See, Hear, and Speak no Evil in Medicare

Although I was very grateful that Medicare was available when I retired two years ago, I’ve also been surprised and concerned about some of what it doesn’t cover. These concerns are especially in the areas of our eyes, ears, and mouth. 

For my mouth, the timing could not have been worse. I had excellent dental coverage with my prior academic medical center work, but rarely needed it. Yes, I knew that basic Medicare did not cover dental work. One could purchase some sort of supplemental coverage, but that seemed to me to be more costly than the coverage was worth. 

Apparently, my good dental health was timed to end when I was just over 65 and had Medicare. Two painful episodes close together with two root canals. A chipped front tooth, not painful, but making me look a little weird. A molar impinging on another tooth that needed to be pulled. Old cavity fillings that failed. Many, many thousands of dollars later, many questions arose. 

How had Medicare avoided dentistry, I asked my dentist? With a wry smile, he said he wasn’t sure, as it came before his practice time, but he was grateful, especially when he heard what the reimbursement was for psychiatrists like myself. Looking this up on the Centers for Medicare & Medicaid Services website, I’m still left confused: 

“The dental exclusion was included as part of the initial Medicare program. In establishing the dental exclusion, Congress did not limit the exclusion to routine dental services, as it did for routine physical checkups or routine foot care, but instead it included a blanket exclusion of dental services. The Congress has not amended the dental exclusion since 1980 when it made an exception for inpatient hospital services when the dental procedure itself made hospitalization necessary.” 

The Coverage Principle states: 

“Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.”

 One has to wonder how often the costs of this dental care prevent the elderly from receiving it. Doing so can not only increase later, even more serious “dental problems,” but perhaps the early detection of related “medical problems,” including cancers of the oral cavity. 

Then there is hearing. Most insurance coverage does not cover much, if any, of the cost of hearing aids. Given the significant cost and concerns about appearance, it might not be surprising that many under 65 forego getting them. 

Medicare also does not cover hearing aids, even though the need increases with age. High-end devices currently cost about $6,000 using a good audiologist. Yet, good hearing is so important for the social interactions that the elderly need. 

I bit the cost bullet years ago and they are worth every penny and more of the cost. However, I could well afford the cost. Many can’t. 

Basic visual care is also not covered by most health insurance. Medicare does not cover eyeglasses or contact lenses, except for one pair of corrective lenses following cataract surgery. I needed two adjustments following my cataract surgery, which my ophthalmologist said was common. Normal visual problems, especially in reading, increase with age. At least glasses and contact lenses are relatively inexpensive, for good vision is quite important for the everyday lives of the elderly, ranging from reading to avoiding traumatic falls. 

Obviously, there must be something in common for Medicare not to cover these dental, auditory, and visual services. Surely, the intent was not evil. It seems these services fell for the most part into the area of normal deterioration of bodily function than disease. Nevertheless, these aspects of bodily functioning surely are important for one’s broad sense of health and well-being. They can’t be taken for granted. 

Perhaps that original decision may not have been wise in the first place. Moreover, as our population ages, the potential problems in these areas will increase and last longer. 

Since the elderly know the serious repercussions of not receiving dental, auditory, and visual care, it may be up to us to lobby Congress to make that better for the next generations. The phrase “see no evil, hear no evil, and speak no evil” generally refers to those who ignore and turn away from improprieties. Let us over 65ers not turn away from these problems.  

Though I’m not sure of the exact figures, I would surmise that saving money from unnecessary and very costly end of life care and intensive care would more than make up for adding the omitted services that would help our eyes, ears, and mouth, and thereby the quality of life in old age.

H. Steve Moffic, M.D., 67, retired from clinical practice at 66. He was fondly deemed a “psychiatric gadfly” by the Chair of the Department of Psychiatry where he first trained. His book The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare, published in 1997, was the first extended discussion of the ethics of managed mental health care.

[See here, here, and here, for previous Over 65 posts that link finding savings within Medicare to funding the kinds of extensions Dr. Moffic envisages.]