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. 2019 Jan 24;137(4):391–398. doi: 10.1001/jamaophthalmol.2018.6799

Trends in Eye Care Use and Eyeglasses Affordability

The US National Health Interview Survey, 2008-2016

Varshini Varadaraj 1, Kevin D Frick 2, Jinan B Saaddine 3, David S Friedman 1, Bonnielin K Swenor 1,✉
PMCID: PMC6459103  PMID: 30676634

Key Points

Question

What are the trends in using eye care and affording eyeglasses among Americans 18 years and older from 2008 to 2016?

Findings

In this analysis of National Health Interview Survey data including 9 annual cross-sectional population-based samples, decreased difficulty affording eyeglasses was observed from 2014 to 2016. Women, individuals with visual impairment, and racial/ethnic minorities were less likely to use eye care and/or afford eyeglasses irrespective of survey year.

Meaning

While decreased difficulty affording eyeglasses may reflect post–Great Recession economic recovery and/or health care reform–related changes among Americans overall, these results suggest women, individuals with visual impairment, and racial/ethnic minorities may still be more likely to face difficulties in using and/or affording eye care.

This analysis of National Health Interview Survey data reports trends in using eye care and affording eyeglasses among US adults between 2008 and 2016.

Abstract

Importance

Understanding eye care use over time is essential to estimate continued unmet health care needs and help guide future public health priorities.

Objective

To update trends in using eye care and affording eyeglasses in the United States.

Design, Setting, and Participants

This analysis of data from the US National Health Interview Survey included adults 18 years and older from 9 annual cross-sectional population-based samples ranging in size from 21 781 to 36 697 participants from 2008 to 2016. Data were analyzed from August 2017 to February 2018.

Exposures

Visual impairment, defined as self-reported difficulty seeing despite wearing eyeglasses.

Main Outcomes and Measures

Outcome measures included visits to an eye care professional and inability to afford eyeglasses when needed in the past year. Survey logistic regression, adjusted for age, sex, race/ethnicity, visual impairment status, education, employment, general health, poverty-income ratio, and vision insurance, was used to examine associations between survey year and eye care outcomes.

Results

Analyses included 9 annual cross-sectional population-based samples pooled from 2008 to 2016, ranging in size from 21 781 to 36 697 participants aged 18 years or older. Compared with 2008, greater proportions of the US population were 65 years or older, Hispanic, or Asian in 2016. There was a significant trend for eye care use and difficulty affording eyeglasses from 2008 to 2016. In fully adjusted models, Americans were less likely to use eye care in 2014 compared with 2008 (odds ratio [OR], 0.90; 99.9% CI, 0.82-0.98; P < .001). Compared with 2008, Americans were also less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.82; 99.9% CI, 0.69-0.97; P < .001; 2015: OR, 0.81; 99.9% CI, 0.69-0.96; P < .001; 2016: OR, 0.70; 99.9% CI, 0.59-0.82; P < .001). After adjusting for all covariates, including survey year, those with visual impairment compared with those without were more likely to use eye care (OR, 1.54; 99.9% CI, 1.45-1.65; P < .001) but had greater difficulty affording eyeglasses (OR, 3.86; 99.9% CI, 0.58-0.72; P < .001). Women were also more likely to use eye care (OR, 1.42; 99.9% CI, 1.37-1.48; P < .001) and report difficulty affording eyeglasses (OR, 1.68; 99.9% CI, 1.56-1.81; P < .001) compared with men. Compared with non-Hispanic white individuals, black, Asian, and Hispanic individuals were less likely to use eye care, and Asian and black individuals were less likely to have difficulty affording eyeglasses.

Conclusions and Relevance

These data indicate decreased difficulty affording eyeglasses among Americans from 2014 to 2016, possibly related to economic recovery and health care reform. However, the findings suggest women and racial/ethnic minorities are more likely to have lower use of eye care or inability to afford eyeglasses.

Introduction

Visual impairment (VI) has negative implications at the individual, community, and national levels. Prior studies have shown that VI is associated with diminished daily functioning,1 loss of independence,1 and worse health outcomes.2,3 Aside from the adverse health implications, the economic burden of VI is high, costing the United States $5.5 billion each year.4

While improvement of the country’s eye and vision health is a priority, as highlighted in national disease prevention initiatives like the Healthy People 2020 campaign,5 prior research has shown that substantial barriers exist for Americans to access, use, and afford eye care.6,7 Furthermore, studies have also shown that individuals with VI experience greater problems with health care access, including obtaining medical and dental care and prescription medications, owing to higher costs of care, limited insurance coverage, transportation barriers, and more instances of refusal of care by health care professionals.8

Understanding changes in using eye care and affording eyeglasses for Americans over time, especially in light of recent health care reforms over the past decade, is essential to estimate any continued unmet health care needs of this population and help guide future public health priorities. Here, we analyzed nationally representative data from the National Health Interview Survey (NHIS) over a 9-year period from 2008 to 2016 to update trends in using eye care and affording eyeglasses in the United States. We additionally used stratified analyses to examine differential use and affordability by VI status.

Methods

Study Population

The NHIS uses cross-sectional, multistage probability samples of the US civilian noninstitutionalized population, conducted annually through in-person household interviews by the US Centers for Disease Control and Prevention National Center for Health Statistics.9 Of note, the NHIS is not a longitudinal study, and participants from one year are not necessarily surveyed in subsequent years. The National Center for Health Statistics Institutional Review Board approved the protocols for the conduct of NHIS, and interviewers obtained verbal informed consent from all participants. We limited our analysis to the adult sample populations from the NHIS 2008 to 2016 cycles.

Outcome Measures

Eye care use measures were based on self-report. These outcome measures included 2 outcome variables: (1) eye care use, defined by response to the question, “During the past 12 months, have you seen or talked to an optometrist, ophthalmologist, or eye doctor (someone who prescribes eyeglasses) about your own health?” and (2) eyeglasses affordability, defined by response to the question, “During the past 12 months, was there any time when you needed eyeglasses, but didn’t get it because you couldn’t afford it?” (this is a 2-part question because only those who needed eyeglasses and had trouble affording them were classified as having difficulty affording eyeglasses).

Other Measures

Sociodemographic characteristics (ie, age, sex, race/ethnicity, education, employment, poverty-income ratio [PIR], general insurance coverage, and vision insurance coverage) and health characteristics (ie, smoking, diabetes, general health, and VI status) were also collected. Visual impairment was defined as present if participants responded yes to the question, “Do you have any trouble seeing, even when wearing glasses or contact lenses?” Participants were coded as having vision insurance if they answered yes to having a single-service plan for vision care. Educational attainment was categorized as less than high school, high school graduate or general equivalency diploma, some college, and college graduate or higher. Employment status was categorized as not working, looking for work, and working. Poverty-income ratio, an income index in relation to federal poverty thresholds, was used to designate socioeconomic status.10 A PIR score of 1.00 represents the official federal poverty threshold level; PIR was categorized as less than 1.00, 1.00 to 1.99, 2.00 to 3.99, and 4.00 or greater. General health was coded as good health if self-reported health status was excellent, very good, or good and as poor health if reported as fair or poor.

Statistical Analysis

The cross-sectional design of the NHIS does not permit longitudinal analysis, as the same individuals are not sequentially followed up over time. Instead, the health information collected can be trended over time for the country as a whole, as other NHIS-based studies have done.11 Here, we assessed trends in eye care use and eyeglasses affordability from 2008 to 2016, anchored to a baseline year (2008) to allow year-to-year comparisons.

Sociodemographic and health characteristics were summarized from 2008 to 2016 as weighted percentages. Categorical variables were compared using χ2 test, and unadjusted survey logistic regression models were used to examine trends in eye care use and eyeglasses affordability over the study period. Fully adjusted multivariable survey logistic regression models, including the covariates survey year, age, sex, race/ethnicity, education, employment status, PIR, general health status, VI status, and vision insurance status, were used to examine associations between survey year and each eye care outcome separately. Additional analyses were conducted stratified by self-reported VI status.

Covariates were included based on clinical relevance and/or previous demonstration of an association with eye care use. We conducted a sensitivity analysis adding diabetes status into our fully adjusted models (not shown) and noted no changes in our estimates. All analyses accounted for the complex survey design of the NHIS. Taylor series linearization was used for variance estimation.12 Given the large sample size, to keep estimates conservative, we used 99.9% confidence intervals. All P values were 2-tailed, and statistical significance was set at a P value less than .001. All analyses were conducted in Stata version 14 (StataCorp).

Results

Population Characteristics

Analyses included 9 annual cross-sectional population-based samples pooled from 2008 to 2016, ranging in size from 21 781 to 36 697 participants aged 18 years or older. Compared with 2008, greater proportions of the US population were 65 years or older, Hispanic, and Asian in 2016. They were also more likely to have completed college or higher, public health insurance, and vision coverage and less likely to be working and smoke (Table 1).

Table 1. Population Characteristics Across Years in Weighted Percentages.

Characteristic % P Value
2008 2009 2010 2011 2012 2013 2014 2015 2016
No. 21 781 27 731 27 157 33 014 34 525 34 557 36 697 33 672 33 028 NA
Age category, y <.001
18-<27 17 16 16 16 16 16 16 16 16
27-<40 23 23 23 23 22 22 22 22 23
40-<65 44 44 44 44 44 43 43 43 42
≥65 17 17 17 17 18 18 19 19 20
Female 52 52 52 52 52 52 52 52 52 .99
Race/ethnicity <.001
Non-Hispanic white 69 69 69 68 67 67 66 66 65
Black 12 12 12 12 12 12 12 12 12
Asian 5 5 5 5 5 6 6 6 6
Other 1 1 1 1 1 1 1 1 1
Hispanic 14 14 14 14 15 15 15 16 16
Education <.001
<High school 15 15 14 14 14 14 13 13 12
High school graduate/GED 28 28 27 27 26 26 26 25 25
Some college 20 20 20 20 21 20 20 20 20
≥College graduate 37 37 39 39 39 40 41 43 43
Working status <.001
Not working 32 33 32 33 33 34 34 34 35
Looking for work 4 6 7 7 6 6 5 4 4
Working 64 61 61 60 61 61 61 61 61
Poverty-income ratioa <.001
<1.00 12 13 14 14 15 14 14 12 13
1.00-2.99 31 33 33 33 33 34 34 33 32
3.00-3.99 16 15 15 15 14 14 15 14 14
≥4.00 41 39 38 38 38 38 37 40 41
Insurance type <.001
None 16 18 18 17 17 16 13 10 9
Private only 57 55 54 54 53 53 54 55 54
Public only 18 19 20 21 21 22 25 26 28
Both private and public 9 9 9 9 9 9 9 9 9
General health status .36
Fair or poor 13 13 13 13 13 13 13 13 13
Good, very good, or excellent 87 87 87 87 87 87 87 87 87
Diabetes 9 10 10 10 10 11 11 11 12 <.001
Smoking <.001
Never 58 57 59 59 60 60 61 63 62
Former 22 22 22 22 22 22 22 22 22
Current 21 21 19 19 18 18 17 15 16
Visually impaired 11 9 9 9 9 9 9 9 10 <.001
Blind (among those with visual impairment) 4 4 5 5 6 5 4 3 4 .004
Vision insurance present 15 15 16 16 17 18 18 19 20 <.001
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Abbreviations: GED, general equivalency diploma; NA, not applicable.

a

Poverty-income ratio, an income index in relation to federal poverty thresholds, was used to designate socioeconomic status. A poverty-income ratio score of 1.00 represents the official federal poverty threshold level.

Eye Care Use in the Full Population

In unadjusted analyses, the trends for eye care use and difficulty affording eyeglasses were significant from 2008 to 2016 (Figure 1) (eFigures 1 and 2 in the Supplement). In other unadjusted analyses, further exploring differences in each survey year compared with 2008 (where 38.6% of Americans visited an eye care professional), a slight increase in eye care use was noted from 2015 onwards (2015: 40.5%; P < .001; 2016, 41.7%; P < .001). Compared with 2008, where 8.0% of Americans reported difficulty affording eyeglasses, a decrease in difficulty was seen from 2014 onwards (2014: 6.5%; P < .001; 2015: 6.4%; P < .001; 2016: 5.6%; P < .001).

Figure 1. Use of Eye Care Services and Difficulty Affording Eyeglasses.

Figure 1.

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Percentage of the US population that self-reported that they visited an eye care professional in the past year and that they were unable to afford eyeglasses when needed in the past year. Error bars indicate 99.9% CIs.

In fully adjusted models, compared with 2008, Americans were less likely to use eye care in 2014 (odds ratio [OR], 0.90; 99.9% CI, 0.82-0.98; P < .001) (Table 2). Also, compared with 2008, Americans were less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.82; 99.9% CI, 0.69-0.97; P < .001; 2015: OR, 0.81; 99.9% CI, 0.69-0.96; P < .001; 2016: OR, 0.70; 99.9% CI, 0.59-0.82; P < .001).

Table 2. Multivariable Regression Analysis in Full Population.

Characteristic Reference Eye Care Visit in Past Yeara Difficulty Affording Eyeglassesa
OR (99.9% CI) P Value OR (99.9% CI) P Value
Survey year
2009 2008 0.99 (0.90-1.09) .70 1.09 (0.93-1.28) .07
2010 2008 0.97 (0.89-1.05) .22 1.11 (0.96-1.30) .02
2011 2008 0.95 (0.88-1.03) .05 1.04 (0.89-1.21) .39
2012 2008 0.94 (0.86-1.03) .02 0.98 (0.84-1.15) .74
2013 2008 0.93 (0.86-1.01) .01 0.93 (0.78-1.09) .13
2014 2008 0.90 (0.82-0.98) <.001 0.82 (0.69-0.97) <.001
2015 2008 0.98 (0.90-1.08) .54 0.81 (0.69-0.96) <.001
2016 2008 1.02 (0.94-1.11) .41 0.70 (0.59-0.82) <.001
Age, y
27-<40 18-<27 0.81 (0.75-0.86) <.001 1.25 (1.09-1.43) <.001
40-<65 18-<27 1.32 (1.24-1.40) <.001 1.76 (1.55-1.99) <.001
≥65 18-<27 2.95 (2.73-3.19) <.001 0.53 (0.45-0.62) <.001
Female Male 1.42 (1.37-1.48) <.001 1.68 (1.56-1.81) <.001
Race/ethnicity
Black Non-Hispanic white 0.87 (0.82-0.92) <.001 0.86 (0.77-0.96) <.001
Asian Non-Hispanic white 0.82 (0.75-0.89) <.001 0.68 (0.57-0.81) <.001
Other Non-Hispanic white 0.93 (0.76-1.13) .20 0.97 (0.71-1.34) .79
Hispanic Non-Hispanic white 0.81 (0.76-0.86) <.001 0.96 (0.87-1.06) .22
Education
High school graduate/GED <High school 1.31 (1.22-1.41) <.001 0.95 (0.86-1.05) .11
Some college <High school 1.71 (1.58-1.85) <.001 1.10 (0.99-1.22) .004
≥College graduate <High school 1.95 (1.80-2.11) <.001 0.91 (0.82-1.01) .003
Poverty-income ratiob
1.00-2.99 <1.00 1.17 (1.09-1.25) <.001 0.83 (0.76-0.90) <.001
3.00-3.99 <1.00 1.42 (1.31-1.53) <.001 0.44 (0.39-0.50) <.001
≥4.00 <1.00 1.76 (1.64-1.90) <.001 0.19 (0.17-0.22) <.001
Working status
Looking for work Not working 0.70 (0.63-0.77) <.001 1.97 (1.72-2.25) <.001
Working Not working 0.83 (0.79-0.87) <.001 1.19 (1.09-1.29) <.001
Good general health Poor health 0.87 (0.82-0.93) <.001 0.48 (0.44-0.52) <.001
VI No VI 1.54 (1.45-1.65) <.001 3.86 (3.52-4.23) <.001
Vision insurance present No vision insurance 1.73 (1.65-1.83) <.001 0.65 (0.58-0.72) <.001
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Abbreviations: GED, general equivalency diploma; OR, odds ratio; VI, visual impairment.

a

Adjusted for survey year, VI, age, sex, race/ethnicity, education, poverty-income ratio, general health, and vision insurance.

b

Poverty-income ratio, an income index in relation to federal poverty thresholds, was used to designate socioeconomic status. A poverty-income ratio score of 1.00 represents the official federal poverty threshold level.

Compared with those aged 18 to 27 years, Americans aged 27 to 40 years reported less eye care use, while older age categories reported greater use. Compared with those aged 18 to 27 years, those aged 27 to 40 years and 40 to 65 years had greater difficulty affording eyeglasses, while the oldest age group (aged 65 years or older) had less difficulty. Black, Asian, and Hispanic individuals were less likely to use eye care than non-Hispanic white individuals, and Asian and black individuals were less likely to have difficulty affording eyeglasses. Increasing education compared with less than high school education was associated with greater eye care use. Increasing socioeconomic class, as indicated by PIR levels, was associated with greater eye care use and less difficulty affording eyeglasses compared with those with a PIR less than 1.00. Better general health compared with worse general health was associated with lower eye care use and less difficulty affording eyeglasses. Working Americans as well as those looking for work were less likely to use eye care and more likely to have difficulty affording eyeglasses compared with those neither working nor looking to work (Table 2).

Americans with insurance for vision care were more likely to use eye care and less likely to report difficulty affording eyeglasses. Women were more likely to use eye care but also more likely to report difficulty affording eyeglasses than men. Similarly, those with self-reported VI were more likely to use eye care but also substantially more likely to report difficulty affording eyeglasses than those without VI (Table 2).

Eye Care Use by VI Status

In unadjusted analyses, among Americans with self-reported VI, the trend in eye care use was not statistically significant (Figure 2A), but there was a significant trend in difficulty affording eyeglasses from 2008 to 2016 (Figure 2B). In the non-VI group, the trends for eye care use and difficulty affording eyeglasses were significant from 2008 to 2016. In other unadjusted analyses exploring differences in each survey year compared with 2008, there were no changes in eye care use among the VI group. However, among Americans without VI, increased use was noted from 2015 onwards (2015: 39.2%; P < .001; 2016: 40.4%; P < .001) compared with 37.2% in 2008. No significant changes in difficulty affording eyeglasses was seen from 2008 to 2016 in the VI group, while a decrease was seen in the non-VI group from 2014 onwards (2014: 4.9%; P < .001; 2015: 5.0%; P < .001; 2016: 4.2%; P < .001) compared with 6.1% in 2008.

Figure 2. Use of Eye Care Services and Difficulty Affording Eyeglasses by Visual Impairment (VI) Status.

Figure 2.

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A, Percentage of the US population that self-reported that they visited an eye care professional in the past year. B, Percentage of the US population that self-reported that they were unable to afford eyeglasses when needed in the past year. Error bars indicate 99.9% CIs.

In fully adjusted models, compared with 2008, there were no significant differences in use of eye care or eyeglasses affordability from 2009 to 2016 among Americans with self-reported VI (Table 3). Among the group without VI, Americans were less likely to use eye care in 2014 compared with 2008 (OR, 0.89; 99.9% CI, 0.81-0.97; P < .001). Americans without VI were also less likely to report difficulty affording eyeglasses from 2014 onwards (2014: OR, 0.77; 99.9% CI, 0.63-0.93; P < .001; 2015: OR, 0.80; 99.9% CI, 0.67-0.96; P < .001; 2016: OR, 0.67; 99.9% CI, 0.56-0.82; P < .001) compared with 2008.

Table 3. Multivariable Regression Analysis Stratified by Visual Impairment (VI) Status.

Characteristic Reference Eye Care Visit in Past Yeara Difficulty Affording Eyeglassesa
OR (99.9% CI) P Value OR (99.9% CI) P Value
With Self-reported VI
Survey year
2009 2008 1.06 (0.82-1.36) .44 1.25 (0.91-1.70) .02
2010 2008 0.94 (0.74-1.19) .41 1.17 (0.88-1.56) .07
2011 2008 0.97 (0.77-1.21) .62 1.15 (0.84-1.57) .15
2012 2008 0.95 (0.76-1.18) .41 1.06 (0.78-1.43) .54
2013 2008 0.99 (0.77-1.27) .88 1.15 (0.85-1.56) .12
2014 2008 0.95 (0.74-1.23) .55 1.01 (0.73-1.40) .89
2015 2008 1.05 (0.80-1.39) .52 0.88 (0.65-1.19) .16
2016 2008 1.06 (0.84-1.35) .40 0.77 (0.56-1.04) .004
Without Self-reported VI
Survey year
2009 2008 0.98 (0.88-1.08) .49 1.05 (0.88-1.26) .33
2010 2008 0.97 (0.89-1.06) .27 1.10 (0.93-1.31) .06
2011 2008 0.95 (0.87-1.03) .05 1.01 (0.86-1.20) .80
2012 2008 0.93 (0.85-1.03) .02 0.97 (0.82-1.15) .51
2013 2008 0.92 (0.84-1.00) .003 0.87 (0.72-1.05) .01
2014 2008 0.89 (0.81-0.97) <.001 0.77 (0.63-0.93) <.001
2015 2008 0.97 (0.89-1.07) .36 0.80 (0.67-0.96) <.001
2016 2008 1.01 (0.93-1.11) .60 0.67 (0.56-0.82) <.001
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Abbreviation: OR, odds ratio.

a

Adjusted for survey year, age, sex, race/ethnicity, education, poverty-income ratio, general health, and vision insurance.

Discussion

We examined trends in using eye care and affording eyeglasses among adults 18 years and older in the United States over a 9-year period using nationally representative data. Our results indicate that there was decreased difficulty affording eyeglasses from 2014 to 2016 compared with 2008 (Figure 1) (Table 2). While it is difficult to predict how meaningful these small changes are (unadjusted percentage, 8.0% in 2008 vs 5.6% in 2016), perhaps it is of substantial impact when extrapolated to a national level. No significant change in use of eye care services was noted from 2008 to 2016. Irrespective of survey year, Americans were generally more likely to see an eye care professional and less likely to experience difficulty affording eyeglasses if they were older, white, had higher levels of education and income, and had vision insurance. Women and Americans with VI were more likely to use eye care services but less likely to be able to afford eyeglasses when needed.

These results of vision health disparities by age, race/ethnicity, education, and income are consistent with previous studies.6,11,13 Of note is our finding that those with some college education had greater difficulty affording eyeglasses than those with less than high school education. Since this was a 2-part question, this finding may be because of fewer people with less than high school education needing or perceiving a need for eyeglasses. Alternatively, it may be that those with some college education are less likely to have insurance coverage while those with less than high school education may be more likely to be covered by Medicaid,14 which, depending on the state, may include coverage for eyeglasses.15 Another unexpected finding was that Asian and black individuals were less likely to report difficulty affording eyeglasses than non-Hispanic white individuals. It is possible that the relatively higher prevalence of myopia in Asian populations16 may mean that they are more likely to prioritize purchasing insurance that will cover their eyeglasses. However, it is hard to explain why black individuals may experience less difficulty. We also found that the oldest age group (aged 65 years and older) was the least likely to have difficulty affording eyeglasses, suggesting that this age group with high prevalence of presbyopia17 is likely purchasing inexpensive reading eyeglasses easily found in department stores in the United States. Additionally, Medicare Part B helps pay for corrective lenses following certain types of cataract surgery.18

Sex differences in health-seeking behavior and health care use have undergone considerable scrutiny.19,20 Chiang et al21 reported as early as 1990 that women had a substantially higher annual rate of eye care–related outpatient visits than men in the US. The finding that women were more likely to experience difficulty affording eyeglasses when needed than men despite being more likely to have visited an eye care professional that year may be because of complex sex disparities in income and economic decision making that are beyond the scope of this analysis.

Our finding that those with self-reported VI were also more likely to have seen an eye care professional while being more likely to have difficulty affording eyeglasses is in line with previous literature. Spencer et al8 showed that individuals with VI and blind individuals reported having more difficulty accessing health care, including necessary medical care, prescription medications, and dental care, from 2002 to 2004, citing financial and transportation barriers, inadequate insurance coverage, and service refusal by health care professionals. It might follow that these difficulties translate to procurement of prescription eyeglasses as well. This study highlights that while existing policies may allow those with VI to access an eye care professional, there is still a considerable gap in getting them the eyeglasses that they need.

Zhang et al20 reported that individuals with vision insurance were more likely than those without vision insurance to use eye care services, consistent with our findings. However, they were less likely to afford eyeglasses when needed. Vision insurance is usually purchased as a supplement to general medical plans to help offset costs of routine eye examinations, prescription lenses, and frames.20 It may be that vision insurance plans cover eye examinations more completely than the cost of prescription eyeglasses.

The Great Recession, a period of economic decline from 2007 to 2009, was associated with financial instability and consequent loss of health insurance for many Americans.22,23 We speculate that perhaps the decrease in difficulty affording eyeglasses observed in recent years may be related to post-recession economic recovery, although our analysis adjusted for income and employment. Another plausible explanation is the influence of the provisions of the Affordable Care Act (ACA) and 2014 Medicaid expansion. Recent data indicate declines in rates of uninsured Americans aged 18 to 64 years from 20% in 2013 to 12% in 2016.24 Shi et al25 predicted the potential effect of the ACA on racial/ethnic disparity in eye examination rates among working-age individuals with diabetes from 2014 to 2017 and forecasted improved but persisting racial disparity in eye examination rates. Our data also show an overall decrease in difficulty affording eyeglasses, although racial/ethnic and sex disparities persist. However, it is important to note that the ACA does not include adult vision care as a mandated essential health benefit category.26 It allows each state to define essential benefits for itself, and some states may have chosen benchmark plans that include vision care. Those covered by expanded Medicaid pursuant to the ACA are also entitled to the essential health benefits from the state’s benchmark plan, which may or may not include vision care and/or eyeglasses. Likewise, traditional Medicaid makes optometry services and eyeglasses optional benefits and, thus, state dependent.15 Therefore, to truly infer that the decrease in difficulty affording eyeglasses is related to passage of the ACA or Medicaid expansion requires state-specific analysis. Regardless, our data also suggest that any changes in the country’s health care policies and/or economic recovery may have afforded differential assistance by VI status, where those without VI experienced increases in ability to afford eyeglasses from 2014 onwards while those with VI did not.

Limitations

This study has limitations. First, our estimates of VI and eye care outcomes are based on self-reported data that are implicitly subject to recall bias. Additionally, since VI is self-reported, by definition, those individuals classified as having VI are more likely to have used eye care. Second, the NHIS study population does not include residents in long-term care facilities, the incarcerated, and persons on active duty, and therefore, results are not generalizable to them. Third, all participants, irrespective of the need for eyeglasses, were queried about difficulty experienced with affording eyeglasses when needed, meaning that the denominator not only included participants that did not have difficulty purchasing eyeglasses when needed but also participants who felt they did not need eyeglasses. This likely attenuated estimates of the proportion of participants reporting difficulty affording eyeglasses. Lastly, this affordability question does not provide detail on what proportion of individuals had difficulty affording eyeglasses for reading vs for distance, nor does it capture any difficulty around affording contact lenses. Additionally, the role of rates of cataract and refractive surgery on any changes in the need for, and therein the affordability of, eyeglasses remains to be elucidated.

Conclusions

In conclusion, we estimated trends in use of eye care and affordability of eyeglasses in the United States from 2008 to 2016 and noted decreased difficulty affording eyeglasses from 2014 to 2016 while finding continued unmet eye care needs among some subsets of Americans. While speculative, these results may reflect economic recovery after the Great Recession and/or health care changes owing to the ACA and Medicaid expansion. Marginalized populations continue to face difficulties with using and/or affording eye care. Since enhancing the affordability of eye care has not adequately changed whether certain groups use the care they need, focusing future health care priorities on further expanding the availability and accessibility of eye care in addition to making them more affordable to the most vulnerable may be important factors to consider.

Supplement.

eFigure 1. Use of eye care services shown by age category on a magnified scale.

eFigure 2. Difficulty with affording eyeglasses shown by age category on a magnified scale.

Click here for additional data file. (215.9KB, pdf)

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eFigure 1. Use of eye care services shown by age category on a magnified scale.

eFigure 2. Difficulty with affording eyeglasses shown by age category on a magnified scale.

Click here for additional data file. (215.9KB, pdf)

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