Impacts of Medicaid Vision Coverage on Eye Care Use, Out-of-Pocket Spending, and Diagnoses Among Duals

• In Event: Tracking policy changes and health impacts of access to specific forms of care among Medicaid populations

Abstract

Vision problems are prevalent among older adults, with 92% of Medicare enrollees ages 65 and older using vision correction, and 39% of Medicare enrollees who use vision correction reporting trouble seeing even with eyeglasses. Fee-for-service Medicare covers medically necessary treatments for eye disease, but generally does not cover routine eye exams or glasses for refraction. While many Medicare Advantage plans cover some vision services, this coverage is often incomplete involving substantial out-of-pocket costs. These cost barriers may prevent Medicare enrollees from maintaining up-to-date vision correction. Furthermore, several systemic health conditions including hypertension, hypercholesterolemia, and coronary heart disease, among others, can be identified during a routine eye exam. Therefore lack of routine eye care may represent a missed opportunity to identify and treat early-stage systemic health issues.

We examine the impacts of Medicaid coverage of routine vision services among dual Medicare and Medicaid enrollees (“dual eligibles”) using 2002-2019 data from the Medicare Current Beneficiary Survey (MCBS). The MCBS includes self-reported survey data and claims-enhanced event files that allow us to examine eye care services use and associated out-of-pocket spending. We estimate two-way-fixed effects models and also examine the results of newer methods that account for variation in treatment timing.

Our main findings from the survey file indicate that Medicaid routine vision benefits are associated with a significant 6.0 percentage point increase in self-reported eye exams, or a 12% increase relative to the sample average rate (49%). We also find a significant increase of 4.4 percentage points in current use of eyeglasses, or a 6% relative increase. Our findings from the claims-enhanced event files provide supportive evidence of significant increases of 3.2 and 4.9 percentage points in calendar year optometry and glasses events, respectively. In terms of spending on glasses, we find that routine vision benefits are associated with a significant increase in any Medicaid spending and an increase in continuous Medicaid spending of about 17.1 log points. We find about a 5.0 log point reduction in out-of-pocket spending (P<0.10).

Finally, we examine the association between routine vision benefits and past-year diagnoses of hypertension, hypercholesterolemia, and coronary heart disease (CHD), all of which can be identified during a routine eye exam and also had consistent data across a number of years in the MCBS. We find some evidence supportive of an increase in past-year hypertension and CHD diagnoses.

In robustness and extension analyses, we generally do not find evidence of violations of the parallel trends assumption and results are generally similar when using alternative difference-in-differences estimators or when including pandemic years (2020-2021). We find some evidence that more frequent vision benefits (i.e., offering exams and glasses more vs. less frequently than every 2 years) are associated with larger impacts. Moreover, in subgroup analyses, we find that vision benefits increase use of eye care among most groups with differences generally not being statistically significant.

These findings indicate that Medicaid routine vision benefits increase eye care access among dual eligibles and may have systemic health benefits beyond improving eyesight.

Author

• Brandy Lipton, University of California Irvine
  Presenting Author