health counselors, primary care providers, care coordinators, and others – to give this care.
• It also described “a fundamental mismatch” between the need for coordinated care and Medicare’s refusal to pay for the services of trained care managers and psychiatric consultations.

We could add a third.  State cutbacks to existing Medicaid programs and states’ refusals to implement the ACA Medicaid expansion compromise our most vulnerable aging adults.  Those with mental illness and other chronic conditions usually have few resources of their own to pay for their care.

The question raised by the way we treat elders with mental illness is an important one.  Do federal and state policymakers mean to throw the neediest of us out into the cold as we age?

If you have questions about this column, or wish to receive an email notifying you when new Our Health Policy Matters columns are published, please email gionfriddopaul@gmail.com.  For more columns about mental health policy, click on the “Mental Health” tab at the top of the page.