Breast cancer patients needs protection
[Op-Ed]

By Rep. Anna Eshoo
San Antonio Express-News
January 27, 1997

Breast cancer can be one of the most traumatic experience a woman ever endures. Unfortunately, many health insurance companies are making the experience even worse by denying women coverage for something that is essential to their physical and mental recovery from the disease - reconstructive breast surgery.

It's gotten to the point that breast cancer patients need federal action to change the way insurance companies operate.

More than 180,000 American women are diagnosed with breast cancer each year, and approximately 85,000 of them undergo a mastectomy.

For those women who live through the disease, horrible scarring and emptiness often replace what had been a fundamental part of their identities as women, mothers, lovers and whole human beings. In fact, studies show that fear of losing a breast is a leading reason why many women do not participate in early breast cancer detection programs.

It is no surprise, then, that more than 25,000 mastectomy patients each year elect to undergo a second procedure, known as breast reconstruction, which restores the breast mound to a natural shape and establishes symmetry between diseased and nondiseased breasts. Yet despite the high level of success of reconstructive breast surgery, many women are unaware that reconstruction is an option following mastectomy, and they put off testing and/or treatment for breast cancer until it's too late.

Reconstructive surgery is clearly an important component to breast cancer detection and recovery, yet insurance companies don't always see it that way. Even though many of them are willing to pay for mastectomies, some balk at covering breast reconstruction.

A recent survey conducted by the American Society of Plastic and Reconstructive Surgeons, or ASPRS, found that 84 percent of respondents had up to 10 patients who were denied insurance coverage for reconstruction of an amputated breast. The study also revealed that the top three procedures denied most often are symmetry surgery on a nondiseased breast, revision of breast reconstruction, and nipple areola reconstruction.

The top five states of residence of those patients reporting denied coverage are Florida, California, Texas, Pennsylvania and New York. California and Florida also are among the 13 states that have passed laws requiring breast reconstruction coverage after mastectomy.

However, state laws fail to provide adequate coverage for women because states do not have jurisdiction over interstate insurance polices provided by large companies under the Employee Retirement Income Security Act, or ERISA, which sets a bare minimum level of coverage that these companies must meet with their insurance policies.

The current situation means that women with breast cancer often are victimized twice - first by the disease, then by their insurance companies. That's why it is essential for Congress to pass the Reconstructive Breast Surgery Benefits Act, which I recently introduced in the U.S. House of Representatives.

The legislation requires health insurance companies that provide coverage for mastectomies to cover reconstructive breast surgery that results from those mastectomies (including surgery to establish symmetry between breasts).

The proposal prohibits insurance companies from denying coverage for reconstruction on the basis that the procedure is cosmetic surgery and forbids companies from denying a woman eligibility or continued eligibility for coverage just to avoid paying for reconstruction.

It also stops companies from providing money or other rebates to women to encourage them to accept less than the full protections to which they are entitled under the act.

Finally, the initiative pre-empts any state laws that require coverage for reconstructive breast surgery if those laws fail to provide a level of coverage that is at least equal to the level provided in the legislation.