Understanding Our Shifting Health Insurance Landscape – and What It Means for People with Vision Loss

Guest blogger Rebecca Sheffield, Ph.D., is the Senior Policy Researcher with the American Foundation for the Blind (AFB) Public Policy Center in Washington, D.C. The AFB Public Policy Center collaborates with policy makers in Congress and the Executive Branch to ensure that Americans with vision loss have equal rights and opportunities to fully participate in society.

She also is the author of two important and helpful Public Policy Center publications: Research Navigator, a quarterly series that keeps readers informed of user-friendly facts and figures and the latest research pertaining to people with vision loss, and Statistical Snapshots, a one-stop, regularly updated source for statistical facts, figures, and resources about Americans with vision loss.

In this guest post, Dr. Sheffield explains the components of the American health insurance system, including how people with vision loss make use of public and private insurance options. You can read the full text of her remarks and research at Research Navigator: We’ve Got You Covered – How People with Vision Loss Participate in America’s Health Insurance Systems at the American Foundation for the Blind website.

America’s Health Insurance System

Please note: As of March 24, 2017, the decision by the President and the United States House leadership to pull the proposed American Health Care Act “repeal and replace” bill and not put it up for vote by the full House of Representatives leaves the future of health care-related legislation uncertain. 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.

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 1930s, 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 to bring down costs for enrollees. The government and other insurers’ desire to keep costs down provides an incentive for them to participate in cost-saving programs, such as preventive care, screenings, and wellness programs.

How Do People Acquire Health Insurance?

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 (VA), 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 enrollment 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, 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 (ACS) 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 ACS, 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).

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.

The population of people with vision loss is predominantly older; therefore, changes that impact Medicare and programs for seniors will certainly have an impact on 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:

The new administration has provided its take on coming changes to national health care policy: Providing Relief Right Now for Patients
The Henry J. Kaiser Family Foundation has published a range of non-partisan summaries in plain language, especially helpful for understanding the current healthcare debates:
- Summary of the Affordable Care Act (P.L. 111-148)
- Summary of the American Health Care Act (H.R. 1628) (introduced in the House of Representatives on March 6, 2017, updated with the latest amendments)
- Side-by-side comparison of key provisions of the Affordable Care Act and the American Health Care Act (as most recently amended).
Health Insurance Coverage for Americans with Pre-Existing Conditions: The Impact of the Affordable Care Act (PDF)
The Congressional Budget Office released an estimate of potential budgetary effects of the American Health Care Act (Updated as of March 23, 2017)
The Affordable Care Act: A Brief Summary (PDF): The National Conference of State Legislatures produced a two-page summary of the Affordable Care Act and its implications.
The Effect of the 2014 Medicaid Expansion on Insurance Coverage for Newly Eligible Childless Adults by the Rand Foundation.

How You Can Get Involved

If you feel strongly about healthcare (like we do!), we encourage you to get involved in local, state, and national advocacy efforts. The American Foundation for the Blind (AFB) is a member of the Consortium for Citizens with Disabilities (CCD). Check out the CCD Health Task Force’s letters and advocacy materials at CCD Task Force on Health and the CCD Long Term Services and Supports Task Force.

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 reading The Medicare Demonstration of Coverage for Low Vision Devices Act of 2015 Needs Your Advocacy and Support, which discusses a bill that was introduced, but not passed, in 2015/2016.

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Thank You to Dr. Rebecca Sheffield

We thank Dr. Sheffield for her skilled advocacy and research on behalf of blind and visually persons throughout the United States. You can email Dr. Sheffield at RSheffield@afb.net. You can keep in touch with ongoing research via the following resources: