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Military Medical Care (MMC)
14 July 2000


 I.  Goal:

A robust Military Health Services System (MHSS), funded to ensure medical readiness, as it provides quality military medical care to all users, regardless of age, status or location.

 II.  Issue:

Accumulating Department of Defense (DOD) budget cuts, base closures,  piecemeal legislation and policy planning, as capacities in the Military Health Services System (MHSS) degrade, bring America's military medical care away from a clear-cut goal to the point of system failure.

To control escalating costs, improve MHSS access by users, and recover system efficiency, DOD employs a regional management administration, called Tricare, to coordinate facilities of the three Military Departments, as it expands local networks of civilian health care providers.

DOD and Congress face profound questions of MHSS system recovery, such as:

(a) mounting risk to medical readiness, as it impacts overall force readiness, recruiting and retention

(b) snowballing demand on the DOD budget, with inflation, as scarce resources are diverted to civilian medical care providers

(c) growing doubt about performance, as Tricare imposes cost cutting measures

(d) Abating care for MHSS users, starting with those who are not active duty service members, as grave uncertainty confronts all users about medical care after age 65.

 III.  Action:

The Retired Officers Association (TROA) and The Military Coalition (TMC), embracing 30 military and veterans organizations, are among groups advancing Congressionally mandated legislation, leading with a roughly three-pronged approach toward more decisive MHSS reform.

As part of a spectrum of initiatives, TROA and TMC, claiming to represent 5 million members of the uniformed services, place emphasis on gaining:

(a) access to Federal Employees Health Benefits Program (FEHBP) coverage for MHSS users 

(b)  Medicare Subvention, a concept to direct Medicare to reimburse DOD for Military Treatment Facility (MTF) care given medicare-eligible MHSS users

(c) effective, unrestricted, pharmacy access for all MHSS users.

DOD and the Clinton Administration oppose some of this, and other action; concerned about added outlays of several billions of dollars a year to achieve the required repair of the MHSS.

Congress responds by mandating demonstration tests of proposals for MHSS repair, in progress, to evaluate costs and doability.  Public pressure mounts to expand the so called demonstrations as rapidly as possible in order to achieve worldwide application of essential reform measures.

 IV.  Opportunity:

The House version of the FY2001 Defense Authorization bill proposes significant changes in military medical care, including achieving Medicare Subvention by 2006 and rapid DOD study of medical care options.  The Senate version proposes access to Tricare programs by retired MHSS users aged 65 and over, as a result of the Warner Amendment (adopted 96-1); and if seconded by the House, will move military medical care in the direction of its historic goal.

Increasing insistence has generated a host of additional bills for MHSS reform, steadily gaining in cosponsors on the Hill, across party lines.  Among them, H.R. 2966, 205, 3573, 1067, and S. 2003 plus 2013 lead in advancing FEHBP access for MHSS users.  Identical bills H.R. 1413 and S. 915 provide for Medicare Subvention, as does H.R. 3655.  Pharmacy benefits are advanced in H.R. 3697, 113, and S. 2486. 

There is a wide opening for Americans to weigh in on the military medical care issue, to demand a clear goal for the nation's MHSS; and to contribute to the development and advance of useful measures needed to repair the military medical care system.

Elected representatives pursuing military medical care legislation as a matter of priority require support.  There is a need to build as many cosponsors as possible for initial reform legislation and to demonstrate commitment to further decisive action.  Responsible Administration and DOD officials must be held accountable.  Military and veterans organizations need backing.

In the end, much more money must be dedicated to military medical care. This demands a clear-cut political decision to define the MHSS in terms of our vital national security interest.

 IV.  A, B, C's of Military Medical Care:

A is for APPROPRIATION of resources by Congress for military medical care, managed as the MHSS (Military Health Services System).  Since 1997,  the General Accounting Office (GAO) has maintained that military medical care costs are likely to be greater than Department of Defense (DOD) estimates.  With DOD shifting reliance to pricey civilian medical sources, MHSS costs are certain to be higher than in the past.  The $16.8B appropriated to MHSS in FY2000 is not adequate to the historic purposes of military medical care, which require: 

(a) ensuring medical readiness for war 

(b) administering a robust Defense Health infrastructure

(c) providing medical care directly to users

(d) obtaining any medical care needed by users from civilian sources.

The Administration requested AUTHORIZATION to spend only $17.2B in FY2001. Funding of military medical care is inadequate, by any standard.

B is for BRAC (Base Realignment and Closure) actions, which during 1987-1997 terminated 35% of the DOD Medical Treatment Facilities (MTF) providing medical care directly to MHSS users. The number of such users declined only 9% in that decade.  Worldwide, 88 hospitals and 516 clinics remain; with 29,000 civilians, and 68,000 military personnel (a 15% cutback in recent years).  Military Treatment Facilities (MTF) supporting military medical care are insufficient to sustain medical readiness in peace and assure preparedness for war.

C is for CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), incorporated in the DOD Tricare medical management structure which coordinates all 3 Military Department medical facilities.  The program, called Tricare Standard, or CHAMPUS/Tricare Standard, obtains medical care from civilian sources, as MHSS capacity for direct medical care of users is diminished.  Annual costs may be $3 to $4B.  Though compared to a premium free health insurance plan, it applies to only certain MHSS users who are dependents of active duty service members, some military retirees, dependents of retirees, and survivors of deceased members.   The program provides no care to any MHSS user after age 65, the point at which retired service members are eligible for Medicare.  The baseline MHSS civilian care program delivers poorly for 50% of MHSS users who are retired, now some 1.2 million, and growing.

D is for DEMONSTRATION PROGRAMS, as those mandated by Congress to test options for overcoming MHSS system failure due to insufficient funding, lack of facilities, inadequacy and inequality of programs for obtaining medical care required from civilian sources.  These include: 

(a) "FEHBP Demonstration" being evaluated at ten sites, through 2002; testing access to the Federal Employees Health Benefit Program by military retirees 

(b) "Tricare Senior Prime" being assessed at 6 sites through 2000, testing the concept for Medicare to reimburse DOD for care of Medicareeligible MHSS users at Military Treatment Facilities (MTF) 

(c) "Tricare Senior Supplement Demonstration" (TSSD), a complement to Medicare test; running at 2 sites through 2002

(d) "Pharmacy Redesign Pilot Program" a DOD sponsored pharmaceutical utility at two sites. 

Piecemeal demonstrations will not impact military medical care, absent rapid transition from "testing" to full implementation of codified policies and specific programs.

E is for ENROLLMENT FEES, copayments, and other charges to MHSS users. By their commitment to uniformed service, members of the armed forces earn comprehensive military medical care for themselves, dependents, and survivors, extending throughout retirement.  This is an extraordinary, but exceedingly modest, element of compensation for the unparalleled demands of duty imposed by the profession of arms.  Enrollment in all Tricare programs and Congress' demonstration programs now lays down a variety of complex charges such as, for example, tests of some annual premiums approaching $600, deductible costs of $300, copayment of 25% of civilian medical fees, and more in many cases, and so on.  Legislation is proposed, for example, in H.R. 3565 and 3655, and elsewhere, to eliminate copayments, and other charges to MHSS users.  Any cost of military medical care to MHSS users, whatsoever, is an added tax, constituting a direct loss of earned compensation, which can only be measured as improper, no matter budget constraint. 

F is for FEHBP (Federal Employees Health Benefit Program), a shorthand- term for the military medical care proposal to give MHSS users access to the civil service FEHBP system.  Over DOD and Clinton Administration objections, the Congress mandated a test of this concept, known as "FEHBP Demonstration", and further legislation leading to full permanent institution of this measure is proposed by Senators McCain, Johnson, and Coverdell, Representatives Shows, Moran, Thornberry, and others in bills such as H.R. 2966, 205, 1067, 3573, and S. 2003 plus 2013.  Access to the FEHBP would allow Medicare-eligible MHSS users who have no access to MHSS or who are denied access, to enroll in FEHBP; where the Government pays about 72% of the annual enrollment fees for civil service employees and retirees. Legislative proposals include measures which would extend coverage to all retired MHSS users, and provisions for Government payment of 100% of the premium to those who served before 1956.  At an estimated cost of $2B to $4B annually, full implementation of FEHBP options would demonstrate a powerful commitment to expend added funds needed for military medical care reform, as it would give retired MHSS users a wide choice in medical care providers, without affecting delivery of care to active duty MHSS users.

G is for GHOSTS, a colloquial term citing the large number of retirees and dependents for whose lifetime medical care DOD is accountable, but who are inactive MHSS users.  Many who receive health benefits from a civilian employer, or other non-DOD sources, might consider becoming active MHSS users, were military medical care to offer, and equitably deliver, comparable, accessible, and affordable (or no-cost) care. Concern over possible resulting increases in the MHSS budget, creates a significant drag on DOD support of essential overhaul of military medical care.

H is for HEALTH AFFAIRS (HA), the entity in the Office of the Secretary of Defense, which in 2000 is headed by Mary Gerwin, Assistant Secretary of Defense (HA), answerable to the Secretary for medical readiness, MHSS policy, planning, programming, and Tricare oversight management.  The Secretary of Defense is directly accountable for repair of any military medical care failure, and no greater responsibility can be reasonably conceived. 

I is for IMPROVEMENTS IN TRICARE, which refers to proposals to attain better routine administrative management needed for viable care for active duty and retiree families under 65 years of age.  Enduring program shortcomings include:

(a) poor access to MTF clinics

(b) insufficient medical personnel

(c) inadequate reimbursement levels

(d) slow claims processing, which deter many quality civilian care providers from participating in military medical care programs. 

Regardless of policy and program adequacy, citizens concerned for the health and welfare of MHSS users seek improvement in military medical care, whatever operating system is in place. 

J is for JOSEPH's INTERPRETATION to the Congress by the Assistant Secretary of Defense (HA), in 1998, that since retirees believe they have a promise of no-cost lifetime health care, the DOD has an "obligation", but DOD is unclear about what that means.  Legislative reaction is a 1998 SENSE OF THE CONGRESS that the nation has a "moral obligation" to provide health care to active and retired service members; and it is necessary "to provide quality, affordable care" to retired members.  Well meant declarations are meaningless, absent unambiguous policy which directs specific doable programs to reverse the military medical care system failure.

K is for KOENIG's INTERPRETATION to the Congress by a Deputy Assistant Secretary of Defense (HA), in 1993, that the DOD is not required to provide no-cost lifetime health care to MHSS users.  Given this dated construction of DOD policy, MHSS programs and demonstrations for overcoming system failure demand that most MHSS users pay fees, premiums, and other charges.  Narrow and contradictory DOD descriptions of the purposes of military medical care confuse and deter clear-cut definition of the MHSS in terms of vital national security interest.

L is for LEGISLATION proposed in 1999 and 2000 bills to fill critical gaps in the MHSS programs resulting from incomplete, and indecisive interpretations of military medical care. Most would provide extensive care to MHSS users after age 65 through access to FEHBP, Medicare Subvention, and Pharmacy access.  Some would extend demonstration projects in these areas or expand them worldwide.  Other important legislation moves further in the direction of restoring zero cost military medical care by having DOD pay 100% of FEHBP premiums on behalf of MHSS, eliminating copayments, and so on.  All the bills entail significant new expenditures, suggesting that the first bullet that must be bitten, in order for the nation to get on with restoring military medical care, is, at the bare minimum, $10B a year. 

M is for MEDICAL READINESS, which begins with maintaining the health of active duty service members, and the capacity to deliver health care in war or emergency; but embraces much more.  This means the role of the Military Health Services System (MHSS) as part of  the nation's security structure is qualitatively different, and, thus, not comparable to health care in the civilian sector.  The teaching and expansion base provided by military treatment facilities (MTF) is a unique military force requirement.  The contribution of assured military medical care to motivation for signing up for, and commitment to, a military career is of inestimable importance to national security.  These security realities mark investment in medical readiness as key to our nation's core investment in the military academies, strategic intelligence, research and development, strategic reserves, and an expandable regular combat force.  By focusing on military medical care in 2000, the Joint Chiefs of Staff are demonstrating their independent accountability to the President and other National Security Council members, as the impact of effective military medical care on the health, welfare, discipline, readiness, and morale of the armed forces is of immeasurable importance to the national security.

N is for NO MILITARY MEDICAL CARE, a prospect which is unthinkable, but one that creates anxiety among all categories of MHSS users, conscious of the steady erosion of military medical care.  There are actual proposals on the table to exclude dependents and retirees from the MHSS altogether.  Loss of health care is a reality as military hospitals and clinics close in communities with large numbers of new residents seeking access to the MHSS.  Active-duty family members who are not enrolled, or cannot enroll, in Tricare Prime confront uncertainty.  Retirees, their family members and survivors enrolled in Tricare Prime, who live apart from military treatment facilities, or cannot find space at MTF confront difficult choices, especially approaching age 65.  Absent a clear-cut MHSS solution for such conditions, recruitment, retention, and survival in retirement becomes increasingly problematic.

O is for OBLIGATION, as the Nation's obligation to defend and preserve itself; marking how our professional military institutions have profound accountability for maintaining all the elements of national security capacity prepared for the unknown and unpredictable future; and how a robust capacity for military medical care, and its contribution to overall readiness has been a major, irreparable factor.  Properly Congress, military and veterans organizations, and others intent on recovering from military medical care failure have evoked the related national obligation to the individuals who served in uniform in peace, and in World War, Korea, Vietnam, and countless other conflicts.  This is expressed as a "moral obligation", "honoring health care commitments" to MHSS users, "keeping health care promises", and so on.  The overriding obligation is that of the nation to provide for its self defense, with the obligation to protect and care for our service men and women, as an essential element of our security capacity.

P is for PHARMACY, with reference to a variety of plans, proposals, and procedures, mainly focused on obtaining support for retirees over age 65.   Both the House and Senate FY2001 authorization bills would allow Medicare-eligible MHSS users access to the DOD National Mail-Order and Tricare retail pharmacy program, and further pharmacy legislation is proposed by Senators Warner and McCain, Representatives Cunningham, Abercrombie, and Vitter, and others in bills such as H.R. 3697, 113, and S. 2486.  However, the ongoing demonstration test "Pharmacy Benefit Pilot Program" for MHSS users over the age of 65, imposes a $250 annual enrollment fee, which is under fire by military and veterans organizations; as are fees in other already established pharmacy programs.  All require copayments, deductible charges, and so on.  All Food and Drug Administration (FDA) approved medication is not available to all users.  A fully stocked, cost free, pharmacy component for military medical care is widely said to be one of the most pressing needs of reform. 

Q is for QUADRENNIAL DEFENSE REVIEW (QDR), a 1997 DOD document, foretelling further reduction in "infrastructure" along with increased outsourcing of medical care to civilian sources, under the MHSS.  Military medical care and medical readiness no longer appear to receive essential priority for protection or unique consideration from defense planners.

R is for REGIONS, comprising the DOD Tricare management structure, responsible for integrating care at all military treatment facilities within 15 geographic areas in the U.S., and overseas; and for undertaking local expansion of independent medical contracting. Regional management of military medical care places emphasis on reducing costs and facilitating the DOD shift to reliance on civilian medical care providers.

S is for SUBVENTION, the program called Medicare Subvention, which the House has voted to implement nationwide by 2006.  If enacted, Subvention would direct Medicare to reimburse DOD for care provided at military treatment facilities to MHSS users covered by Medicare. The Clinton Administration has supported, at least, the ongoing Subvention demonstration test, called "Tricare Senior Prime"; and further legislation to advance beyond the testing phase is proposed by Senators Gramm, Representatives Hefley, Abercrombie and others in identical bills H.R. 1413 and S. 915, as well as H.R. 3655.  Subvention would give Medicare-eligible MHSS users access to health care either in military facilities or, to a lesser degree, through civilian network providers under contract with those facilities.  Full implementation of Medicare Subvention would provide a powerful and logical source for some of the funding needed for military medical care recovery, while making care at Military Treatment Facilities (MTF) available to far more MHSS users, including those over 65.

T is for TRICARE, the DOD management structure, headed, in 2000, by Dr. H. James T. Sears, Executive Director, Tricare Management Activity (TMA), seeking cost control, improved MHSS access by users, and recovery of system efficiency, by coordinating facilities of the three Military Departments, as it expands local networks of civilian health care providers.  TMA provides MHSS users military medical care regionally, through:

(a) direct care under DOD's managed HMO (Health Maintenance Organization), called Tricare Prime

(b) care on a fee-for-service basis using civilian providers under Tricare Standard (CHAMPUS)

(c) a  variant to Tricare Standard care, called Tricare Extra which offers a preferred provider organization from which MHSS users obtain a 5% discount on civilian medical fees.

Tricare maximizes the use of facilities for Tricare Prime users.  Retired service members who do not, or cannot, participate in Tricare Prime can only get services in MTFs on a space-available basis.  Tricare programs should improve care for active duty MHSS users, although it risks problems experienced in civilian HMO's.  However, absent full implementation of demonstration programs and management discipline, Tricare risks less available space for military treatment facility users who are retirees.

U is for USERS of the MHSS (Military Health Services System), comprising (a) all active duty service members; (b) all active duty dependents; (c) all military retirees and their dependents; (d) all survivors of deceased members; (e) Reserve Component personnel and their dependents, under certain conditions; (f) certain foreign military personnel on active duty in the U.S.; and (g) certain government officials, subject to a fixed fee, including the President and Members of Congress.  Users do not have equal access to Military Treatment Facility (MTF) care; and military medical care users are not comparable to civil sector health program "beneficiaries" since they are not guaranteed equitable access to DOD's "HMO" facilities, or to care from civilian sources.  Regardless of status, age, or location, all MHSS users require military medical care at no cost, as a part of the compensation uniformed members receive for military service.

V is for VA (Veterans' Affairs), under which veterans, including military retirees, who can prove financial incapacity, are USERS of Department of Veterans' Affairs (VA) medical facilities.  Such use does not, and must not deny, or limit, access by any MHSS user to MHSS military treatment facilities or Tricare programs. 

W is for WAR, a condition which cannot be explained in advance.  However, revised national security policy is based on the proposition that the most likely future commitment of armed forces will be of limited duration, involving small numbers of troops.  Force planning no longer assumes a full-scale, extremely violent war in Europe; or perhaps, anywhere else.  Strategic planning has reduced military capabilities, required a smaller MHSS and fewer medical personnel, counting on "local treatment of casualties" with increased reliance on "telemedicine".  Policy and plans for military medical care do not recognize that the future cannot be predicted.

X is for X, traditionally the unknown part of a problem, which demands solution or explanation.  House of Representatives FY2001 Defense Authorization bill (H.R. 4205) would first require DOD to do an all-inclusive study by 2002 to solve for one  unknown - how military health care is provided MHSS users covered by Medicare.  Beyond that, the fundamental goal for military medical care appears unclear; perhaps even an unknown quantity.  Those accountable, beginning with the Secretary of Defense and the Joint Chiefs of Staff, have the duty to explain the purposes of the Military Health Services System (MHSS), in terms of our vital national security interest; and their own direct responsibility for the servicemen and women the people entrust in their care.

Y is for YOUR OPPORTUNITY,  as a uniformed service member, private citizen, or military retiree to independently judge whether, or how, the Nation needs to devote more modern planning, direction, and the added resources needed for medical readiness and military medical care.  In the short term, options proposed by the people's representatives in Congress, for fixing things, include: 

(a) access to Tricare programs by retired MHSS users aged 65 

(b) improving the Tricare system to attract quality health care providers to participate

(c)  expanding Medicare-eligibles MHSS users access to Tricare through Medicare Subvention, whereby Medicare is directed to reimburse DOD for seeing additional Medicare-eligible MHSS users in military hospitals and clinics

(d) opening DoD retail and mail-order pharmacy services to Medicare-eligible MHSS users

(e) offering Medicare-eligible MHSS users the option to enroll in the Federal Employees Health Benefits Program (FEHBP) for civil service retirees.

Beyond that there is a need to demand a clear goal for the nation's MHSS, framed in terms of our vital national security interest.  The bullet to bite, in the end, is commitment to spending much more money for America's military medical care.

Z is for ZEAL, undiminished among analysts and well intentioned observers, with no accountability, who advocate:

(a) curtailing MHSS appropriations to provide only essential wartime services while limiting peacetime MHSS users to active duty service members, excluding dependents and retirees from the MHSS; a proposition which  the Congressional Budget Office concluded, in 1997, could save $2B a year

(b) significantly increasing enrollment fees and premiums for Tricare programs

(c) other proposals, counter to the historic MHSS purpose which ensures medical readiness and no-cost care to members of the uniformed services, their dependents, and survivors, given the aim of fostering 20 or more years of service to the nation. 

Those accountable for the nation's military medical care have the commitment to control, lead, and direct military medical care policy and planning; based on their unique and direct responsibility for medical readiness and for all our service men and women, be they in or out of uniform, and their families. 

 -----------  END WORK SHEET DRAFT  -----------

See <http://www.tricare.osd.mil/> for DOD management of MMC under the Military Health Services System (MHSS)

See (no cost, or obligation) <http://militaryhub.com for broad tracking of military issues and services

Type in "tricare" at <http://thomas.loc.gov/bss/d106query.html> for status of all MMC legislation

See TROA's <http://www.troa.org/HealthCare/> for "Bills of Interest" under "Lobbying Congress")