Review Article
Risk Factors for Visual Impairment in an Uninsured Population and the Impact of the Affordable Care Act
Weixia Guo11, Maria A Woodward2, Michele Heisler3, Taylor Blachley2, Leah Corneail2, Jean Cederna2, Ariane D Kaplan2 and Paula Anne Newman Casey2*
1Department of Internal Medicine, University of Cincinnati, USA
2Department of Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center, USA
3Department of Internal Medicine, University of Michigan, USA
*Corresponding author: Paula Anne Newman Casey, Department of Ophthalmology and Visual Sciences, University of Michigan Kellogg Eye Center, USA
Published: 07 Dec, 2016
Cite this article as: Guo W, Woodward MA, Heisler M,
Blachley T, Corneail L, Cederna J, et al.
Risk Factors for Visual Impairment in an
Uninsured Population and the Impact
of the Affordable Care Act. Clin Surg.
2016; 1: 1236.
Abstract
Purpose: To assess risk factors for visual impairment in a high-risk population of people: those without medical insurance. Secondarily, we assessed risk factors for remaining uninsured after
implementation of the Affordable Care Act (ACA) and evaluated whether the ACA changed
demand for local safety net ophthalmology clinic services one year after its implementation.
Methods: In a retrospective cohort study of patients who attended a community-academic
partnership free ophthalmology clinic in Southeastern, Michigan between September 2012 - March
2015, we assessed the prevalence of presenting with visual impairment, the most common causes
of presenting with visual impairment and used logistic regression to assess socio-demographic
risk factors for visual impairment. We assessed the initial impact of the ACA on clinic utilization.
We also analyzed risk factors for remaining uninsured one year after implementation of the ACA
private insurance marketplace and Medicaid expansion in the state of Michigan.
Results: Among 335 patients, one-fifth (22%) presented with visual impairment; refractive error was
the leading cause for presenting with visual impairment. Unemployment was the single significant
risk factor for presenting with visual impairment after adjusting for multiple confounding factors
(OR = 3.05, 95% CI 1.19-7.87, p=0.01). There was no difference in proportion of visual impairment
or type of vision-threatening disease between the insured and uninsured (p=0.26). Seventy six
percent of patients remained uninsured one year after ACA implementation. Patients who were
white, spoke English as a first language and were US Citizens were more likely to gain insurance
coverage through the ACA in our population (p≤ 0.01). There was a non-significant decline in the
mean number of patient treated per clinic (52 to 43) before and after ACA implementation (p=0.69).
Conclusion: Refractive error was a leading cause for presenting with visual impairment in this
vulnerable population, and being unemployed significantly increased the risk for presenting with
visual impairment. The ACA did not significantly reduce the need for our free ophthalmology
services. It is critically important to continue to support safety net specialty care initiatives and
policy change to provide care for those in need.
Keywords: Ophthalmology; safety net clinic; Charity care; Affordable Care Act; Uncorrected refractive error; Risk factors for visual impairment; Poverty
Introduction
Prior to full implementation of the ACA in early 2014, 49 million United States (US) residents
were uninsured [1], with 1.1 million uninsured residing in Michigan [2]. While 11.7 million adults
gained insurance through the ACA nationwide over its first two open enrollment periods in 2014
and 2015, 37.3 million remain uninsured in the US and approximately 0.3 million remained
uninsured in Michigan [2,3]. Visually impaired adults in the US are more likely to lack insurance
coverage than non-visually impaired adults, with an estimated 1.5 million visually impaired US
adults without insurance coverage [4].
In US in 2015, a total of 1 million people were blind, and approximately 3.22 million people
were visually impaired. An additional 8.2 million people had visual impairment due to uncorrected
refractive error. As the population ages, these numbers are projected to double by 2050 with estimates
of 2 million people blind, 7 million people with visual impairment and 16.4 million with visual
impairment due to uncorrected refractive error [5,6]. Older adults
and minorities are currently, and will continue to be, disparately
affected by visual impairment [5,7]. A few global and national studies
have identified various risk factors for visual impairment, including:
older age [5,8-11], time since last eye exam [8], lower educational
attainment [8,9,12], living in a rural area [9,11], being unemployed
[9], and being of lower socioeconomic status [10-13].
In our academic-community-free clinic partnership to provide
free ophthalmic care to the uninsured from two counties in Southeast
Michigan, we had the opportunity to assess risk factors for visual
impairment in a local high-risk population of people: those without
medical insurance. We also assessed risk factors for remaining
uninsured after ACA implementation and evaluated whether the
ACA changed demand for the safety net clinic services.
Figure 1
Figure 1
System for comprehensive vision care provided by a collaborative effort between the Hope Clinic and the University of Michigan, Department of
Ophthalmology.
Methods
Study population
The study population included all patients who were referred for
ophthalmic care at the free clinic between September 2012 – March
2015. In 2011, the University of Michigan began a partnership
with the Hope Clinic, a non-profit organization that provides free
primary care, dental care and social services to uninsured, lowincome
individuals in Southeast Michigan. Hope Clinic has two
sites, one in Ypsilanti, Washtenaw County, Michigan and one in
Westland, Wayne County, Michigan. The collaboration provides
ophthalmology referral services to patients seen through either Hope
Clinic site. Providing specialty care at the Hope Clinic itself is not
feasible as the clinic lacks necessary specialty equipment. Therefore,
the University allowed its physicians to volunteer to see Hope patients
in University clinics with full access to necessary equipment outside
standard hours.
Hope primary care physicians refer patients to the ophthalmology
clinic that occurs every two months on a Saturday. Referred patients
include those who have vision complaints, are at high risk for eye
disease including those with diabetes, a family history of glaucoma,
or high risk medication use such as Plaquenil. Patient charts are
brought from Hope Clinic for the University volunteer physicians,
and then Hope Clinic facilitates the implementation of physician
recommendations. Glasses are provided free of charge through
a partnership established between a local optical shop (Stadium
Opticians, Ann Arbor, MI) and the University. The frames are donated
by the university, and the lenses are made by the optical shop. Any
patients that require surgical intervention or complex medical care
meet with a financial counselor during the clinic to sign up for charity
care for the University if they are not eligible for insurance through
the marketplace or through Medicaid (Figure 1).
On January 1, 2014, people who had enrolled in private insurance
plans through the first open enrollment period (10/1/2013 –
2/15/2014) of the ACA became insured. On April 1, 2014, additional
patients gained coverage through Medicaid by Michigan’s Medicaid
expansion program, Healthy Michigan [6]. Healthy Michigan
expanded Medicaid coverage to those at or below 133% of the federal
poverty level ($16,000 for a single person or $33,000 for a family of
four) from 100% of the federal poverty level ($12,000 for a single
person or $24,800 for a family of four) [14]. Government subsidies
were available on the private insurance marketplace for those people
earning up to 400% of the federal poverty level. The second open
enrollment period for private insurance plans through the ACA was
November 15, 2014 – February 15, 2015. We divided our Hope Clinic
patient population into those who became insured and those who
remained uninsured after two rounds of enrollment in the ACA and
the initiation of Healthy Michigan.
Measurements
At each visit, clinical testing included: visual acuity, manifest
refraction, pupillary response, extra ocular motility and alignment,
confrontation visual fields, intraocular pressure (Goldmann
applanation tonometry), slit lamp biomicroscopy and dilated fundus
exam (DFE). Visual fields (Humphrey 24-2) were performed if deemed
necessary by the ophthalmologist. Demographic data were abstracted
from the medical record and included: gender, age, race/ethnicity,
primary language, homelessness status, marital status, student status,
and residency status. Financial information was abstracted from each
subject’s financial questionnaire, a standard Hope Clinic intake form
and included: employment status, occupation, medical coverage,
monthly income, and number of dependents. Insurance status was
abstracted from the Hope Clinic medical record at the time of the analysis.
Main outcome measures
The main outcomes were rates of visual impairment (presenting
visual acuity < 20/40 in the better-seeing eye), prevalence of vision
threatening eye disease and risk factors for presenting with visual
impairment. Vision threatening eye disease was defined as any
ocular disease that could lead to visual impairment or blindness if
left untreated. Vision threatening diagnoses were grouped into 7
categories by an ophthalmologist (PANC). These included diabetes,
glaucoma, retina, refractive error, anterior segment disease, cataract,
and neuro-ophthalmology. The specific diagnoses included in
the categories are detailed in Appendix 1 (available online). We
separated the population into those who obtained insurance after
the implementation of the ACA and Healthy Michigan and those
who remained uninsured. Secondary outcomes included sociodemographic
risk factors for remaining uninsured after healthcare
expansion.
Data analysis
We summarized participant characteristics for the entire sample
using means and standard deviations for continuous variables and
frequencies and percentages for categorical variables. We used
Chi-square tests, Fisher exact tests and two-sample t-tests to assess
the associations between demographic characteristics and visual
impairment status. Logistic regression was used to predict the odds
of visual impairment using imputed data sets to account for missing
covariates. Odds ratios, confidence intervals, and p-values were
calculated by combining point estimates and variances from the
analysis on each imputed dataset. We plotted the number of patients
seen and percentage of patients requiring new glasses over time from
November 2011 to March 2015. Third order regression curves were
fit to the line graphs. We used Fisher exact tests, Chi-square tests, and
Wilcoxon-Mann-Whitney test to evaluate the association between
demographic characteristics and insurance status. All analyses were
performed using SAS, version 9.3 (SAS institute, Cary, NC).
IRB approval was obtained from the University of Michigan and
adheres to the guidelines of the Declaration of Helsinki.
Table 1
Table 1
Demographic characteristics by visual impairment (visual acuity of 20/40 or worse in best-seeing eye), N (column %) or Mean (SD).
Table 2
Figure 2
Figure 2
Number of patients seen and percent of patients requiring glasses at the Hope-Kellogg Clinic from November 2011 through March 2015. Time points A
and B represent the times at which ACA private insurance plans and Medicaid Expansion plans became effective, respectively.
Results
The study population included 335 participants, of whom 43%
were male (n=144) and the mean age was 56 years (±12 years). The
average no-show rate to the eye clinics was 18.4% (range 6.1%-
33.9%). Of the 335 participants, 168 (50%) were white, 84(25%) were
African/African-American, 38(11%) were Asian, 27(8%) were of
other ethnicities, including Hispanic and Middle Eastern and 18(6%)
had no recorded race/ethnicity. Ninety-one patients (27%) did not
speak English as their first language and 231(69%) were unemployed
(Table 1). Of these participants, 31 became insured before the ACA
programs were implemented. Of the 304 remaining participants, only
71 became insured through the ACA programs, leaving 233(76%)
uninsured more than one year after health insurance expansion. The
majority of patients who obtained health insurance were approved
for Medicaid (61%) while 39% became insured through the private
marketplace.
Visual impairment
Of the patients who presented to the Hope Ophthalmology Clinic,
75 (22%) were visually impaired. The top four primary diagnoses
of vision threatening eye disease were diabetes (142/335) (42.4%),
refractive error (57/335) (17.0%), cataract (45/335) (13.4%) and
glaucoma (33/335) (9.9%). Those with visual impairment were more
likely to have a diagnosis of glaucoma, cataract, refractive error or
anterior segment disease (p=.007). Though diabetics were the largest
category of patients with potentially vision-threatening disease,
they were not most likely to be visually impaired. Among the 142
patients with diabetes, 37 patients (26%) had diabetic retinopathy;
the majority of the retinopathy did not cause visual impairment.
Those who were visually impaired were more likely to be unemployed
(84% vs. 65%, p=0.002). There was no significant difference in the
likelihood of visual impairment by age, gender, homeless status,
marital status, income, race/ethnicity, citizenship or insurance status
(p >0.05 for all comparisons). Those who were unemployed had a
205% increased odds of being visually impaired compared to those
who were employed after adjusting for multiple confounding factors
in multivariable analysis [OR = 3.05, 95% CI 1.19-7.87, p=0.01]
(Table 2).
Insurance coverage
Though there was a trend demonstrating that fewer of those
with visual impairment gained insurance coverage, with 23% of the
uninsured population being visually impaired compared to 17% of
the insured population, this was not statistically significant (p=0.26),
(Table 1). Likewise, there was no significant difference among types
of vision-threatening disease between those who did and did not
become insured (p=0.16). However, there was an interesting trend
among glaucoma patients where the prevalence of glaucoma was
much lower (3%) among those who became insured compared to
those who did not (11%) (Table 1). Among those who became insured,
69% were white, 16.9% were African-American, 2.8% were Latino
and 1.4% were Asian compared to those who never became insured
among whom 45.5% were white, 28% were African-American, 3.0%
were Latino and 14% were Asian. White patients were significantly
more likely to obtain insurance coverage through the ACA (p< 0.01).
Patients who spoke English as a first language were more likely to
gain insurance coverage through the ACA (p=0.01) (Table 1). US
Citizens were more likely to gain insurance coverage through the
ACA compared to Permanent Residents (p< 0.01), (Table 1). There
was no difference in mean age, gender, homeless status, or marital
status between those who did and did not gain insurance coverage (p
>0.05), (Table 1).
Demand for free clinic services
Though there was a decline in the mean number of patients
treated per clinic (52 to 43) before and after health insurance coverage
expansion, this was not statistically significant (p=0.69) (Figure 2).
Additionally, the percent of patients in need of glasses at each visit
remained constant over time. Approximately one-third of patients
(38.4%) needed glasses prior to ACA implementation compared to
34.7% after (p=0.62) (Figure 2).
Discussion
One-fifth (22%) of patients who presented to the Hope
Ophthalmology clinic were visually impaired. Visual impairment
was most likely due to uncorrected refractive error, cataract or
glaucoma. Among this population at high risk for visual impairment
due to their limited financial means and lack of health insurance,
unemployment remained the single most important predictor of
presenting with visual impairment. Those who were unemployed
had more than double the odds of presenting with visual impairment
compared to those who were employed. In a population-based study
in Korea, Rim and colleagues also found a more than double the odds
of visual impairment among those who were unemployed (OR 3.3,
95% CI 1.0-10.9, p< 0.05) [9]. Employer sponsored health insurance
currently comprises two thirds (66.7%) [15], of all insurance in the
US, even after implementation of the Affordable Care Act. Alongside
having fewer financial resources to access insurance without being
employed, the lack of employer sponsored health insurance may also
be playing a role in making unemployment such a significant risk
factor for lacking health insurance.
About one-fifth (23%) of patients seen in this free clinic gained
insurance through the ACA. The majority (61%) of the patients who
became insured obtained insurance through Healthy Michigan, the
Michigan Medicaid expansion program, which is comparable to what
was seen on a state-wide level where 69% of those who became insured
during this time period did so through Medicaid expansion [3].
There was a non-significant trend demonstrating that fewer of those
people presenting with visual impairment gained insurance coverage
(23% of the uninsured population presented with visual impairment
compared to 17% of the insured population). There was also a trend
demonstrating that fewer of those patients with glaucoma gained
insurance coverage (11% of the uninsured population had glaucoma
compared to 3% of the insured population). Patients, who were white,
spoke English as a first language and were US. citizens were much
more likely to gain insurance coverage through the ACA compared to
racial/ethnic minority patients, non-native English speaking patients,
or patients who were permanent residents. These data demonstrate
that among a population of lower socio-economic status, there were
racial and ethnic disparities in access to health insurance even after
the implementation of the ACA.
Implementation of the ACA did not significantly decrease
demand for the free ophthalmology services over the study period.
Demand for glasses remained steady, with refractive error remaining
a leading cause of visual impairment both before and after ACA
implementation. Our study findings demonstrate that there is a
continued need for safety net clinic programs in our community,
especially among traditionally underserved populations.
While the number of patient visits to our free eye clinic program
began to trend downwards after the implementation of health care
expansion, the percent of patients in need of glasses remained steady.
Interestingly, we even had patients return for “glasses only” visits
after becoming insured. While Healthy Michigan offers eye exams
and new glasses every 24 months, private insurance only provides
glasses coverage as a separate add-on plan for an additional fee. In
Michigan during the 2013-2014 open enrollment periods, only 13%
of those who purchased insurance through the private marketplace
elected to purchase the separate vision care option [7]. Those with
Medicaid coverage for glasses face other barriers to obtaining glasses,
such as difficulty finding optical shops that accept Medicaid. Potential
barriers to using covered vision services is an area that requires more
in-depth research.
The issue of insurance coverage for spectacle correction is quite
important. Refractive error is the leading cause of correctable visual
impairment in the US, accounting for 80% of visual impairment
among people ≥12 years old [16]. Those with visual impairment due
to uncorrected refractive error report worse physical functioning,
general health, social functioning, mental health [17], and quality of
life [18,19]. Though these negative outcomes can be easily ameliorated
by spectacle correction, financial barriers keep many people from this
easy solution [20,21].
Providing an examination and glasses to every US citizen with
refractive error over the age of 40 would cost an estimated $5.5 billion
annually [16,22,23]. Uncorrected refractive error is estimated to lead
to a net productivity loss of at least $6.5 billion per year [23]. If we
attempt to add in the cost of unemployment compensation to the
net productivity loss for only one-quarter of those with uncorrected
refractive error, as we know that those people are much more likely
to face unemployment, we uncover an even larger financial burden.
Using the national average of $300/week x 26 weeks of unemployment
compensation, we find an additional burden of $35.7 billion, leaving
the system with $42.4 billion of unintended expenditures that could
be mitigated with $5.5 billion to correct refractive error. Uncorrected
refractive error is not only a burden to individuals, but also to society.
Therefore, in creating a program to attempt to address the vision
health needs of our local community, it was important to be able to
provide glasses for free or an affordable fee. The only way in which
we were able to consistently provide glasses was through the unique
public-private partnership we established between our university, a
local free clinic and a local optical shop. Collecting used glasses and
trying to re-dispense them was quite time consuming and led to suboptimal
refraction for each patient. Local charities did not have the
capacity to provide this volume of glasses. Our university optical shop
identified a community partner who was willing to donate glasses for
each patient, and Stadium Optical has now dispensed over 300 pairs
of glasses free-of-charge in the last four years.
Similarly, we found it imperative to be able to get patients
definitive treatment if needed. There was a higher prevalence of
patients who had glaucoma among those who did not gain insurance
coverage compared to those who did. Glaucoma is a chronic disease
that requires long-term treatments to mitigate the risks of blindness.
It is but one example of an ophthalmic disease that requires more
intensive treatment than can be provided in a screening clinic setting.
Therefore, we had patient financial counselors present who enrolled
patients in charity care if needed.
This academic-free clinic partnership was unique in that it
focused both on screening and helping patients obtain definitive
care. This program framework could be a paradigm that could be
replicated to provide vision care for other uninsured populations. In
this study, we found that there was still a significant need for free
ophthalmic services after the passage of health care reform. However,
many safety net clinics have faced threats to their funding sources
due to the perception that their services were no longer needed since
ACA implementation, and some free clinics have even had to close
their doors [24-26]. Continued funding for safety net clinic initiatives
to help uninsured patient’s access definitive ophthalmic treatment is
imperative in ameliorating needless visual impairment in the US.
This study had a number of limitations. Our population was
limited to those uninsured people who receive primary care from
the Hope Clinic, and is not representative of the entire uninsured
community in our state. We could not track visual acuity or disease
status outcomes in patients once they became insured as they generally
no longer attended our clinic. This study only assessed outcomes one
year after implementation of the ACA; outcomes may continue to
change as people have more continuous access to health insurance
and health care. We did not track the number of patients who came
for follow-up after being referred for more intensive medical or
surgical care; this is an area we plan to evaluate in the future.
Conclusion
Unemployment was a significant risk factor for living with visual impairment in a low-income population presenting to a free ophthalmology clinic. The most common reason to present with visual impairment was uncorrected refractive error. Uncorrected refractive error remains a serious challenge in the US. Uncorrected refractive error has a very simple solution, glasses, and yet for many people this simple solution remains out of reach. Policy change, insurance reform and free outreach programs must continue to work to ameliorate this needless cause of visual impairment.
Acknowledgment
National Eye Institute 1K23EY02532 (PANC), Research to Prevent Blindness (PANC), National Eye Institute K23EY023596 (MAW).
Appendix 1
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