Demand Parity for Flat Closure – Amend the WHCRA

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What is the WHCRA?

The Women’s Health and Cancer Rights Act (WHCRA) is national legislation passed in 1998 which required most insurance companies to cover breast mound reconstruction (BMR) after mastectomy, surgery and reconstruction of the other breast to produce a symmetrical appearance, breast prostheses, and treatment of physical complications of the mastectomy. But there’s a catch.

What the WHCRA didn’t cover, was flat closure.

In the 1990’s, less than 20% of mastectomy patients elected BMR. Flat closure was the default, but it didn’t have a name – it was just “a mastectomy without reconstruction.”

Since there’s a near complete lack of data on patient satisfaction with flat closure aesthetics, we can’t say for sure whether flat closure quality has declined as BMR rates have soared – currently hovering at around half of all patients electing BMR. Certainly, anecdotal evidence would suggest that it has. But we do know that right now, at least 1/4 of women going flat are dissatisfied with their aesthetic result, and 1 in 20 are intentionally denied a flat closure.

We also know anecdotally that women frequently encounter insurance denials of coverage for flat closure and revision services. And we know that when insurance companies were denying coverage for BMR, patient advocates fought to pass the WHCRA… and that solved that problem.

The next step is obvious – amend the WHCRA to include coverage for flat closure and revision services!

Why do we need to amend the WHCRA?

To ensure insurance coverage for flat closure and revision services… so that women going flat don’t have to worry about fighting their insurance companies.

Aesthetic flat closure is not too much to ask.

Too often, if the option to go flat is mentioned at all in the surgical consult, it’s cast as a choice that’s “less than.” Most of the time, the idea of an aesthetic plastics closure isn’t even entertained for women going flat… whereas it is routine for women electing BMR.

In terms of getting revision surgery to achieve an aesthetic result they can live with, many women simply don’t have the ability to fight their insurance company during their recovery – so they are forced to live with a “mangled” chest. Whereas their sisters who choose breast reconstruction have their two, three, even up to nine or more surgeries covered by insurance without any suggestion that their surgeries are “cosmetic”.

Without corrective action, this disparity will endure.

The original intent of the WHCRA was to ensure that women facing breast cancer surgery were able to achieve aesthetic results they could live with. Who could have forseen that helping women who choose breast reconstruction would end up harming the rest who choose to go flat? Without corrective action, this disparity will endure.

Flat closure does not rebuild the shape of the breast, but it DOES correct a deformity caused by the mastectomy – it restores the normal anatomic contour of the chest wall (hence, “chest wall reconstruction”) – and therefore it is truly reconstructive (NOT cosmetic).

Our proposed amendment

It’s clear, from a reading of the WHCRA text, why flat closure is often interpreted as being excluded from coverage. However, this is an easy thing to fix – we simply need to change “breast” reconstruction in the legislation to “breast or chest wall” reconstruction. It’s that simple!

“… who elects either breast or chest wall reconstruction in connection with such mastectomy, coverage for— all stages of reconstruction of the breast or chest wall on which the mastectomy has been performed; surgery and reconstruction of the other breast or chest wall to produce a symmetrical appearance…”

Women’s Health and Cancer Rights Act of 1998

Amending the WHCRA is critical to ensure parity.

One in eight women will face a breast cancer diagnosis in their lifetime. And four out of five women over the age of 60 who have mastectomies, decide to go flat. That’s a lot of women potentially facing suboptimal care and additional hardship at one of the most vulnerable times in their lives.

Amending the WHCRA to include insurance coverage for flat closure (chest wall reconstruction) will be a critical step in ensuring these women receive the care they deserve.

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Published by Not Putting on a Shirt

Founder of Not Putting on a Shirt, a mastectomy patients' rights organization that advocates for optimal surgical outcomes for patients going flat.

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