“We have a fairly large Medicaid population here. There’s no industry, no jobs, no decent wages. Most people seem to work minimum wage fast food jobs. There’s one factory,” explains James Sawyer, OD. He’s been practicing in the town where he was born and raised—Monticello, KY (population, 6,116; median household income, $26,005)—for 32 years now, and he says his personal income has remained relatively flat since he first opened.¹ But, “coming back to my home town was a priority for me,” he says. So, he set up shop in an old grocery store, hired a staff of four and, when he’s not seeing patients, advocates for optometry by sitting on the Medicaid Optometric Technical Advisory Committee. It’s never been easy to encourage patients to come to the optometrist. If their coverage doesn’t include a new pair of glasses, he says, many don’t see the point in getting routine exams at all. He estimates approximately 60% of his patients receive Medicaid benefits.

Soon, though, he may be seeing fewer patients than ever, as the state adopts new rules cutting off vision benefits for routine services to Kentucky’s 450,000 patients impacted by expanded Medicaid coverage.

“I wish they’d come to Monticello for a while and see how people struggle to get by,” he says.

Short Sight

In a move the American Optometric Association (AOA) referred to as a “short-sighted and retaliatory choice,” Kentucky Governor Matt Bevin announced the cuts last week after a judge rejected his original health proposal. That original proposal would have required people to work or volunteer at least 20 hours a week and pay monthly premiums. The Bevin Administration told the Louisville Courier-Journal the suspension of vision benefits was “an unfortunate consequence of the judge’s ruling.”² The administration also made similar cuts to dental benefits.

Doctors fear removing these benefits could leave recipients in dire straits. “Often, medical issues are detected during routine visits the population will now likely forego since they are not covered,” explains Aaron McNulty, OD, who practices in Louisville, KY. Doctors themselves may also face some hard choices.

“I’ll probably have to look for another place to practice if Medicaid is not intact,” Dr. Sawyer says, adding that he’d likely be forced to shutter his solo private practice and work as an employee for a large group practice. “The patients will suffer, and I think it will end up costing the state a lot more in disability claims.” For example, he says if a patient loses vision because they missed preventable disease progression, that’ll take more people out of the workforce and qualify them for disability coverage.

In fact, diabetic retinopathy is one of the leading causes of blindness and in 2017, doctors of optometry diagnosed more than 400,000 cases of diabetic retinopathy in patients who did not know they had diabetes, the AOA says in a statement.

“We know that undiagnosed chronic systemic disease such as diabetes is a massive problem, not only for individual patients but for the healthcare system as a whole. In a largely rural state such as Kentucky, optometry has an extensive footprint (111 of 120 counties) and we are well equipped to reduce the cases of undiagnosed diabetes. This improves individual outcomes and saves money for the state in the long run,” says Dr. McNulty.

The federal government funds approximately 80% of the state’s $11 billion-a-year Medicaid program.

Organized Optometry

The decision has led to an outcry from optometric advocates and other groups, particularly the Kentucky Optometric Association (KOA), which was taken by surprise. “We were initially disappointed when the KY HEALTH waiver application was filed, and ‘routine vision benefits’ were treated as something that the able-bodied, adult population had to ‘earn,’” says KOA Executive Director Dinah Bevington. “Only after the KY HEALTH program was halted did we learn that the administration had actually filed a State Plan Amendment to the Medicaid plan in KY, which impacted covered adults. On April 23^rd, the administration filed the amendment to remove all routine vision services for the population, regardless. We were caught completely off guard when the KY HEALTH program was halted, yet we reverted back to a plan that had a substantial change—there was no longer routine vision coverage.”

Dr. Sawyer adds that organized optometry isn’t the only one who intends to challenge the governor’s decision. “The payers see the frustration—they’ve signed on to take care of their members, the patients of Kentucky, but the lack of knowledge about what the government is doing is tremendous.”

“The KOA will continue to advocate for patient access and will partner with the Cabinet to help get these services re-authorized as soon as possible,” says Ms. Bevington.

Dr. Sawyer believes with a little education about optometry, the governor will come around to reinstating the Medicaid benefits. “If the governor could come down to Wayne County and spend a week with us and see the needs of the people, he’d see the perspectives are completely different,” he says. “I hope common sense will prevail.”