This story was originally published by ProPublica.
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The night the EMTs carried Elizabeth Nakagawa from her home, bleeding and in pain, the tarp they’d wrapped her in reminded her of a body bag.
Nakagawa, 39, is a Coast Guard commander: stoic, methodical, an engineer by trade. But as they maneuvered her past her young daughters’ bedroom, down the narrow steps and into the ambulance, she felt a stab of fear. She might never see her girls again.
Then came a blast of anger. She’d been treated for a miscarriage before. She knew her life never should have been in danger.
Earlier that day, April 3, 2023, Nakagawa had been scheduled to have a surgical procedure called a D&C, or dilation and curettage, to remove fetal tissue after losing a very wanted pregnancy. But that morning, she was told the surgery had been canceled because Tricare, the military’s health insurance plan, refused to pay for it.
While her doctor appealed, Nakagawa waited. Then the cramps and bleeding began.
In recent months, ProPublica and other media outlets have told the stories of women who died or nearly died when state abortion restrictions imposed after the Supreme Court’s 2022 Dobbs decision impeded them from getting critical care.
But long before Roe v. Wade was overturned, military service members and their families have faced strict limits on abortion services, which are commonly used to resolve miscarriages.
Under a decades-old federal law, the military is prohibited from paying for abortions except in cases of rape, incest or to save the life of the mother. This applies even to service members based in states where abortion is legal; Nakagawa lives in Sonoma County, California.
There’s also no exception for catastrophic or fatal fetal anomalies. In such cases, service members either have to pay out of pocket for abortions or carry to term fetuses that won’t survive outside the womb.
Tricare does allow abortions in cases like Nakagawa’s, in which the fetus has no heartbeat. But even then, some doctors who treat military service members say that Tricare requires more documentation and takes longer to approve these procedures than other insurers, putting women at risk.
“There definitely have been cases where our Tricare patients have required emergency services, emergency D&C procedures, blood transfusions, things that have been critical to lifesaving care because their procedure had yet to occur,” said Dr. Lauren Robertson, an OB-GYN who has served military members and their spouses in San Diego for more than a decade.
“It just feels very unnecessary.”
Since the Dobbs decision, abortion care for service members seems to be coming under heightened scrutiny, said retired Rear Adm. Dana Thomas, who was until recently the Coast Guard’s chief medical officer and advocated for Nakagawa.
“Trust me, post Roe v. Wade, I’m sure people felt there was much more of a spotlight,” Thomas said. “I think they were more guarded after June of ’22.”
After being rushed to the emergency room, Nakagawa hemorrhaged for four more hours before doctors performed the surgery Tricare had refused to authorize. Later, Tricare and Defense Department officials would all agree that Nakagawa should have been treated as her doctor recommended, and she said they told her they’d taken steps to prevent future mistakes.
But her experience, which doctors say nearly cost Nakagawa her life, laid bare the challenges service members have long faced in obtaining reproductive health care. And it raises questions about whether the Supreme Court’s ruling has created a chilling effect that has further complicated access to these procedures.
Officials at the Defense Health Agency, which runs the military health system, including Tricare, did not respond to specific questions from ProPublica, but they provided a statement saying its policies haven’t budged.
“There have not been any changes to Tricare coverage or documentation requirements for medically necessary care of D&Cs following the Supreme Court’s Dobbs decision,” the statement said. “Medically necessary care was, and continues to be, covered.”
The agency declined to answer questions about Nakagawa, saying that “as a matter of practice” it doesn’t discuss individual beneficiaries’ care. (ProPublica is involved in an unrelated public records lawsuit with the DHA.)
As a senior officer, Nakagawa felt duty-bound to press for answers about what happened to her.
“The abortion policy, in theory, is supposed to protect life, and in my case it did the opposite,” Nakagawa said. “It almost led to my children not having a mother.”
After the Supreme Court upended Roe, the Biden administration took steps to reassure service members that their access to reproductive health care would remain unaffected by a wave of state abortion bans.
An October 2022 memo from Defense Secretary Lloyd Austin pledged to facilitate leave for service members seeking abortions that were not covered by Tricare, and to pay for travel if care wasn’t available nearby. It also emphasized that these procedures would be “consistent with applicable federal law.”
The statute barring the Defense Department from paying for most abortions goes back to 1985 and mirrors language in what’s called the Hyde Amendment. Named for its author, Henry Hyde, a Republican representative from Illinois, Congress has attached the amendment to spending bills since the late 1970s to prohibit the use of federal funds on abortion.
With Congress in control of military spending, abortion care is highly politicized, said Kyleanne Hunter, a Marine Corps combat veteran and senior political scientist at RAND Corp. “There’s been a lot of backlash and a lot of scrutiny and a lot of congressional disapproval as to how the DOD has engaged with abortion care, D&C care and the like.”
About 9.5 million people, including active-duty service members and their families as well as military retirees and their dependents, rely on Tricare for health services. Women make up a growing portion of the active-duty force, more than 17%. They also leave the military at higher rates. Research by RAND and others suggests the military’s reproductive health policies may make it harder to recruit and retain them.
Dr. Toni Marengo, a former Navy OB-GYN, said she left the service in part because she felt unable to provide patients with appropriate care. Many of them only discovered how sharply Tricare’s policies curtailed access to procedures like D&Cs when they needed them.
“It was like living in a pre-Roe world,” said Marengo, now chief medical officer at Planned Parenthood of the Pacific Southwest.
The effects have been felt for decades. In 1994, Maureen Griffin and her then-husband, a captain in the Air National Guard, ended her pregnancy after learning their baby had anencephaly, a fatal birth defect. They found out the military considered her induced labor an abortion when she got a phone call from a bill collector for the hospital seeking thousands of dollars in reimbursement for the procedure.
“I said: ‘We have full coverage. My husband’s in the military.’ And they said, ‘They don’t pay for abortions,’” Griffin recalled. “We were completely blindsided. I mean, no one called it an abortion. It was a horrible tragedy.”
Griffin, then known as Maureen Britell, was so outraged that she sued the Defense Department, winning a judgment in federal district court in 2002. Two years later, an appeals court reversed the decision, upholding the Defense Department’s refusal to cover abortions in such circumstances.
Twenty-five years after Griffin’s pregnancy, Samantha Babcock spent the equivalent of seven paychecks to fly home from her husband’s Air Force base in Okinawa, Japan, for an abortion Tricare wouldn’t cover.
She was five months pregnant when doctors told her that her fetus had multiple abnormalities and wasn’t viable.
The grief was crushing. Then she found out that, by law, the military couldn’t perform or pay for a surgery called a D&E, or dilation and evacuation, which her military doctors agreed was the safest option. She and her family paid $14,000 — most of it for plane tickets — with help from a GoFundMe so that she could go home to Portland, Oregon, to get the procedure.
She still can’t believe such a step was necessary.
“I assumed Tricare had my best interest at heart,” she said. “If the condition was fatal, why wouldn’t they help me?”
Babcock said her specialist told her that the military would pay to transfer her temporarily to Hawaii for more testing. They also offered to move her family to a location where they would have access to specialty care for the baby in the unlikely chance she survived outside of the womb.
For Babcock, that was untenable. “I did not want to keep growing a baby that wouldn’t live,” she said.
In August 2022, Thomas, the Coast Guard’s chief medical officer, was galvanized into action when a service member sought help to end her pregnancy after receiving a diagnosis similar to Babcock’s.
Doctors had recommended that, like Babcock, she have a D&E. Because the fetus still had a heartbeat, Tricare would not approve the procedure.
Thomas called Tricare daily trying to find a solution, then elevated the case to leaders at the DHA, which sets policy for the health plan. “We have to do something,” she told them.
Tricare stuck to its denial even after the service member’s doctor appended a note explaining that continuing the pregnancy would endanger the patient’s life.
That was the first case Thomas had taken on after Dobbs.
The second was Nakagawa’s.
Nakagawa and her husband, Matt, met a couple years after earning engineering degrees from the Coast Guard Academy in the mid-2000s. Their path to a family was long and bittersweet. In 2015, they suffered a miscarriage. A year later, their first daughter was born. Then came a second miscarriage, followed by the birth of a healthy girl.
For the next three years, they tried for another child. Then Nakagawa got pregnant in 2021, only to learn at 10 weeks there was no fetal heartbeat. She waited, hoping to miscarry naturally, then tried abortion pills.
When a follow-up exam showed she hadn’t passed all the fetal tissue, her OB-GYN scheduled a D&C. The procedure was approved by Tricare, and she had the surgery soon afterward.
By early 2023, Nakagawa had risen to become chief of engineering at the Coast Guard’s training center in Petaluma, California, and her husband had left the service and was supporting her as a stay-at-home dad. They were thrilled to learn she was pregnant, only to have their joy turn to devastation when two ultrasounds showed that once again, her fetus had no heartbeat.
This time, since abortion pills hadn’t worked in 2021, Nakagawa and her OB-GYN agreed the best course would be to schedule a D&C as soon as possible. Her doctor’s office scheduled the procedure for Monday, April 3, and requested approval in advance, or prior authorization, from Tricare.
Then, five hours before the procedure was scheduled to begin, the office told Nakagawa the surgery was canceled — Tricare had refused to cover it.
In its denial letter, Health Net Federal Services, the contractor that administered claims for Tricare’s western region, said the services requested were “not a covered benefit.”
The insurer’s letter also said it had requested additional information from Nakagawa’s doctor, but that the information had not been sent. (Health Net declined to answer questions from ProPublica about Nakagawa even though she waived her right to privacy.)
Her doctor maintains that wasn’t the case. She declined to be identified, citing concerns about safety.
“Tricare has always been difficult to work with for coverage of women’s health care — they require records more than other insurances — this often creates a delay in care,” the doctor said via text.
The office staff appealed the denial, telling Nakagawa they’d provided documentation of the ultrasounds showing no fetal heartbeat. The staff also told her a Tricare medical director wasn’t available to review it that day and that it might take an additional three to five days to get a response.
Nakagawa called Tricare for answers herself, only to be told her options were to wait or pay out of pocket — not only for the surgery but for any follow-up care, including mental health counseling.
“It was surreal. I was angry and shaking,” Nakagawa said. She couldn’t understand why Tricare had approved her D&C in 2021 under similar circumstances, then denied the same care two years later.
Overwhelmed by emotion, she climbed into bed and cried herself to sleep.
At about 5 p.m., her doctor provided a prescription for abortion pills as a backup plan. But before Nakagawa could pick it up, she started to miscarry.
The first signs were mild cramping and spotting. Soon after, the fetus passed. Nakagawa yelled for her husband and sobbed. They consoled themselves with the thought that they’d made it through the hardest part.
“At least this is over,” Nakagawa recalled saying. “At least God’s giving us a break for once.”
Then the hemorrhaging started — fist-sized clots of blood that soaked through sanitary pads in minutes. Nakagawa lay in the fetal position on towels, in so much pain she couldn’t sit up.
Around 9 p.m., her husband called the doctor, who recommended they go to the emergency room.
At the hospital, she was given fluids, a clotting drug and a transfusion, but her bleeding continued.
After four hours, doctors decided her condition was critical and they needed to intervene. They performed a D&C to remove the remaining tissue.
Nakagawa’s recovery took more than a week. Lying on her couch, unable to walk, she was determined to ensure other service women would get the care she was denied. Taking a risk, she banged out a long email to Thomas, who had a reputation for being approachable.
“I feel compelled to report a traumatic experience I went through that will undoubtedly impact more women in the CG and DOD if the TRICARE policy is not changed,” the email began. “The summary is that I nearly lost my life last week due largely to a TRICARE policy regarding miscarriages and abortions.”
Thomas connected Nakagawa to the Defense Health Agency’s chief medical officer, Dr. Paul Cordts, who called her personally a month after her emergency surgery.
Nakagawa said that Cordts seemed apologetic and even angry on her behalf. “This shouldn’t have happened to you,” she recalled him saying, adding that he’d get to the bottom of what went wrong. (Cordts didn’t respond to emails from ProPublica.)
Two days later, a new record appeared in Nakagawa’s Tricare file: a letter approving the scheduled D&C she’d never received and no longer needed. “Please contact the provider to schedule your appointment(s),” it said.
Cordts also arranged for Col. John Verghese, Tricare’s chief of clinical oversight and integration, to look into her case. Nakagawa said she had two calls with Verghese, who looped in a senior official at Health Net, the Tricare contractor that had dealt with the request to cover her D&C.
In one, she said, Verghese acknowledged Tricare had become more conservative in reviewing requests for D&Cs, requiring more documentation to justify approving these procedures. (Verghese, who has retired, declined to answer questions from ProPublica about the case.)
He admitted that until her case, Tricare hadn’t understood that delaying or denying care could put women at risk, she said. This infuriated Nakagawa.
“I just said, ‘Well, maybe you didn’t realize there would be physical negative consequences, but you had to know there would be mental and emotional consequences to making women carry around their [dead] fetuses’” after a miscarriage.
Verghese quickly apologized, she said.
On the final call, Nakagawa said that Verghese and the Health Net official told her that from now on, they would no longer require doctors to submit proof of no fetal heart tones to get approvals for D&Cs and would speed up reviews of appeals.
In its statement to ProPublica, the DHA maintained that Tricare’s coverage and documentation requirements for D&Cs have not changed.
Nakagawa is one of few women in senior leadership within Coast Guard civil engineering. She remains committed to serving in the military. But she worries about the impact the Defense Department’s reproductive health policies could have on service members and their spouses and daughters. Junior members especially might be less able to advocate for themselves, she said.
“At the very least, this policy will likely encourage women, like myself, to work for a company that has insurance that will cover these procedures,” she said, “At the worst, it will lead to service members or their dependents losing their lives.”
