Bridging the Hearing Divide: Policy Solutions for Aging Americans

Abstract

Hearing loss affects approximately two thirds of adults in the United States aged 70 years or older and frequently remains untreated despite its well-documented harms, including accelerated cognitive decline, increased caregiver burden, and higher health care expenditures.

We examine the major barriers to accessing high-quality hearing care, with particular attention to the complex and fragmented landscape of insurance coverage across Medicare, Medicaid, the US Department of Veterans Affairs, private plans, and over-the-counter (OTC) products. We review key legislative and regulatory developments over the past decade, most notably the 2022 establishment of OTC hearing aids, and summarize early opportunities and remaining gaps. We then propose targeted reforms to improve access and affordability, including more consistent Medicaid benefits, selective Medicare expansion, integration of teleaudiology, and strengthened oversight and consumer protections for OTC devices. Finally, we advance a technology-driven policy framework that integrates artificial intelligence–supported risk prediction, teleaudiology, real-time insurance verification, and a transparent device marketplace to modernize delivery and evaluation.

Together, these strategies can catalyze a fundamental rethinking of how hearing health is prioritized and managed within the broader United States health care ecosystem.

Nearly two thirds of adults aged 70 years or older in the United States experience hearing loss, with the prevalence rising sharply from 45% among those 70 to 74 years of age to more than 80% among those aged 85 years and older.^1,2 Hearing loss is associated with cognitive decline, social isolation, diminished quality of life, safety concerns, and poorer mental health outcomes.^2–5 Despite its prevalence and well-documented consequences, access to effective hearing health care, including hearing aids, remains constrained by gaps in health insurance coverage and systemic policy barriers.²

The 2016 National Academies of Sciences, Engineering, and Medicine (NASEM) report Hearing Health Care for Adults: Priorities for Improving Access and Affordability identified critical barriers to hearing health care, including the high cost of hearing aids, inadequate insurance coverage, and limited public awareness of hearing loss.² The report recommended enhancing access, affordability, and integration of hearing care within public health.² Since the publication of the NASEM report, legislative changes, the advent of over-the-counter (OTC) hearing aids, and growing evidence of the cognitive and social benefits of early intervention collectively underscore the need to update policy recommendations to address persistent disparities in hearing health care access.^3,5,6

This article offers 3 key contributions for policymakers, researchers, and public health stakeholders. First, it updates the policy landscape since the 2016 NASEM report, highlighting the Food and Drug Administration (FDA) 2022 rule permitting OTC hearing aids for mild to moderate hearing loss and recent actions by the Centers for Medicare & Medicaid Services (CMS) to expand audiology access for Medicare beneficiaries.

Second, it examines persistent gaps in insurance coverage, including Medicare’s exclusion of hearing aids, the limited uptake of Medicare Advantage benefits, state-level variability in Medicaid coverage, geographic restrictions in Veterans Affairs (VA) benefits, and the inconsistent and costly nature of private insurance. It also reviews financing strategies such as standardized benefit criteria, payer–government risk sharing, and bundled payments.

Third, it proposes a framework for improving access to hearing care through digital technologies and artificial intelligence across the continuum of service delivery. This framework emphasizes practical tools such as risk prediction, mobile self-assessment, telehealth rehabilitation, and real-time insurance navigation, all supported by safeguards for privacy, equity, and interoperability.

AGING AND UNTREATED HEARING LOSS: PUBLIC HEALTH IMPLICATIONS

In the United States, the population aged 65 years and older is expected to reach 82 million by 2050, a 47% increase from 50 million in 2022.⁷ This demographic surge amplifies concerns about untreated hearing loss, which is linked to higher risks of cognitive decline and dementia.^8,9 In turn, these health effects intensify public health challenges by escalating health care costs, increasing program expenditures for aging services, and elevating caregiver burden.¹⁰ Given the global increase in dementia cases to approximately 153 million in 2025, with hearing loss contributing to 7% of these cases, the need for targeted audiological interventions to mitigate cognitive decline has become increasingly relevant.^8,9

Beyond dementia, untreated hearing loss may increase safety risks; although evidence is mixed, some studies link it to higher rates of falls and motor vehicle crashes, likely through impaired perception of environmental cues.^4,11 Moreover, communication difficulties exacerbate caregiver burden and stress, creating an often-overlooked strain on familial and informal care networks.¹² Audiological care, including access to hearing aids, can help contain these individual and caregiver health-related costs by preserving functional independence.^2,4,12

Economically, untreated hearing loss hinders individuals’ employment prospects and job retention, leading to greater financial instability.¹³ This dynamic not only diminishes quality of life but also strains health care systems through a higher reliance on social welfare programs.^2,10,13 Conversely, improving hearing aid accessibility enhances self-sufficiency and workplace productivity, thereby contributing to economic stability for both aging populations and health care infrastructures.^2,13

The Aging and Cognitive Health Evaluation in Elders (ACHIEVE) trial, a landmark multicenter randomized controlled study, offers particularly compelling evidence regarding the benefits of early hearing intervention.⁹ ACHIEVE enrolled older adults with mild to moderate hearing loss from 2 cohorts, participants from the Atherosclerosis Risk in Communities study and a newly recruited community sample.⁹ Participants were randomly assigned to receive either immediate hearing care, including hearing aids fitted by audiologists, or a successful aging intervention as the control condition.⁹ During 3 years of follow-up, participants from the Atherosclerosis Risk in Communities cohort (at elevated risk for cognitive decline) who received timely hearing aids had a 48% lower risk of cognitive decline than those not involved in the intervention.⁹ By combining standardized audiological and neurocognitive measures, ACHIEVE demonstrated that hearing interventions preserve cognition and are cost-effective in reducing dementia risk.⁹

Data from the 2003–2004 National Health and Nutrition Examination Survey demonstrate a clear gradient in hearing loss by income and education: adults in the lowest income quartile had 1.64 times the odds of bilateral hearing impairment (95% confidence interval [CI] = 1.09, 2.47) relative to compared with those in the highest quartile, and individuals without a high school diploma had significantly greater odds of high-frequency hearing loss than college graduates.¹⁴ These findings highlight resource-driven disparities in audiological care and risk factor exposure.¹⁴ Therefore, addressing hearing health is a public health imperative closely linked to health equity and resource optimization.^2,14

ASSESSING RECENT DEVELOPMENTS IN EVIDENCE AND POLICY

This analytic essay synthesizes recent developments in US hearing health policy. In doing so, we initially conducted an unstructured review of peer-reviewed publications, policy analyses, and legislative and regulatory documents published between July 2008 and May 2025. To ensure a comprehensive view of the current policy environment, we also consulted Web sites and resources from key agencies and organizations including the FDA, the CMS, the Centers for Disease Control and Prevention, NASEM, state Medicaid agencies, and the Kaiser Family Foundation.

The evidence was organized into 4 broad domains (policy, device type, service modality, and cross-cutting themes) and examined in terms of relevance to access, coverage, financing, and equity. The findings were triangulated across the peer-reviewed literature, regulatory documents, policy analyses, and Web sites, with cross checking across independent sources to strengthen reliability and consistency. The search strategy, including databases used, key terms, and inclusion criteria, is described in more detail in the Appendix (available as a supplement to the online version of this article at http://www.ajph.org). A list of key sources by domain is provided in Appendix Table A, which serves as a compact evidence map of the literature informing US hearing health policy. The complete set of 37 sources, classified by publication type, subtype, and year of publication, is presented in Appendix Table B. The temporal distribution of these sources is shown in Appendix Figure A.

REVIEW OF EVIDENCE

Systemic barriers continue to restrict older adults’ access to high-quality audiologic care, thereby limiting hearing aid use.^2,15 As of 2019, fewer than one third of adults aged 70 years and older who could benefit from hearing aids had ever used them.^2,16,17 The 2021 National Health Interview Survey revealed a similarly low usage rate of 14.4% among adults aged 65 years and older, with men more likely than women to use hearing aids.¹⁸

Hearing Health Access in the United States: Core Issues

Low rates of use of hearing aids stem from multiple interdependent factors. Restricted access to audiological care, primarily driven by high costs and variable insurance coverage, remains a key barrier.^2,19 Limited awareness of hearing care needs, low self-perceived need for hearing aid use, and uncertainty about coverage options further discourage individuals from seeking treatment.^18–20 Even among those who obtain hearing aids, insufficient patient education, training, and follow-up by health care professionals can compromise device effectiveness.^2,19,20 Solutions to these issues include individualized device fitting, patient education and training, and clear information on coverage and services.²

The introduction of OTC hearing aids, following the FDA’s final rule published in August 2022 and implemented in October 2022, has markedly enhanced affordability and accessibility for adults with perceived mild to moderate hearing loss.^6,21 This regulatory change enables consumers to purchase hearing aids directly without requiring a prescription or an initial professional evaluation, thereby reducing cost barriers and expediting access.^6,21 Furthermore, updated coverage guidelines from the CMS, as outlined in the 2023 Physician Fee Schedule Final Rule, have streamlined audiology service referral processes, further expanding access to hearing care.²² Box 1 provides an overview of recent advancements in hearing health care access.

BOX 1— Recent Developments in Hearing Health Care Access.

Development	Year(s)	Key Provisions	Potential Impact
FDA authorization of OTC hearing aids	2022	Final rule published in August 2022 and implemented in October 2022.6,21 Permits direct, prescription-free purchase of hearing aids for mild to moderate loss.6,21 Eliminates the need for an initial professional evaluation.6,21	Reduces cost barriers and expedites access to hearing care.6,21,34 Supports early intervention but may be less suitable for severe or complex hearing loss.6,21
CMS revised guidelines and referral protocols	2022–2023	Updates outlined in the 2023 Physician Fee Schedule Final Rule streamline audiology service referral processes.22 Expands access to hearing care for Medicare beneficiaries by reducing the administrative barrier of obtaining a physician referral.22	Medicare beneficiaries can directly access 36 specific audiology services for nonacute hearing conditions without a physician or nonphysician practitioner order once every 12 months.22

Note. CMS = Centers for Medicare & Medicaid Services; FDA = Food and Drug Administration; OTC = over the counter.

However, despite these advancements, notable limitations persist. OTC devices typically exclude professional services such as fitting, calibration, and audiological rehabilitation, rendering them unsuitable for individuals with severe hearing loss (who represent 4.2% of adults aged 71 years and older according to the 2021 National Health Aging and Trends Study) and potentially exacerbating disparities in care.^6,17,21 Moreover, many older adults, particularly those with multiple comorbidities, require comprehensive audiological evaluations to optimize device programming and ensure long-term adherence.^2,6,17,21

In addition, although the revised CMS guidelines and streamlined referral protocols have improved access, challenges persist as they apply only to a restricted set of 36 Current Procedural Terminology codes for nonacute, gradually progressive hearing loss and exclude coverage for hearing aid assessment, fitting, acquisition, and ongoing care.²² All other audiology services, including the aforementioned, continue to require an order from a physician or nonphysician practitioner.²² This inconsistency frequently leads to out-of-pocket costs for patients and creates administrative burdens for providers, particularly in settings with limited audiology support.^20,22 Thus, simply supplying a hearing aid, whether OTC or not, cannot surmount these barriers; a comprehensive hearing care model that includes professional assessments, precise device fitting, rehabilitative services, and ongoing follow-up is essential to fully leverage the benefits of amplification.²

These utilization challenges underscore the limitations of current service models and highlight the need for policy updates that address inconsistencies in coverage and ensure ongoing support for hearing aid users.^2,19 The sections to follow examine how insurance frameworks and regulatory practices contribute to these barriers and offer actionable strategies to improve hearing care access and affordability.

Insurance and OTC Hearing Aids: Gaps and Policy Advances

Medicaid coverage for hearing aids varies substantially across states, creating geographic disparities in access unrelated to medical need and preventing many low-income older adults from accessing hearing care.² Although the Affordable Care Act expanded Medicaid in many states and mandates coverage for essential health benefits, it does not require hearing aid coverage, leaving this benefit optional.^2,23,24 For example, California’s Medi-Cal covers hearing aids for adults aged 65 years and older and requires an audiological evaluation and physician prescription.²⁵ Coverage includes a $1510 annual cap and previous authorization for expenses exceeding $254.²⁵ By contrast, neighboring Arizona’s Medicaid program offers no coverage for hearing aids for older adults.²⁶ The Build Back Better Act, proposed in 2021, included reforms to expand hearing aid coverage that would have substantially improved access for Medicaid beneficiaries; however, although it passed the House of Representatives, it failed to advance in the Senate and ultimately did not become law.²⁷

Medicare’s lack of hearing aid coverage results in high out-of-pocket costs for older adults that limit access to essential audiological care.^2,17 Traditional Medicare excludes coverage for hearing aids and routine hearing examinations, requiring beneficiaries to cover these costs entirely.^2,17,28 This coverage gap has persisted for decades without substantive policy intervention.^17,28

Medicare Part B does cover diagnostic hearing exams when ordered by a physician to determine the need for medical treatment.^2,28 According to the policy introduced in January 2023 by the CMS, patients can directly access audiologists for diagnostic tests related to nonacute hearing conditions once every 12 months without requiring a physician’s referral.^2,22 Despite this change, the policy continues to exclude services related to hearing aids and examinations for prescribing, fitting, or adjusting hearing aids.^2,22 Consequently, beneficiaries must seek coverage through Medicare Advantage plans or pay out of pocket.^2,17,20,29

Although 97% of Medicare Advantage plans offer hearing benefits, utilization remains low, with only 5% of enrollees undergoing routine hearing tests, 4% receiving hearing aid fittings, and just over 2% purchasing hearing aids.^17,18,29 Several factors may contribute to this low uptake. Many beneficiaries are unaware of their coverage.²⁰ In addition, out-of-pocket costs, including copays and limited allowances for hearing aids, deter use.^2,20,29 Complex plan structures, such as restrictions on covered providers and variability in benefit design, pose further barriers.^2,20

Two recent legislative proposals aimed at improving Medicare hearing aid coverage for older adults failed to be passed into law. The Medicare Hearing Aid Coverage Act, introduced in the House in February 2021 to expand Medicare benefits for hearing aids, did not progress beyond the committee stage.³⁰ The Build Back Better Act also contained provisions to expand Medicare coverage for hearing care services; however, these measures were not enacted as the bill stalled in the Senate.²⁷

The VA hearing aid program provides free devices and services to eligible veterans, but challenges remain in ensuring timely and convenient access to these services.³¹ Geographic barriers, particularly for rural veterans who often live far from specialized hearing care facilities, are a major issue.³¹ Although VA coverage has increased hearing aid usage and remote care initiatives have begun to alleviate these challenges, additional improvements are necessary to enhance access to hearing care.³¹ Potential measures include the distribution of low-cost devices for all veterans, expanded broadband access in rural areas, and the development of integrated smartphone applications with user-friendly interfaces for remote hearing assessments.³²

Private health insurance provides limited coverage for hearing aids, typically as optional add-ons.²³ High out-of-pocket costs, with an average bundled price of $2500, make hearing aids financially inaccessible for 77% of Americans with hearing loss; among those who would need to pay such an amount, an estimated 4% could be pushed into poverty.^2,23,33

The FDA’s approval of OTC hearing aids represents a pivotal step in addressing accessibility gaps by eliminating the need for prescriptions or audiologist fittings.⁶ Although OTC devices have expanded access for many, their overall effectiveness remains under evaluation; cost-effectiveness analyses suggest that OTC hearing aids must deliver at least 55% of the utility benefit of traditional devices to be considered a viable alternative.³⁴ Moreover, because OTC devices are unsuitable for severe hearing loss, they leave a coverage gap for those with the greatest need.^6,33,34 In addition, recent assessments have raised important consumer protection concerns.^2,35 Issues such as misleading product labeling, questionable FDA certifications, and the lack of robust mechanisms for recourse in cases of defective or ineffective devices underscore the need for enhanced regulatory oversight.^2,35 Comprehensive policy reforms to close regulatory gaps and strengthen consumer safeguards are essential for equitable, effective hearing care.^2,35,36

Box 2 offers a comparative analysis of hearing aid coverage, patterns of use, access disparities, out-of-pocket costs, and population reach across different insurance models and OTC devices. The data show marked disparities in coverage, costs, and utilization, underscoring systemic inequities. Note that this wide variation in costs results from differences in insurance coverage, such as state-specific Medicaid benefit caps or the complete absence of hearing aid benefits in some states.^23,25,26 Traditional Medicare excludes routine hearing aid coverage, leaving older adults to cover full costs, whereas private insurance varies in benefit design and OTC devices are sold at unregulated prices.^{2,23,28,29,34}

BOX 2— Comparative Analysis of Hearing Aid Coverage, Use, Access, Costs, and Population Reach Across Insurance Models and OTC Devices.

Insurance Type	Coverage Details	Use Challenges	Out-of-Pocket Costs	Population Coverage
Medicaid	Coverage varies by state; some states offer partial or full benefits, whereas others provide no benefits.2,23,25,26	Substantial geographic disparities in coverage because of state-level variations.2,23 Previous authorization for expenses and caps on coverage limit accessibility.2,23	Some states impose annual caps (e.g., $1510 in California), and many provide no coverage at all.25,26	Approximately 40%–50% of low-income individuals in states with Medicaid hearing aid benefits.16–19
Medicare	Traditional Medicare does not cover routine hearing exams or hearing aids.28 Diagnostic exams are covered under Part B only when ordered by a physician.28,29 Medicare Advantage plans may offer hearing benefits, but use remains low.28,29	High out-of-pocket costs persist, with only 5% of Medicare Advantage enrollees undergoing routine hearing tests and just 2% purchasing hearing aids.16,18,29	Hearing aids cost between $2500 and $6000, with 100% of the cost paid by beneficiaries unless covered under Medicare Advantage.2,29,33	Among adults aged 65 years or older, nearly 100% are Medicare beneficiaries.16–18 About 50% of Medicare beneficiaries are enrolled in Medicare Advantage plans, but only 14.4% of adults aged 65 years or older report using hearing aids.16–18
VA	Eligible veterans receive free hearing aids and audiology services through the VA.31,32 However, rural veterans face access barriers.31,32	Despite free hearing aids, use remains low, especially among rural veterans.31 Barriers include uncertainty about access and individuals declining hearing aids because of cost concerns.31 Telehealth aims to improve access, but infrastructure challenges persist.31,32	Hearing aids are free for eligible veterans, but travel costs pose financial burdens, especially for rural veterans with limited VA access.31	Approximately 70% of eligible veterans are enrolled in VA health care.31,32 Among veterans with self-reported hearing loss, 66.9% have sought hearing care.31
Private Insurance	Coverage is optional with high out-of-pocket costs, and few plans offer comprehensive hearing aid benefits.2,23,33	High out-of-pocket costs deter utilization; only a small percentage of individuals with hearing loss have employer-based or private insurance coverage.2,23,33	$2000–$3500 for basic hearing aid devices; optional plans have high premiums and copays.2,23,33	Only 20% of individuals with hearing loss have private insurance coverage.2,23,33
OTC hearing aids	Designed for mild-to-moderate hearing loss, available without a prescription.6 Effectiveness varies, with ongoing regulatory concerns.6,35	Limited consumer safeguards, potential fraud risks, and uncertain efficacy for individuals with severe hearing loss; the issue of a comprehensive hearing care ecosystem remains unaddressed.6,21,35	OTC hearing aids range from $500 to $1200 per device, varying by features and brand.6,34,35	OTC hearing aids could benefit millions with mild to moderate hearing loss, but adoption remains low; only 2% of adults with hearing difficulties have purchased one, and 4% plan to do so within a year.18,19,21

Note. OTC = over the counter; VA = Veterans Affairs.

ANALYSIS

A multifaceted approach that addresses policy gaps, insurance limitations, and care delivery challenges is important for enhancing hearing health access among older adults in the United States. This will require strategies to optimize coverage, affordability, and service integration.^2,13

Implementation Barriers: Analysis and Strategic Pathways

Federal Medicaid mandates with targeted reimbursement incentives could help make hearing aid coverage more consistent across states and reduce geographic disparities; however, budget constraints and administrative complexities remain challenges.^2,23 A potential solution is a federal and state cost-sharing model that improves the existing Federal Medical Assistance Percentage formula specifically for hearing services.³⁷ For instance, implementing an initial 90% federal match for hearing services alongside federally established baseline coverage standards could promote greater consistency.³⁷ Although an enhanced federal and state cost-sharing model may initially seem costly, this model would incorporate cost-containment measures by linking additional funding to measurable performance outcomes, thereby incentivizing states to adopt efficient, cost-effective practices.^2,37 Targeted grant funding for community education and outreach would further ensure that expenditures directly enhance access to hearing care.^2,20 Over time, improved health outcomes may yield long-term health care savings that offset initial investments.^2,13

Expanding traditional Medicare coverage to include routine hearing exams and hearing aids, coupled with sliding-scale subsidies that adjust support according to individual income and need, could greatly improve affordability.^2,24,28 Although current federal budget constraints may make full coverage impractical, targeted subsidies could ensure that lower-income beneficiaries receive necessary assistance.^2,14,16 To address challenges such as provider shortages and long wait times, one strategy might be to incentivize the expansion of the audiology workforce through scholarships, loan forgiveness programs, and residency expansion for audiology training.^2,28,29 Improving timely, high-quality hearing care can prevent falls, cognitive decline, and hospitalizations, lowering long-term costs and improving outcomes.^2–4

Particularly for rural and mobility-limited older adults, integrating teleaudiology services into Medicare and Medicaid, building on the VA model, could improve access and reduce costs.^31,32 However, infrastructure deficiencies and digital literacy barriers among older adults may limit adoption.³² Expanding broadband access and investing in targeted digital training programs could extend the reach of hearing care services and reduce travel-related barriers for older adults in rural areas.^20,32 Timely access to hearing care could reduce the harms of untreated impairment and ease federal health care costs in growing high-risk populations.^2,8,10

Despite expanded coverage under Medicare Advantage, hearing services remain underused. Targeted outreach efforts, conducted in collaboration with local community health centers and senior advocacy organizations, could improve awareness and help beneficiaries navigate their benefits.^2,20,23,29 Integrating teleaudiology services into Medicare Advantage networks could help reduce travel-related barriers to hearing care for rural populations.^20,22,32 Moreover, Medicare Advantage plans could form public–private partnerships with hearing aid manufacturers, state agencies, and community organizations to offer rebates, bulk purchasing, and subsidized hearing centers, reducing costs and out-of-pocket expenses.^2,29,33

Effective OTC hearing aid implementation requires monitoring outcomes and ensuring insurance coverage for rehabilitation and fitting to preserve efficacy and affordability.^2,6,34,35 However, associated enforcement costs and persistent concerns, such as misleading product labels and unverified performance claims, have the potential to undermine regulatory oversight and erode consumer confidence.^2,35 To address these challenges, public awareness campaigns should provide clear, evidence-based information through standardized educational materials, webinars, and community workshops while provider-led education programs guide consumers in selecting and using their devices appropriately.^2,36 Implementing robust quality assurance measures, such as independent product testing and clearly defined performance benchmarks, would streamline regulatory oversight by establishing standardized compliance criteria.^2,35,36 Leveraging third-party verification by accredited external organizations would allow regulatory agencies to monitor compliance with safety and performance standards more efficiently, minimizing the need for resource-intensive oversight.^2,35,36

Motivating private insurance to improve hearing care coverage could involve targeted, incremental changes rather than large-scale reform.^2,23,24 Specifically, providing modest tax incentives to employers that voluntarily expand their employee hearing coverage could promote broader participation without placing substantial burdens on federal budgets.^2,23,33,36 In addition, encouraging insurers to adopt standardized benefit criteria, eligibility thresholds, covered device types, and minimum rehabilitative services would promote consistency across plans.^2,23,33,35 Structured insurer–government risk sharing, tied to outcomes and cost metrics, could sustainably incentivize coverage.^2,33,36

Targeted pilot programs could be implemented in select regions with unmet hearing care needs to test innovative payment and service delivery models.^2,8,9,20 For example, a bundled payment could cover diagnostics through follow-up (fitting, rehabilitation) with provider–payer risk sharing.^2,33,36 These pilots would collect data on patient outcomes, service use, and cost metrics to compare against traditional fee-for-service models.^2,33,36 These data would guide cost-effectiveness assessments and performance-based reimbursement.^2,33,36 If successful, such a model would provide a scalable blueprint for improving service delivery and reducing economic burdens without imposing additional costs on the federal government.^2,33,36

Solutions from Emerging Technologies

To address persisting gaps in access, coverage, and affordability, we propose a technology-enabled framework that integrates digital tools, artificial intelligence, and real-time insurance verification across the hearing care continuum for older adults. Machine learning models trained on deidentified or consented electronic health records, pharmacy data, and claims would identify and stratify risk according to clinical, behavioral, and demographic indicators (e.g., ototoxic medications, comorbidities, social isolation, missed visits, audiometric data), recalibrating as new information arrives to target resources efficiently. Predictive analytics would operate under strict privacy safeguards with patient agency over data use, transparent consent, audit trails, and compliance with the Health Insurance Portability and Accountability Act and related regulations.

Scalable, low-cost self-assessment tools, mobile hearing tests, and adaptive questionnaires would be deployed via smartphones, loaned tablets, and secure community kiosks to triage candidates, reduce unnecessary referrals, and reserve audiologists for complex cases. Telehealth visits, asynchronous fitting and rehabilitation, and scheduling algorithms would expand capacity and lower travel and facility costs.

Real-time insurance navigation would query Medicare, Medicaid, and private-payer application programming interfaces to check eligibility, prefill forms, and submit authorizations; blockchain-based smart contracts could automate approvals, cut overhead, accelerate reimbursement, and reduce denials. A government-certified device marketplace would provide price transparency, bulk purchase rebates, standardized reporting, and targeted subsidies for low-income users. To promote digital equity, touchscreen kiosks and digital health coaches in rural and low-income areas would offer multilingual support and accessibility features for users with vision or dexterity challenges. Continuous improvement would rely on anonymized outcome data shared with regulators and payers to flag substandard products, misleading advertising, or inequities. Financial viability would be anchored in public–private alignment, with bundled-payment pilots and performance-based contracts to support risk sharing and value-based care. To maximize effectiveness and impact, the approach should be tested in real-world settings and scaled systematically. Box 3 summarizes the key challenges and proposed strategies related to enhancing health care coverage for hearing health services.

BOX 3— Implementation Challenges and Solutions for Expanding Hearing Health Access.

Health Care Coverage Policy Reform	Implementation Challenges	Solutions
Medicaid coverage	State budget constraints may limit expansion of Medicaid benefits without supplemental federal funding.2,23 Administrative challenges include variability in state Medicaid programs and difficulties integrating new mandates into existing frameworks.2,23,24	Adopt a federal–state cost-sharing model that improves the FMAP formula for hearing services, including an initial 90% federal match.2,37 Establish baseline coverage standards through federal guidelines.2,37 Provide targeted grant-based funding and performance-based incentives to encourage state participation.2,13,37
Medicare and Medicare Advantage hearing aid access and coverage	A limited audiology workforce, insufficient training programs, and high patient demand contribute to longer appointment wait times, particularly in rural and underserved areas.17,20,28,29 Low use of hearing services in Medicare Advantage plans persists despite available coverage.17,29	Incentivize expansion of the audiology workforce—through scholarships, loan forgiveness, and residency expansion—to address provider shortages and long wait times.2,29,36 For Medicare Advantage beneficiaries, outreach through community health centers and senior advocacy organizations can boost awareness.2,29,36 Integrating teleaudiology can reduce travel costs for rural patients.20,32 Public–private partnerships can lower costs through shared funding and negotiated pricing, such as rebate programs, bulk purchasing, and joint funding for community hearing centers.2,29,36
Teleaudiology expansion	Limited broadband access in rural areas and digital literacy barriers among older adults reduce teleaudiology adoption.20,31,32	Federal broadband grants to improve connectivity2,32 Community-based digital literacy programs for older adults2,32 User-friendly interfaces to enhance accessibility. 2,32 Enhancing these factors will bolster successful models such as the VA hearing care program, with the potential for these improvements to extend to other insurance delivery systems.2,31,32
OTC hearing aid regulation	Enforcement costs can pose a substantial financial burden.35,36 Lack of consumer confidence in the efficacy and safety of OTC hearing aids remains a barrier.21,34,35	Launch campaigns using standardized educational materials to deliver clear, evidence-based information.2,35 Establish programs to guide consumers in selecting and effectively using their hearing devices.2,35 Implement independent product testing and clearly defined performance benchmarks to create standardized compliance criteria.2,35 Leverage external verification to monitor adherence and reduce resource-intensive enforcement activities.2,35
Private insurance reform	Insurers may resist expanding coverage because of cost concerns and financial risk.2,23	Urge insurers to standardize hearing aid benefits using evidence-based guidelines to ensure consistent coverage.2,23 Implement risk-sharing agreements between insurers and the government that tie financial responsibility to specific patient outcomes and cost metrics, promoting sustainable coverage availability.2,23,33
Artificial intelligence–driven, technology enabled framework	Data privacy and security risks with health and claims data Algorithmic bias and inequities in predictions Technology interoperability and reliability Provider resistance and workflow disruption.	Deidentification, federated learning, blockchain audit trails Diverse data sets, bias audits, recalibration with outcome feedback Standardized data formats, phased rollouts, certification Codesign with clinicians and offer efficiency incentives

Note. FMAP = Federal Medical Assistance Percentage; OTC = over the counter; VA = Veterans Affairs.

LIMITATIONS

There are certain limitations to this article. It is an analytic essay rather than a systematic review, and as such it draws from an unstructured review of peer-reviewed publications, policy analyses, and regulatory and legislative documents supplemented by targeted consultation of agency and organizational resources. This approach emphasizes breadth and policy relevance but does not follow a protocol-based systematic process, so some emerging studies or reports may not have been captured. The synthesis reflects developments through the first half of 2025, and, given the rapidly evolving policy landscape, periodic reassessment will be needed. Together, these considerations provide a context for the conclusions drawn and the priorities for future research.

CONCLUSIONS

Hearing loss among older adults remains widespread and undertreated, impairing social connections and cognitive health and driving avoidable health care costs.^3–5,8 Despite policy progress, coverage through Medicare, Medicaid, VA, and private insurers is fragmented and often inadequate, limiting affordable care.^16–19 Closing these gaps requires integrating hearing health into mainstream policies with strengthened financing, workforce development, and outreach.^2,13,34,36 System resilience, informed consumers, and equitable access are vital for sustained improvement.^2,35,36 Recent federal approval of OTC devices and CMS efforts to expand audiology access demonstrate promising momentum.^{2,6,13,32,35,36} Building on this progress, payment reforms and digital health innovations could help better align incentives.

Looking forward, researchers, economists, and policymakers should collaborate on pilot initiatives, including bundled payment schemes, risk-sharing arrangements, and investments in digital health infrastructure, to identify effective approaches and guide reform. Future research should also update and expand the current evidence base by generating real-world data on the feasibility and scalability of technology-enabled hearing care models, with an emphasis on cost-effectiveness, workforce integration, and equity across diverse populations. These steps will help foster a hearing health care system that is accessible, affordable, and resilient.