America uncovered

Last week, I mentioned how I got to meet Scout Basset, a triathlete and marathoner, at the recent Amputee Coalition of America National Conference. A question I simply must ask her in the future is why someone would want to hurt their body in 3 extravagantly different and unique ways – swimming, biking, and running – instead of in the much more conventional single way (running). Is it not enough to endure shin splints, IT band syndrome, back pain, and blisters? Do triathletes have a little-known chromosome that makes the threat of drowning, ingesting contaminated ocean water, getting breakdown in unmentionable areas of the body from a bike seat, or getting thrown onto pavement at high speeds a pleasure-triggering event? Or alternatively, are they simply missing a chromosome that inhibits the fear response present in normal human beings? This is obviously ripe for future discussion and clinical research. But I digress.

Scout, who apparently has a high threshold for boredom, was asking me to describe what I do in my current position at Ossur. The soporific effect of talking people through my responsibilities is almost magical. When my five-year-old daughter can’t fall asleep, I tell her what I do for a living. It’s a failsafe. Minutes later, she’s happily cavorting in the fields of Nod, drool pooling on her pillow while I’m left to ruminate about whether I should be seeking therapy for finding enjoyment in something that has the same effect as Ambien on the rest of humanity.

But Scout stuck with me through my explanation, which included a description of my interest in finding new ways to give people with limb loss/difference access to appropriate prosthetic devices. At that point, she stopped me, cocked an eyebrow, and said, “I know what you’re talking about – my insurance only covers $1,000 per year for prosthetics.” She then asked me to explain how her insurance company could do that when California has a “Prosthetic Parity” law (passed in 2006) requiring insurers to offer the same limits for prosthetics as other major benefits under the insurance policy. This led to the following dialogue

Dave: Do you have your own insurance?

Scout: No – I’m on my parents’ policy.

Dave: Your mom’s or your dad’s?

Scout: My father’s.

Dave: Let me make a prediction – he works for a big company, right? [Pulls large, sequined, puffy headwear with feather out of back pocket and places it on his head while, simultaneously and without hesitation, uses other hand to pull small envelope out of front pocket and places it against his forehead while closing his eyes and concentrating intently.]

Scout: Sort of big. [Alarm and fear in her voice upon seeing said headwear and envelope materialize on/in front of Dave’s head/face, respectively.]

Dave: Well, how many employees does his company employ?

Scout: He works for [an international hotel chain].

Dave: [Animated, as if the following words that will spill out of his mouth are interesting, when in fact, they are most decidedly NOT. And simultaneously pulling envelope away from his head and opening it to reveal a small card with the words, “ERISA-based plan” on it.] Your father works for a company that I can say with 99.9 percent certainty, and without ever having seen the policy to confirm it, is self insured.

Scout: [Stepping backwards from Mad-Hatter-like character now thrusting card with gibberish scrawled on it into her face.] And what does that mean?

Dave: Large companies usually self-insure their employees. Those kinds of polices are called “ERISA-based plans.” And ERISA-based plans aren’t controlled by state laws – the Federal Government oversees those kinds of policies.

Scout: [Eyes widening, reaching for card still being held in front of her face.] So that’s why they can put that limit in my policy?

Dave: Precisely! [Bows deeply in front of Scout, hand sweeping headwear down to the ground in a grand gesture, followed by puff of smoke and Dave’s corporeal body vanishes, leaving Scout clutching the card and staring at the bejeweled and feathered hat remaining on the floor.]

(This is literally the only way to make a discussion of insurance interesting.)

Notwithstanding a few literary flourishes, the core of the dialogue I had with Scout is accurate and true. And why is that important to you?

The majority of working people in the United States work for companies that self-insure their employees (59%). That number has climbed steadily since 1999, increasing by roughly 15%. Since self-insured (ERISA-based) plans fall outside the scope of state regulation, that means that even in the 19 states that have passed prosthetic parity laws, many people with limb loss/difference face exactly the same limitations as Scout does.

Now, this is a complex issue and I do not want to oversimplify. (Something I am rarely accused of. Because of both my educational background and an undiagnosed mental defect of some kind, I am rarely incapable of answering “yes/no” questions in less than 1500 words. My professional peers will validate this if asked.) Some ERISA-based plans provide excellent prosthetic coverage. However, many do not, and people with limb loss/difference – from now on, in this blog, “LL/D” – suffer as a result.

Even when employers offer different tiers of ERISA-based plans – for example, an HMO (low end), POS (mid-range) and PPO (high end) – it’s not uncommon to see the $1,000/yr or $25,000/lifetime cap in all tiers offered to employees. So people with LL/D are trapped. They can’t “buy up” into an appropriate plan, and are left to shoulder virtually all of their prosthetic costs out of pocket.

As a result, the Amputee Coalition of America, with the support of the American Orthotic and Prosthetic Association, has kick started the effort to pass a Federal law that would apply to these self-insured plans. That effort continues today, almost exactly one year after the ACA, with valuable assistance from AOPA, pulled off a successful “Capitol Hill Day” focusing on Federal prosthetic parity. I was lucky enough to be one of numerous amputees from around the U.S. that stormed Capitol Hill last September. (I should emphasize, it was a fairly slow and entirely nonviolent storming, martial imagery aside.) For more information about the current state of these efforts, visit the ACA’s Federal parity page.

Scout Basset (remember her?) is lucky – she’s an elite athlete who, by virtue of her unique talents, hard work, and a great team of health care providers behind her, can access what she needs despite the $1,000/year limit on her policy. But make no mistake – whatever you think about the cost of prosthetics in the US, $1,000 per year offers only the illusion of coverage, not the real thing. Unlike Scout, most people with limb loss/difference have to forgo a prosthesis when faced with similar insurance restrictions.

I thank Scout for letting me tell her insurance story here. She’ll soon have her own bully pulpit on this fantastic, newfangled interweb. We’ll be sure to pass on that info as soon as it’s publicly available.

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