During the course of our Q&A profiles of the artists and sponsors, some interesting questions arose about vision health and insurance. So I asked Erin Gill Ninehouser from the Pennsylvania Health Access Network (PHAN) to take a stab at some of these issues.
Organization Twitter: @pahealthaccess
Organization Website: www.pahealthaccess.org
What sort of work does PHAN do specifically around vision health (advocacy, enrollment, etc)?
PHAN helps people make sense of our health care system, and make it work for them. That’s a lot easier now with the Affordable Care Act because people have real choices, and can actually find affordable, comprehensive health insurance — that covers routine eye care. Through educational events at libraries and with community partners, we give people the tools and know-how to apply for health insurance, understand that coverage, and use it to get important preventive services and better manage existing health issues. We also provide one-on-one assistance through every step of the process of applying for health insurance, in person or on the phone, daytime, evenings and weekends (via our Helpline: 1.877.570.3642).
Can you tell us why vision health (or dental health) is something separate from general health in most insurance packages? It’s an unintended consequence of the way our health care and health insurance system developed — piece by piece, not as a deliberate, strategic act. Our patchwork system was the result of years of fits and starts, beginning in the 1920s when General Motors offered coverage to 120,000 workers. Soon after, Blue Cross began selling private coverage for hospital care. In the 1940s, prepaid group health care began, and quickly became popular as a way for employers to get around World War II wage and price controls that made it tougher to attract workers. In the 1950s, the price of hospital care doubled, hundreds of insurers entered the market and we began to see the stark separation and growing disparities between those who had employer coverage and those who didn’t that the Affordable Care Act is working to address today. Health insurance developed in response to a need to cover major, expensive medical procedures like surgery and unfortunately, vision and dental care evolved on a separate track — added as “supplements” to employer policies and sold separately by insurance companies on the individual market.
Can you tell me what percentage of Americans with health insurance still cannot afford vision health? That’s a tough thing to assess, especially now that more than 8 million Americans have more comprehensive health insurance through the Affordable Care Act. In many policies, routine eye care, including the recommended standard of one eye exam every two years, is covered. Plus, depending on the diagnosis, treatment for glaucoma, cataracts, and eye health needs related to a medical condition like diabetes are often covered — especially when your doctor takes the extra steps to contact your insurer and ask for clarity on entering the correct diagnosis and treatment codes.
Do Medicare and Medicaid cover these health needs? While Medicare doesn’t include comprehensive vision benefits, it does cover eye care related to chronic illnesses like diabetes. For example, Medicare Part B (the part that covers doctor visits and outpatient care with a 20% co-pay) does cover a yearly eye exam for diabetic retinopathy. Medicare also covers a glaucoma test once every 12 months for people at high risk (which they define as: diabetics, people with a family history of glaucoma, African Americans over age 50, and Latinos over age 65). Tests and treatment for age-related macular degeneration are also covered, as are surgeries to repair damage to the eyes caused by chronic conditions like cataracts and glaucoma. An exam to uncover the cause of current vision problems that may indicate a serious eye disease is also covered.
Medicaid doesn’t have as many restrictions on when they cover vision services. Pennsylvania’s current Medicaid program includes coverage for routine eye care, including eyeglasses and lenses.
How did the Affordable Care Act improve access to vision health services? The Affordable Care Act put quality, comprehensive health insurance within reach of millions of Americans who were previously shut out from getting covered because the costs were too high and insurance companies had the power to deny you if you’d been sick in the past. Many people don’t realize what a difference the financial assistance provided by the law makes. I’ve worked with hundreds of people in Western PA who are seeing prices of $25 or $50/month for private insurance with low co-pays and small deductibles. That’s because under the law, what you pay is based on your income. Plus, plans now cover preventive services without a co-pay.
While vision care for adults is not one of the ten “Essential Health Benefits” defined by the law as the new baseline for private insurance plans, many plans do cover routine eye care like exams every two years, discounts on frames and lenses, and coverage for eye problems related to medical conditions like diabetes. Also, certain eye treatments like drops for cataracts are also covered under a plan’s prescription drug benefit. It’s always good to do some digging before deciding on a plan, and that’s what organizations like ours help people do. We work with folks to get comfortable communicating with insurance companies and confident in asking the right questions to come away with clear, actionable information like specifically, what vision services are covered and under what circumstances.
Having insurance makes a difference in whether or not you can get routine care and manage illnesses that may affect your eyes down the road. I’d urge everyone to check out your options, make a list of questions and connect with someone — a navigator or Certified Application Counselor — who can give you accurate, unbiased information and help you through the process. The next Open Enrollment period begins November 15, 2014 and continues through February 15, 2015.
How can it be improved to access even more vision health services? On a policy level, adding vision care for adults as one of the Essential Health Benefits would drastically improve access to vision health services. That’s unlikely to happen at the federal level with the current makeup of Congress, but it’s an important change to pursue — perhaps, at the state level first. Pennsylvania’s Legislature can mandate coverage of certain services in private plans sold in Pennsylvania, so a state bill requiring comprehensive vision benefits would also be an effective strategy.
Are there programs available for people to get help with eyeglass expenses? Not a lot, unfortunately. Here are two:
New Eyes for the Needy: This program will cover the cost of a basic pair of frames and single or bifocal lenses to people meeting the eligibility criteria who have had a recent eye exam. Their program requires a social service provider or doctor to complete part of the application.
American Optometric Association Vision USA Program: This program will provide a free eye exam by a participating optometrist in your area. To qualify, you must be uninsured, fall within the income guidelines, and not have had an eye exam in the past 2 years.
You’ll be tabling at the Silence Auction Event on September 12. How can everyone who stops by your table advocate for vision health? Real simple — take information about the Affordable Care Act and share it with your friends and family! The number one place Americans get their information about the new health care law isn’t cable news, or talk radio (thank God), or even the newspapers — it’s friends and family. The fog of misinformation that prevented so many people from understanding the new law and the new options and protections it brings, is finally beginning to clear. But it’s not gone yet. Connecting people with credible information about enrolling in health coverage is an act of advocacy — you are arming someone with the information they need to go forward and make good health care decisions. Informed policyholders, just like informed voters, are influential in shaping policy.
There’s a pervasive stigma about wearing glasses for young and old, but an equally pervasive idea that glasses indicate intelligence (or hipness.) Explain that duality.
I don’t know if I can explain that, but I do know that if more kids watched this Mr. Rogers episode, they might feel a little less nervous to don their first pair of glasses.
Tell me about a character in literature, film, television or other pop culture who wore glasses and how that resonated with you for good or for bad. Well, he’s not a pop culture or literary figure, but my Dad is a real character, and he’s always worn glasses and contacts. When I was little, I’d watch him “take his eyes out” — as he called it, when removing his contacts — after work. I always thought of contacts as a little sci-fi, but cool. I’m lucky to have always had great eyesight, but if that ever changed, I’d probably go all Buddy Holly on the style.
Thank you, Erin. If anything resonated with you – from needing support signing up for the Affordable Care Act to selecting a policy that covers your vision health needs, Erin and PHAN will be at the Silent Auction on September 12.