Why Can’t the Military Provide Better Breast Cancer Care?

Oksana Reed was a 24-year-old officer in the Air Force when she was diagnosed with breast cancer in 2022. Her job, supporting the operations of Air Force One at Joint Base Andrews in Maryland, was challenging and exciting, and she loved being part of the hardworking team in the 89th Airlift Wing. 

But Oksana was wary about getting cancer care in the military health system. The process of getting her diagnosis at military health facilities had been difficult, including long, stressful delays in having imaging tests done. Like all active-duty military members, she had Tricare Prime, a government-funded insurance plan that’s designed to provide comprehensive coverage and good access to care. But that coverage has limitations, and as it turned out, she would continue to have trouble getting the care she needed. 

For one thing, Reed couldn’t choose her surgeons. She was interested in a nipple-sparing and sensation-preserving mastectomy, but the military hospital where she received care didn’t have any surgeons experienced in those techniques. Her tissue expander placement surgery was botched by an inexperienced plastic surgeon, causing a painful complication called symmastia. And then she couldn’t get the type of breast reconstruction that she felt was best for her: a DIEP flap procedure. Now she’s flat on one side, even though she would have preferred to get reconstruction.  

“What I want Americans to know is that military members aren’t getting the highest quality health care available in the United States. I didn’t get the standard of care I would have received at a civilian cancer center,” says Reed. “When I joined the Air Force, I didn’t realize I was giving up my right to choose where and how I received my health care.”

Now Reed is one of a growing number of voices calling for changes to how Tricare covers breast cancer care, especially DIEP flap and other breast reconstruction surgeries. They’re pushing for policy changes that would give people with Tricare more choices in their surgical care. Without these changes, experts say, many military members and their family members are at risk of receiving worse care than people with private insurance plans.

“It’s time for the military to level up,” says Elisabeth Potter, MD, a plastic surgeon in Austin, Texas, who specializes in autologous breast reconstruction and has been working with Reed to help raise awareness of the issues with Tricare coverage. “Patients with Tricare need to have better access to breast reconstruction.” 

Tricare is one of the largest health insurers in the U.S., with more than 9.3 million enrollees who are active duty military members, retirees, and their family members. Out-of-pocket costs with Tricare are often lower than with private insurance, and for active duty members with a Tricare Prime plan, most health care within the military system is free. But the downsides can include long wait times to get appointments at military health care facilities, referral hassles, and fewer specialists. People with Tricare Prime can in some cases see doctors outside the military system if they get a referral — but then it can be hard to find civilian doctors who accept Tricare because of low reimbursement rates.   

Active duty military members — like Reed was — don’t have a choice about their insurance; they’re required to enroll in a Tricare Prime plan. It’s common for them to receive most or all of their cancer care at military hospitals. Family members of active duty members and retirees have more options — they can choose other types of Tricare plans such as Tricare Select, which has fewer restrictions, or other kinds of insurance.

“I could see the tumor growing under my skin and I was afraid it could spread if I spent more time fighting Tricare to authorize a referral.”

Access to experienced specialists was an issue for Reed’s care. Her breast surgeon at Walter Reed National Military Medical Center was a general surgeon who didn’t have advanced training in breast surgery. And her plastic surgeon wasn’t board-certified in plastic surgery. The military prioritizes staffing its hospitals with general surgeons, who have a more flexible skillset in case they need to be deployed to a war zone. 

Reed wasn’t comfortable with the surgical team assigned to her, and asked to be referred to a civilian cancer center in the Tricare network instead. But she was turned down because of her active duty status and other restrictions related to her Tricare plan.  

“I moved forward with my surgeries at Walter Reed even though I wasn’t confident in my surgeons because I felt I was running out of time. I could see the tumor growing under my skin and I was afraid it could spread if I spent more time fighting Tricare to authorize a referral,” says Reed, who had already experienced other delays in her care.

Another barrier Tricare members face is that the culture of military health care can make it harder to speak up about your preferences and needs. 

“It can be uncomfortable to advocate for yourself when your doctor is wearing a military uniform displaying their higher rank,” says Reed. “Military rank structure serves an important purpose,” but in an exam room, she explains, it’s intimidating. 

Becca Holland, who had Tricare Prime insurance when she was treated for breast cancer at Brooke Army Medical Center in Fort Sam Houston, Texas, says she also experienced this dynamic. The general surgeon at Brooke Army who performed her initial breast cancer surgeries in 2022 was often dismissive of her preferences and concerns. 

“He was used to barking orders and telling patients what to do,” Holland says. “It’s unfortunate that in the military health care system, patients are treated like we don’t have as much of a voice as we do in the outside world.”

At several points in her treatment, Holland felt pressured to get surgeries that she thought were wrong for her. During her first lumpectomy surgery, the outer edge of the tissue surrounding the removed tumor was found to have cancer cells (the surgeon didn’t get “clear margins”). So she needed to have another surgery to remove the remaining cancerous tissue. At this point, Holland wanted to have a double mastectomy to lower her risk, but the surgeon urged her to get a second lumpectomy surgery to just remove the cancerous cells. In the end, she managed to talk him into it — and it was the right call because during the surgery cancer was found in another part of her breast.  

She also wanted breast reconstruction, but not with implants. Because she has lupus, an autoimmune disease, she was sure her body would reject them. But her military doctors weren’t giving her the option of autologous (flap) reconstruction at that time, so she moved forward with implant surgery. One month later she needed to have the implants removed because of complications related to her autoimmune condition. 

Holland thinks people with Tricare often end up in a bind: they have to either fight the system or accept inferior surgery outcomes.   

“It’s a lot of extra stress to have to deal with when you’re battling breast cancer,” she says. “It was very hard on me emotionally.” 

Among breast cancer patient advocates, one limitation of Tricare insurance has been the focus of attention recently: insufficient coverage for DIEP flap breast reconstruction.   

In a DIEP procedure, a flap of tissue that includes skin, fat, blood vessels, and sometimes nerves is removed from the lower belly and transferred to the chest to rebuild one or both breasts. It’s the most popular and commonly done autologous (flap) reconstruction surgery.

After the problems with their earlier surgeries, Reed and Holland both wanted DIEP flap surgery. 

For some people, it’s the best or only good option for reconstruction, especially if they aren’t good candidates for implants or already had a failed implant surgery. Using your own tissue for reconstruction means avoiding some of the potential complications and maintenance requirements of implants. And unlike some older, less advanced types of flap reconstruction, like TRAM flap surgery, a DIEP flap procedure doesn’t involve moving or cutting muscle, which can cause problems like muscle weakness and hernia.  

“Tricare paid about seven cents on the dollar of what was billed for my 10-hour surgery, plus all the follow-up care from my surgeon.” 

But compared to most other types of breast reconstruction, DIEP flap is a longer, more complex, and more expensive surgery — and it requires more specialized training. Surgeon reimbursement rates for the procedure vary a lot among different insurers.

Tricare technically covers DIEP flap surgery, but people with Tricare can’t always get it. There are only a few plastic surgeons at military hospitals nationwide who are experienced in the microsurgical techniques needed to do a DIEP flap procedure. And most civilian plastic surgeons who are experienced with DIEP flaps don’t accept Tricare because the reimbursements are too low to cover their costs. 

A typical plastic surgeon’s fee for a DIEP flap surgery is $15,000–$20,000 or more when billed through many private insurance plans. Many private insurance plans do typically pay that amount (though, as with any medical procedure, people may have out-of-pocket costs with that). Tricare, by contrast, only pays about $2,000–$2,500. 

“I get paid really poorly for doing DIEP flap cases through Tricare. I’m losing money doing those cases,” says Potter, who is in private practice and runs the RedBud Surgery Center. “But I do them because I think it’s the right thing to do and I don’t want to turn those patients away.”

Government insurance plans — not just Tricare, but also Medicare and Medicaid — tend to have low reimbursements for DIEP flap surgery (and other similar procedures). And reimbursement affects who can get these more advanced types of breast reconstruction. A 2023 study found that people with private insurance were nearly twice as likely to get DIEP flap and other autologous types of reconstruction than people with Medicare or Medicaid. And those with Medicare and Medicaid who did get autologous reconstruction were more likely to get older types of surgeries that have a higher risk of complications like muscle weakness.   

Reed and Holland both had trouble finding a civilian plastic surgeon in their area who would do DIEP flap surgery for them with their Tricare coverage. In the end, Reed couldn’t find one. Holland managed to find a plastic surgeon in private practice who took on her case. She pushed hard for Tricare to pay him more than their usual rate, even writing to and calling her members of Congress and the Defense Health Agency (the federal agency that oversees Tricare), but didn’t have any luck. In the end, her surgeon’s practice was paid less than what it cost them to do her surgery. 

“Tricare paid about seven cents on the dollar of what was billed for my 10-hour surgery, plus all the follow-up care from my surgeon,” Holland says.  

Their experiences mirror what Potter has seen many times in her 13 years as a plastic surgeon. She regularly meets with people from around the country who have either Tricare or Medicare and can’t find a surgeon to do their DIEP flap surgery. Some are told they aren’t good candidates for DIEP surgery, when in fact the surgeons just don’t want to do the procedure for Tricare’s reimbursement rates. Others weren’t told about all their reconstruction options at the beginning of their treatment, and then ended up having surgeries that weren’t right for them. 

Recently, Potter met with a high-ranking colonel who had latissimus dorsi flap reconstruction breast reconstruction surgery at a military hospital. This surgery involves using a flap of tissue that includes muscle from the back to rebuild the breast(s). Because of the downsides of the procedure — such as how it can cause muscle weakness — it usually isn’t recommended over a DIEP flap. The colonel was unhappy with how her reconstructed breasts looked and lost a lot of strength in her back and shoulder, and wanted to know if those problems could be fixed.   

“She had never been told at that military hospital that DIEP flap surgery would have been a better option for her,” Potter says. “It’s troubling that people with Tricare aren’t being educated about all their reconstruction options in a full and transparent way.” 

Getting a system as big and bureaucratic as military health care to change isn’t easy. But some advocates are optimistic.

In 2024, Reed and Potter, who had recently met at Camp Breastie, a retreat for people affected by breast and gynecologic cancers, went to Washington, D.C., and visited the offices of eight members of Congress. Their request: Add $5 to $7 million to the military budget bill (the National Defense Authorization Act or NDAA) for fiscal year 2026 so that Tricare can pay surgeons for DIEP flap surgery at the same rates that private insurance plans usually do. This would likely also lead to a secondary benefit: more civilian plastic surgeons choosing to be in-network for Tricare.

“The members of Congress and staff we spoke with — both Republicans and Democrats — were supportive and felt our requests were worth pursuing,” says Reed, who is now medically retired from the Air Force, after being diagnosed with metastatic breast cancer in 2024. 

Reed and Potter had to put their request on hold at that time, though. Congress was focused on the 2024 election, and the timing wasn’t right to move it forward. 

Reed and Potter now plan to visit Congress again and ask for the funding for DIEP flap surgeries for Tricare beneficiaries to be added to the NDAA for fiscal year 2028. 

This won’t be the first time in recent history advocates have had to fight for access to DIEP flap surgery. In 2023, Dr. Potter and a coalition of patient advocacy organizations, medical societies, members of Congress, and others won a battle to maintain certain billing codes. Preserving those codes meant that plastic surgeons could continue billing private insurance companies for DIEP flap surgeries at a rate that allows them to cover their costs. 

Eventually, though, Potter thinks much bigger policy changes are needed to address the varying reimbursement rates for breast reconstruction surgeries among different insurers. This could help everyone have more equal access, whether they have Tricare or any other type of insurance.

“There shouldn’t be such disparities in reimbursement rates,” Potter says. “I’m more and more convinced we need a bigger system overhaul to address the problems that exist for people with breast cancer who want reconstruction.”

One thing that could help, for example, is federal legislation requiring all types of insurance plans — including public ones — to cover all types of breast reconstruction, and for DIEP flap surgery to be covered at a rate that adequately reimburses surgeons. It would also help if all insurers were required to have at least one in-network surgeon experienced in each type of reconstruction in a given area.    

But until policy changes like these are put into place, many patients are carrying the burden of navigating a confusing and broken system.   

“I don’t want the woman coming behind me to have to fight as hard as I did to access her reconstructive options,” says Holland, noting that it took her months to find a plastic surgeon who would accept her Tricare insurance and perform a DIEP flap.

“I often think about the woman who is newly diagnosed, frightened, and overwhelmed, who may not know where to turn or have the energy to keep hearing ‘no.’ Access to care shouldn’t depend on how relentless a patient is willing or able to be,” she says. “Until coverage on paper translates into real access to care, there’s still work to be done, and those of us who’ve lived it aren’t going to stop speaking up.” 

 

This content made possible, in part, by Pfizer and Novartis.