SYRACUSE, N.Y. – Ten years after the government ordered health insurers to cover plastic surgery for women who lose one or both breasts to cancer, insurance issues are still making it difficult – if not impossible – for some women to have such operations.

Many plastic surgeons refuse these cases. They say insurers – especially government health insurance programs such as Medicaid – pay too little for the often complex reconstructive procedures, which can take six hours or longer.

For some patients, the insurance problem compounds the fear and anxiety that come with a cancer diagnosis and the prospect of losing one or both breasts in a mastectomy.

A 1998 federal law was supposed to make it easier for breast cancer patients to have reconstructive surgery.

The federal Women’s Health and Cancer Rights Act requires health insurers that cover mastectomies also cover breast reconstruction.

But the law does not specify how much insurers must pay. Some insurers, especially Medicaid, the government insurance program for low-income people, pay so little many plastic surgeons won’t see Medicaid patients, according to Dr. Kara Kort, director of SUNY Upstate Medical University’s Breast Care and Endocrine Surgery Center in Syracuse.

The national average plastic surgeon’s fee for the most complicated reconstruction operation is about $9,300 per breast, according to the American Society of Plastic and Reconstructive Surgeons. The top rate paid by New York’s Medicaid program is $600.

In addition to six to eight hours of surgery, the more complex reconstructions require the plastic surgeon to see the patient after surgery in a hospital intensive care unit and provide follow-up care for several months after discharge.

At that rate, considering the time involved, “A plumber gets more than that to fix your sink,” Kort said.

The problem is national in scope, according to Dr. Amy Alderman, a plastic surgeon and assistant professor at the University of Michigan medical school. Alderman, a leading researcher on breast reconstruction, is surveying plastic surgeons nationwide and finding many of them refuse to accept Medicaid and other insurance plans for this procedure. In Lansing, Mich., there are no plastic surgeons who will do complex reconstructions because of low reimbursement, she said.

A study Alderman did two years ago showed 16.5 percent of breast cancer patients nationwide who had mastectomies also had breast reconstruction surgery. She believes the rate is much lower than it should be. The rate is particularly low among African-Americans, Latinos and people with low incomes, she said.

There are many reasons other than insurance why breast reconstruction rates are low, according to Alderman. She did a study last year that showed that most women who have mastectomies are not referred to plastic surgeons. The research also showed that general surgeons who are women are more likely than men to refer patients to a plastic surgeon.

Cultural issues also play a big part, she said. “For some women their health-care decision is based on their religious beliefs and social framework,” Alderman said. “Some women see this as their lot in life. They are not going to do anything extra because this is what God has given them to deal with and they are just going to plow through this.”

Breast reconstruction is often done at the same time as a mastectomy. After a general surgeon removes one or both breasts, a plastic surgeon takes over. Several different techniques are used to rebuild the breast, ranging from insertion of an implant to more complex operations in which muscle, fat and skin from the abdomen are used to rebuild the breast.

Implant procedures are much less expensive. The national average surgeon fee for an implant is $2,841, more than three times less than the most complicated reconstructions that use a woman’s own tissue, according to the American Society of Plastic and Reconstructive Surgeons. Body type, health status, the type of cancer treatment, patient preference and other factors are used to determine the surgical method. Reconstruction using the patient’s own tissue is a longer operation with a longer recovery time. Implants, however, don’t last forever, meaning the patient may need more surgery in the future to replace or remove an implant.

SUNY Upstate’s Kort says it’s important to offer reconstruction as an option to all patients.

“It’s bad enough to have cancer,” she said. “Some of these women are only in their 20s and 30s. Female anatomy defines who you are.”

Kort performs mastectomies and lumpectomies on cancer patients and tries to find plastic surgeons to do the reconstruction because SUNY Upstate doesn’t have its own plastic surgeon. Kort said it’s so hard finding plastic surgeons to take Medicaid patients that she started a grant program in 2006 to pay for these women’s reconstructions.

Susan G. Komen for the Cure, the global breast cancer fundraising and support group, donated $25,000 to the program and an anonymous breast cancer survivor pledged $100,000. The money has helped 11 women so far.

Barbara Beamish, 47, of Potsdam, N.Y., is one of them. She was diagnosed with breast cancer in 2006 and told she needed a mastectomy. She was shocked to learn plastic surgeons in Syracuse would not accept her insurance, the state program Family Health Plus, for reconstruction.

“It was kind of a letdown,” Beamish said. “When somebody tells you have to have a mastectomy, the first thing that goes through your mind is, “Oh my God. I’m going to be disfigured.”‘

Beamish is a single mother who works as a housekeeper. She could not afford to pay for the plastic surgery herself. So Kort arranged for the grant program to pay.

“It was heaven-sent,” Beamish said. “I’m glad I had it done. It’s made a big difference physically and emotionally.”

Medicaid rates vary from state to state. New York’s Medicaid rates for all services and procedures tend to be among the lowest in the nation.

New York recognizes that the rates for breast reconstruction and many other procedures need to be increased, said Jeffrey Hammond of the state Health Department, which administers Medicaid in New York. The state plans to raise Medicaid rates Jan. 1 for all procedures by an average of 50 percent, Hammond said.

Dr. Guillermo Quetell did the reconstruction on Beamish and all the other women covered by Upstate’s grant program.

“My greatest fear is that there may come a point that only those who can afford it will have it,” Quetell said.

Quetell said he used to accept whatever insurers paid for reconstruction and “ate” the difference. But Quetell said he got fed up and stopped participating with some insurance plans. That means some patients who come to him for reconstruction are asked to pay up front in cash, then seek reimbursement from their insurers.

That’s what happened to Brenda Coffman. The Waterville, N.Y., woman was diagnosed with breast cancer in 2001. Kort performed a lumpectomy on her and she went through chemotherapy and radiation. “We really thought we licked it,” Coffman said.

But in March she was diagnosed with an aggressive form of breast cancer. Kort recommended Coffman have both breasts removed because tests showed her tumorless breast was full of suspicious cells. She also recommended Coffman have reconstructive surgery and referred her to Quetell.

Coffman’s husband is a state employee and has family health insurance coverage through the state’s Empire Plan. Quetell recently stopped participating in that plan. Coffman said Quetell’s office told her she’d have to pay $18,600 up front for reconstruction before Quetell would schedule her surgery, then submit a claim to her health plan for reimbursement. Her insurance was willing to pay about $16,300.

Quetell said he had no other choice but to ask Coffman to pay in advance because he does not participate with her insurance plan. “She obviously did not like that,” he said. “Nobody does in the heat of the moment.”

Coffman said she could not come up with the money. “I’m a stay-at-home mom,” she said. “We live paycheck to paycheck.”

She had her mastectomy and reconstruction at Bassett Hospital in Cooperstown, N.Y. A plastic surgeon there accepted her insurance.

Having to shop around for another surgeon delayed Coffman’s operation by three weeks. “Psychologically, I almost had a nervous breakdown over it,” she said.

The operation on April 7 took 11 hours.

“It’s a hell of a surgery,” Coffman said. “I look like a monster. I have lots of scars. But I’m glad I did it. At least I will look normal in clothes.”