Medicare's blind spot: Why 1.2 million potentially unsafe elderly drivers remain on the roads

BOSTON — Every morning across America, millions of senior citizens grab their car keys and head out to doctors’ appointments, grocery stores, and social gatherings. For most, these routine drives maintain their independence and connection to the world. But beneath this everyday scene lies a troubling reality: nearly one in six older drivers experiences mild cognitive impairment, and our healthcare system lacks a reliable way to determine who among them should no longer be behind the wheel.

With 48 million licensed drivers over 65 in the United States as of 2020, and approximately 17% of seniors experiencing mild cognitive impairment, we’re facing an unprecedented challenge in ensuring road safety while preserving independence. A recent analaysis by researchers from Brigham and Women’s Hospital suggests the healthcare system must do a better job of monitoring and testing older adults still licensed to drive.

The numbers paint a sobering picture: in 2020 alone, motor vehicle crashes led to 7,480 deaths and nearly 150,000 non-fatal injuries among drivers over 65. As the research notes, “With approximately 17% of people older than 65 years (roughly 8.2 million people) experiencing mild cognitive impairment and at increased risk of motor vehicle crashes, it is critical to have a health care system that appropriately evaluates and addresses driving safety among older adults.”

Most family doctors find themselves in an impossible position when asked to evaluate an older patient’s driving ability. Current cognitive screening tests prove inadequate, and even specialists struggle with these assessments. Making the wrong call either way carries serious consequences: prematurely taking away someone’s license can lead to depression and social isolation, while failing to identify truly dangerous drivers puts everyone at risk.

Specialized driving evaluation programs offer a solution. These assessments include what the researchers describe as “direct (often on-road) observations of a patient’s driving competence, conducted in clinical settings by occupational therapists or other skilled professionals.” Rather than relying solely on office-based cognitive tests, these programs evaluate real-world performance, offering concrete data about a person’s ability to navigate traffic safely.

However, these vital assessments come with a significant barrier: cost. In Massachusetts, comprehensive driving evaluations including road tests range from $500 to $800. Without Medicare coverage, many seniors simply can’t afford this potentially life-saving service. As the researchers emphasize, “in the absence of Medicare coverage, driving assessments must be paid for privately, an expense that can be prohibitive for most people.”

The stakes extend beyond individual safety. Annual Medicare expenses for traumatic brain injuries in 2016 were estimated to be more than $19 billion, with motor vehicle crashes being an important source of these injuries in older adults. Prevention through proper driving assessments could potentially reduce these costs while protecting both seniors and other road users.

Major patient advocacy groups, including AARP and the Alzheimer’s Association, strongly recommend that at-risk drivers undergo comprehensive driving evaluations by qualified specialists. These assessments aim to identify individuals who cannot drive safely and to suggest restrictions, compensatory strategies, or training for those with less severe deficits.

Medicare already covers fall risk assessments by occupational therapists, recognizing that preventing falls saves both lives and money. The same logic should apply to driving safety. Like falls, car crashes represent a preventable source of injury and death among seniors. The current policy creates an artificial barrier between different types of safety assessments, leaving a dangerous gap in preventive care.

Critics argue about standardization and best practices in driving assessment programs. While evaluation criteria may vary somewhat between programs, there’s general agreement on what constitutes dangerous driving behavior, like crossing into oncoming traffic or failing to notice traffic signals. The field continues to evolve, with promising developments in GPS-logged driving data and simulator technology potentially offering more cost-effective screening options in the future.

Changing Medicare policy requires congressional action and financial commitment. However, the cost of inaction — both in human lives and healthcare expenses — far outweighs the investment needed to implement this coverage. We can’t afford to wait for a perfect system while millions of potentially impaired drivers navigate our roads without proper evaluation.

“Driving is a multifaceted activity that requires learned skills and the coordination of complex cognitive and physical functions. As we age, we are vulnerable to declines in our cognitive, visual and motor skills that can impact our ability to drive safely,” says corresponding author Kirk Daffner, in a statement. “Therefore, it is imperative to support programs in our healthcare system that can evaluate driving safety of at-risk individuals in a manner analogous to Medicare’s coverage of a fall risk assessment.”

Just as we wouldn’t want pilots flying commercial aircraft without regular safety assessments, we shouldn’t leave the evaluation of at-risk drivers to chance or financial circumstance. It’s time for Medicare to acknowledge that driving safety isn’t just a transportation issue – it’s a critical public health concern that deserves coverage under our national healthcare system.