When You Have No Choice in a Pro-Violence Society

In significant parts of this country, the Supreme Court's June 2022 decision to overturn Roe v. Wade returned Americans to a half-century-old situation in which hundreds of thousands of women, faced with unwanted pregnancies, were once forced to resort to costly, potentially deadly underground abortions. My spouse's employer, the Pentagon, recently announced that its own abortion policy, which allows military insurance to cover the procedure when a pregnancy results from rape or incest, or poses a threat to the mother's life, still holds.

Sadly enough, this seems an all-too-hollow reassurance, given the reality that pregnant women in the military are, in many places, likely to face an uphill battle finding providers trained and--here's the key, of course--willing to perform the procedure. The Supreme Court abortion ruling in Dobbs v. Jackson Women's Health leaves it up to the states to determine whether to allow abortions. In doing so, it ensures that the access of military populations to that procedure will be so much more complicated, especially for spouses who need to seek off-base care, including ones like me who have chosen the military insurance option TRICARE Select that allows us to access almost exclusively civilian providers. America's 2.6 million military dependents now live in a country where an ever-changing patchwork of state laws can make seeking an abortion costly, risky, and stressful in the extreme.

Any military spouse with young children in tow who's had to relocate somewhere in this nation's vast network of military bases can tell you that just caring for another person is challenging in itself. Upon learning you're pregnant, you practically need a Ph.D. to locate a competent obstetrician who also accepts military insurance.

And even when you do, don't discount the problems to come. After an ultrasound, my first provider in the military's TRICARE Select healthcare program told me that my child was missing a foot. (In fact, he was just positioned with his back to the camera.) My second provider almost injured that same child by attempting to apply force during labor when his head was stuck against my hip bone.

And once you've actually had the child, you're likely to find yourself bickering for hours with uninformed military insurance providers simply to get coverage for a breast pump so you can feed your baby and go to work. Your military-approved pediatrician may--or may not!--know anything about local TRICARE Select specialists who can help you address common family problems like deployment-related anxiety in kids. And childcare? This country's childcare facilities are already stuffed to the gills and that's even more true of military childcare centers. Typically enough, I fear, I was on wait lists for them for years without the faintest success.

Now, add the devastating Dobbs decision to that military reproductive healthcare landscape. Imagine that you want and need an abortion and rely on TRICARE Select, especially if you and your family are stationed in one of the 13 states that have near or total bans on the procedure. If you're lucky enough to have the funds and social connections, you may be able to call in your babysitter to watch your older children and let your employer know that you've got to travel out of state for a medical procedure--as if they wouldn't know what kind! Then you'll spend what disposable income you have, if any--poverty and food insecurity being rampant in today's military--to head out of state alone in hopes of getting access to an abortion.

You may want your partner to come with you. If he's not deployed and assuming he supports your choice to seek an abortion, the two of you will face a barrier peculiar to military life: any service member who needs medical leave must request it through a commanding officer. To be sure, the Army and Air Force have issued directives to commanders not requiring soldiers to state why they're requesting it. Still, it's hard to imagine how a pro-life commanding officer wouldn't see right through such a sudden request and deny it. This is one of the many reasons you may find yourself alone on your journey.

And oh, the places you'll go! The nearest abortion clinic likely won't be off base over on Main Street. The states with the most restrictive laws governing abortion also have among the highest concentrations of military bases. So military dependents and soldiers whose insurance or health conditions require them to go off base will likely have to travel across state lines (possibly many state lines) to get the services they need and, of course, do so on their own dime. And by the way, the anti-abortion states are also among those with the largest number of per capita troop hometowns, meaning that military personnel from them are unlikely to get access to care if they go home to be with family during a time when they undoubtedly need extra support.

In other words, in the military world, Dobbs is a recipe for disaster.

Military Health Insurance 101

For those unfamiliar with the military's insurance system, let me make a key distinction. Military family members like myself get to choose between two main types of health insurance. The first, called TRICARE Prime, lets you access care in Department of Defense healthcare facilities military bases or posts. This is how active-duty troops typically get care as well. A case manager refers you to various primary and specialty-care providers as needed. With TRICARE Prime, you'd be using federal facilities, so you might, at least theoretically, have an easier time getting access to an abortion when, under a narrow set of conditions, the federal government is willing to cover such a procedure.

In my experience as a therapist listening to military spouses over the years, to seek healthcare at military facilities almost invariably involves conflicts of interest. Doctors there tend to treat you as though your concerns about your health or that of your children are remarkably insignificant compared to the needs of the troops. They tend to speak to spouses like me as if we were the only ones responsible for the health of our families, in the process essentially dumping such issues (and the services that go with them) onto the unpaid shoulders of us and us alone.

To offer an example, a mother I knew in Washington State was increasingly worried about her toddler's rapidly declining weight, only to have that phenomenon dismissed by physicians at a military hospital as the result of poor parenting. In the end, her suspicion that her child was gravely ill turned out to be all-too-sadly correct. Another military wife I interviewed went to couples' therapy on a military base to discuss how an upcoming move might impact their marriage. The counselor they saw, she told me, emphasized her spouse's service to the country, suggesting that she prioritize his career over hers and complete the move.

Perhaps because of such conflicts of interest and the greater choice offered by civilian-based health plans, most military dependents (72% in 2020) choose the second military-authorized insurance program, TRICARE Select. There, you manage your own care by finding civilian doctors willing to accept the Select plan or you simply pay out of pocket for civilian providers, hoping for some reimbursement sooner or later. With this option, if you were faced with an unwanted pregnancy, you would be subject to any abortion restrictions in your surrounding area.

Keep in mind that specialty care like obstetric services is not likely to be easy to find when you're looking for military providers in your community. A recent Pentagon evaluation of access to healthcare found that 49% of the people with TRICARE Select could not find a specialist in their community who accepted TRICARE patients, nor could 34% travel the necessary distance to reach an appropriate specialist. Meanwhile, 46% couldn't access a specialist in a timely manner due to long wait lists. Worse yet, overall access to specialist care within 24 to 48 hours for TRICARE Select beneficiaries decreased significantly between 2016 and 2019 and continued to do so through the first half of 2021.

Lack of access is not an accident. Despite the monstrous size of the Pentagon budget in these years, the Department of Defense actually decreased its health expenditures for all medical programs relative to its overall spending between 2017 and 2020.

New Barriers to Treating Patients and Even Saving Lives

In such an environment, it's hardly surprising that state abortion bans containing exceptions in cases when pregnancy threatens the parent's life will not easily result in access to the procedure. For example, Tennessee, home to five military bases and with a per capita troop concentration about 10% greater than the national average, provides exceptions to its ban when a parent's life is at risk. Here's the catch: doctors need to be prepared to show evidence that the procedure is necessary to prevent the impairment of a parent's major bodily functions were the pregnancy to continue--enough evidence that a team of prosecutors with its own expert medical witnesses could not convincingly argue otherwise in court. If not, a doctor could face felony charges and up to 15 years in prison.

Under such circumstances, if you were a doctor considering whether to terminate a life-threatening pregnancy for a patient, would you choose the patient or protect your ability to stay with your own family, avoiding the risk of prison? I'm not sure what I would do in such a situation.

There's reason to believe that even military dependents not seeking abortions could end up struggling to get the pregnancy care they need because of the restrictions doctors will face when it comes to treating complicated pregnancies. For example, the drugs used to induce abortion by medication, misoprostol and mifepristone, are also the most effective ones for treating patients experiencing miscarriages. At the Cleveland Clinic Emergency Department, under Ohio's new "heartbeat ban," which makes it a felony to end a pregnancy after a fetal heartbeat has been detected, women could soon enough have to wait 24 hours before receiving treatment for miscarriages, since anything earlier might qualify as an illegal abortion. Thankfully, for the time being two judges have placed a pause on the ban.

Another troubling fallout from new state abortion bans is the way providers and their patients are now being left to handle exceptions when a pregnancy results from rape. Many abortion bans contain sexual assault reporting requirements that make it all but impossible for doctors to avoid serious liability. For example, Utah's new abortion law permits the procedure in cases of rape, but for a doctor to perform it without risking criminal charges, he or she would need to report the rape to law enforcement. Similarly, in Wyoming (a state with just one abortion clinic that has two providers), the new exception in cases of rape does not specify how a client should prove that rape occurred, again leaving it up to doctors to decide how to treat patients and protect their own lives from devastating consequences.

The assaulting of civilian women by soldiers is not a widely studied subject, but accounts by activists and journalists suggest that it is a significant problem. What's more, about 80% of rapes committed by soldiers are never officially reported because victims fear retaliation either from their rapist or others in their communities, including their own or their spouse's commands. If the rapist happens to be their spouse, reporting the rape in order to obtain an abortion could mean that the family loses its sole source of income, since a convicted rapist would assumedly be discharged from duty. In addition, it's widely known that people who report sexual assaults often face uninformed responses from law enforcement officers who doubt their stories or blame them for being attacked, only increasing the trauma of the situation.

Pro-Lifers, Their Pro-Violence Society, and a New Approach to Reproductive Rights

The pro-life activists and policies behind those cowardly laws belie the fact that much of what far-right Americans and their elected representatives support undermines human life. Look at the violence and poverty some of the same leaders who advocate abortion bans allow in a country whose politicians generally choose to sanction war and investments in weapons development over better social services. Look at the way a significant minority of the citizenry support elected officials who encourage violence against other Americans of differing political beliefs. Look at the way some of us would support the separating of parents and children at the end of life-saving journeys away from drug wars and poverty in their home countries.

Given such political headwinds, it's worth remembering that a pregnant person is not a passive receptacle but a worker, whether for nine months or the rest of her life. If anyone should have the power to choose death, she should, because there is always a damn good, heart-wrenching reason for doing so.

I don't know how many people realize this, but if Roe had not become the law of the land in 1973 to protect abortion rights, a different case might have taken its place. In the early 1970s, the late Supreme Court Justice Ruth Bader Ginsburg, then a lawyer for the American Civil Liberties Union, took up the case of an Air Force nurse in Vietnam named Susan Struck who was told (as was the military's policy at that time) that she would be discharged if she were to carry her pregnancy to term.

Captain Struck was a devout Catholic who wanted to keep her job and have that baby. Ginsburg argued that all government attempts to regulate reproduction constituted sex discrimination, whether it involved restricting pregnancies or abortions. The Supreme Court agreed to hear the case in 1972, but before that could happen, the military changed its policy, rendering the case moot. Had Ginsburg won that case before the Supreme Court, our legal system might have prioritized parents, not the state, as the ultimate decision-makers--heroes no longer navigating a landscape of red tape and indignities.

Last June, right after Roe was overturned, I contacted a fellow military spouse visibly pregnant with her first child. She told me how complicated her feelings were about showing up in Washington, D.C., to advocate for abortion rights just after the draft decision to overturn Roe was leaked this past May. Would people misunderstand her presence at that demonstration? About a year ago, she'd sought emergency care for a miscarriage, which she might not have been able to get had abortion rights already been taken away. Perhaps, in the absence of adequate care, she might have suffered complications that prevented her from becoming pregnant this time around. She did, however, attend that demonstration, convinced that advocacy was as important to self-care as any other act in this country.

Hers is a true pro-life position. It's the position of someone who has for years moved from one military base to another. Loving both yourself and your baby is a struggle, not a campaign slogan. As a parent myself, I think that parenting is a journey many more pregnant people would happily embrace if the conditions in this country were significantly more humane. Right now, if you truly care about the lives of us all, it's up to you (and me) to join women like my friend in her post-Roe advocacy.