US HEALTH REFORM-MONITORING AND IMPACT Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. Are Vision and Hearing Benefits Needed in Medicare? Anuj Gangopadhyaya, Adele Shartzer, Bowen Garrett, and John Holahan November 2021 As part of the budget reconciliation discussions, Congress has considered expanding traditional Medicare to cover preventive dental, vision, and hearing services. The initial legislation, modeled after expansions in the Elijah E. Cummings Lower Drug Costs Now Act (H.R. 3), 1 proposed to add all three services as benefits under Medicare Part B. The Congressional Budget Office estimated the cost of the H.R. 3 benefits expansion at $358 billion over 10 years. 2 During negotiations between the White House and congressional leaders, the package was pared down, and the Build Back Better legislation passed by the House in November 2021 focuses only on hearing services. 3 A recent Urban Institute brief assessed the need for dental benefits in Medicare (Shartzer et al. 2021); here we conduct similar analyses that describe current use of and spending on routine vision and hearing services among all Medicare beneficiaries and select subgroups. Background Vision. Vision loss is common among the elderly; approximately one in three has a vision-reducing eye disease by age 65 (Quillen 1999), which can affect functional ability and mental health. The most common eye diseases among the elderly are age-related macular degeneration, glaucoma, cataracts, and diabetic retinopathy. In 2018, more than 41 percent of Medicare Part B fee-for-service (FFS) beneficiaries had a claim with a diagnosis for one of these four eye disorders (Wittenborn et al. 2021); 34 percent had cataracts, 13 percent had glaucoma, 9 percent had age-related macular degeneration, and 3 percent had diabetic retinopathy. Total Medicare payments for eye care services and drugs related to the four conditions reached $10.1 billion in 2018. About US Health Reform-Monitoring and Impact With support from the Robert Wood Johnson Foundation, the Urban Institute has undertaken US Health Reform-Monitoring and Impact, a comprehensive monitoring and tracking project examining the implementation and effects of health reforms. Since May 2011, Urban Institute researchers have documented changes to the implementation of national health reforms to help states, researchers, and policymakers learn from the process as it unfolds. The publications developed as part of this ongoing project can be found on both the Robert Wood Johnson Foundation's and Urban Institute Health Policy Center's websites. For all traditional FFS beneficiaries, Medicare pays for fees charged by ophthalmologists and optometrists for covered services, such as treatment for ocular illness (like conjunctivitis), cataract surgery, and injury to the eye. However, traditional Medicare does not cover routine preventive eye exams (also called eye refractions) for eyeglasses or contact lenses for all beneficiaries. Some beneficiaries may have coverage for exams and screenings based on preexisting conditions or other characteristics that elevate risk for eye disease. For beneficiaries with diabetes, Medicare Part B covers an annual eye exam and a glaucoma test from an eye doctor licensed to perform the test in a beneficiary's state. Medicare also covers glaucoma screening tests for other beneficiaries at high risk, including those with diabetes, those with a family history of glaucoma, Black beneficiaries over age 50, and Hispanic beneficiaries over age 65. In addition, Medicare covers diagnostic tests and treatment of eye diseases and conditions if a beneficiary has age-related macular degeneration. Nearly all beneficiaries enrolled in Medicare Advantage plans have access to vision benefits that provide coverage for eye exams and eyewear and are subject to annual dollar limits that average $160 in 2021 (Freed et al. 2021). Medicare enrollees dually enrolled in Medicaid (hereafter called "dual enrollees") may have access to vision benefits depending on their state of residence. In 2018, 43 states provided adult Medicaid coverage for optometry services, and 33 states provided Medicaid coverage for prescription eyeglasses. 4 Hearing. About half of Medicare beneficiaries self-report having a little (39.9 percent) or a lot (4.9 percent) of trouble hearing (Thai and Megwalu 2021). Functional hearing loss is associated with decreased access to care, increased likelihood of delaying needed medical care, increased emergency room use, and increased health care spending (Reed et al. 2021). Beneficiaries with hearing impairment also report reduced social engagement (Shukla et al. 2021), decreased satisfaction with care (Nicholas et al. 2021), and greater difficulty understanding Medicare program information (Willink and Reed 2020). Traditional Medicare does not cover hearing aids or exams for fitting hearing aids. Most beneficiaries in Medicare Advantage have access to supplemental hearing benefits that provide access to both hearing exams and hearing aids, though most of these enrollees face cost sharing, frequency limits, or annual dollar limits for hearing aids (Freed et al. 2021). As with vision services, some dual enrollees may have access to hearing benefits, depending on their state of residence. In 2018, 28 states provided adult Medicaid coverage for hearing aids or other hearing devices. 5 2 ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? Because Medicare does not generally cover corrective lenses or hearing aids, many beneficiaries must pay out of pocket for those items. The costs of available options vary considerably. Though eyeglasses and contact lenses are available either over the counter or through a prescription, hearing aids are currently a regulated medical device that typically requires a visit with a health care professional. However, Congress passed a law in 2017 authorizing over-the-counter hearing aids for adults with mild to moderate hearing loss, and the US Food and Drug Administration released draft guidance in October 2021 that would allow hearing aids to be sold directly to consumers in stores or online without a medical exam or fitting by an audiologist (FDA 2021). This regulatory action is expected to reduce the costs of and improve access to hearing aids. Data and Methods We use the Urban Institute's Medicare policy microsimulation model, MCARE-SIM, to investigate 2020 vision and hearing use and spending patterns among Medicare enrollees. MCARE-SIM uses data from the 2015 Medicare Current Beneficiary Survey (MCBS) and projects Medicare enrollment and spending estimates to 2020. The MCBS provides nationwide information on demographic characteristics, use of medical services, medical expenditures, health status, access to health care, and sources of supplemental insurance coverage for Medicare enrollees. To capture vision services, we use information on the use of and spending on optometry services and prescription eyeglasses. To capture hearing services, we use information on the use of and spending on audiology services and hearing or speech devices. To project vision and hearing spending to 2020, we assume a growth rate that is the average of Parts A, B, and D growth rate projections from the 2019 Medicare Trustees report (Medicare Trustees 2019). We estimate 2020 vision and hearing services use and both total and out-of-pocket expenditures for these services for Medicare beneficiaries overall. We further examine these outcomes by the following subgroups: Medicare coverage type (FFS versus Medicare Advantage), income group relative to the federal poverty level (FPL), and dual Medicaid enrollment status. Findings In this section, we describe utilization of and spending on vision and hearing services for Medicare enrollees. Medicare enrollees spent more on vision than on hearing services in 2020, though spending on both was small relative to Medicare spending overall. In table 1, we show that 66.9 million Medicare enrollees spent $8.4 billion on routine vision services and $5.7 billion on routine hearing services in 2020. Most of this, $5.4 billion on vision services and $4.7 billion on hearing services, was spent directly out of pocket. For context, total Medicare, out-of-pocket, and third-party expenditures for Medicare Parts A, B, and D services were an estimated $1.1 trillion in 2020. 6 Table 1 also shows that fewer people used hearing services than vision services, but for those who used these services, both total and out-of-pocket expenditures were substantially higher for hearing services than for vision services. Finally, the share of ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? 3 total expenditures enrollees paid out of pocket was larger for hearing services than for vision services, suggesting lower insurance coverage for hearing services than for vision services. TABLE 1 Medicare Enrollees' Spending on and Use of Vision and Hearing Services, Overall and among Fee-for- Service and Medicare Advantage Enrollees, 2020 All Medicare Fee-for-service Medicare Advantage enrollees enrollees enrollees Spending on and use of vision services N (millions) 66.9 45.2 21.7 Total expenditures (billions) $8.4 $5.9 $2.6 Total OOP expenditures (billions) $5.4 $3.6 $1.8 Share with any vision services 30.7% 29.6% 33.0% Average expenditures (if any) $411 $437 $361 Average OOP expenditures (if any) $263 $268 $252 Ratio of OOP to total expenditures 63.9% 61.4% 69.8% Spending on and use of hearing services N (millions) 66.9 45.2 21.7 Total expenditures (billions) $5.7 $4.2 $1.5 Total OOP expenditures (billions) $4.7 $3.4 $1.2 Share with any hearing services 6.5% 6.7% 6.2% Average expenditures (if any) $1,032 $1,379 $1,127 Average OOP expenditures (if any) $1,068 $1,134 $919 Ratio of OOP to total expenditures 82.1% 82.2% 81.6% Source: MCARE-SIM estimates based on the 2015 Medicare Current Beneficiary Survey. Notes: OOP is out-of-pocket. Vision services include optometrists visits and purchase of eyeglasses. Hearing services include audiologist visits and purchase of hearing or speech devices. Enrollment estimates are for people ever enrolled in Medicare during the year. About 31 percent of Medicare enrollees used routine vision services within the past year, and their average vision expenditures were $411. Of the $8.4 billion Medicare enrollees spent on vision services (primarily optometry, eyeglasses, and contact lenses), $5.4 billion was paid out of pocket. Table 1 also shows that 30.7 percent of Medicare enrollees used at least one vision service annually. For those who used vision services, average expenditures were $411 and out-of-pocket expenditures were $263. The ratio of out- of-pocket to total vision expenditures was 63.9 percent; in other words, 36.1 percent was paid by third- party insurers. FFS enrollees had greater expenditures on routine vision services than did Medicare Advantage enrollees, and insurance covered a greater share of FFS enrollees' spending. The 45.2 million FFS enrollees in 2020 spent $5.9 billion in total and $3.6 billion out of pocket on vision services. Among these enrollees, 29.6 percent used at least one vision service. Their average expenditures were $437 and their out-of-pocket expenditures were $268. The ratio of out-of-pocket to total vision expenditures was 61.4 percent. The 21.7 million Medicare Advantage enrollees accounted for $2.6 billion in total vision expenditures and spent $1.8 billion out of pocket on such services. For the 33.0 percent of Medicare Advantage enrollees who used vision services, average expenditures were $361, well below such 4 ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? expenditures for FFS enrollees. Out-of-pocket expenditures were $252, slightly below such expenditures for FFS enrollees. This suggests Medicare Advantage plans provide less coverage of vision services than the coverage some FFS enrollees had through Medicaid, Medigap, retiree, or other supplemental plans. The ratio of out-of-pocket to total vision expenditures was higher (i.e., insurance coverage is lower) for Medicare Advantage enrollees than for FFS enrollees (69.8 versus 61.4 percent). Despite Medicare Advantage plans frequently providing vision services, only 30 percent of overall vision spending was covered by these plans. Only 6.5 percent of Medicare enrollees used a routine hearing service within the past year, but average hearing spending was high ($1,302) among those who did. Medicare enrollees spent $5.7 billion in total and $4.7 billion out of pocket on hearing services. Only 6.5 percent of Medicare enrollees used a hearing service (either an audiologist visit or hearing aids) in the past year. Among those who used hearing services, however, average expenditures were $1,302 and out-of-pocket expenditures were $1,068. The ratio of out-of-pocket to total expenditures was 82.1 percent. In other words, third-party payers covered only about 18 percent of spending on hearing services. Spending on routine hearing services was similar for FFS and Medicare Advantage enrollees. A small percentage of FFS enrollees (6.7 percent) used hearing services. Their average total spending was $1,379, and their average out-of-pocket expenditures were $1,134. Low annual utilization of hearing services and high expenditures were consistent among both FFS and Medicare Advantage enrollees; 6.2 percent of Medicare Advantage enrollees used a routine hearing service, and their average expenditures were $1,127 in total and $919 out of pocket. Thus, fewer Medicare enrollees used hearing services than vision services, but average expenditures for hearing services were substantially higher and insurance covered less hearing benefits. Of the 30 percent of Medicare enrollees with spending on vision services in 2020, only 6.6 percent had spending exceeding $1,000. Table 2 shows the distribution for total and out-of-pocket expenditures on vision and hearing services across the Medicare population. We show that 69.6 percent had no such expenditures within the year. A small share (5.9 percent) had low expenditures between $1 and $100. Another 23.6 percent of all Medicare beneficiaries had total expenditures between $101 and $1,000. Finally, 2 percent had expenditures exceeding $1,000. Of those with any spending, about 74.0 percent had expenditures between $101 and $1,000, and 6.6 percent had spending above $1,000. Out-of- pocket expenditures show a similar pattern; about 17 percent of beneficiaries had out-of-pocket expenditures between $101 and $1,000, and only 1 percent spent more than $1,000. ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? 5 TABLE 2 Spending Distributions for Vision and Hearing Services among Medicare Enrollees, 2020 Percent Total Expenditures Out-of-Pocket Expenditures Share among Share of Medicare Share of Share among Medicare enrollees with any Medicare Medicare enrollees enrollees spending enrollees with any spending Spending on vision services $0 69.6 n/a 73.4 n/a $1–50 3.4 11.3 5.7 21.4 $51–100 2.5 8.1 2.9 10.8 $101–250 8.1 26.6 5.9 22.1 $251–500 8.7 28.5 7.1 26.5 $501–1,000 5.8 18.9 4.1 15.5 > $1,000 2.0 6.6 1.0 3.8 Total 100.0 100.0 100.0 100.0 Spending on hearing services $0 93.7 n/a 95.0 n/a $1–50 1.2 19.6 1.5 30.9 $51–100 1.0 15.6 0.6 12.3 $101–250 1.0 15.9 0.6 11.7 $251–500 0.6 10.1 0.3 6.4 $501–1,000 0.7 11.4 0.4 8.7 > $1,000 1.7 27.5 1.5 30.0 Total 100.0 100.0 100.0 100.0 Source: MCARE-SIM estimates using the 2015 Medicare Current Beneficiary Survey. Notes: n/a is not applicable. Vision services include optometrist visits and purchase of eyeglasses. Hearing services include audiologist visits and purchase of hearing or speech devices. Less than 7 percent of Medicare enrollees used routine hearing services in 2020; of these, 27.5 percent had spending greater than $1,000. The distribution of spending for routine hearing services differs from the distribution for vision services; total and out-of-pocket spending on hearing services were skewed higher among those who used services. We show that 93.7 percent of Medicare enrollees spent nothing on hearing services. Small percentages had spending between $101 and $1,000. Another 1.7 percent had spending greater than $1,000. Of those who had any hearing expenditures, about 37.4 percent had spending between $101 and $1,000, and another 27.5 percent had spending exceeding $1,000. Out-of- pocket expenditures were similar; 95 percent had no out-of-pocket expenditures. Of those with any spending, 30 percent had spending greater than $1,000. Use of vision and hearing services increased markedly with income. Table 3 provides the same data as table 1 broken out by income and whether individuals are dually enrolled in Medicaid and Medicare. Among beneficiaries with incomes below the FPL, 23.3 percent used a vision service, whereas 36.1 percent of people with incomes above 400 percent of FPL used a vision service. The share of enrollees using hearing services also varied by income, increasing from 4.4 percent of people with incomes below the FPL to 8.3 percent of people with incomes above 400 percent of FPL. 6 ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? TABLE 3 Spending on and Use of Vision and Hearing Services among Medicare Enrollees, by Income and Dual Medicaid Enrollment Status, 2020 Income as % of FPL Dual Status All 100– 200– No Medicaid enrollees < 100% 200% 400% > 400% Medicaid enrolled Spending on and use of vision services N (millions) 66.9 10.9 18.4 18.7 18.9 53.5 13.4 Total expenditures (billions) $8.4 $0.7 $1.9 $2.6 $3.2 $7.7 $0.7 Total OOP expenditures (billions) $5.4 $0.4 $1.1 $1.8 $2.2 $5.0 $0.4 Share with any vision services 30.7% 23.3% 25.9% 34.3% 36.1% 33.4% 19.9% Average expenditures (if any) $411 $290 $400 $409 $465 $433 $261 Average OOP expenditures (if any) $263 $154 $225 $275 $318 $282 $135 Ratio of OOP to total expenditures 63.9% 52.9% 56.2% 67.2% 68.4% 65.0% 51.7% Spending on and use of hearing services N (millions) 66.9 10.9 18.4 18.7 18.9 53.5 13.4 Total expenditures (billions) $5.7 $0.3 $1.2 $1.6 $2.6 $5.3 $0.3 Total OOP expenditures (billions) $4.7 $0.3 $0.8 $1.3 $2.2 $4.5 $0.2 Share with any hearing services 6.5% 4.4% 5.3% 7.2% 8.3% 7.1% 4.2% Average expenditures (if any) $1,032 $659a $1,181 $1,204 $1,659 $1,404 $616 Average OOP expenditures (if any) $1,068 $569a $870 $988 $1,414 $1,176 $348 Ratio of OOP to total expenditures 82.1% 86.3%a 73.6% 82.1% 85.3% 83.7% 56.5% Source: MCARE-SIM estimates using the 2015 Medicare Current Beneficiary Survey. Notes: FPL is federal poverty level. OOP is out-of-pocket. Vision services include optometrist visits and purchase of eyeglasses. Hearing services include audiologist visits and purchase of hearing or speech devices. Enrollment estimates are for people ever enrolled in Medicare during the year. a Estimates are derived from an underlying sample of fewer than 100 respondents. Expenditures on both vision and hearing services also clearly increased with income. Spending on routine vision services was $0.7 billion among people with incomes below the FPL and $1.9 billion for people with incomes between 100 and 200 percent of FPL in 2020. In contrast, those with incomes above 400 percent of FPL spent $3.2 billion on vision services. Among enrollees with any vision expenditures, average spending was $290 for those with incomes below the FPL; this rose to $465 for those with incomes above 400 percent of FPL. Differences in out-of-pocket vision spending across incomes were similar. Average out-of-pocket expenditures for people with any vision spending ranged from $154 for those with incomes below the FPL to $318 for those with incomes above 400 percent of FPL. The ratio ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? 7 of out-of-pocket to total spending also rose with income; the lowest-income group presumably had lower ratios because they were more likely to have Medicaid coverage. Enrollees with low incomes had lower vision expenditures but more of these expenditures were paid by insurance. Enrollees with incomes above 400 percent of FPL paid for 68.4 percent of their vision expenditures out of pocket; that is, only 31.6 percent of such expenditures were covered by third-party insurance. As noted above, both total and out-of-pocket hearing expenditures were lower than such expenditures for vision services. Total spending on hearing services among those with incomes below the FPL was $0.3 billion but increased to $2.6 billion among those with incomes above 400 percent of FPL. Out-of-pocket hearing expenditures ranged from $0.3 billion for those with incomes below the FPL to $2.2 billion for those with incomes above 400 percent of FPL. Enrollees in the highest-income group were more likely than those in the lowest-income group to use hearing services, and spending levels among high-income enrollees using such services were substantially higher. For enrollees with incomes below the FPL with any hearing expenditures, total spending averaged $659; this rose to $1,659 for those with incomes above 400 percent of FPL. Out-of-pocket spending ranged from $569 for those with incomes below the FPL to $1,414 for those with incomes above 400 percent of FPL. The ratio of out-of- pocket to total expenditures for hearing services showed no pattern by income. Spending on vision services by dual enrollees was far below that of other Medicare enrollees. Among dual enrollees, 19.9 percent used a vision service, whereas 33.4 percent of Medicare enrollees not dually enrolled in Medicaid used such services. For people with vision expenditures, total spending averaged $261 for dual enrollees versus $433 for those without Medicaid; these beneficiaries' out-of-pocket expenditures were $135 and $282. The ratio of out-of-pocket to total vision expenditures was lower for those with Medicaid. Somewhat surprisingly given Medicaid's coverage policy, dual enrollees still had substantial out-of-pocket expenditures (51.7 percent of spending). Dual enrollees' spending on routine hearing services was also far lower than that of enrollees not covered by Medicaid. Finally, dual enrollees had much lower expenditures for hearing services than Medicare enrollees without Medicaid ($0.3 billion versus $5.3 billion), and their out-of-pocket spending was also substantially lower. Dual enrollees were less likely to have obtained a hearing service than those without Medicaid. Average hearing expenditures were $616 for those enrolled in Medicaid but $1,404 for those without Medicaid. Out-of-pocket expenditures also varied considerably, ranging from $348 for those with Medicaid to $1,176 for those without Medicaid. Dual enrollees also paid a substantially lower share of such expenditures out of pocket than did people without Medicaid (56.5 versus 83.7 percent). Discussion Routine vision services (optometry, eyeglasses, and contact lenses) and hearing services (audiologist services and hearing aids) are being considered as possible traditional Medicare benefits. Medicare enrollees spent $8.4 billion on vision services and $5.7 billion on hearing services in 2020. These amounts are small compared with current Medicare, out-of-pocket, and third-party spending on 8 ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? services covered under Parts A, B, and D, which totaled $1.1 trillion in 2020. Both use of and spending on vision and hearing services would increase substantially if Medicare were to cover them, but the data still suggest covering either or both services would only be a small add-on to current Medicare spending. We show that 30.7 percent of Medicare enrollees used vision services, and average spending for those using services was $411. In contrast, only 6.7 percent of Medicare enrollees used hearing services, but their average expenditures were $1,302. This implies that expanding Medicare to include vision services would provide benefits to more people, whereas providing hearing benefits would give substantially more help to a smaller number of people. We also show a significant income gradient for both vision and hearing services. Many more high- income beneficiaries used these services relative to those with lower incomes. For those using vision services, beneficiaries with incomes below the FPL spent $190 and those with incomes above 400 percent of FPL spent $465. For enrollees using hearing services, such expenditures were $659 for those with incomes below the FPL and $1,659 for those with incomes above 400 percent of FPL. This suggests people with lower incomes may have considerable unmet needs for these services. Moreover, that the income gradient persists among those with any use of vision or hearing services suggests an income gradient exists in the quality of eyeglasses or hearing aids acquired. A related finding is that though Medicaid often offers a broad benefit package for people with low incomes, benefits vary greatly across states, and in general Medicaid is not providing much help with vision and hearing services to Medicare enrollees with low incomes. Finally, we did not investigate differences in vision and hearing use by race and ethnicity because of small sample sizes among some racial and ethnic enrollee groups. However, because beneficiaries' incomes and races and ethnicities are related, the observed income gradients likely reflect wide differences in the use of and spending on vision and hearing services by race and ethnicity; specifically, rates of use and spending amounts for these services are likely greater for non-Hispanic white beneficiaries than they are for non-Hispanic Black or Hispanic beneficiaries. Notes 1 Elijah E. Cummings Lower Drug Costs Now Act, H.R. 3, 116th Cong. (2019–20). 2 Philip A. Swagel (director, Congressional Budget Office), letter to Frank Pallone Jr. (chairman, Committee on Energy and Commerce, US House of Representatives), regarding, "Budgetary Effects of H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act," December 10, 2019, https://www.cbo.gov/system/files/2019- 12/hr3_complete.pdf. 3 Tony Romm, "House Approves $2 Trillion Spending Plan," Washington Post, November 19, 2021, https://www.washingtonpost.com/us-policy/2021/11/19/house-spending-reconciliation-bill/. 4 "Medicaid and CHIP," Kaiser Family Foundation, accessed November 9, 2021, https://www.kff.org/state- category/medicaid-chip/medicaid-benefits/. ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? 9 5 "Medicaid Benefits: Hearing Aids and Other Hearing Devices," Kaiser Family Foundation, accessed November 9, 2021, https://www.kff.org/medicaid/state-indicator/hearing- aids/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. 6 The 2021 Medicare trustees report finds that 2020 Medicare expenditures for Parts A, B, and D totaled $925 billion (Medicare Trustees 2021). To estimate beneficiary cost-sharing amounts, we applied average enrollee cost sharing (inclusive of third-party contributions), by part, derived from MCARE-SIM. Estimated beneficiary cost sharing totaled $184 billion. References FDA (US Food and Drug Administration). 2021. "Regulatory Requirements for Hearing Aid Devices and Personal Sound Amplification Products: Draft Guidance for Industry and Food and Drug Administration Staff." Washington, DC: US Food and Drug Administration. Freed, Meredith, Juliette Cubanski, Nolan Sroczynski, Nancy Ochieng, and Tricia Neuman. 2021. "Dental, Hearing, and Vision Costs and Coverage among Medicare Beneficiaries in Traditional Medicare and Medicare Advantage." San Francisco: Kaiser Family Foundation. Medicare Trustees (Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds). 2019. 2019 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Washington, DC: Medicare Trustees. ---. 2021. 2021 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Washington, DC: Medicare Trustees. Quillen, David A. 1999. "Common Causes of Vision Loss in Elderly Patients." American Family Physician 60 (1): 99– 108. Reed, Nicholas S., Lama Assi, Wakako Horiuchi, Julie E. Hoover-Fong, Frank R. Lin, Lauren E. Ferrante, Sharon K. Inouye, et al. 2021. "Medicare Beneficiaries with Self-Reported Functional Hearing Difficulty Have Unmet Health Care Needs: Study Examines the Level of Access to a Usual Source of Care for Medicare Beneficiaries Who Reported Hearing Loss." Health Affairs 40 (5): 786–94. https://doi.org/10.1377/hlthaff.2020.02371. Reed, Nicholas S., Emily F. Boss, Frank R. Lin, Esther S. Oh, and Amber Willink. 2021. "Satisfaction with Quality of Health Care among Medicare Beneficiaries with Functional Hearing Loss." Medical Care 59 (1): 22–28. https://doi.org/10.1097/MLR.0000000000001419. Shartzer, Adele, Anuj Gangopadhyaya, John Holahan, Bowen Garrett, and Nikhil Rao. 2021. "Is a Dental Benefit Needed in Medicare?" Washington, DC: Urban Institute. Shukla, Aishwarya, Thomas K. M. Cudjoe, Frank R. Lin, and Nicholas S. Reed. 2021. "Functional Hearing Loss and Social Engagement among Medicare Beneficiaries." Journals of Gerontology, Series B 76 (1): 195–200. https://doi.org/10.1093/geronb/gbz094. Thai, Anthony, and Uchechukwu C. Megwalu. 2021. "Association of Self-Reported Hearing Loss Severity and Healthcare Utilization Outcomes among Medicare Beneficiaries." American Journal of Otolaryngology 42 (4): 102943. https://doi.org/10.1016/j.amjoto.2021.102943. Willink, Amber, and Nicholas S. Reed. 2020. "Understanding Medicare: Hearing Loss and Health Literacy." Journal of the American Geriatrics Society 68 (10): 2336–42. https://doi.org/10.1111/jgs.16705. Wittenborn, John S., Qian Gu, Erkan Erdem, Farah Ahmed, Ping Zhang, Jinan Saaddine, Elizabeth A. Lundeen, and David B. Rein. 2021. "The Prevalence of Diagnosis of Major Eye Diseases and Their Associated Payments in the Medicare Fee-for-Service Program." Ophthalmic Epidemiology, 1–13. https://doi.org/10.1080/09286586.2021.1968006. 10 ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? About the Authors Anuj Gangopadhyaya is a senior research associate in the Health Policy Center at the Urban Institute. His research focuses on the impact of safety net programs on health and well-being, family income, and education achievement outcomes for children in low-income families. He has focused on the impact of Medicaid eligibility expansion on children's education achievement, maternal and child health effects of the earned income tax credit program, and the impact of the Affordable Care Act Medicaid expansion on adult labor supply and fertility rates of women of reproductive age. He also helps lead Urban's Medicare simulation model (MCARE-SIM), estimating potential impacts of proposed policy changes on program spending, beneficiary spending, and use of services. Gangopadhyaya received his PhD in economics from the University of Illinois at Chicago. Adele Shartzer is a research associate in the Health Policy Center, where her work focuses on health coverage, access to care, and the health care delivery system; her research has been published in notable health policy journals. Before joining Urban, she worked as a program analyst in the Office of Health Policy in the Office of the Assistant Secretary of Planning and Evaluation at the US Department of Health and Human Services. She has also worked in health policy at several nonprofits in the Washington, DC, area. Shartzer holds a bachelor's degree in bioethics from the University of Virginia and an MPH in health policy from George Washington University. She received her PhD in health services research from the Johns Hopkins Bloomberg School of Public Health. While there, she received a doctoral dissertation award in patient-reported outcomes and was a National Research Service Award trainee. Bowen Garrett is an economist and senior fellow in the Health Policy Center. His research focuses on health reform and health policy topics, including health insurance and labor markets, Medicare's prospective payment systems, and evaluation of the Strong Start for Mothers and Newborns program. He leads the development of the Urban Institute's Medicare policy simulation model (MCARE-SIM). Previously, Garrett was chief economist of the Center for US Health System Reform and McKinsey Advanced Health Analytics at McKinsey and Company. Garrett received his PhD in economics from Columbia University in 1996 and was a postdoctoral research fellow in the Robert Wood Johnson Foundation's Scholars in Health Policy Research Program at the University of California, Berkeley, from 1996 to 1998. John Holahan is an Institute fellow in the Health Policy Center, where he previously served as center director for over 30 years. His recent work focuses on health reform, the uninsured, and health expenditure growth, developing proposals for health system reform most recently in Massachusetts. He examines the coverage, costs, and economic impact of the Affordable Care Act (ACA), including the costs of Medicaid expansion as well as the macroeconomic effects of the law. He has also analyzed the health status of Medicaid and exchange enrollees, and the implications for costs and exchange premiums. Holahan has written on competition in insurer and provider markets and implications for premiums and government subsidy costs as well as on the cost-containment provisions of the ACA. Holahan has conducted significant work on Medicaid and Medicare reform, including analyses on the ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? 11 recent growth in Medicaid expenditures, implications of block grants and swap proposals on states and the federal government, and the effect of state decisions to expand Medicaid in the ACA on federal and state spending. Recent work on Medicare includes a paper on reforms that could both reduce budgetary impacts and improve the structure of the program. His work on the uninsured explores reasons for the growth in the uninsured over time and the effects of proposals to expand health insurance coverage on the number of uninsured and the cost to federal and state governments. 12 ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? Acknowledgments This brief was funded by the Robert Wood Johnson Foundation. The views expressed do not necessarily reflect the views of the Foundation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. The authors thank Stephen Zuckerman for providing feedback on the brief, Nikhil Rao for research assistance, and Rachel Kenney for editing. ABOUT THE ROBERT WOOD JOHNSON FOUNDATION The Robert Wood Johnson Foundation (RWJF) is committed to improving health and health equity in the United States. In partnership with others, we are working to develop a Culture of Health rooted in equity, that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have. ABOUT THE URBAN INSTITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people's lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness 500 L'Enfant Plaza SW and enhance the well-being of people and places. Washington, DC 20024 Copyright © November 2021. Urban Institute. Permission is granted for www.urban.org reproduction of this file, with attribution to the Urban Institute. ARE VISION AND HEARING BENEFITS NEEDED IN MEDICARE? 13