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Running head: ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 1
Analyzing the Impact of the Medicare Coverage Gap on Counseling Professionals:
Results of a National Study
Matthew C. Fullen
mfullen@vt.edu
Virginia Polytechnic Institute and State University
School of Education
College of Liberal Arts and Human Sciences
1750 Kraft Drive
Suite 2000, Room 2005
Blacksburg, VA, USA 24061
Gerard Lawson
glawson@vt.edu
Virginia Polytechnic Institute and State University
School of Education
College of Liberal Arts and Human Sciences
Jyotsana Sharma
jyots21@vt.edu
Virginia Polytechnic Institute and State University
School of Education
College of Liberal Arts and Human Sciences
Acknowledgments: Thank you to the American Counseling Association for its support of this
project.
ACCEPTED IN ITS CURRENT FORM ON JULY 23, 2019 BY JOURNAL OF
COUNSELING AND DEVELOPMENT
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 2
Abstract
The authors surveyed 6,550 members of the American Counseling Association regarding the
current impact of Medicare policy on counseling professionals. Over half of respondents
(54.8%) had been directly impacted by Medicare reimbursement barriers, including 70.0% of
practicing counselors. Statistical analyses indicated significant associations between years in the
profession, direct experience with the Medicare coverage gap, and participation in professional
advocacy related to Medicare. Implications for counselors, counselor educators, and counseling
scholarship are discussed.
Keywords: Medicare, professional issues, older adults, aging, gerontological counseling,
disability
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 3
Analyzing the Impact of the Medicare Coverage Gap on Counseling Professionals:
Results of a National Study
Currently, Medicare is the primary insurance provider for approximately 59 million
Americans (Kaiser Family Foundation, 2017), and that figure is expected to reach 80 million by
2030 (Medicare Payment Advisory Commission, 2015). In regard to the provision of
psychotherapy services, Medicare recognizes psychiatrists, psychologists, clinical social
workers, and psychiatric nurses as eligible providers. Notably, this excludes licensed
professional counselors (LPCs) and licensed marriage and family therapists (LMFTs), who
collectively make up close to half of the total number of master’s-level mental health
professionals nationwide (American Counseling Association, n.d.).
The list of eligible providers was last updated in 1989, when clinical psychologists and
clinical social workers were added to the Medicare program (U.S. Congress, 1989). During the
thirty-year period since the provider list was last updated, the mental health landscape has
changed markedly. Counseling licensure exists in all fifty states, there is a well-established
accreditation process that many counselor training programs ascribe to, and the ratio of
counselors to other mental health provider types has increased. Concurrently, there has been a
sharp increase in Medicare enrollment that has accompanied population-level demographic
changes (i.e., 10,000 people turning 65 each day; Short, 2016), as well as a growing awareness
that Medicare beneficiaries (i.e., people over 65 years old and younger people with permanent
disabilities) experience restricted access to mental health care due to a lack of professionals who
are available to work with the Medicare-insured (Institute of Medicine, 2012), particularly within
rural areas (Larson, Patterson, Garberson, & Andrilla, 2016; Stewart, Jameson, & Curtin, 2015).
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 4
The Needs of the Medicare-Insured
There is a great deal of research suggesting that the Medicare-insured are in need of
mental health care. Approximately 10% of men and 15% of women over age 65 experience
depressive symptoms, and these symptoms are often correlated with greater functional disability,
higher rates of physical illness, and increased risk of dementia (Federal Interagency Forum on
Aging Related Statistics, 2016). Among younger beneficiaries, Medicare insures individuals
who live with disabilities -- including the 37% of all beneficiaries with a disability who have a
mental disorder (Center for Medicare Advocacy, 2013) -- individuals with chronic physical
conditions such as arthritis or musculoskeletal disorders, and beneficiaries living with HIV/AIDS
(Claypool, Crowley, & LaManna, 2015). In fact, Medicare is the second largest source of
funding for HIV/AIDS care (Kaiser Family Foundation, 2015). Professional advocacy groups
have described the numerous mental health needs of the Medicare-insured (Medicare Mental
Health Workforce Coalition, 2019), including the fact that Medicare is the largest single payer
for opioid hospitalizations (Song, 2017).
Other scholars have noted that the Medicare coverage gap (MCG) may be particularly
detrimental to Medicare beneficiaries who live in rural localities. This is due to the fact that
there are fewer mental health providers overall in rural areas, and those providers are more
commonly licensed professional counselors and licensed marriage and family therapists
(Christenson & Crane, 2004; Larson et al., 2016). This means that Medicare beneficiaries in
these areas may be particularly burdened by current policy. In a qualitative study of the
experiences of Medicare-ineligible mental health providers, we found that practicing counselors
were aware of the discrepancy of mental health resources between rural and non-rural localities
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 5
(Fullen, Wiley, & Morgan, under review), and multiple interviewees referenced that Medicare
beneficiaries are at-risk of undertreatment or hospitalization due to the MCG.
Medicare Advocacy
Due to these circumstances, Medicare reimbursement of counselors has become one of
the counseling profession’s top priorities (Field, 2017; Fullen, 2016). Professional organizations
that represent counselors began formally lobbying Congress over fifteen years ago, and
legislation to add LPCs and LMFTs to the list of eligible Medicare providers has passed in both
the House and Senate, albeit not in the same congressional cycle (Field, 2017). One example of
the prioritization of Medicare reimbursement to the counseling profession is the frequent
reference to the issue within Counseling Today, the professional trade magazine published by the
American Counseling Association. A brief scan of recent Counseling Today issues located
nineteen references to the Medicare issue dating back to 2006. Although this observation is
anecdotal, it speaks to the profession’s awareness that the MCG is relevant to the future viability
of the profession, not to mention its detrimental impact on the Medicare-insured.
Counselors have a long history of engagement with social policy and legislative advocacy
(Kiselica & Robinson, 2001), and social justice has been described as an essential characteristic
of what it means to be a counselor (Chang, Crethar, & Ratts, 2010). In more recent years, a great
deal of attention has been paid to cultivating social justice advocacy within counselor training
curricula, with expressed goals such as identifying how exemplar counselor-advocates develop
(Swartz, Limberg, & Gold, 2018), and creating new models for how advocacy identity might be
synthesized with counselor and scholar identities (Ratts & Greenleaf, 2018). The growth of the
social justice advocacy movement within the counseling profession has clear implications for the
issue of Medicare reimbursement for counselors. Consider that the MCG restricts access to
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 6
mental health services for a particular part of the population: those who have Medicare
insurance. As such, it could be argued that the policy unduly limits the accessibility of
counseling services to people over 65, as well as to younger people with permanent disabilities.
Notwithstanding the counseling profession’s commitment to social justice advocacy,
there are indications that this commitment has not been fully actualized in regard to the MCG.
Consider the counseling literature, where social justice advocacy has been named a priority
(Chang, Crethar, & Ratts, 2010); however, aside from Medicare references in Counseling Today,
there have been very few allusions to the issue within the scholarly literature in spite of over
fifteen years of advocacy (exceptions Field, 2017; Fullen, 2016; Reiner, Dobmeier, &
Hernández, 2013). Similarly, although the profession has been in agreement about the need to
change Medicare policy for this length of time, there have not been corresponding efforts to
collect data about the prevalence of Medicare beneficiaries who are turned away due to their
insurance coverage, the impact on counseling professionals, and the resulting levels of advocacy
engagement in which counseling professionals have participated. In spite of Kiselica and
Robinson’s (2001) recommendation that “[c]ounselors…use their assessment and research skills
to evaluate their advocacy initiatives” (p.393), there are currently no empirical studies that probe
the prevalence or impact of the MCG on counseling professionals.
Current Study
To address this gap in the literature, we sought to collect data that would provide the
counseling profession with baseline information regarding the prevalence and impact of the
MCG. By asking counselors directly about their experiences with the MCG, we intended to
begin a professional dialogue about the impact of Medicare’s mental health provider policy. Due
to the prioritization of Medicare reimbursement among counseling professional organizations
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 7
(Medicare Mental Health Workforce Coalition, 2019), we also intended to ascertain how direct
experience with the MCG informs participation in grassroots advocacy related to Medicare
reimbursement for counselors. Therefore, to generate additional dialogue as a profession about
the MCG and its impact on counseling professionals and their communities, we posed the
following research questions:
RQ1: In regard to Medicare, how many counseling professionals have turned away or referred
clients, or used a sliding scale to serve clients due to reimbursement barriers?
RQ2: Is there a difference among types of counseling professionals (i.e., practicing counselors,
counselor educators, master’s-level students, doctoral students) when it comes to experience with
the MCG?
RQ3: Are practicing counselors more likely to have direct experience with the MCG the longer
they are members of the profession?
RQ4: Does direct experience with the MCG influence participation in Medicare-related
professional advocacy?
Methods
The data used to answer our research questions was drawn from a larger survey of
American Counseling Association members. In light of the lack of baseline knowledge about the
current impact of the MCG, survey methodology was deemed appropriate due to a need to
directly access counseling professionals’ experiences (Young, 2010). Prior to developing a
questionnaire, we attained permission from the American Counseling Association (ACA) to
develop and conduct a survey of its members, with a specific focus on the issue of Medicare
reimbursement for counselors. The full survey was intended to better ascertain the impact of
Medicare ineligibility on the counseling profession, current engagement in professional
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 8
advocacy, and other key issues that might illuminate how to improve Medicare reimbursement
advocacy going forward. The full survey contained the following: a) personal (e.g., age, sex,
race/ethnicity) and professional (e.g., years in profession; professional status; specialization;
training accreditation) demographic information; b) exploratory items regarding the prevalence
of turning away or referring the Medicare-insured (Table 2); c) qualitative descriptions of what
occurs when the Medicare-insured seek services from counseling professionals; d) current level
of advocacy participation on key issues, including Medicare reimbursement of counselors; e) a
validated measure of members’ engagement in social advocacy (Nilsson, Marszalek,
Linnemeyer, Bahner, & Misialek, 2011); f) a validated measure of attitudes about aging (Levy,
Kasl, & Gill, 2004); g) an original assessment of factual knowledge about Medicare policy &
professional advocacy; and h) opinions about who is responsible for Medicare advocacy (Reiner
et al., 2013).
Prior to disseminating the survey several efforts were made to assess the
comprehensibility of the items. A pilot version was disseminated to a group of graduate students
and licensed professional counselors affiliated with the authors’ institution. We solicited
feedback and amended items that were deemed unclear. We also provided a copy of the full
survey to the American Counseling Association for its review. Upon approval of the full survey
by an appropriate ACA designate, temporary access to a membership list was provided and
authorized for use to conduct the survey. The survey and ensuing research were approved via
exempt status by the Western Institutional Review Board.
Participants
The survey was sent to 51,221 ACA members using Qualtrics beginning in August 2018;
629 emails were returned as undeliverable, resulting in a sampling frame of 50,592 (Figure 1).
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 9
Survey invitations were sent on three separate occasions over a period of approximately five
weeks. No participant incentives were provided. In total, 6,550 responses were returned
(12.95%), although the number of responses provided to specific survey items varied. To put the
sample size and response rate into context, a recent systematic review published by the Journal
of Counseling and Development indicates that there have been 45 studies of counseling
professional association members that used online recruitment measures. Sample sizes for these
studies ranged from 13 to 2,092, whereas response rates ranged from 1.5% to 54.0% (M =
20.1%, SD = 12.7%) (Poynton, DeFouw, & Morizio, 2019).
For the current study, participants were screened based on whether they clearly
responded Yes, None, or Not Sure to a series of questions about whether they have been directly
impacted by the MCG (Table 2). Although an Other category was provided for the purpose of
better understanding the intricacies of the MCG, visual inspection of these responses indicated a
wide range of possibilities (i.e., “All my work is pro bono” [sic]; “My clinic services are funded
by a grant”; “I have not worked with clients beyond internship yet”) that made interpretation
difficult. Therefore, 465 Other responses were excluded from the current analysis. Additionally,
15 participants omitted a response to this item and were excluded. In total, this resulted in 480
(7.33%) responses that were excluded from the present analysis, resulting in 6,070 remaining
responses.
We calculated descriptive statistics pertaining to demographic variables for the sample of
6,070 participants whose responses were eligible for analysis (Table 1). When possible we
compared our sample to the demographic information of the full ACA membership list, which
was provided directly by ACA (R. Sites, personal communication, October 10, 2018). These
comparisons are formatted below as study sample versus full ACA membership circa 9/1/2018.
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 10
In comparison with the full membership of the ACA, our sample had a slightly higher proportion
of female respondents (79.90% vs. 74.34%) and was more racially and ethnically diverse than
the full ACA membership (24.50% vs. 17.47% non-White), with a greater composition of
respondents who identify as Hispanic/Latinx (4.90% vs. 3.30%), Multiracial (2.90% vs. 1.37%),
and African American (10.90% vs. 8.14%). Although professional demographic data published
by the ACA is somewhat limited in scope, we were able to make rough comparisons based on
estimates of professional type. For example, our sample differed in terms of the number of
students responding (28.80% in our sample vs. 38.85% ACA student members). Additionally,
the 6.00% of our sample identifying as counselor educators appears to be in line with recent
estimates of ACA membership (6.61% according to May 2019 ACA membership data;
September 2018 data was inconclusive). These comparisons imply that our sample may include
a higher proportion of practicing counselors, although this is difficult to confirm based on how
the ACA organizes membership.
Procedures
In the current study, several of the questions were culled from the larger survey to
elucidate current experiences among counseling professionals regarding the MCG. First, to
address the lack of existing data on how many counseling professionals are directly impacted by
the MCG, participants were asked, “Have you ever had to deny/refer potential or existing clients
because of a lack of Medicare reimbursement?” (Table 2). Respondents could answer
affirmatively by selecting one of three primary categories related to the MCG, and there were
selections for Other, Not Sure, and None. The affirmative responses included: a) Turning away
potential clients; b) Referring potential or existing clients; and c) Using a sliding scale (inclusive
of a pro bono service) to provide care. The response categories were developed by the authors
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 11
based on sustained engagement in Medicare reimbursement advocacy. Specifically, the
categories were informed by personal communication with licensed professional counselors who
have described the impact on current or potential clients due to Medicare ineligibility, as well
direct involvement with historical and on-going efforts by the ACA to lobby for Medicare
eligibility. For example, the ACA has periodically requested testimonials in which members are
asked to describe experiences in which existing clients are no longer eligible due to a shift to
Medicare insurance.
The Other and Not Sure categories were included in the questionnaire to increase the
likelihood that respondents would provide valid responses. Participants could select more than
one choice, although responses were screened prior to data analysis to ensure that responses did
not include both Yes and No responses simultaneously. As a measure of validity, we assessed
how many respondents simultaneously answered Yes and None, or Yes and Not Sure. In total,
there were only 14 cases (0.21%) in which Yes and None were selected at the same time, and
only 12 cases (.18%) in which Yes and Not Sure were selected simultaneously. This indicates
that although the items used here were exploratory, they appeared to have a high degree of both
content and face validity. Regarding Not Sure responses, when only this response was selected
(i.e., respondent did not simultaneously select Yes), the answer was treated as a non-Yes
response for subsequent analyses, resulting in a binary variable (i.e., Yes vs. None/Not Sure) that
was used to estimate the prevalence of the MCG among ACA members.
The survey also included questions about respondents’ participation in professional
advocacy, both by key issue (e.g., Medicare, licensure portability, more funding for school
counselors) and by specific type of engagement (e.g., social media, phone call to legislators, in-
person meeting with legislators). Specific to our current inquiry, we gleaned data on whether
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 12
respondents had engaged in Medicare-related advocacy, as well as which forms of engagement
they had participated in.
Statistical Method
Statistical analyses were conducted using SPSS (Version 25). We conducted all analyses
with an alpha level of .01 as the benchmark for statistical significance. Quantitative methods,
including a combination of frequency counts, chi-square analyses, and odds ratios were used to
answer our research questions. We conducted all analyses with an alpha level of .01 as the
benchmark for statistical significance. Statistical assumptions for the chi-square goodness-of-fit
test (i.e., independence of observations and expected frequency greater than five in all cells)
were satisfied in all cases (Lomax & Hahs-Vaughn, 2012). Effect sizes were calculated using
Cramer’s V, with an estimation of .06, 0.17, and 0.29 as Small, Medium, and Large effect sizes,
respectively (when df = 3; Cohen, 1988). Raw data were re-coded when necessary to answer the
research questions. Missing data were handled on a per question basis. In RQ2, 140 participants
either omitted information related to professional type, or provided information that could not
easily be coded as one of the four predominant categories (i.e., practicing counselor, counselor
educator, master’s student, and doctoral student). Therefore, these responses were excluded due
to author concerns about imputing demographic information. In RQ3, only data provided by
practicing counselors was used (N = 3,392). We used this approach due to the greater likelihood
that the MCG would impact practicing counselors relative to the full ACA sample, as well as to
isolate the impact of years of experience on exposure to the MCG.
A subset (N = 5,145) of the larger survey sample was used to answer RQ4. This subset
consisted of participants who, in addition to providing information about the Medicare coverage
gap, also answered a series of questions related to participation in Medicare reimbursement
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 13
advocacy. Although this subset was smaller than the full sample used to answer RQ1 (i.e., N =
6,070), the sample was sufficiently large to answer RQ4 at the predetermined alpha level. As a
point of reference, those who were included in RQ4 (by virtue of also answering questions about
Medicare reimbursement advocacy) differed slightly from those who did not complete this part
of the broader survey (N = 925). By comparison, those who were included in RQ4 were slightly
older (45.31 vs. 42.04), and more likely to identify as White/Non-Hispanic (76.9% vs. 72.9%)
and male (18.8% vs. 16.6%). They were also more likely to be classified as practicing
counselors (63.8% vs. 57.4%) or counselor educators (6.4% vs. 3.7%), and had more experience
in the counseling profession (19.1% vs. 16.5% at fifteen or more years in the profession).
Results
Prevalence of MCG
Frequency data showed that more than half of the 6,070 respondents (54.8%) had been
directly impacted by Medicare reimbursement barriers, whereas 45.2% responded that they had
not or were unsure. Of those who reported being directly impacted by Medicare reimbursement
barriers, 36.5% of participants had turned away new or potential clients, 29.1% had referred
existing clients, and 31.9% had seen a client pro bono or on a sliding scale due to ineligibility for
Medicare reimbursement. When only practicing counselors were examined (e.g., excluding
students and counselor educators), there was a noticeable increase in the prevalence of the MCG.
Out of 3,392 practicing counselors, 70.0% had been directly impacted by Medicare
reimbursement barriers, with 50.3% of participants having to turn away new or potential clients,
38.8% referring existing clients, and 39.9% seeing a client pro bono or on a sliding scale.
Differential Impact
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 14
Next, we used chi-square analysis to identify any group differences based on professional
status (i.e., practicing counselor, counselor educator, master’s student, and doctoral student)
(Table 3). This analysis revealed that practicing counselors were considerably more likely to
have direct experience with the MCG compared to all other groups. In terms of overall
experience with the MCG, the previously referenced 70.0% of practicing counselors had been
directly impacted by the MCG, whereas only 48.3% of counselor educators, 48.8% of doctoral
students, and 20.9% of master’s students had such an experience. A chi-square test of goodness-
of-fit was performed, which indicated that direct impact of the MCG was not equally distributed
across the groups, Χ2 (3, N = 5,930) = 1075.06, p < .001; Cramer’s V = .426). This is a large
effect size.
Analyses for each sub-type of direct experience with the MCG were also statistically
significant. There was a difference among groups in terms of turning away potential clients: Χ2
(3, N = 5,930) = 876.931, p < .001; Cramer’s V = .385); referring existing clients: Χ2 (3, N =
5,930) = 507.310, p < .001; Cramer’s V = .292); and working with beneficiaries pro bono/via
sliding scale: Χ2 (3, N = 5,930) = 373.233, p < .001; Cramer’s V = .251). Each of these effect
sizes is in the large or medium-large range.
Impact of Years of Experience
We then examined whether years of experience had an influence on experience with the
MCG. A total of 44.5% of counseling professionals with 0-1 years of experience reported
directly experiencing the impact of the MCG, whereas 56.2% of those with 2-3 years, and 71.5%
of those with 4-7 years had this experience. A total of 80.8% of counseling professionals with 8-
14 years of experience, and 82.1% of those with 15+ years of experience also described direct
experience with the MCG. A similar pattern was observed when specific phenomena (i.e.
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 15
turning away; referring; treating pro bono/sliding scale) were analyzed. A chi-square test of
goodness-of-fit was performed, which indicated that direct impact of the MCG was not equally
distributed across the groups, Χ2 (4, N = 3,392) = 273.118, p < .001; Cramer’s V = .284). This is
considered a medium-large effect size, and it indicates that counseling professionals with more
time in the profession are increasingly likely to have direct experience with the MCG (Figure 2).
To further explore this phenomenon, we calculated an odds ratio that compared ACA
members with three or fewer years in the profession with those with four or more years. The
corresponding test once again revealed group differences depending on years in the profession:
Χ2 (1, N = 3,392) = 232.158, p < .001, Cramer’s V = .262; OR = 3.281, CI [2.806, 3.836]. This
means that practicing counselors with four or more years of experience in the counseling
profession are more than three times as likely to experience the MCG as those with fewer than
four years of experience.
MCG Experience and Medicare Advocacy
Finally, chi-square analyses were used to determine whether experiencing the impact of
the MCG was related to participation in professional advocacy. A total of 5,145 respondents
answered questions about both MCG impact and participation in several forms of engagement
related to Medicare advocacy. Advocacy participation ranged from 25.7-28.9% in less time-
intensive efforts (e.g. social media, VoterVoice), to 12.4%-18.4% in moderately time-intensive
efforts (e.g. phone call, personal letter), and 2.5-3.6% in considerably more time-intensive forms
of engagement (e.g. meeting in capitol office, local meeting). A chi-square test of goodness-of-
fit was performed. Across each type of engagement there were statistically significant
relationships between having been directly impacted by the MCG and counseling professionals’
participation in Medicare advocacy, meaning that those who had turned away, referred, or treated
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 16
beneficiaries pro bono/via sliding scale were more likely to participate in each form of Medicare
professional advocacy. Respondents who were impacted were more likely to advocate by social
media: Χ2 (1, N = 5,145) = 222.992, p < .001, Cramer’s V = .208; OR = 2.777 [CI95 = 2.422,
3.185); VoterVoice: Χ2 (1, N = 5,145) = 268.515, p < .001, Cramer’s V = .228; OR = 2.939 [CI95
= 2.576, 3.353); phone call: Χ2 (1, N = 5,145) = 194.61, p < .001, Cramer’s V = .194; OR = 3.972
[CI95 = 3.233, 4.879); and personal letter: Χ2 (1) = 222.295, p < .001, Cramer’s V = .208; OR =
3.303 [CI95 = 2.806, 3.887). Each of these effect sizes is in the medium range. Further, they
were also more likely to participate in a local meeting with lawmakers or their staff: Χ2 (1, N =
5,145) = 37.703, p < .001, Cramer’s V = .086; OR = 2.850 [CI95 = 2.806, 3.887), as well as
meetings in the state or national capitol: Χ2 (1, N = 5,145) = 9.405, p < .001, Cramer’s V = .043;
OR = 1.782 [CI95 = 1.226, 2.591); although, these effect sizes were much smaller.
Discussion
This study was designed to examine the prevalence and impact of the MCG, its
relationship to counselor variables (i.e., years in the profession), and its impact on participation
in Medicare-related advocacy. Our investigation yielded several findings that elucidate the
current impact of Medicare ineligibility on the counseling profession. In regard to how many
counseling professionals have turned away potential clients, referred existing clients, or used pro
bono/sliding scale approaches to work with the Medicare-insured, our finding that over half (i.e.,
54.8%) of all respondents and more than two-thirds (i.e., 70.0%) of practicing counselors
responded affirmatively is sobering. Although it is not possible to fully generalize these data to
the full population of ACA members or non-ACA member counselors, these data suggest that
the MCG is impacting a large number of counselors, and by implication, an even larger number
of Medicare-insured individuals who are subsequently impacted by the MCG. This finding
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 17
corroborates what has been implied in other studies (i.e., Larson et al., 2016); however, the
current study is the first to provide a concrete estimate of how many counseling professionals
have directly experienced the impact of Medicare ineligibility.
Broad Impact on Counseling Profession
Contrary to the notion that Medicare ineligibility only impacts a select number of
counselors, the prevalence of MCG impact, coupled with the very small amount of respondents
who said they primarily work with people over age 65 (i.e., 1.6%), suggests an impact that is
much more broad. These data indicate that the counseling professionals who have been
impacted by the MCG, by and large, do not consider their primary client populations to be
individuals aged 65 and older. Although this may be an artifact of the current Medicare policy
itself, the data may also signal that the Medicare-insured are seeking services in community-
based, or generalist, settings. Although specific survey items related to practice context were not
included, one interpretation of these data is that Medicare beneficiaries are seeking mental health
services in community-based settings and private practice, not merely within settings that have
been traditionally associated with aging (e.g., assisted living, long-term care facilities, hospice).
This is corroborated by additional research; for example, we found in a related, qualitative study
that reference to the MCG impacting community-based providers was commonplace (Fullen,
Wiley,& Morgan, under review). The finding is also consistent with the shift in age-based care
for more home and community-based services, such that currently, the majority of Medicare
beneficiaries live independently in their communities, and only a small percentage (i.e., 4%)
reside in long-term care facilities (Kaiser Family Foundation, 2017).
Burden on the Medicare-Insured
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 18
These data also suggest that current Medicare policy is directly impacting the ability of
the Medicare-insured to access mental health services across the country. In contrast to the myth
that Medicare beneficiaries are not interested in seeking mental health services, the data indicate
that potentially thousands have sought out care, only to have these efforts thwarted. Several
consequences may ensue when this happens. When potential clients are turned away, they may
experience long wait-lists prior to being seen by a Medicare-eligible provider (Fullen, Wiley, &
Morgan, under review), or they may elect not to seek alternative treatment, resulting in no
treatment or undertreatment of mental health conditions. These responses to being unable to
work with an LPC or LMFT may be detrimental to their mental health, especially given that
there are serious consequences to foregoing treatment or undertreating mental health conditions,
particularly for the people who comprise the Medicare program. For example, comorbidity
among depression and chronic disease results in higher health care costs (Unützer et al., 2009).
Hospitalization due to untreated mental health conditions creates a burden on both individual
beneficiaries and the system on the whole. For example, the reimbursement rate for a single day
of inpatient psychiatric hospitalization is equivalent to approximately twelve 45-minute
counseling sessions (American Psychological Association, 2015; Centers for Medicare and
Medicaid Services Inpatient Psychiatric Facility Prospective Payment System, 2019). Removing
the possibility of high-quality outpatient care is inefficient due to the likelihood that
undertreatment, overtreatment in the form of hospitalization, or no treatment will ensue. Our
data suggest that by restricting provider access, the current policy may exacerbate this issue for
Medicare beneficiaries who seek out counseling services.
Detrimental Impact on Counseling Professionals
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 19
When considering that 29.1% of total respondents (and 38.8% of practicing counselors)
had referred an existing client due to the MCG, additional detrimental consequences are worthy
of consideration. Early withdrawal from mental health treatment is inefficient, and potentially
harmful, to both clients and counselors (Barrett, Chua, Crits-Christoph, Gibbons, Casiano, &
Thompson, 2008). Having to refer an existing client may be particularly problematic given the
emphasis that counselors place on the therapeutic alliance. The psychological benefits that are
associated with the therapeutic alliance (Wampold, 2015) may be undermined when a provider
has to terminate treatment due to a client aging into Medicare coverage or qualifying for
permanent disability while in the middle of treatment. In light of shifting population
demographics, it is increasingly likely that counselors will experience working with an
individual who uses a non-Medicare form of insurance, only to later have to cease treatment
when that individual turns 65 and transitions to Medicare.
The preponderance of counseling professionals who indicated that they had worked with
Medicare beneficiaries using a sliding scale or pro bono approach was also striking. On one
hand, this finding demonstrates that many counseling professionals are employing a form of
social justice advocacy at the client-level (Ratts & Hutchins, 2009) in an attempt to circumvent
the challenges associated with the MCG. The need to extend services in spite of receiving a
reduced fee may be particularly pressing in rural communities due to the dearth of Medicare-
eligible providers who are in close proximity to the practicing counselor (Larson et al., 2016).
Although this form of client-level social justice advocacy is laudable and necessary (Lopez-Baez
& Paylo, 2009), it is important to consider whether it is sustainable in the long term. Drawing on
findings from a related study, many counseling professionals indicated problems with this
approach, such as working for agencies that would not allow them to provide pro bono services,
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 20
the inability of many clients to pay directly for services, even when they were offered at a sliding
scale rate, and the long-term economic ramifications on their own professional practices due to
providing services at reduced fees (Fullen, Wiley, & Morgan, under review).
Our finding that practicing counselors were significantly more likely to have experienced
the impact of the MCG suggests that, when it comes to the MCG, the modal experience of
practicing counselors differs from that of counselor educators, doctoral students, and master’s
students. The medium-large effect sizes related to these group differences are compelling,
especially in light of the large sample that was used to investigate the MCG’s impact.
Additionally, our data provide strong evidence for a relatively greater impact of Medicare
ineligibility for those who have spent more time in the counseling profession, specifically among
practicing counselors. Although it is not surprising that counselors with more experience are
relatively more likely to encounter problems related to the MCG, the correlation suggests that
Medicare ineligibility becomes increasingly problematic the longer one works in the counseling
profession. In total, it appears that practicing counselors have disparate experiences related to
the MCG, and these differences may widen as counselors accumulate years in the profession.
Repercussions for Advocacy Engagement
At first glance, our finding that those with direct MCG experience were more likely to
participate in Medicare-related advocacy signals at least a correlational relationship between
ACA members’ personal experiences with Medicare ineligibility and their willingness to
participate in advocacy initiatives. This is consistent with theory related to how individuals learn
to engage in social justice advocacy. For example, in the Social-Cognitive Model of Social
Justice Interest and Commitment, Miller and Sendrowitz (2011) highlight the importance of two
key elements that contribute to the formation of social justice advocacy commitment: personal
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 21
moral imperative and counselor training environment. In regard to personal moral imperative,
the authors state that individuals discover forms of social injustice that provide motivation to
think and act as agents of social justice. Drawing on Bandura’s work in social cognitive theory
(1991), the authors suggest that personal moral imperative, along with training environments that
model social justice advocacy, results in the cultivation of social justice interest.
In the language of this model, it is possible that ACA members who directly experience
the consequences of the MCG develop a personal moral imperative related to the needs of
Medicare-insured individuals. These experiences may activate counseling professionals’ interest
in Medicare advocacy, including grassroots lobbying efforts. Miller and Sendrowitz (2011)
describe this as “the process by which individuals discover for themselves certain aspects of
social injustice that compel them to action” (p. 160). Although advocacy participation is costly
due to the time and attention it requires, counseling professionals who possess firsthand
experiences with the MCG may be more willing to participate, both due to the impact on their
livelihood and their concern for clients. Aligned with the aforementioned model, these
professionals may then experience greater self-efficacy in regard to social justice advocacy
(Miller & Sendrowitz, 2011), positive feedback from legislators in regard to the seriousness of
the issue, and increased willingness to stay engaged in an issue as it plays out over the course of
months and years.
Impact on Counselor Training
On the other hand, our data suggest that counselor educators, and graduate students at all
levels, were less likely to have direct experience with the MCG, which may suggest a subsequent
impact on participation in Medicare-related advocacy. In a related study, we found that
master’s-level counseling students were significantly less likely to state that Medicare
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 22
reimbursement negatively impacts the profession, and they also were significantly less likely to
agree that older adults benefit from counseling services (Fullen, Lawson, & Sharma, under
review). We also found that these students were significantly less likely to have engaged in any
form of Medicare-related advocacy. Therefore, in keeping with Miller and Sendrowitz’s model,
it is possible that trainees lack exposure to the MCG, thus limiting their interest in addressing the
issue at a time when they are shaping their social justice advocacy identities.
Furthermore, it is necessary to consider the role of counselor educators and other
professional leaders when it comes to inspiring social justice advocacy about the MCG within
counselor training programs. Miller and Sendrowitz argue that “program faculty can have a
large impact in shaping the environment by modeling, supporting, and facilitating social justice
engagement and discussions” (p.160). Whereas there have been frequent references to social
justice advocacy in the scholarly literature over the last fifteen or more years, there has been
relatively little scholarly inquiry into the impact of the MCG. It is possible that the frequent
allusions to Medicare in practice publications like Counseling Today, coupled with the lack of
scholarship around this issue, is further evidence of a bifurcation between counselor practice and
counselor training.
Implications
The results of this study have implications for counseling practice, counselor education,
and counseling scholarship. In regard to counseling practice, the prevalence of counseling
professionals who have been directly impacted by the MCG has major implications for the well-
being of clients, the professional viability of licensed counselors, and participation in legislative
advocacy related to this issue. As the population continues to grow older and the number of
Medicare beneficiaries grows (Medicare Payment Advisory Commission, 2015), an increasing
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 23
number of Americans may have difficulty accessing mental health care, due in part to the MCG.
In spite of scholars calling for more resources for older Americans (Institute of Medicine, 2012),
especially those who live in rural areas (Stewart, Jameson, & Curtin, 2015), as long as the
current policy is in place, Medicare beneficiaries will continue to experience systematic barriers
to receiving mental health services.
Implications for Counselors
Consistent with our findings, practicing counselors are most likely to bear the largest
brunt of Medicare ineligibility, particularly as the number of Medicare-insured individuals
grows. More so than students or counselor educators, practicing counselors may be forced to
make difficult decisions about how to respond when a community member with Medicare
insurance contacts them in search of mental health treatment. Practicing counselors may also
have a difficult time finding employment within particular contexts in which Medicare
reimbursement makes up a sizeable proportion of revenue. Specifically, integrative care contexts
such as hospitals, federally qualified health centers, accountable care organizations, or patient-
centered medical homes may be less willing to hire licensed counselors knowing that these
employees will be unable to be compensated by Medicare (Fullen, Wiley, & Morgan, under
review).
Additionally, these results suggest that practicing counselors, especially those with more
years of experience, have a unique responsibility to tell their stories about the MCG to legislators
and other key stakeholders. From a systems advocacy perspective, harnessing the experiences of
counseling professionals who are willing to speak about their direct experiences with the MCG is
vital given that legislators are more likely to be compelled to act when they hear from
constituents who share direct information about a phenomenon in a manner that requires the
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 24
constituents’ time and energy (Cluverius, 2017). In light of the value of advocacy efforts,
counseling professionals who have compelling stories to share will continue to be relied upon
when grassroots advocacy is employed. Given the double-burden facing counselors, in which
they have to navigate how to best respond to Medicare beneficiaries who seek treatment and tell
their MCG stories in a timely fashion to lawmakers, further work is needed to identify how to
provide support to this group.
Implications for Counselor Education
Within counselor education, our results could be used to inform strategies to mobilize and
maximize advocacy efforts among counseling students and counselor educators. At the student
level, it appears that a lack of exposure to the direct effects of the MCG may inhibit engagement
with professional advocacy efforts. Strategies to reverse this trend should begin with counselor
educators and supervisors due to their influence in the student-professor and supervisee-
supervisor relationship (Fullen, 2018). Naming Medicare reimbursement for counselors as one
of the more pressing issues facing the profession is a good first step, but it may be necessary for
counselor educators to invest time in explaining why current Medicare policy is burdensome to
clients and counselors, as well as how beneficiaries are uniquely disadvantaged by current
policy. Framing the MCG as a social justice issue may activate interests among counselor
trainees and increase their interest in and commitment to this issue (Miller & Sendrowitz, 2011).
There are many specific domains within the counselor education curriculum where these
conversations could emerge. Within a professional orientation course, students might learn
about the history of becoming a profession and how Medicare reimbursement would symbolize
full recognition as a nationally-recognized profession. Rather than ending the discussion at this
point, counselor educators could illustrate the detrimental impact of the MCG on clients and
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 25
counselors by using a case study approach. By describing a particular client (real or
hypothetical) who has been turned away from services or referred mid-treatment due solely to
the type of insurance they have, counselor educators have the opportunity to generate dialogue
about the consequences of current Medicare policy, as well as the connection to broader social
justice issues such as access to mental health services. This case could then be re-visited in other
counselor education classes to reinforce the importance of the policy, such as in courses related
to ethics (e.g., Is it ethical to abruptly stop counseling a client when they transition to
Medicare?), multicultural counseling (e.g., How does Medicare policy unduly impact older
people, people with disabilities, and people living in rural areas), human growth and
development (e.g., How do societal attitudes about aging and mental health influence interest in
Medicare’s policy?), and addictions (e.g., What do you make of the fact that Medicare is the
single largest payer for opioid use hospitalizations?; Song, 2017). By infusing discussion about
this particular issue across several teaching domains, counselor educators could create the sort of
counselor training environment that is conducive to promoting professional advocacy on this
issue (Miller & Sendrowitz, 2011).
Implications for Counseling Scholarship
Finally, there are implications for counseling scholarship. In light of Kiselica and
Robinson’s (2001) recommendation that counselors should use their skills in assessment and
research to assess progress on advocacy, it is concerning that so few scholarly articles about
Medicare advocacy have emerged. Although broad efforts to cultivate social justice advocacy
skills and dispositions have greatly influenced the counseling profession, it is possible that more
work is needed to apply these skills in a systematic manner that transforms specific public
policies. Echoing Lee and Rodgers (2009), several steps are required to influence systemic
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 26
change, including working alongside stakeholders outside of the profession, communicating with
the media, and lobbying policymakers. More than fifteen years into working on Medicare
reimbursement for counselors, there have no doubt been countless phone calls and meetings with
legislators, all in the real hope of effecting systemic change. What has been missing, though,
may be the systematic inquiry that comes with scholarship, such as the collection and analysis of
data to indicate progress, precise communication about the problem, and empirically-supported
work that informs whether advocacy strategies have been successful. Given the slow rate of
change within the legislative process, it may be beneficial to examine the current policy’s impact
in a more systematic manner in the event that policy change is still years away.
Limitations and Directions for Future Research
Although this investigation begins to illuminate the prevalence and differential impact of
the MCG, there are several limitations that should be considered. First, although the sample size
exceeds that of previous studies on counseling professional association members (Poynton et al.,
2019), the relatively modest response rate means that results may not accurately generalize to the
full population of ACA members. It is possible that individuals who had direct experience with
the MCG were more likely to participate than those who had not had that direct experience.
Relatedly, not all counselors are members of the ACA, which means that our results may not be
generalizable to the entirety of counseling professionals in the United States who are impacted
by the MCG. Future research might focus on increasing response rate and ensuring that non-
ACA members’ experiences are also represented.
Additionally, there are limitations related to the questionnaire that was used to assess the
prevalence of direct experience with the MCG. The primary question used to gauge experience
with the MCG was intended to have a high degree of face validity. Nevertheless, it is possible
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 27
that respondents misinterpreted the selections, or that additional response categories should have
been included. The low number of clearly invalid scores (e.g., Yes and No simultaneously), as
well as the large effect sizes associated with our data analysis suggest that participants accurately
interpreted and responded to the item described in Table 2. However, future research is certainly
needed to replicate our findings on the prevalence of the MCG’s impact; ideally, co-occurring
with the development of more psychometrically rigorous tools to assess the prevalence of the
MCG.
Finally, although the use of a survey instrument is helpful in exploring an understudied
phenomenon (Young, 2010), there are specific questions that were not addressed within the
current questionnaire, such as how training (e.g., type of educational track) or practice (e.g., type
of counseling practice; geographical location) variables impacted the experience of the MCG.
For example, our data does not differentiate between the experiences of those who specialize in
rehabilitation counseling, addictions counseling, or clinical mental health counseling. Nor does
our current study indicate whether the MCG is more problematic in rural vs. non-rural settings,
as has been suggested by other researchers (Larson et al., 2016). Future research that examines
how these contextual variables impact experience with the MCG is needed.
Conclusion
The prevalence of counselors who have been impacted by current Medicare policy
suggests that Medicare beneficiaries are systematically restricted from access to mental health
services. Given the growing number of Medicare beneficiaries, there is reason to believe that
this problem will continue to worsen until the policy is changed. In light of the fact that greater
than half of survey respondents reported direct experience with the MCG, there is a need for
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 28
greater awareness of the prevalence and scope of the problem, as well as additional research to
illuminate the impact of Medicare ineligibility on counseling professionals and their clients.
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ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 33
Table 1
Descriptive Statistics
Mean
Standard Deviation
Minimum
Maximum
Age
(N = 5,835)
44.81
14.40
21
97
Female
Male
Additional categories
Sex
(N = 6,066)
79.9%
18.5%
1.6%
White/Non-
Hispanic
African
American
Asian/Pacif
Islander
American
Indian/Native
American
Hispanic/
Latinx
Multi
racial
Additional
categories
Race
(N = 6,055)
76.5%
10.9%
2.3%
0.6%
4.9%
2.9%
1.8%
Practicing counselor
Counselor
educator
Master’s
student
Doctoral student
Other
Prof. Statusa
(N = 6,068)
62.9%
6.0%
25.2%
3.6%
2.3%
0-1 yrs
2-3 yrs
4-7 yrs
8-14 yrs
15+ yrs
Years in
Professionb
(N = 5,339)
18.5%
24.6%
20.0%
15.5%
21.3%
Addictions
Career
CMHC
College
CFC
Past-
oral
Rehabilitation
School
Special-
ization
(N = 6,052)
7.0%
1.1%
75.0%
2.7%
6.3%
1.2%
1.8%
4.7%
0-15 yrs
15-24 yrs
25-44 yrs
45-64 yrs
65+ yrs
Primary
client age
group
(N = 6,005)
13.9%
19.6%
52.2%
12.8%
1.6%
Yes
No
CACREP-accredited program?
(N = 6,061)
77.1%
22.9%
Member of state counseling association?
(N = 6,066)
57.4%
42.6%
aWhich current professional status best describes you? bHow many years have you been a member of the counseling
profession? [Text box provided; raw data later categorized by research team]
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 34
Table 2
Survey item used to direct experience with Medicare ineligibility
Have you ever had to deny/refer potential or existing clients because of a lack of Medicare
reimbursement? (Check all that apply.)
Yes, I have turned away new/potential client(s) due to ineligibility for Medicare
reimbursement.
Yes, I have referred existing clients due to ineligibility for Medicare reimbursement.
I have had to work with a client pro bono or on a sliding scale due to ineligibility for Medicare
reimbursement.
Other [Text box provided]
None of the Above
Not Sure
Table 3
Percentage of ACA members impacted by MCG, by professional type
Experience
Total Impacted
Turned Away
Referred Existing
Pro Bono/Sliding Scale
Practicing counselor
70.0%
50.3%
38.8%
39.9%
Counselor educator
48.3%
24.4%
22.7%
29.1%
Doctoral student
48.8%
23.8%
23.3%
33.3%
Master’s student
20.9%
8.2%
8.2%
12.7%
N = 5,930 (missing data consists of 140 respondents who omitted response to professional type item)
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 35
Figure 1. Recruitment for Medicare advocacy study
ACA members completed survey
(n = 6,550 (12.95%))
Completed surveys eligible for current
analysis (n = 6,070 (92.67%))
Surveys deemed ineligible for current
analysis (n = 480 (7.33%))
Participant
selected Other
(n = 465)
Participant did not respond
to necessary items
(n = 15)
ACA members received survey
(n = 50,592)
(
Surveys sent to ACA database (n = 51,221);
629 returned as undeliverable
ANALYZING THE IMPACT OF THE MEDICARE COVERAGE GAP 36
Figure 2. ACA members directly impacted by Medicare coverage gap
