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Reducing Barriers and Increasing Access to Children’s Vision Care Services

Policy Date: 11/1/2011
Policy Number: 20116

In past policy statements, the American Public Health Association (APHA) has recognized the importance of children’s vision in 2 resolutions. One resolution addressed “vision screening with follow-up programs and/or vision examinations for all children prior to entry into school”[1] and the other focused on improving the identification and treatment of vision conditions in early childhood development to include a regular comprehensive eye examination schedule as opposed to just screening.[2] This new policy statement serves to reduce barriers and improve access to children’s vision care services, as well as incorporating results from current, seminal National Institutes of Health children’s vision studies.[3,4] The new resolution does not supersede, or call for archival of, former resolutions.

Vision disorders, including amblyopia, strabismus, and significant refractive errors, are the most prevalent disabling childhood conditions in the United States,[5,6] and 1 in 4 children have some form of vision problem.[7] Impaired vision can affect a child’s cognitive, emotional, neurological, and physical development by potentially limiting the range of experiences and kinds of information to which the child is exposed.[8] Childhood visual impairment is associated with developmental delays, lower educational attainment, and the need for special education and for vocational and social services, often into adulthood.[9]

Analysis of data from the Maternal and Child Health Bureau’s National Survey of Children With Special Health Care Needs indicates that children without health insurance were approximately 5 times more likely to have an unmet vision care need.[10] Furthermore, racial and ethnic disparities among insured and uninsured children are well documented, and vision-related services under Medicaid and the State Children’s Health Insurance Program vary significantly among states.[11,12] A review of health records from 9 states by the US Office of the Inspector General found that 60% of those states’ children on Medicaid did not receive vision screenings under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program, which is intended to screen, diagnose, and treat children for vision conditions at early, regular intervals.[13] Research also suggests that children are being screened at low rates and that those who are screened often do not receive the necessary follow-up diagnosis and treatment services,[7,14] which suggests a lack of coordination, consistency, and accountability for national and state vision programs.[15–17]
Evidenced-based vision screenings using testing instruments with high sensitivity can serve as a complement to early and periodic comprehensive eye examinations as an approach to diagnosing the vision and eye problems of children. However, such screening does not replace a comprehensive vision examination performed by an eye doctor.[18] The methodology of the National Eye Institute’s VIP study of preschool vision screening of children established a comprehensive eye examination performed by ophthalmologists and optometrists as the “gold standard.”[3] In this study, a comprehensive eye examination included established diagnostic examination procedures and tests used by optometrists and ophthalmologists in children’s examinations.[3]

The Patient Protection and Affordable Care Act creates a new system of state-based health insurance exchanges and mandates children’s vision care as an essential health benefit.[19] Similarly, APHA Policy Statement 201013, “American Public Health Association Child Health Policy for the United States,” states that “children should have access to developmentally appropriate, integrated health care (physical, mental, developmental, oral and vision) that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.”[20] Unfortunately, there is little or no coordination of existing vision care services in state health department programs, and many states do not require any vision screenings or eye examinations and follow-up services.[21,22]

Therefore, APHA recommends that—

1. The Health Resources and Services Administration (HRSA) through the Maternal and Child Health Bureau should allocate new resources to improve access and reduce barriers for comprehensive vision care services for all children. In addition, HRSA should increase resources to state health departments by expanding state performance measures to better coordinate, track, evaluate, and report on state vision screening and follow-up of comprehensive examinations and treatment through their state Title V (maternal and child health) programs.

2. The Centers for Medicare and Medicaid Services should ensure the availability and accessibility of all vision services as required health care under the Early Periodic Screening, Diagnostic, and Treatment prevention and treatment program by reassessing current regulations to improve the quality and outcomes of screening, diagnostic, and treatment services, and in addition by requiring states to report vision screenings and follow-up diagnosis and treatment services.

3. Both public and private insurance programs should designate comprehensive vision care for children birth to age 21 years as an essential standard benefit. Coverage should include comprehensive vision and eye health examination by an ophthalmologist or optometrist at regular intervals, as well as eyeglasses, contact lenses, and any other vision care services that are determined to be necessary.

4. All national professional vision-related associations should educate parents and health professionals about the importance of children’s vision care through culturally competent eye and vision health education and health promotion programs.

1. American Public Health Association. APHA Policy Statement 82-03: Children’s Vision Screening. 1982. Available at: Accessed January 10, 2011.
2.American Public Health Association. APHA Policy Statement 2001-1:
Improving Early Childhood Eyecare. 2001. Available at: Accessed January 10, 2011.
3. Vision in Preschoolers Study Group. Preschool vision screening tests administered by nurse screeners compared to lay screeners in the Vision in Preschoolers Study. Invest Ophthal Vis Sci. 2005;46:2639–2648.
4. Vision in Preschoolers Study Group. Comparison of preschool vision screening test as administered by licensed eye care professionals in the Vision in Preschoolers Study. Ophthalmology. 2004;111:637–650.
5. Improving the Nation’s Vision Health: A Coordinated Public Health Approach. Atlanta, GA: Centers for Disease Control; 2006. Available at: Accessed January 10, 2011.
6. Vitale S, Cotch M, Sperduto R. Prevalence of visual impairment in the United States. JAMA. 2006;295:2158–2164.

7. Donahue S, Johnson T, Ottar W, et al. Sensitivity of photoscreening to detect high-magnitude amblyogenic factors. J AAPOS. 2002;6:86–91.
8. What Is Vision Impairment? Atlanta, GA: National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention; 2004. Available at: Accessed December 2010.
9. National Eye Institute. Report of the Task Force on Vision Impairment and Its Rehabilitation. Washington, DC: National Eye Institute; 1998.
10. Data Resource Center for Child and Adolescent Health, Maternal and Child Health Bureau. The National Survey of Children With Special Health Care Needs, 2005-6. Rockville, MD: Health Resources and Services Administration, US Dept of Health and Human Services. Available at: Accessed January 2011.
11. Newacheck P, Stoddard J, Hughes D, et al. Health insurance and access to primary care for children. N Engl J Med. 1998;338:513–519.
12. Kemper A, Bruckman D, Freed G. Patterns of vision care among Medicaid-enrolled children. Pediatrics. 2004;113:190–196.
13. Office of Inspector General. Most Medicaid Children in Nine States Are Not Receiving All Required Preventive Screening Services. Washington, DC: Dept of Health and Human Services; May 2010.
14. Vision Council of America. A summary of medical literature on vision screenings and eye exams, 2004. Available at: Accessed January 2010.
15. Walker DK. Building a Comprehensive Child Vision Care System: A Report of the National Commission on Vision and Health. Alexandria, VA: National Commission on Vision and Health; 2009.
16. Kimel L. Lack of follow-up exams after failed school vision screenings: an
investigation of contributing factors. J Sch Nurs. 2006;22:156–162.
17. Longmuir SQ, Pfeifer W, Leon A, Olson RJ, Short L. Nine-year results of a volunteer lay network photoscreening program of 147,809 children using a photoscreener in Iowa.
Ophthalmology. 2010;117:1869–1875.
18. Prevent Blindness America. Our vision for children’s vision: a national call to action for children’s vision health, 2010. Available at: Accessed November 2010.
19. The Patient Protection and Affordable Care Act (PPACA), Pub L No. 111-148, Essential Health Benefits Requirements (D) (1) Section 1302; March 2010.
20. American Public Health Association. APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States. 2010. Available at: Accessed December 20, 2011.

21. Ciner EB, Dobson V, Schmidt PP, et al. A survey of vision screening policy of preschool children in the United States. Survey Ophthalmol. 1999;43(5):445–457.
22. National Association of Chronic Disease Directors. A Plan for the Development of State Based Vision Preservation Programs: Summary of a Retreat on Public Health Vision Preservation. Washington, DC: Prevent Blindness America and National Association of Chronic Disease Directors; 2005.