Hearing for the masses.

One of the many strange ironies of medicine in the United States today is that an individual with profound hearing loss can receive a cochlear implant fully covered by medical insurance, whereas an individual with moderate to severe hearing loss will rarely receive insurance coverage for a hearing aid. This frustrating scenario is carried out in different forms throughout various fields of medicine, leaving patients to ponder why it is that they can qualify for an expensive surgically implanted hearing device but not a simple hearing aid. When one considers the clear fact that many more patients in the world would benefit from conventional amplification rather than surgical implantation, an obvious question presents itself—why is it so? And immediately thereafter, the next question arises—how can we change this? It is hard to ignore the realities that although the dollar may be the bottom line, it does not appear that all the dollars being spent are necessarily distributed in the most reasonable way. There are numerous patients that I see from inner-city neighborhoods in Baltimore who require hearing aids. When I suggest that this is the best option for them and that insurance is not likely to cover it, I am usually met with a wry, sad laugh. There is simply no way for so many patients to even consider obtaining a hearing aid without the assistance of medical insurance. When they learn the out-of-pocket prices for even a relatively feature-less device, the conversation usually ends right there. Although I can direct them to some helpful resources, we simply do not have hearing aids to give to patients. Nine times out of 10 (at least), these patients come back the following year with slightly worse hearing, but no hearing aids. The visit is much the same, with the same diagnosis (hearing loss), the same recommendation (amplification), and the same outcome (nothing). Although I can make little claim to understand the politics and economics that dictate medical decisions in this country, it is jarring to me that I feel this way as a practicing physician fully ensconced in the medical establishment. From the perspective of somebody outside the field of medicine, I can only imagine how they fill in the blanks in the great mysteries of how insurance companies decide who to cover, what to cover, and what to reimburse. There are few other issues of such central social importance where urgent matters are handled with a complete and intentional lack of clarity or transparency. Unfortunately, with the lack of consensus that defines the healthcare debate, rational strategies for improvement seem to disappear powerlessly in a sea of rhetoric. Health care providers and their patients—the essential core unit on which medicine is based—remain somehow a marginal part of the decision-making process that determines how effective their interaction will ultimately be. Of course, we need to accept responsibility for our cultural sensibilities. The U.S. medical culture has always embraced technology and excelled in cutting-edge research. When we are sick, we generally believe in our right to be treated with the best available methods until we say stop. As a country, it seems that we find it important and valuable that U.S. hospitals provide the highest levels of medical care in the world for complex conditions, despite the costs that doing so incurs. Have we gone too far toward this extreme? Technology does not come cheaply, and non–government sponsored medical device manufacturers have the right to be subject to the same market forces as any other business. This background may explain in part why it is that hearing aid manufacturers typically do not spend the majority of their efforts on making a “minimal design” hearing aid, in their search to produce the “best” technology. If we combine this reality with the over-whelming number of individuals with hearing loss worldwide, it takes only a moment to recognize that most people in the world who need hearing aids do not have them. If a patient who lives in inner city Baltimore finds it impossible to obtain a hearing aid, then how must a patient living in a Third world country without basic essentials such as running water or electricity regard this issue? In light of these thoughts, I am personally glad to read Bento and Penteado's article, included in this issue, titled “Designing of a Digital Behind-the-Ear Hearing Aid to Meet the World Health Organization Requirements.” The authors admirably approach this important issue from a commonsense, pragmatic perspective that is necessary in today's times. I cannot say that the findings are really surprising in a traditional sense. However, the sheer importance of the goals—to design a hearing aid that can truly be used to help the masses that need them within the context of hearing aid manufacturer practices yet without the constraints that limit typical consumer hearing aid purchases—cannot be understated. This is significant work that hopes to make hearing aids more widely available worldwide, so that we can get closer in reality to Howard House's great ideal that the whole world may hear.