Overview
Military health care encompasses a diverse range of programs, each serving a total military population of more than 9.7 million people, including active duty personnel and families, as well as retirees and their families . An estimated 22.7 million veterans receive coverage and access to care through the Department of Veterans Affairs . The major military health care programs are operated through the Department of Defense (DoD) and the Department of Veterans Affairs. The Department of Defense covers active duty service members and retirees from all branches of the military and their families while the Department of Veterans Affairs covers veterans and their eligible family members. Each program has different eligibility criteria, benefits packages, and financing structures.
Active Duty and Military Personnel
The Department of Defense purchases and provides health care for approximately 8.3 million beneficiaries, including active duty personnel and retirees, and their The Department’s health care is provided at more than 530 Army, Navy, and Air Force military treatment facilities worldwide and is supplemented by the TRICARE program’s network of civilian providers through contracts with civilian managed health care providers. TRICARE covers active duty service members, retirees, activated Guards/Reserves, and their family members, providing them with government-subsidized medical and dental care. The Army, Navy, and Air Force each have a surgeon general who directs the military providers in each branch and acts as a health care advisor to the Secretary of the respective branch.
TRICARE
TRICARE is the Department of Defense’s managed health care program for active duty military, active duty service families, retirees and their families, and other beneficiaries from any of the seven services - Army, Navy, Marine Corps, Air Force, Coast Guard, Public Health Service, and National Oceanic and Atmospheric Administration as well as select National Reserve and Guard members. National Reservists and Guards on active duty for more than 30 consecutive days have comprehensive health care coverage under TRICARE. Their family members’ health and dental care are also covered under several TRICARE program options.
Beneficiaries can choose from three health coverage plans: (1) TRICARE Prime, the HMO option of TRICARE; (2) TRICARE Extra, which has a larger provider network but also a deductible; (3) TRICARE Standard, formerly known as CHAMPUS. While the benefits are the same across all three plans, there are differences in who is eligible, the provider networks, and the out-of-pocket costs under each plan. In addition, the TRICARE Reserve Select program is a health plan that eligible National Guard and Reserve members can buy into by paying monthly premiums, and the program is open to most members of the Reserves who are not on active duty. Covered benefits are comparable to TRICARE Extra and Standard packages.
TRICARE for Life (TFL) is available to Medicare-eligible military retirees and their family members and survivors who are enrolled in Medicare Part B. For services covered by both Medicare and TRICARE, Medicare acts as the first payer and TRICARE pays the remaining out-of-pocket costs. Unlike the other TRICARE programs, TRICARE for LIFE is an entitlement program so it does not require annual renewals by Congress.
Veterans
Veterans Affairs
The Veterans Health Administration (VHA) is the branch of the U.S. Department of Veterans Affairs that purchases coverage for and delivers health care to veterans and their families. The VHA operates the nation’s largest integrated health care system, and provides care to over 5 million inpatients and outpatients at its vast network of hospitals, outpatient clinics, nursing homes, residential rehabilitation treatment programs, and readjustment counseling centers.
Eligibility for VA health care benefits depends solely on active military service in the Army, Navy, Air Force, Marines, or Coast Guard. Most of the nation’s 24 million veterans are eligible for some aspect of VA’s health care services if they choose to enroll. Enrolled veterans are assigned to one of eight priority levels (P1 through P8) based on their service-connected disabilities, income levels, and other factors. Under this priority system, the Secretary of Veterans Affairs decides each year whether VA’s medical budget is adequate to serve veterans in all priority groups who seek care.
Historically a health care system serving only veterans with service-connected disabilities, the VA is now open to all veterans and has become an important “safety net” for many low-income veterans who would otherwise be uninsured. However, 1.8 million U.S. veterans under age 65 continue to lack health insurance or access to care at Veterans Affairs hospitals as of 2004. This means that one in eight, or 12.7 percent of non-elderly veterans are uninsured, up from 9.9 percent in 2000. About half of the 1.8 million uninsured veterans are classified in the lowest priority group (P8), and are not currently eligible for VA healthcare, while the rest may be eligible, but live too far from VA facilities to access services.
The VA provides a uniform Medical Benefits Package to all enrolled veterans, covering preventive and primary care, outpatient and inpatient services within the VA health care system, and prescription drugs. Based on priority status, the VA provides additional services, such as nursing home and dental care, for some veterans and makes these services available to other veterans on a discretionary basis as resources permit.
There are over 9.5 million U.S. veterans who are over 65 years of age and eligible for both VA health care and Medicare. Currently, veterans who are enrolled in both Medicare and VA health must choose either Medicare or VA to pay for services each time they need care. And while Medicare-eligible veterans are unable to use Medicare coverage at VA hospitals and facilities, Medicare can help pay for some co-payments charged by the VA.
CHAMPVA
CHAMPVA (Civilian Health and Medical Program of the Department of Veteran Affairs) provides medical care for spouses and dependent children of disabled or deceased disabled veterans who meet the eligibility requirements of the Veterans Administration. Qualified beneficiaries of CHAMPVA receive coverage for the same package of benefits offered under traditional VA, and seek care within the VA network of providers.
Financing
Services received by active duty military personnel and their families are funded through Congressional appropriations to the Department of Defense budget, as is TRICARE. The Department of Defense uses the Medicare Eligible Retiree Health Care Fund (MERHCF) to pay for health benefits for Medicare eligible Department of Defense military retirees, retiree family members, and survivors up to age 65.
Congress also appropriates funds annually for the VA to provide health care services to eligible veterans. Since demand is often greater than available resources, veterans assigned to higher priorities are enrolled first with the possibility that those in lower priorities may not receive care. While funding levels for the VA have increased in each of the President’s budget requests for fiscal years 2003 through 2006, the proposals assumed that management efficiency initiatives that would save money without compromising access or quality. However, these savings have failed to materialize, resulting in a funding shortfall.
Coordination
One issue that challenges both the VA and Department of Defense is the transition process for service members moving from active duty into the VA health care system. The VA and Department of Defense operate distinct systems that offer differing levels of benefits and often use different standards for assessing severity of illness or injuries. These differences have resulted in some gaps in medical service.
Quality
The Department of Veterans Affairs has been recognized as a leader in improving the quality of health care, including pioneering work in the implementation of technologies and systems to improve the delivery of care. VA leadership has also been recognized for the establishment of a quality measurement program that holds regional managers accountable for processes in preventive care and in the management of common chronic conditions. The Department of Defense also has undertaken major quality improvement initiatives. However, there have been some difficulties in sharing information between the two departments in part because the two Departments have differing interpretations of federal privacy provisions governing the sharing of individually identifiable health data. The difficulties experienced by disabled soldiers and the coordination of their care as they transition to civilian life has been a major driver of recent legislative efforts, congressional hearings and federal investigations to improve support services for veterans returning from Iraq and Afghanistan.
Disability
Compensation
The U.S. government has long recognized the need to provide disability compensation to veterans for health problems associated with military service. Veterans must undergo medical evaluations for each condition they are claiming and must file claims with the Veterans Benefits Administration, which rate service-related injuries on a sliding scale. These ratings assess the effects on earning capacity from such injuries and disabilities. However, the fairness of this approach has raised concern because while a disability may not impair the ability to work in many occupations, it may still significantly affect quality of life, which has historically not been a major factor in disability ratings.
Mental Health
One common type of health problem for which disability compensation is requested is mental health conditions. Exposure to a combat environment can disrupt civilian life and can have a strong impact on a service member’s mental health and psychological well-being. Among just the U.S. troops returning from Iraq and Afghanistan, nearly 40 percent of soldiers, a third of Marines, and half of the National Guard members report symptoms of psychological problems. [12] Of note has been the increasing incidence of post-traumatic stress disorder (PTSD), a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, or violent personal assaults like rape. Another overarching concern is the stigma associated with disclosing mental health symptoms and asking for help within the military culture, both within the armed services and to a lesser extent in VA settings. (cite) The Department of Defense has been working on mental health services, particularly improving post-deployment mental health assessments to better understand the psychological effects of combat and related mental health care needs of those returning from combat.
Conclusion
Given the growing need for providing health care and related benefits to the nation’s service members, policymakers will continue to focus on strengthening both the Department of Defense Military Health System and the Department of VA health care system, which operate in parallel and in conjunction with each other. There is also greater emphasis in policy circles on ensuring a “seamless transition” process for service members moving from active duty into the VA health care system. Areas of focused attention include coordination between health and other benefits offered by the DoD and the VA, improving care for injured service members, and easing the transition from combat service to other military or civilian life.