Sheila Seidman's hearing became a problem in her 60s. She found herself asking "What?" way too often. When she'd go out with friends, she couldn't make sense of their stories. "I really would try to listen, and I just couldn't get it," she said.
The Plymouth Meeting woman started to feel left out and depressed. Plus, she thought her hearing loss was dangerous. She couldn't hear cars well enough when she was walking. "It's like going out in the street without your glasses and being blind," she said.
The thought of hearing aids made her feel old, though, and they were expensive. She delayed. About eight years ago, she finally broke down and got them. She was thrilled to hear the rush of wind, the crinkle of money. Now Seidman, 77, a frequent visitor to the Center at Journey’s Way, a senior center in Roxborough, is an evangelist for hearing aids.
“I couldn’t do without them. I tell everybody that. Once you get yourself used to it, you have to have them,” she said. She knows a lot of people at the center who need them. “A lot of them can’t financially afford it,” she said. Her most recent pair cost $3,500, and that was with a little help from her Medicare Advantage plan. An average set costs about $4,500, and they need to be replaced every five to seven years. Traditional Medicare does not cover hearing aids at all, an exclusion that surprises and upsets many seniors and their caregivers.
“That’s huge,” said Frank Lin, director of the Cochlear Center for Hearing and Public Health at Johns Hopkins University, of the $4,500 average. “It’s out-of-pocket. It’s crazy.”
Medicare’s lack of coverage is getting more scrutiny as evidence mounts that uncorrected hearing loss is more than an annoyance. Over the last decade, studies have shown that people who can’t hear well are at higher risk for dementia, falls, depression, and social isolation. They have higher health-care costs.
As Seidman can attest, hearing is now recognized as a major factor in physical and psychological health. A National Academy of Medicine report in 2016 recommended insurance coverage.
In 1965, though, Medicare’s framers saw hearing loss as a normal part of aging. Medicare, which doesn’t pay for glasses, either, was for sickness. It would now take an act of Congress to change the rule. Several bills have been introduced to do just that, including one sponsored by Pennsylvania Sen. Bob Casey Jr. and the cleverly named the “Seniors have Eyes, Ears, and Teeth Act” in the House. The obvious barrier to passage is cost, which has not even been estimated.
Forty percent of people older than 60 have clinically important hearing loss, said Charlotte Yeh, chief medical officer for AARP Services Inc. Two-thirds of people in their 70s and even more in their 80s need hearing help. “It is a huge epidemic that we never talk about,” Yeh said. “It’s silent.”
The thought that any of the bills will pass soon is "very, very optimistic," said Susan Pilch, senior director of government relations for the American Academy of Audiology. Audiologists are the professionals who test hearing and help patients choose and use hearing aids.
In the meantime, some hearing experts hope that new federal rules that will allow over-the-counter sales of hearing aids as early as next year will lower prices and improve access.
Personal experience opened David Nash’s eyes to the importance of hearing health. A decade ago, the health policy expert at Jefferson Health scoffed when a major health organization listed improved hearing care as one of its top five health-care goals. “I thought, ‘Good Lord, we have so many more important issues,’” he said.
Now Nash is almost 64 and a few months into wearing the $6,000 pair of hearing aids his wife strongly encouraged him to buy. His insurance plan chipped in about $1,100 for this doctor who is dean emeritus of Jefferson’s College of Population Health. He is well-aware that the “average bear” lacks his resources.
“I use it as a teachable moment and say, ‘I’m grateful I can afford it — like a lot of health care,’” Nash said. He now thinks that Medicare should offer “at least some baseline coverage. ... We need broader national discussion about hearing loss. I was wrong to think it was a subsidiary issue.”
Medicare Advantage, a managed-care alternative to traditional Medicare, has more leeway to offer hearing and vision services, and some plans have been improving benefits. Hearing experts said private plans for younger people have very slowly been adding hearing benefits.
So far, the connection between hearing loss and health problems is an “association.” The problems are often found together, but that doesn’t mean that one causes the other. At Johns Hopkins, Lin is running a $20 million, federally funded study to find out whether giving people hearing aids reduces their risks compared with people who don’t get hearing aids. Results won’t be available until 2022. Also, UnitedHealthcare, an insurance company, said it plans to study whether a more robust hearing-aid benefit reduces any other costs.
Lin, who thinks Medicare should cover hearing loss services, said hearing loss could increase risk for dementia in several ways. One is that garbled sounds increase “cognitive load” on the brain. “The brain is constantly having to work hard when it could have been using its resources for things like thinking and memory,” he said. In addition, the lack of sensory input from the ear may hasten rates of brain atrophy. Lastly, hearing loss often leads to loneliness and social isolation, which are themselves risk factors for dementia.
Cognitive load may also be a factor in the relationship between hearing loss and falls, Lin said. “Gait is actually a very, very demanding task,” he said. This is why people often slow down during a serious phone call. People also lose environmental cues that help with balance, such as the sound of a foot hitting the ground or someone walking nearby. Plus, many older people see poorly and hearing loss is an “additional hit on the system.”
Another Johns Hopkins program run by Carrie Nieman, is looking at whether using trained community peers to help seniors choose over-the-counter hearing amplifiers leads to greater improvements in hearing. Amplifiers are an unregulated market, Nieman said, and many are “junk,” but some “function just like hearing aids.”
Only 15 percent to 20 percent of people who need hearing aids wear them, Nieman said. Cost is obviously part of the reason, but uptake is only 25 percent to 30 percent in the United Kingdom, where people can get them for free.
Adam Wojcik, general manager of UnitedHealthcare Hearing, would not divulge any specific numbers, but said that only a small percentage of customers use their Medicare Advantage hearing-aid benefit. There’s a “lot of room to educate the market,” he said. Demand is higher in plans with lower co-pays.
Stigma is also a problem, experts said. People think hearing aids make them look old, though they discount the effect of forcing people to shout at them. "The hearing loss is going to be much more conspicuous than wearing a hearing aid," Wojcik said. Seidman's and Nash's hearing aids are barely noticeable. A small part fits behind the ear lobe and a transparent tube snakes into the ear.
Many experts hope that baby boomers accustomed to ear buds and head phones will be more likely than previous generations to embrace hearing aids as their hearing fails. Some audiologists think stigma is already fading. Nash loves that he can hear phone calls and music through his hearing aids. "I have the most expensive ear buds you could buy," he jokes.
A problem that’s harder to conquer is that hearing loss sneaks up on you. Primary-care doctors don’t focus on it, and the changes are so gradual that many patients don’t notice them. “It’s not denial so much as adjustment,” said Lise Hamlin, director of public policy for the Hearing Loss Association of America.
Lin said older people should listen when others tell them they have a problem. "Most people with hearing loss don't know," he said, "but all their friends and relatives know."
People who have experienced hearing loss said it's easy to start withdrawing from life. Maybe you stop going to church because you can't hear the sermon. You stop going out to eat with friends because of restaurant noise. You fake your way through conversations, terrified that you'll get something wrong.
“It changes your whole way of being with other people,” said Margie Gale, 69, of Roxborough, who has coped with hearing loss since she developed Meniere’s disease in her 50s. “You do a lot of smiling and nodding. … You tend to pick not being with people because it’s more comfortable.” She says she couldn’t live without hearing aids now.
B.J. Kittredge, 75, of Haddonfield, got hearing aids about five years ago when she couldn’t hear conversations in restaurants. She now feels more alert, energetic, and engaged with the world. A retired health-care consultant, she and a friend are finishing a book about senior activists.
When she got her hearing aids — for $7,500 — she could hear running water again, the walnuts striking her roof, the birds. She realized she had been settling for a muted world. “It was fabulous. It was like being set free in a way that I didn’t expect,” she said. “I didn’t realize how much pleasure in hearing there was.”
She was also newly delighted by social experiences. “You go to the orchestra or a film or a party, and it’s like, ‘Here I am again.’”
While traditional Medicare is forbidden from covering hearing aids, Medicare Advantage plans, which offer a managed care alternative, have permission to provide additional coverage, and they often do.
James Michel, director of policy and research for the Better Medicare Alliance, which represents Medicare Advantage plans, said 68% of such plans offer some kind of hearing coverage, including audiologist visits. Fifty-five percent cover hearing aids to some degree.
In a written statement, Heidi Syropoulos, medical director for Independence Blue Cross, said the company considers hearing coverage an “important benefit and one that is crucial to our members’ health.” Its TruHearing program helps members schedule exams and fitting appointments. If the member buys a hearing aid, there is a flat copay of $499 to $999.
The company also sells Medigap plans for traditional Medicare beneficiaries that offer hearing aid discounts.
Ninety-four percent of Aetna’s Medicare Advantage plans offer some coverage. Ten years ago, a typical plan would have paid $250 toward the price of a hearing aid, said Bob O’Connor, chief Medicare officer for Pennsylvania, West Virginia, and Delaware. For 2020, some plans pay $1,250, enough to cover the cost of some hearing aids in the company’s network.
UnitedHealthcare has also made hearing health a priority. One Advantage option is to use a network of audiologists and receive “custom-programmed” hearing aids by mail. Out-of-pocket costs in its plans start at $100, but it’s more common for them to top $700.
Audiologists said customers should beware of some programs that limit access to audiologists for tuning. Co-pays for those visits can quickly add up.