Should insurance cover breast augmentation, the procedure commonly known as a boob job?

Most people would say “no, of course not.” That’s a cosmetic procedure, and health insurance shouldn’t pay for a procedure done to make someone look better. But what if it is part of breast reconstruction after breast cancer surgery, or part of gender reassignment surgery for a transgender patient?

That’s different, they might say.

Sometimes there’s a fine line between a cosmetic procedure and a medically necessary one. As a society, we have decided that most cosmetic procedures are elective and thus should be paid for by the individuals having them, while medically necessary procedures are covered by insurance. This makes it difficult for people who want to have surgery for conditions that fall in the gray zone between cosmetic and medically necessary, difficult for the doctors who take care of them, and a challenge for insurers whose goal is to minimize their expenses.

At the core of this issue is how we define the terms cosmetic and medically necessary. The traditional distinction is that cosmetic treatments are merely enhancements that improve appearance, while medically necessary treatments address a disease and are necessary for health or survival. But this distinction can be arbitrary.

Further complicating matters is the role that health care plays in our lives. One important role, to be sure, is to preserve and extend people’s lives or, in the language of medicine, to reduce mortality and morbidity. Those outcomes are relatively easy to measure. But health care should also strive to improve something that’s less easily defined: quality of life. Most people live long lives these days but many of them also develop chronic health problems, despite the pace of medical advances. We are living longer than ever, but not necessarily better.