title: Federal Health Coverage Mandates and Health Care Utilization: The Case of the Women's Health and Cancer Rights Act and Use of Breast Reconstruction Surgery.
abstract: BACKGROUND
  Utilization of breast reconstruction services remains low among women who underwent mastectomy despite the improvement in quality of life associated with this treatment. The objective of this study is to identify the effect of the Women's Health and Cancer Rights Act (WHCRA)-an understudied ongoing federal law that mandated insurance coverage of breast reconstruction following mastectomy beginning in 1999-on use of reconstructive surgery after mastectomy.
  
  
  METHODS
  We use a difference-in-differences (DD) approach to identify the change in breast reconstruction utilization induced by WHCRA by comparing the pre- and post-policy changes in utilization between states that did not have existing laws mandating coverage before the WHCRA (treatment group) and those that had such state laws (control group). The data are from the Surveillance, Epidemiology, and End Results program. The main sample includes 15,737 female patients who were under the age of 64 and underwent mastectomy within 4 months of diagnosis of early stage breast cancer during 1998 and 2000.
  
  
  RESULTS
  Based on the DD model, the odds of using reconstruction services in the states without preexisting laws increased after the WHCRA by 31% in 1999 and 36% in 2000 (compared with 1998 before the WHCRA). These effects are masked in a simple pre/post model for change in reconstruction across all states. Additional analyses through 2007 indicate that the WHCRA had long-term effects on utilization. Furthermore, analyses by state indicate that most states in the treatment group experienced a significance increase in utilization.
  
  
  CONCLUSIONS
  The use of breast reconstruction after mastectomy significantly increased after the WHCRA. At a minimum, our estimates may be considered the lower bound of the real policy effect.
authors.affiliation: 1 Department of Pharmacy Practice and Science, University of Iowa , Iowa City, Iowa.
authors.forename: Yang
authors.initials: Y
authors.lastname: Xie
authors.affiliation: 1 Department of Pharmacy Practice and Science, University of Iowa , Iowa City, Iowa.
authors.forename: Yuexin
authors.initials: Y
authors.lastname: Tang
authors.affiliation: 2 Department of Health Management and Policy, University of Iowa , Iowa City, Iowa.|3 National Bureau of Economic Research , Cambridge, MA.
authors.forename: George L
authors.initials: GL
authors.lastname: Wehby
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000191:economics / Q000473:pathology / Q000601:surgery*; D005260:Female; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D019458:Insurance Coverage / Q000191:economics / Q000706:statistics & numerical data*; D007348:Insurance, Health / Q000706:statistics & numerical data*; D016462:Mammaplasty / Q000191:economics / Q000706:statistics & numerical data*; D008408:Mastectomy / Q000706:statistics & numerical data*; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D017060:Patient Satisfaction; D011788:Quality of Life; D018426:SEER Program; D016387:Women's Health / Q000191:economics