NLS operates a program that provides free reading materials for residents and citizens of the United States and its territories as well as U.S. citizens residing abroad who are generally unable to read standard print because of a visual or physical disability. Under its authorizing statute, the program may provide reading materials in braille, audio, and other formats, and since the 1940s, may provide devices for reproducing audio recordings. The types of materials that NLS provides include books, magazines, music scores and materials for music instruction. In addition, NLS users have access to over 400 state, national, and international audio and braille newspapers through Newsline, a telephone and internet-based service. The Free Matter for the Blind and Other Physically Handicapped Persons program, administered by USPS, assists NLS in circulating materials to its users. In fiscal year 2016, USPS had a budget of approximately $55.1 million for free delivery of mail in the NLS program and certain other purposes. USPS delivered 43.9 million pieces of mail through the program during fiscal year 2015. NLS is within the LOC’s Office of National and International Outreach, under LOC’s organizational structure effective Oct. 1, 2015 (see fig. 1). NLS receives its own congressional appropriation; however, LOC oversees the budget and activities of NLS and approves its budgeting decisions. For instance, if NLS’s budgetary plan includes investing in a new technology initiative, it must submit a proposal for approval by LOC’s Information Technology Steering Committee. LOC also oversees NLS’s strategic planning process. NLS is currently in the process of developing its first comprehensive strategic plan, which NLS officials stated will be completed in fiscal year 2016. LOC will review this plan to ensure it aligns with LOC’s overall strategic plan. In addition, LOC has oversight of NLS through processes such as monitoring, checks of internal control procedures, and performance management. Administration of the NLS program is shared between NLS headquarters and a national network of libraries and outreach centers. Headquarters is located in Washington, D.C., and its staff’s functions and responsibilities include selection and production of reading materials, procurement of playback equipment, establishment of standards and assurance of quality products and services, and development, maintenance, and circulation of the specialized music collection. In addition, NLS relies on a network of 101 regional and sub-regional libraries and outreach centers to implement the program. Most states have one regional library participating in the network that is operated by the state or other entity. Some states also have sub-regional libraries that coordinate with the regional libraries to serve a specific geographical area, and are generally operated by public libraries. NLS network libraries conduct outreach to potential users; screen applicants for eligibility; provide customer service to users such as assistance with selecting an appropriate NLS device and identifying preferred reading materials; store, maintain, and circulate NLS books and machines; and report to NLS on equipment, books, and users. The operating costs for these activities and services are not funded by NLS but rather by state, local, and other sources. Under LOC regulations, the following four categories of individuals are eligible to access the NLS program: This refers to persons whose visual acuity is 20/200 or less in the better eye with correcting glasses or who have a restricted field of vision. This refers to persons whose visual disability with correction prevents the reading of standard printed material. This refers to persons who are unable to read or unable to use standard printed material because of physical limitations. Reading Disability Resulting From Organic Dysfunction This refers to persons who have a reading disability resulting from organic dysfunction that is severe enough to prevent them from reading printed material in a normal manner. An NLS factsheet states such reading disabilities may include dyslexia, attention deficit disorder, autism, or developmental disabilities. Under the LOC regulations, a competent authority is required to determine the eligibility of all potential users. In cases of blindness, or visual or physical disabilities, a variety of professionals are permitted to certify an individual’s eligibility, including doctors of medicine, registered nurses, therapists, social workers, and certain hospital staff, among others. In the absence of any of the competent authorities listed in the regulation, a professional librarian may approve eligibility. By contrast, in the case of those with a reading disability, the competent authority must be a doctor of medicine who may consult with colleagues in associated disciplines. Estimates of the blind and visually disabled population vary widely, and the precise number who may be eligible for NLS is unknown. Estimates for this population are often based on self-reported information and rely on different definitions of blindness and visual disability. For example, according to the National Health Interview Survey (NHIS), in 2012 there were approximately 21 million adults ages 18 and older who reported that they had “trouble seeing.” However, according to the American Community Survey (ACS), in 2013 there were approximately 7 million adults ages 18 and older who reported that they were blind or experienced “serious difficulty seeing.” It is also difficult to estimate the number of people who would potentially qualify for the NLS program based on reading and physical disabilities. With regard to reading disabilities, a National Center for Learning Disabilities (NCLD) report estimated that in 2012 there were approximately 2.4 million public school students who qualified for special education programs under the Individuals with Disabilities Education Act (IDEA) based on learning disabilities, and many of these students had reading disabilities specifically. In addition, according to the Survey of Income and Program Participation in 2010, there were at least 3.5 million adults ages 18 and older with learning disabilities, including reading disabilities such as dyslexia. Regarding physical disabilities, NLS officials said that the wide range in the types and severity of potentially qualifying conditions and the lack of centralized data make it difficult to estimate the population of potentially eligible users of the NLS program. In fiscal year 2014, about 430,000 individuals used the NLS program, with the majority being older individuals who were blind or had other visual disabilities. The majority of NLS users were aged 60 and over (about 70 percent), with almost 20 percent at least 90 years of age (see fig. 2). In addition, almost 85 percent of NLS users were either blind or had other visual disabilities resulting in their inability to read standard print (see fig. 3). NLS officials told us that the majority of users have age-related vision loss and therefore did not qualify for services until later in life. About 6 percent of NLS users had physical disabilities, which include multiple sclerosis and Parkinson’s disease, according to officials we spoke with from network libraries. Another nearly 6 percent of users had reading disabilities. NLS guidance explains, and network library officials corroborated, that users’ reading disabilities generally include dyslexia, autism, and traumatic brain injuries. In part because of their older age, many users have physical dexterity issues which compound their other disabilities, according to NLS officials. Although NLS does not track users’ mobility or dexterity limitations as part of its annual data collection efforts, a survey of users and non-users NLS contracted for in 2013 indicated that almost half of users had limited mobility, and about a third had problems with manual dexterity. NLS’s 2013 survey of users and non-users indicated that NLS users generally have retired from employment or are unemployed, have low or fixed incomes, and are more likely to live alone than non-users. In addition, 13 percent of the user respondents reported having served in the military. The number of NLS users remained stable from fiscal year 2010 through fiscal year 2014, according to NLS data. NLS officials said they estimated about 10 percent turnover in their users each year. While they recruit new users, they said the number of older users who die each year generally results in the number of users staying about the same. Although NLS does not project user estimates for future years, the proportion of the U.S. population age 65 and older is expected to increase from 13 percent in 2010 to more than 20 percent in 2050, which may increase the number of NLS’s older users. While NLS serves individuals with a range of disabilities, an eligibility requirement specific to individuals with reading disabilities may hinder this group of potentially eligible users from accessing services. Specifically, the regulatory requirement that only doctors of medicine may certify a reading disability was cited as a barrier to services by staff with whom we spoke at 5 of the 8 network libraries, 2 organizations that provide similar services to NLS, and 2 organizations specializing in learning disabilities. This eligibility requirement, which originated in 1974 and has remained largely unchanged since, creates additional steps and costs for applicants with reading disabilities in comparison to other groups, and may hinder some individuals’ access to services. For example, officials we spoke with from a network library said that many of their potential users have little money and live in rural areas that are far from doctors, which limits their ability to get the necessary certification. Furthermore, a medical diagnosis is not necessary to determine if an individual has a reading disability, according to a number of groups we interviewed and the policies of other organizations that support people with these disabilities. According to staff we spoke with at two organizations specializing in learning disabilities, and 6 of the 8 network libraries, special education teachers and school staff are typically also knowledgeable about reading disabilities. Recognizing this, certification of reading disabilities is conducted by non-medical personnel for other disability services. For example, under IDEA educational services are provided to eligible children with disabilities, including learning disabilities, which may affect reading. However, IDEA does not require a doctor’s certification of eligibility; this determination is instead made by the child’s parents and a special education team generally comprised of the child’s teacher and at least one other person qualified to conduct diagnostic examinations of children, such as a school psychologist or remedial reading teacher.