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Research Navigator: We've Got You Covered- How People with Vision Loss Participate in America's Health Insurance Systems

Published March 24, 2017, Updated March 24 at 4:00PM EST


As of this writing, Friday afternoon, March 24, the decision by the President and the U.S. House leadership to pull the proposed "repeal and replace" bill and to not put it up for vote by the full House of Representatives today leaves the future of health care-related legislation uncertain at the very least. Advocates know, however, that the public policy process is inherently unpredictable and that we need to be prepared to make the most of any and all opportunities to address the policy objectives that are of importance to people who are blind or visually impaired. We expect that this edition of the Navigator will help all of us gain a better understanding of the health care landscape for people living with vision loss.


This edition of the Research Navigator focuses on the American health insurance system, including how people with vision loss make use of public and private health insurance options. Highlights include:

About This Series

Older couple talking with health worker

Older couple on couch talking with health worker

Welcome to the tenth edition of AFB's Research Navigator. This is a quarterly series - accompanying AFB's DirectConnect newsletter - from the AFB Public Policy Center. The purpose of this series is to keep you informed of user-friendly facts and figures and the latest research pertaining to people with vision loss. The series will also include the necessary background information so you may use the information most accurately. Have an idea for a Research Navigator topic? Want to know more about a statistic or line of research? Send your thoughts to AFB's Senior Policy Researcher, Rebecca Sheffield. Readers are also encouraged to check out AFB's Statistical Snapshots. This webpage is regularly updated with a wide variety of information and tools that address commonly asked questions about people with vision loss.

America's Health Insurance System

Health insurance has been a part of Americans' financial and personal lives since the Great Depression, when hospitals recognized a need for service plans to help patients manage risk while ensuring a guaranteed income (Morrisey, 2013). Today's health insurance system is infamously more complicated than those early systems of the 1930's, though some of the basic principles remain the same. By having people (and in some cases the government) regularly contribute into the healthcare system, whether or not they currently need care, the system is prepared to offer lower costs to those who do need care. Without insurance, unanticipated medical costs could be financially devastating, forcing people in crisis to choose between lifesaving care and catastrophic debt. Insurance companies also have the ability to negotiate prices for routine services and pharmaceuticals, leveraging market principles to bring down costs for enrollees. The government and other insurers' desire to keep costs down leads them to incentivize cost-saving programs like preventative care, screenings, and wellness programs.

American families acquire comprehensive health insurance in one of seven different ways:

  • through a current or former employer or union,
  • through direct purchase of insurance from an insurance company,
  • through TRICARE or other military health care,
  • through Medicare (for people 65 and over or those with certain disabilities),
  • through Medicaid, Medical Assistance, or other state-run government assistance plans for those with low incomes and/or disabilities,
  • through the Veterans Administration, and/or
  • through the Indian Health Service (U.S. Census Bureau, 2015).

Since health insurance is about balancing costs and managing risks, health insurance systems work best when many people are enrolled, especially younger, healthier people who rarely incur large health expenses. Following the enactment of the Patient Protection and Affordable Care Act (henceforth "Affordable Care Act") in 2010, as an effort to encourage people to participate in the insurance market, people without insurance have been at risk of financial penalties. However, for most categories of health insurance, there is no automatic enrolment process, and health care premiums are often high, despite efforts to control costs. Though 20.4 million more people now have insurance than in 2010 when the Affordable Care Act was enacted, a significant proportion of the U.S. population does not have comprehensive health insurance (especially younger, healthier people who feel they are less likely to need medical attention). According to the National Center for Health Statistics (2017), the rate of insurance in the United States (based on data from January to September of 2016) is approximately 91.2%, an all time high.

How do people with vision loss make use of the insurance system?

In the past, people with some preexisting conditions like diabetes could have been denied comprehensive coverage or required to pay much higher premiums because of their medical histories. The Affordable Care Act prevents insurers from denying coverage based on preexisting conditions; therefore, people with vision loss have equal access to all the health insurance programs previously listed. Estimates from the American Community Survey help us understand the extent to which enrollment rates for people with self-identified vision loss (and children whose parents/guardians have identified them as having vision loss) are insured in one or more of the various types of comprehensive insurance programs.

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans:

  • Overall, 91% of Americans with vision difficulty are insured (90% for those without vision difficulty**).
  • 94% of children (ages 0-18) with vision difficulty are insured (95% for those without vision difficulty).
  • 78% of young adults (ages 19-25) with vision difficulty are insured (84% for those without vision difficulty).,
  • 85% of working-age adults (ages 26-64) with vision difficulty are insured (87% for those without vision difficulty).
  • 99% of seniors (ages 65+) with vision difficulty are insured (99% for those without vision difficulty).

** - This is lower than the previously cited rate of 91.2% because it is based on data collected throughout the year during 2015, rather than the updated estimate from 2016.

Note: These age categories were selected to highlight age differences in insurance eligibility. State-run children's health insurance (CHIP) programs typically provide coverage for eligible children through age 18. The Affordable Care Act enabled young adults to stay on their parents' health insurance plans through age 25. Most seniors become eligible for Medicare at age 65.

Looking at ACS data from 2009-2015, we can see a positive trend beginning in 2014 (the year implementation of key provisions of the Affordable Care Act) with increasing rates of insurance for people with and without vision loss.

  • In 2009, 87% of people with vision loss were insured (85% of people without vision loss).
  • In 2010, 87% of people with vision loss were insured (84% of people without vision loss).
  • In 2011, 87% of people with vision loss were insured (85% of people without vision loss).
  • In 2012, 87% of people with vision loss were insured (85% of people without vision loss).
  • In 2013, 88% of people with vision loss were insured (85% of people without vision loss).
  • In 2014, 90% of people with vision loss were insured (88% of people without vision loss).
  • In 2015, 91% of people with vision loss were insured (90% of people without vision loss).

Employer-provided insurance

Many employers provide insurance to their employees at a better rate than the employees would pay for similar coverage on the open market. The Affordable Care Act established minimum requirements for quality and cost of employer-provided insurance for most employers. Although we know that many people with vision loss are not employed/not participating in the labor market, people with vision loss who are not employed may still be insured through a family member's employer-provided coverage.

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans with comprehensive health insurance:

  • Overall, 32% of those with vision difficulty have employer-provided insurance (60% for those without vision difficulty).
  • 35% of children (ages 0-18) with vision difficulty have employer-provided insurance (54% for those without vision difficulty).
  • 48% of young adults (ages 19-25) with vision difficulty have employer-provided insurance (67% for those without vision difficulty).
  • 38% of working-age adults (ages 26-64) with vision difficulty have employer-provided insurance (71% for those without vision difficulty).
  • 23% of seniors (ages 65+) with vision difficulty have employer-provided insurance (33% for those without vision difficulty).

Insurance purchased directly from an insurance provider

Physical evaluation of woman by doctor

Physical evaluation of woman by doctor

Individuals who are not employed or who work for an employer who does not offer coverage may choose to purchase insurance through exchanges or directly from insurance providers. The Affordable Care Act was designed to increase the quality, availability, and affordability of these types of insurance policies (in reality, data suggests the ACA has had mixed success in achieving these goals). The private insurance market also provides supplemental coverage for seniors receiving Medicare.

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans with comprehensive health insurance:

  • Overall, 19% of those with vision difficulty have insurance purchased directly from a provider/marketplace (15% for those without vision difficulty).
  • 7% of children (ages 0-18) with vision difficulty have insurance purchased directly from a provider/marketplace (8% for those without vision difficulty).
  • 16% of young adults (ages 19-25) with vision difficulty have insurance purchased directly from a provider/marketplace (15% for those without vision difficulty).
  • 12% of working-age adults (ages 26-64) with vision difficulty have insurance purchased directly from a provider/marketplace (14% for those without vision difficulty).
  • 19% of seniors (ages 65+) with vision difficulty have insurance purchased directly from a provider/marketplace (15% for those without vision difficulty).

TRICARE or other military-provided insurance

Tricare is overseen by the Defense Health Agency to provide civilian health benefits for military personnel, retirees, and their dependents, including some from the military's Reserve Component. Tricare includes a range of policies with varying eligibility requirements and coverage options, including supplemental options for seniors receiving Medicare. Learn more at https://www.tricare.mil/

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans with comprehensive health insurance:

  • Overall, 4% of those with vision difficulty have TRICARE or other military insurance coverage (3% for those without vision difficulty).
  • 3% of children (ages 0-18) with vision difficulty have TRICARE or other military insurance coverage (3% for those without vision difficulty).
  • 4% of young adults (ages 19-25) with vision difficulty have TRICARE or other military insurance coverage (4% for those without vision difficulty).
  • 3% of working-age adults (ages 26-64) with vision difficulty TRICARE or other military insurance coverage (3% for those without vision difficulty).
  • 5% of seniors (ages 65+) with vision difficulty have TRICARE or other military insurance coverage (6% for those without vision difficulty).

Medicare

Note: The three previously discussed insurance categories are considered private health coverage. Medicare and the remaining categories of insurance to be discussed in this report are forms of public health coverage. Unlike the previously discussed private insurance options, some public insurance options are based on individual eligibility and do not extend to family members.

Medicare Part A covers hospital and nursing facility care, hospice, lab tests, surgeries, and home healthcare. Medicare Part B is similar to traditional health insurance, covering doctors' visits, medical equipment, outpatient care, etc. Medicare coverage is available to people receiving Social Security benefits, including people under age 65 who have been receiving Social Security Disability benefits. Medicare recipients typically pay monthly premiums (adjusted based on financial need) as well as deductibles and coinsurance, and they have options for purchasing additional coverage.

Medicare is funded through two federal trust fund accounts: the Hospital Insurance Trust Fund and the Supplementary Medical Insurance Trust Fund. Taxpayers and beneficiaries contribute to these funds through payroll taxes, income taxes on Social Security benefits, and premiums for Medicare Part A and Medicare Part B.

The intricacies of Medicare eligibility, coverage types, and benefits are beyond the scope of this article; however, you can learn more at https://www.medicare.gov/ and at the Center for Medicare Advocacy's site http://www.medicareadvocacy.org/

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans with comprehensive health insurance:

  • Overall, 60% of those with vision difficulty have Medicare coverage (22% for those without vision difficulty).
  • 2% of children (ages 0-18) with vision difficulty have Medicare coverage (1% for those without vision difficulty).
  • 6% of young adults (ages 19-25) with vision difficulty have Medicare coverage (2% for those without vision difficulty).
  • 31% of working-age adults (ages 26-64) with vision difficulty have Medicare coverage (10% for those without vision difficulty).
  • 98% of seniors (ages 65+) with vision difficulty have Medicare coverage (96% for those without vision difficulty).

Medicaid, Medical Assistance, or other state-run government assistance plans for those with low incomes and/or disabilities

Medicaid and programs like it differ from state to state, using (in part) federal funds to provide healthcare coverage to people with low incomes and people with disabilities.

Each state must file a plan with the federal government to describe how it will administer its Medicaid and Children's Health Insurance Program (CHIP) programs. The federal government requires mandatory Medicaid eligibility for people meeting certain income and/or disability criteria. CHIP provides coverage for children and pregnant women whose incomes are low, but not low enough to qualify for Medicaid (again, eligibility and benefits differ from state to state).

States have options for expanding coverage to more people as well as for creating Medicaid waiver programs, which test out strategies for extending eligibility or benefits based on different criteria. In most states, school districts can request reimbursement for certain services provided to Medicaid-eligible students with disabilities. Since 2014, "Medicaid expansion" provisions in the Affordable Care Act have enabled participating states to serve adults under Medicaid who traditionally would have been ineligible due to somewhat higher incomes.

As with Medicare, Medicaid is a very complex healthcare system (really a set of 53 different state and district healthcare systems). For more information, visit https://www.medicaid.gov/

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans with comprehensive health insurance:

  • Overall, 40% of those with vision difficulty have Medicaid coverage (22% for those without vision difficulty).
  • 65% of children (ages 0-18) with vision difficulty have Medicaid coverage (41% for those without vision difficulty).
  • 42% of young adults (ages 19-25) with vision difficulty have Medicaid coverage (19% for those without vision difficulty).
  • 46% of working-age adults (ages 26-64) with vision difficulty have Medicaid coverage (16% for those without vision difficulty).
  • 30% of seniors (ages 65+) with vision difficulty have Medicaid coverage (14% for those without vision difficulty).

Veterans Administration (VA) Health Care

The Veteran's Health Administration is an integrated network of medical centers and clinics, serving 8.76 million veterans annually at over 1,700 sites. Anyone who served in active military service, excepting those who received dishonorable discharge, is likely to be eligible for VA health care benefits. Reserves/National Guard active duty service can also qualify someone for VA health care.

Once enrolled, most all veterans are allowed the same VA health care benefits. However, due to limited funds, enrollment in the VA health care system is based upon priority groups. Veterans who have more severe and service connected disabilities receive higher priority. Some veterans with higher incomes may be asked to pay copays, and some may not be eligible for enrollment. For helpful explanations, visit https://www.va.gov/health/

Under certain circumstances, the spouse/widow, caregiver(s), and dependent child(ren) of a qualifying veteran may be eligible for some VA healthcare benefits, including reduced/eliminated costs for medical supplies, office visits, and prescriptions.

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans with comprehensive health insurance:

  • Overall, 6% of those with vision difficulty have VA health care coverage (2% for those without vision difficulty).
  • 1% of children (ages 0-18) with vision difficulty have VA health care coverage (less than 0.5% for those without vision difficulty).
  • 1% of young adults (ages 19-25) with vision difficulty have VA health care coverage (0.5% for those without vision difficulty).
  • 5% of working-age adults (ages 26-64) with vision difficulty have VA health care coverage (2% for those without vision difficulty).
  • 10% of seniors (ages 65+) with vision difficulty have VA health care coverage (8% for those without vision difficulty).

Indian Health Service

Like the Centers for Medicare and Medicaid Services, the Indian Health Service (IHS) is a program within the U.S. Department of Health and Human Services, and like the Veterans health care system, the Indian Health Service provides care through its own network of programs specifically for American Indians and Alaska Natives. Over 60% of the funding for IHS is administered by the Native American and Alaska Native tribes. In situations where there is not an IHS facility nearby equipped to provide emergency/specialty care, patients meet stricter eligibility requirements can be served through a "purchased/referred care" relationship with a non-IHS provider. IHS has limited funding and therefore is the payer of last resort for non-IHS care. Learn more at https://www.ihs.gov/

Because the IHS has limited funding and is not an entitlement or insurance program with an established benefits package, the U.S. Census Bureau considers persons who have only Indian Health Service health care coverage to be uninsured.

The following estimates are from the 2015 American Community Survey, for civilian, non-institutionalized Americans with comprehensive health insurance:

  • Overall, 1% of those with vision difficulty have IHS coverage (less than 0.5% for those without vision difficulty).
  • 1% of children (ages 0-18) with vision difficulty have IHS coverage (0.5% for those without vision difficulty).
  • 1% of young adults (ages 19-25) with vision difficulty have IHS coverage (less than 0.5% for those without vision difficulty).
  • 1% of working-age adults (ages 26-64) with vision difficulty have IHS coverage (less than 0.5% for those without vision difficulty).
  • 0.5% of seniors (ages 65+) with vision difficulty have IHS coverage (less than 0.5% for those without vision difficulty).

What's Going on With Our Health Care?

Anyone who has turned on the news in the past three months knows that healthcare is a hotly debated topic - from the halls of the U.S. Congress to lively debates at your neighborhood pub (our office's favorite silly argument is "Get the government out of my Medicare!")

Recognizing that there are many opinions about the role of federal and state governments in our nation's health care system, we hope that the previously stated figures will be useful as we all consider the potential impacts of changes to the Affordable Care Act, Medicaid, Medicare, the VA, etc.

the American flag

The population of people with vision loss is predominantly older - therefore changes that impact Medicare and programs for seniors will certainly impact our field. Let us also remember that 30% of seniors with vision loss also depend on Medicaid, and 10% receive care through the VA system; in both cases these rates are disproportionally higher than for seniors without vision loss.

Children with vision loss also are much more likely than their sighted peers to benefit from Medicare and Medicaid - and school districts are using the Medicaid reimbursement system to help recover some of the costs of providing essential, health-related services which enable kids to attend school (as mandated by the Individuals with Disabilities Education Act). Cuts or caps on Medicaid will shift costs to states, and many states may be unable to maintain non-mandatory services which are vital to children and families.

Young and working-age adults with vision loss have lower insurance rates than the national average (particularly the 19-25 year-olds). As a field, we must investigate ways to educate and encourage enrollment in public/private healthcare programs to promote health and financial wellbeing across the lifespan.

For more details about the Affordable Care Act and about proposed changes/replacement plans, please check out the following resources:

If you feel strongly about health care (like we do!), we encourage you to get involved in local, state, and national advocacy efforts. The American Foundation for the Blind is a member of the Consortium for Citizens with Disabilities (CCD). Check out the CCD Health Taskforce's letters and advocacy materials at http://c-c-d.org/rubriques.php?rub=taskforce.php&id_task=6 , and also the CCD Long Term Services and Supports Taskforce materials at http://c-c-d.org/rubriques.php?rub=taskforce.php&id_task=9

AFB has been working in partnership with the American Council of the Blind and other organizations for many years to increase access to low vision devices through Medicare, especially for seniors, and we continue to look for opportunities to expand comprehensive insurance coverage to include essential technologies and services for people who are blind or visually impaired. Learn more by joining AFB's 21st Century Agenda on Aging and Vision Loss and/or read VisionAware's blog post on low vision devices from last summer (referring to a bill that was introduced but not passed in 2015/2016).


Many thanks to Shanna Gordon and Sarah Malaier for their contributions to this edition of the Research Navigator!


Please subscribe to the DirectConnect Newsletter to stay informed about updates to the Data Workbook (as well as to receive the quarterly Navigator and other important updates from the AFB Policy Center). To subscribe, go to http://www.afb.org/myafb.aspx and login in (if you have logged in before) or follow the link to "become a member" to create a newsletter account. Once you have an account and are logged in, follow the link to "Newsletters," check the box next to AFB DirectConnect, and click submit!

References

Morrisey, M. (2013). History of health insurance in the United States. In Health Insurance, (2nd ed.) (pp. 3-25). Chicago, IL: Health Administration Press. Retrieved from https://www.ache.org/pubs/Morrisey2253_Chapter_1.pdf

National Center for Health Statistics (2017). Health insurance coverage: Early release of estimates from the National Health Interview Survey, January - September 2016. Retrieved from https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201702.pdf

U.S. Census Bureau (2015). American Community Survey and Puerto Rico Community Survey 2015 subject definitions [PDF report]. Retrieved from https://www2.census.gov/programs-surveys/acs/tech_docs/subject_definitions/2015_ACSSubjectDefinitions.pdf

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