Abstract
This study quantifies the change in travel times for military service personnel to abortion facilities following the US Supreme Court Dobbs decision and estimates the cost of an abortion-related travel reimbursement policy.
The June 24, 2022, Dobbs v Jackson Women’s Health Organization decision changed the geographic availability of abortion services in the US, exacerbating existing barriers to care.1 Early estimates found approximately 3000 fewer abortions were performed monthly following the decision.2 US military service members, sometimes involuntarily stationed in locations with abortion bans, were among those affected.3 Abortion access for military personnel is complex and was partially limited before the Dobbs decision due to restrictions on federal dollars funding abortions.3 Prior to Dobbs, service members paid out of pocket for abortion-related travel. Following Dobbs, the Department of Defense (DoD) enacted a policy offering leave and travel reimbursement to military personnel stationed in locations without access to abortions.4
We quantified the change in travel times for US military personnel to abortion facilities following Dobbs and estimated the volume and cost of an abortion-related travel reimbursement policy.
Methods
We calculated surface travel time (eg, by train, car) from each census tract in the contiguous US to the nearest abortion facility, following our previous approach.1 We compared pre-Dobbs travel times (using 2021 abortion facility data) with a simulated post-Dobbs period (assuming all facilities in states with full or post-6-week bans as of September 2023 were closed). We calculated travel times from each census tract, weighted these by the number of military workers per tract, then aggregated by state. Travel times were analyzed overall and by the presence of statewide abortion bans.
To model the yearly number of service members obtaining abortions, statewide population data on active-duty personnel was acquired from MilitaryOneSource.mil and limited to reproductive-age servicewomen (<45 years, ~95%3). These figures were multiplied by 2020 abortion rates of 11.2 and 14.4 per 1000 from Centers for Disease Control and Prevention and Guttmacher Institute, respectively.
To model travel reimbursement costs, we assumed $98 lodging, $59 meals and incidentals, and $0.655/min travel (assuming 1 mile/min), per 2023 DoD per diem rates. One and 4 days of travel were modeled for all states, given variable abortion waiting periods. Costs were modeled for travel beyond 50 minutes because DoD reimburses travel when abortions are unavailable locally (a simplification of DoD’s 50-mile reasonable commute distance policy), regardless of the presence of a state abortion ban.4 R version 4.2.1 was used for analyses.
Results
Median travel time for military personnel to the nearest abortion facility was 14.2 minutes (IQR, 6.5-52.7) pre-Dobbs and 22.1 minutes (IQR, 7.7-152.9) post-Dobbs. In states with abortion bans, median (IQR) estimated travel time for military personnel to the nearest abortion facility was 40.4 minutes (12.4-67.9) pre-Dobbs and 227.8 minutes (141.2-426.1) post-Dobbs. In states without bans, median (IQR) travel time was 11.4 minutes (5.5-28.6) pre-Dobbs and post-Dobbs. Louisiana and North Dakota had the longest median travel times (>500 minutes) post-Dobbs, while Louisiana and Texas had the largest increase (>400 minutes) (Table). We estimated 57 898 active-duty reproductive-age servicewomen live in the 17 states with abortion bans, and 5594 live in 3 states without bans but without locally available facilities. We estimated between 711 and 914 military personnel may travel more than 50 minutes for an abortion each year. A travel reimbursement policy costs an estimated $611 to $1082 per abortion, totaling $434 186 to $988 870 yearly, in addition to time off work.
Table. Estimated Changes in Travel Time to Nearest Abortion Facility Before and After Dobbs Supreme Court Decision by US State as of September 2023, With Projected Volume and Cost of a Reimbursement Program for Travel-Related Expenses.
State namea,b | Full or post-6 wk abortion ban as of September 2023a | Pre-Dobbs travel time to nearest abortion facility, median (IQR), minc | September 2023 travel time to nearest abortion facility, median (IQR), minc | Change in median travel time to nearest abortion facility, min | Estimated No. of reproductive-age personnel | Estimated yearly No. who would travel for abortions, range | Estimated range of travel cost/abortion, US$ | Estimated range of total cost yearly, US$ |
---|---|---|---|---|---|---|---|---|
Alabama | Yes | 15.5 (8.9-68.4) | 217.3 (179.6-248.1) | 201.8 | 1331 | 14.9-19.2 | 501-972 | 7463-18 622 |
Arkansas | Yes | 26.0 (21.7-47.0) | 364.0 (352.2-371.3) | 338 | 609 | 6.8-8.8 | 693-1164 | 4726-10 206 |
Georgia | Yes | 17.9 (10.2-45.8) | 176.4 (129.3-187.3) | 158.5 | 9101 | 101.9-131.1 | 447-918 | 45 577-120 326 |
Idaho | Yes | 46.2 (11.5-55.3) | 282.0 (235.4-288.7) | 235.8 | 599 | 6.7-8.6 | 585-1056 | 3931-9119 |
Indiana | Yes | 25.8 (13.0-57.6) | 109.2 (99.2-119.6) | 83.3 | 92 | 1.0-1.3 | 359-830 | 371-1101 |
Kansas | No | 123.0 (45.6-125.0) | 123.0 (45.6-125.0) | 0 | 2901 | 32.5-41.8 | 377-848 | 12 253-35 432 |
Kentucky | Yes | 58.8 (39.7-60.1) | 233.9 (134.7-234.9) | 175.1 | 4627 | 51.8-66.6 | 522-993 | 27 077-66 198 |
Louisiana | Yes | 32.9 (12.2-130.1) | 537.8 (432.1-603.0) | 504.9 | 2150 | 24.1-31.0 | 920-1391 | 22 163-43 077 |
Mississippi | Yes | 61.7 (58.6-79.0) | 306.3 (292.5-379.9) | 244.6 | 2345 | 26.3-33.8 | 617-1088 | 16 208-36 741 |
Missouri | Yes | 130.6 (65.2-136.0) | 141.2 (65.3-146.4) | 10.5 | 2843 | 31.8-40.9 | 401-872 | 12 767-35 700 |
New Mexico | No | 97.3 (10.5-245.2) | 99.7 (10.5-245.8) | 2.5 | 2091 | 23.4-30.1 | 347-818 | 8118-24 619 |
North Dakota | Yes | 314.4 (93.0-323.4) | 505.8 (315.7-509.6) | 191.4 | 1339 | 15.0-19.3 | 879-1350 | 13 171-26 013 |
Oklahoma | Yes | 74.8 (12.0-77.8) | 226.0 (155.9-226.8) | 151.2 | 3391 | 38.0-48.8 | 512-983 | 19 447-47 999 |
South Carolina | Yes | 14.1 (6.0-35.6) | 94.2 (87.3-186.0) | 80.1 | 6407 | 71.8-92.3 | 339-810 | 24 353-74 765 |
South Dakota | Yes | 337.0 (268.2-343.5) | 363.1 (312.4-367.3) | 26.1 | 556 | 6.2-8.0 | 692-1163 | 4305-9304 |
Tennessee | Yes | 51.4 (43.4-55.5) | 242.9 (239.1-251.9) | 191.5 | 414 | 4.6-6.0 | 534-1005 | 2478-5995 |
Texasd | Yes | 43.0 (10.4-61.7)d | 477.8 (276.3-547.2) | 434.8d | 22 004 | 246.4-316.9 | 842-1313 | 207 492-416 015 |
West Virginia | Yes | 30.9 (22.8-38.0) | 144.2 (34.3-157.2) | 113.3 | 15 | 0.2-0.2 | 405-876 | 69-192 |
Wisconsin | Yes | 27.9 (14.9-74.8) | 107.9 (67.6-129.9) | 80.1 | 75 | 0.8-1.1 | 357-828 | 300-895 |
Wyoming | No | 52.1 (51.5-77.4) | 52.1 (51.5-77.4) | 0 | 602 | 6.7-8.7 | 284-755 | 1918-6550 |
US overall | 182 687b | 711-914 | 611-1082 | 434 186-988 870 |
All states in the contiguous US where abortion was not locally available to military personnel (within 50 minutes), sorted alphabetically.
119 195 servicewomen of reproductive age are estimated to live in the 29 states where abortion is locally available (within 50 minutes). These states include Arizona, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Illinois, Iowa, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, Virginia, Washington. No travel reimbursement costs were estimated in these states.
Travel times weighted by the distribution of military workers within each state.
Texas facilities may have stopped performing some or all abortions in September 2021 due to Texas Senate Bill 8, and therefore the pre-Dobbs travel times may underestimate the true amount of travel required during this period. However, the enforcement capability of the Texas bill was still unresolved when the Dobbs decision was issued.
Discussion
After the Dobbs decision, geographic accessibility of abortion services decreased for some US service personnel. Recent reports suggest that more than 4000 active-duty personnel could be affected by Dobbs yearly3; however, the present study estimated that fewer than 1000 service members would travel for an abortion (ie, not all affected will obtain an abortion). The resulting travel reimbursements would cost the DoD less than $1 million annually (compared with the $58.4 billion Military Health System 2023 budget). However, these figures are likely overestimates, given lower reported abortion rates in the military vs civilian populations,5 many service members may self-manage an abortion medically,6 and possible cost savings from flying compared with long-distance surface travel.1 Additional limitations include the assumptions that service members may use 4 days of travel or always notify their command for reimbursement. Not all states had local access to abortions before Dobbs and the estimated costs reflect a combination of Dobbs-related increased travel distances and a shift in travel cost burden from military personnel to the DoD. Abortion procedure costs remain borne by personnel.
While the Dobbs decision hampered access to abortion services for US military personnel, this study suggests that reimbursing travel expenses represents a small cost for the DoD.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Karen Lasser, MD, and Kristin Walter, MD, Senior Editors.
Data Sharing Statement
References
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