Uncorrected vision impairment and other untreated eye conditions can adversely impact quality of life. For children, vision is critical for the acquisition of skills that will be important for future human capital investments. Although the patterns of use and expenditures for adults are relatively well known,28-33
less is known about eye-care and vision services for children. According to the 1971–1972 National Health and Nutrition Examination Survey, depending on age, about 28 per 1,000 children 12–17 years old needed eye care and about 20 per 1,000 children were under such care.34
According to the 1979 National Health Interview Survey, children <17 years experienced about 133 eye care visits per 100 persons in the past year (compared to 149 for all ages).35
About 1% of 3 year-olds wore corrective lenses, but about 46% of females and about 29% of males aged19–21 years wore corrective lenses. About 19% of the total eye-care visits in 1979 were by children <17 years, with boys experiencing about 21% of the visits and girls 18%. About 19% of visits by Black patients were by children <17 years old (16% for White patients). More recently, Kemper, using the 1998 Medical Expenditure Panel Survey and the 2000 National Health Interview Survey, estimated that 25% of the 52.6 million children aged 6–18 years had corrective lenses.36
Girls were more likely to have corrective lenses, and among Black or Hispanic children, the insured were more likely to have corrective lenses than the uninsured. Hodges and Berk reported on the 1994 Robert Wood Johnson Access to Care Survey and found that 2% of children had an unmet need for eyeglasses (5.3% for the general population).37
Other than the studies cited here, which have focused on corrective lenses, we could not identify any more recent reports of eye-care use/expenditure patterns for children.*
The results of use and expenditure patterns, especially those stratified by socioeconomic factors, that we have presented above are needed to help policy-makers and clinicians plan for future delivery of children's eye and vision care services and assess progress toward Healthy People 2010 goals.1
This paper has presented a method for using a large and ongoing nationally representative survey of the health care experiences of United States residents — the Medical Expenditure Panel Survey — to describe the health care experiences of children < 18 years old with diagnosed or treated eye conditions. The MEPS provides information on the use of services, insurance status, employment factors, and health measures for sampled household members. This wealth of linked information provides an opportunity to conduct research that can provide a fuller understanding of children's use and expenditure patterns for eye care and non-eye care services
As expected, children with diagnosed eye conditions had higher overall and higher eye-related use and expenditure levels. This is consistent with previously reported findings reported above. However, we also found that children with diagnosed eye conditions had higher use and expenditure levels for non-eye related services, which we believe is a novel set of findings. These relationships were robust to controls for systemic and chronic illness, which may be correlated with eye conditions. We also found that average expenditures tended to be higher after excluding children whose only diagnosis was related to disorders of the conjunctiva, which is consistent with the increased likelihood that those remaining children are seen strictly by specialists rather than also by primary care physicians.
Not only do children with diagnosed eye conditions have increased expenditure levels, but families of those children also incurred higher out-of-pocket expenditures. We also found evidence of socioeconomic disparities. Black children and children living below 400% Federal Poverty Level had lower use and expenditure levels indicating, even after controlling for other socioeconomic and health measures, indicating that those children are receiving fewer and less intensive services. The generally higher use/expenditure levels for emergency department and inpatient services for black and less well-off children implies that those children are seeking both their eye and non-eye related services in settings rather than office-based or outpatient settings. Previously we found that white children and children living in higher income families had a higher likelihood of having a diagnosed condition indicating possible differential access to eye care services.8
Our additional findings reported here on use and expenditure disparities suggest not only some degree of under-diagnosis but also under-treatment among certain underprivileged groups of children. Given that it is unlikely that the eye conditions are inherently less common or less severe among certain groups, our findings on access disparities most likely confirm recent evidence from the National Health Interview Survey that most of the race/ethnicity and economic differences in health are due to disparities in access to care and screening.38
This is further supported by other evidence that income, access to care, and insurance are highly correlated.4
Although children with diagnosed eye and vision conditions can be identified in the MEPS and can be linked to their use of medical care in a straight-forward and reproducible way, there are a number of limitations to this project. Although the quantitative information we present on use and expenditure patterns are important for policy purposes, the MEPS did not contain information on the quality of the eye-related and non-eye-related services the children received, therefore we caution readers from making inferences about quality of services. Furthermore, even though we do find differences in use and expenditures between income groups, we do not suggest, necessarily, that the use and/or expenditure levels represent optimal levels for either group.
The identification of diagnosed eye conditions was not based on screening examinations, but rather on the presence of diagnosis codes and other information indicative of a condition.8
Although our estimates of the use and expenditure levels for the children identified here are unlikely to be biased (subject to the representativeness and quality of the MEPS data), they probably underestimate the number of children with eye conditions, and should be considered as lower use and expenditure estimates. Furthermore, since the presence of a diagnosis in the MEPS is mostly dependent on a health care event, there may be a tendency to identify more severe cases because a problem has to be serious enough to be diagnosed, possibly upwardly biasing the estimates of mean expenditure levels. However, since the focus of this paper is to examine the distribution of children's use and expenditure patterns, the broad definition of having an eye condition coupled with the health services information in the MEPS, is sufficient to indicate a diagnosed problem and a past or future need for some type of care.