Supporters say new federal report provides a green light for VBM accountability legislation

In its newly released report examining the vision benefit middleman (VBM) industry, the Government Accountability Office (GAO)—Congress’ independent investigative arm—has, for the first time, documented the structure and concentration of control in the marketplace, spotlighting the urgent need for comprehensive reform.  

The GAO’s findings reveal extraordinary levels of market power dominance and limited transparency. In some states, the three largest VBMs control as much as 95.5% of the employer-based vision benefits market, with a single plan controlling more than 80% in certain states. Even at the median level nationwide, the three largest VBMs control more than three-quarters of the group market. In the individual market, concentration is even higher—reaching as much as 98.8% market control by the three largest plans in some states. 

The findings underscore serious concerns among policymakers in the nation’s capital and in state capitals about ensuring competition, accountability and patient choice within the vision benefits system. 

“The report not only validates longstanding concerns about the VBM industry but it also goes even further by putting forward important new questions for that industry to have to answer,” says Jacquie M. Bowen, O.D., AOA president. “Over the next few days, through our AOA on Capitol Hill mobilization, hundreds of doctors of optometry will be in Washington, D.C., to meet with and urge their U.S. Senators and House members to support the bipartisan DOC Access Act and to continue to actively investigate VBM abuses.”  

Lawmakers call for Congress to act 

Leading lawmakers are already calling for VBM accountability legislation to be prioritized and cite the GAO as providing a critical green light for Congress to act.       

"In its blockbuster report released this week on growing consolidation and vertical integration in the vision benefits industry, the GAO made clear that a very small number of VBMs are in near-total control of the vision care market and are seemingly operating in the shadows at the expense of patients, independent providers and local communities,” says Rep. Buddy Carter, R-Ga. "Our families deserve better; we need full VBM transparency and accountability, reinstatement of real choice, and a working market that helps drive down costs and provides patients with the access to care they want and need. While Congress and federal regulators double down on VBM investigations, these findings make clear that it's time to pass my legislation, the DOC Access Act, to help bring some sanity back into this market." 

“The GAO’s new report should be a wake-up call for Congress and the American people, that during a time where health care is becoming even less equitable, that just a handful of large companies control a huge share of the vision care market through Vision Benefit Managers, and that power is driving up costs while limiting where patients can go for care," says Rep. Yvette Clarke, D-N.Y. "Families deserve the freedom to choose their own eye doctor and receive the care they need without hidden rules or middlemen getting in the way. That’s why I’m proud to lead the DOC Access Act, which will crack down on these abusive practices and bring fairness and transparency back to the system. It’s time to put the power back in the hands of the patients and their doctors, not insurance executives."  

Rep. Brett Guthrie, R-Ky., chair of the U.S. House panel with jurisdiction over VBM reform legislation, championed the study to help inform Congress’s consideration of the issue. In a 2024 letter to the GAO, Rep. Guthrie tasked officials with producing a “study that details the state of consolidation and vertical integration in the vision and dental benefits industries…and evaluate[s] the impacts of such consolidation and vertical integration on consumers and independent health care practices.” 

Warning signs 

As now documented by the GAO, the AOA and other patient advocacy organizations, several warning signs demand attention from Congress and state policymakers: 

• Extraordinary market concentration. In many states, a small number of vision benefit administrators dominate the marketplace, limiting meaningful competition and concentrating decision-making power over patient access to care.
• Insufficient transparency and oversight. The GAO notes that the complexity of ownership structures, business relationships and plan operations makes it difficult for regulators, employers and patients to fully understand how these entities operate or influence the marketplace. 
• Growing vertical integration. The largest vision benefit administrators increasingly control multiple layers of the vision care system—from insurance products to provider networks and retail operations—creating potential conflicts that can restrict patient choice and steer care. 
• Rising pressure on patients and doctors. With so much market power concentrated among a few plans, doctors often face restrictive contract terms in order to treat patients covered by those plans, while families encounter confusion, fewer provider options and increasing costs. 

Patient advocacy groups say the findings also reinforce the need for even greater scrutiny of the VBM industry.  

“The GAO report raises important questions about how vision and dental insurance markets operate and whether growing consolidation may affect patient choice and provider independence,” says Terry Wilcox, executive director of Patients Rising, a strong supporter for the AOA-backed DOC Access Act. “When a small number of companies control large portions of a market while participating in multiple parts of the system, it is reasonable for policymakers to ask whether the system is working as intended for patients. Congress should take these findings seriously and continue examining how vision benefit managers operate.”  

A critical moment 

As part of their thorough approach to the task of informing members of Congress, GAO investigators specifically cast doubt on a key element of competition data put forward by an industry source, possibly to indicate a far lower VBM market share.  According to the GAO, the industry study findings “differed from ours in part because the study was based on a broader definition of the vision insurance market … and included vision care transactions from self-pay consumers who did not use vision insurance.” 

Taken together, there is now further confirmation of what doctors and patients have been experiencing: the vision benefits market is becoming increasingly consolidated, complex and difficult to navigate. 

The report arrives at a critical moment as more than 220 million patients with vision benefits and doctors increasingly confront the growing control of vision benefits by a small number of powerful plan administrators and the array of harms being faced by patients due to individual decision-limiting tactics and strategies, including fewer and fewer choices about their care, restricted and discouraged access to doctors of their choosing and dramatically increasing costs.  

If you experience payer issues, please contact stopplanabuses@aoa.org to enlist AOA support on your behalf.