A high proportion of older people with hearing aids, especially those with lower incomes, report having trouble hearing and difficulty accessing hearing care services, according to a study from researchers at Johns Hopkins Bloomberg School of Public Health.

The researchers, whose analysis is based on Medicare survey data and appears in the January issue of Health Affairs, suggest that the federal government expand Medicare and/or Medicaid coverage of hearing care services.

The study of 1,133 Medicare participants found that having a hearing aid that functioned well appeared to depend greatly on income level. Among low-income Medicare beneficiaries dually eligible for Medicaid, 27 percent of respondents reported having a lot of trouble hearing with a hearing aid. By contrast, just 11 percent of those in the highest income category -- at least four times the poverty level -- reported a lot of hearing-aid difficulties. In all, 442, or 39 percent, of the 1,133 hearing-aid users reported using hearing care services in the previous year.

"This study highlights the fact that hearing aids alone don't necessarily improve hearing -- hearing care services are important too, but there are barriers that prevent many people from accessing those services," says study co-author Nicholas Reed, AuD, who is a member of the core faculty at the Bloomberg School's Cochlear Center for Hearing and Public Health and is also an assistant professor of audiology in the Department of Otolaryngology -- Head and Neck Surgery at the Johns Hopkins University School of Medicine.

Two-thirds of U.S. adults over the age of 70 experience hearing loss, which reduces quality of life and has been linked to depression, dementia and a worsened risk of falls. Yet most older adults do not wear hearing aids. The devices and the audiology services needed to fit them are specifically excluded from Medicare coverage. Medicaid does provide some coverage for lower-income elderly people with hearing loss, but that coverage is far from comprehensive even in the 28 states that have it.

Apart from the hearing aid itself, which typically is priced at more than $2,000 for a single unit, the cost burden includes the services of an audiologist or other licensed hearing aid dispenser -- traditionally the only providers permitted to sell hearing aids. Recent legislation, the Over-the-Counter Hearing Aid Act of 2017, will by 2020 allow people to buy hearing aids directly ("over the counter") from FDA-approved manufacturers. "Probably that will make hearing aids more affordable," Reed says. "But it won't affect the barriers to accessing hearing care services, which generally are needed to optimize the function of these devices. Most people, if you put two hearing aids in their hand, will have little idea of what to do with them."

For their analysis, Reed and his colleagues, including first author Amber Willink, PhD, an assistant scientist in the Bloomberg School's Department of Health Policy and Management and the Cochlear Center for Hearing and Public Health, examined data from the 2013 Medicare Current Beneficiary Survey. This survey included 9,062 Americans age 65 and over, 1,133 of whom reported having used a hearing aid in the previous year.

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The study found that 71 percent of hearing-aid users in the lowest income category reported not receiving hearing care services in the prior year, while only 58 percent of the highest-income users reported accessing such services.

The researchers conclude that access to hearing care services to optimize and maintain hearing -aid function is limited, especially for lower-income people.

They recommend that access be made easier by including hearing care services as a mandatory Medicaid benefit, or -- preferably, since it would affect many more hearing-aid users -- removing the exclusion of these services from the Medicare program.

"If Medicare were to cover hearing care services, then that should improve access to those services, which over time should result in better functioning hearing aids for older people," Reed says.

"Access To Hearing Care Services Among Older Medicare Beneficiaries Using Hearing Aids" was written by Amber Willink, Nicholas Reed and Frank Lin.

The research was supported in part by funding from the Bloomberg School's Cochlear Center for Hearing and Public Health and from the Commonwealth Fund (Grant No. 20171061).