II 113th CONGRESS 2d Session S. 2687 IN THE SENATE OF THE UNITED STATES July 30, 2014 Mrs. Shaheen (for herself, Mr. Reid , Mrs. Murray , Mr. Brown , Mrs. Gillibrand , Mrs. Boxer , Mr. Durbin , Ms. Baldwin , Mr. Blumenthal , Ms. Stabenow , Mrs. Feinstein , Ms. Hirono , Mr. Franken , Mr. Schatz , Mr. Tester , Mr. Wyden , Ms. Warren , and Mr. Begich ) introduced the following bill; which was read twice and referred to the Committee on Armed Services A BILL To amend title 10, United States Code, to ensure that women members of the Armed Forces and their families have access to the contraception they need in order to promote the health and readiness of all members of the Armed Forces, and for other purposes.

1. Short title This Act may be cited as the Access to Contraception for Women Servicemembers and Dependents Act of 2014 . 2. Findings Congress makes the following findings: (1) Women are serving in the Armed Forces at increasing rates, playing a critical role in the national security of the United States. More than 350,000 women serve on active duty in the Armed Forces or in the Selected Reserve. (2) Nearly 10,000,000 members of the Armed Forces (including members of the National Guard and Reserves), military retirees, their families, their survivors, and certain former spouses, including nearly 5,000,000 female beneficiaries, are eligible for health care through the Department of Defense. (3) Contraception is critical for women's health and is highly effective at reducing unintended pregnancy. The Centers for Disease Control and Prevention describe contraception as one of the 10 greatest public health achievements of the twentieth century. (4) Contraception has played a direct role in the greater participation of women in education and employment. Increased wages and increased control over reproductive decisions provide women with educational and professional opportunities that have increased gender equality over the decades since contraception was introduced. (5) Studies have shown that when cost barriers to the full range of methods of contraception are eliminated, and women receive comprehensive counseling on the various methods of contraception (including highly effective Long-Acting Reversible Contraceptives (LARCs)), rates of unintended pregnancy decline dramatically. (6) Research has also shown that investments in effective contraception save public and private dollars. (7) The 2011 recommendations of the Institute of Medicine on women’s preventive health services include recommendations that health insurance plans cover all methods of contraception approved by the Food and Drug Administration, sterilization procedures, and patient education and counseling for all women with reproductive capacity without any cost-sharing requirements. (8) The recommendations described in paragraph (7) are reflected in provisions of the Patient Protection and Affordable Care Act ( Public Law 111–148 ), and thus group and individual health insurance plans must provide such coverage. The recommendations have also been adopted by the Office of Personnel Management, and thus all health insurance plans that are part of the Federal Employees Health Benefits Program must provide such coverage. (9) Under the TRICARE program, servicewomen on active duty have full coverage of all prescription drugs, including contraception, without cost-sharing requirements. However, servicewomen not on active duty, and female dependents of members of the Armed Forces, who receive health care through the TRICARE program do not have similar coverage of all prescription methods of contraception approved by the Food and Drug Administration without cost-sharing. (10) Studies indicate that servicewomen need comprehensive counseling for pregnancy prevention, particularly in their predeployment preparations, and the lack thereof is contributing to unintended pregnancies among servicewomen. (11) An analysis by Ibis Reproductive Health of the 2008 Survey of Health Related Behaviors among Active Duty Military Personnel found a high unintended pregnancy rate among servicewomen. Adjusting for the difference between age distribution in the Armed Forces and the general population, the rate of unintended pregnancy among servicewomen is higher than for the general population. (12) With the integrated use of electronic medical records throughout the Department of Defense, the technological infrastructure exists to develop clinical decision support tools. These tools, which are incorporated into the electronic medical record, allow for a point-of-care feedback loop that can be used to enhance patient decisionmaking, case and patient management, and care coordination. Benefits of clinical decision support tools include increased quality of care and enhanced health outcomes, improved efficiency, and provider and patient satisfaction. (13) The Defense Advisory Committee on Women in the Services (DACOWITS) has recommended that all the Armed Forces, to the extent that they have not already, implement initiatives that inform servicemembers of the importance of family planning, educate them on methods of contraception, and make various methods of contraception available, based on the finding that family planning can increase the overall readiness and quality of life of all members of the military. (14) Health care, including family planning for survivors of sexual assault in the Armed Forces is a critical issue. Servicewomen on active duty report rates of unwanted sexual contact at approximately 16 times those of the comparable general population of women in the United States. Through regulations, the Department of Defense already supports a policy of ensuring that servicewomen who are sexually assaulted have access to emergency contraception. 3. Contraception coverage parity under the TRICARE program (a) In general Section 1074d of title 10, United States Code, is amended— (1) in subsection (a), by inserting for members and former members after Services available ; (2) by redesignating subsection (b) as subsection (d); and (3) by inserting after subsection (a) the following new subsections: (b) Care related to prevention of pregnancy Female covered beneficiaries shall be entitled to care related to the prevention of pregnancy described by subsection (d)(3). (c) Prohibition on cost-Sharing for certain services Notwithstanding section 1074g(a)(6) of this title or any other provision of law, cost-sharing may not be imposed or collected for care related to the prevention of pregnancy provided pursuant to subsection (a) or (b), including for any method of contraception provided, whether provided through a facility of the uniformed services, the TRICARE retail pharmacy program, or the national mail-order pharmacy program. . (b) Care related to prevention of pregnancy Subsection (d)(3) of such section, as redesignated by subsection (a)(2) of this section, is further amended by inserting before the period at the end the following: (including all methods of contraception approved by the Food and Drug Administration, sterilization procedures, and patient education and counseling in connection therewith) . (c) Conforming amendment Section 1077(a)(13) of such title is amended by striking section 1074d(b) and inserting section 1074d(d) . 4. Access to broad range of methods of contraception approved by the Food and Drug Administration for members of the Armed Forces and military dependents at military treatment facilities (a) In general Commencing not later than 180 days after the date of the enactment of this Act, the Secretary of Defense shall ensure that every military treatment facility has a sufficient stock of a broad range of methods of contraception approved by the Food and Drug Administration, as recommended by the Centers for Disease Control and Prevention and the Office of Population Affairs of the Department of Health and Human Services, to be able to dispense at any time any such method of contraception to any women members of the Armed Forces and female covered beneficiaries who receive care through such facility. (b) Covered beneficiary defined In this section, the term covered beneficiary has the meaning given that term in section 1072(5) of title 10, United States Code. 5. Comprehensive standards and access to contraception counseling for members of the Armed Forces (a) Purpose The purpose of this section is to ensure that all health care providers employed by the Department of Defense who provide care for women members of the Armed Forces, including general practitioners, are provided, through clinical practice guidelines, the most current evidence-based and evidence-informed standards of care with respect to methods of contraception and counseling on methods of contraception. (b) Clinical practice guidelines (1) In general Not later than one year after the date of the enactment of this Act, the Secretary of Defense shall compile clinical practice guidelines for health care providers described in subsection (a) on standards of care with respect to methods of contraception and counseling on methods of contraception for women members of the Armed Forces. (2) Sources The Secretary shall compile clinical practice guidelines under this subsection from among clinical practice guidelines established by appropriate health agencies and professional organizations, including the following: (A) The United States Preventive Services Task Force. (B) The Centers for Disease Control and Prevention. (C) The Office of Population Affairs of the Department of Health and Human Services. (D) The American College of Obstetricians and Gynecologists. (E) The Association of Reproductive Health Professionals. (F) The American Academy of Family Physicians. (G) The Agency for Healthcare Research and Quality. (3) Updates The Secretary shall from time to time update the list of clinical practice guidelines compiled under this subsection to incorporate into such guidelines new or updated standards of care with respect to methods of contraception and counseling on methods of contraception. (4) Dissemination (A) Initial dissemination As soon as practicable after the compilation of clinical practice guidelines pursuant to paragraph (1), but commencing not later than one year after the date of the enactment of this Act, the Secretary shall provide for rapid dissemination of the clinical practice guidelines to health care providers described in subsection (a). (B) Updates As soon as practicable after the adoption under paragraph (3) of any update to the clinical practice guidelines compiled pursuant to this subsection, the Secretary shall provide for the rapid dissemination of such clinical practice guidelines, as so updated, to health care providers described in subsection (a). (C) Protocols Clinical practice guidelines, and any updates to such guidelines, shall be disseminated under this paragraph in accordance with administrative protocols developed by the Secretary for that purpose. (c) Clinical decision support tools (1) In general Not later than one year after the date of the enactment of this Act, the Secretary shall, in order to assist health care providers described in subsection (a), develop and implement clinical decision support tools that reflect, through the clinical practice guidelines compiled pursuant to subsection (b), the most current evidence-based and evidence-informed standards of care with respect to methods of contraception and counseling on methods of contraception. (2) Updates The Secretary shall from time to time update the clinical decision support tools developed under this subsection to incorporate into such tools new or updated guidelines on methods of contraception and counseling on methods of contraception. (3) Dissemination Clinical decision support tools, and any updates to such tools, shall be disseminated under this subsection in accordance with administrative protocols developed by the Secretary for that purpose. Such protocols shall be similar to the administrative protocols developed under subsection (b)(4)(C). (d) Access to contraception counseling As soon as practicable after the date of the enactment of this Act, the Secretary shall ensure that women members of the Armed Forces have access to counseling on the full range of methods of contraception provided by health care providers described in subsection (a) during health care visits, including, but not limited to, visits as follows: (1) During predeployment health care visits, with the counseling to be provided during such visits emphasizing the interaction between anticipated deployment conditions and various methods of contraception. (2) During health care visits during deployment. (3) During annual physical examinations. (e) Incorporation into surveys of questions on servicewomen experiences with family planning services and counseling (1) In general Not later than 90 days after the date of the enactment of this Act, the Secretary shall integrate into the Department of Defense surveys specified in paragraph (2) questions designed to obtain information on the experiences of women members of the Armed Forces— (A) in accessing family planning services and counseling; (B) in using family planning methods, which method was preferred and whether deployment conditions affected the decision on which family planning method or methods to be used; and (C) if pregnant, whether the pregnancy was intended. (2) Covered surveys The surveys into which questions shall be integrated as described in paragraph (1) are the following: (A) The Health Related Behavior Survey of Active Duty Military Personnel. (B) The Health Care Survey of Department of Defense Beneficiaries. 6. Education on family planning for members of the Armed Forces (a) Education program (1) In general Not later than one year after the date of the enactment of this Act, the Secretary of Defense shall establish an education program for all members of the Armed Forces, including both men and women members, consisting of a uniform standard curriculum on family planning. (2) Sense of Congress It is the sense of Congress that the standard curriculum should use the latest technology available to efficiently and effectively deliver information to members of the Armed Forces. (b) Elements The standard curriculum under subsection (a) shall include the following: (1) Information on the importance of providing comprehensive family planning for members of the Armed Forces, and their commanding officers, and on the positive impact family planning can have on the health and readiness of the Armed Forces. (2) Current, medically accurate information. (3) Clear, user-friendly information on the full range of methods of contraception and where members of the Armed Forces can access their chosen method of contraception. (4) Information on all applicable laws and policies so that members are informed of their rights and obligations. (5) Information on patients’ rights to confidentiality. (6) Information on the unique circumstances encountered by members of the Armed Forces, and the effects of such circumstances on the use of contraception. 7. Pregnancy prevention assistance at military treatment facilities for women who are sexual assault survivors (a) Purpose The purpose of this section is to provide in statute, and to enhance, existing regulations that require health care providers at military treatment facilities to consult with survivors of sexual assault once clinically stable regarding options for emergency contraception and any necessary follow-up care, including the provision of the emergency contraception. (b) In general The assistance specified in subsection (c) shall be provided at every military treatment facility to the following: (1) Any woman who presents at a military treatment facility and states to personnel of the facility that she is a victim of sexual assault or is accompanied by another individual who states that the woman is a victim of sexual assault. (2) Any woman who presents at a military treatment facility and is reasonably believed by personnel of such facility to be a survivor of sexual assault. (c) Assistance (1) In general The assistance specified in this subsection shall include the following: (A) The prompt provision by appropriate staff of the military treatment facility of comprehensive, medically and factually accurate, and unbiased written and oral information about all methods of emergency contraception approved by the Food and Drug Administration. (B) The prompt provision by such staff of emergency contraception to a woman upon her request. (C) Notification to the woman of her right to confidentiality in the receipt of care and services pursuant to this section. (2) Nature of information The information provided pursuant to paragraph (1)(A) shall be provided in language that is clear and concise, is readily comprehensible, and meets such conditions (including conditions regarding the provision of information in languages other than English) as the Secretary may provide in the regulations under this section.