This is the brick wall we have run up against. The wording in the Federal statute is used as the justification for this kind of thing. Now, optometry has a lot to add and a lot to contribute to the vocational rehab programs in the States. I think this highlights the kind of problem that we run into.

When you think about the problem, the factor that some of these clients have to wait many months in order to see an ophthalmologist when optometrists are specifically trained to render this type of service and are State licensed to do so, when you think they are competent members of the health team and Congress has certainly recognized this is so in providing funds for training, it just does not add up. This is an inequity in the present statute that we would certainly like the committee to most carefully consider when this bill is reported out and marked up.

Now, I would like also now to make a few remarks

The CHAIRMAN. You say you filed a statement before the House committee but did not appear in person?

Dr. MCCRARY. No, sir. Frankly, Senator, we were a little late. When we studied the bill and considered the import and began to consider the fact that it was about time we tried to get this vocational rehabilitation problem straightened out, the hearings had already been scheduled. We were not able to get a live witness, but we did manage to file a statement for the record.

Now, the importance of good vision care, I could talk about for months and I realize we have only a very few minutes. But I think it is important to realize that to the effectiveness of a rehabilitation program, vision is an extremely important factor. That is not the only factor. There are a lot of important factors, but one of them is vision. Optometrists are capably trained. They are federally recognized, they are State licensed to render a broad variety, a broad spectrum of vision care services. Some of the rules and regulations of the department unfortunately inhibit this utilization. To that extent, we feel it decreases the potential effectiveness of the programs.

Optometry is a valuable member of the health care profession and I am very pleased to say that we are currently in the process of establishing a school of optometry at the University of Alabama. This program is now about 2 years along and this is of course a result of the Health Education and Professional Assistance Act. This school will be graduating fine young men who are going into optometry. We need to make maximum utilization of all areas. These factors we think are extremely important.

There is one additional comment I would like to make. When we think of vocational rehabilitation or visual impairment, a lot of people think right away of blind persons. There is a type of adjustment and rehabilitation program which is particularly designed to have maximum effectiveness for blind persons. But even between the blind and the normally sighted, if we may use that term, there are a great number of people who fall within what we call partially sighted. Secretary Cohen, Wilbur Cohen of the Department of Health, Education, and Welfare, in a recent speech said there are about 400,000 blind persons in the United States and the best estimate they have is that there are at least three and a half million partially sighted. So we are talking about a great bulk of people, not a few people. Even those who have rehabilitation problems which are

not specifically visual in origin, the proper care will have a great deal of effect upon their capacity to learn and acquire new skills and to learn to manage such situations.

So I simply want once again to highlight the importance of good vision care, the interest that my profession, has, the desire that we have to work cooperatively with other professions in strengthening these programs.

(The prepared statement of Mr. Fleming follows:)

PREPARED STATEMENT OF PAUL N. FLEMING, O.D., WISCONSIN RAPIDS, WIS., REPRESENTING THE AMERICAN OPTOMETRIC ASSOCIATION

Mr. Chairman and members of the Committee: I appreciate this opportunity to present views of the American Optometric Association on H.R. 16819, the Vocational Rehabilitation Amendments of 1968.

I am Dr. Paul Fleming, a practicing optometrist in Wisconsin Rapids, Wisconsin. A copy of my resume is attached to this statement for your information.

In 1955, the Congress demonstrated its awareness of the need for sound programs in the field of vocational rehabilitation by enacting the major provisions of the present law which has provided an excellent framework for constructive programs. These programs have enabled thousands of individuals throughout the nation to lead more productive lives.

Members of the American Optometric Association agree that rehabilitation programs require expansion and extension, to assure better services for more individuals needing assistance. It is in the spirit of co-operation and assistance that we present our thoughts and recommendations today.

AOA's amendments will assure the availability of optometric services for individuals whose visual impairments prevent them from participating in useful vocations.

The recently published Monograph No. 4 of the National Institute of Neurological Diseases and Blindness, titled "Vision and Its Disorders," emphasizes throughout the hardships and costs created by blindness. Its introduction states: "Costs to this Nation in suffering and loss of productivity from eye damage. short of blindness, are also commanding. the economic costs of visual impairment are equivalent to those of blindness itself . .

The National Institute for Neurological Diseases and Blindness contends that anyone whose vision is not correctable to 20/20 is visually handicapped.

In a 1966 speech then Under-Secretary Wilbur Cohen of the Department of Health, Education and Welfare, said: "Today, in the United States, there are about 400,000 blind persons and 32 million persons with only partial vision." The definition of blindness adopted by States participating in NINDB's Model Reporting Area for Blindness Statistics (MRA) is: "Visual acuity of 20/200 cr less in the better eye with best correction, or visual acuity of better than 20/200 if the widest diameter of the field of vision subtends an angle no greater than 20 degrees." We in optometry hold the conviction that anyone with minimal residual vision can usually improve his functional vision by the application of modern optometric science, techniques and specialized optical aids.

Optical aids represent only one means of rehabilitating individuals with limited vision. Optometrists continue to make major contributions in the area of visual rehabilitation through imaginative use of visual training for individuals of all ages. In dealing with debilitating visual impairments of the aging, optometrie visual training techniques can be highly effective, especially when coupled with psychological or psychiatric treatment designed to instill the necessary motivation in the patient.

An example of visual rehabilitation benefits is O. B. Minner, who served as ( Special Consultant with the Oklahoma League for the Blind. Legally blind, (Visual acuity of 5/200) he is a graduate of the Oklahoma School for the Blind. He subsequently earned a bachelor's degree from the University of Oklahoma, then his M.A. and Ph.D. in philosophy and psychology from Harvard. Writing in the October-November 1964 issue of the California Optometric Association Journal, this gentleman stated: "For thirty-five years I have been a living example of the benefits of optical aids-during that time I have read literally tons of printed and written material through a 20x lens with a focal distance of one half inch." This is an example of visual rehabilitation in its most dramatic

form. No one would expect every person who undergoes an optometric examination and is fitted with optical aids would go on to such a level of academic achievement. Such examples, however, do support the position that individuals who may have otherwise been written off as "blind" can be visually rehabilitated and subsequently make tangible contributions to society.

Several studies show that optometric low-vision clinics have successfully helped 70 per cent of their patients with use of optical aids. The Industrial Home for the Blind in Brooklyn, N.Y. reported that 68% of its 500 patients had been successfully fitted with optical aids. While a higher success ratio would be desirable, 68% represents a sizeable number of patients who, through optical aids, were rehabilitated to a point they were visually capable of performing some type of work. Why, then, have so few optometric low-vision clinics been established?

There are many reasons, but probably the major one is that such clinics are usually dependent upon the participation of optometrists. However, even those optometrists who have demonstrated proficiency in this highly specialized field of low-vision rehabilitation have been discouraged from trying to establish clinics. How does this discouragement come about? It comes right back to the public law under which vocational rehabilitation programs are presently administered, and the following statement contained in Chapter 19, Part 5, Number 4 of the Vocational Rehabilitation Manual issued in 1955 by the Department of Health, Education and Welfare:

"Diagnostic and treatment services for clients with any type of visual impairment should be provided by, or under the direction of, qualified ophthalmologists. Upon the recommendation of the examining physician, State agency policies may permit referral of clients to licensed optometrists for eye examinations and the provision of those services in which they have special training (i.e., prescribing lenses, orthoptics and other aids to subnormal vision), provided that there is some assurance that there is no eye disease present or that some general physical condition is not present which might affect the individual's vision."

While the language quoted seems to make adequate provision for vision rehabilitation services by optometrists, we have found that in actual practice relatively few referrals are made to optometrists. Further, where such referrals are made, they frequently involve little more than dispensing services-functions which are not even mentioned in the Manual as those in which optometrists have specialized training.

In one Southern State, for example, the State Vocational Rehabilitation agency responded to an optometrist who inquired about payment for services he rendered an eligible vocational rehabilitation client with this statement: "Present Vocational Rehabilitation regulations will permit us to authorize visual services from opthalmologists only." We know of a mid-western State where the visual rehabilitation program has precluded the use of optometrists because of a similar regulation.

It appears that vocational rehabilitation clients can be assured of the availability of needed optometric services only if the law itself specifically includes optometry or optometric vision care.

H.R. 16819 calls for participating States to establish "Comprehensive State Plans" for vocational rehabilitation. Considering the percentage of visual impairments among individuals who have benefitted from rehabilitation programs to date, there seems no doubt that optometric services must be included in every State vocational rehabilitation plan if the plan is in fact truly "comprehensive." The potential benefits are great; the challenge to our profession is stimulating. We are anxious to meet the challenge and put forth our best efforts on behalf of the visually limited vocational rehabilitation client.

In one Southern State, for example, the State Vocational Rehabilitation agency responded to an optometrist who inquired about payment for services he rendered an eligible vocational rehabilitation client with this statement: "Present Vocational Rehabilitation regulations will permit us to authorize visual services from ophthalmologists only." We know of a mid-western State where the visual rehabilitation program has precluded the use of optometrists because of a similar regulation.

It appears that vocational rehabilitation clients can be assured of the availability of needed optometric services only if the law itself specifically includes optometry or optometric vision care.

H. R. 16819 calls for participating States to establish "Comprehensive State Plans" for vocational rehabilitation. Considering the percentage of visual impairments among individuals who have benefitted from rehabilitation programs to

date, there seems no doubt that optometric services must be included in every State vocational rehabilitation plan if the plan is in fact truly "comprehensive." The potential benefits are great; the challenge to our profession is stimulating. We are anxious to meet the challenge and put forth our best efforts on behalf of the visually limited vocational rehabilitation client.

As you members of this Committee are keenly aware, a shortage of practitioners within every health care discipline exists throughout the country. The growing demands for health care services call for maximum utilization of optometry which constitutes a valuable rehabilitation resource.

H.R. 16819 calls for comprehensive services. Congress on several occasions when amending the Public Health Service Act, for example, has called for comprehensive health planning "which shall include representatives of State and local agencies and non-governmental organizations and groups concerned with health and of consumers of health services. . . ." There is no question that Congress has intended that representatives of the various health professions be included.

The Congressional intent regarding comprehensive health services was reflected by HEW when Wilbur Cohen, then Under-Secretary, testified last September before the Senate on the Partnership for Health Amendments of 1967. He said: "We have as a Nation committed ourselves to promoting and assuring the best level of health attainable for every person in this country. The magnitude and complexity of that commitment require that we marshall all our available health resources, public and private, in a vital partnership to achieve that objective.

When calling for comprehensive health programs, Congress apparently has intended that all licensed personnel in "sciences related to health" are to participate. Undoubtedly the desire for greater utilization of all practitioners has brought about the use of the term "health" rather than the word "medical." The word "health" has far broader meaning and denotes a degree of comprehensiveness not inherent in the word "medical." To indicate that rehabilitation services are in fact to be comprehensive as stated in H. R. 16819, we suggest that the word "medical" be changed to the word "health" as noted in our suggested amendments.

Congress has in recent years also used the term "sciences related to health." A House committee report on the "Medical Library Assistance Act of 1965" (P.L. 89-291), included in the term sciences related to "health medicine, dentistry, optometry, pharmacy, osteopathy and other health-related sciences."

Other of our amendments would help to assure a more comprehensive range of services, by more fully utilizing optometrists' services within rehabilitation programs. We respectfully submit for your consideration the following amendments:

(1) On page 12, line 14, delete the word "medical" and replace it with the word "health.";

(2) On page 12, line 17, after the word "therapy," insert the following: “(4) vision evaluation and correction," and re-number as (5) through (12) the other numbered items in subsection (c);

(3) On page 2, line 25, strike the words "medical and related";

(4) Page 13, line 2, delete the word "or" and replace it with a comma after the word "medicine" and strike the words "in the State" at the end of the line; (5) Page 13, line 2, insert the following after the word "surgery": ", dentistry or optometry, for services provided within the scope of practice of each respective profession as defined by the law of the State.";

(6) Page 20, line 9, delete the word "medical," and substitute the word "health,";

(7) Page 20, line 14, after the words "intelligence level" insert the following: "visual abilities and current visual performance levels,".

(8) Page 25, add new section after line 2, with the heading "Freedom of Choice", "Notwithstanding any other provision of this Act, whenever payment is authorized for services which an optometrist is licensed to perform the beneficiary shall have the freedom to obtain the services of either a physician skilled in diseases of the eye or an optometrist, whichever he may select.

The House Education and Labor Committee's report on H.R. 16819 contains the following statement: "The Committee takes cognizance of the fact that Optometrists can and do contribute a valuable service to the visually impaired. It is with this fact in mind that we urge that the services of Optometrists be used by the State Agency whenever practical and consistent with the Act and rules and regulations of the Secretary." While we optometrists appreciate the

House committee's concern, we do not feel such a statement of intent is strong enough to assure that optometric services will be available to those who need such services in future yreas.

The 14,500 members of the American Optometric Association urge adoption of the amendments offered as well as ultimate enactment of H.R. 16819.

PAUL N. FLEMING, O.D.

Birthdate: April 25, 1920.

Residence:

1610 48th Street, South
Wisconsin Rapids,

Wisconsin 54494

Office:

478 East Grand Avenue,

Wisconsin Rapids,

Wisconsin 54494

Academic background:

Pre-optometry, University of Wisconsin.

Optometry (O.D.), Northern Illinois College of Optometry, Chicago, Ill.,

1948.

Military:

Air Force, 1940-45, Major.

Memberships and fellowships:

American Optometric Association, 1949-present.

American Optometric Foundation, 1949-present.
Optometric Extension Program, 1949-present.

Wisconsin Optometric Association (President, 1963–64).

Other:

Wisconsin Rapids Rotary Club (President-1955-56).

Chairman of Official Board of the Methodist Church (1960-present).

Chairman, Wisconsin Policy Board for Statewide Planning-Vocational
Rehabilitation.

The CHAIRMAN. We want to thank you very much for your testimony and for your recommendations which you brought us this morning. We appreciate them and we will certainly consider them very carefully.

Dr. MCCRARY. Thank you, sir.

The CHAIRMAN. Be sure to convey my very best wishes to Mr. McCracken, will you?

Dr. MCCRARY. Yes, sir, I will be very glad to do that.

The CHAIRMAN. At this point I order printed prepared statements submitted by those unable to attend the hearing.

(The prepared statements referred to above follow:)

PREPARED STATEMENT OF IRVIN P. SCHLOSS, LEGISLATIVE ANALYST, AMERICAN FOUNDATION FOR THE BLIND

Mr. Chairman and members of the Subcommittee, I appreciate this opportunity to present the views of three national organizations in work for blind persons on H.R. 16819, a bill to extend and inprove provisions of the Vocational Rehabilitation Act and the authorizing legislation for the President's Committee on Employment of the Handicapped.

The three organizations I am representing are the American Foundation for the Blind, which is the national voluntary research and consultant organization in the field of services to blind persons of all ages; the American Association of Workers for the Blind, which is the national professional membership organiza tion in the field; and the Blinded Veterans Association, which is the national membership organization of the war-blinded.

All three of these organizations endorse enactment of H.R. 16819 with a modification to strengthen the effectivenes: of services to school-age disabled youth. The extension of expiring provisions of the Vocational Rehabilitation Act is essential to permit the orderly expansion and improvement of this vital program.