News | Life and Limb: Advocates for Utah amputees rally for fair health-insurance coverage for prosthetics 

She spent the next year undergoing several surgeries. She developed a bone infection, which complicated her recovery. Ultimately, doctors had to amputate her leg. But her troubles didn’t end there.

“As soon as my leg was removed, that’s when they wouldn’t pay to replace it,” Stanley says, though her insurance paid almost $1 million on three surgeries before the amputation. “I had two insurance polices when I was amputated, through a school district and my husband’s work. Between the two of them, I couldn’t get it covered.”

Stanley, like many nonveteran amputees nationwide, found that inconsistent health insurance coverage for prosthetic replacements would force her to enroll in Medicaid, where 80 percent of prosthetic care is covered without spending caps. Stanley is now leading a fight as chairwoman of the Amputee Coalition of America’s Utah branch to require the state’s private health insurers to match the Medicaid standard. Stanley has teamed with state Rep. David Litvack, D-Salt Lake, to push legislation that would mandate equitable coverage from private health insurers for prosthetic coverage.

But, given the strong conservative bent of the Legislature, some, like Rep. Lorie Fowlke, R-Orem, may find a mandate on health insurers to be a pill too hard to swallow. “If you mandate everything, than government really is Big Brother in every aspect of your life,” Fowlke says. “I’m not interested in increasing the level of government involvement.”

The bill never made it out of committee last session, but in the interim, Stanley has taken the offensive. She is holding town-hall meetings across the state in her fight for equitable treatment. She also conducted a survey of a number of major health insurance carriers in Utah and discovered the level of prosthetics coverage varied widely. Only two—Intermountain Health Care and the LDS Church’s Deseret Members Benefits Administration—do not place caps or restrictions on prosthetics coverage.

While many private carriers matched the 80 percent standard of Medicaid, the restrictions on types of prosthetics offered, Stanley argues, burden many who could otherwise remain active after their amputation. “The level of coverage is based on what is the cheapest and the cheapest is usually not even the most adequate for the nonactive person.”

Stanley estimates there are more than 12,000 amputees in Utah, and she hopes to rally them to the cause. But Stanley and Litvack realize they have an uphill battle. Previous attempts to achieve insurance parity through mandates for mental-health coverage and oral contraceptives have failed repeatedly.

“‘Mandate’ is a very scary word up at the Legislature,” Litvack says. “[But] I think we are seeing a big failure in the private sector to address this issue.” Litvack argues that since health insurers are scaling back benefits for amputees, the end result is limitation of amputees’ mobility. They often end up with even more health problems and that adds burdens to an overstressed health-care system.

“Without necessary care, it’s not uncommon for people to become sedentary and need more expensive care for problems like diabetes and heart disease,” Litvack says. “Per member, per month, this has a relatively minor fiscal impact, but a huge impact for those who have the need for prosthetic care.”

For Fowlke, the problem isn’t cost as much as practice. As Stanley’s legislator, Fowlke was the first representative she approached to sponsor the legislation. Fowlke turned her down. “Where do we draw the line?” Fowlke asks. “How far does the government go to see that people take care of each other? Or should that be something privately people are allowed to do without government interference?”

Stanley, an Orem Republican, shares Fowlke’s hesitation about government meddling but believes the mandate would keep other individuals from having to rely on federal programs like Medicaid. “By allowing insurance companies to pick and choose prosthetic services, the burden shifts from private to public. Essentially, the government becomes the service provider,” Stanley says. “By doing nothing, we are asking for the government’s involvement.”

Kelly Atkinson, executive director of the Utah Health Insurance Association, worries what increased costs would do to employers’ bottom lines. “Every little bit adds [to the cost of insurance] and, for small businesses, it could be the difference between them purchasing coverage or not.”

Atkinson points out that even if the bill passed, a federal rule would exempt large health-insurance carriers from having to follow any state mandates. He says the rule would exempt two-thirds of Utah’s health insurers, leaving mostly small businesses to have to struggle with the new costs. Atkinson feels this initiative would be better served on a federal level.

“Everyone that wants to mandate a benefit says, ‘Well, I can’t do it in Washington, so I’ll start here.’” Atkinson says. “The problem is we’re having trouble insuring [Utah’s] individuals and small businesses—so do I want to perpetuate the problem by adding costs to that segment? We’ll cover any mandate that is asked for but there will be a price tag associated.”

Stanley will make her case at the Orem Friendship Center, 7 p.m., June 10 where she hopes to rally support from Utah’s amputee population. “We have been a quiet population so far,” she says. “But mine is not the only story.”