Case Overview, Medicare Funding for Optometric Training

This document provides background information and summarizes the debate over funding for optometric training. The links to the left will lead you to public documents that we have found.


           One of the recurring problems in the federal financing of health care is reimbursement for medical providers who aren't M.D.'s. For podiatrists, dentists, chiropractors, and social workers, there has been an ongoing struggle to obtain federal funding for services provided or for better rates for reimbursement mechanisms that include these providers. Among these other health care professions are optometrists. Unlike ophthalmologists, who are M.D.'s specializing in care of the eye, optometrists are trained in their own graduate schools rather than in medical school. The primary job of optometrists is to assess and measure vision for eyeglass or contact lens correction. At the same time they're broadly trained and play a vital role in identifying eye diseases and routing their customers to ophthalmologists who can treat them. As a representative of the profession put it, "we're primary eye care providers, we're first contact providers. People go to the optometrist because they're available, around." He went on to note that in many small towns and rural areas there are no ophthalmologists, making it all the more important that optometrists receive the best training possible.

           A problem that rankles the optometry profession is that the federal government doesn't financially support their residency training. Part of the problem explained an industry spokesperson, is that "Physicians, dentists, podiatrists, have residency training-that's training after their [doctor degree] for specialty areas. Optometry has no specialty defined areas. So while we have residency training in areas of advanced competence, if you will, there are no licensing requirements for residency to get board certification in an area. We're not there yet."

           Since there is no immediate plans for changing residency training, optometrists decided to push ahead for federal support without this change in their graduate education. The American Optometric Association developed a lobbying strategy aimed at Medicare, the federal government's program for medical care for senior citizens. The organization did not believe it could get Health and Human Services (HHS), the department of the federal government that administers Medicare, to take initiative on its own support this residency training. An alternative approach, moving a separate piece of legislation going through the Congress, was unrealistic as well. Rather, the organization's strategy was to get legislative language inserted in a health-related bill that would indicate to administrators that Medicare money could be used for optometry training purposes.

           Getting such language into a health bill was no easy task because legislators might believe it necessary to reduce support for some other program to fund the optometrists' training. (Social scientists call this kind of tradeoff a "zero sum" game.) As one legislative aide to a Senator put it, "[you'd be] adding a new specialty practice into an already strained program." Moreover, ophthalmologists would put up a fight as they would see such a change as an opening for optometrists to acquire the expertise to allow them to compete directly with them for some eye care problems. In the end this push in the 107th Congress fell short and no new federal funding for optometry training emerged.