By Melanie Zanona
This article appeared in CQ Weekly on March 30, 2015
In the military, access to reproductive health services has long involved its share of unique bureaucratic and logistical hurdles.
To refill prescriptions for birth control, active-duty women may have to take a monthly helicopter ride to an on-base treatment facility with limited varieties and supplies of contraceptives. Nonactive-duty women and their dependents who don’t live near a base face copayments if they fill such an order at a local drug store. And emergency contraception and counseling can be scarce, according to surveys.
With unplanned pregnancy rates in the armed services an estimated 50 percent higher than in the general population, congressional Democrats plan to use the annual defense policy bills to more closely align the policies of the Pentagon’s health system, Tricare, with the health care law, which requires most private insurers and employers to provide birth control to employees at no cost.
Although past efforts have been scuttled by abortion foes, they may dovetail this year with those of a bipartisan group of lawmakers on the House Veterans’ Affairs Committee, who are looking to potentially address a related policy. Some panel members participated in a roundtable discussion last month on fertility challenges for veterans with disabilities.
“It was basically an opportunity to get people in the room that are actually involved [with the issue] to talk to one another,” says VA Health Subcommittee Chairman Dan Benishek, R-Mich., who led the discussion.
The thinking is that efforts to bring health benefit parity to the more than 3 million women in Tricare may overcome traditional divisions over abortion and contraception. Fertility treatment options for service members and veterans — including those incapable of getting pregnant due to their war wounds — are limited at the federal agencies responsible for their care. There has been some bipartisan interest in tackling the discrepancy, with the Senate Budget Committee adopting an amendment to its budget resolution this month to encourage expanding fertility treatment options for veterans.
Women’s health advocates say successful efforts on less contentious issues such as veterans’ fertility could create a blueprint for lawmakers to address other reproductive issues that have stalled in the past.
“All these issues are connected, and all of them are related to women’s well-being,” says Leila Abolfazli, senior counsel for the National Women’s Law Center. “It’s all about improving women’s reproductive health in different ways, but whether a congressman or congresswoman will see that the same way is a different question.”
Messaging that focuses on granting service members the same health care access as civilians could help Congress overcome traditional battle lines over abortion and contraception. “If you think family planning is important, then you should think all the pieces are important,” Abolfazli says.
At least some of the provisions could be attached to must-pass legislation. The defense authorization bills, due this spring, are the preferred vehicle because they set policy and recommend spending levels for more than a half-trillion dollars in programs at the Pentagon and other security agencies.
And while the annual budget resolution doesn’t have the force of law, the Senate Budget Committee signaled some willingness to tackle veterans’ fertility issues with the unanimous approval of the amendment to the budget resolution.
One possible provision for inclusion by Rep. Jackie Speier, D-Calif., would require Tricare to cover any Food and Drug Administration-approved form of contraception, as well as family counseling services, without a copayment. Military treatment facilities would also be required to stock a wider selection of birth-control measures.
Although Tricare covers a wide range of contraceptive methods, base facilities where many servicewomen receive care are not required to stock all of them. A third of active-duty military women said they could not get their preferred form of birth control while abroad and 41 percent had difficulty obtaining contraception requiring a refill, according to a study by Ibis Reproductive Health. Servicewomen can also face confusion about when to take oral contraceptives because they often cross multiple time zones when deployed overseas.
“For women members of the military who are being deployed for nine, 12 months in Afghanistan and Iraq, this bill requires that they get family planning counseling before they are deployed and enough contraception for that period of time,” Speier says.
Supporters maintain the measure ensures that long-acting birth-control methods, such as intrauterine devices, are more readily available to service members being deployed in foreign countries. They argue that increased access to family planning counseling prior to deployment will help women make informed decisions about their reproductive health, which also can enhance military readiness.
The existing barriers to contraceptive access stem from prohibitions on sexual relationships between soldiers of different ranks, although birth control can still be prescribed for a variety of reasons. A current congressional aide and former service member, speaking on the condition he not be identified, said some military doctors will leave out bowls of condoms on bases in an effort to bridge the gap between the outdated policies and reality, but there are no formal requirements about providing contraception.
Speier’s measure also would permit all Tricare beneficiaries, including members of the Reserves, National Guard and military dependents, to obtain birth control with no copayment at pharmacies off military bases.
“When non-deployed service members go to get their contraception at a local pharmacy, they should have the same benefits that every woman in this country has, which is no copayment,” Speier says.
As a member of the House Armed Services Committee, Speier has fought against sexual assault in the military and sponsored related amendments to annual legislation to authorize the Defense Department. Her contraception measure includes requirements that medical facilities on bases stock emergency contraception and inform all sexual assault victims that it is an available option — a provision that could be a sticking point for lawmakers who view the so-called morning-after pill as a form of abortion.
“I couldn’t support that, because that would be taxpayer funds for what is considered by many to be abortion,” says Republican Rep. John Fleming of Louisiana, a member of Armed Services, although “someone paying for that themselves is a whole other issue. I get that.”
Republicans also are likely to paint Speier’s bill as an attempt to expand the reach of the contraceptive mandate in the health overhaul, which could influence lawmakers who have vowed to dismantle the law.
Another reproductive health issue that could spur changes is a policy at the Veterans Affairs Department that bars in vitro fertilization. Improvised explosive devices in Iraq and Afghanistan have caused more service members to suffer spinal cord injuries and trauma to their reproductive and urinary tracts, which can render them infertile.
The Pentagon provides in vitro fertilization, but has narrow eligibility requirements, and the treatments are only performed at a handful of facilities.
“You can imagine the wait-list,” says Helen Hare, spokeswoman for Sen. Patty Murray, D-Wash. “It’s very difficult to access.”
She says many veterans and ineligible service members would have to pay for treatments out of pocket, costing thousands of dollars for some families.
Murray is pressing to lift the VA’s ban and expand treatment options and eligibility requirements at the Defense Department, including for spouses and surrogates. The measure also would provide financial assistance to wounded veterans seeking to adopt children and make permanent a child care services pilot program at the VA.
“We should be doing everything we can, with the best science and health services available, to help our veterans and their loved ones have children despite their injuries,” Murray said in a statement to CQ Roll Call.
Similar legislation advanced out of the Senate Veterans’ Affairs Committee in the 113th Congress, with one Republican, Sen. Richard M. Burr of North Carolina, recorded in opposition. A version of the bill passed the chamber by unanimous consent in the 112th Congress but was not taken up last year in the Republican House.
Burr, who was then the panel’s ranking member, raised concerns over the cost and effectiveness of the measure in a 2013 committee report. But Burr said he agreed with the principle of the bill. VA officials took issue with the inclusion of surrogates in the legislation, as well as its price tag.
On the other side of the Capitol, Hare is hoping the recent roundtable discussion on fertility issues for veterans is a sign that some Republicans may be willing to support provisions in Murray’s bill. But Benishek says some of the issues could be resolved without congressional intervention.
Speier and Murray were encouraged by the inclusion of language in last year’s year-end spending package that allows Peace Corps members to use federal funding for abortions in the cases of rape, incest or when the mother’s life is in danger.
The military contraception bill was introduced last Congress and has a Senate companion sponsored by Democrat Jeanne Shaheen of New Hampshire. But it has never been marked up in committee, and Republican support is less clear.
At least one Republican has voiced potential support for the bill: Freshman Rep. Ryan Zinke, an Armed Services member, says he has not seen the exact text of Speier’s bill yet but generally backs extending contraceptive access for service members. The Montana Republican is a former Navy SEAL officer and could have an influential voice on the panel.
Fellow committee member Jackie Walorski — who was at the forefront of a stand by female GOP lawmakers earlier this year against a 20-week abortion ban bill — says she is “wide open” to working on veterans’ issues, though she has not seen Speier’s bill. The Indiana Republican recently introduced legislation with Democrat Tulsi Gabbard of Hawaii to expand veterans’ access to health care.
“I do a lot of stuff across the aisle with Democratic women,” Walorski said off the floor. “VA bills aren’t partisan, they aren’t Republican or Democratic — they’re American issues.”