Provision of cochlear implants (CIs) for those within the criteria for implantation remains lower in the United States than in some other developed nations. When adults and children are grouped together, the rate of utilization/provision remains low at around 6%. For children, the provision rate is about 50% of those who could benefit from an implant, compared with figures of about 90% for the Flanders part of Belgium, the United Kingdom and other European countries. The probable reasons for this underprovision include: low awareness of the benefits of CIs among the population; low awareness among health-care professionals; the lack of specific referral pathways; some political issues relating to the Deaf Community; and financial issues related to health provision. Such financial issues result in situations which either fail to provide for access to implants or provide too low a level of the necessary funding, especially for low-income individuals covered by public health-care programs such as Medicaid. These issues might be mitigated by adoption and publication of standards for best clinical practices for CI provision, availability of current cost-effectiveness data, and the existence of an organization dedicated to cochlear implantation. Such an organization, the American Cochlear Implant Alliance (ACI Alliance), was recently organized and is described in the paper by Niparko et al. in this Supplement.

Pediatric access to care was excellent for children with the exception of Germany and the United States where there is an inadequate referral system. Adult utilization was low everywhere because of the lack of screening for adults and the fact that primary care physicians and even audiologists are unfamiliar with CI candidacy criteria and outcomes, and hence typically do not make patient referrals.

Objective:To present key data from a private marketing report that characterizes U.S. cochlear implant (CI) utilization, potential CI candidate and recipient population sizes, and CI market growth.Patients:Individuals who may benefit from CI and CI recipients in the United States.Interventions:Cochlear implantation.Main outcome measures:CI utilization, potential CI candidate and recipient population sizes, and CI market size and value.Results:As of 2015, a cumulative 170,252 people (240,056 devices) had undergone cochlear implantation in the United States. In the year 2015, approximately 30% of devices were implanted in bilateral CI patients, through simultaneous or sequential implantation. When considering traditional audiometric CI candidacy criteria (patients with severe to profound sensorineural hearing loss in the better hearing ear), utilization rates among the population who may benefit from CI approximated 12.7%. When considering expanded criteria including individuals with single-sided deafness or asymmetrical hearing loss (severe to profound hearing loss in the worse hearing ear), utilization rates approximated 2.1%. In 2015, there was a net increase of 20,093 individuals who may have benefited from CI who had not undergone CI, adding to the group of about 1.3 M untreated audiometric CI candidates who existed prior to that year. The CI market was valued at $450.8 M in 2015, with an average device selling price of $25,701 per device.Conclusions:CI utilization rates remain low among individuals who meet audiometric criteria for CI. Although the annual proportion of CI recipients to new audiometric candidates has increased, the total population of untreated audiometric CI candidates continues to rise.

Persistent underutilization of cochlear implants (CIs) in the United States is in part a reflection of a lack of hearing health knowledge and the complexities of care delivery in the treatment of sensorineural hearing loss. An evaluation of the patient experience through the CI health care delivery process systematically exposes barriers that must be overcome to undergo treatment for moderate-to-severe hearing loss. This review analyzes patient-facing obstacles including diagnosis of hearing loss, CI candidate identification and referral to surgeon, CI evaluation and candidacy criteria interpretation, and lastly CI surgery and rehabilitation. Pervasive throughout the process are several themes which demand attention in addressing inequities in hearing health disparities in the United States.

Early-intervention professionals are the common denominator for families seeking information and services because they explain, help initiate, and expedite diagnostic and treatment services. Because low- and moderate-income families may have greater difficulty negotiating the cochlear implant process, EI can facilitate full access to this intervention by those with fewer financial resources.

Objective: The study documented the role of Medicaid in the provision of cochlear implants and identified access barriers due to states’ adopted rules. An historical review of federal legislation provided a basis for evaluating the original Congressional intent and how this national purpose aligns with how state programs are currently operating. Study Design: A SurveyMonkey questionnaire was used to facilitate data collection from 47 clinics across 35 states after an initial inquiry was made to each clinic to determine an appropriate point of contact, generally a cochlear implant audiologist. Respondents were from all regions of the United States and represented a diversity of clinic types of varying program size. Data were collected for two calendar years—2015 and 2016. Results: Medicaid was the funding source for an average of 55% of pediatric surgeries based on 36 US clinics. For the 23 clinics returning information on adults, Medicaid was the health insurer for an average (mean) of 22% of cochlear implants (CI) surgeries; the median was 13%. Four access concerns were identified: 1) equipment replacement and processor upgrade policies; 2) low reimbursement by state Medicaid for cochlear implant surgery and related services; 3) Medicaid Managed Care (MCO) and the complexity these providers can add for a specialized service like CI that is offered at a limited number of facilities; and 4) obtaining authorization for CI surgery and related services. Conclusions: The intent of the 1989 legislative changes in Medicaid was to ensure that children received appropriate healthcare services wherever they lived in the country. What has transpired over the years, vis-à-vis CI, is a Medicaid system that varies depending upon the state's individual rules.

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Audiologists and acoustical engineers have urged that acoustics be considered in the design of classrooms for more than 30 years. Research has demonstrated that children with hearing loss have great difficulty understanding speech in noisy, reverberant environments. However, there has never been a legal mechanism to require local educational systems to address acoustics in the design and construction of schools. An effort by a broad-based coalition of engineers, audiologists, parents, architects, and educators is now underway to develop a standard for acoustics that would then be referenced in the Americans with Disabilities Act (ADA). Although the legal mechanism for this action is to address the needs of children with disabilities as the ADA requires (most notably, children with hearing impairments, but also those with central auditory disorders, attention deficit disorders, and vision impairments), the impact will be more far-reaching. All children-whether or not they have a disability-will benefit from a favorable acoustical environment.