Abstract
This cross-sectional study compares trends in insurance coverage and out-of-pocket medical spending from 2014 to 2024 among US adults aged 19 to 65 years with and without visual impairment.
Introduction
Uncorrectable vision impairment (VI) affects over 7 million people in the US.1 VI is associated with adverse health outcomes, including difficulties with activities of daily living,2 cognitive impairment,3 falls and hip fractures,4 long-term care admissions,5 and mortality.6 We examined trends in insurance coverage and out-of-pocket (OOP) medical spending among adults under age 65 years with and without VI from 2014 to 2024.
Methods
This cross-sectional study using publicly available, deidentified data from the 2014-2024 Current Population Survey (CPS) Annual Social and Economic Supplements was deemed not human participants research and was exempted from approval and informed consent by the University of California, Irvine’s institutional review board. It followed the STROBE reporting guideline. Our main outcomes were insurance coverage at the interview date (uninsured, private, Medicaid, or Medicare) and total nonpremium family OOP medical spending during the previous 12 months (any, continuous, and ≥10% of family income). The sample included adults aged 19 to 64 years with and without self-identified VI.
We estimated weighted outcome rates to examine unadjusted trends and linear yearly outcome trends with regression models adjusted for demographic and health-related covariates. Analyses, conducted using Stata, version 17, accounted for the survey’s complex design using replicate weights. Two-sided P < .05 was considered significant. The eMethods in Supplement 1 provide additional details.
Results
Among 12 166 adults with VI, 51.8% (95% CI, 46.8%-56.8%) were female and 48.2% (95% CI, 43.2%-53.2%) were male; most were aged 50 to 64 years (56.2%; 95% CI, 52.3%-60.0%) and unmarried (64.1%; 95% CI, 59.2%-68.7%), and 40.4% (95% CI, 38.3%-42.6%) had annual household income below $30 000. Among 1 074 969 adults without VI, 50.8% (95% CI, 46.7%-54.8%) were female and 49.3% (95% CI, 45.2%-53.3%) were male, 32.1% (95% CI, 29.1%-35.3%) were aged 50 to 64 years, 47.9% (95% CI, 41.0%-54.9%) were unmarried, and 14.6% (95% CI, 14.3%-14.8%) had household income below $30 000 (Table).
Table. Sociodemographic Characteristics of Adults With and Without Vision Impairment, per CPS ASEC 2014-2024.
| Characteristic | Adults, No. (weighted % [95% CI])a | Difference, pp | P value | |
|---|---|---|---|---|
| Visual impairment (n = 12 166)b | No visual impairment (n = 1 074 969)c | |||
| Sex | ||||
| Female | 6583 (51.8 [46.8-56.8]) | 558 313 (50.8 [46.7-54.8]) | 1.06 | .15 |
| Male | 5583 (48.2 [43.2-53.2]) | 516 656 (49.3 [45.2-53.3]) | 1.06 | |
| Age, y | ||||
| 19-34 | 2265 (19.6 [16.4-23.4]) | 361 894 (36.0 [31.6-40.7]) | −16.36 | <.001 |
| 35-49 | 3099 (24.2 [23.2-25.1]) | 378 445 (31.9 [30.5-33.4]) | −7.75 | |
| 50-64 | 6802 (56.2 [52.3-60.0]) | 334 630 (32.1 [29.1-35.3]) | 24.11 | |
| Marital status | ||||
| Married | 4723 (35.9 [31.3-40.8]) | 602 946 (52.1 [45.1-59.0]) | −16.16 | <.001 |
| Single, divorced, or widowed | 7443 (64.1 [59.2-68.7]) | 472 023 (47.9 [41.0-54.9]) | 16.16 | |
| Race and ethnicityd | ||||
| Hispanic | 2317 (17.3 [15.6-19.1]) | 216 436 (18.3 [16.9-19.8]) | −1.03 | <.001 |
| Non-Hispanic Black | 2282 (18.4 [17.2-19.8]) | 123 083 (12.5 [10.8-14.5]) | 5.95 | |
| Non-Hispanic White | 6518 (57.6 [55.0-60.3]) | 626 098 (60.1 [57.1-63.1]) | −2.50 | |
| Other | 1049 (6.7 [6.1-7.3]) | 109 352 (9.1 [8.8-9.3]) | −2.41 | |
| Citizenship status | ||||
| Noncitizen | 778 (5.9 [5.4-6.5]) | 110 722 (10.1 [9.9-10.2]) | −4.11 | <.001 |
| Citizen | 11 388 (94.1 [93.5-94.6]) | 964 247 (90.0 [89.8-90.1]) | 4.11 | |
| Educational level | ||||
| <High school | 2388 (19.1 [18.2-20.1]) | 101 231 (9.0 [8.4-9.6]) | 10.13 | <.001 |
| High school | 4218 (35.3 [33.2-37.4]) | 302 461 (28.1 [26.7-29.4]) | 7.18 | |
| Some college | 3556 (29.3 [28.0-30.7]) | 308 278 (28.7 [28.1-29.4]) | 0.58 | |
| ≥College degree | 2004 (16.4 [14.9-17.9]) | 362 999 (34.2 [31.7-36.9]) | −17.88 | |
| Annual household income, $ | ||||
| <30 000 | 4910 (40.4 [38.3-42.6]) | 152 821 (14.6 [14.3-14.8]) | 25.86 | <.001 |
| 30 000-74 999 | 3968 (32.9 [31.3-34.4]) | 325 622 (30.3 [30.1-30.5]) | 2.53 | |
| 75 000-149 999 | 2355 (19.0 [18.0-20.0]) | 360 190 (32.9 [32.6-33.1]) | −13.89 | |
| >150 000 | 933 (7.8 [7.2-8.3]) | 236 336 (22.3 [22.0-22.5]) | −14.51 | |
| Employment status | ||||
| Employed | 4429 (35.7 [34.1-37.4]) | 794 235 (73.1 [71.5-74.6]) | 37.38 | <.001 |
| Not working | 7737 (64.3 [62.6-65.9]) | 280 734 (26.9 [25.4-28.5]) | 37.38 | |
| Own children in household, No. | ||||
| 0 | 7827 (68.9 [65.1-72.5]) | 532 688 (56.7 [51.2-62.1]) | 12.20 | <.001 |
| 1 | 2285 (16.9 [15.0-19.1]) | 209 861 (17.7 [15.8-19.8]) | −0.82 | |
| ≥2 | 2054 (14.2 [12.3-16.2]) | 332 420 (25.5 [22.2-29.2]) | −11.38 | |
| Area of residence | ||||
| Metropolitan | 9135 (80.5 [78.9-82.1]) | 884 799 (87.0 [86.1-87.7]) | −6.42 | <.001 |
| Nonmetropolitan | 2870 (18.5 [17.0-20.1]) | 179 503 (12.3 [11.6-13.1]) | 6.19 | |
| Not identified | 161 (1.0 [0.7-1.3]) | 10 667 (0.8 [0.6-1.0]) | 0.22 | |
| Health insurance | ||||
| Medicaid | 3449 (28.0 [26.5-29.6]) | 145 674 (13.1 [12.4-13.8]) | 14.97 | <.001 |
| Medicare | 1528 (13.3 [12.4-14.2]) | 24 506 (2.4 [2.4-2.5]) | 10.85 | <.001 |
| Dual Medicaid and Medicare | 1156 (9.6 [8.8-10.4]) | 11 919 (1.1 [1.1-1.2]) | 8.43 | <.001 |
| Private only | 4632 (37.3 [35.2-39.5]) | 758 485 (70.3 [68.2-72.2]) | −32.95 | <.001 |
| Uninsured | 1401 (11.8 [11.0-12.6]) | 134 385 (13.09 [11.9-14.4]) | −1.30 | .04 |
| General health status | ||||
| Excellent or very good | 3299 (26.8 [25.6-28.1]) | 679 548 (63.3 [62.9-63.7]) | −36.49 | <.001 |
| Good | 3426 (27.9 [26.8-29.0]) | 283 832 (26.2 [25.9-26.5]) | 1.68 | |
| Fair | 3140 (26.1 [24.9-27.2]) | 84 570 (7.9 [7.8-8.0]) | 18.18 | |
| Poor | 2301 (19.2 [18.3-20.2]) | 27 019 (2.6 [2.5-2.7]) | 16.64 | |
| Disabilities | ||||
| Hearing difficulty | 2255 (19.1 [18.0-20.1]) | 13 552 (1.2 [1.2-1.3]) | 17.82 | <.001 |
| Difficulty remembering | 3637 (31.0 [29.5-32.4]) | 29 051 (2.9 [2.5-3.3]) | 28.08 | <.001 |
| Physical difficulty | 4618 (38.6 [36.6-40.6]) | 38 736 (3.7 [3.5-3.8]) | 34.89 | <.001 |
| Disability limiting mobility | 3751 (32.4 [30.4-34.4]) | 23 666 (2.3 [2.1-2.6]) | 30.06 | <.001 |
| Personal care limitation | 1969 (17.1 [16.0-18.1]) | 11 233 (1.1 [1.0-1.2]) | 15.96 | <.001 |
Abbreviations: CPS ASEC, Current Population Survey Annual Social and Economic Supplements; pp, percentage points.
All percentages were weighted using CPS sampling weights.
Included adults who reported severe difficulty seeing or blindness, corresponding to a weighted population of 25.8 million person-years.
Included adults who did not report severe difficulty seeing or blindness, corresponding to a weighted population of 2.3 billion person-years.
Ascertained by self-report. “Other” includes American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, multiracial, and other or unknown non-Hispanic race.
The Figure, A, illustrates unadjusted trends in coverage types from 2014 to 2024. Among adults with VI, the uninsured rate declined from 15.1% (95% CI, 12.3%-17.9%) to 10.1% (95% CI, 8.0%-12.3%), consistent with a significant adjusted downward trend (adjusted odds ratio [AOR], 0.94; 95% CI, 0.92-0.96). There were increases in private coverage and Medicaid coverage among adults with VI, whereas Medicare coverage declined, with the sharpest drop after 2021. However, only the adjusted trend for Medicaid coverage in adults with VI was significant (AOR, 1.05; 95% CI, 1.03-1.07). Uninsured rates were similar in both groups, but private coverage was substantially lower and Medicaid and Medicare coverage were higher among adults with VI.
Figure. Trends in Health Insurance Coverage and Out-of-Pocket (OOP) Spending Among Adults With and Without Vision Impairment (VI) Per Current Population Survey Annual Social and Economic Supplements, 2014-2024.
Data markers in A and B indicate estimates of weighted outcome rates. A, Adjusted odds ratios (AORs) for adults without insurance: VI, 0.94 (95% CI, 0.92-0.96) and non-VI, 0.96 (95% CI, 0.95-0.96); for Medicaid: VI, 1.05 (95% CI, 1.03-1.07) and non-VI, 1.07 (95% CI, 1.07-1.08); for Medicare: VI, 0.99 (95% CI, 0.97-1.01) and non-VI, 1.02 (95% CI, 1.01-1.03); for private insurance: VI, 1.00 (95% CI, 0.97-1.02) and non-VI, 0.98 (95% CI, 0.98-0.99). B, For adults with VI, the AOR for any OOP spending was 0.95 (95% CI, 0.92-0.97) and for OOP spending of 10% or more of income was 0.97 (95% CI, 0.95-0.99); for adults without VI, the AOR for any OOP spending was 0.97 (95% CI, 0.97-0.98) and for OOP spending of 10% or more of income was 1.00 (95% CI, 0.99-1.00). C, Data markers indicate weighted mean nonpremium OOP spending during each calendar year among adults with nonzero spending, adjusted to constant 2024 US dollars using the Consumer Price Index.
The Figure also shows unadjusted trends in OOP spending from 2014 to 2024. Among adults with VI, the prevalence of any OOP spending declined slightly (AOR, 0.95; 95% CI, 0.92-0.97) (Figure, B). Analogously, the percentage of adults with VI whose OOP was 10% or more of family income decreased from 17.9% (95% CI, 15.1%-20.7%) to 11.1% (95% CI, 8.7%-13.5%) (AOR, 0.97; 95% CI, 0.95-0.99), but this percentage remained more than double that among adults without VI in 2024. Mean OOP spending among adults with VI also declined, from $2907.58 (95% CI, $2568.48-$3246.69) to $2495.27 (95% CI, $2088.51-$2902.02), with a significant adjusted trend (−$101.92; 95% CI, −$141.38 to −$62.46) (Figure, C). Among adults without VI, mean OOP remained more stable over time, with a small adjusted downward trend (−$49.14; 95% CI, −$56.97 to −$41.32).
Discussion
After the Affordable Care Act’s implementation, uninsured rates fell, rates of private and Medicaid coverage increased, and Medicare coverage decreased among adults with VI. Changes in the composition of coverage sources among adults with VI may have important implications for health care access, utilization, and health, given differences in services covered, practitioner networks, and patient cost sharing across coverage types. Increased Medicaid coverage may have contributed to lower cost sharing,7 although access to practitioners may depend on the structure of state Medicaid programs and practitioner supply.
We also found reductions in OOP health care spending, with a decline in rates of OOP expenses of 10% or more of family income from nearly 18% in 2014 to about 11% in 2024. However, adults with VI still had more than double the rate of high OOP burden vs those without VI in 2024. Adults with vs without VI have been shown to have higher health care spending for health services both related and unrelated to eye care.5,8 Future research is warranted to identify targeted policy interventions that may help close gaps.
Our study has limitations. First, VI and all outcome measures were self-reported and could be subject to bias. Second, individuals with significant disabilities may be less likely than those without to participate in surveys such as CPS. Third, our measure of OOP spending was based on family-level spending, and we could not distinguish spending on different types of care (eg, eye care).
eMethods
eReferences
Data Sharing Statement
References
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Associated Data
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Supplementary Materials
eMethods
eReferences
Data Sharing Statement
