While the Over-the-Counter Hearing Aids Act1 promises to make hearing aids more affordable for people with mild to mild-to-moderate hearing loss, barriers to audiologist service accessibility remain. Audiologists are well-acquainted with the health care policy landscape that they navigate as allied health care providers between state licensing regulations and federal health policy effects on their practice. Classified as “non-physician providers,” audiology services are not typically covered by Medicare beyond physician-referred assessments in support of a diagnosis.2 Because the Centers for Medicare and Medicaid Services (CMS) is the de facto regulator of health care, many private health insurance plans follow suit.3 In the absence of Medicare and—in most states—Medicaid coverage,4 audiology services are not affordable for many older adults who complain of hearing and balance-related issues. This results in low utilization. More than two-thirds of older adults report that they have not had their hearing tested in the last decade, and one in three did not use audiologist services—even after a primary care provider referral—due to cost in the absence of insurance coverage.5,6 Furthermore, hearing aid uptake in older adults with hearing loss is low7-9 and concentrated in high-income households.10
Moreover, the cost of foregone care for patients can be measured in at least two ways. First, studies show that rural residents have longer distances to audiology services, and longer periods prior to adoption of hearing aids compared with their urban counterparts.11 A stronger association exists between hearing loss and loss of employment among rural residents compared with their urban counterparts,2 which complements prior findings that adults with hearing loss have lower incomes and lower workforce participation compared with adults without hearing loss.13 Second, hearing loss is associated with higher rates of dementia, risk of adverse events in medical settings, and higher reported rates of social isolation.14-16 Moreover, older adults with hearing loss have a threefold risk of falls,17 which comprised the largest percentage of deaths from unintentional injuries between 2007 to 2016,18 costing about $50 billion in Medicare and Medicaid expenditures on fall-related hospitalizations.19
For my recent study published in Social Science and Medicine,20 I hypothesized that, in the absence of private and public health plan coverage of audiology services, audiologists have a strong incentive to locate in areas with higher household incomes, which also have younger populations. This is counter to the characteristics of the populations most in need of their services—older adults typically living on fixed incomes with limited mobility.20 Using membership data from the American Speech Language-Hearing Association (ASHA), I mapped and modeled audiologists’ spatial distribution at the county level. Across states, there was wide variation in the per capita supply of providers, ranging from 2.1 to 7.6 audiologists per 100,000 population. Audiologist availability (are there providers in this county?) and supply (how many providers are there?) at the county level are inversely associated with (i) the proportion of older adults reporting hearing difficulty and (ii) median age, and more rural counties were nearly three times less likely to have audiologists than metropolitan counties. Bottom line, there is a strong urban bias in audiologist locations at the county scale, and the supply of audiologists is lower in counties with older populations and higher proportions of older adults reporting difficulty hearing.20
Coupled with prior audiologist supply trends, wherein the attrition rate, after factoring for retirement was 41 percent between 1985 and 2012,21 and enrollment in clinical audiology (AuD) programs fell by 40 percent, simultaneous to a halving of the number of programs between 1997 and 2012,22 these findings suggest that provider decisions have consequences for service accessibility.
3. Givan RK The Challenge to Change: Reforming Health Care on the Front Line in the United States and the United Kingdom. Ithaca, NY. Cornell University Press. 2016
4. Arnold ML, Hyer K, & Chisolm T Medicaid Hearing Aid Coverage for Older Adult Beneficiaries: A State-By-State Comparison. Health Affairs
, 2017;36(8):1476-1484. doi:10.1377/hlthaff.2016.1610
5. Crowson MG, Schulz K, and Tucci DL Access to Health Care and Hearing Evaluation in US Adults. Annals of Otology, Rhinology & Laryngology
. 2016;125(9):716- 721.
6. Mahboubi H, Lin HW, and Bhattacharyya N Prevalence, Characteristics, and Treatment Patterns of Hearing Difficulty in the United States. JAMA Otolaryngol Head Neck Surg
. 2018;144(1):65-70, doi: 10.1001/jamaoto.2017.2223.
7. Oberg M, Marcusson J, Nagga K, Wressle E Hearing difficulties, uptake, and outcomes of hearing aids in people 85 years of age. Int J Audiol
8. Popelka MM, Cruickshanks KJ, TL Wiley, TS Tweed, BE Klein, and R Klein Low prevalence of hearing aid use among older adults with hearing loss: The Epidemiology of Hearing Loss Study Journal of the American Geriatrics Society 1998 46 9 1075–1078
9. Smeeth L, Fletcher AE, Ng ES, et al Reduced hearing, ownership, and use of hearing aids in elderly people in the UK–the MRC trial of the assessment and management of older people in the community: a cross-sectional survey. Lancet 2002 359 1466–1470
10. Horner-Johnson W, Dobbertin K, Lee JC, Andresen EM Expert Panel on Disability and Health Disparities. Disparities in Health Care Access and Receipt of Preventative Services by Disability Type: Analysis of the Medical Expenditure Panel Survey. Health Services Research. 2014;49(6). 1980-99. Doi: 10.1111/1475-6772.
11. Chan S, Hixon B, Adkins M, Shinn J, & Bush M Rurality and determinants of hearing healthcare in adult hearing aid recipients. Laryngoscope
, 2017;127(10), 2362-2367. doi:10.1002/lary.26490.
12. Hixon, B, Chan, S, Adkins M, Shinn JB, Bush ML. Timing and impact of hearing healthcare in adult cochlear implant recipients: A rural-urban comparison. Otology and Neurotology, 2016;37(9) 1320-1324. DOI: 10.1097/MAO.0000000000001197.
13. Jung D, Bhattacharyya N Association of Hearing Loss with Decreased Employment and Income among Adults in the United States. Ann Otol Rhinol Laryngol
. 2012;121(12): 771-775.
14. Lin F, Metter E, O'Brien R, Resnick S, Zonderman A, & Ferrucci L Hearing loss and incident dementia. Archives of Neurology, 2011;68, 214–220. doi:10.1001/archneurol.2010.362.
15. Mick P, Foley DM, and Lin FR Hearing loss is associated with poorer ratings of patient-physician communication and healthcare quality. J Am Geriatr Soc
. 2014 Nov;62(11):2207-9. doi: 10.1111/jgs.13113.
16. Alexander A, Ladd P, and Powell S Deafness might damage your health. Lancet
. 2012 Mar 17;379(9820):979-81. doi: 10.1016/S0140-6736(11)61670-X.
17. Lin F, and Ferucci L Hearing Loss and Falls Among Older Adults in the United States. Arch Intern Med
. 2012 Feb 27; 172(4): 369–371. doi: 10.1001/archinternmed.2011.728.
19. Florence CS, Bergen G, Atherly A, Burns ER, Stevens JA, Drake C (2018) Medical Costs of Fatal and Nonfatal Falls in Older Adults. Journal of the American Geriatrics Society
, 2018 March;66(4), 693-698. DOI:10.1111/jgs.15304.
21. Windmill IM, Freeman BA Demand for Audiology Services: 30 Year Projections and Impact on Academic Programs Journal of the American Academy of Audiology 2013 24 407–416
22. Windmill IM Academic Programs, Class Sizes, and Obstacles to Growth in Audiology. Journal of The American Academy of Audiology
, 2013;24(5), 417-424.