I formerly served as Director of the Center for Women Veterans at the Department of Veterans Affairs (VA). I am also a VA patient: I choose to get my health care from VA because the care I get from my patient-aligned care team is comprehensive and integrated; my provider takes the time to address all my needs. It is also important to me that my providers understand my military-specific risks and exposures; I am screened for military sexual trauma, and my doctor knows what burn pits are.

 

Among women veterans using VA health care, 43 percent are of reproductive age (18–44). Reproductive health needs, such as contraceptive care, pelvic exams, and obstetrics, are one of the top five reasons women veterans of reproductive age seek care from VA.[i] To meet the fundamental health care needs of women veterans, it is important for VA to be able to provide the full spectrum of reproductive health care. On July 1, 2020, I testified before this HVAC’s Subcommittee on Health on this topic, recognizing VA’s areas of strength while also noting that there were deficits related to provision of in vitro fertilization, contraception, and abortion.[ii] Since that time, VA has made significant changes in provision of equitable, lifesaving care, including removing the full exclusion on abortions and abortion counseling from the medical benefits package. The proposed regulation to reinstate it is poor policy that will harm women’s health.

 

The Dobbs v. Jackson Women’s Health Organization Supreme Court decision limited some women veterans’ access to the full scope of reproductive health care, as those living in many states no longer have access to abortion care in their communities. This has a direct impact on their health, since abortion can be medically necessary.[iii] The rule on reproductive health services in place at VA since 2022 supports women veterans’ access to needed abortion treatment by removing the exclusion on abortion counseling from the medical benefits package and allowing enrolled veterans “to obtain abortions, if determined needed by a health care professional, when the life or the health of the pregnant veteran would be endangered if the pregnancy were carried to term or the pregnancy is the result of an act of rape or incest.” While not expansive enough to cover all situations in which abortion could be beneficial for enrollees, this rule will protect the lives and health of many vulnerable veterans.

 

Having a service-connected disability is a primary way veterans qualify to enroll in VHA care, and research has shown that VHA users tend to be older, sicker, and of lower socioeconomic status than veteran nonusers.[iv] VA estimates that 72 percent of current veteran VHA users who are capable of pregnancy have a service-connected disability rating of 30 percent or higher.[v] Women veterans who use VA have high burdens of chronic disease and a significant rate of mental health conditions.[vi] For example, pregnant women veterans have extremely high rates of depression and often discontinue medications for this and other conditions, such as posttraumatic stress disorder (PTSD), during their pregnancies.[vii] Abortion counseling is especially important to ensure that veterans have accurate and unbiased information to inform health care decisions that are based on their health history and personal circumstances.

 

Furthermore, some mental health conditions are associated with worse pregnancy outcomes: Women veterans with PTSD are more likely to experience gestational diabetes, preeclampsia, and preterm birth.[viii] Accordingly, it is exceedingly important that they be able to access the care their providers deem medically necessary for their health. Restrictions on reproductive health care at the state level mean that women veterans in certain states are no longer able to access such care from non-VA providers. To ensure optimal health outcomes for women veterans, VA must be able to provide that care.

 

Although all states allow abortions to save the life of the woman and most allow abortions for the woman’s health, restrictive abortion policies are having a “chilling effect” that can delay needed care, including treatment for cancer.[ix] Dangerous delays in providing necessary health care are killing women.[x] Providers in some states face prosecution and jail for providing abortion treatment and, given these risks, may delay or deny needed health care for pregnant women.[xi] Access to medication needed for other services can also be affected, as pharmacists are reluctant to fill prescriptions for drugs that can have multiple uses in addition to medical abortions, such as managing miscarriage or treating chronic disease.[xii] VA’s current rule allows veterans to access care their VA providers determine is necessary to protect their lives or their health; the proposed rule will subject these patients to all those documented risks.

 

It is also important that VA be able to provide these services directly because VA provides high-quality, evidence-based, culturally competent care.[xiii] For example, VA trains providers to provide trauma-informed pelvic examinations, which can be particularly important for women veterans who have experienced military sexual trauma. Findings from the Women’s Reproductive Health Survey show that the majority of active-duty women do not receive contraceptive counseling and may be entering the VA health system unaware of the totality of their reproductive health care options.[xiv] A large percentage also were unable to access their first-choice contraception methods. VA providers can be armed with this knowledge to meet the needs of women veterans. It is important for VA to be able to provide this care directly because fragmented care can lead to worse health outcomes, particularly for those already at high risk.[xv] The relatively small number of patients who are likely to qualify for these services are particularly likely to be vulnerable veterans deserving of compassionate, respectful care during a difficult time.

 

In conclusion, veterans who need covered abortions benefit from being able to receive them within the VA system, optimizing their continuity of care and access to needed support services. Changing this rule will harm their health, risk their lives, and damage their relationship with the Department.

 

Kayla M. Williams

U.S. Army Veteran

​

​

_______________________________

 

[i] Susan M. Frayne, Ciaran S. Phibbs, Fay Saechao, Sarah A. Friedman, Jonathan G. Shaw, Yasmin Romodan, Eric Berg, Jimmy Lee, Lakshmi Ananth, Samina Iqbal, Patricia M. Hayes, and Sally Haskell, Sourcebook: Women Veterans in the Veterans Health Administration: Vol. 4, Longitudinal Trends in Sociodemographics, Utilization, Health Profile, and Geographic Distribution, Washington, D.C.: Women’s Health Evaluation Initiative, Women’s

Health Services, Veterans Health Administration, Department of Veterans Affairs, 2018.

[ii] Kayla M. Williams, “Veterans’ Access to Reproductive Healthcare: Enhance Equity Now,” testimony presented before the House Veterans Affairs Committee Subcommittee on Health on July 1, 2020, Washington, D.C.: Center for a New American Security, 2020.

[iii] American College of Obstetricians and Gynecologists and Physicians for Reproductive Health, “Abortion Can Be Medically Necessary,” news release, September 25, 2019.

[iv] Christine Eibner, Heather Krull, Kristine M. Brown, Matthew Cefalu, Andrew W. Mulcahy, Michael S. Pollard, Kanaka Shetty, David M. Adamson, Ernesto F. L. Amaral, Philip Armour, et al., “Current and Projected Characteristics and Unique Health Care Needs of the Patient Population Served by the Department of Veterans Affairs,” RAND Health Quarterly, Vol. 5, No. 4, 2016, https://www.rand.org/pubs/periodicals/health-quarterly/issues/v5/n4/13.html.

[v] U.S. Department of Veterans Affairs, “Regulatory Impact Analysis for RIN 2900-AR57(IF), Reproductive Health Services,” Washington, D.C., August 29, 2022, p. 3, https://www.regulations.gov/document/VA-2022-VHA-0021-0002.

[vi] Frayne et al., 2018.

[vii] A “large study assessing needs [and] experiences of pregnant and postpartum veterans” found that 49 percent of pregnant women veterans had a history of depression and 34 percent had PTSD (Mike Richman, “Large Study Assessing Needs, Experiences of Pregnant and Postpartum Veterans,” VA Research Currents, June 7, 2017).

[viii] Yael I. Nillni, Danielle R. Shayani, Erin Finley, Laurel A. Copeland, Daniel F. Perkins, and Dawne S. Vogt, “The Impact of Posttraumatic Stress Disorder and Moral Injury on Women Veterans’ Perinatal Outcomes Following Separation from Military Service,” Journal of Traumatic Stress, Vol. 33, No. 3, June 2020; Jonathan G. Shaw, Steven M. Asch, Jodie G. Katon, Kate A. Shaw, Rachel Kimerling, Susan M. Frayne, and Ciaran S. Phibbs, “Post- Traumatic Stress Disorder and Antepartum Complications: A Novel Risk Factor for Gestational Diabetes and Preeclampsia,” Paediatric and Perinatal Epidemiology, Vol. 31, No. 3, May 2017; Peggy Willoughby, “Improving Reproductive Health for Women with PTSD,” U.S. Department of Veterans Affairs, March 30, 2021.

[ix] Selena Simmons-Duffin, “For Doctors, Abortion Restrictions Create an ‘Impossible Choice’ When Providing Care,” NPR, June 24, 2022. See also Whitney Arey, Klaira Lerma, Anitra Beasley, Lorie Harper, Ghazaleh Moayedi, and Kari White, “A Preview of the Dangerous Future of Abortion Bans—Texas Senate Bill 8,” New England Journal of Medicine, Vol. 387, No. 5, August 4, 2022.

[x] Andrea Suozzo, Sophie Chou, and Lizzie Pressler, “Rates of pregnancy-related sepsis and deaths grow in Texas after abortion ban.” Texas Tribune. February 20, 2025, https://www.texastribune.org/2025/02/20/texas-abortion-ban-impact-death-hospitalization/.

[xi] Lauren Coleman-Lochner and Elaine Chen, “Doctors Fearing Legal Blowback Are Denying Life-Saving Abortions,” Bloomberg Law, July 12, 2022; Selena Simmons-Duffin, “Doctors Weren’t Considered in Dobbs, But Now They’re on Abortion’s Legal Front Lines,” NPR, July 3, 2022.

[xii] See, for example, Christina Cauterucci, “Abortion Bans Are Already Messing Up Access to Other Vital Meds,” Slate, May 24, 2022; and Dan Diamond, “Federal Officials Warn Pharmacists About Denying Abortion Medication,” Washington Post, July 13, 2022.

[xiii] Rebecca Anhang Price, Elizabeth M. Sloss, Matthew Cefalu, Carrie M. Farmer, and Peter S. Hussey, “Comparing Quality of Care in Veterans Affairs and Non–Veterans Affairs Settings,” Journal of General Internal Medicine, Vol. 33, No. 10, 2018; Terri Tanielian, Coreen Farris, Caroline Epley, Carrie M. Farmer, Eric Robinson, Charles C. Engel, Michael William Robbins, and Lisa H. Jaycox, Ready to Serve: Community-Based Provider Capacity to Deliver Culturally Competent, Quality Mental Health Care to Veterans and Their Families, Santa Monica, Calif.: RAND Corporation, RR-806-UNHF, 2014, https://www.rand.org/pubs/research_reports/RR806.html.

[xiv] Sarah O. Meadows, Rebecca B. Collins, Megan S. Schuler, Robin L. Beckman, and Matthew Cefalu, The Women’s Reproductive Health Survey (WRHS) of Active-Duty Service Members, Santa Monica, Calif.: RAND Corporation, RR-A1031-1, 2022, www.rand.org/t/RRA1031-1.

[xv] See, for example, Joshua M. Thorpe, Carolyn T. Thorpe, Walid F. Gellad, Chester B. Good, Joseph T. Hanlon, Maria K. Mor, John R. Pleis, Loren J. Schleiden, and Courtney Harold Van Houtven, “Dual Health Care System Use and High-Risk Prescribing in Patients with Dementia: A National Cohort Study,” Annals of Internal Medicine, Vol. 166, No. 3, February 7, 2017.