Editor’s Note: This article is part of MOAA’s 2020-21 TRICARE Guide, brought to you by MOAA Insurance Plans, administered by Mercer Consumer. A version of the guide appeared in the November 2020 issue of Military Officer magazine.
Protecting the military health care benefit is one of MOAA’s highest priorities. This year, we have focused on halting military treatment facility (MTF) restructuring and medical billet cuts, and also getting legislation to increase DoD reporting requirements and congressional oversight of the process.
MOAA is still working to ensure key provisions addressing these issues are included in the FY 2021 National Defense Authorization Act (NDAA). The conference report may not be released until late fall and the final legislation will shape our priorities moving forward, but we have already started discussions on our top goals for military health care in FY 2022 and beyond.
As we develop our advocacy priorities for the upcoming year, there are several key factors MOAA must consider, including:
Military Health System Reform
With the FY 2017 NDAA, Congress directed reforms and restructuring that touch almost every element of the Military Health System (MHS). Reforms are intended to find efficiencies across the system but also seek to address a variety of problems with both uniformed medical provider readiness and the provision of beneficiary care.
Some of those problems include:
- Smaller MTFs with suboptimal case load for maintaining uniformed medical provider currency in skills needed for combat casualty care.
- Low surgical volumes in some MTFs, leading to patient safety issues and concerns about uniformed surgeon skill degradation.
- Patient dissatisfaction with access and quality of care/patient experience within MTFs.
- Lack of focus on value and patient outcomes in the TRICARE purchased care network.
Many reforms, including higher TRICARE co-pays and a new enrollment requirement, were implemented in 2018, but others — including MTF restructuring and the transition of MTFs to Defense Health Agency (DHA) management and administration — are only now reaching the implementation phase.
On Aug. 5, service secretaries and service chiefs sent a letter to Secretary of Defense Mark Esper asking him to suspend all transition activities that impact MTFs and appoint a working group to explore different options for management of military hospitals and clinics. They report the COVID-19 response has demonstrated the reform “introduces barriers, creates unnecessary complexity and increases inefficiency and cost” and said the pandemic has shown that the plan to transition the services’ hospitals and clinics to DHA is “not viable.”
Until the FY 2021 NDAA is signed into law, MOAA will be focused on making sure provisions to halt MTF restructuring and medical billet cuts are included in the final legislation.
National Defense Strategy
The National Defense Strategy (NDS), released by former Secretary of Defense James Mattis in 2018, acknowledges an increasingly complex security environment and calls for aggressive investment in capabilities needed for a more lethal force. Because DoD’s budget has not grown at the rate needed to fully implement the NDS, DoD leaders are seeking to fund some of these investments through reform, including the realignment of resources from lower priority programs and activities.
The Military Health System became a target of these efforts with the FY 2020 budget request when DoD announced significant cuts to medical billets so they could be transitioned to lethality roles. DoD has asserted that approximately 18,000 medical billets (about 20% of the medical force) are not contributing to the readiness mission. Under DoD’s plan, beneficiary care associated with these billets will be transitioned to civilian employees, contractors or the TRICARE network.
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Budget-driven challenges will continue as Congress’ fiscal response to COVID-19 is likely to create even more pressure on DoD budgets in the future.
Advocacy Priorities for FY 2022
While MOAA works on dozens of legislative and policy issues related to military health care throughout the year, we establish priorities annually to guide our efforts based on the importance to MOAA members and the broader uniformed services community. These priorities fit with our mission and consider the broader context of congressional and DoD factors, and their priorities, as noted above.
The following threats to military health care will be part of ongoing discussions as we determine our top priorities for FY 2022:
- TRICARE fees and cost sharing: Some pending TRICARE cost increases — such as the pharmacy co-pay schedule and the new TRICARE Select enrollment fee — were passed into law with previous MHS reform legislation and are lower than proposed fee increases thanks to MOAA’s advocacy efforts. Co-pay increases have likely created a barrier to access, particularly for recurring specialty appointments such as physical/occupational/speech therapy and mental health visits. As the DoD budget continues to be squeezed, it is likely there will be additional efforts to shift health care costs to beneficiaries.
- Direct Care System restructuring and medical billet cuts: While we understand and appreciate Congress’ intent to make improvements and find efficiencies across the MHS and DoD’s need to balance risk across the department, the magnitude of proposed cuts to military medicine is alarming. Cuts to military medicine cannot be reversed easily; they should be undertaken only after rigorous analysis of civilian care availability and medical manpower requirements. The recent request from services’ leadership to Esper for a blanket suspension of transition activities is also likely to impact MHS reforms and Defense-Wide Review-driven cuts to military medicine moving forward.
- TRICARE Pharmacy: Implementation of Tier 4 (TRICARE non-covered prescription drugs) continues with regular formulary determinations. Threats to retiree access to zero co-pay prescription medications at MTF pharmacies will likely persist. Pharmacy co-pays governed by statute mean beneficiaries pay full co-pays even when refill limits are capped.
- Fixing TRICARE coverage gaps: The value of the military health care benefit is not only a function of low out-of-pocket costs, but also depends on coverage policies that evolve with advances in medical technology and treatment protocols. The list of coverage gaps between TRICARE and high-quality commercial plans continues to grow and includes young adult eligibility, chiropractic care, diagnostic genetic testing, the shingles vaccine (for TFL), eating disorder treatment, access to mental health care, and occupational COVID-19 testing.
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- U.S. dependence on overseas pharmaceutical manufacturing: U.S. dependence on China and other nations for pharmaceuticals and other medical equipment and supplies threatens not only military health care, but the entire U.S. health care system.
MOAA looks forward to taking on these threats to military health care while also fighting for tangible improvements to access, quality of care, and the patient experience to ensure the health care benefit reflects the value of military service.
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