Does WHCRA Work? As Paul McCartney famously sang, “With a Little Luck”

Lily Pond in New Orleans Botanical Garden - City Park

Last month I wrote about Janet Franquet, the young woman whose difficulties obtaining insurance coverage for her breast reconstruction inspired the passage of the Women’s Health and Cancer Rights Act (WHCRA) of 1998. This federal law intended that no woman should ever again have to endure what Janet did. Has that intent been realized? The answer for many women is yes. That’s definitely cause to celebrate! But still far too many women endure the heartbreak and frustration that Janet suffered fourteen years ago. Whether they are able to receive this life-changing surgery depends upon a variety of factors, not the least of which, these days, seems to be luck.

 Jackson Square

While miraculous advances have been made in the field of breast reconstruction, they are not available to all women. Even those fortunate enough to have private health insurance experience increasing difficulty obtaining approval for the reconstructive procedures and/or the surgeons they choose. This is especially true if they opt for reconstruction that uses their own tissue rather than implants. “Autologous” reconstruction is more costly for insurance providers and often requires surgical expertise only available “out-of-network.” Insurance companies frequently balk and build barriers to reimbursement, hoping women will tire of the appeals process and go with a quicker, cheaper alternative, even though it may cause her further health issues down the road. Some doctors refuse to work with certain insurance companies or require their fees paid up-front, leaving the hassle of reimbursement to the patients. Yet these women are still the luckier ones.

Although WHCRA is a federal law, it does not require Medicaid or Medicare to cover breast reconstruction after mastectomy. Huh??? These programs were established as an amendment to the Social Security Act in 1965, and even though the federal government matches state dollars to fund them and mandates that some general medical needs be provided, each state has a great deal of latitude. Each administers its own program, establishes its own eligibility standards, and determines the type, amount, duration, and extent of services. And a few states have opted not to provide for reconstruction after breast cancer!!! (Please excuse my past and forthcoming editorial punctuation.)

Sculpture Garden
 New Orleans Museum of Art - City Park

So, are the opting-out states like Mississippi, Colorado, Georgia, and a handful of others, the “bad” states? And are the majority who do provide Medicaid coverage for breast recon “good”? Unfortunately, just because a state (or an insurance company) uses pretty policy verbiage claiming it provides benefits consistent with or even exceeding WHCRA, doesn’t guarantee there’s much meaning behind the words. Or I should say, dollars behind the words.

According to the American Society of Plastic and Reconstructive Surgeons, the national average fee for the more advanced types of breast reconstruction is approximately $9300 per breast (as of 2011). Now let’s pick a “good” state, which uses exceptionally beautiful policy verbiage, like New York. How much does its Medicaid provide for reconstruction after breast cancer? Would you believe $600??? I wonder how many surgeons, or anyone else, would be willing to provide their services at a 94% discount.

Fortunately, thankfully, there are a few surgeons who will take on patients whose coverage via Medicaid or private insurers is woefully low. Sometimes these are salaried surgeons working for a clinic or hospital willing to forgo profits. Or doctors in private practice who do other types of cosmetic surgery to help counterbalance the losses incurred by treating uninsured or underinsured breast cancer patients.

Some women have been helped by benefactors through religious organizations or foundations, such as Breastoration, which helps cover ancillary expenses of breast reconstruction surgery. And some women fortuitously find surgeons willing to take them on, purely out of the goodness of their hearts, as do some surgeons in the New Orleans area. That’s a whole different level of lucky! But what woman deserves to rely on luck when she’s going through, perhaps, the worst trial of her life? And what about the woman who is just plain out of luck?

NOLA’s own Big Al Carson sings: ...If it wasn’t for bad luck, I wouldn’t have no luck at all…

Sir Paul McCartney sings : With a Little Luck (This could serve as Breastoration's rallying theme song!)

End note: Linda McCartney, singing in this video, died in 1998 at age 56, three years after her diagnosis with breast cancer. One year later, Paul McCartney and others performed a tribute, “Concert for Linda,” raising over $2 million for cancer research at Memorial Sloan-Kettering and Arizona Cancer Center, where she received her treatment. According to Wikipedia, her husband’s last words to her were: You’re up on your beautiful Appaloosa stallion. It’s a fine spring day. We’re riding through the woods. The bluebells are out, and the sky is clear-blue.