STATEMENT
OF
THE MILITARY COALITION
BEFORE THE
TOTAL FORCE SUBCOMMITTEE
HOUSE ARMED SERVICES COMMITTEE
February
25, 2004
Presented by
Robert Washington
Fleet Reserve Association
Co-Chairman, Health Care Committee
Sue Schwartz, DBA, RN
Military Officers Association of
America
Co-Chairman, Health Care Committee
.Air Force Association
.Air Force Sergeants Association
.Air Force Women Officers Associated
.American Logistics Association
.AMVETS (American Veterans)
.Army Aviation Association of America
.Association of Military Surgeons of the
United States
.Association of the United States Army
.Chief Warrant Officer and Warrant Officer
Association, U.S. Coast Guard
.Commissioned Officers Association of the
U.S. Public Health Service, Inc.
.Enlisted Association of the National
Guard of the United States
.Fleet Reserve Association
.Gold Star Wives of America, Inc.
.Jewish War Veterans of the United States
of America
.Marine Corps League
.Marine Corps Reserve Association
.Military Chaplains Association of the
United States of America
.Military Officers Association of America
.Military Order of the Purple Heart
.National Association for Uniformed
Services
.National Guard Association of the United
States
.National Military Family Association
.National Order of Battlefield Commissions
.Naval Enlisted Reserve Association
.Naval Reserve Association
.Navy League of the United States
.Non Commissioned Officers Association
.Reserve Officers Association
.The Retired Enlisted Association
.The Society of Medical Consultants to the
Armed Forces
.United Armed Forces Association
.United States Army Warrant Officers
Association
.United States Coast Guard Chief Petty
Officers Association
.Veterans of Foreign Wars
.Veterans' Widows International Network
The Military Coalition, Inc., does not
receive any grants or contracts from the
federal government.
The Coalition would like to thank the
Subcommittee once again for sponsoring a
wide range of legislation that is helping
servicemembers, veterans, their family
members and survivors. We deeply appreciate
the Subcommittee's continued leadership and
commitment to those who are in uniform today
and those who have served our nation in the
past.
Force health protection, covers many areas:
fitness and health, protection and
prevention, and treatment. We would like to
focus our attention today on deployment
health policy, practices and procedures.
Critical to this effort is effective
coordination and collaboration between the
Defense Department (DoD) and the Department
of Veterans Affairs (VA). The Coalition
believes both departments are working
together better than in the past, though we
believe more must be done.
Pre - and Post - Deployment Assessment.
In April 2003, the Under Secretary of
Defense for Personnel and Readiness, Dr.
David Chu, endorsed a policy that now
requires all commands to have an enhanced
post-deployment health assessment process.
The Coalition agrees with a GAO assessment
that there has been significant improvement
in compliance with DoD guidance.
Unfortunately, the war against terrorism was
well underway before this guidance was
finally enforced.
DoD is to be commended for making headway in
pre-deployment health assessment, continuous
hazard and health monitoring in the field,
and a post-deployment assessment.
Individual serum samples are collected and
maintained in the DOD serum repository.
Occupational and environmental health
surveillance programs help monitor members'
deployment health.
The pre- and post-assessment forms (DD Form
2795/2796) are self-administered documents
and medical personnel review the forms with
servicemembers. Any positive responses
trigger additional review and referral for
follow-up care.
The Coalition has reviewed these documents
and we have concerns about subjectivity and
the human dimension of the evaluation
process.
The Coalition recognizes that the men and
women of the uniformed services are truly
dedicated to their mission -- protecting the
interests of our nation. We fear the "zeal"
to deploy may cause some individuals to
overlook any physical aliments they believe
may cause them to remain behind. Our men and
women want to serve and go to great lengths
to do so. We can see that it would be easy
to overlook or even deny a condition when
completing self-reporting documents,
especially with the pre-deployment form (DD
2795).
Subjectivity also can complicate the more
thorough post-deployment assessment (DD
2796), since servicemembers are eager to
"get out" or "get home." They may overlook
or deny conditions in their desire to return
home or for fear that their return may be
delayed in a medical hold status.
Several recent GAO reports have addressed
compliance with force health protection
policies (September 2003, October 2003 and
others). While these investigations have
dealt with the process, the Coalition asks
the Subcommittee to provide oversight to
evaluate the effectiveness of the content
and the outcomes of a program that has a
subjective self-assessment component coupled
with some aspects of a "medical" review.
The problem is that these procedures and the
resources to support them vary considerably
among the Services and their Reserve
components.
The Coalition urges the Subcommittee to
direct a study of the effectiveness of the
self-administered pre - and post -
deployment assessment and continue providing
oversight to ensure compliance with pre- and
post-deployment policies and procedures.
National Guard and Reserve Deployment and
Post-Deployment Health Issues.
The Military Coalition is most appreciative
to Congress for including the Temporary
Reserve Health Care Program (Section 702) in
the FY 2004 National Defense Authorization
Act. This program will provide temporary
coverage, until December 2004, for National
Guard and Reserve members who are uninsured
or do not have employer-sponsored health
care coverage. TRICARE officials plan to
build on existing TRICARE mechanisms to
assist in implementation; however, TMA is
not certain how long this will take.
Reserve Component members are anxious to
enroll, and fear that the coverage period
may be lost. Immediate implementation is
required.
The Coalition is also grateful to the
Subcommittee for Sections 703 and 704 of the
NDAA. Section 703,
Earlier
Eligibility Date for TRICARE Benefits for
Members of Reserve Components,
provides TRICARE health care coverage for
reservists and their family members starting
on the date a "delayed-effective-date order
for activation" is issued.
Section 704,
Temporary
Extension of Transitional Health Care
Benefits, changes the period
for receipt of transitional health care
benefits from 60 or 120 days to 180 days for
eligible beneficiaries. These provisions
should be easier to implement than the
TRICARE buy-in provision of Section 702 and
we understand that the technical fixes to
the Defense Eligibility and Enrollment
Reporting System (DEERS) are being made to
implement the Section 704 benefits. We are
concerned, however, that the latest word
from DoD, a February 12, 2004 press release
announcing the implementation of these
benefits, provided few details about the
implementation and continued to encourage
beneficiaries to save their receipts for
health care incurred in the demonstration
period "in the event the sponsor is
determined to be eligible and the care
qualifies for retroactive TRICARE
reimbursement once the 2004 Temporary
Reserve Health Benefit Program begins."
Congress recognized the extraordinary
sacrifices of our citizen-soldiers by
extending this pre- and post-mobilization
coverage. Now it's time to recognize the
changed nature of 21st century service in
our nation's reserve forces by making these
pilot programs permanent.
To
support military readiness, recruitment /
retention programs, deployment health, and
reserve family morale, the Military
Coalition strongly urges the Subcommittee to
endorse permanent authorization of all
provisions of the Temporary Reserve Health
Care Program (Sec 702, 703, and 704 P.L.
108-136).
President's Task Force Recommendations.
The Coalition endorsed the final Report (May
2003) of the President's Task Force (PTF) to
Improve Health Care Delivery for Our
Nation's Veterans.
A
major PTF recommendation is a seamless
transition to veteran status for separating
and retiring servicemembers. As soon as an
individual enters the armed forces, DoD and
VA should have a stake in monitoring and
evaluating the member's health. Force
health protections, medical readiness, and
research into occupational exposures are all
important government interests in this
collaboration.
Lessons learned from the first Gulf War
taught us that a better job must be done to
collect, track and analyze occupational
exposure data. Without this information,
benefits determinations cannot be fairly
adjudicated, nor can the causes of
service-related disorders be better
understood. The enhanced post-deployment
health assessment for servicemembers serving
in Operation Iraqi Freedom is designed to
capture occupational exposure information.
The objective is to benchmark information
for future reference and intervention as
necessary.
To
do so, both departments must share exposure
information and any other health status data
electronically. VA and DoD need to complete
development of an interoperable
bi-directional electronic medical record (EMR)
-- the lynchpin to a seamless transition (PTF
Recommendation 3.3). The technology exists
but the will must be found to move forward
to completion.
Another important PTF recommendation is "the
one-stop physical" upon separation or
retirement. Offering one discharge physical,
providing outreach and referrals for a VA
Compensation and Pension examination (PTF
Recommendation 3.4), as well as following up
on claims adjudication and ratings is not
just more cost effective in terms of capital
and human resources, it is the right thing
to do -- to ensure that servicemembers
receive the benefits they have earned and
deserve.
There is an ideal mechanism for this
approach and that is the Department of
Veterans Affairs Benefits Delivery at
Discharge (BDD) program. Presently, the
various VA regional offices have ongoing BDD
programs at 136 military installations in
the United States and overseas in Korea and
Germany to ensure that separating military
members, who participate in the program,
receive a VA Compensation and Pension
examination leading to a disability
compensation rating immediately upon
separation.
The BDD program has proven extremely
successful but so far occurs only through
local agreements between the regional office
directors and installation commanders.
TMC recommends a national Memorandum of
Understanding between the Secretaries of
Defense and Veterans Affairs is now critical
to achieve the maximum efficiency and
cohesive support for this exemplary program.
Finally, the government has been talking
about developing an electronic DD 214 for
years, yet the document remains in paper
format. Initial start-up costs would be
paid back many times over in efficiencies
gained. This is not just a matter of
conserving resources. It is essential to
remove barriers that in the past have denied
servicemembers and veterans proper medical
care and benefits determinations.
Other commissions have worked toward the
same goals in the past, only to have their
recommendations sit on the shelf.
Successful implementation will require
Congressional direction and additional
funding.
The Military Coalition asks the Subcommittee
to work with the Veterans Affairs Committee
and the Departments of Defense and Veterans
Affairs to ensure action on the PTF
recommendations including seamless
transition, a bi-directional electronic
medical record (EMR), enhanced
post-deployment health assessment, and
implementation of an electronic DD214.
Tracking Occupational Exposure Data.
The PTF made additional recommendations
regarding collecting and sharing
comprehensive servicemember data to
determine the effects of service on veteran
health. Significant issues arise when
attempting to assess the health of veterans
whose condition may have resulted from
exposures to occupational/environmental
hazards during military service. Agent
Orange and Gulf War Undiagnosed Illnesses
challenges were made more difficult by the
inability to determine where members served,
the environmental condition, and personal
exposure.
To
put it simply, medical records must be tied
to personnel records to effectively evaluate
the cause and effect of exposures. The
Coalition is grateful that this Subcommittee
recognized this problem by enacting Section
767 (P.L.105-85), Tracking Service Member Location.
The
issue is even more critical in light of the
increased threat of biological or chemical
warfare. The Coalition is mindful of the
national security implications of this task,
as stated in the PTF report: "Providing VA
occupational exposure data, however, must be
weighed against the potential security
concerns of releasing these data, as in
matters involving individual location for
certain types of individuals, such as
Special Forces, or assignment detail for
sensitive areas."
However, not all orders are classified and
much could be done to tie medical and
personnel records for cases of exposures
during routine operations. The Coalition
notes that by 2006, the Defense Integrated
Military Human Resources System (DIMHRS) is
expected to consolidate the personnel and
pay systems. This will provide a single
service record and service activities.
However, the PTF noted, ".many elements
related to tracking an individual's specific
location, activities and exposures will
remain undocumented."
In
a hearing before the Subcommittee on
National Security, Emerging Threats and
International Relations, House of
Representatives Committee on Government
Reform (March 25, 2003), Dr. William
Winkenwerder, Jr., Assistant Secretary of
Defense for Health Affairs, reported that since
DIMHRS is still several years away,
the department has offered a temporary
solution -- an interim deployment medical
surveillance system, the force health
protection portal. The Coalition is
concerned whether this measure is adequate
given the very high stakes posed by the war
on terrorism.
The Coalition urges the Subcommittee to
continue to monitor implementation of
Section 767 of P.L. 105-85) and take steps
to facilitate the PTF recommendation that
the VA and DoD provide sharing of
servicemembers' assignment history,
location, occupational exposure, and
injuries information.
Dental Readiness.
The number one deployment
problem in the First Gulf War was dental
"un-readiness" and the same is true today.
Reserve Component members are required on
their own to maintain a certain level of
dental readiness, known as "Classification
T-2" for mobilization purposes.
Classification T-2 means that no emergency
dental procedures would be required for at
least six months.
Unfortunately, the current DoD Selected
Reserve dental program does not provide a
benefits package that can assure
participants would meet "Classification T-2"
standards. In addition, only five percent
of eligible Guard and Reserve members are
enrolled. The program provides diagnostic
and preventive care for a monthly premium,
and other services including restorative,
endodontic, periodontic and oral surgery
services on a cost-share basis, with an
annual maximum payment of $1,200 per
enrollee per year.
During this mobilization, soldiers with
repairable dental problems had teeth pulled
at mobilization stations to meet deployment
timetables. Congress responded by passing
legislation that allows DoD to provide
medical and dental screening for Selected
Reserve members who are assigned to a unit
that has been alerted for mobilization. But,
waiting for an alert to initiate screening
is too late. For Operation Iraqi Freedom
call-ups, the average time from alert to
mobilization was less than 14 days,
insufficient to address deployment dental
standards. In some cases, units were
mobilized before receiving their alert
orders. This lack of notice for mobilization
continues, with many reservists getting
notification days prior to call-up.
The Military Coalition recommends increasing
the government subsidy under the Selected
Reserve TRICARE Dental Plan and enhancing
the benefit package to allow reservists to
meet readiness and deployment dental
standards.
Other medical and family readiness issues of
concern to TMC include the following:
-
Optional
Payment of Premiums for Employer or
Personal Health Insurance.
Guard and Reserve family members are
eligible for TRICARE if the member's
orders to active duty are for more than
thirty days; but some families would
prefer to preserve the continuity of their
own health insurance. Being dropped from
private sector coverage as a consequence
of extended activation adversely affects
family morale and military readiness and
discourages some from reenlisting. Many
Guard and Reserve families live in
locations where it is difficult or
impossible to find providers who will
accept new TRICARE patients.
Recognizing these challenges for its own
reservist-employees, the Department of
Defense routinely pays the premiums for the
Federal Employee Health Benefit Program (FEHBP)
when activation occurs. In addition,
Congress authorized all other Federal
departments and agencies to provide this
benefit. If this benefit is good for the
roughly 10 percent of the Selected Reserve
who are federal workers, it ought to be
provided in kind to the rest of the Guard
and Reserve as an option.
The Military Coalition urges the
Subcommittee to authorize payment of part or
all of civilian health care premiums as an
option for mobilized service members.
-
Inadequate Resources and Policy Gaps Cause
Medical 'Holds".
The Coalition is grateful for the
Subcommittee's leadership in drawing
attention to and directing action on the
medical hold backlogs. While the
Coalition appreciates the Subcommittee's
efforts as well as those of the defense
medical community, we believe that a root
cause of medical holds is the lack of
consistent and comprehensive screening
protocols, and the resources to support
them.
Reserve component members often must
complete military medical exams in the
private sector. The requirement for a
medical examination (a "physical") varies by
military specialty, but it is the
Coalition's understanding that the general
standard for active duty and reserve
servicemembers is that one must be conducted
every five years. For reservists who do not
have insurance there is an understandable
reluctance to incur a personal expense that
the government does not reimburse. Even for
those with employer-sponsored insurance or
insurance through others means, a routine
physical is often not a covered benefit.
(Routine physicals are not a TRICARE
Standard benefit either).
The Military Coalition
recommends that Congress provide the
Services and their reserve components with
adequate resources to meet and maintain
deployment medical standards prior to
mobilization.
-
Coordination
of TRICARE - VA Benefits During
Post-Deployment Period.
In 2002, the VA established a policy
permitting returning National Guard and
Reserve combat theatre veterans to have
two-years' access to VA care without
regard to a VA disability rating (VHA
Directive 2002-049). Servicemembers are
assigned to VA priority group '6' pending
completion of their ratings. While TMC
applauds this effort to provide extended
benefits, we have several concerns.
During transition there will be an
overlapping period when servicemembers will
have both TRICARE and VA benefits. The
Coalition has concerns about "the handoff"
of these individuals from one system to the
other. What kind of support is available to
assist them to better understand which
benefit to use and when? How proactive are
both departments in educating servicemembers?
Eventually, these new veterans will undergo
medical evaluation and some may receive a VA
disability compensation rating. For those
assigned to VA priority groups 1-6, the
usual access rules will apply. Unless they
have been reliant on VA services those
assigned to VA priority 7 or 8 could be
disenrolled from VA health care. That could
defeat the objective of continuous health
surveillance beyond the two-year window.
The Military Coalition is grateful for
extended TRICARE and VA health benefit
coverage for returning reservists and we
recommend closer collaboration between DoD
and VA to ensure servicemembers are educated
on their coverage alternatives during
transition.
Mental Health Care Services.
United Press International reported on
February 18, 2004 that
between 8 and 10 percent of
the nearly 12,000 soldiers evacuated in the
war on terror had mental problems, according
to the commander of the Landstuhl Regional
Medical Center in Germany, Colonel Rhonda
Cornum, USA. (COL Cornum is a decorated
combat veteran and former-POW of the First
Gulf War). COL Cornum said the ill troops
had "psychiatric or behavioral issues".
As
we noted earlier, acute physical injuries
arising from combat receive world-class
care. But TMC is also concerned about the
growing number of returning troops who have
scars that are not visible and may be
overlooked -- the psychological conditions
that inevitably arise from war, such as PTSD
and other problems that have led to domestic
violence. The demographics of the volunteer
force today are vastly different than the
largely conscripted forces of conflicts
before the first Gulf War and more than 50%
of the force is married, many with dependent
children.
While both the DoD and the VA have
experience treating mental illness caused by
war, our concern is also for the families
who must adjust to servicemembers who return
with the physical, emotional, and
psychological scars of war. Who will be
there to help the family members
whose lives will be changed forever?
Reserve component members and their families
- many of whom live far from the support
services provided on military
installation-may experience additional
stressors as a result of the disruption from
mobilization. The Coalition is also
concerned that some mental health issues may
not emerge until sometime in the future,
after these families' eligibility for
TRICARE has ended. Where will these families
find the help they may need? How will
deployment-related mental health issues that
emerge among reserve component
servicemembers and their families after the
servicemembers' return to their civilian
occupation and communities be identified and
tracked in statistics of deployment-related
health care issues.
The
Coalition notes that all servicemembers and
reserve component personnel and their
families can now access the "One Source"
24-hour information and referral service
previously available only for Marine Corps
and Army personnel. One Source provides
information and assistance in such areas as
parenting and childcare, educational
services, financial information and
counseling, civilian legal advice, elder
care, crisis support, and relocation
information. The service is available via
telephone, email, or the web and is designed
to augment existing Service support
activities and to link customers to key
resources, web pages and call centers. It
will also be available to family center
staff.
The
Coalition hopes that these assistance
programs will serve as a useful augmentation
and relieve the burden of counseling that
traditionally has fallen on family service
centers and Chaplains. The Coalition
believes that our families will need all
available resources and more.
Care and Transition Support for Less Acute
Patients.
The Coalition believes that those who are
acutely injured are getting "five star" care
from the DoD with a smooth handoff to the VA
for follow up care. Collaboration in these
efforts is unprecedented. VA Social
Workers, Disabilities Specialists and others
are working in the military's direct care
system to facilitate the transition of
injured servicemembers to the VA system. We
are also pleased to note the development of
a post-deployment health clinical practice
guideline so that DoD and VA providers will
use the same tool to provide effective and
appropriate evaluation and response to the
medical concerns of those servicemembers
returning.
However, TMC is concerned over questions
related to the care of those with less acute
conditions who is not being cared for at
major military medical centers. We are less
confident that the handoff between the DoD
and VA at a smaller installation is as
effective as that of the larger facilities.
The Coalition believes that coordination
activities for the less acutely disabled
could be improved. Currently 250,000 troops
are being rotated in and out of Iraq - the
largest peacetime rotation since WWII. It
is imperative that the VA and DoD build on
their collaboration by improving outreach
and transition services at all military
hospitals, re-deployment sites and
separation activities.
TMC recommends that the Subcommittee oversee
the transition process for less acute
patients and ensure there are sufficient
resources to support the needs of returning
ill and wounded servicemembers, including
the more than 350,000 members of the Guard
and Reserve who have been mobilized since
9/11.
CONCLUSION
The Military Coalition reiterates its
profound gratitude for the extraordinary
progress this Subcommittee has made
in the
area of deployment health policy, practices
and procedures as well as
securing a wide range of personnel and
health care initiatives for all uniformed
services personnel and their families and
survivors. The Coalition is eager to work
with the Subcommittee in pursuit of these
goals as outlined in our testimony.
Thank
you very much for the opportunity to present
the Coalition's views on these critically
important topics.