Eye Care Policy in the United States
Individuals in the United States get their health coverage from a variety of sources. The type and comprehensiveness of health insurance determines the availability and cost of eye care services. Vision care is included in Medicare and Medicaid—programs that the U.S. government funds for those aged 65 and older, individuals with specific disabilities, and people with low income.
- Medicare is a health insurance option for people age 65 or older, or under the age 65 with certain disabilities. One must have entered the United States lawfully and have lived in the U.S. for 5 years to be eligible for Medicare. Medicare covers some preventive and diagnostic eye exams. For example, Part B covers yearly eye exams for diabetic retinopathy. Medicare does not cover routine eye exams (refractions) for eye glasses/contacts and generally does not cover eyeglasses or contact lenses. However, following cataract surgery with an implanted intraocular lens, Medicare Part B helps pay for corrective lenses. Medicare holders enrolled in Parts A and B are eligible for these types of vision coverage:(1)
- Glaucoma screening can be obtained once every 12 months for individuals with diabetes, with a family history of glaucoma, who are African American over age 50, and who are Hispanics aged 65 and older. Glaucoma screening consists of a comprehensive eye exam by an eye doctor, including dilation and intraocular pressure measurement.
- Cataract surgery may be needed for one or both eyes, involving implantation of an intraocular lens. Medicare will cover the basic costs of lenses. Individuals can choose to pay extra for the difference in cost for new multifocal intraocular lenses that can often restore sight at all distances.
- Medicaid is a welfare program for certain low-income populations, providing medical and long-term care to more than 16% of the population. However, Medicaid does not cover all those with low incomes or all of the uninsured; it is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to individuals; instead, it sends payments directly to health care providers. The following vision benefits are available for children under 21 under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program of Medicaid:(2)
- Eye exams
- Eyeglass frames
- Private Insurance is the main source of coverage for Americans under the age of 65. Most people with private health insurance get coverage through an employer—their own, a spouse’s, or a parent’s. Employer-based health insurance is popular because it usually offers the most comprehensive coverage and it is subsidized, with employers and tax breaks paying some or most of the premium. Vision benefits depend on which coverage plan you have.
Approximately 47 million people in the U.S. do not have health care coverage, which is a number that is on the rise. The uninsured population comes from every age group and every income level, and 8.7 million are children. A common misconception is that those who are uninsured are also unemployed. The truth is that more than eight out of ten individuals who lack insurance are in working families. While the 47 million without coverage come from all different socioeconomic backgrounds and ethnicities, the picture of the uninsured that emerges is generally of young people who work in small businesses and who earn low wages.
Why is the uninsured population such an issue? A large uninsured population has adverse effects for both the individuals who lack health coverage and for those who are covered. People without health insurance often go without care or delay care, and the care they do receive is likely to be of lower quality. Uninsured Americans are more than twice as likely as their insured counterparts to report a medical need that went unmet because of cost. The lack of health insurance coverage, differences in Medicaid coverage and benefits across states, and inadequate reimbursements are likely to limit capacity and access to vision care professionals. For example, the uninsured are much less likely to receive preventive eye care in the form of eye doctor visits or dilated eye examinations than were the insured, which is consistent with a recent article on the use of other recommended preventive services.(3) Using data from the 2000 Behavioral Risk Factor Surveillance System, it was found that uninsured persons with diabetes were less likely to have an annual dilated eye examination and to undergo other tests related to diabetes management.(4)
"The association between low eye care utilization rates and lack of, or inconsistent, health insurance coverage...suggests that overall ocular health care access would be enhanced if progress is made toward securing coverage for the 46.6 million Americans who do not currently have health insurance...There are also troubling gaps in eye care utilization among adults with health insurance coverage.”(5)
Community Health Centers (6)
Federally-funded community health centers, which are mandated to provide comprehensive primary care in underserved communities, are an option for low-income residents.(7) Because health centers are located in low-income and medically vulnerable communities, most patients are either uninsured or covered under Medicaid.
With respect to certain chronic conditions, health centers are known to be able to provide high quality care despite limited financial resources, a shortage of primary care providers, and greater health care demands. What is not well known is the extent to which health centers are able to provide on-site professional vision care. Because comprehensive eye exams are not acknowledged as an essential primary care service, most Americans receive vision exams only after noticing significant vision problems. One study found the vast number of health centers do not have an on-site optometrist or ophthalmologist who bills for comprehensive eye exams; only 20 % of health centers have an onsite eye care professional.(8) Major barriers to providing on-site comprehensive eye care services include the inability to afford necessary equipment and the perceived lack of reimbursement or inadequate reimbursement from Medicaid, Medicare and private insurers.
At the same time, health center capacity is limited due to general mal-distribution and shortage of primary care and specialty providers. For example, while preliminary non-diagnostic vision screenings are conducted by 93 % of health centers, only 28 % report that dilated eye exams are performed for individuals with diabetes and less than 18 % have on-site optometrists providing comprehensive eye examinations.(9) Visual acuity screenings cannot substitute for comprehensive eye exams by eye doctors.
Not surprisingly, use of eye care services is uneven in the United States, a special concern because of the growing demand for vision and eye care with a growing older population and the asymptomatic nature of many eye diseases in their early stages. Rural populations and low-income groups appear to be at higher risk for vision problems compared to wealthier and urban Americans. In addition to general financial and insurance coverage barriers, the lack of access to qualified vision care professionals also presents a major challenge for persons in low-income communities and geographically isolated and medically underserved areas, including rural areas.(10) In the past, optometrists could participate in the National Health Service Corps (NHSC) program, serving in underserved communities, and in particular health centers, in exchange for educational loan subsidies.(11) While optometry is no longer eligible for the NHSC program, some health centers recognize the importance of vision care and partner with optometry residency programs(12) as well as some ophthalmology residency programs to ensure access to eye care.(13) In conclusion, it is clear that access to quality preventive eye care services is complex and fragmented in the current U.S. health care system.
(1) Vessel, Madeleine. Medicare and Medicaid Vision Benefits. http://www.allaboutvision.com/vision-insurance/medicare-medicaid.htm Accessed October 26, 2009.
(3) Ross JS, Bradley EH, Busch SH. Use of health care services by lower-income and higher-income uninsured adults. JAMA. 2006;295:2027-2036.
(4) Nelson KM, Chapko MK, Reiber G, Boyko EJ. The association between health insurance coverage and diabetes care: data from the 2000 Behavioral Risk Factor Surveillance System. Health Serv Res. 2005;40:361-372.
(5) Lee, D. J., Lam B. L., Arora, S., Arheart, K. A., McCollister, K. E., Zheng, D., Christ, S. L., Davila, E. P.. (2009). Reported Eye Care Utilization and Health Insurance Status Among US Adults. Archives of Ophthalmology , 303-310.
(6) Adapted from http://www.gwumc.edu/sphhs/departments/healthpolicy/CHPR/downloads/Assessing-the-Need-for-On-Site-Eye_02-19-2009.pdf Accessed October 26, 2009.
(7) Section 330 of the Public Health Service Act [42 U.S.C. 254b], 42 C.F.R. Part 51c, 42 C.F.R. Part 491. Also, see Bureau of Primary Health Care Policy Information Notice: 98-23. Health Center Program Expectations. August 17, 1998.
(8) Shin, Peter. Assessing the Need for On-Site Eye Care Professionals in Community Health Centers. http://www.gwumc.edu/sphhs/departments/healthpolicy/CHPR/downloads/Assessing-the-Need-for-On-Site-Eye_02-19-2009.pdf Accessed October 26, 2009.
(10) Owsley C, McGwin G, Scilley K, Girkin CA, Phillips JM, and Searcey K. Perceived barriers to care and attitudes about vision and eye care: focus groups with older African Americans and eye care providers. Ophthalmology and visual science, 2006, 47(7):2797-2802.
(11) CMS, Physician Bonuses. http://www.cms.hhs.gov/hpsapsaphysicianbonuses (Accessed October 26, 2009).
(12) American Optometric Association of Community Health Center Committee. Affiliations of community health centers with the accredited schools and colleges of optometry in the states and territories of the United States. Optometry 2008; 79: 581-586.
(13) E.g., Yale School of Medicine. http://www.eyes.yale.edu/education/residency_training.html (October 26, 2009).