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Colorado Grassroots Coalition Achieves Prosthetic Parity
By Sherry Metzger, MS Prosthetic parity is defined by the Amputee Coalition of America (ACA) as "insurance companies covering appropriate prosthetic care." In 2001, Colorado was the first state to achieve parity legislation under the leadership of Jeffrey Cain, MD, chief of Medicine at Children's Hospital, Denver.
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Jeffrey Cain, MD |
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With the rise of managed care in Colorado in early 2000, prosthetic coverage was limited only to certain devices and insurance benefits were capped at about $1,000, barely covering the cost of one prosthesis. "Without adequate coverage, not only will amputees not be able to afford limbs, but prosthetic manufacturers and prosthetists will lose their customer base," says Cain. "By working together they can define their futures: active lives for amputees and viable businesses for prosthetists and manufacturers."
Cain understood the importance of proper insurance coverage when he was faced with his second transtibial amputation and mounting bills. "I was lucky enough to be able to afford another leg. Had I been a schoolteacher, I might not have had the money," he says. "I saw this as a matter of social injustice. Without mandates to provide adequate prosthetic coverage, working amputees will literally not be able to afford a leg to stand on."
Group Mobilizes for Success
Cain founded the Colorado Coalition of Working Amputees and mobilized the grassroots group dedicated to helping amputees have full, effective lives with affordable prostheses. The all-volunteer group included members of the US Disabled Ski Team and amputee support groups with backgrounds in conservation and labor politics along with prosthetists. They met with legislators, hired lobbyists, and put together a press kit. Local prosthetic manufacturers and politicians from both political parties sponsored and supported their effort. Over the course of a year, the group had to actively follow legislation in the House of Representatives and the Senate to insure the bill would not be repealed or watered down.
The result was a bill that, Cain says, "includes compromises, but is very fair." Insurance companies are now responsible to pay 80 percent of costs and the patient pays 20 percent. One major benefit of the bill is that it states that the medical necessity of a device will be defined by a patient's treating physician, not the insurance company. This difference allows devices such as
C-legs®, myoelectric arms, and energy-storing feet, which have been termed experimental or not medically appropriate by insurance companies, to be covered when physicians recommend them. When coverage is refused, the bill now enables prosthetists and their patients to file complaints with the Insurance Commissioner's Office.
Insurance companies have complained that healthcare mandates are too expensive. But, according to Cain, such legislation costs less than $1.50 a year per member. "Insurance companies have been able to limit benefits in the past because until now there has not been a visible advocacy group," Cain says. "It is important that the industry and amputees work together. Legislation requires time and money for mailings, organization, and hiring lobbyists, which the industry can provide. This can appear self-serving without amputees who are willing to share their stories and challenges."
Other States Follow
Following Colorado's lead, several states have organized efforts to pass similar legislation. "Colorado has set the standard for prosthetic parity work," says Morgan Sheets, ACA's national campaign director. "[Cain's team] developed tools that we are currently using all over the country." The ACA has developed the Action Plan for People with Limb Loss (APPLL) to promote insurance parity nationwide.
"With a rise in the incidence of diabetes, the leading cause of amputations, and an aging population, there are more people with greater needs and less coverage," says Cain. "We must be proactive to insure the vitality of our industry and patients."
To learn more, visit www.amputee-coalition.org/aca_advocacy_stateparity.html
Sherry Metzger, MS, is a freelance writer with degrees in anatomy and neurobiology. She is based in Westminster, Colorado, and may be reached at sherry@opedge.com 
Table Of Contents - June 2006
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