WHCRA: Past, present and the push for modernization

A small but transformative piece of legislation – the Women's Health and Cancer Rights Act (WHCRA) – was enacted in 1998 to safeguard care for millions of women. This federal law was the result of sustained advocacy by physicians, patient advocates and survivors – all determined to secure essential medical care for women with breast cancer. Among those instrumental in bringing the bill to fruition was plastic surgeon Todd Wider, MD.

Dr. Wider's commitment to the cause began after treating his patient, Janet Franquet, who was diagnosed in 1997 with an aggressive form of breast cancer. Following a medically necessary mastectomy, Janet sought breast reconstruction.

When Dr. Wider contacted her insurance company, he was told that reconstruction was considered cosmetic and, therefore, not covered. Instead, they recommended a less-expensive skin graft instead of the pedicled TRAM flap Dr. Wider deemed appropriate. Outraged by the denial, Dr. Wider performed Janet's reconstruction free of charge and began advocating to ensure no other woman would face the same barrier to care.

Dr. Wider reached out to his legislators and Sen. Alphonse D'Amato (R-N.Y.) called back the next day, pledging his support after having heard similar stories from his constituents. Bipartisan support from Sen. Diane Feinstein (D-Calif.) was achieved and, later that year, President Bill Clinton signed the WHCRA into law.

Under the WHCRA, any group health plan or insurance issuer that covers mastectomies must also provide coverage for:

• All stages of breast reconstruction on the affected breast
• Surgery on the opposite breast to produce a symmetrical appearance
• Protheses
• Treatments of physical complications of mastectomy, including lymphedema

The law ensures that these services are provided in consultation with the patient's attending physician. Although plans may apply standard deductibles and coinsurance, they cannot deny coverage outright. Insurers are also required to provide written notice of these rights at the time of enrollment and annually thereafter.

Today's reality

Although WHCRA was groundbreaking at the time, it was written in an era when breast reconstruction options were more limited. Today's advances in cancer treatment, reconstructive surgery and genetic testing have created scenarios not explicitly addressed when the law was enacted.

A plethora of examples abound for many facets of breast reconstruction: women encounter denials for mesh and acellular dermal matrices, flat closures for mastectomies and staged procedures to save the nipple areola complexes in patients with genetic predisposition to breast cancer (e.g., a lift followed by a mastectomy and reconstruction with implants) just to name a few. As a result, insurance companies have found loopholes to deny patients coverage, claiming that certain modern procedures are "not medically necessary" or are "experimental."

Additionally, insurance companies make it extremely challenging to fight coverage denials. Physicians must write letters, request peer-to-peer reviews (often with non-surgeons) and invest significant time from their practice to advocate for their patients. Making matters even more frustrating, prior authorization can be reversed and repayments demanded by the insurance companies if they change their minds on whether the service was covered. Perhaps most vexing is that insurance companies will sometimes refuse services that their policies clearly state are covered – but they face no negative consequences.

"The spirit of the law was to provide women with breast cancer some peace in not having to worry about whether their insurance carrier would cover breast reconstruction," Dr. Wider said in a recent conversation. "Patients should fight their illness, not their insurance company."

Modernizing WHCRA

In order to renew this same spirit, the bill must be updated to fit today's advances in medicine. Nearly three decades after the original passage of the WHCRA, a new bill has been proposed to remedy these denials and restore care to the millions of women diagnosed with breast cancer yearly. The updated Women's Health and Cancer Rights Modernization Act would secure health insurance coverage for women facing denials for breast reconstruction surgeries following cancer treatments, allowing them access to treatments that were not explicitly covered in the old bill.

ASPS members in July attended the Advocacy Summit in Washington, D.C., where they met with legislators to discuss healthcare policies affecting both patients and plastic surgery practices.

Among the bills members discussed with lawmakers was the Women's Health and Cancer Rights Modernization Act. Sponsored by Rep. Kat Cammack (R-Fla.) and Rep. Lucy McBath (D-Ga.), the bill has already garnered bipartisan support from Rep. Debbie Dingell (D-Mich.); Rep. Young Kim (R-Calif.); Rep. Ashley Hinson (R-Iowa); and Rep. April McClain Delaney (D-Md.) – signifying the widespread belief that no woman should be denied medically necessary reconstruction after breast cancer treatment. Reflecting on his patient Janet Franquet, who spurred his own advocacy journey nearly 30 years ago, Dr. Wider said she embodied both grace and decency.

"When I visited her in hospice, she told me she was so grateful to have played a part in the passage of the WHCRA," he recalls. "She said her efforts at advocacy gave meaning to the final chapter of her life. She was glad to have spent that year fighting for this cause, and she hoped other women with breast cancer would not have to battle their insurance companies in the future. She should be remembered with gratitude for her generosity of spirit."

In the coming months, ASPS will build a grassroots campaign for a cause that allows the plastic surgeon and patient to be the determinant of breast reconstruction care – rather than the insurance company. We hope we have your support when we call you to action on behalf of all of the breast cancer patients that we serve.

Lauren McNulty, a first-year law student at Stetson University College of Law in Gulfport, Fla., attended the ASPS Advocacy Summit in July with Dr. Billington, who is in private practice in Tampa and a Legislative Advocacy Subcommittee vice chair.