Virginia Tech professor's research influences a historic expansion of Medicare’s mental health coverage

In the last six months, the United States has seen the largest expansion of Medicare’s mental health coverage in history – and a Virginia Tech professor helped make it happen. 

Historically, the more than 60 million Americans covered by Medicare, which is federal health insurance for people older than 65 years old, were not able to access services from marriage and family therapists or mental health counselors. That is until a law, heavily influenced by research at Virginia Tech, went into effect in early 2024.  

The law gave mental health professionals not previously covered the opportunity to enroll as Medicare providers. So far, about 43,000 mental health counselors and marriage and family therapists have opted in, according to the Centers for Medicare and Medicaid Services, allowing those 60 million people covered by Medicare to have access to services they wouldn’t have had before.

Matthew Fullen, associate professor of counselor education at Virginia Tech, has been one of the nation’s leaders in this arena. For years, he’s been advocating for health care professionals to be able to accept Medicare coverage. And by working with the American Counseling Association (ACA), the National Board of Certified Counselors, and other organizations associated with the Medicare Mental Health Workforce Coalition, his ideas finally took hold and influenced policy.  

"Modernizing mental health access for Medicare recipients is incredibly timely,” said Fullen, who has worked at Virginia Tech for seven years. “Working alongside colleagues and graduate students to articulate why this change is needed has been the highlight of my career."

Why is the law important?

• This law opened the doors for about 400,000 counselors and marriage and family therapists to accept Medicare payments. 

• Those providers account for about 40 percent of America’s mental health workforce and have largely been unable to accept Medicare enrollees who couldn’t afford to pay out of pocket until now. 

• So far this year, 36,000 licensed counselors and 7,000 licensed marriage and family therapists have enrolled as Medicare providers.  

• According to the Administration for Community Living (ACL), the United States will see major growth in those covered by Medicare due to an aging population, which means the number of providers will need to increase to keep pace. Right now, there are roughly 65 million older adults covered by Medicare. The ACL predicts that number will hit 90 million to 95 million in the next 20 or 25 years. 

History of Fullen's work

Before the most recent update to Medicare coverage, the policy hadn’t been updated since 1989. 

Recognizing that this legislation was in desperate need of an update, Fullen led research by students and faculty at Virginia Tech, both through the School of Education and the Institute for Society, Culture and Environment, with the focus of defining and describing the impacts of the outdated Medicare policy. 

“The research that Dr. Fullen and his team were able to produce was, by all accounts, the central reason that this advocacy effort finally came to fruition,” said Gerard Lawson, interim director for the School of Education. “There were thousands upon thousands of older adults, veterans, and individuals with disabilities who were in desperate need of mental health support and were waiting months for appointments. This was especially true for people living in rural areas. Stakeholders that had been struggling with this issue for decades needed data to help legislators understand the scale and scope of the problem, and Dr. Fullen’s research did just that.”   

That research then contributed to a larger conversation at the legislative level, helping lawmakers understand how the outdated policy had tangible negative effects in communities nationwide. 

“What that research trajectory helped to define was, ‘How many providers are being impacted by this outdated policy?'” said Fullen. “Then, we added qualitative research focused on individual Medicare recipients who had not been able to find services because so much of the mental health workforce was not included.”

According to Lawson, research like this is the bread and butter of the School of Education’s counselor education program. 

“This project and the positive impact made by this research and advocacy are right in the wheelhouse for faculty in our counselor education program,” said Lawson. “The faculty in that program are actively engaged in research and advocacy to address thorny issues like this one, as well as school climate and working conditions, rural school counseling, serving LGBT and gende-expansive clients, anti-racist pedagogy, and more. Research and advocacy go hand in hand, and the counselor education faculty are improving the lives of individuals who are receiving mental health services on a day-to-day basis.”   

Why did it take so long?

The actual administrative process of making changes to the policy isn’t easy. Medicare is federal law, meaning any revisions to the policy require an act of Congress. But as former chair of the American Counseling Association’s government relations committee, Fullen is no stranger to the work it takes to make legislative change. 

While there were some obvious hurdles, years of advocacy work paired with the change in public discourse helped change the tide. 

“Thanks to Dr. Fullen’s dedication to the counseling field and support for increased mental health access, mental health counselors, and marriage and family therapists are seen as major actors in addressing the needs of older adults with mental health conditions and increasingly sought by behavioral health systems and health care providers for their expertise in the older adult space,” said Joel Miller, executive consultant with the National Board for Certified Counselors and Affiliates.   

Much of that advocacy work was spearheaded by the Medicare Mental Health Workforce Coalition. The CEO of the American Counseling Association, which is a part of the coalition, explained that Fullen’s work has been “pivotal” in moving this landmark legislation forward.  

“His relentless advocacy and active participation in the Medicare Mental Health Workforce Coalition, along with his seminal 2019 research which analyzed the impact of the Medicare coverage gap on counseling professionals, is helping to provide those in need with greater access to essential mental health services,” said the association's CEO Shawn Boynes.  

Another catalyst that helped change perceptions of mental health was the pandemic because it pushed the needs of often overlooked populations into the spotlight. While a study from the Administration for Community Living shows that older adults fared better in terms of mental health during the height of the pandemic when compared to younger generations, isolation during COVID-19’s peak made discussing mental health more mainstream. 

While changing federal law is no easy feat, Fullen said there was overwhelming bipartisan support behind the policy updates. 

What’s next? 

Now that licensed counselors and marriage and family therapists are approved providers under Medicare, Fullen said his job on the panel is to continue to advise the Centers for Medicare and Medicaid Services on mental health policies. 

Looking forward, Fullen said a major goal is to aim for as many providers to enroll as possible. With the influx of new providers, there will also need to be training to help prepare them on how to best help older adults specifically. 

Fullen’s appointment to the federal Advisory Panel on Outreach and Education is for two years, and he is one of several professionals on the panel focusing on mental health.  

“It's a unique opportunity to represent the mental health community,” said Fullen. “It’s like adding to a part of the conversation that has really not been there before because we didn't get invited to these panels when we weren't part of the program.”