California kids and Seniors are going without vision care, and the problem is getting worse

California kids are going without vision care, and the problem is getting worse | KPBS Public Media

INFORMED PROSTATE CANCER SUPPORT GROUP (IPCSG)

COMMUNITY HEALTH REPORT – ACCESS & EQUITY

 

Blind Spots: How Broken Insurance

Leaves Millions of Americans

Without the Vision Care They Need

From schoolchildren misdiagnosed as behavioral problems to seniors who cannot read their medication labels, the gap between what is legally required and what is actually delivered is widening – with consequences for learning, independence, and quality of life. New technology offers partial bridges across this gap, but system reform remains essential.

 

Prepared for the IPCSG Newsletter  |  April 2026  |  Based on published research, government data, and current legislation

 

BOTTOM LINE UP FRONT (BLUF): America faces a compounding vision care crisis. Myopia now affects an estimated 36% of U.S. children and is projected to worsen, yet only 16% of Medi-Cal-enrolled California children saw an eye doctor between 2022 and 2024. The coverage system is structurally broken at both ends of the age spectrum: Medicaid mandates eye care for children but provider reimbursement rates are so low that only ~10% of California optometrists accept it; Medicare explicitly excludes routine vision care for the 68 million seniors who depend on it. New federal legislation introduced in 2025 aims to fix the Medicare gap, but the same budget cycle enacted nearly $990 billion in Medicaid cuts, threatening the children's coverage that already exists in law but fails in practice. On a more hopeful note, emerging technologies — adjustable self-refraction spectacles, 3D-printed custom eyewear, and smartphone-based screening tools — offer practical interim bridges between a failed screening referral and formal optometric care, and deserve urgent integration into school-based vision programs.

 

KEY STATISTICS

36%

Estimated prevalence of myopia among U.S. school-age children

16%

California Medi-Cal children who actually received eye care, 2022-24

68 Million

Medicare beneficiaries with no routine vision coverage

$47

California Medi-Cal reimbursement for a comprehensive eye exam — unchanged for 25 years

 

I. The Myopia Epidemic: A Growing but Under-Addressed Threat

Nearsightedness is quietly becoming one of the dominant public health challenges of our era. Researchers using 2020 U.S. Census data and Kaiser Permanente Southern California pediatric eye exam records have estimated that approximately 19.5 million American children — a nationwide prevalence of 36.1% — are myopic. Urban children bear the greatest burden at 41%, while rural areas show a rate of around 15.7%. By adolescence, the toll climbs even higher: a large Southern California cohort study found that nearly half of 11- to 13-year-olds were already myopic.

The global trajectory is equally alarming. A February 2025 systematic review and meta-analysis published in the British Journal of Ophthalmology, drawing on data from 1990 through 2023, projects that global myopia incidence will exceed 740 million cases by 2050. The Brien Holden Vision Institute estimated that 50% of the world’s population will be nearsighted by 2050, compared to 23% in 2000. The World Health Organization has separately warned that up to one-fifth of those individuals will face a significantly elevated risk of blindness from complications including glaucoma, cataract, retinal detachment, and myopic macular degeneration.

In the United States, the National Eye Institute projects 44.5 million Americans will be nearsighted in 2050, with steeper increases among African-American and Hispanic populations. Oregon Health & Science University’s Casey Eye Institute notes that the prevailing cause of the rise is behavioral and environmental: the surge in time spent on close-range screens and the steep decline in time outdoors during childhood. Critically, national U.S. prevalence data are now more than 20 years old — predating widespread tablet, smartphone, and laptop use as well as the COVID-19 pandemic’s indoor quarantine period — meaning current estimates almost certainly undercount the true scope.

High myopia — generally defined as a refractive error greater than -6.00 diopters — carries especially serious long-term consequences. A 10-year longitudinal study published in 2025 found that between 2.38% and 3.96% of highly myopic children and adolescents progressed to moderate-to-severe visual impairment over the decade. Early-onset myopia during the school years dramatically increases the probability of reaching high myopia thresholds by adulthood, making childhood the most important window for intervention.

II. The Education Catastrophe Hidden in Blurry Blackboards

The link between uncorrected vision and academic underperformance is well established and clinically significant. An estimated 80% of what a child learns during the first 12 years of life is delivered through visual processing. When refractive errors go uncorrected, the consequences go far beyond squinting at the chalkboard.

A 2024 systematic review published in the Journal of Optometry, examining seven high-quality studies, consistently found that visually impaired students read more slowly than their normally sighted peers, with early intervention offering the most meaningful improvements in educational outcomes. A large Spanish cohort study enrolling more than 10,000 elementary school children found that those with poor academic performance were substantially more likely to have binocular vision disorders (19.98% vs. 7.66%) and abnormal eye motility.

A 2025 study from Shandong Province, China published in Scientific Reports, examining 1,766 primary school children, found that more than half of myopic children were under-corrected. Compared to fully corrected peers, those with undercorrected myopia scored significantly lower in Chinese language, mathematics, and overall average scores. The academic penalty for inadequate vision correction is measurable and statistically robust.

Perhaps the most directly applicable U.S. research comes from Johns Hopkins Wilmer Eye Institute and UCLA, whose independently validated studies of the Vision to Learn school-based glasses program found that children who received glasses gained the equivalent of 2 to 6 additional months of learning per year — with the greatest gains concentrated among students in the bottom quartile of their class. The impact surpassed that of far more costly interventions such as lengthening the school day, providing computers, or creating charter schools.

Yet behavioral misdiagnosis remains a serious systemic problem. Children who cannot see the board or a textbook do not typically report the limitation — they act out, become distracted, appear disengaged, and are misidentified as having behavioral disorders or learning disabilities. In California’s Pomona school district, pediatric optometrist Dr. Ida Chung reports that up to 35% of students fail the school vision screening each year, yet only about 7% of those students then visit an eye doctor and return with glasses. The gap is not a minor administrative inefficiency; it is a structural failure with lifetime consequences for affected children.

 

“First and second graders who try on glasses the first time are blown away because they just thought that’s how the world looked.”

— Damian Carroll, Vision to Learn

 

Vision to Learn: A Mobile Solution Illuminating the Scale of Failure

The nonprofit’s school-based mobile optometry program has found that in the California schools it serves, approximately 70% of children previously prescribed glasses did not own a pair, and another 20% had glasses with outdated prescriptions. In underserved communities nationally, the organization estimates that 95% of children who need glasses do not have them.

III. The Coverage Framework: Strong on Paper, Weak in Practice

Federal law is nominally clear. Under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, children and young adults up to age 21 are entitled to comprehensive vision services — routine eye exams, eyeglasses, contact lenses when medically necessary, and treatment for conditions including amblyopia (lazy eye) and strabismus — at no out-of-pocket cost. These requirements are mandatory and do not vary by state.

But the gap between statutory entitlement and actual care delivery is enormous. In California, a report commissioned by the California Optometric Association based on two years of Medi-Cal data found that just 16% of school-age children on Medi-Cal had a vision-related encounter between 2022 and 2024 — down from 19% eight years earlier. Nearly 47 of California’s 58 counties showed declining rates. Colusa County fell from 20% to just under 2%.

The primary driver of provider non-participation is straightforward: money. California’s Medi-Cal reimbursement rate for a comprehensive eye exam is approximately $47. The California Optometric Association estimates that only about 10% of its members accept Medi-Cal patients. According to Association Executive Director Kristine Shultz, “Our reimbursement rates haven’t increased in 25 years.” In rural counties, even a single optometrist departing from a Medi-Cal panel can eliminate access for thousands of families.

IV. The Medicare Gap: Seniors Left Out Entirely

If the children’s coverage system is broken in practice, the seniors’ coverage system is broken by design. Original Medicare — Parts A and B — explicitly excludes routine eye exams, eyeglasses, and contact lenses for the 68 million Americans age 65 and older who depend on it. If a Medicare beneficiary needs a new eyeglass prescription, Medicare will not pay for the exam.

Limited exceptions exist: Medicare Part B covers annual diabetic retinopathy screenings for individuals with diabetes, annual glaucoma tests for high-risk individuals, and treatment for conditions including age-related macular degeneration and cataracts. Following cataract surgery, Medicare will cover one pair of standard eyeglasses or contact lenses. Medigap supplemental policies do not fill the routine vision gap.

By age 65, approximately one in three Americans has some form of vision-reducing eye disease. Regular exams are not merely cosmetic — they are essential for detecting early-stage conditions when treatment is most effective and for identifying systemic health issues including diabetes and hypertension through the eye. Yet without coverage for routine exams, many seniors forgo care until vision loss is already significant.

Medicare Advantage (Part C) plans commonly include routine vision coverage, but terms, copays, allowances, and provider networks vary substantially. Many seniors, particularly those in rural areas or with limited health literacy, are enrolled in Original Medicare without supplemental coverage. The Prevent Blindness Organization notes that adult vision coverage under Medicaid is optional for states and highly variable — with 12% of Medicaid-enrolled adults in states that provide no routine vision care whatsoever.

V. Emerging Technologies: Bridging the Gap Between Screening and Care

One of the most significant — and underappreciated — failures in the school vision care pipeline is the interval between a failed screening and the receipt of corrective lenses. Even when a school nurse flags a child and sends home a referral note, weeks or months may pass before formal optometric care is obtained, if it is obtained at all. Research consistently shows that referral notes are lost in backpacks, appointments are not made, and children continue to struggle in class with uncorrected vision. Several emerging technology categories offer practical interim correction during this gap — and some could transform the screening-to-correction pipeline entirely.

A. Self-Adjustable and Dial-Adjusted Spectacles

This is the most clinically validated category for interim correction. Two optical mechanisms have been developed and extensively studied in both developed and developing countries.

Fluid-filled lenses (AdSpecs, Adaptive Eyecare Ltd, Oxford, UK): The fluid-filled lenses consist of two thin membranes sealed at a circular perimeter and secured by a frame. The optical power of the lens is determined by the curvature of its surfaces, controlled by varying the volume of liquid in the lens via two user-controlled pumps marked in diopters attached to the sides of the frames. The lens is sealed and the adjustment mechanism removed after the desired power is obtained. This design provides spherical correction in the range of -6 to +6 diopters.

Alvarez-principle sliding lenses (U-Specs, FocusSpecs, Adlens): These employ two polycarbonate lens elements that slide over each other in a spectacle frame, causing changes in lens power with a simple dial. No fluid is required. A dial on the spectacles can be adjusted to provide refractive correction in the range of approximately -6 to +3 diopters.

Clinical validation in children is encouraging. A randomized clinical trial of children aged 5-11 at Duke University’s pediatric eye clinic found that self-refraction using adjustable-focus spectacles was noninferior to noncycloplegic autorefraction — the standard used in many school screenings. Visual acuity corrected to 20/25 or better was achieved in 79.5% of patients using self-refraction, compared to 85.7% with noncycloplegic autorefraction. Studies in Chinese school children using AdSpecs found even stronger results: the proportion of urban children with visual acuity of 6/7.5 in the better eye improved from 34.8% with their habitually worn (or absent) correction to 92.4% with self-refraction — a dramatic functional improvement that could be delivered on the day of the school screening.

The critical limitation is that all currently available adjustable-focus spectacle technologies only provide spherical correction — addressing myopia and hyperopia — but not cylindrical correction for astigmatism. This is a meaningful constraint: astigmatism affects a substantial minority of children requiring correction. For the majority without significant astigmatism, however, these devices offer a validated, low-cost path to functional vision correction that can be deployed by a trained paraprofessional without an optometrist present.

The published literature is clear on the benefits: self-adjusted spectacles offer the potential for correction of both distance and near vision, applicability for all ages, the empowerment of lay workers, reduced costs of optical and refraction units in low-resource settings, and a relative reduction in costs for refraction services. Cosmetic acceptability — the frames are currently bulkier than standard children’s eyewear — remains a challenge for adoption in U.S. schools, and ongoing design improvements are addressing this.

B. 3D-Printed Custom Glasses

A breakthrough presented at the 2024 American Academy of Ophthalmology (AAO) annual meeting in Chicago deserves serious attention from school-based vision program administrators. Pediatric ophthalmologist Donny Suh, MD, and engineer James Hermsen developed Omni Glasses — 3D-printed adjustable eyewear originally designed for children with ear and facial abnormalities who cannot wear standard glasses — and then investigated extending their use to underserved children with complex eye conditions in remote areas.

A study in Ensenada, Mexico, showed significant improvement in refractive errors among children with amblyopia or strabismus. The glasses are lightweight, customizable on the fly, and manufacturable for as little as $1 per frame. Both children and parents rated their experience highly, averaging 4.75 out of 5. A separately published design study in Contact Lens and Anterior Eye proposed a one-size-fits-all 3D-printed frame with circular lens mounts that can accommodate any axis of astigmatism — addressing the major limitation of fluid-filled and Alvarez-type self-refraction spectacles, which cannot correct astigmatism.

The practical advantage of 3D-printed frames extends beyond cost. Because frames are printed to specification rather than selected from a fixed inventory, they can be customized to fit children with unusual facial geometries, a historically underserved population. The flexible design allows distribution in rural and urban environments alike, with minimal training required to fit and assemble. The frame cost of approximately $1 means that even the lens cost — which still requires conventional optician grinding for a precise prescription — becomes the dominant expense rather than the frame, representing a meaningful reduction in total cost.

In 2025, Modo Eyewear announced that its Buy a Frame – Help a Child See programme, in partnership with Seva Foundation, had reached two million vision screenings, eye exams, prescription glasses, and corrective treatments provided to children at no cost. The company and foundation have committed to establishing Vision Centres in India and Nepal. While this program uses conventional frames, it illustrates the philanthropic and commercial infrastructure emerging around school-based vision care delivery that 3D-printed frames could complement.

C. Smartphone-Based Screening and Refraction Tools

These tools don’t provide correction directly, but they dramatically improve the quality and efficiency of the first step — identifying who needs glasses, and potentially determining the approximate prescription needed. Modern photoscreeners use infrared illumination and digital imaging, have autorefraction capabilities, and typically include decision-support software. Current devices in this category include the Spot Vision Screener, PlusoptiX, and the GoCheck Kids smartphone-based variant, all of which can be operated by trained school staff rather than eye care professionals.

The Peek Acuity app (an Android-based smartphone visual acuity test) has been validated in multiple school-based programs across Kenya, Pakistan, and Paraguay. In a Pakistan school-based program from January 2022 to September 2024, 151,456 children were screened by trained school health supervisors — 5.7% were referred for follow-up care. The smartphone-based approach is particularly promising for rural settings where specialist eye care professionals may be absent.

A 2025 paper in Frontiers in Bioengineering and Biotechnology described an advanced smartphone-based system using image analysis algorithms to derive not just visual acuity but also pupillary distance, sphere, cylinder, and axis of astigmatism simultaneously, with 85% of measurements within 0.50 diopters of clinical standards. This level of accuracy, if it can be achieved consistently across device types and ages, would be sufficient to guide the fitting of self-refraction spectacles or to generate a near-prescription for expedited grinding of inexpensive glasses.

Companies such as EyeQue have developed small clip-on devices that attach to smartphones and use interactive self-refraction to estimate a refractive error, enabling users to obtain approximate prescription data without an in-person optometrist visit. While the American Academy of Ophthalmology has noted limitations — and these tools are not currently designed or marketed for young children — the underlying technology trajectory points toward increasingly accurate remote refraction that could eventually be adapted for school-based use with appropriate clinical oversight.

D. FDA-Approved Myopia-Slowing Spectacle Lenses (Essilor Stellest)

This category does not bridge the gap to care — it changes the nature of the intervention needed. On September 25, 2025, the FDA officially approved Essilor Stellest lenses as the first spectacle lens specifically designed to manage pediatric myopia progression. Unlike standard glasses that only sharpen vision, these lenses are engineered to influence how the eye develops. Children wearing Stellest lenses showed a 71% slower rate of myopia progression over two years compared to those with traditional single-vision lenses, and eye axial length growth was reduced by 53%.

Vanderbilt Eye Institute is currently enrolling children in an NIH-funded, multi-center trial testing Stellest lenses in combination with atropine eyedrops to determine whether the combination outperforms either treatment alone. The study is funded by the National Eye Institute and conducted by the Pediatric Eye Disease Investigator Group, with study visits, eye drops, and eyeglasses provided to participants at no cost.

The significance for the school-based vision care discussion is this: if myopia-slowing lenses become standard of care, the argument for early identification and early correction becomes even more powerful. A child who goes without glasses for two years while waiting for Medi-Cal follow-up not only suffers academically — that child’s myopia may progress significantly faster than a child who received corrective lenses promptly. The case for interim correction technology therefore extends beyond academic performance to preventing the progression toward high myopia and its associated lifetime risk of blindness.

E. The Remaining Bottleneck: Technology Without System

The honest assessment is that the technology for interim correction already exists and is clinically validated for straightforward myopia and hyperopia without significant astigmatism — the majority of cases among school-age children. What is missing is not the optics but the system: a trained school-based facilitator to guide the self-refraction process, a mechanism to distribute the glasses, and a clear protocol for transitioning children to formal optometric care. The self-adjustable spectacles in particular require at least a trained paraprofessional for guidance in younger children.

Programs like Vision to Learn already deploy exactly this kind of school-based infrastructure, with licensed optometrists arriving by mobile clinic and providing same-day exams and glasses. The logical near-term next step would be integrating self-refraction spectacles as an immediate interim measure within that same framework — allowing children to start seeing clearly on the day they are screened, while the mobile clinic appointment is scheduled. For communities where even mobile clinics face long wait times, this interim correction could represent weeks or months of restored learning.

VI. The Legislative Picture: Proposed Fixes Collide With Budget Cuts

Legislation / Bill

 

H.R. 2045 / Medicare Dental, Vision, and Hearing Benefit Act of 2025  [PENDING]

Rep. Lloyd Doggett (D-TX) & Sen. Bernie Sanders (I-VT). Would expand Original Medicare to cover routine eye exams, eyeglasses, and contact lenses for all 68 million beneficiaries. A 2024 Data for Progress poll found 92% of Americans support this expansion. Introduced March 11, 2025 with 115+ cosponsors.

 

H.R. 2527 / Early Detection of Vision Impairments for Children Act of 2025  [PENDING]

Would authorize $5 million per year, FY 2026-2030, for statewide early vision detection and intervention programs, requiring coordination across Medicaid, CHIP, IDEA, and state educational agencies.

 

California AB (Ahrens) — Vision Benefit Quality Measures  [PENDING]

Assemblymember Patrick Ahrens (D-Cupertino), sponsored by California Optometric Association. Would require California to establish vision benefit quality measures and report performance data publicly, enabling identification of counties with deficient access.

 

H.R. 1 / “One Big Beautiful Bill Act” (P.L. 119-21)  [ENACTED]

Signed into law July 4, 2025. Cut gross federal Medicaid and CHIP spending by $990 billion over 10 years per CBO estimates. The law’s work requirements and eligibility restrictions are projected to increase the uninsured population by 7.5 million by 2034 from Medicaid/CHIP cuts alone. Policy analysts warned that states unable to absorb cost shifts would be forced to cut optional Medicaid benefits — including vision care for adults — and reduce provider payments, further shrinking the pool of providers accepting patients.

The intersection of these legislative developments creates a profound tension. Progressive legislators are attempting to add routine Medicare vision coverage for seniors — a reform with overwhelming bipartisan public support — while the enacted reconciliation law simultaneously cuts nearly $1 trillion from the Medicaid system that, imperfectly and inadequately, delivers vision care to children. Georgetown’s Center for Children and Families notes that the law’s per-capita financing constraints are expected to push states toward eliminating optional benefits and cutting provider payments — the precise mechanisms that have already driven California’s optometric participation rate down to 10%.

VII. What Would Actually Work: Evidence-Based Paths Forward

Research consistently points toward several interventions that meaningfully close the gap between entitlement and delivery. Mobile school-based optometry programs — such as Vision to Learn’s model, validated by Johns Hopkins and UCLA — eliminate the most common barriers: transportation, scheduling, and parental follow-through. Children receive an exam, prescription, and glasses in a single school-day visit.

Integration of interim correction technology into school-based programs represents the most promising near-term innovation. Self-adjustable spectacles, deployed by trained school staff on the day of a failed vision screening, could restore functional vision for the majority of myopic and hyperopic children while formal optometric appointments are arranged. 3D-printed frames expand this to children with atypical facial geometries and, with appropriate lens pairing, to children with astigmatism. Smartphone-based refraction tools offer a path toward same-day prescription approximation that could enable expedited lens grinding without a full optometrist visit.

Increases in provider reimbursement rates are a necessary — if insufficient — structural fix. California’s $47 exam reimbursement, unchanged for 25 years, is the root cause of provider non-participation. Even modest increases toward market rates would bring more optometrists into the Medi-Cal network, particularly in rural counties where access currently depends on a single provider.

Mandatory public reporting of vision care utilization rates by county and managed care plan — as proposed in California’s Ahrens bill — would create accountability where none currently exists. You cannot manage what you do not measure.

For seniors, the evidence-based solution is straightforward in principle: include routine vision care in Original Medicare. Polling shows near-universal public support across partisan lines. The Medicare Dental, Vision, and Hearing Benefit Act of 2025 would do exactly that. The legislative obstacle is not lack of support — it is cost, and the political willingness to structure a financing mechanism to cover it.

Time, however, is a cost too. Every year that a child with uncorrected myopia sits in a classroom seeing a blurry board is a year of academic development lost. Every year that a senior with an uncorrected refractive error cannot read a prescription bottle or recognize a grandchild’s face is a year of independence and quality of life diminished. The myopia epidemic is accelerating, the coverage mechanisms are eroding, and the children most affected are the ones who can least afford to wait. Emerging technology offers a partial and immediate remedy that demands urgent attention from program designers, school administrators, and policymakers alike.

 

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