Overview
Military health care encompasses a diverse range of programs that serve active duty members of the military, their families, as well as retirees and their families as well as veteran . The major military health care programs are operated through the Department of Defense (DoD) and the Department of Veterans Affairs. The Department of Defense provides coverage to active duty service members and retirees from all branches of the military and their families while the Department of Veterans Affairs operates a network of hospitals and clinics that serve veterans and their eligible family members. The two departments work together, but have some 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. Beneficiaries can choose from different health coverage plans that offer the same benefits but vary largely in out-of-pocket costs and the provider networks. TRICARE for Life (TFL) is available to Medicare-eligible military retirees and their family members and survivors 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.
Veterans
Veterans Affairs
An estimated 22.7 million veterans receive coverage and access to care through the Department of 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, comprised of a 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 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. This has been challenging for veterans rated with disabilities that are on the lower end of the severity scale yet have not be eligible to receive services through the VA.
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, one in 10 nonelderly veterans reports neither having health insurance coverage nor using VA health care. 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, as well as prescription drugs. Based on their 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. 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 (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.
Quality of Care
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. Additionally, the two departments have different systems for assessing benefits and disability status. 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 efforts to improve support services, particularly as more veterans return from Iraq and Afghanistan.
One growing area of attention has been the rising number of women in the armed forces as well as their changing roles and the military’s capacity to meet women’s health needs. One of the most urgent needs is the prevention and treatment of sexual assault, or military sexual trauma among active duty and veteran women. Other areas that have received some attention are ending the prohibition on abortions in military facilities, improving primary reproductive health care for women in the military, and better understanding differential gender effects of PTSD.
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
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. There is an estimate that 20% of Operation Enduring Freedom and Operation Iraqi Freedom veterans have experienced 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.[13] 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. [14]
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.