Breast reconstruction and correcting course on the Women's Health and Cancer Rights Act

Getting an insurance carrier to pay for breast reconstruction after a mastectomy was difficult before 1998 and the passage of the Women's Health and Cancer Rights Act (WHCRA). After 1998, it seemed like progress was being made, and women saw a world of reconstruction options opening before them. So why is it that nearly 30 years later, patients are venting their frustrations about obtaining reconstruction coverage and calling to fight with their insurance company as mentally taxing as coping with a cancer diagnosis?

Does it sound too far-fetched to compare fighting cancer to fighting for insurance coverage? Not to the patients impacted by companies utilizing frustrating delay tactics and strategies designed to exploit legislative language loopholes to deny breast reconstruction coverage. It feels like, instead of advancing and making progress, things have reverted to a pre-1998 era where options and coverage for breast reconstruction were dangled painfully out of reach for many.

Patients and plastic surgeons call for change, but correcting course is difficult in a complicated legal, legislative and technological landscape. New legislation, backed by patients and many in the healthcare community, is aimed at changing the tide, again, preventing healthcare groups from denying and delaying critical coverage for reconstruction patients.

27 years later: How has WHCRA fallen short?

What should be a guarantee of coverage according to WHCRA is anything but in today's complicated healthcare climate. Plastic surgeons are having to dedicate more time to educating patients on their payment options and answering insurance questions than discussing post-cancer treatment and reconstruction options. It is not so much that the original WHCRA law has fallen short of its promises, but more that, over the years, insurance providers have found ways to exploit specific legal language to save themselves money and increase profit margins.

Warren Ellsworth, IV, MD, praised the advancements in breast reconstruction technology at plastic surgeons' fingertips today.

"We have highly cohesive implants," said Dr. Ellsworth. "We have mesh, both human dermis and synthetic mesh, that have revolutionized my ability to create a natural, long-lasting result with implants. And we have fat grafting, which has been proven safe in breast reconstruction and gives a more supple, natural shape and feel."

Unfortunately, the law hasn't kept pace with technological advancements, and many insurance companies are using loopholes to delay or deny vital breast reconstruction coverage to the patients who need it the most.

"These things we routinely have to fight for coverage, and still, probably 30 percent of the time, I have difficulty getting these types of things covered because they aren't necessarily protected by the initial act," said Dr. Ellsworth.

Many plastic surgeons find themselves boxed in by a patient's insurance coverage constraints, forced into the difficult position of explaining to patients that they can only choose from column A, as insurance won't cover anything in column B.

"It's the hardest part for me as a surgeon who can do these things is when I'm told I can't do these things only because the patient has an insurance that won't allow her access to such," said Dr. Ellsworth. "It seems crazy, but that happens routinely."

Alicia Billington, MD, PhD, faces the same challenges. For many plastic surgeons, it can be frustrating to navigate insurance issues. Sometimes, it can feel like the insurer, not the doctor, is dictating the patient's care.

"If you have a fracture, an orthopedic fracture, sometimes a splint is the right option," said Dr. Billington. "Sometimes you need to go in and put a rod in, sometimes you need a plate. It really depends on the mechanism of injury, the fracture, is this open or closed. Similarly, with breast reconstruction, there are so many other factors that go into play besides just the fact that the patient has breast cancer. Are they going to get a lumpectomy? Are they going to get a unilateral? Do they have a lot of soft tissue? Do they not? What does their chest wall anatomy look like?"

For patients and physicians, they know that insurers aren't in the thick of the situation. Companies may want to dictate the types of breast reconstruction options patients have, but without the understanding or nuance of the effects of radiation on the patient's body or all the other factors that come into play.

"The conversations I have with patients about what type of breast reconstruction to get, it's over an hour, right?" said Dr. Billington. "So, you can't just say, 'Oh, well, we have this one type and it works for everybody.' That's not how this works."

Critical medical decisions should always be made between a patient and their doctor. However, for many people, insurance companies continue to feel like an intrusive force in the process, potentially limiting the options a patient can choose from and affecting the overall outcome of their recovery, something the original 1998 legislation was supposed to fix, but time and new insurance strategies mean an upgrade is in order.

How doctor-patient interactions are changing due to WHCRA limitations

You get a direct answer when Dr. Billington discusses how her bedside manner has changed over the years.

"A significant amount of time in my practice is spent talking about how to help patients with the insurance denials or the delays or the claw backs when we should be talking about their breast cancer care," said Dr. Billington. "It's gotten so, so bad, and it affects so many patients that I have now incorporated it into my routine discussions with every single patient. I start the conversation with, 'How are you feeling, how are things going, have you had any issues with denials for your care?' It gets equal time as, 'Have you had any fevers, chills, redness, drainage?'"

That insurance discussions are becoming as commonplace as a patient's surgical recovery should be shocking.

"I just want to do a mental health check and for us we have found that we have to do this because so many times they're afraid to talk to me about it because the physician and the money part are so separate and so I just bring it up now and I was completely shocked by how many patients are like, 'Yeah, actually I do have a problem with this,'" said Dr. Billington.

Correcting course: Putting the power back in the hands of patients and doctors

Thanks to a core group of legislators, physicians and patient rights advocates, a modernized and updated version of WHCRA is in the works. A new measure – the Advancing Women's Health Coverage Act (AWHCA) – seeks to close loopholes and fill gaps left by the original 1998 legislation. It aims to ensure women have access to the latest breast reconstruction treatment options and that those options will be covered by their health insurance provider.

Representative Kat Cammack (R-FL) has been an outspoken supporter of increased reimbursement and healthcare access for breast cancer patients and recently spoke about updating the WHCRA during a 2025 ASPS Advocacy Summit. There is now bipartisan support for the measure, with Rep. Debbie Dingell (D-MI) and Rep. Lucy McBath (D-GA) getting behind updating the outdated legislation.

Key goals of the new measure include language that explicitly states that all types of breast reconstruction, both present and future, should be covered and expanding coverage options to include modern techniques and medical advancements in breast reconstruction and care. The updated legislation also seeks to ensure patients have access to in-network providers and reconstruction options while removing additional access barriers and addressing gaps in reconstruction care.

Dr. Billington explained that the new legislation says that everyone agreed this made sense back in 1998. Now that so many critical gaps in coverage are appearing and so frequently, it is time to change and rework the language so that it is not up to the insurance company's interpretation.

In short, Dr. Billington summed up the new measure: "It's saying we still feel the same way. Breast reconstruction should be covered, period."

The passion over the topic was palpable as Dr. Ellsworth explained why now is the time to move toward passing this new and monumental measure.

"I think people are passionate about a woman's right to have access to care because number one, breast cancer is so common," said Dr. Ellsworth. "It touches all our lives."

There is a reason everyone gets decked out in pink in October to support breast cancer awareness. According to statistics from the American Cancer Society, breast cancer is one of the most common forms of cancer in the United States. There is a one in eight chance that a woman develops breast cancer in her lifetime. If an individual personally hasn't been diagnosed with breast cancer, chances are good that a family member, friend, co-worker or neighbor has.

When a disease touches so many lives, it is natural that people will want to band together to help shift the momentum back toward giving those people the best chance possible at reconstruction, recovery and leading a whole and fulfilling life without having to make agonizing, financially based decisions about their care.

Revising and reintroducing legislation at the federal level based on the spirit of WHCRA can help clarify misinterpretations of the old law while improving and expanding comprehensive reconstruction options for all breast cancer patients, women, and men.

As far as medical technology has come, there are still breast cancer patients who find themselves barred from accessing the reconstructive resources and care they deserve without going bankrupt in the process. With the continued support of dedicated and passionate medical professionals, patients and Congressional advocates, change may be just around the corner.

At the end of the day, Dr. Billington summarized it all: "I think we're just demanding the care that patients deserve, and that they should have had all along."

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.