NTU Submits Comments on the FTC's Updated Contact Lens Rule

Federal Trade Commission
Office of the Secretary
600 Pennsylvania Ave NW
Suite CC-5610 (Annex B) 
Washington, DC 20580
 
RE: Contact Lens Rule Review, 16 CFR part 315, Project No. R511995
 
On behalf of National Taxpayers Union (NTU), the nation’s oldest taxpayer advocacy organization, I write to offer the following comments in response to the Federal Trade Commission’s Supplemental Notice of Proposed Rulemaking (SNPRM) dated May 28, 2019 as it relates to modernizing the Contact Lens Rule.
 
As you are keenly aware, the landscape for purchasing contact lenses has drastically changed since the late 1990s. For decades, optometrists had what appeared to be a commanding position on the sale of contact lenses due to the fact that American consumers were so often limited to purchasing lenses from the provider who wrote them their prescription. This principal-agent model is a clear conflict of interest, where consumers are the principals and the optometrists are the agents. By dominating the marketplace, this group was able to control many pricing decisions and thereby the cost of lenses. 
 
However, in 2003, Congress passed, and the president signed signed into law, the Fairness to Contact Lens Consumers Act (FCLCA), which the Federal Trade Commission subsequently implemented through its Contact Lens Rule in 2004. The rule, which was intended to facilitate consumer choice and spur competition among sellers of contact lens products, requires contact lens prescribers to give a copy of the prescription free of charge to the patient after an examination. In addition, prescribers are also required to verify the patient’s prescription to anyone, including contact lens providers, authorized by the patient. 
 
The FTC should be commended for adopting a rule that has spurred innovation and promoted competition in the private market. Yet, as the FTC fully acknowledges, the Contact Lens Rule is in need of updating. To address issues with the existing rule, particularly the automatic prescription-release requirement, the FTC began a process to amend the Contact Lens Rule that would require eye doctors to provide patients with a signed acknowledgement form, which would inform them of their rights to a prescription and the ability to purchase lenses from other retailers. 
 
As NTU has noted in numerous past statements and analyses to FTC, taxpayers have a major stake in the outcome of this rulemaking. According to a Pew Charitable Trusts report, utilizing data from the Milliman Atlas of Public Employee Health Plans, in 2013 states and their employees spent $30.7 billion to provide health coverage to 2.7 million households of active state-level employees (not including local government employees, even those who could join state-level plans). State governments – i.e., taxpayers – covered $25.1 billion of this cost (the employees themselves covered the remainder). This is probably the smallest universe of expense attributable to state and local employee insurance. Taxpayers cover more than 70 percent of the premium cost associated with the Federal Employee Health Benefits Program, which pays out over $40 billion to current workers and retirees. Vision care is available through most of these government plans. In addition, other government health programs (such as Medicaid) are gradually providing more options for vision care, while online examination technologies that have matured in the contact lens marketplace are propelling the use of ocular telemedicine. This promises health care savings for rural and underserved areas in particular. 
 
NTU applauds the dedicated work of the FTC to revise and retool any regulation as time moves on and as the marketplace changes. We are particularly supportive of FTCs recent efforts to update the aforementioned Contact Lens Rule. As we noted in comments from March of 2018, “it is even clearer that the proposed updates to the rule – including more safeguards to ensure consumers have access to their prescriptions for purposes of shopping where they choose – are necessary. Purchasers need more assurance of a competitive marketplace, and providers need more regulatory certainty. Yet, allowing consumers greater freedom to shop for eyewear needs has also served taxpayers well, and can continue to inspire new developments in other types of health services.”
 
We hope these comments will guide the FTC to finalize a rule in a timely fashion to ensure greater competition and taxpayer protection in contact lens markets. They respond to several specific questions the Commission posed on digital technologies to deliver customer prescriptions, competition in the marketplace, compliance burdens, and anecdotal evidence of customer complaints.
 
1) Digital Prescription Technologies. A key feature of the SNPRM is a new option that would allow prescribers to comply with the automatic prescription-release requirement through options beyond a paper copy, should the customer elect to do so and the provider has the capability. Methods include email, text, or through an online patient portal.
 
The FTC has invited comment about the viability of such a proposal. NTU believes that the FTC’s caveats toward this approach, as outlined in the SNPRM, are critical to such viability, chief among them the continued availability of a paper option to customers or providers choosing to use it. We would further observe that the FTC’s caution over the evolution of the technology as well as consumer preferences regarding digital prescriptions is well-placed. We can speak from some experience on this matter, based on the realm of tax administration. 
 
In 1996 and 1997, NTU’s then-Executive Vice President served with the National Commission on Restructuring the Internal Revenue Service, whose recommendations became the bedrock for the comprehensive IRS Restructuring and Reform Act of 1998. We can still recall vividly the considerable time and effort the Commission spent on the question making “paperless filing the preferred and most convenient means of filing for the vast majority of taxpayers.” The savings for both the government and taxpayers would be considerable. In its final report, the Commission noted that it had “received an estimate from the Private Sector Council that a project by a Fortune 100 company to automate paper processing experienced a six to one cost differential of paper to electronic processing costs.” Digital economics have changed somewhat since 1997, but clearly some differential, accruing to the benefit of both eye care providers and customers, would exist today.
 
Unfortunately, the ambitious goal set by the Restructuring and Reform Act to move from 21 percent of e-filed individual tax returns in 1998 to 80 percent within 10 years was not met. By 2007, the IRS Oversight Board reported that the e-filing rate was just 57 percent, necessitating a heavier reliance on paper return filings than the government had anticipated. This occurred despite surveys from the IRS Oversight Board affirming public support for an e-filing option at or above 80 percent. The e-filing push from the IRS was even accompanied by a coordinated and massive outreach effort among practitioners and other businesses in the tax field to encourage this new option. 
 
A number of reasons were postulated (and some statistically supported) for why it took the Service many years longer to meet its e-filing goals than anticipated. Of course, a federal mandate requiring paid preparers to e-file their clients’ returns beginning with the 2011 filing season gave a late boost to the effort. So did taxpayers’ increased comfort level with the IRS’s online systems, but it was not until the 2010 filing season that the Service unveiled its modernized e-file application for common forms and schedules. Meanwhile, the Great Recession gave many taxpayers cause to save out-of-pocket costs by purchasing tax software, which made secure e-filing more attractive to households with fewer financial resources. Despite all of these factors, however, paper returns were still a choice for more than 10 percent of the individual tax return filing population well into the 2010s. 
 
The tax system may indeed be more complex than the information transactions in the health system, but with the plethora of government and insurer procedures involved in the latter, comparing the similarities here is hardly out of order. And while all kinds of other IT architecture had to be built around e-filing for taxes, this only illustrates some of the challenges to which the FTC alluded for prescription release: “technology may be developing still or be costly to implement.” 
 
Furthermore, it may be true the IRS’s e-filing initiative was launched at a time when the online Information Age was in its infancy and most consumers were unfamiliar with directly accessing and utilizing digital records. Yet, NTU would argue that the unfamiliarity has been replaced in significant measure with fears of identity theft or compromised privacy – a problem with which the IRS still wrestles today. The FTC has likewise devoted considerable fiscal resources to policing consumer privacy and identity theft issues, which could be exacerbated without a thoughtful approach toward providing prescriptions digitally. 
 
Finally, moving too quickly on digital prescription release, without providing a paper backup for at least a few years, could lead to some technology-reluctant consumers being deprived of obtaining any prescription to shop elsewhere. Such consumers could include those who are concerned about identity theft or privacy, or those who have limited access online. 
 
It bears mentioning here that one other major reason the IRS finally achieved its e-filing goals was assistance from the private sector. Knowing that the agency lacked the institutional capacity to stand up and manage a complete e-filing operation, the IRS entered a public-private partnership with tax preparation companies in 2003 known as the Free File program. This consortium, which offers e-filing to middle-and low-income software users, is just one of several ways that non-government entities have, over time, popularized cost- and time-saving financial tools. Although Free File was the subject of concerns from some Members of Congress during recent debate over IRS reform legislation known as the Taxpayer First Act, NTU would encourage the FTC to review the Free File program for additional insight on how digital prescription portals (and customer reactions to them) may evolve. 
 
2) Competition in the Marketplace. As the Commission has noted in many instances involving eye care services, the principles of free-market competition – reducing barriers to entry such as excessive licensure, bans on advertising, and restrictions on business organization models – can lower costs for consumers without sacrificing quality of services. This dynamic likewise benefits taxpayers who may help to fund government employee health insurance and, in the future, eye care provided through Medicaid, Medicare, or other public programs. 
 
As the marketplace evolves, however, it is necessary for policymakers to re-evaluate laws and rules, thereby minimizing private- and public-sector compliance costs while maximizing consumer welfare. So it has been with the Eyeglass Rule of 1978 as well as the Contact Lens Rule of 2004. 
 
While NTU has made numerous other comments on the importance of competition toward improving the well-being of consumers and taxpayers, it may be useful here to recount the Commission’s own high-quality analytical work in the area of vision care over time. One particularly useful document NTU has reviewed is a 1986 staff report from the Bureau of Consumer Protection entitled “Ophthalmic Practice Rules: ‘Eyeglasses II’” (16 CFR Part 456). Published in October 1986, the report spans an important period in the development of pro-consumer, pro-taxpayer vision care rules: between the “Eyeglass Rule” of 1978, which focused a great deal of attention on advertising as a way of increasing competition and lower prices, and follow-on work which focused on other competitive obstacles as well as their application in the contact lens market. One conclusion of the report was how the FTC’s deployment of systematic evidence from carefully-controlled studies on price and quality produced deliberative, prudent policymaking that balanced numerous interests:
 
“As the Eyeglasses I investigation progressed, the staff realized that restrictions on advertising were only one part of a larger system of public restraints which appeared to limit competition, increase prices and reduce the quality of care. Broadening the scope of the inquiry, the staff entered the second phase of this investigation, known as Eyeglasses II. Eyeglasses II focused on commercial practice restrictions. These restrictions prevent optometrists from engaging in certain business practices such as working for non-optometrists or corporations, locating practices in certain commercial locations, operating more than one or two offices or practicing under trade names. 
 
The FTC Studies provide reliable, convincing evidence that restrictions which prevent or limit competition from optometric chain firms, large-volume firms and other commercial providers raise prices to consumers and do not increase the quality of care in the market. The record contains no persuasive survey evidence pointing to a contrary conclusion. Anecdotal evidence was not persuasive in countering the results of systematic and reliable survey evidence. Substantial evidence, including survey evidence, also demonstrates that the restrictions actually reduce the quality of eye care by reducing the frequency with which consumers obtain vision care. Again, no substantial evidence was presented to the contrary.”
 
The conditions resulting from business practice restrictions upon which the FTC concentrated 33 years ago are certainly different today. Chain and large volume firms in the vision care markets are far more prevalent. Yet, as the FTC contemplated the pros and cons of what NTU approvingly terms “deregulatory rulemaking” toward eyeglasses, and new steps regarding contact lenses, the arguments made by incumbent providers against such liberalization bear a close resemblance to comments made in the current SNPRM process today: consumer health is endangered, the independent judgment of individual practitioners is being undermined, costly new mandates will destroy small operators, and the FTC’s evidentiary research is flawed. 
 
Despite these criticisms, as well as patient rebuttals from the FTC throughout the 512-page document, the conclusion in 1986 presaged what would become necessary through subsequent rulemakings. And while the FTC did not have as strong a collection of data at that time to warrant a new approach to prescription release for contact lenses, the Commission’s direction toward removing barriers to entry as they are encountered later became evident in the FCLCA and the Contact Lens Rule. As the report concluded:
 
“The Contact Lens Study indicates that commercial optometrists fit cosmetic contact lenses at least as well as noncommercial optometrists and other provider groups but charge significantly lower prices. Since each of the restrictions at issue in this proceeding hinders the development of commercial practices and restricts competition in the marketplace. The study provides persuasive evidence that the restrictions raise prices to consumers without increasing quality.”
 
Perhaps the most remarkable testament to the subsequent success of FCLCA and the Contact Lens Rule comes from some of the price statistics cited in the 1986 report. According to the FTC’s research, the average price of a contact lens “package” involving an exam, a pair of soft lenses, a follow-up exam, and a care kit, was between $159 and $253 in the year 1980. Adjusted for inflation, those prices would be $494 and $833 today. Such amounts are a far cry from less expensive actual “package” prices for exams and lenses now, which can come in many combinations of in-person initial exams, online renewal exams for certain customers, and lens purchases from other parties. Much of this benefit in price and convenience can be attributed to the FTC’s efforts to encourage competition and innovation. 
 
The SNPRM should be viewed as a natural evolution of ongoing “deregulatory rulemaking” that, against resistance from some entrenched stakeholders, has nonetheless made a genuine difference on behalf of consumers and taxpayers.
 
3) Paperwork Burdens. As you know, the National Taxpayers Union has an abiding interest in the accurate and holistic measurement of compliance and paperwork burdens imposed by statutes, regulations, or mandates. To our knowledge, among organizations outside government NTU has published the longest-running annual analysis (since 1999) of such burdens associated with the federal tax system. We are therefore greatly concerned that any FTC rulemaking is designed with strong cost-benefit calculations and utmost consideration of real-world impact on businesses large and small. 
 
In a previous December 27, 2018 analysis from NTU and several taxpayer organizations prepared for the Commission, we explored the methodology and results of an Avalon Health Economics and the American Optometric Association report that estimated the industry-wide compliance costs associated with the Contact Lens Rule update to be as high as $744 million annually, and compared it to FTC’s own estimates, which are in the tens of millions.
 
Since publication of our December 2018 analysis, and subsequent review of the SNPRM, we believe that the FTC’s estimates are plausible, and given some of the underlying assumptions, may prove to be conservative (i.e., erring on the higher side of some of the cost burden calculations). For example:
 
While tax laws often require a degree of professional expertise commanding fees of $155 per hour (in the case of accountants) or higher (for attorneys), FTC has wisely drafted the SNPRM to permit support staff as well as optometrists to obtain signed prescription acknowledgments from customers. Yet, the FTC assumes in its $4.9 million labor cost burden of this task that only optometrists (at the hourly mean wage level of $57.26) would perform the work. 
 
Unlike tax laws, in which the IRS may or may not provide formal guidance (or private letter rulings, which may not be relied upon by taxpayers in similar situations), FTC is furnishing flexible standards for confirming prescription release to a customer, along with sample form language for doing so. In fact, the FTC has been so meticulous in this area that the first three options in the SNPRM directing a prescriber to provide a confirmation of prescription release do not even constitute an information collection under the Paperwork Reduction Act (although obtaining the customer’s signature and storing that data does qualify as one). 
 
Even though states already impose recordkeeping requirements on eye care providers, and businesses might be able to store new documentation stipulated under the SNPRM using existing electronic procedures potentially in a matter of seconds, the FTC assumed every provider would spend at least one minute per confirmation. 
 
Importantly, the FTC did not account for potentially offsetting reductions in burden hours on eye care providers because of reductions in time and effort spent on responding to prescription verification requests (which would be reduced by some amount because of better prescription recordkeeping envisioned under the SNPRM). Measuring the net impact of any law or rule is critical to conducting an accurate cost-benefit analysis. In this case, even a modest reduction in burdens from verifications could have a significant balancing effect.
 
Some of the most detailed compliance-burden examinations have been undertaken with the federal tax system and have relevance to these proceedings. At an April forum sponsored by the Bipartisan Policy Center (in which NTU participated), a wide range of estimates have been conducted to suggest that “the aggregate cost of federal tax compliance for these taxpayers probably exceeds $200 billion annually.” Still, as many experts at this forum discussed, how and where those costs are incurred remain important. Most acknowledged components of time burdens, for example, are more heavily weighted toward the “back end” – the time spent learning about and devising financial strategies to cope with the law, as opposed to filling out the actual tax forms. 
 
In accordance with the Paperwork Reduction Act, the Internal Revenue Service commissioned a study by Arthur D. Little to survey taxpayers about the amount of time they spent on tax compliance activities for the 1983 tax year. This landmark study has since been critiqued, refined, and built upon for more than three decades. But among the more cogent summations of the Little study, which has direct impact on the contact lens SNPRM, came from Professor James L. Payne in the 1993 book Costly Returns:
 
“Against [the] tendency to overreport [filling out tax returns] is a tendency to overlook many types of tax compliance activities when they take place in small, undramatic ways… One compliance task that is almost certain to be underreported is learning about tax requirements. Throughout our lives, we spend a great deal of time reading about tax requirements and discussing tax issues with friends and acquaintances. All this attention is unlikely to be specifically recalled as tax compliance labor… On balance then, the self-report of tax compliance activities would seem to have two offsetting biases: the tendency to exaggerate intense work done on a frustrating task, and the tendency to overlook smaller tasks and “background” tax compliance activities.”
 
Avalon’s analysis bears some resemblance to the survey-based methodology employed by Little. Yet, there are obvious as well as subtle differences between the U.S. tax laws – amounting to tens of thousands of pages whose contents are constantly changing – and the SNPRM, which seeks to provide greater assurance and documentation for one much narrower law (the FCLCA) and the subsequent implementing regulations that have been in effect for some 15 years. 
 
To apply Payne’s analogy more fully to the SNPRM, “learning about requirements” primarily entails an understanding of the new customer acknowledgment form that must be provided along with any other exam paperwork, the three-year recordkeeping requirement, and in the case of certain sellers, changes to procedures for verification of prescriptions. As far as business and financial planning would go, eye care providers would need to consider whether the electronic portal option is worthwhile for providing prescription portability, whether current electronic record capacity is sufficient to store the new acknowledgment forms, and generally the overhead in training staff about the provisions of the SNPRM. As several previous commenters – among then the Information Technology and Innovation Foundation and Consumer Action – have stated to the Commission, this additional overhead could be far smaller than Avalon suggests.
 
NTU would agree. To provide some context, according to Commerce Department statistics, in 2017 Offices of Optometrists classified as Employer Firms (NAICS classification 62132) were reported to have spent a total of $106 million on “electronic health record systems.” Is it possible eye care industry professionals would have to spend seven times this amount (which would include personnel and time costs) only to comply with modifications to an existing rule based on a statute enacted in 2003? Or that the component of the Avalon study most closely related to the labor costs of prescription requirement would, at $108 million, approximate all the money spent by tens of thousands of optometry establishments on their entire electronic recordkeeping systems? We believe in this area, FTC’s estimates remain more reasonable. 
 
Still, no business sector’s concerns about compliance costs should be dismissed – but is there a way to square FTC’s cost estimates with those of Avalon, or at least put them in context? We would suggest at least one explanation. 
 
FTC has criticized the Avalon study’s “reliability and usefulness,” because most of its findings are based on an “open-ended question regarding total indirect costs of adhering to government regulations.” Could respondents to the survey have been inordinately focusing on the “frustrating tasks” Payne described, e.g., getting a customer signature on a one-page form or handling a prescription verification call, instead of paying attention to the much larger “background compliance activities” that plague their businesses? If so, what would those activities be? 
 
A strong candidate is compliance with insurance and privacy requirements, many of which are imposed by government. In our December 2018 analysis, we noted that while Medicare provides little in the way of vision benefits, “Medicare provider participation rules, as well as establishing infrastructure for ICD-10 codes utilized by public and private insurers, can be onerous, particularly for smaller eye care establishments.” This has become increasingly true since passage of the Health Insurance Portability and Accountability Act of 1996. Yet another contributor is licensure requirements and, rather ironically, taxes. 
 
A 2012 account of the challenges facing Dr. Jon Bailey, owner of a small optometry business, is instructive. Here we are indebted to the North Carolina-based Civitas Institute, a free-market think tank, for documenting Mr. Bailey’s concerns. We reprint a passage from Civitas at length because of this broad perspective:
 
“Like other fields in the healthcare industry, optometry is subject to state and federal regulations. Bailey said regulations imposed by Medicare are among the most intrusive into his practice and to the optometry field in general. Bailey revealed some of the regulatory and licensure protocols by which optometrists must abide. For instance, prospective optometrists must pass multiple board examinations before gaining a license to practice: three examinations given by the National Board of Examiners in Optometry and a North Carolina Board of Optometry examination all must be passed – and paid for.
 
One area of particular regulatory burden for Bailey and his business pertains to ICD-10 codes (ICD-10 is short for International Statistical Classification of Diseases and Related Health Problems). These are diagnostic codes used by private insurance companies and Medicaid and Medicare to classify medical conditions, diseases and symptoms. According to Bailey, complying and keeping up with these codes is extremely burdensome, even to the point of almost requiring him to hire a full-time employee simply to keep up with the regulations. Interestingly, he considers the codes to be tantamount to the burdens placed upon him by tax laws. If he had his way, he would remove the “gazillion” regulations produced by the ICD-10 codes and simplify the system. Furthermore, he would seek to make insurance more user-friendly for the patient and doctor.
 
Bailey indicated that regulations have increased vastly since he started his business in 1987. Insurance regulations were not as cumbersome back then, and the only government intrusion to his business pertained to the State Board’s examination and requirements for optometrists to have 20 hours of continuing education. Things have certainly changed over the years, and the change has not been for the better.
 
As for the matter of taxation, Bailey hires a tax accountant who makes sure his business is complying with the strict guidelines of the IRS. He noted that this incurs a significant cost to him, but he stated that, ‘there are only so many hours in the day and I can’t be burdened with the [complexities of the] tax code.’” 
 
Given this account, one no doubt shared by many optometrists, it becomes easier to understand why some of the Avalon survey participants may have been giving high estimates of government compliance burdens on their businesses. With so many concerns that appear far greater than a new set of adherence standards to the contact lens rule, NTU will reiterate that public officials need to concentrate on fundamental policies that overburden and create barriers to entry for all types of businesses. 
 
Many of these policies are outside of FTC’s purview, though as our December 2018 analysis noted, encouraging interstate licensure compacts (as some members of the optometry industry have suggested) would be a most valuable action for the Commission to take. In addition, we would suggest that staff from the FTC, the Office of Advocacy at the Small Business Administration, the Office of Management and Budget, and the Department of Health and Human Services conduct a formal collaborative effort to address the larger concerns over regulatory burdens on eye care services outlined above. 
 
4) Customer Complaints. Throughout this comment period, some parties have expressed the notion that consumer complaints over not receiving their prescriptions in accordance with FCLCA are so rare as to not justify the changes contemplated in the SNPRM. For example, in a July 18 letter to Chairman Simons, a group of United States Senators asserted that According to the FTC's own data, “few complaints regarding prescription release have been received.” Others have disputed this contention, citing anecdotal or survey evidence in support of their conclusion. FTC has sensibly concluded that while “none of the surveys, in and of itself, could be considered definitive,” and acknowledged “that there are inherent limitations to survey evidence,” nonetheless noted “the evidence was sufficient to indicate a significant problem with prescription-release compliance, particularly when the surveys were viewed in conjunction with supporting evidence from other sources and the lack of contradictory evidence.”
 
Among this supporting evidence has been anecdotal material, to which NTU wishes to make a modest contribution. The author of these comments has worn contact lenses since 1977, having a variety of experiences with the eye care profession. Recently, the author’s change of residence gave cause to seek an Optometrist nearer to his residence in Silver Spring. Accordingly, he conducted a short search of reviews on the popular website Yelp. 
 
One of his previous providers, located in Wheaton, Maryland, is affiliated with a national eye care chain. A total of 14 comments were logged on Yelp, three of which concerned problems obtaining or honoring a prescription that could be used to make a purchase off-premises. The author then surveyed two other nationally-affiliated chains located closer to his current residence, amounting to 54 comments. Two of these 54 comments involved complaints of a similar nature, one even noting that the customer reminded the business of his rights under FCLCA as advised by FTC. Thus, five out of 68 comments regarding three establishments concerned prescription portability matters of some kind. 
 
To be certain, the large majority of comments reflected high customer satisfaction. Yet, how many of these customers were even aware of their rights under FCLCA?
 
I cite this somewhat unscientific survey for a few reasons. First, the fact that this type of irregular reporting still generated prescription complaints from a metropolitan area with sophisticated consumers and providers located less than 20 miles from FTC’s headquarters is concerning. Second, since Yelp reviews are largely positive to begin with, it is quite possible that some “satisfied” customers did not know about their rights to receive their prescription automatically. Finally, with government statistics reporting nearly 48,000 employer firms as “offices of optometrists,” the FTC’s ability to adequately police the problem without additional automatic regulatory mechanisms will be difficult. 
 
Conclusion. Government has created a mandate on this consumer market in the first place – an obligation on the patient to possess a valid prescription in order to be able to purchase a given product. This requirement, more than any other today, drives the compliance costs imposed on all stakeholders: 1) optometrists, who must maintain equipment and provide certain services to meet the demands of issuing the prescription; 2) product sellers, who must provide eyewear in accordance with the terms of the prescription; 3) customers, who must bear time and out-of-pocket costs for obtaining the prescription; 4) insurers, who must process claims and other overhead associated with prescription-based vision care; and 5) taxpayers, who not only bear the costs of overseeing this system, but also share in paying claims for customers and insurers of government employees and other participants in government-funded care programs. 
 
NTU would contend that streamlining regulatory impacts in this basic process, rather than focusing on the burden associated with collecting and retaining customer data of a confirmation form likely spanning less than a page, is a more productive exercise for all stakeholders. For example, as our December 27, 2018 analysis noted, the American Optometric Association has made several entirely sensible recommendations to FTC outside of this SNPRM pertaining to HIPAA requirements as well as interstate licensing.
Taxpayers and consumers alike commend you for your continued commitment to expand accessibility and affordability, but to be clear, the FTC stands at a critical juncture between progress and stagnation. The original Contact Lens Rule, which has served as a bridge to connect customers, eye care professionals, and eyewear providers in more efficient and effective ways, needs to be upgraded to both embody and inspire new advances in consumer-driven health systems. Failing to do so will signal to those customers – as well as taxpayers – that they will not take part in the exciting benefits of these advances even as other areas of care continue to innovate. 
 
From the perspective of free-market, limited-government advocates, the Contact Lens Rule has been one of the most balanced and successful examples of “deregulatory rulemaking” in the FTC’s history. The updated rule the FTC has proposed reflects equal care and foresight. If we can be of assistance, please do not hesitate to contact me, or NTU Policy and Government Affairs Associate Thomas Aiello at Thomas.aiello@ntu.org. Thank you for your consideration of these comments.
 
Sincerely, 
 
Pete Sepp, President
National Taxpayers Union