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Correspondence to Ya-Ping Jin, MD, PhD, Department of Ophthalmology and Vision Sciences, University of Toronto, 340 College Street, Suite 400, Toronto, Ont. M5T 3A9;
Institute of Medical Science, Toronto, Ont.Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.
To describe patterns of access to eyeglass insurance by Canadians.
Design
A population-based, cross-sectional survey.
Participants
A total of 134 072 respondents to the Canadian Community Health Survey 2003 who were aged ≥12 years.
Methods
We compared self-reported insurance coverage for eyeglasses or contact lenses provided by private, government, or employer-paid plans.
Results
Overall, 55.0% of Canadians aged ≥12 years had insurance that covers all or part of the costs of optical correction. School-age children (63.3%) and individuals aged 20–39 years (55.9%) and 40–64 years (59.5%) had higher coverage rates than seniors (aged ≥65 years) (33.8%, p < 0.05). Canadians residing in the 3 territories had the highest coverage (76.9%), while those in Quebec had the lowest coverage (39.1%, p < 0.05). Lower coverage was reported among immigrants (47.3%) versus nonimmigrants (57.4%, p < 0.05), nonwhites (49.2%) versus whites (56.4%, p < 0.05) and aboriginals (70.7%), and the self-employed (38.5%) versus employees (63.8%). Among Canadians in the 20–64 years age group, individuals in the lower or middle income bracket were 40% (prevalence ratio [PR] 0.60, p < 0.05) less likely to have insurance than those in the upper-middle or higher income bracket after adjusting for ethnicity, immigrant status, and education. Compared to those with university or college education, individuals with less than secondary school education were 13% (adjusted PR 0.87, p < 0.05) less likely to have insurance.
Conclusions
Significant disparities exist in eyeglass insurance coverage in Canada. Individuals with low levels of income and education, and the self-employed, seniors, immigrants, nonwhites, and residents of Quebec had less coverage. Studies are needed to understand whether these disparities contribute to the visual impairment burden in Canada.
RÉSUMÉ
Objet
Décrire l’accessibilité des Canadiens à une assurance lunettes ou lentilles.
Nature
Sondage transversal basé sur la population.
Participants
Un total de 134 072 personnes d’au moins 12 ans ont répondu à l’Enquête sur la santé dans les collectivités canadiennes de 2003.
Méthodes
Nous avons comparé la couverture d’assurance (lunettes ou lentilles) offerte par les polices privées, par le gouvernement et par les employeurs, selon les déclarations des répondants.
Résultats
Dans l’ensemble, 55,0 % des Canadiens d’au moins 12 ans avaient une assurance qui rembourse, en tout ou en partie, les coûts liés à la correction de la vue. Les enfants d’âge scolaire (63,3 %) ainsi que les sujets de 20 à 39 ans (55,9 %) et de 40 à 64 ans (59,5 %) avaient un taux de couverture plus élevé que les personnes d’au moins 65 ans (33,8 %; p < 0,05). Les Canadiens vivant dans les 3 territoires disposaient du taux de couverture le plus élevé (76,9 %) et les Québécois, du taux le plus faible (39,1 %; p < 0,05). On a noté un taux de couverture plus faible chez les immigrants (47,3 %) comparativement aux non-immigrants (57,4 %; p < 0,05) et chez les non-Caucasiens (49,2 %) comparativement aux Caucasiens (56,4 %; p < 0,05) et aux Autochtones (70,7 %), de même que chez les travailleurs indépendants (38,5 %) comparativement aux employés (63,8 %). Au sein des Canadiens âgés de 20 à 64 ans, les sujets à revenu faible ou intermédiaire étaient 40 % (rapport de prévalence [RP]: 0,60; p < 0,05) moins susceptibles d’avoir une assurance que les sujets à revenu intermédiaire élevé ou à revenu élevé, après ajustement pour l’origine ethnique, le statut d’immigrant et le niveau d’éducation. Comparativement aux sujets qui avaient un diplôme universitaire ou collégial, les sujets qui n’avaient pas de diplôme du secondaire étaient 13 % (RP ajusté: 0,87; p < 0,05) moins susceptibles de disposer d’une assurance.
Conclusions
On constate des disparités significatives en matière d’assurance lunettes ou lentilles au Canada. Les sujets à faible revenu et peu éduqués, de même que les travailleurs indépendants, les personnes âgées, les immigrants, les non-Caucasiens et les résidents du Québec disposaient d’une couverture moindre. Des études devront être réalisées pour découvrir si ces disparités accroissent le fardeau lié au handicap visuel au Canada.
Eyeglasses and contact lenses are the primary means to correct vision problems resulting from refractive errors. One study reported that 57% of Canadians over the age of 20 years had some form of vision problem requiring optical correction.
This percentage increased to 80% among Canadians over the age of 50 years. In the U.S., a similar study reported that clinically important refractive errors affect half of the population.
Despite the fact that vision problems due to refractive error are common and readily correctable, uncorrected or undercorrected refractive errors (URE) account for 53% of moderate and severe visual impairment globally.
The World Health Organization has established a global initiative for eliminating avoidable blindness and has identified URE as one of the 5 working priorities to achieve this goal.
Blindness: Vision 2020—control of major blinding diseases and disorders.2014; (Available at: www.who.int/mediacentre/factsheets/fs282/en/. Accessed April 18, 2017)
We believe the cost of corrective eyeglasses or contact lenses may in part account for these findings. We previously reported that the average cost of a pair of prescription eyeglasses in Canada is in the range of $240–$1000.
Furthermore, no Canadian provincial health insurance plans cover the cost of eyeglasses and contact lenses. Vision benefits cover part of the cost of eyeglasses through provincial low-income assistance or disability assistance programs for individuals meeting program requirements.
How Ontario Works can help you: Health benefits.2016; (Available at: www.mcss.gov.on.ca/en/mcss/programs/social/ow/help/benefits/health_benefits.aspx. Accessed September 30, 2017)
Supplemental health benefit programs also cover part of the cost of eyeglasses for specific populations (e.g., veterans, refugees, First Nations, and Inuit).
Medical coverage: other publicly-funded optometry programs.2017; (Available at: www.optom.on.ca/OAO/Patients/Medical_Coverage/OAO/Patients/Medical_Coverage.aspx?hkey=2807b89e-3348-49be-8e0d-629def9ceea2. Accessed September 3, 2017)
First Nations & Inuit Health Non-Insured Health Benefits (NIHB) Program.2016; (Available at: www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/gener-qa-qr-eng.php. Accessed January 28, 2017)
The majority of Canadians, however, pay out of pocket or rely on private or employment-associated insurance plans to obtain optical correction.
To date, no studies have reported on the number of individuals with eyeglass insurance coverage. In this study, we describe the self-reported pattern of access to eyeglass insurance in Canada and examine associated sociodemographic and geographic factors.
Methods
Data source
We analyzed the nationwide self-reported data from the Canadian Community Health Survey (CCHS) Cycle 2.1. The CCHS is a survey of individuals aged 12 years or older and living in private dwellings in Canada. The survey has been performed regularly since 2000 with contents changing from cycle to cycle. Nearly 10 CCHS surveys have been conducted so far, but Cycle 2.1 in 2003 is the only survey that asked information on insurance coverage at a nationwide level. Survey subjects were randomly chosen from a complex design with 2 sampling processes: household sampling and individual sampling.
Standardized questionnaires were used to collect information. In Cycle 2.1, 134 072 Canadians responded to the survey, representing an 87.1% response rate at the household level and 92.6% at the individual level.
“Now, turning to your insurance coverage. Please include any private, government or employer-paid plans.
Do you have insurance that covers all or part of:
•
the cost of your prescription medications?
•
your dental expenses?
•
the costs of eye glasses or contact lenses?
•
hospital charges for a private or semi-private room?”
An answer was positive if respondents indicated they had insurance coverage for the relevant question.
Other study information
Age, sex, and province of residence of respondents were self-reported. If a respondent was not born a Canadian citizen, this respondent was classified as an immigrant. If the cultural or racial origin of the respondent was self-reported as white, he or she was labeled as white. Respondents who identified as nonwhite and those who identified as aboriginal were considered separately because First Nations and Inuit health insurance are separately covered by the federal government.
The highest education level acquired by any member of the household was obtained through a series of questions and was grouped into 4 categories by Statistics Canada: less than secondary school graduation, secondary school graduation but no postsecondary education, some postsecondary education, and postsecondary degree/diploma.
Similarly, income data were classified into 5 categories by Statistics Canada based on total household income in 2002 and the number of people living in the household, as shown in Table 1.
Table 1Income classification of the Canadian Community Health Survey Cycle 2.1
Lowest
<$10 000 if 1 to 4 people, or <$15 000 if 5+ people
Lower-middle
$10 000 to $14 999 if 1 or 2, or $10 000 to $19 999 if 3 or 4, or $15 000 to $29 999 if 5+
Middle
$15 000 to $29 999 if 1 or 2, or $20 000 to $39 999 if 3 or 4, or $30 000 to $59 999 if 5+
Upper-middle
$30 000 to $59 999 if 1 or 2, or $40 000 to $79 999 if 3 or 4, or $60 000 to $79 999 if 5+
The survey weights provided by Statistics Canada were used for all analyses. These weights accounted for the complex survey design and sample selections; they also adjusted for nonresponse, seasonal effect, and poststratification. The weighted data are therefore more representative of the survey population and are required by Statistics Canada for reporting when producing population estimates.
Insurance coverage was calculated as the proportion of people who self-reported having insurance coverage for the question surveyed among all respondents. The 95% confidence interval for coverage was calculated using PROC SURVEYFREQ for proportions in SAS (SAS Institute, Cary, N.C.) with the bootstrap weight provided by Statistics Canada. The association between insurance coverage and examined sociodemographic factors was measured using prevalence ratios (PR), rather than odds ratios, due to the common occurrence of the outcome. Adjusted PR was estimated through multivariate log-Poisson regression analyses with robust variance estimation.
Overall, 55.0% of Canadians aged 12 years or older self-reported having insurance that covers all or part of the costs of eye glasses or contact lenses. This coverage was lower than insurance for prescription medications (78.9%, p < 0.05), dental expenses (61.1%, p < 0.05), and hospital coverage for private or semiprivate rooms (61.8%, p < 0.05).
Seniors (33.8%, p < 0.05) had the lowest eyeglass insurance coverage compared with individuals in the working age groups of 20–39 years (55.9%) and 40–64 years (59.5%) and school-aged individuals aged 12–19 years (63.3%). The coverage for seniors in the lower to middle income bracket (18.1%) was about half that of their peers in the upper-middle to higher income group (37.5%, p < 0.05).
Canadians residing in the 3 territories had the highest eyeglass insurance coverage (76.9%), whereas those living in Quebec had the lowest coverage (39.2%, p < 0.05, Fig. 1). Compared with nonwhites (49.3%), white Canadians (56.4%, p < 0.05) had 7.1 additional individuals with eyeglass insurance per 100 people. Aboriginal respondents had the highest coverage (70.7%) compared with white and nonwhite Canadians. Within whites, individuals with less than secondary school graduation had significantly lower levels of insurance coverage than those in the other categories of education (Table 2). This finding held true in each age group.
Fig. 1Insurance coverage by provincial region. The labelled values indicate the percentage of individuals with eyeglass insurance. *Region with the highest eyeglass insurance coverage.
Across all age groups, eyeglass insurance coverage among individuals in the lowest to middle income category was only about half the coverage of individuals in the upper-middle or highest income category (Fig. 2). Additionally, employed individuals (63.8%) had 25.3 additional individuals with eyeglass insurance per 100 people compared with self-employed individuals (38.5%).
Fig. 2Eyeglass insurance coverage by income levels.
Compared with immigrants (47.3%), nonimmigrants (57.4%, p < 0.05) had 10.1 additional individuals with eyeglass insurance per 100 people. However, the coverage gap between immigrants and nonimmigrants narrowed with increasing income (Fig. 3). For example, in the 40–64 years age group, the coverage gap between immigrants and nonimmigrants was 13.0% for those in the lowest income category and 1.7% for those in the highest income category. This decreased insurance gap with increasing income level did not hold true among seniors (Fig. 3). There was no significant difference in eyeglass insurance coverage between men (55.7%) and women (54.3%, p > 0.05).
Fig. 3Eyeglass insurance by income level comparing nonimmigrants and immigrants. The vertical bars and the labels indicate the percent difference in coverage between nonimmigrants and immigrants.
When comparisons were made among Canadians in the age 20–64 years working age group, individuals in the lower to middle income bracket were 40% (adjusted PR 0.60, p < 0.05) less likely to have eyeglass insurance than those in the upper-middle to higher income bracket after adjusting for the effects of ethnicity, immigrant status, and education. Compared to those with university or college education, individuals with less than a secondary school education were 13% (adjusted PR 0.87, p < 0.05) less likely and individuals with secondary school education were 4% (adjusted PR 0.96, p < 0.05) less likely to have insurance coverage (Fig. 4).
Fig. 4Adjusted prevalence ratio (PR) of having eyeglass insurance coverage among Canadians aged 20–64 years. Vertical lines represent the 95% confidence interval. *p < 0.05.
This study provides the first evidence-based insight into self-reported access to corrective lens insurance in Canada. We report that eyeglass insurance coverage is lower than dental care, prescription medication, and hospital insurance coverage. This may reflect the perceived lack of importance and the cost of vision care compared with other health care insurance for both employers and the insured. Individuals with low levels of income and education, self-employed individuals, seniors, immigrants, nonwhites, and residents of Quebec have the least insurance coverage for optical care. School-aged (12–19 years) individuals and those living in the northern territories have the greatest coverage.
Dental insurance usually includes all aspects of dental care, including diagnostic dental examinations,
How do I compare dental insurance plans?.2017; (Available at: www.sbis.ca/dental-insurance-article-how-do-i-compare-dental-insurance-plans.html. Accessed September 30, 2017)
whereas eyeglass insurance only refers to the cost of eyeglasses or contact lenses. We do not know if eyeglass insurance as reported by the CCHS respondents includes the cost of eye examinations. Eye examinations are a necessary first step to obtain eyeglasses. This information should be clarified and collected in future surveys.
Eyeglasses are expensive and are not included in the list of government-sponsored health insurance plans. It is therefore expected that individuals with low levels of income and education will have less coverage. Our results are in line with findings from the U.S., where Zhang et al. reported that almost 5 million adults at high risk for vision loss cannot afford eyeglasses.
Another U.S. study of school-aged children reported that parents in the lowest income bracket or those lacking health insurance were less likely to be able to afford eyeglasses for their children.
Clearly, affordability is a significant barrier to optical correction. Recognizing this issue, each provincial government in Canada has a government-funded, low-income vision support program to aid those in need of necessary vision care, including paying part of the eyeglass cost.
However, our previous study reported that these government-funded, low-income support programs do not meet the needs of low-income individuals for access to eye examinations and eyeglasses.
This conclusion is reinforced by the results of the current study. As eye examinations are necessary to obtain eyeglasses, we believe low-income individuals and seniors need more government support to access both eye examinations and eyeglasses.
Supplemental health benefit programs that include coverage for eyeglasses have been created by provincial governments for specific populations (e.g., low income, veterans, refugees, First Nations, and Inuit).
Medical coverage: other publicly-funded optometry programs.2017; (Available at: www.optom.on.ca/OAO/Patients/Medical_Coverage/OAO/Patients/Medical_Coverage.aspx?hkey=2807b89e-3348-49be-8e0d-629def9ceea2. Accessed September 3, 2017)
Data regarding program usage are not currently available. However, inclusion criteria for such programs are highly specific and stringent; therefore, difficulties in meeting the program requirements and lack of awareness regarding available funding for specific populations may also contribute to the reported low rates of self-reported eyeglass coverage.
Both lack of eyeglass insurance coverage and the presence of visual impairment are more prevalent among individuals with lower levels of educational achievement and income.
Further research is needed to identify whether some of the visual impairment in these social segments can be corrected with an appropriate pair of eyeglasses. However, we believe a positive answer is very likely based on studies from the U.S. and Australia that identified URE as the most common cause of visual impairment.
Seniors are the population segment most affected by vision problems. However, eyeglass insurance coverage for seniors (33.8%) is only about half that of other age groups (55.9%−63.3%). Additionally, the coverage for lower- to middle-income seniors (18.1%) was about half of their peers with upper-middle to high income (37.5%). In 2003, the average after-tax income was $23 000 for Canadian seniors living alone and $43 800 for senior families (2 or more individuals), compared with the national average of $59 900 for families.
Furthermore, data from Statistics Canada demonstrate a trend of increasing out-of-pocket costs for private insurance for prescription drugs and dental care from 1997 to 2009.
Sanmartin C, Hennessy D, Lu Y, Law M. Trends in out-of-pocket health care expenditures in Canada, by household income, 1997 to 2009. Statistics Canada. Available at: www.statcan.gc.ca/pub/82-003-x/2014004/article/11924-eng.htm. Accessed October 05, 2017.
Prescription drug insurance.2016; (Available at: www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/Pages/prescription-drug-insurance.aspx. Accessed August 21, 2016)
With reduced income, increased demand for medications, and loss of employment-associated benefits, seniors may prioritize other costs over eyeglass insurance coverage. Taken together, we suspect that lower eyeglass insurance coverage in seniors is likely a result of affordability.
Across Canada, the province of Quebec has the lowest coverage whereas the 3 territories have the highest coverage. Quebec, however, has the highest insurance coverage for prescription medications. The high medication coverage in Quebec may be due to the provincially funded Régie de l'assurance maladie du Québec (RAMQ) program, which covers prescription drugs for those without a private plan.
Prescription drug insurance.2016; (Available at: www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/Pages/prescription-drug-insurance.aspx. Accessed August 21, 2016)
Coverage of services provided by optometrists.2015; (Available at: www.ramq.gouv.qc.ca/SiteCollectionDocuments/citoyens/en/depliants/depl-services-optometriste-en.pdf. Accessed August 21, 2016)
We could not identify a clear reason to explain why Quebec has the lowest eyeglass insurance coverage across Canada.
The 3 northern territories have higher rates of insurance coverage not only for eyeglasses, but for dental care, hospital rooms, and prescription drugs. We believe this is likely a result of the federally funded noninsured health benefits for First Nations and Inuit.
First Nations & Inuit Health Non-Insured Health Benefits (NIHB) Program.2016; (Available at: www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/gener-qa-qr-eng.php. Accessed January 28, 2017)
This is supported by the finding that aboriginal respondents have the highest rate of coverage, compared with white and nonwhite Canadians. The contrast between the models in northern territories and Quebec suggests that provincial and federal insurance plans, which provide coverage for health benefits, make a significant difference regarding accessibility to health services, particularly for eyeglasses.
There are some limitations to this study. First, data analyzed in this study were collected in 2003 and are the most recently available data. More recent nationwide data are desirable. However, since this is the first study to report on nationwide access to eyeglass insurance, the results from 2003 are necessary to establish baseline values for future comparisons. Despite this limitation, government health insurance plans for eyeglasses have not changed in the last decade.
Therefore, although the results reported in this study may not reflect the current situation, they provide valuable information about the factors that influence access to coverage. This limitation also emphasizes the need for Statistics Canada to reintroduce the insurance coverage question into the CCHS survey.
Second, the cross-sectional design of the study prevents establishment of a causal relationship. Additionally, the self-reported nature of the study cannot rule out biases associated with self-reporting.
Third, there are limitations in the scope of vision care information within the CCHS survey. For example, the survey does not ask whether an individual respondent has vision problems due to lack of corrective lenses. Therefore, we cannot determine how many individuals with vision problems have or do not have eyeglass insurance. Lastly, the type of insurance coverage (private vs employment associated vs low-income government assistance) and the amount of coverage was not asked in the survey. This information would help identify whether having only partial coverage (thus requiring copayment) is a secondary barrier to access for corrective lenses. This would be useful information to collect in future Statistics Canada surveys.
Strengths of this study include the large number of respondents, a nationwide survey, random sampling, and diverse population characteristics. These features can only be achieved by Statistics Canada.
Conclusion
We described for the first time that half of Canadians self-reported having eyeglass insurance coverage. Compared with other types of health care insurance, eyeglass insurance coverage is the lowest. Canadians with low levels of income and education, self-employed individuals, seniors, immigrants, and residents of Quebec have significantly less optical insurance coverage. Studies are needed to understand whether these findings hold true in 2017 and whether disparities in eyeglasses coverage contribute to the reported visual impairment burden in Canada.
We strongly advocate that Statistics Canada consider reintroducing questions regarding eyeglass insurance coverage in future CCHS surveys.
Disclosure
This work was supported by The Canadian Institutes of Health Research (CIHR) (Grant SEC 117120 and HRA 126901).The authors have no proprietary or commercial interest in any materials discussed in this article. This research was supported by funds to the Canadian Research Data Centre Network (CRDCN) from the Social Science and Humanities research Council (SSHRC), the Canadian Institute for Health Research (CIHR), the Canadian Foundation for Innovation (CFI) and Statistics Canada.
Although the research and analysis are based on data from Statistics Canada, the opinions expressed do not represent the views of Statistics Canada or the Canadian Research Data Centre Network (CRDCN).
References
Perruccio A.V.
Badley E.M.
Trope G.E.
A Canadian population-based study of vision problems: assessing the significance of socioeconomic status.
Blindness: Vision 2020—control of major blinding diseases and disorders.2014; (Available at: www.who.int/mediacentre/factsheets/fs282/en/. Accessed April 18, 2017)
How Ontario Works can help you: Health benefits.2016; (Available at: www.mcss.gov.on.ca/en/mcss/programs/social/ow/help/benefits/health_benefits.aspx. Accessed September 30, 2017)
Medical coverage: other publicly-funded optometry programs.2017; (Available at: www.optom.on.ca/OAO/Patients/Medical_Coverage/OAO/Patients/Medical_Coverage.aspx?hkey=2807b89e-3348-49be-8e0d-629def9ceea2. Accessed September 3, 2017)
First Nations & Inuit Health Non-Insured Health Benefits (NIHB) Program.2016; (Available at: www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/gener-qa-qr-eng.php. Accessed January 28, 2017)
How do I compare dental insurance plans?.2017; (Available at: www.sbis.ca/dental-insurance-article-how-do-i-compare-dental-insurance-plans.html. Accessed September 30, 2017)
Sanmartin C, Hennessy D, Lu Y, Law M. Trends in out-of-pocket health care expenditures in Canada, by household income, 1997 to 2009. Statistics Canada. Available at: www.statcan.gc.ca/pub/82-003-x/2014004/article/11924-eng.htm. Accessed October 05, 2017.
Prescription drug insurance.2016; (Available at: www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/Pages/prescription-drug-insurance.aspx. Accessed August 21, 2016)
Coverage of services provided by optometrists.2015; (Available at: www.ramq.gouv.qc.ca/SiteCollectionDocuments/citoyens/en/depliants/depl-services-optometriste-en.pdf. Accessed August 21, 2016)
Canadian Ophthalmological Society,
June 17, 2016 (Available at: www.cos-sco.ca/wp-content/uploads/2012/06/Valuation_uninsured_services-1.pdf. Accessed June 11, 2017)
The study abstract was presented at the Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting in Seattle, Wash., May 3, 2016, and the 2016 Annual Meeting of the Canadian Ophthalmological Society (COS) in Ottawa, Ont.
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