Abstract
Knee osteoarthritis (OA) is among the most prevalent chronic conditions in the United States, affecting approximately 4% of US adults, or over 10 million people (Bedenbaugh et al., 2021), with prevalence rising sharply with age. For many of these patients, non-surgical interventions such as unloader knee braces promise pain relief and mobility. Yet despite their clinical potential, access to these devices is not straightforward. Braces can cost several hundred to several thousand dollars (Lee et al., 2017), and insurance coverage is inconsistent. Braces are also not always a perfect fit, requiring costly customization that makes them even more resource intensive. Access depends less on clinical need than on negotiations among physicians, insurers, manufacturers, and regulatory bodies.
The accessibility of orthopedic devices such as OA braces is shaped not only by medical evidence but also by competing agendas among social groups. The American Medical Association (AMA), for instance, plays a pivotal role in determining Current Procedural Terminology (CPT) codes (Smetherman, 2019), which influence whether insurers reimburse a device. Medtech companies design devices and lobby for favorable coverage, while insurers weigh costs against their business models. Physicians act as both advocates for their patients and gatekeepers constrained by prior authorization rules. Meanwhile, patient advocacies and nonprofits push to reduce disparities in access, especially for older adults, women, and low-income populations who disproportionately bear the burden of OA (Hunter & Bierma-Zeinstra, 2019).
Although braces are often described as straightforward medical treatments, their distribution is entangled in a social and economic competition that challenges the assumption that clinical need dictates access.
Access to expensive medical braces in the U.S. is determined less by medical necessity than by the outcomes of negotiations among insurers, physicians, manufacturers, and advocacies where patients’ needs are often subordinated to institutional interests. This paper approaches that problem through the lens of Actor-Network Theory (ANT), examining how human and nonhuman actors collectively shape access. To trace this dynamic, the analysis focuses on the United States from 2010 to the present and proceeds in three parts. Here, the effects of insurance reimbursement structures on coverage decisions, the role of physicians and device customization in mediating access, and the influence of patient advocacy and equity claims are in turn examined.
