Executive Summary

The American Optometric Association (AOA), with more than 36,000 members in 6,500 communities across the nation, remains committed to serving America’s veterans, including those blinded and vision disabled. Today, thousands of highly trained doctors of optometry now provide a critical array of high quality care, prevention, treatment and rehabilitation options to our veterans through Department of Veterans Affairs (VA) service and affiliations in the field and at hundreds of in-patient and out-patient facilities across the nation and throughout the world.

Today, the AOA is appreciative for the opportunity to provide testimony and we applaud the introduction of The Blinded Veterans Adapted Housing Improvement Act of 2010 (HR 5360). We believe that this important effort would provide a much needed update to Special Housing Adaptations (SHA) grant requirements by applying an appropriate standard of visual acuity for eligibility. The standard currently applied to SHA requirements is four-times the known and documented standard for recognizing blindness. We believe that this definition can and must be fixed.

Currently, the law governing SHA requirements states that disabled veterans or servicemembers would be entitled to compensation for permanent and total service-connected disability due to blindness in both eyes with a 5/200 visual acuity or less, or the anatomical loss or loss of use of both hands, or the permanent and total disability due to a severe burn injury. However, AOA believes that the requirement of 5/200 visual acuity or less is excessive and not in-line with recognized standards, which typically identifies blindness as 20/200.

AOA fully supports the changes proposed by The Blinded Veterans Adapted Housing Improvement Act of 2010, which would modify the extreme 5/200 visual acuity or less requirement to 20/200 visual acuity or less, the recognized standard. AOA would further recommend that the language also recognize the use of a standard correcting lens. AOA believes that the word “standard “ should be inserted before “correcting lens” in order to create an important allowance for the use of rehabilitative low vision adaptive medical devices

(e.g. specialty or non-standard correction) without cause for veteran discrimination of the important benefits afforded by this legislation.

The AOA knows that veterans seriously disabled during their service to our country have earned the SHA benefit and the updates sought would help ensure that worthy veterans receive this important assistance on behalf of a grateful nation. We fully support the changes proposed by The Blinded Veterans Adapted Housing Improvement Act of 2010 and look forward to working with Congress to pass this legislation and provide needed assistance to our disabled veterans.

Introduction

The American Optometric Association (AOA) appreciates the opportunity to provide our views on the “Blinded Veterans Adapted Housing Improvement Act of 2010 (HR 5360), which seeks to modify the standard of visual acuity eligibility for specially adapted housing assistance.” We commend you, Chairwoman Herseth Sandlin, Ranking Member Boozman -an esteemed colleague, and Members of the Subcommittee, for the leadership and vision you have shown as you continue working to make certain that America fulfills her promise to all veterans, including ensuring full access to the vision and eye health care services they need and deserve.

AOA optometrists remain committed to serving America’s veterans. Many years ago, we proudly supported the creation of the Veterans Health Administration (VHA) Optometry Service. And, during the more-than-a-quarter century since its inception, the Optometry Service has evolved into providing the majority of primary eye care and low vision rehabilitation services for our nation's veterans. Today, thousands of highly trained doctors of optometry now provide a critical array of high quality care, prevention, treatment and rehabilitation to our veterans through Department of Veterans Affairs (VA) service and affiliations in the field and at hundreds of in-patient and out-patient facilities across the nation and throughout the world.

We thank this Subcommittee for the opportunity to provide testimony today and applaud the introduction of The Blinded Veterans Adapted Housing Improvement Act of 2010. We believe that this important effort would provide a much needed update to special home adaptations grant requirements by applying an appropriate standard of visual acuity for eligibility. The AOA knows that veterans seriously disabled during their service to our country have earned this benefit and the updates sought would help ensure that worthy veterans, including those blinded and vision disabled, receive this important assistance on behalf of a grateful nation.

Special Home Adaptations

Congress developed the Special Housing Adaptations (SHA) program to provide assistance to a growing number of American servicemembers injured on the field of battle during the most recent overseas operations, including thousands returning home with combat eye trauma and vision disorders. The program was also designed to address and provide a level of assistance and independence for an aging population of disabled veterans from previous wars and conflicts with aged-related physical impairments, including vision disorders and related diseases of the eye.

Through these grants, certain veterans or servicemembers with specific service-connected disabling conditions are entitled to VA funding for purposes of adapting an existing dwelling to meet their specific needs. The SHA grant is generally used to assist veterans with mobility throughout their homes. An eligible veteran or servicemember may receive an SHA grant for the actual cost to adapt a house or for the appraised market value of necessary adapted features already in a house when it was purchased. Under this entitlement, a temporary grant (TRA) may also be available to veterans who are/will be temporarily residing in a home owned by a family member.

Currently, the law states that disabled veterans or servicemembers would be entitled to compensation for permanent and total service-connected disability due to blindness in both eyes with a 5/200 visual acuity or less, or the anatomical loss or loss of use of both hands, or the permanent and total disability due to a severe burn injury. Overall, the program has been highly successful among disabled veterans with the VA averaging about 1,000 adaptive housing grants applications per year. AOA also applauds this Committee and Congress for passing legislation in 2008 which removed the one-time use limit and now allows eligible veterans or servicemembers to use the benefit up to three times, so long as the total grant stays within the specified limits of the law.

In the coming months and years, the AOA anticipates that even more of these grants and other like initiatives will be needed to assist severely injured soldiers as they attempt to adjust to life back at home and with a disability. AOA is thankful that with the advent of new and improved body armor that protects vital organs and the skull; many more servicemembers are surviving battlefield injuries. But troops' eyes and limbs remain particularly vulnerable to the blizzard of shrapnel from new and more damaging types of explosions and the data shows that many returning home are impacted with eye trauma or disorders affecting vision, including Traumatic Brain Injury (TBI).

In fact, according to the DOD Global War on Terrorism Casualties Web site, from Oct. 7, 2001 to May 29, 2010 there have been 36,230 Operation Iraqi Freedom (OIF) and 7,217 Operation Enduring Freedom (OEF) servicemembers wounded in action and this number continues to grow with the current battles in Afghanistan. With an ever aging veteran population from previous conflicts and a growing number of wounded returning home from recent overseas operations, this and other programs will be critical to providing freedom and independence at home for America’s veterans while cutting overall health care costs. If disabled veterans are not able to make adaptive changes to their homes, they run the risk of falls and injuries that result in expensive emergency room and costly hospital admissions.

Recommendations

The AOA applauds the creation and Congress’ ongoing and increasing support for the Special Housing Adaptations grant program. We believe this and other like programs provide a vital link for our wounded warriors and help them gain some sense of normalcy as they adjust to civilian life and a new disability. However, AOA is concerned that the currently used requirement that a veteran must have a service-connected disability due to blindness in both eyes with a 5/200 visual acuity or less, is not in-line with recognized standards and, as a result, is denying severely injured veterans an earned benefit and needed assistance. In fact, a 5/200 visual acuity or less requires veterans’ visual status to be four-times worse than that of most other recognized definitions of blindness.

Congress has already established a precedent for improving veterans’ law when it updated the definition of blindness as it relates to low-vision matters. Congress made an important change to Title 38, when it enacted a modification of the rate of visual impairment for payment of disability compensation by striking 5/200 and inserting 20/200. Other Federal agencies, such as the Centers for Disease Control and Prevention, define blindness as follows:

(42 USC §416(i)(1)(B) [T]he term "blindness" means central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes in this paragraph as having a central visual acuity of 20/200 or less.

AOA believes that the important differences including, 1) a visual acuity of 20/200 as opposed to a four-times worse requirement of 5/200 and 2) the use of a qualifying statement, “with the use of a correcting lens” are both critical elements. The qualifier “with the use of a correcting lens” , is necessary in order to disqualify veterans who would demonstrate this reduced level of vision simply due to standard uncorrected refractive error (e.g. uncorrected myopia, hyperopia or astigmatism) that could otherwise be corrected with a correcting lens.

Therefore, the AOA recommends that the final language of The Veterans Adapted Housing Improvement Act of 2010 read: Section 101(b)(2)(A) of title 38, United States Code, is amended by striking ‘‘5/200 visual acuity or less’’ and inserting ‘‘20/200 visual acuity or less, in the better eye with the use of a standard correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes in this paragraph as having a central visual acuity of 20/200 or less”.

The AOA believes that the word “standard “ should be inserted before “correcting lens” in order to create an important allowance for the use of rehabilitative low vision adaptive medical devices (e.g. specialty or non-standard correction) without cause for veteran discrimination of the important benefits afforded by this legislation. In doing so, this action will bridge any barriers to vision rehabilitation that a service member may have because they do not want to use adaptive medical devices that may improve their vision, disqualifying them from important benefits afforded in this legislation. As a matter of fact, a word insertion of “standard” will allow a veteran fit with low vision adaptive medical devices, the use of which may temporarily improve the visual function above these stated threshold levels of acuity or visual field, the important ability to access the benefits contained within the Blinded Veterans Adapted Housing Improvement Act of 2010.

Furthermore, the AOA would like to bring to your attention data that further supports the Blinded Veterans Adapted Housing Improvement Act of 2010.

Visual impairment is strongly associated with falls and hip fractures1234. This can be due to a number of associated vision and eye health problems, including poor visual acuity, reduced visual field, impaired contrast sensitivity and cataract2. In the Blue Mountain Eye Study both impaired vision and reduced visual field were found to double the risk of falls. For those aged 75 or older, moderate visual impairment was associated with a nine-fold increase in risk of hip fracture during the subsequent two years2. As such, we believe that the Blinded Veterans Adapted Housing Improvement Act of 2010 may serve to reduce health care costs of our veterans.

Conclusion

In conclusion, the AOA applauds the important work of this Subcommittee in crafting the Blinded Veterans Adapted Housing Improvement Act of 2010 and will remain available for any additional advice or consultation that may become necessary through your deliberations. Again, we commend you, Chairwoman Herseth Sandlin, Ranking Member Boozman, and Members of the Subcommittee, for the leadership and vision you have shown as you continue working to make certain that America fulfills her promise to all veterans, including ensuring full access to the vision and eye health care services they need and deserve. The AOA and doctors of optometry around the country remain committed to serving America’s wounded warriors and we look forward to working with this Committee now and in the future to help ensure that veterans seriously disabled during their service to our country, including those blinded and vision disabled, receive every benefit and any assistance they may need on behalf of a grateful nation.

1 Abdelhafiz, A.H. and Austin, C.A Visual factors should be assessed in older people presenting with falls or hip fracture Age and Ageing, 32, 26-30, 2003

2 Ivers RQ, Cumming RG, Mitchell P et al. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J. Amer Ger. Soc. 46(1): 58-64, 1998

3 Cummings SR. Treatable and untreatable risk factors for hip fracture. Bone 18(3 suppl): 165S-167S, 1996

4 Jack DI, Smith T, Neoh C et al. Prevalence of low vision in elderly patients admitted to an acute geriatric unit in Liverpool: elderly people who fall are more likely to have low vision Gerontology, 41, 280-5, 1995