In September 2025,  LDI Maternal and Reproductive Health Working Group members Caitlin (Cat) Russell, PhD, MBE and Alice Abernathy, MD, MSHP and Perelman School of Medicine Assistant Professor Libby Wetterer, MD submitted a comment in response to a Department of Veterans Affairs proposed rule that would revoke the changes made in September 2022 that permitted veterans to access abortion and abortion counseling in the cases of rape, incest, and the health of the mother.

The comment highlights evidence about why the existing policy is necessary, the need for abortion care among veterans, and how ending the coverage could endanger the lives of veterans.

Views expressed by the researchers are their own and do not necessarily represent those of the University of Pennsylvania Health System (Penn Medicine) or the University of Pennsylvania.

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September 3, 2025

Via Electronic Submission
Department of Veterans Affairs
810 Vermont Avenue NW,
Washington, DC 20420

Re: RIN 2900-AS31

Dear Madam or Sir:

Thank you for the opportunity to comment on “Reproductive Health Services: A Proposed Rule” (DVA, 38 CFR Part 17, RIN 2900-AS31). This proposed rule would revoke the changes made in September 2022 that permitted veterans to access abortion and abortion counseling in the cases of rape, incest, and the health of the mother.

The Maternal and Reproductive Health Working Group at the Leonard Davis Institute of Health Economics at
the University of Pennsylvania submits this comment on behalf of the below signed researchers, all of whom also provide medical care and are experts on maternal health. The views expressed here represent our expert opinions, and do not represent the views of the University of Pennsylvania or Penn Medicine.

As women’s healthcare professionals and policy experts, we emphatically oppose this change, which would remove access to lifesaving care for women who have been victims of rape or incest, or whose health or life would be jeopardized by continuing a pregnancy.

1. Coverage for abortion care in cases of rape and incest does not exceed the scope of the Hyde Amendment. The rule asserts that the September 2022 change was a case of “federal overreach” and that the previous administration created “a purported Federal entitlement to abortion for veterans where none had existed before”. The Hyde Amendment has permitted federal funds to be used for abortion care in cases of rape and incest since 1993.¹ However, the federally funded military health insurance TRICARE did not provide this same coverage to active duty service women until 2013.² The Shaheen Amendment, which added this coverage, was not creating a new entitlement, it was correcting a disparity in coverage that provided civilians with care that was not provided to the very women who had volunteered to defend this nation. Likewise, the September 2022 VA coverage expansion was not creating a “purported Federal entitlement,” but providing the same coverage for women who have served this country that is extended to its civilian population receiving federally funded healthcare.
2. Ending this coverage will endanger the lives of women veterans. Although the rule asserts that “No state law prohibits treatment for ectopic pregnancies or miscarriage to save the life of a mother,” since the Dobbs decision, there has been an increase in maternal mortality and severe maternal morbidity, which is projected to continue to rise.³ Due to some states’ adoption of policies that are not based in medical science, and the fear of prosecution resulting from a confusing legal landscape, many physicians in some states are no longer able to practice high-quality, life-saving, evidence-based healthcare, and are forced to delay or deny critical care for women.^4,5 There are multiple cases where women have been denied life-saving care and died as a result.^6,7,8
   
   Miscarriage is the most common complication of pregnancy and may occur in the first or second trimester an average of 1,034,000 times per year in the U.S. which is more than one in four pregnancies. Because management of these complications of pregnancy requires similar medications and procedures, limitations on abortion care limit miscarriage support. Specifically, the combination of mifepristone and misoprostol for miscarriage management, compared to misoprostol alone, requires less procedural intervention and incurs fewer medical costs. Any restrictions on mifepristone threaten access to evidence-based miscarriage management and life-saving procedures for pregnant people.
   
   Currently, three of the five fastest growing cohorts of reproductive age (18-44) female veterans are in states with some of the most stringent abortion bans in the country: Texas, Florida, and Georgia.⁹ Without the VA to connect female veterans with high-quality, life-saving, evidence-based healthcare, they will suffer from an increased risk of maternal mortality and severe maternal morbidity.
3. Female veterans have more risks than civilian women that can necessitate abortion care. Women who have served in the military are more likely than women who have not served in the military to experience intimate partner violence and sexual assault.¹⁰ Female veterans are also more likely to experience an ectopic pregnancy or early pregnancy loss compared to women who have never served in the military, both of which can necessitate life-saving abortion care.¹¹ Furthermore, female veterans have higher levels of suicide, especially during the perinatal period, when compared to civilian women.¹² These risks are compounded by restricting access to abortion care. Women who have served this country deserve better than to be forced to carry to term a pregnancy that is the result of a sexual assault, which could result in their suicide. The women who volunteered to die for this country in battle deserve better than to die in a hospital bed from a preventable pregnancy-related complication.
4. The lack of utilization of this service does not indicate a lack of need. The rule asserts that because the number of abortions provided by the VA is lower than projected, the coverage is unnecessary. No research has been done on if veterans are aware that this service is offered through the VA. The VA has long had challenges engaging female veterans for care or communicating VA benefits to veterans. All veterans should be entitled to lifesaving abortion care if they need it.

Thank you for the opportunity to comment. We urge you to retain the 2022 rule, so that veterans who need access to abortion care in cases of rape, incest, or their health needs can access such care through the VA.

Sincerely,

Caitlin Russell, PhD, MBE, WHNP-BC
Postdoctoral Fellow, National Clinician Scholars Program, Perelman School of Medicine
MSHP Student, Perelman School of Medicine
Associate Fellow, Leonard Davis Institute of Health Economics
catruss@nursing.upenn.edu

Alice Abernathy, MD, MSHP
Assistant Professor, Obstetrics and Gynecology, Perelman School of Medicine
Co-Director, Penn LDI Maternal and Reproductive Health Working Group
Senior Fellow, Leonard Davis Institute of Health Economics
alice.abernathy@pennmedicine.upenn.edu

Libby Wetterer, MD
Assistant Professor, Family Medicine and Community Health, Perelman School of Medicine
RHEDI Director, University of Pennsylvania Family Medicine Residency
libby.wetterer@pennmedicine.upenn.edu

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1. Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act.; 1993. Accessed August 23, 2025. https://uscode.house.gov/statutes/pl/103/112.pdf
2. National Defense Authorization Act For FY 2013.; 2013. Accessed August 23, 2025. https://www.congress.gov/112/plaws/publ239/PLAW-112publ239.pdf
3. Srinivasulu S, Heiland FW. How Will Abortion Bans Affect Maternal Health? Forecasting the Maternal Mortality and Morbidity Consequences of Banning Abortion in 14 U.S. States. J Womens Health. 2025;34(6):843-854. doi:10.1089/jwh.2024.0544
4. Buchbinder M, Arora KS, McKetchnie SM, Sabbath EL. Medical uncertainty in the shadow of Dobbs: Treating obstetric complications in a new reproductive frontier. Soc Sci Med. 2025;369:117856. doi:10.1016/j.socscimed.2025.117856
5. Grossman D, Joffe C, Kaller S, et al. Care Post-Roe: Documenting Cases of Poor-Quality Care since the Dobbs Decision.; 2024. Accessed August 23, 2025. https://www.ansirh.org/sites/default/files/2024-09/ANSIRH%20Care%20Post- Roe%20Report%209.04.24_FINAL%20EMBARGOED_0.pdf
6. Tal E, Paul R, Dorsey M, Madden T. Comparison of early pregnancy loss management between states with restrictive and supportive abortion policies. Womens Health Issues. 2023;33(2):126–32
7. Simmons-Duffin S Her miscarriage left hew bleeding profusely. An Ohio ER sent her home to wait. NPR; elluck P They had miscarriages, and new abortion laws obstructed treatment. New York Times [Serial on the Internet]. 2022. July 17. Available from: https://www.nytimes.com/2022/07/17/health/abortion-miscarriage-treatment.html
8. Méndez María. Texas laws say treatments for miscarriages, ectopic pregnancies remain legal but leave lots of space for confusion. Texas Tribune. [Serial on the Internet] 2022. July 20. https://www.texastribune.org/2022/07/20/texas-abortion-law-miscarriages-ectopic-pregnancies/
9. Department of Veteran Affairs. Veteran Population Projections 2020-2040. Accessed August 23, 2025. https://www.va.gov/vetdata/docs/Demographics/New_Vetpop_Model/Vetpop_Infographic2020.pdf
10. Women Veterans Health Center. Intimate Partner Violence. Women Veterans Health Center. Accessed August 23, 2025. https://www.womenshealth.va.gov/topics/intimate-partner-violence.asp
11. Quinn DA, Mor MK, Sileanu FE, et al. Measuring female veterans’ prepregnancy wellness using Department of Veterans Affairs’ health record data. Obstet Gynecol. 2021;137(3):471-480. doi:10.1097/AOG.0000000000004293
12. Szpunar MJ, Crawford JN, Baca SA, Lang AJ. Suicidal Ideation in Pregnant and Postpartum Women Veterans: An Initial Clinical Needs Assessment. Mil Med. 2020;185(1-2):e105-e111. doi:10.1093/milmed/usz171