After years of lobbying by women's health advocates and amidst much fanfare, the 1998 Federal Breast Cancer Reconstruction Law (also referred to as the Women's Health and Cancer Rights Act of 1998, or WHCRA) was signed into law by President Bill Clinton.1 Passage of this legislation marked the culmination of intensive lobbying efforts by breast cancer survivors, clinicians, researchers, and policymakers to ensure coverage of breast reconstruction following mastectomy by health care payers. In the 2 decades prior to the passage of the WHCRA, a growing body of research demonstrated significant psychosocial and quality-of-life benefits for those receiving breast reconstruction.2-4 Largely as a consequence of these studies, provider and patient perceptions evolved away from viewing breast reconstruction as a "cosmetic" procedure. Instead, health care professionals and consumers concluded that the creation of a new breast following mastectomy was a reconstructive operation and, for many women, an important element in breast cancer recovery. Despite changing attitudes, some health care payers had failed to include breast reconstruction among their covered benefits, steadfastly maintaining that these operations were cosmetic in nature. With enactment of the WHCRA, this barrier was removed. The law mandated that health plans include breast and nipple reconstruction as well as contralateral breast symmetry procedures among their benefits afforded to mastectomy patients.
The WHCRA was a significant milestone in several respects. It was a tangible sign that breast cancer had become a prominent issue in health care policy and that breast cancer advocacy had evolved into a potent lobbying force on the national political scene. The new law also signaled that breast reconstruction had become widely recognized as an important element in breast cancer treatment and rehabilitation. Finally, the WHCRA demonstrated the power of consumers to impact health care policy on a national level.
Currently, the WHCRA has been the law of the land for 10 years. The following is a discussion of the effects of this federal mandate, along with other factors, on breast reconstruction practice patterns.
Measuring the current rate of breast reconstruction may seem like a straightforward proposition. In fact, determining recent rates of postmastectomy reconstruction in the United States presents a daunting challenge, largely due to the fragmented nature of clinical databases in this country. While many other developed countries have nationalized health care systems with comprehensive patient databases, the US system, with its hodgepodge of public and private payers, does not currently possess a single data clearinghouse for the entire patient population. Researchers seeking to evaluate national trends for health care utilization are forced to rely on databases that include only segments of the treatment population. Thus, the generalizability of the results of these studies is severely limited. For example, the Medicare database contains a nationwide sample of patients, but is largely restricted to those over 65 years of age. Since breast reconstruction is relatively uncommon in the elderly, using Medicare data to study reconstruction rates for the general population would ...