Experts disagree in Vermont committee over S64 expansion of optometry procedures; testimony focuses on training, safety and access

Dr. Libby HooL, a practicing ophthalmologist in Vermont, told the House Health Care committee she opposes S64 as written because its training and oversight requirements fall short of what is needed to ensure safe invasive eye care. "S64 does not define how proficiency is evaluated," she said, noting the bill requires at least eight hours of didactic and clinical instruction per procedure and a minimum of two supervised cases per procedure. "Two cases...does not begin to capture the complexity, difficulties encountered, or proficiency assessment that are integral to surgical training," she said.

Her testimony focused on what she described as gaps in the bill's structure: no objective skill assessments, no specification of case complexity or outcome documentation, minimal continuing-education requirements, unclear standards for preceptors, and vague adverse-event reporting without independent review or enforcement. She also highlighted the need for emergency readiness and clinician availability for post-operative complications, saying "performing eye surgery requires providing emergency call coverage for our post-operative patients. Failure to provide emergency availability for post-operative patients is considered to be patient abandonment."

Opposing that view in the same hearing, Dr. Nate Lighheiser, dean at the Oklahoma College of Optometry, argued that optometrists in multiple states already perform laser and certain injection procedures under established training and regulatory systems. Lighheiser said classroom instruction, laboratory practice on model eyes, proficiency testing, and supervised clinical experience combine to produce competent practitioners. "There are currently 16 states across the United States that authorize optometrists to perform laser procedures," he said, and "22 states that authorize optometrists to do local anesthesia or injections into the eyelid," adding that an advanced 32-hour course is widely used as part of post-graduate training.

Lighheiser also cited outcomes data he said were reported to state boards in jurisdictions that allow these procedures: "Outcomes of over 146,000 laser procedures, and there were two registered complaints," which he characterized as a very low complaint rate; he further said malpractice premiums have not risen noticeably in those states.

Medicaid and implementation considerations figured into the committee's discussion. Ashley Berliner, director of Medicaid policy at the Agency of Human Services, told the committee that expanding Medicaid coverage for optometrist-performed procedures would require a state plan amendment (SPA) submitted to the Centers for Medicare & Medicaid Services. Berliner said the SPA process requires at least a 30-day public notice and CMS review (CMS has up to 90 days to respond, though real-world timing varies) and that producing a realistic fiscal estimate now would be difficult; she indicated a likely implementation timeline could extend to 2028 and that more detailed analysis would be done closer to any implementation date.

Members pressed both clinical witnesses on specifics. Committee member Brian asked whether any training short of medical school and residency could satisfy safety concerns; Dr. HooL replied that surgical competency is built through extensive, graduated clinical experience and that short courses cannot substitute for residency-based training. Dr. Lighheiser countered that in states where optometrists are authorized, supervised clinical training occurs and produces clinicians who perform office-based laser and eyelid procedures successfully.

Why it matters: S64 would change who can perform certain ocular procedures in Vermont, with practical implications for patient safety, access to care—especially in rural areas—and Medicaid coverage. The committee heard competing professional perspectives on whether the bill's proposed training and oversight are sufficient and was warned that expanding coverage for those services will require administrative steps at the federal level.

Next steps: The committee moved on to other agenda items after testimony was completed; further hearings, regulatory design and fiscal analysis were identified as needed before any implementation could occur.