Defense Health Primer: Selected Contraceptive Services

The Fiscal Year 2016 National Defense Authorization Act (P.L. 114-92, §718) requires the Department of Defense (DOD) to make contraceptive services available to all female active duty servicemembers. DOD regulations make these services available to all Military Health System (MHS)-eligible beneficiaries. DOD operates the MHS, which delivers certain health entitlements under Chapter 55 of Title 10, U.S. Code, to beneficiaries that include military personnel, retirees, and their families. Health care services are available through DOD-operated hospitals and clinics, collectively called military treatment facilities (MTFs), or through civilian health care providers participating in the TRICARE program.

What are contraceptive services and which does DOD offer?

The U.S. Centers for Disease Control and Prevention (CDC) defines contraceptives as medical procedures, products, drugs, or services designed to "minimiz[e] the risk for an unintended pregnancy." DOD offers counseling and contraception methods in accordance with the CDC's medical eligibility and selected practice recommendations. MTFs and TRICARE providers only offer methods of contraception that the Food and Drug Administration (FDA) recognizes. These include

• Short-Acting Reversible Contraceptives (SARCs): oral contraceptive, patch, vaginal ring, injection;
• Long-Acting Reversible Contraceptives (LARCs): intrauterine device, implantable rod;
• Barriers: diaphragm, cervical cap, sponge, male/female condom;
• Sterilization: male/female surgical sterilization, permanent implant; and
• Emergency Contraceptives: oral pills (i.e., Plan B One-Step or Ella).

Beneficiaries may obtain FDA-approved contraceptives and related counseling through scheduled or walk-in visits, or through telehealth services (e.g., secure electronic messaging, video teleconferencing, mobile applications) with their primary care provider or other appropriate clinician. Electronic prescriptions may also be generated through a telehealth appointment and transmitted to an MTF or retail pharmacy for dispensing.

Figure 1 illustrates contraception use in 2017-2021 among female active duty servicemembers of childbearing age (i.e., 17 to 49). In 2021, SARCs (23.4%) and LARCs (22.4%) were the prevalent methods of contraception among female active duty servicemembers, followed by surgical sterilization (3.0%), counseling only (2.1%), and emergency contraception (1.1%).

Patient Costs

In general, active duty military personnel incur no out-of-pocket costs for contraceptive services from a DOD or TRICARE provider. Other DOD beneficiaries, including certain members of the reserve component, may be subject to cost-sharing based on their TRICARE health plan, beneficiary category, and type of medical service received.

Are all contraceptive methods available at every military treatment facility?

Since clinical services and formularies vary by facility, MTFs are not required to stock every FDA-approved contraceptive. If a contraceptive is not readily available at an MTF, a provider is to refer the patient to another MTF or TRICARE provider. Prescriptions may be filled at an MTF, retail, or mail-order pharmacy.

Are contraceptives available to deployed servicemembers?

Deployed military personnel may receive prescribed contraceptives (up to 180-day supply) and related counseling prior to their departure and while in-theater (90-day supply increments) when subscribed to the Deployed Prescription Program (DPP). In-theater military health care providers may also issue new or renewal prescriptions that would be filled through the DPP.

Does the Affordable Care Act's contraception coverage requirement apply to DOD?

The Patient Protection and Affordable Care Act's (ACA; P.L. 111-148, §2713) requirement for private and certain employer-based health insurance plans to cover contraceptive services at no cost, does not apply to DOD.

Can DOD provide abortion services?

Title 10, Section 1093 of the U.S. Code prohibits DOD from directly providing or paying for abortion services. In certain instances, DOD may perform or pay for abortion services if the "life of the mother would be endangered if the fetus were carried to term or in a case in which the pregnancy is the result of an act of rape or incest."

Does DOD train its health care providers on the methods of contraception offered in MTFs?

The Defense Health Agency (DHA) offers training for all DOD health care providers on counseling and the methods of contraception offered in MTFs. DOD policy also requires health care providers certified as sexual assault forensic examiners to be trained on emergency contraception counseling and referral procedures for follow-up care.

Are all DOD health care providers required to provide contraceptive services?

DOD policies allow for a health care provider to opt-out of delivering specific health care services if those services contradict a provider's own religious or moral beliefs. These policies direct health care providers to register their objections with their respective MTF leadership, disclose objections (related to course of treatment) to their patients, and transfer patient care to another health care provider.

Figure 1. Contraceptive Use Among Female Active-Duty Servicemembers, 2017-2021

Source: CRS graphic based on analysis of DHA data, July 2022. Notes: DHA's data methodology stated that "women who used multiple types of contraceptives during a given calendar year were assigned to one of four mutually exclusive groups, with group assignment as follows (in decreasing order of priority): permanent sterilization, LARCs, SARCs, and contraceptive counseling. Emergency contraception use was measured independently from the other categories of contraceptives." DHA did not report prevalence rates for barrier devices.

DOD policies also require MTF and TRICARE to "disclose to patients financial arrangements, contractual restrictions, ownership of or interest in healthcare facilities, matters of conscience, or other factors that could influence medical advice or treatment decisions."

How does DOD collect data on the use of contraceptive services?

DOD collects administrative and clinical data through its electronic health record systems, including utilization and outcomes data on certain contraceptive services. DOD also collects contraception-related data on individual and population health metrics, epidemiological trends, health care utilization, and health care improvement initiatives. DOD uses these data to monitor "process and outcome metrics that address progress toward the achievement" of the Department of Health and Human Services' Healthy People 2030 objectives for family planning. DOD also surveys military personnel on contraception use during the individual's yearly Periodic Health Assessment. Similar questions were included in the 2020 DOD Women's Reproductive Health Survey and the 2018 DOD Health Related Behavior Survey of active and reserve servicemembers.

Selected Issues for Congress

• Cost-sharing disparities between DOD and health insurance plans subject to ACA. Some DOD beneficiaries are required to share certain costs of contraceptive services. This contrasts with ACA's requirement for private and certain employer-based health insurance plans to provide contraceptive services at no cost to the patient. Congress could consider legislation to address these beneficiary cost-sharing disparities.
• DOD's "Ensuring Access to Reproductive Health Care" Initiatives. In October 2022, the Secretary of Defense issued a memorandum that affirmed the Department's policy of offering "comprehensive access to contraception and family planning services." The memo also directed DOD to conduct a "comprehensive contraception education campaign" to enhance awareness of available services, expand publicly displayed information, and improve online resources and assistance for beneficiaries experiencing difficulties accessing reproductive health care. Oversight considerations for Congress could include monitoring DOD implementation of these initiatives and their effects on access to care and beneficiary satisfaction.

U.S. Army Captain Elena Spielmann contributed research and analysis to this product while at CRS.