Enough is enough

Excerpted from page 26 of the Summer 2025 edition of AOA Focus 

 “Gross.” 

It’s the only word that came to mind when Monique Flores furrowed her brow in frustration upon hearing how vision benefit managers (VBMs) control unseen facets of her relationship with her doctor of optometry. After collecting her thoughts,  

Flores found more choice words.  

Flores expressed her thoughts during a panel discussion on VBMs at last year’s Patients Rising annual Washington, D.C., fly-in called We the People on Capitol Hill. The patient advocacy group featured a panel discussion on so-called “health care gatekeepers,” where Flores shared her personal challenges in accessing vision benefits for a chronic condition. 

Rapidly developing astigmatism, which began with severe discomfort to sunlight as a 2-year-old, eventually led to Flores’ four decades of vision impairment. During the panel, she described her lifelong need for thick lenses and the subsequent teasing and difficulty with self-confidence. Little did Flores know that her “profoundly high prescription” would saddle her with a lifetime of out-of-pocket costs, simply to maintain her most critical sense. 

“Regardless of my insurance, I’ve always had to come out of pocket for minimum glasses,” she said. “And that doesn’t include the ‘vanity’ piece of it—[correcting] for thick lenses.” 

Unfortunately, Flores hasn’t always been able to pay out of pocket. Many times, she has been forced to let her vision care lapse when the costs simply weren’t within reach. 

Flores’ optometrist of nearly two decades, Tommy Lucas, O.D., chimed in on the panel to provide additional context. He explained that Flores’ VBM required the use of its proprietary optical lab for her lenses despite there being numerous labs closer to Dr. Lucas, including one in his own practice. Thus, Flores’ high-prescription glasses would be handled where her VBM dictated, not where it made the most sense for quality control or turnaround time—two factors that aren’t insignificant to Flores. 

“Her prescription is so profound that if the axis of her astigmatism is off by one degree ... that’s two lines on the acuity chart, from 20/20 to 20/30,” Dr. Lucas said. “When glasses require that kind of precision, the doctor is advocating for their patient to have the clearest vision possible.” 

Of course, Flores’ VBM has different priorities. “They want the doctor to send her glasses to some lab because they own it or control it or have a deal with it, so it disempowers me, as Monique’s doctor, to make good choices with her and help her get the apparatus that she needs to function well,” Dr. Lucas said. 

What Flores and Dr. Lucas described in that panel discussion, and again in a September 2024 briefing in the U.S. House Oversight and Accountability Committee hearing room, is all too familiar for optometry practices. In fact, it’s the VBM paradigm. 

What’s the current paradigm? 

Roughly 200 million Americans have preventive eye exam and materials benefits that are administered by a VBM—the two most dominant of which cover nearly 85% of the market. And in 28 states, one of those companies alone controls more than three-quarters of the market. Years of strategic vertical integration by these corporations now allow them to influence nearly every step of the patient journey—from the doctors patients see to the materials they select. And of course, this level of market dominance continues to tighten the squeeze on independent optometry practices. 

In economic terms, it’s called a monopsony—a market condition in which a single purchaser exerts downward pressure on pricing. But in the case of VBMs, that pricing pressure does not benefit consumers. Rather, it’s designed to shift operating margins away from providers and toward plans. When doctors are forced to operate on razor-thin margins, they often have no choice but to transfer costs, and particularly to patients without vision benefits. Two reports from Avalon Health Economics (2016 and 2021) underscored this concern, sounding the alarm for the future of the eye care market should VBMs continue to operate unchecked. 

“We’re going to see less access to care, higher prices and less transparency as these closed systems continue to amass power,” Dr. Lucas explained during the Patients Rising panel. “At this point, the VBMs pretty much exist to serve themselves, to serve their own profit-making initiatives, versus the patients or the doctors’ offices that are providing the actual care.” 

Dr. Lucas’ explanation echoed Patients Rising’s years-long fight against pharmacy benefit managers (PBMs).  

“Working in the PBM space a few years ago, patient advocates didn’t really know what PBMs were, but now they hate them more than anyone,” Patients Rising CEO Terry Wilcox shared in a briefing of optometry’s advocates at AOA on Capitol Hill in April 2024. “Patients don’t really know what’s happening to them, but they suspect something is up.” 

Federal scrutiny builds on VBMs 

The good news is that the AOA isn’t the only voice in this fight. Optometry’s advocates have built a weighty coalition of support to help canvas Capitol Hill and amplify the message that VBM reform is overdue.  

Patients Rising represents tens of millions of patients nationwide, advocating for reforms that return decision-making power to patients and their doctors. In addition to hosting optometry’s advocates in its VBM panel discussion in 2024, the group has committed its 110,000-member advocate network to intensifying the fight against VBM abuses. And they are not pulling any punches. 

“Like we see with pharmacy benefit managers, dental and vision benefit managers are out of control—and patients are literally paying the price,” Wilcox noted in a statement. “With only a handful of insurers dominating the market, their middlemen are hard at work setting prices and rigging a system that benefits only them at the expense of patients and our communities. The last place your insurer should be is in the exam room with you and your doctor.” 

The National Consumers League (NCL), America’s oldest consumer advocacy organization, also is championing reforms to prevent plans from dictating doctor-patient decision-making. NCL Executive Director Sally Greenberg joined Wilcox and optometry’s advocates for a Capitol Hill briefing on Sept. 9, 2024, where she referred to the current VBM paradigm as “troubling.” 

“It’s very concerning when patients can’t get the care they need by just walking in the door,” Greenberg told Hill staffers. “Instead, there’s the lack of transparency, then steering them to their own manufacturers, their glasses makers and then charging them these outrageous prices for what should be a very standard level of care. 

“We want patients and doctors to have the freedoms to use the labs they want to use,” Greenberg said. “All that closed circle, that concentration, the lack of transparency, is having a terrible impact on consumers. And that’s where we come in, and that’s where we speak out.” 

The chorus of voices joining optometry’s advocates continues to grow at a crucial time in Washington, D.C. Congressional awareness of VBM-related issues has never been higher, reflected in a string of federal developments illustrating the breadth of the AOA’s advocacy. 

It starts with key federal legislation. In February, longtime champions of VBM reform, Reps. Buddy Carter, R-Ga., and Yvette Clarke, D-N.Y., reintroduced the Dental and Optometric Care Access Act (H.R. 1521), and the bill is quickly gaining new bipartisan support. The legislation seeks to reduce costs and return control over health care decisions to patients and their doctors by banning: 

• VBM price-setting on noncovered services and materials 
• VBMs from restricting doctors and patient choice of optical lab 
• Never-ending, one-sided VBM contracts  

The DOC Access Act exclusively targets ERISA and other federally regulated plans, reinforcing vision and dental laws that are already on the books in most states. However, the act would be a crucial move, considering roughly one-third to one-half of plans operating in any given state can sidestep those state-level laws because they are federally regulated.  

Optometry’s advocates are no strangers to championing the DOC Access Act. Like all legislation, it takes time to develop awareness, build support and identify the right opportunity to advance it for a vote. And that opportunity may be approaching, considering Carter and Clarke now hold influential roles in Congress: Carter is chair of the House Energy and Commerce Health Subcommittee, and Clarke chairs the Congressional Black Caucus and is a leading member of the House Energy and Commerce Committee. 

“It is important that we continue to work toward affordable, accessible and high-quality health care for all Americans,” Carter stated. “The DOC Access Act moves us in the right direction by ensuring dentists and optometrists can make decisions that are best for them and their patients, not the insurance company.” 

Adds Clarke: “Every year, countless Americans are forced to confront inordinate roadblocks to the vision and eye care they need due to unnecessary restraints on their optometrists. People should always be empowered to make their own health care decisions, just as good doctors should always be available to carry them out.” 

But the DOC Access Act isn’t the only federal legislation to keep eyes on. On the Senate side, S. 5375, the Vision Lab Choice Act, proposed a prohibition on VBM optical lab and suppliers requirements. Introduced late in the last Congress by Sens. Chris Murphy, D-Conn., Kevin Cramer, R-N.D., and Markwayne Mullin, R-Okla., the bill would also limit contracts between doctors and plans for limited-scope vision benefits to two-year terms, unless the doctor chooses to extend for longer. The AOA supported the bill, as did Patients Rising, NCL and the Southern Christian Leadership Conference. The Vision Lab Choice Act had yet to be reintroduced in 2025 as of press time. 

Beyond legislation, a series of high-level congressional investigations are adding serious momentum to reform efforts. Over the past 24 months, three separate and expanding federal probes have taken aim at the growing influence and questionable practices of VBMs. 

• U.S. House Committee on Oversight and Accountability. In 2024, Committee Chair James Comer, R-Ky., called on the Department of Justice (DOJ) to evaluate the impact of VBM market consolidation and vertical integration with manufacturers and retailers on patients. This is the committee’s second such probe in as many years. In 2023, Comer requested information from the Federal Trade Commission (FTC) to document how VBM market consolidation affects consumer costs and choice. With Comer still leading the committee, both investigations are active and expanding in scope. 
• Government Accountability Office (GAO). Prompted by former Rep. Cathy McMorris Rodgers, R-Wash., and Rep. Brett Guthrie, R-Ky., who at the time chaired key health care oversight bodies, the House Energy and Commerce Committee formally requested a GAO investigation in 2024. The office was tasked with evaluating how vision and dental benefit manager consolidation, market concentration, and the acquisition of independent practices affect consumers, particularly in terms of pricing and access to health care providers 
• U.S. Senate Appropriations Committee. In August 2024, former Sen. Joe Manchin, I-W.Va., penned appropriations language that initiated a third federal investigation into VBM abuses, expressing concerns “that stand-alone vision and dental insurance plans may be using ERISA preemption authorities to avoid certain state laws that are meant to protect consumers and providers from abusive practices.” 

The investigation by the U.S. Senate Appropriations Committee came as a direct result of legal developments that have escalated to the nation’s highest court. In May 2024, the U.S. Supreme Court agreed to review an appeal by Oklahoma’s insurance commissioner, challenging a 10th Circuit Court of Appeals ruling that preempted state laws regulating PBMs. The commissioner argued that the court’s decision effectively granted PBMs a “get-out-of-state-regulation-free card.”  

In June 2024, the AOA, the American Dental Association and several other health care provider organizations jointly filed an amicus brief in support of the state of Oklahoma, seeking to reverse a lower court decision allowing federal ERISA rules to supersede state regulation of insurance plans. At least 31 states and Washington, D.C., back the review of the decision. 

What exactly is on the line here? If the Supreme Court overturns the 10th Circuit Court decision, then ERISA plans will need to comply with the state laws they are providing benefits in, ensuring all patients receive the same legal protections.  

“Unfortunately, we know that VBMs will try and bend the laws whenever they can to get out of following the rules and regulations that the rest of us need to follow,” says Steven Eiss, O.D., AOA Third Party Center Executive Committee chair. “The use of the ERISA laws to get out of following state consumer protections laws is just another example of this. It would be paramount for the SCOTUS to overturn the lower court decision and require all VBMs to follow state laws. 

“When the state legislators determine that these protections are needed based on the past behavior of these plans, there should not be a loophole for these plans to utilize to get out of complying in order to increase their own profits to the detriment of the patients we care for,” he says. 

Time to Shift the Paradigm 

For too long, VBMs have used their market dominance to impose terms and policies that primarily benefit payers—often at the expense of optometry practices. Even five years ago, an AOA Health Policy Institute (HPI) survey revealed that 70% of practicing doctors of optometry had not received a fee schedule increase from their largest vision plan in the previous five years. One-third reported never having received a rate increase.  

That same HPI report concluded that vision plan fee schedules are often comparable with Medicaid, which is usually the lowest payer in health care. The authors of the report stated: “Doctors may be expected to contribute to the public good by seeing  

Medicaid patients at reduced rates, but no such goodwill should be required to subsidize billion-dollar vision plans.” 

If stagnant fee schedules are the rock, then inflation is the hard place, and optometry practices are caught in between. Costs could ultimately leave patients with less access and fewer choices. Without reform, it’s a lose-lose scenario for both providers and patients.