On a beautiful summer day a few months ago, I walked down to the part of the Connecticut River that separates Vermont from New Hampshire, and rented a kayak. I pushed myself off the dock—and the next thing I remember is being underwater. Somehow, the kayak had capsized as it entered the river. I tried to swim up, toward the light, but found that my own boat blocked my way to safety. Doing my best not to panic, I swam down and away before finally coming up for air a few yards downriver. I clambered onto the dock, relieved to have found safety, but I was disturbed to find that the world was a blur. Could the adrenaline rush have been so strong that it had impaired my vision? No, the answer to the puzzle was far more trivial: I had been wearing glasses—glasses that were now rapidly sinking to the bottom of the Connecticut River.
If the whole experience was, in retrospect, as funny as it was scary, the most annoying consequence was the need to regain the faculty of sight. I did not have any backup glasses or spare contact lenses on hand. The local optometrists did not have open slots for an eye exam. Since the United States requires patients to have a current doctor’s prescription to buy eyewear, I was stuck. In the end, I had to wear my flowery prescription sunglasses—in offices and libraries, inside restaurants and aboard planes—for several days.
Then I went to Lima, Peru, to give a talk. There, I found a storefront optician, told a clerk my strength, and purchased a few months’ worth of contact lenses. Though my Spanish is rudimentary, the transaction took about 10 minutes.
The ordeal led me to look into a fact that has puzzled me ever since I moved to the United States a dozen years ago. In every other country in which I’ve lived—Germany and Britain, France and Italy—it is far easier to buy glasses or contact lenses than it is here. In those countries, as in Peru, you can simply walk into an optician’s store and ask an employee to give you an eye test, likely free of charge. If you already know your strength, you can just tell them what you want. You can also buy contact lenses from the closest drugstore without having to talk to a single soul—no doctor’s prescription necessary.
So why does the United States require people who want to purchase something as simple as a curved piece of plastic to get a prescription, preceded by a costly medical exam?
The standard argument in favor of the American status quo is that impaired vision may point to serious health problems that a new pair of glasses will neither treat nor heal. Compelling Americans to see an optometrist helps to ensure that the largest possible number of cases of progressive eye diseases will be caught at an early stage.
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As Barbara Horn, O.D., the president of the American Optometric Association (AOA), told me, “Today, at least 2.2 billion people around the world have a vision impairment, of whom at least 1 billion have a vision impairment that could have been prevented or has yet to be addressed … That’s why it’s clear to health experts, policymakers, the media, and the public that increased access to eye exams and eye doctors are needed to safeguard health and vision.”
But this argument rather begs the question. After all, the added cost of having to see an optometrist presumably stops many Americans from accessing the corrective lenses they need to improve their vision. Is the desirability of an eye exam performed by a medical professional a sufficient reason to prevent Americans who would rather not—or cannot—visit an optometrist from buying glasses and contacts? We can only answer this question by acknowledging a trade-off between competing goods.
On the one hand, some number of Americans who visit an optometrist to get a new prescription will indeed discover that they have a serious condition that requires immediate care. On the other hand, it is likely that a much greater number keep wearing glasses that are too weak—or won’t wear glasses at all—because they want to avoid the cost, time, or stress of a visit to a doctor.
I have not been able to find any studies that credibly assess how this barrier affects Americans’ quality of life. But it’s reasonable to assume that it has an adverse impact on many people, especially underprivileged Americans—those who don’t have insurance, have little cash, or lack the social or financial capital to navigate our country’s byzantine medical system.
How many thousands of Americans go through life seeing less well than they might because they don’t have an up-to-date prescription? How many students do poorly in school because they can’t read what’s written on the blackboard? And how many accidents are caused by drivers who can’t see the road as well as they should?
One possible reason for such strict vision-wear rules is that many people have a financial interest in this burdensome system. If Americans no longer needed to book appointments with optometrists to buy glasses or contacts, many optometrists would see their salaries cut, and some might go out of business altogether.
Optometrists are also a source of revenue for opticians, from large chains like Specsavers to independent stores in malls and town centers across the United States. Since they often work on-site, they have an incentive to nudge their patients to buy the products on hand.
When I last went to an eye exam at a storefront optician in the United States, for example, the staff gave me the hard sell on glasses that would have cost hundreds of dollars, as well as on contact lenses that were much more expensive than identical ones sold by online retailers. Thankfully, I knew that two laws, one passed in 1997 and the other in 2003—which had, incidentally, been loudly opposed by the AOA—gave me the right to demand a copy of my prescription. I stood firm, and later went online to order perfectly fine glasses and contact lenses at a fraction of the price. But how many customers give in to heavy-handed sales tactics?
It is little wonder, then, that American optometrists spend a lot of money on lobbying. According to the Center for Responsive Politics, for example, the AOA spent $1.8 million on lobbying and another $1.4 million on campaign contributions in 2016. And although the AOA was unsuccessful in its attempt to block the laws requiring optometrists to give patients a copy of their prescription, any attempt to remove the need for frequent office visits (the exact figure depends on whether you wear glasses or contacts, among other factors) is likely to meet with stiff resistance.
Like the citizens of virtually every other country around the world, Americans should be allowed to buy any pair of glasses or set of contact lenses at a moment’s notice. While the requirement to get a medical exam from an optometrist who has spent a minimum of seven years in higher education may have good effects in some cases, it also creates unreasonable costs—and unjustifiable suffering.
Even in times of extreme polarization and a deeply broken Congress, this is one piece of sensible legislation that should be able to command bipartisan support. Republicans who believe in the free market should look on this red tape as an unnecessary intrusion on free enterprise. Democrats who care about the well-being of the socioeconomically disadvantaged—and are worried about the health disparities between different ethnic groups—should be outraged by the unreasonable burden the situation places on underprivileged Americans.
Put Americans in charge of their own vision care, and abolish mandatory eye exams.