Primary Care Vision Testing Rates Associated with Health Insurance Status

Published on: 

The adjusted odds of vision testing decreased by 41% for uninsured and 24% for publicly insured participants versus those with private insurance.

An analysis of the 2018 to 2020 National Survey of Children’s Health (NSCH) study indicates primary care vision testing rates were low in children with notable differences by insurance status.1

Recommendations cite the need for yearly vision testing for children aged 3 to 5 years; however, the analysis suggests less than half of children with private insurance were tested for vision and reported even lower rates among children without private insurance.

“Vision testing by primary care physician is critical to identify vision problems impeding learning and amblyopia risk factors before vision loss,” wrote the investigative team led by Olivia J. Killeen, MD, University of Michigan. “Results of this analysis build on studies reporting an association between insurance status and unmet eye care needs.”

Undiagnosed vision problems have associations with amblyopia, or lazy eye, a reduction in vision in one eye caused by abnormal visual development early in life.2 The American Academy of Pediatrics recommends vision testing at well-child visits beginning at 3 years old, but regional studies have identified low testing rates.3 Testing rates for individuals in the US aged 3 to 17 years, as well as the association between vision testing and insurance, are unknown.

Investigators in the current analysis pooled data from the nationally representative, cross-sectional 2018 - 2020 NSCH study.1 Parents or caregivers were asked, “During the past 12 months, has this child had his or her vision tested, such as with pictures, shapes, or letters?” and where the testing occurred (eye doctor's office, pediatrician, or other general doctor’s office, clinic or health center, school, or other).

Investigators obtained insurance status (public only, private only, private and public, or no insurance) from parents or caregivers. After categorizing private and public insurance into the private only category, the analysis left 3 insurance categories: no insurance, public insurance, and private insurance. Study covariates included the survey year, age (3 - 5, 6 - 11, or 12 - 17 years), sex, race and ethnicity, preventive health visits in the past year, and special health care needs.

Multivariable logistic regression evaluated the odds of primary care physician vision testing by insurance status, adjusting for covariates. The study sample included 89,936 participants: 48.1% females with a mean age of 10.1 years. Upon analysis, investigators estimated 30.7% of the study sample received primary care physician vision testing.

The analysis showed the adjusted odds of vision testing decreased by 41% (odds ratio [OR], 0.59; 95% CI, 0.49 - 0.72) for uninsured and 24% (OR, 0.76; 95% CI, 0.70 - 0.82) for publicly insured participants versus those with private insurance.

Study investigators identified the adjusted estimated probability of primary care physician vision testing as 22.0% (95% CI, 18.8% - 25.2%) for uninsured, 26.6% (95% CI, 25.3% - 27.9%) for publicly insured, and 32.3% (95% CI, 31.4% - 33.2%) for privately insured participants.

Among those aged 3 to 5 years, the estimated probability of vision testing was 29.7% (95% CI, 25.6% - 33.7%) for uninsured, 35.2% (95% CI, 33.1% - 37.3%) for publicly insured, and 41.6% (95% CI, 39.8% - 43.5%) for privately insured children.

Investigators noted limitations in obtaining vision testing information from parents and caretakers, as they may be unaware of the details of vision testing, if any, which may have led to the underestimation or overestimation of the insurance–vision testing association. Meanwhile, the team did not analyze the implication of the gaps in insurance testing coverage for primary care physician vision testing.

“Results may have also been affected by the COVID-19 pandemic, during which there were lower preventive services use and continuous Medicaid eligibility,” investigators wrote.


  1. Killeen OJ, Choi H, Kannan NS, Asare AO, Stagg BC, Ehrlich JR. Association Between Health Insurance and Primary Care Vision Testing Among Children and Adolescents. JAMA Ophthalmol. Published online August 17, 2023. doi:10.1001/jamaophthalmol.2023.3644
  2. Boyd K. Amblyopia: What is Lazy Eye? American Academy of Ophthalmology. April 6, 2023. Accessed August 21, 2023.
  3. Hagan JF Jr, Shaw JS, Duncan PM, eds. Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 4th ed. American Academy of Pediatrics; 2017