Biden Administration

Democrats Plan to Expand Medicare Hearing Benefits. What Can Consumers Expect?

President Joe Biden’s mammoth domestic spending bill would add hearing benefits to the traditional Medicare program — one of three major new benefits Democrats had sought.

The Biden administration appears to have fallen short of its ambition to expand dental and vision along with hearing benefits. Sen. Bernie Sanders (I-Vt.) and other progressives have long pushed for more generous benefits for seniors. Citing the cost, Sen. Joe Manchin (D-W.Va.) opposed such expansion.

Biden and Democratic leaders in Congress pared back the scope of the new benefits after the total budget bill — which funds health care and other domestic initiatives — was whittled from a proposed $3.5 trillion to $1.75 trillion to meet demands of the party’s moderates. The new hearing benefits would become available in 2023.

Democrats have little room for maneuvering on the bill. They need all 50 Democratic senators to support it and can lose only three members of the House on a vote. Those tight margins have made for difficult negotiations and boosted the ability of any one lawmaker to set terms. The progressive and moderate wings of the party have been at odds on the deal for months, and negotiations are ongoing.

Nonetheless, if the hearing proposal survives, it would be a significant change. Here are answers to questions seniors might have about the benefit.

Q: What does the plan do?

The draft legislation unveiled in the House proposes adding coverage to traditional Medicare that includes hearing assessment services, management of hearing loss and related treatment. About 36 million people are enrolled in original Medicare. Many of the private Medicare Advantage plans other seniors have opted to join already offer similar hearing services. According to the Centers for Medicare & Medicaid Services, roughly 27 million seniors are enrolled in a Medicare Advantage plan this year. CMS projects that number will increase to 29.5 million next year.

The new benefits include coverage of certain hearing aids for “individuals diagnosed with moderately severe, severe, or profound hearing loss,” and allows seniors enrolled in traditional Medicare to get a hearing aid for each ear every five years. The new benefits cover devices furnished after a written order from a physician, audiologist, hearing aid professional or other clinician. The Food and Drug Administration separately has moved to make hearing aids available over the counter, in a bid to make them cheaper.

Q: Why are the benefits needed?

Research has shown that hearing loss can undermine seniors’ overall quality of life, leading to loneliness, isolation, depression, anxiety, communication disorders and more. According to the Centers for Disease Control and Prevention’s National Health Interview Survey, in 2019 nearly 1 in 3 people age 65 and over reported difficulty hearing even with a hearing aid. Biden administration officials said when unveiling the package last week that of seniors who could benefit from hearing aids, only 30% over age 70 have used them.

Hispanic adults 65 and up were more likely than other demographic groups to report having severe hearing problems, the survey found.

A KFF analysis from September found that the 4.6 million Medicare beneficiaries who used hearing services in 2018 paid $914 out-of-pocket on average. That figure includes seniors who receive benefits in traditional Medicare as well as people enrolled in Medicare Advantage plans.

Q: How many people would benefit?

The total is still up in the air as Democrats continue to negotiate details, but it’s possible the number of beneficiaries could be in the millions. According to the National Institutes of Health, about 1 in 3 Americans ages 65 to 74 have hearing loss, and nearly half of those older than 75 have difficulty hearing.

To date, there’s been an important distinction between seniors enrolled in traditional Medicare and those in Medicare Advantage plans. A research paper published by the Commonwealth Fund in February found that nearly all Medicare Advantage plans offered dental, vision and hearing benefits.

Still, even with Medicare Advantage, seniors can struggle to afford care, and what is covered varies by the plan. The KFF analysis found that seniors in Medicare Advantage plans spent less out-of-pocket for dental and vision care than traditional Medicare enrollees in 2018, but there was no difference in spending on hearing care.

Q: Will dental and vision benefits be added?

Leaving dental and vision benefits on the cutting room floor will disappoint progressive lawmakers.

“In Vermont and all over this country, you’ve got senior citizens whose teeth are rotting in their mouth, older people who can’t talk to their grandchildren because they can’t hear them because they can’t afford a hearing aid, and people can’t read a newspaper because they can’t afford glasses,” Sanders said on NBC earlier this year. “So to say that dental care and hearing aids and eyeglasses should be a part of Medicare makes all the sense in the world.”

According to KFF, the 31.3 million Medicare beneficiaries who needed dental services in 2018 paid $874 out-of-pocket on average. The 20.3 million who needed vision care spent $230.

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Despite Restraints, Democrats’ Drug Pricing Plan Could Still Aid Consumers

The Medicare prescription drug pricing plan Democrats unveiled this week is not nearly as ambitious as many lawmakers sought, but they and drug policy experts say the provisions crack open the door to reforms that could have dramatic effects. 

Tamping down drug expenses has been a longtime rallying cry for consumers beset by rapidly rising prices. Although people in private plans had some protections, those on Medicare often did not. They had no out-of-pocket caps and frequently complained that federal law kept them from using drugmakers’ coupons or other cost-cutting strategies.

A plan offered earlier this year by House Democrats — which included robust negotiation over drug prices in Medicare — was blocked by a handful of moderates who argued that the price curbs would stifle innovation. The legislation also was on a course to hit roadblocks among senators.

The moderates favored more limited negotiation over drugs only in Medicare Part B — those administered in doctors’ offices and hospitals. Most people in Medicare get their drugs through Part D, which covers medicine dispensed at a pharmacy.

When it appeared that the bill to fund President Joe Biden’s social agenda would move forward without a drug pricing proposal, the pressure built, intense negotiations were held, and a hybrid proposal was unveiled. It includes identifying 100 of the most expensive drugs and targeting 10 of them for negotiations to bring those costs down beginning in 2025. It will also place inflation caps on prescription drug prices for all insurance plans, restrict copays for insulin to no more than $35, and limit Medicare beneficiaries’ annual out-of-pocket drug costs to $2,000.

“There was a sense that the government had its hands tied behind its back. Now a precedent is being set,” said Senate Finance Committee Chairman Ron Wyden (D-Ore.), who led the talks for the senators. “There’s going to be negotiation on the most expensive drugs: cancer drugs, arthritis drugs or the anticoagulants. And that’s a precedent, and once you set a precedent that you can actually negotiate, you are really turning an important corner.”

Drugmakers say the changes could stymie consumers’ options. “Under the guise of ‘negotiation,’ it gives the government the power to dictate how much a medicine is worth,” Stephen Ubl, CEO of the trade group PhRMA, said in a statement, “and leaves many patients facing a future with less access to medicines and fewer new treatments.”

But how, exactly, will the changes be felt by most Americans, and who will be helped?

The answers vary, and many details would still have to be worked out by government agencies if the legislation passes. House members warned some minor changes were still being made Thursday night, and it all has to pass both chambers.

Controlling Insulin Costs

One of the most obvious benefits will go to those who need insulin, the lifesaving drug for people with Type 1 diabetes and some with Type 2 diabetes. Although the drug has been around for decades, prices have risen rapidly in recent years. Lawmakers have been galvanized by nightmarish accounts of people dying because they couldn’t afford insulin or driving to Canada or Mexico to get it cheaper.

Under the bill, starting in 2023, the maximum out-of-pocket cost for a 30-day supply of insulin would be $35. The benefit would not be limited to Medicare beneficiaries.

That cap is the same as one that was set in a five-year model program in Medicare. In it, the Centers for Medicare & Medicaid Services estimated that the average patient would save about $466 a year.

Detailed analyses of the proposals were not yet available, so it is unclear what the fiscal impact or savings would be for patients outside of Medicare.

Limiting Out-of-Pocket Spending

Another obvious benefit for Medicare beneficiaries is the $2,000 cap on out-of-pocket costs for prescription drugs. Currently, drug costs for people in the Part D prescription drug plans are calculated with a complicated formula that features the infamous “doughnut hole,” but there is no limit to how much they might spend.

That has led to consumers with serious diseases such as cancer or multiple sclerosis paying thousands of dollars to cover their medication, a recent KFF analysis found. Under current law, when an individual beneficiary and her plan spend $4,130 this year on drugs, the beneficiary enters the doughnut hole coverage gap and pays up to 25% of the price of the drug. Once she has spent $6,500 on drugs, she is responsible for 5% of the cost through the end of the year.

Limiting that expense is an especially big deal for people who get little low-income assistance and have expensive illnesses, said Dr. Jing Luo, an assistant professor of medicine at the University of Pittsburgh’s Center for Research on Health Care. “The patient pays 5% of all drug costs, and 5% of $160,000 is still a lot of money,” he said.

The legislation would alleviate that fear for consumers. “Rather than having a bill at the end of the year, like over $10,000, maybe their bill at the end of that year for that very expensive multiple myeloma treatment is $2,000,” he said.

Negotiating Drug Prices

Medicare price negotiation is probably the highest-profile provision in the legislation — and the most controversial. According to the bill, the Department of Health and Human Services would be responsible for identifying the 100 high-cost drugs and choosing the 10 for price negotiations. That effort wouldn’t start until 2023, but the new prices would go into effect in 2025. Another 10 drugs could be added by 2028. No drugs have been identified yet.

To meet the concerns of some lawmakers, the legislation lays out specific provisions for how HHS would select the drugs to be included. Only drugs identified as one of a kind or the only remedy for a specific health problem would be included.

The list would also be limited to drugs that have been on the market beyond the period of exclusivity the government grants them to be free from competition and recoup costs. For most regular drugs, the exclusivity can last nine years. For the more complicated biologic drugs, the period would be 13 years. Using the exclusivity timing allowed lawmakers to skirt the issue of whether the drugs were still under patent protection.

The measure allows for prices to be negotiated to a lower level for older drugs chosen for the program. So, for example, the negotiated price for a non-biologic drug that has been available for less than 12 years would be 75% of the average manufacturer price. That would fall to 65% for drugs that are 12 to 16 years past their initial exclusivity, and 40% for drugs more than 16 years past the initial exclusivity.

Drugs from smaller companies with sales under $200 million are excluded because lawmakers were afraid tamping down their prices would harm innovation.

Some experts questioned whether the negotiated prices would be directly felt by consumers.

“It helps Medicare, without question, to reduce their expenditures,” said William Comanor, a professor of health policy and management at the UCLA Fielding School of Public Health. “But how does that affect consumers? I bet Medicare doesn’t change the copay.”

Yet, he added, the copayment is less of an issue if a consumer’s prescription expenses are capped at $2,000.

Linking Prices to Inflation

Under the bill, manufacturers would have to report their prices to the HHS secretary, and if the prices increase faster than inflation, the drugmakers would have to pay a rebate to the government. Manufacturers that don’t pay the rebate would face a civil penalty of 125% of the value of the rebate.

The provisions would apply to drugs purchased through Medicare and non-Medicare plans.

Over the long term, the idea is to slow the overall inflation of drug prices, which has exceeded general inflation for decades.

Drug prices would be pegged to what they were in March, and the system would go into effect in 2023, so there would be little immediate impact. (Some lawmakers had hoped to peg the program to prices from several years ago — which might produce a bigger effect — but that was changed in the negotiations over the weekend.) The long-term impact is also hard to judge, because under the current complicated system, many people who pay for drugs get assistance from the drug companies, and most generics in the U.S. are relatively inexpensive, Comanor said.

Over the long haul, though, savings are expected to be substantial for the government, as well as for consumers who don’t qualify for other programs to help pay drug expenses and need high-end medication.

At the very least, the legislation would move the U.S. in the direction of the rest of the world.

“The longer the drug is on the market, the lower the price,” said Gerard Anderson, a professor of health policy at Johns Hopkins’ medical school. “In every other country, the price goes down over time, while in the United States, it is common for prices to increase.”

Update: This story was updated at 3:15 p.m. ET on Nov. 5, 2021, to reflect new language added to the measure that would changed the exclusivity period for negotiating the price of biologic drugs from 12 to 13 years.

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If Congress Adds Dental Coverage to Medicare, Should All Seniors Get It?

William Stork needs a tooth out. That’s what the 71-year-old retired truck driver’s dentist told him during a recent checkup.

That kind of extraction requires an oral surgeon, which could cost him around $1,000 because, like most seniors, Stork does not have dental insurance, and Medicare won’t cover his dental bills. Between Social Security and his pension from the Teamsters union, Stork said, he lives comfortably in Cedar Hill, Missouri, about 30 miles southwest of St. Louis. But that cost is significant enough that he’s decided to wait until the tooth absolutely must come out.

Stork’s predicament is at the heart of a long-simmering rift within the dental profession that has reemerged as a battle over how to add dental coverage to Medicare, the public insurance program for people 65 and older — if a benefit can pass at all.

Health equity advocates see President Joe Biden’s Build Back Better agenda as a once-in-a-generation opportunity to provide dental coverage to those on Medicare, nearly half of whom did not visit a dentist in 2018, well before the pandemic paused dental appointments for many. The rates were even higher for Black (68%), Hispanic (61%) and low-income (73%) seniors.

The coverage was left out of a new framework announced by President Joe Biden on Thursday, but proponents still hope they can get the coverage in a final agreement. Complicating their push is a debate over how many of the nation’s more than 60 million Medicare beneficiaries should receive it.

Champions for covering everyone on Medicare find themselves up against an unlikely adversary: the American Dental Association, which is backing an alternative plan to give dental benefits only to low-income Medicare recipients.

Medicare has excluded dental (and vision and hearing) coverage since its inception in 1965. That exclusion was by design: The dental profession has long fought to keep itself separate from the traditional medical system.

More recently, however, dentists have stressed the link between oral and overall health. Most infamously, the 2007 death of a 12-year-old boy that might have been prevented by an $80 tooth extraction prompted changes to Maryland’s version of Medicaid, the federal-state public insurance program for low-income people. But researchers have also, for example, linked dental care with reduced health care spending in patients with Type 2 diabetes. When the World Health Organization suggested delaying non-urgent oral health visits last year to prevent the spread of covid-19, the American Dental Association pushed back, with then-President Dr. Chad Gehani saying, “Oral health is integral to overall health. Dentistry is essential health care.”

The ADA-backed Medicare proposal would cover only seniors who earn up to three times the poverty level. That currently translates to $38,640 a year for an individual, reducing the number of potential recipients from over 60 million people to roughly half that number. Medicare has never required means testing, but in a world where Congress is looking to trim the social-spending package from $3.5 trillion over 10 years to $1.85 trillion, the ADA presents its alternative as a way to save money while covering those who need a dental benefit the most. A Congressional Budget Office analysis estimated the plan to provide dental coverage to all Medicare recipients would cost $238 billion over 10 years.

Unlike the ADA, the National Dental Association is pushing for a universal Medicare dental benefit. The group “promotes oral health equity among people of color,” and formed in 1913, in part, because the ADA did not eliminate discriminatory membership rules for its affiliates until 1965. Dr. Nathan Fletcher, chairman of NDA’s board of trustees, said he was unsurprised to find his organization at odds with the ADA over this issue of Medicare coverage.

“The face and demographic of the ADA is a white male, 65 years old. Understand that those who make decisions for the ADA are usually the ones who have been in practice for 25 to 30 years, doing well, ready to retire,” Fletcher said. “It looks nothing like the [patients] who we’re talking about.”

Between Social Security and his pension from the Teamsters union, Stork said, he lives comfortably, but $1,000 for a surgical tooth extraction is significant enough that he’s decided to wait until the tooth absolutely must come out.(Joe Martinez for KHN)

Research from the ADA’s Health Policy Institute found cost as a barrier to dental care “regardless of age, income level, or type of insurance,” but low-income older adults were more likely to report it as a barrier.

“It would be tragic if we didn’t do something for those low-income seniors,” said Michael Graham, senior vice president of government and public affairs for the ADA.

Graham is critical of the design of the proposals in Congress for a universal Medicare dental benefit, noting that one includes a 20% copay for preventive services that could block low-income patients from accessing the care they would presumably be gaining.

“Something is better than nothing, but the something [with a copay] almost equals nothing for many seniors,” Graham said.

Graham said the ADA backs covering 100% of preventive services for low-income Medicare recipients.

Of course, covering only low-income seniors presents its own questions, the biggest being: Will dentists even accept Medicare if they don’t have to? Low-income patients often seek care at safety-net clinics that schedule out months in advance. Some dentists worry a Medicare benefit limited to low-income older adults would be easier to shun, pushing even more newly insured Americans into an already burdened dental safety net.

Fewer than half of dentists overall accept Medicaid, but more than 60% of NDA members do, according to Fletcher. The ADA worries the reimbursement rates and bureaucratic paperwork for a Medicare benefit will be similarly unappealing.

But Fletcher, who is dental director for a Medicaid insurance company in Washington, D.C., said participation in Medicaid varies widely across states — and, as with Medicaid, participation in any new Medicare dental program would largely depend on the benefit’s design.

If the reimbursement rates for a Medicare benefit are high enough, Fletcher said, giving coverage to tens of millions of seniors could be quite lucrative for dentists. Ultimately, he said, dentists should have a choice in whether to accept Medicare patients, and all Medicare patients should be entitled to dental services since they paid into the program.

Health advocates see President Joe Biden’s Build Back Better agenda as a once-in-a-generation opportunity to provide dental coverage to people on Medicare, like Stork. Complicating their push is a debate over how many of the nation’s more than 60 million beneficiaries should receive it.(Joe Martinez for KHN)

Dr. Nathan Suter, William Stork’s dentist, sees adding a dental benefit for all seniors as the right thing to do.

A self-described “proud ADA member,” Suter finds himself at odds with the organization, which has showered him with accolades. He was named Dentist of the Year by the affiliated Missouri Dental Association in 2019, and received one of the ADA’s awards for young dentists in 2020.

“I, as an ADA member, think they should be at the table for me, making sure it’s as good a benefit as possible for all of my seniors,” said Suter, who estimated at least 50% of patients at his House Springs, Missouri, practice are older adults.

But rather than push for a universal benefit, the ADA’s well-funded lobbying operation is pushing against congressional Democrats’ proposed plan to add dental coverage for all Medicare recipients. The organization has asked its members to contact their congressional representatives on the topic. Graham said more than 60,000 emails have been sent to Capitol Hill so far.

Suter sees the battle over whom to cover as a generational rift. As an early-career dentist, he prefers adding full dental coverage now so he can adapt his business model sooner. And the more seniors who get dental coverage, the more his potential client base expands. Dentists like him, still building their practices, are less likely to have time to be involved in the ADA’s policymaking process, he said.

Caught up in it all are patients such as Stork, who said the possibility of dental coverage in Medicare is one reason he is holding off on the extraction, even though he knows a benefit is unlikely to be implemented for years, if at all.

Stork also knows the benefit might not cover a middle-class person like himself even if approved. Still, it sure would be nice to have when his tooth cannot wait any longer to come out.

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