Before she migrated into a career in public health leadership, Shaneis Kehoe spent several years in practice as a pediatric O&P clinician. She didn’t last long, she says, because “I had a really hard time not giving folks what they needed.” Patient after patient would have to settle for a second- or third-best option because their insurance plan wouldn’t pay for the solution that supported the best health outcomes.
Things came to a head when Kehoe led a mobility clinic for kids with lower-limb difference. “Everything about that day was just magic,” she says. “We swapped out their feet, and they got to run around, and they had these big smiles on their faces. But the thing that tarnished it was that it was just one day. At the end of the clinic, that was it.” No more running, no more smiles.
Kehoe left the profession and went into health administration, where she gained on-the-job expertise in the factors that inflate insurance costs and patient out-of-pocket expenses. Too often, the cost escalators had little to do with medical need and everything to do with the financial needs of healthcare systems and insurance networks. So when the coalition of amputee advocates behind the So Kids Can Move campaign approached Kehoe last year and asked her to run a fiscal and social analysis of the legislation, she jumped at the chance.
“This was like my dream come true,” she says. “I really wanted to move the needle on healthcare costs. And we need data to do that.”
So Kids Can Move offers a permanent fix to the “one-day-only” limitation of Kehoe’s pediatric mobility clinics: It requires insurers to cover recreational prosthetic devices if medically recommended by the clinician. As we noted in our May print edition, the SKCM bills in New Mexico and other states could not have passed without amputee advocates’ solid grassroots organization, sharp communication, and strong collaboration. But Kehoe’s cost/benefit analysis was equally essential to passage. The data showed convincingly that state healthcare systems could easily absorb the projected cost of covering all those recreational devices.
“The point of our report was to determine the actual impact it could have,” says Kehoe, who collaborated on the research with former Amputee Coalition president Jeffrey Cain and others. “Because while we thought this was a good idea, we weren’t going to actually push for it without understanding what it would cost.” More important, budget-conscious legislators wouldn’t vote for So Kids Can Move if they thought it might burden the state’s public health budget or cause a spike in insurance premiums.
“We asked ourselves, ‘What’s the most fiscally conservative thing we could do?’” Kehoe says. “And the most conservative assumption would be that every single amputee in the state gets a recreational device—even though that would never happen.”
Even in that unrealistically expensive scenario, Kehoe and company found, the premium in the average insurance plan would only increase by eight cents per month per enrolled member. In a more plausible scenario, in which only a percentage of amputees obtain recreational prostheses, the cost increase would be as low as one cent per month per member. To put this into applied terms: A small business with an insurance plan covering 50 employees could expect to pay as little as $10 a year in extra premiums, and no more than $50 a year in a worst-case scenario. A megacorporation with several thousand employees would only see its insurance costs rise by a few thousand bucks.
Kehoe ran the same analysis for two other states and got similar results. In Connecticut, the projected premium increase ranged from one to 11 cents per member per month; in Illinois, the range was one to 37 cents. “The estimated increase to CO, CT & IL is less than 0.003% of the annual amount spent on healthcare per capita in the United States ($10,000),” Kehoe wrote in her report.
In exchange for those negligible costs, public health systems could expect to reap enormous savings due to the improved baseline health of the limb-loss population. A more active, healthier cohort of amputees would place far lower demands on public health and social support systems, reducing expenditures in health treatment, prosthetic care, pharmaceuticals, long-term care, disability benefits, and assorted other interventions.
“People see O&P as a very small niche,” Kehoe says. “What they don’t always understand is how it connects to everything else. The majority of lower-extremity amputations are caused by adult onset diabetes, and those numbers are directly related to obesity. And obesity is incredibly prevalent—69% of Americans struggle with obesity. There are just so many dominoes that are about to fall. I don’t think people quite see it.”
Kehoe’s data clarified the picture for legislators. By her team’s very rough estimates, SKCM legislation could reduce Colorado’s overall healthcare expenditures by $43 billion—yes, billion with a b—over the span of several decades. Connecticut and Illinois also stand to save tens of billions, although the data aren’t precise enough to support specific estimates. All of that, simply by equipping amputees with the devices they need to live healthier lives.
Those numbers are based on high-quality claims data that captures insurers’ actual costs. And the researchers ran their figures through the same actuarial analysis the state of Maine used in 2022 to evaluate its trailblazing recreational-prosthetic insurance law. The methodology was sound enough to merit acceptance by a peer-reviewed journal (the paper appeared last month in Medical Research Archives). Above all, it was persuasive to the elected officials who were considering So Kids Can Move laws in New Mexico, Colorado, Illinois, and elsewhere.
“You just need reputable data,” Kehoe says. “When I went in to talk with legislators [in Colorado] they all said, ‘This is a no-brainer.’ When you can show them your analysis, where even in a worst-case scenario it’s only going to cost pennies, then why not? Why wouldn’t they support it?”
Jim Kaiser, a certified prosthetist who spearheaded the So Kids Can Move advocacy effort in Illinois, says Kehoe’s fiscal and social analysis was the difference-maker in his state. The report also helped tamp down opposition in Colorado, where the bill overcame some entrenched obstacles and procedural hurdles to unexpectedly gain passage. And Kehoe believes this year’s SKCM triumphs—five bills were signed into law—are just the beginning of a bigger, broader reform movement to make prosthetic devices universally accessible.
“There are still so many states that don’t even have basic coverage protections,” she says, referring to Fair Insurance for Amputees laws (which are currently in force in just 22 states). Kehoe is gearing up for a new study that will address the fiscal and social impacts of basic coverage, focusing on more than a dozen states that currently lack Fair Insurance protections. “Once we get at least 33 states with Fair Insurance, that makes it a national movement,” Kehoe says. “And then we go to the federal government.”
After she’s whipped the nation’s prosthetic insurance laws into shape, Kehoe doesn’t plan to stop. Earlier this year she launched a nonprofit, Upstream Informatics, whose mission is to improve health outcomes through data-backed legislative initiatives. “We spend $10,000 per capita every year on healthcare in the United States,” she says, “but we have the lowest life expectancy [among industrialized nations] by several years. The average industrialized country spends $5,000 to $7,000 per capita, and they’re healthier. That’s crazy.”
Can carefully researched, well-presented data lead to saner policies and better outcomes? If it can happen with prosthetic devices, Kehoe believes, there’s no reason it can’t happen throughout the entire healthcare system.