Hospital Program Restores Vision, Cuts Costs for the Underinsured

A hospital-based program that provides essential, medically necessary ophthalmic specialty services at no cost to patients with little to no insurance coverage successfully reduced disparities in vision care by restoring functional vision for patients while reducing their economic burden, according to a prospective cohort analysis of the ACCESS (Alleviating Costs for Critical Eye Specialty Services) program.

Ophthalmologists and optometrists at Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG), combined with medical students and volunteers from the University of California, San Francisco, created ACCESS to address disparities in access to eye health for vulnerable groups, reflecting broader principles championed by global eye health commissions: identifying cost-effective interventions, responding to community needs, and reducing out-of-pocket costs for targeted treatments to close gaps in vision-health equity.¹

“In eye care, inadequate coverage delays or prevents effective treatment of sight-threatening conditions,” the authors explained. “This leaves vulnerable, under-resourced patients at greater risk for visual impairment and associated functional limitations that interfere with daily living, which could otherwise have been avoided.”

Underinsured Patients at Risk of Vision Loss

Inadequate coverage often delays or prevents effective treatment for sight-threatening conditions. This leaves under-resourced patients at greater risk for visual impairment and the functional limitations it can cause, which could have otherwise been avoided. The study notes that the national burden of vision loss in 2022 exceeded $130 billion, with California accounting for $13.5 billion of those costs.

An estimated 6.5 million adults enrolled in Medicaid live in states without comprehensive coverage for routine eye exams, and 14.6 million live in states without comprehensive coverage for glasses, according to a 2024 Health Affairs study.³

ACCESS was developed in response to a pressing need for coverage of key treatments that would substantially improve patient outcomes and quality of life. Targeted services include scleral, rigid gas-permeable (RGP) lenses, soft contact lenses, and prescription glasses. Additionally, compounded eye drops such as autologous serum tears, fortified antibiotics, topical chemotherapy, and low-dose atropine.

Eligible patients are identified by ophthalmologists based on financial need and clinical indications, such as corneal ectasia, corneal opacity, dry eye conditions, refractive error of non-corneal origin, and other ocular pathology. Those requiring refractive correction are referred to on-site optometrists or contracted off-site providers for evaluation and dispensing of appropriate contact lenses or eyeglasses at no out-of-pocket cost to the patient.¹

ZSFG Built a Cost-Coverage Model for Eye Care

Among all ACCESS patients, 72 (63.2%) completed treatment, accounting for a total of 121 eyes. Among eyes that completed treatment, corneal ectasia was the leading indication (58 eyes, 47.9%), followed by corneal opacity (25, 20.7%). Of the 72 treated patients, 48 (66.7%) were visually disabled in at least one eye before treatment, versus only 4 (5.6%) after (P < .0001, McNemar's test). Mean visual acuity improved by 5 Snellen lines (from 20/125 to 20/30, P < .0001, paired t-test), with most patients achieving a clinically significant ≥ 0.2 logMAR (a standard vision-acuity scale) improvement, and some improving by as much as 2.0 logMAR.

In the next 25 years, cases of vision impairment in the US are on track to roughly double, driven by an aging population. The leading cause of vision impairment is uncorrected refractive errors, which can be addressed by enhancing the diagnosis and treatment of the condition through expanded access to routine vision care.³

Of the patients ACCESS treated, 30 had keratoconus. With an estimated 325 to 330 total people living with keratoconus in San Francisco based on national prevalence rates, the program likely reached roughly 9% of the city's estimated keratoconus population. Using a per-person annual cost-of-disability estimate, the 48 disabled patients represented an estimated $808,224 annual economic impact before treatment; restoring functional vision in 44 of them corresponds to an estimated $720,852 annual reduction. As compounded eye drops can't normally be dispensed outpatient at ZSFG, patients needing them (eg, for severe infectious keratitis) would otherwise require inpatient admission, which averaged 7 days at $4471/day in California, meaning ACCESS's partner pharmacy avoids an estimated $31,000 per patient by enabling outpatient access.

Corneal ectasia also carries an estimated lifetime cost of greater than $43,000 per patient. Applying these estimates to treatments delivered through ACCESS yields a projected annual cost savings to patients of roughly $79,000 to $112,000 USD, comprising 70 eyes treated with scleral lenses, 33 eyes with RGP lenses, 2 patients with soft contact lenses, 5 patients with compounded medications, and one patient with glasses. Beyond quantitative measures of cost savings and reductions in disability burden, the ACCESS program showed substantial improvement in patients’ quality of life.¹

Single-Site Study Limitations

The authors noted the study has several methodological limitations. There was no control group, so the study can't establish causation. Standardized quality-of-life, employment, and functional-independence measures weren't collected, which limited how fully the broader impact was captured. Pre-ACCESS care was fragmented (multiple vendors, ad hoc charitable routes) and untracked, part of why there's no institutional baseline to compare against.

As ACCESS is a single-site program at a safety-net hospital, study findings may not be generalizable to other populations or health care systems. The sample size was modest, and treatment completion at the time of analysis was impacted by practical barriers such as scheduling delays and loss to follow-up. Additionally, this evaluation was not designed as a randomized clinical trial, but instead as a pragmatic cohort study grounded in implementation science, aimed at examining real-world care delivery in under-resourced settings and how systemic barriers can be overcome to meet community needs.

Is ACCESS Scalable to Other Safety-Net Hospitals?

The ACCESS program offers a scalable model for expanding access to specialty care and reducing disparities in vulnerable populations. Notably, the model is adaptable beyond ZSFG. In the US, approximately 25% of hospitals qualify as safety-net institutions, defined as medical centers with the highest proportion of Medicaid and uninsured discharges. ACCESS has secured over $700,000 in support total, including approximately $250,000 of initial funding in 2021, and partnerships are continued to be pursued with the city and county health systems, community groups, and nonprofits to extend its reach.

The authors noted that the California Department of Health Care Services has also launched the Mobile Optometric Services Program to provide no-cost vision screening, exams, and glasses in school settings. At the federal level, proposals have also been introduced to expand Medicare coverage to include vision services.

“Together, these state and federal efforts underscore growing recognition of the importance of vision coverage, while also highlighting persistent gaps and administrative barriers that can leave patients insufficiently covered for high-impact specialty interventions,” the authors wrote.

References

1. Morton RA, Pak IJ, Tang AS, et al. Alleviating Costs for Critical Eye Specialty Services (ACCESS): a prospective cohort analysis of a cost-coverage program at a public safety-net hospital. Lancet Reg Health Am. 2026;57:101450. doi:10.1016/j.lana.2026.101450
2. Klein H. Gaps in Medicaid vision care coverage leave millions without essential services. AJMC^®. August 13, 2024. Accessed August 12, 2026. https://www.ajmc.com/view/gaps-in-medicaid-vision-care-coverage-leave-millions-without-essential-services