Lawmakers, Survivors Back Bill to Fix Reconstruction Gaps

Surgeons, breast cancer survivors, advocates and State lawmakers recently met in Mobile to confront persistent gaps in access to breast reconstruction care after mastectomy. The forum underscored how coverage on paper does not always translate into timely, practical care for patients across Alabama.

The January 10 event included reconstructive surgeons, patients and policymakers preparing to introduce State legislation to close access gaps. 

Legislators said the planned bill would make coverage more meaningful by protecting patient’s choice of both the method of reconstruction and their surgeon, curbing administrative delays and improving transparency in insurer contracts.

Speakers stressed that federal law (the Women's Health and Cancer Rights Act of 1998) requires insurance coverage for breast reconstruction after mastectomy, but many patients still struggle to obtain necessary care. Barriers to care can include the limited local availability of advanced surgical techniques, long travel distances to find specialists and insurance hurdles that delay or deny treatment.

“Through our experience over the last two years, while providing these services to the women of Mobile, it became very apparent to us why nobody else was offering these specialized techniques,” said Dr. Mark Stalder, a Plastic and Reconstructive Surgeon focused on post-mastectomy care. “Insurance companies have created an environment of total control over network physician referrals, along with artificially low reimbursement for certain procedures… where if a patient did not have the resources to seek these specialized services out of State, most simply did not receive the care.”

Several patients shared personal accounts of long travel distances, months-long delays for insurance authorization and direct interference by insurer personnel in medical decisions. Two attendees employed by a Mobile-area health system — which also self-insures its workforce — described ongoing battles with their employer’s human resources department over coverage approval. One said her surgery was postponed more than a year because insurers repeatedly denied authorization. Another was told she should seek care four hours away in Birmingham or outside of Alabama.

At the forum, legislators highlighted goals of the forthcoming bill, including preventing excessive administrative delays, requiring third-party standards for insurer negotiations and clearer insurance language to help patients understand covered procedures.

State Representative Jennifer Fidler (R-Silverhill), who plans to carry the legislation in the Alabama House, said the patient stories from the event show how often the system fails those it is meant to protect. 

Organizers said improved access could also lower long-term health costs by reducing complications and repeat procedures tied to delayed or incomplete care.

A Lagniappe Daily investigation found that some breast cancer patients in Mobile whose insurance plans are through Blue Cross and Blue Shield of Alabama received notices before surgery stating that “services … necessary for the treatment of your condition … are not covered,” leaving patients responsible for full payment if they opted to proceed. These forms, handed to patients at check-in, highlighted the divide between legal coverage mandates and real-world insurance practices that can effectively block access to advanced reconstruction techniques. The investigation noted that limited local provider availability means some patients must travel far or go out of state to receive care that is technically covered but not accessible.

Reporting by Lagniappe Daily also found that the dispute centers on how certain advanced breast reconstruction techniques are classified under insurance contracts, even when performed by in-network surgeons at in-network hospitals. Patients interviewed by Lagniappe said they were presented with consent forms warning that procedures deemed outside their benefits would not be covered, despite being part of their cancer recovery plan. One form stated, “There are services that I feel are necessary for the treatment of your condition and maintenance of good health that are not covered by your Blue Cross and Blue Shield of Alabama health benefits contract. You are expected to pay for those services in full.”

Dr. Stalder told Lagniappe the issue is not whether reconstruction is covered under federal law, but whether patients can realistically access the full range of medically appropriate options in Alabama. “Through our experience over the last two years, while providing these services to the women of Mobile, it became very apparent to us why nobody else was offering these specialized techniques,” Stalder said. He pointed to insurer control over physician networks and reimbursement rates that discourage providers from offering complex reconstruction locally, leaving many patients with the choice of traveling out of State or going without certain forms of care.

At press time, the bill was not available on ALISON for review.