State Mandates for Hearing Aid Coverage: An Opportunity for Improving Access to Hearing Health

Often overlooked, hearing loss is a common chronic condition and an important factor in overall health. Twenty-three percent of Americans 12 years and older have at least mild hearing loss.¹ However, the prevalence increases with age from less than 1.0% of those younger than 20 years¹ to 65% of those 71 years and older and 96% of those 90 years and older.² Hearing loss ranges in severity from mild (∼66% of cases), to moderate (∼28%), to severe or profound (∼6%).

Early public health research on hearing loss focused on the association between unaddressed hearing loss among children and outcomes such as lower educational achievement and poorer speech and language development. Subsequent studies have shown the protective effects and importance of early intervention and language access (e.g., language services such as teaching American Sign Language, amplification, cochlear implantation, or some combination of these) and have led to widespread programs such as the universal newborn hearing–screening program tied to federal funding in the 1990s.

More recently, a shift in focus suggests that hearing loss among older adults is associated with lower health-related quality of life,³ incident dementia,⁴ depression,⁵ and increased health care expenditures.⁶ Importantly, most observational studies find that hearing aid use provides a protective effect against negative outcomes. A landmark randomized controlled trial assessing the effectiveness of hearing intervention in reducing cognitive decline over three years among older adults, the ACHIEVE (Aging and Cognitive Health Evaluation in Elders) trial, reported a null overall effect; however, a prespecified subanalysis found that hearing intervention reduced cognitive change among older adults at increased risk for cognitive decline (e.g., those with poorer overall health, lower socioeconomic status).⁷

Hearing aids, a noninvasive, minimal-risk intervention, are the most common and versatile (e.g., indicated for most degrees of hearing loss) treatment of hearing loss but are underutilized. Estimates suggest that only between 16% and 30% of American adults who might benefit from a hearing aid own and use one.² The barriers to hearing care are multifactorial, but often noted key barriers are accessibility and affordability.⁸ The estimated cost at $4700 for a typical pair of hearing aids and accompanying professional services is prohibitive for many Americans, especially given hearing services minimal insurance coverage.⁸

Hearing aids and related services are a statutory exclusion under Medicare, the primary health insurance provider for older Americans. Although many Medicare Advantage programs include hearing aid coverage, evidence on the details and effectiveness of these benefits on hearing aid adoption is limited. As of 2016, only 28 states had some level of Medicaid hearing aid coverage for adults, with benefits varying significantly from state to state.⁹

Recent policies have attempted to improve the accessibility and affordability of hearing care. The Over-the-Counter Hearing Aid Act of 2017 (passed as a rider on the US Food and Drug Administration [FDA] Reauthorization Act of 2017) required the FDA to develop criteria and to implement a new category for a regulated class of over-the-counter hearing aids. These devices would be available to the public without the need to see a licensed professional as a means to decrease access barriers to hearing care. The new FDA regulations became official in November 2022, and any realized increase in hearing aid uptake is still uncertain. The Build Back Better Act of 2021 included provisions that removed the statutory exclusion and expanded hearing care under Medicare; the act passed the US House of Representative but ultimately failed by a single vote in the US Senate.

In recognition of hearing aids’ importance for people with hearing loss, some states and US territories have enacted mandates requiring private health insurance to cover the cost of hearing aids. In an exemplary exercise of policy surveillance, in this issue of the AJPH, Arnold et al. (p. 407) found that as of 2023, there are 28 state mandates in place (27 by the end of 2022 and an additional one in Vermont starting in 2023) requiring private health insurance to cover hearing aids. Unsurprisingly, the authors found vast heterogeneity across state mandates, with variability in exemptions and exceptions of included populations, coverage limits, and intervals for how often benefits could be claimed—a key consideration given the limited lifespan of a hearing aid (∼3–7 years).⁸ The detailed report puts the generosity of these mandates into perspective, as some benefit limits would not cover the average cost of a pair of hearing aids and would leave Americans on the hook for a substantial remaining bill.

Perhaps consistent with the history of the research described, Arnold et al. found that hearing aid policies and state mandates favored US children and adolescents. Because of multiple state mandates, the overall proportion of US individuals whose private health insurance covers at least some costs related to a hearing aid has increased over the past 15 years (2008–present); however, deeper surveillance revealed differences by age group. The proportion of children and adolescents with hearing aid coverage increased from 3.4% to 18.7%, whereas adults aged 19 to 64 years were left behind with only a 0.3% to 4.6% increase. A combination of established research translating to policy, a smaller target population that requires fewer resources to guarantee coverage, and ageism (e.g., overlooked concern for older adults) likely plays a role in the disparities in coverage. However, given the recent work and trial findings, improving hearing care access for older Americans could have an important impact on the overall well-being of society—perhaps even being cost-effective because health care expenditures would be reduced.

In their article, Arnold et al. suggest that higher coverage could be achieved with the implementation of a federal-level mandate or with the relaxation of state mandate exceptions, particularly those pertaining to age limits. However, as the authors mention, the reach of these state mandates is limited, as they do not apply to private employer self-insured group health plans, which cover most privately insured workers.

Moving forward, an important consideration is the need for a deeper understanding of how increased coverage and which aspects of coverage (e.g., plan generosity) translate into realized increases in hearing aid uptake and sustained hearing aid use. Importantly, the authors have provided a valuable contribution to science and have laid the foundation for developing causal inference and econometric models to assess the effectiveness of mandates by publicly disseminating the output of this surveillance research, which compiles and categorizes details of the various state mandates with information on when they go into effect. These data could be a catalyst for new, innovative research and offer a unique opportunity to spur new interest in hearing care research from public health researchers not previously engaged in this area.

Policy surveillance examines the link between law and public health, and it contributes to the development of effective and equitable policies. At the same time, it allows the monitoring of such policies to ensure that these remain relevant to the needs of the population they intend to serve. Policy surveillance analysis pertaining to hearing health care was overlooked until now. The work of Arnold et al. will ease the monitoring and evaluation of these hearing aid mandates for the benefit of the US population while providing new information to consider in the larger framework of hearing care policy research moving forward as their work isolates the effect of new initiatives (e.g., over-the-counter hearing aids) and proposes comprehensive approaches (e.g., combining mandates with Medicare expansion) for improving hearing care uptake in the United States.