WHCRA Amendment

Breast cancer patients are suffering because of a loophole in federal law.

Stand up for patients.

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The Women’s Health & Cancer Rights Act (WHCRA) is a federal law passed in 1998 that requires most health insurance companies to cover the cost of breast reconstruction. But this wording hurts many patients going flat.

Amending the WHCRA to also include chest wall reconstruction will ensure that ALL mastectomy patients get optimal surgical care, by:


Ensuring Insurance Coverage

Health insurance companies will be required to cover chest wall reconstruction (aesthetic flat closure) services just like they cover conventional breast reconstruction. This will minimize denials of necessary care.

Improving Patient Outcomes

Uniform insurance coverage for aesthetic flat closure will ensure that patients going flat can access aesthetic surgical services as the standard of care, and will improve outcomes.

Supporting Informed Choice

Optimized reimbursement for providers will encourage them to present aesthetic flat closure as a valid reconstructive option, which promotes patient autonomy.



It’s not about vanity, it’s about dignity.
Women should determine the outcome of their mastectomy and it should be an outcome they can live with.

Rep. Charen Fegard

The Need for Change

Mastectomy patients going flat are regularly denied insurance coverage for the services of a plastic surgeon, and cancer surgeons who spend extra time to create an aesthetic flat closure at the time of the mastectomy are frequently not reimbursed for their work.

As a result, one in four of the 70,000 patients in the USA going flat end up with egregiously poor aesthetic outcomes (Fig. 1, left). That’s over 17,000 patients every single year who are suffering needlessly. It happens in part because the WHCRA only covers breast reconstruction, not chest wall reconstruction (aesthetic flat closure).

We simply want patients going flat to have the same access to insurance coverage for necessary care that women reconstructing their breasts do.

It’s about health, choice, and dignity.

The WHCRA mentions breast reconstruction three times. All we need to do is amend that to “breast or chest wall reconstruction” and the problem is solved. It’s simple & will have bipartisan support – an “easy win.”

READ MORE

About the WHCRA. The Women’s Health and Cancer Rights Act (WHCRA) is the landmark 1998 legislation that requires insurance to cover breast reconstruction. What it does NOT cover, is chest wall reconstruction – i.e., aesthetic flat closure (NCI), the creation of a smooth, flat chest for patients who choose not to reconstruct their breasts. All patients deserve a surgical outcome that reflects their reconstructive choice with dignity. But that’s not what many patients going flat get. The WHCRA wording plays a big role in that.

What Problem Does The Amendment Aim to Solve? Right now, women are routinely denied insurance coverage for aesthetic flat closure surgery – at their initial surgery, for revision (“clean-up” surgery), and at explant (breast implant removal). About 1 in 4 women going flat receive an egregiously poor aesthetic result, and those who are denied coverage and can’t afford to pay thousands of dollars out of pocket are forced to live with that. It’s an avoidable trauma that can be prevented with a simple amendment to the law.

What is in the Amendment? We simply want to add the phrase “or chest wall” to the three places where the WHCRA mentions “breast reconstruction.”

“… 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…”

What Will Be the Impact? The result of this amendment will be that women going flat will be able to access aesthetic surgical services just like their sisters who choose to reconstruct their breasts. More patients will be able to have a plastic surgeon at their initial surgery… and if they do get a poor aesthetic outcome initially, they will be able to get it fixed. Patient autonomy will be better supported, and outcomes will improve.

Questions? Contact Us.

FREQUENTLY ASKED QUESTIONS (FAQ)

flat denial photos comparison chart acceptable unacceptable aesthetic flat closure after mastectomy Not Putting on a Shirt advocacy pictures of bad mastectomy results full color
Fig. 1 Would you want yourself or your loved one to be left with the results on the left? Patients deserve better. They deserve aesthetic flat closure (right), i.e. chest wall reconstruction.

FAQ for Surgeons

FAQ for the General Public

Initiative FAQ

Questions? Contact Us


Patient Voices

Lonnie

Lonnie

Lonnie’s Story

“I was 59 when I faced breast cancer for the second time. The first time (12 years previously) resulted in a lumpectomy followed by radiation. My only option was a mastectomy. I originally planned to have both breasts removed with immediate reconstruction. I met with the plastic surgeon and scheduled the surgery. I left his office with the brochures from the implant company in my hand.

“I finally read the brochure a few days later… there in writing was their best estimate that there would be a 27% chance of complications, additional surgeries, etc. Following that sentence was the sentence that made me stop in my tracks. The chances of complications doubled if there had been prior radiation. I knew then that I wanted nothing to do with reconstruction and all the potential visits to doctor’s offices, potential complications and potential surgeries. I wanted to LIVE my life… not spend it trying to keep a fake blob on my chest so I would look better in clothes.

“I was fortunate. My breast surgeon did a beautiful job on my breast removal. I have almost invisible scars and no “extra” skin. After a few years I was horrified to see the mangled chests of so many women. It was apparent to me that their doctor’s either didn’t have the proper skills, or just didn’t care that they left them with an unsightly mess.

“We are faced with a difficult decision in these situations. We deserve honesty, compassion and surgical outcomes that don’t leave us embarrassed. We deserve to be treated with respect without doctors making us feel ‘less than’ without breasts.”

“I was fortunate. My breast surgeon did a beautiful job on my breast removal. I have almost invisible scars and no ‘extra’ skin.”

April

April

April’s Story

“Insurance companies consider this [revision] surgery “cosmetic” when all we want is to have a smooth chest instead of pockets of excess skin or “dog ears” under the arms that can cause serious irritation, or worse yet, a completely botched closure that looks like something from a Frankenstein movie. Some surgeons leave extra skin “just in case” a woman changes her mind about reconstruction when she has already requested a flat closure (another argument for another time).

It’s hard enough to have a double mastectomy due to breast cancer, but to have to fight insurance just to be able to look halfway decent and be somewhat comfortable in your own skin is wrong.”

April Warmouth Harvell of Dayton. She chose to forgo breast reconstruction, instantly saving her health insurance company thousands, if not tens of thousands of dollars. However, because Ms. Harvell was left with significant excess skin at the original surgery, she required one additional “revision” surgery to produce an aesthetic result that not only she could live with, but was, at minimum, a result that her surgeons should have given her based on an objectively fair and reasonable medical standard of care. 

To Ms. Harvell’s dismay, her insurance company refused to cover her revision surgery, stating that it was “cosmetic” rather than reconstructive and, therefore, was not covered by the Women’s Health and Cancer Rights Act (WHCRA, 1998). After months of fighting, Ms. Harvell is still facing hundreds of dollars in medical bills for her deductible.

While recovering from major surgery, she has had to spend her limited time and energy just to get the care she needs to move on with her life.

“It’s hard enough to have a double mastectomy due to breast cancer, but to have to fight insurance just to be able to look halfway decent and be somewhat comfortable in your own skin is wrong.”


For Organizations

Stand up for patients by joining our coalition!

What will you need from us?

When your organization joins the coalition, we only ask for:

  1. Your organization’s information (using the JOIN NOW submission form on this page)
  2. Your permission to add your organization’s logo and a one sentence statement about your organization’s work, to this page on our website.
  3. At the appropriate time during the campaign, we will ask you to sign a short letter in support of our initiative that we will then present to legislators.

There are no other requirements for coalition members. Please contact us with questions using our online form or email to WHCRA@notputtingonashirt.org

JOIN NOW

Your support for this initiative will:

  1. Improve patients’ access to care and optimize outcomes
  2. Amplify the voice of an underserved patient population that has long been silent
  3. Put you on the right side of history alongside our current coalition members:
Breast Cancer Hawaii
Breast Cancer Hawaii connects breast cancer patients and survivors in Hawaii with timely and relevant resources and support.
Male Breast Cancer Coalition logo
The mission of the Male Breast Cancer Coalition is to support and advocate for men diagnosed with breast cancer.
Facing our Risk of Cancer Empowered (FORCE) logo
Facing Our Risk of Cancer Empowered (FORCE) provides information and support to individuals and families affected by hereditary breast, ovarian, and related cancers.

Please Share!

WHCRA Coalition Member NPOAS

For Individuals

Not affiliated with a coalition organization? Patient advocates, medical professionals, and others affected by breast cancer can support this initiative in many other ways!

Sign the Petition

After you sign, please consider sharing!

Sign the petition Demand parity for flat closure - amend the WHCRA Not Putting on a Shirt Care2 infographic
Donate Now

Your generous donation will directly fund our work on this initiative. We can’t do it without you!

Write Your Legislators

Make your voice heard! Use the easy Congressional Lookup tool to find your federal legislators (i.e., your state Senator(s) & House Representative(s)). Then use our template to draft a letter – or compose your own – asking them to support this initiative. Note: the factsheet is included in the template!

Volunteer

This work is a team effort! If you’d like to speak to our volunteer coordinator about how you can help, contact us using our online form or by email to WHCRA@notputtingonashirt.org


WHCRA Amendment chest wall reconstruction NPOAS

Frequently Asked Questions (FAQ)

What is the WHCRA?

The Women’s Health & Cancer Rights Act (WHCRA) is a federal law passed in 1998 that requires most health insurance companies to cover the cost of breast reconstruction. (More)

What needs to change in the WHCRA?

The WHCRA does not mention chest wall reconstruction – i.e., aesthetic flat closure (NCI), the creation of a smooth, flat chest for patients who choose not to reconstruct their breasts. All patients deserve a surgical outcome that reflects their reconstructive choice with dignity. But that’s not what many patients going flat get. The WHCRA wording plays a big role in that.

What is in the amendment?

We simply want to add the phrase “or chest wall” to the three places where the WHCRA mentions “breast reconstruction.”

“… 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…”

What problem does the amendment aim to solve?

Right now, women are routinely denied insurance coverage for aesthetic flat closure surgery – at their initial surgery, for revision (“clean-up” surgery), and at explant (breast implant removal). About 1 in 4 women going flat receive an egregiously poor aesthetic result, and those who are denied coverage and can’t afford to pay thousands of dollars out of pocket are forced to live with that. It’s an avoidable trauma that can be prevented with a simple amendment to the law.

How will this amendment impact patients?

The result of this amendment – mandated insurance coverage for chest wall reconstruction – will be that women going flat (about 70,000 people) will be able to access aesthetic surgical services just like their sisters who choose to reconstruct their breasts. More patients will be able to have a plastic surgeon at their initial surgery… and if they do get a poor aesthetic outcome initially – that’s 17,000 patients per year – they will be able to get it fixed. Patient autonomy will be better supported, and outcomes will improve. Patients seeking aesthetic flat closure after explanting their breast implant reconstruction also won’t have to fight their insurance companies in order to get an aesthetic outcome they can live with.

What is chest wall reconstruction?

In this setting, it is reconstruction (surgical restoration or shaping) of the breastless chest wall contour after mastectomy – also called aesthetic flat closure. (More)

What is the definition of breast reconstruction and why isn’t it already inclusive of aesthetic flat closure?

“Breast reconstruction” is defined as surgery to rebuild the shape of the breast after a mastectomy. (NCI) That’s why it is often interpreted to exclude aesthetic flat closure – because the anatomic contour being restored with AFC is not a “breast” – it’s the chest wall. Hence, the need for the addition of “chest wall” into the WHCRA.

What’s the difference between breast reconstruction, and aesthetic flat closure?

Breast reconstruction, sometimes referred to as breast mound reconstruction, restores the shape of the breast that was removed at the time of the mastectomy. Aesthetic flat closure, also called chest wall reconstruction, restores the shape of the (flat, breast-less) chest wall contour rather than the breast.

I am a surgeon and I have technical questions about aesthetic flat closure.

Please see the Provider Resources page (including an FAQ) or contact us.

I am a layperson and I want to know more about aesthetic flat closure.

Please see the Patient FAQ, What is Flat Closure page, the Going Flat surgery guide, the Living Flat page, or contact us.

I am a member of the media and I want to know more about aesthetic flat closure.

Please see the Media Kit (including an FAQ) or contact us.

How will this amendment impact medical providers?

We anticipate cancer surgeons to have an easier time getting fairly reimbursed for their time spent in the operating room contouring their patients’ chest walls at their initial mastectomy. We also expect to see more widespread funding for and utilization of oncoplastic training in aesthetic flat closure techniques, both for general and breast surgeons.

We anticipate it becoming more common for plastic & reconstructive surgeons to be present at patients’ initial mastectomy surgeries in order to produce an aesthetic flat closure at that time. We expect more patients who have forgone conventional breast reconstruction to seek out revision surgery with plastic & reconstructive surgeons in order to improve the contour of their chest wall when they become aware that this is an accessible option.

How will this amendment impact insurance companies?

We anticipate that more mastectomy patients will choose aesthetic flat closure as it becomes offered as a valid and aesthetically pleasing reconstruction choice alongside conventional breast reconstruction. This amendment will directly support that trend because it will improve reimbursement for surgeons providing aesthetic flat closure services.

We do expect there will be some outlay to pay for aesthetic surgery for the patient population going flat because this amendment corrects a historic disparity in access to this type of care. However, because the cost of any type of aesthetic flat closure procedure pales in comparison to the cost of any type of conventional breast reconstruction, on the balance we anticipate cost savings for insurance companies.

I am outside of the United States but would like to support this initiative.

Please contact us so that we can learn how we can best support each other! Our Council of International Advocates includes members from across the globe, and we participate in other global initiatives to promote aesthetic flat closure. We welcome any and all discussion about how to constructively use gains and lessons from US advocacy to other nations so that ALL mastectomy patients can access an optimal standard of surgical care!


Questions? Contact us at WHCRA@notputtingonshirt.org


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