Improved Prognosis

NATIONAL GUARD magazine
February 2017

By William Matthews
(read online digital version)

Congress made good on its promise to reform TRICARE, but work remains on satisfying the needs of the Guard

In a desperate search for survivors, members of two special National Guard rescue teams waded waist deep in a sludge-like mixture of mud, sewage, splintered trees and shattered homes left by a mudslide in Oso, Washington.

Specially trained and equipped, Guard fatality search-and-recovery teams from Washington and Colorado converged on the disaster site in March 2014. But there were few survivors to be found. It took a month to recover all 43 of the victims.

The Oso disaster went on record as the worst mudslide in U.S. history. After 45 days of heavy rain, an unstable hillside collapsed into a fast-moving wall of mud March 22. Crashing downhill, bringing trees and boulders with it, it swept over a rural community, burying a square mile of homes, cars, highway and people under 30 to 70 feet of mud and debris.

Laboring though the muck and splintered ruins was hazardous duty for the Guardsmen. And for the duration of the emergency, they faced an additional hazard—an automatic suspension of their TRICARE health insurance coverage.

Normally, Guardsmen who are part of one of the Guard’s Homeland Response Forces, which includes the search-and-recovery teams, are covered by TRICARE. But when they’re called by a governor to respond to an emergency, they switched from a federal to a state status. For the Oso responders, the move immediately suspended the TRICARE health coverage that normally covered them and their families.

That has changed for 2017. Congress, which was able to agree on little else last year, agreed that “we should not be forcing our National Guard members to choose between helping our communities and caring for their own families,” said Rep. Suzan DelBene, D-Wash. “My bill is a simple fix to an unnecessary problem.”

NGAUS agreed. It was one of the association’s highest priorities last year.

DelBene, whose congressional district includes Oso, pushed through an amendment to the 2017 National Defense Authorization Act that continues TRICARE coverage for certain Guardsmen while they are on state emergency duty. The difference is that the state now picks up the tab.

That change was one several Congress approved to TRICARE for 2017 and beyond. A few of the changes improve TRICARE benefits for Guardsmen, but many other improvements that Guardsmen wanted weren’t included in the authorization act—or at least not without further study.

Lawmakers see the changes as their promised reform of the Pentagon’s massive medical-care system. The provisions fill 40 sections and more than 100 pages of the act. They are designed to find greater efficiency while improving both the access to and quality of care.

“There’s a lot of good stuff in there. There’s a lot of stuff we’re still puzzling over,” Dr. Karen S. Guice, the acting assistant secretary of defense for health affairs last month told Tom Philpott, a nationally syndicated columnist who focuses on military personnel matters.

A big part of the reform is consolidating many of the current TRICARE options under two programs— TRICARE Prime for managed care and the new TRICARE Select offering the preferred-provider network. TRICARE Reserve Select (TRS), which significantly subsidized option for traditional Guardsmen and Reservists, will fall under TRICARE Select. All this takes effect in 2018.

On the plus side for service members more immediately, Congress rejected significant increases in TRICARE fees for 2017. The Defense Department, besieged by rising medical-care costs, sought increases in a number of fees that TRICARE charged individuals and families. Ever increasing health-care costs have pushed Pentagon spending on health care to more than $50 billion a year, approximately 10 percent of the base defense budget. To stem rising medical costs, the department wanted to shift more of that expense to troops and their families.

Congress said no.

Those in TRS will continue to pay about 28 percent of the cost of their insurance plans, with the Defense Department paying the rest. For 2017, that remains essentially unchanged. TRS for individual Guardsmen now costs $47.82 a month, a slight decrease from $47.90 a month in 2016. TRS for families costs $217.51 a month now, a slight increase from $210.83 a month in 2016.

Another TRICARE improvement permits users to get care from urgent-care centers without having to get a referral from a primary-care provider. That’s a big deal for active-duty troops, including full-time Active Guard and Reserve personnel. Traditional Guardsmen and Reservists will benefit from it when they’re on active duty for 30 days or more.

Another congressionally mandated improvement requires military treatment centers that operate urgent-care clinics to keep them open until at least 11 p.m., thus making medical care more readily available. If the facility doesn’t operate such a facility, it must contract with a local civilian urgent-care clinic to provide such care until 11 p.m. But again, part-time Guardsmen will benefit only when they are on active duty for 30 days or more.

Continuity of Care

A longstanding coverage concern for Guardsmen is “continuity of care,” and a matter NGAUS and other associations brought before Congress last year.

Lawmakers listened to Guardsmen’s complaints, but took only a partial step toward resolving them.

One continuity problem arises when Guardsmen who have civilian health coverage are called to active duty for more than 30 days. For many, that means the coverage provided by their civilian employers is suspended and they are covered instead by TRICARE. For Guardsmen and their families, it can mean that the doctors their spouses and children regularly see are no longer available because they don’t accept TRICARE insurance. Or it can mean paying for spouses’ and children’s health care out of pocket.

Instead of approving any of several plans that would solve the problem, the House and Senate ordered a “study on improving continuity of health coverage for reserve components.”

The study is to examine several health-coverage alternatives for Guardsmen and Reservists members, including:

  • Whether to allow current and former Guardsmen and Reservists to receive the same health coverage that other federal government employees receive through the Federal Employees Health Benefit Program. Doing that would give Guardsmen and Reservists access to many more coverage options, possibly even the same health plans they get through their civilian employers.
  • Whether to pay a stipend to Guard and Reservists to continue insurance coverage through private-sector insurance plans while they are on active duty.
  • And, lawmakers said, “any other options for providing coverage to current and former members of the selected reserve the [defense] secretary considers appropriate.”

The secretary has six months to conduct the study and report its findings to Congress.

Lawmakers also ordered “an assessment of the extent to which families of members of the reserve components experience difficulties in transitioning” from their usual health insurance to TRICARE when Guardsmen and Reservists are ordered to active duty for more than 30 days.

Studies and assessments are fine, but organizations that lobby for troops’ benefits were hoping for more.

The Military Coalition, a group of 32 veteran and military organizations that advocate for better military benefits, pressed for actual continuity-of-care reforms. Among them: “Subsidizing premiums paid by private employers to allow continuation of private coverage during periods of activation.”

A provision in the fiscal 2017 NDAA does enable DoD to create a pilot program to test the concept.

NGAUS wanted to go further. The association called for legislation that would permit civilian employers to pay TRS premiums for their Guard and Reserve employees. Such legislation would save companies money because TRICARE premiums are generally cheaper than commercial coverage. And it would improve continuity of care because Guardsmen and Reservists wouldn’t switch insurance plans—and possible doctors—when they were activated.

Congress waved off the proposal.

So for 2017, TRS offers Guardsmen and Reservists this: Sign up for yourself or yourself and your family, find doctors who accept TRICARE payments, pay monthly premiums, pay a deductible, and pay about 15 percent of the cost of whatever fee TRICARE has negotiated for various medical services. Deductibles for 2017 are $50 for individuals, $100 for families of E4s and below; $150 for individuals and $300 for families of E5s and above.

Not a bad deal, considering other health coverage. But it’s not always easy to find doctors who will accept TRICARE. The reimbursement rates—what TRICARE will pay providers—are low, and in areas where there aren’t many active-duty personnel, some providers avoid it due to the time it takes them to get paid for lower rates. Finding good doctors who take TRICARE is especially a problem for Guardsmen and Reservists who live in rural areas, say TRICARE reform advocates.

But even in areas where military personnel are prevalent, it may not be easy to find doctors who will accept TRICARE. In 2015, a survey by the Military Compensation and Retirement Modernization Commission of Fayetteville, North Carolina, in the shadow of the Army’s biggest base at Fort Bragg, found that only 36 obstetricians out of 114 would take TRICARE.

And not all Guardsmen and Reservists are eligible for TRS.

Full-time Guard technicians are considered full-time federal government employees and are offered health insurance through the Federal Employee Health Benefits Plan. Depending on where they live and work, they may have as many as 20 or more different commercial health plans to choose from.

But some technicians say they want TRICARE instead because its premiums are lower. Since the population that TRICARE serves is generally younger than the population of all federal workers, TRICARE insurance rates are correspondingly lower.

For retired Guardsmen who are under 60 years old, there is TRICARE Reserve Retired. It offers TRICARE insurance benefits, but without the 72 percent government subsidy on premiums, so it’s relatively expensive. For 2017, it costs $402.81 a month for individuals and $1,013.36 a month for families.

When retired Guardsmen and Reservists turn 60, they become eligible for the same TRICARE insurance options that retired active-duty personnel receive, which cost about half as much as TRICARE Reserve Retired. And when they hit 65, they are eligible for Medicare and TRICARE for Life, which is a wraparound supplement to Medicare Part B. It serves as a second payer for medical expenses and offers pharmaceuticals at low or no cost.

TRICARE Feedback

In 2016, three organizations— NGAUS, the Enlisted Association of the National Guard of the United States, and the Reserve Officers Association—published a survey of TRS users.

“Most of our members are on TRS and they like it, when it works as designed,” says Scott Bousum, the EANGUS legislative director. But TRS doesn’t always work well.

Among the survey findings:

  • Only 40 percent said they had access to qualified specialists all of the time; 28 percent said they had access some of the time. Others had little or no access;
  • 48 percent said TRS provided prompt health care all of the time; 36 percent said it did some of the time;
  • Just 38 percent said they had access to a good selection of in-network doctors;
  • 21 percent said the quality of care was excellent; 29 percent rated it very good; and
  • 73 percent said the cost of medical care was less through TRICARE than through private providers.

There is no shortage of recommendations to improve medical coverage for Guardsmen and Reservists. In 2015, the Compensation and Retirement Modernization Commission offered two suggestions to improve continuity of care. One was to offer Guardsmen and Reservists “a menu of DoD-sponsored commercial health insurance plans” in addition to TRICARE.

The commission argued that commercial plans “could more closely resemble the plans offered through reserve component members’ [civilian] employers,” and could eliminate the need for Guardsmen and Reservists to switch from employer-provided health insurance to TRICARE when they are called up for active duty.

Another commission proposal was to provide them with an allowance to pay for employer- sponsored health-insurance plans. That way, “instead of relying on particularly meager TRICARE provider networks in rural areas far from military installations, reserve component members would have the opportunity to select from several commercial health insurance plans operating in their area,” the commission said.

The commission also called for speeding up TRICARE’s “adoption of the latest technological, clinical, or business advancements in the medical industry.” Slow-moving TRICARE sometimes leaves patients “unable to access the medical technology, procedures, or treatments available to civilians who have private-sector health insurance,” the commission reported.

So far, Congress has not accepted these suggestions. One commission recommendation that Congress flatly rejected was raising TRICARE fees.

The commission noted that TRICARE has substantially higher “utilization” rates than do private insurance plans. That is, TRICARE users seek more medical treatment than do users of commercial medical insurance plans.

The commission blamed TRICARE’s “relatively low” expenses including low co-payments, deductibles and coinsurance compared to its civilian counterparts. The logic is that since medical treatment under TRICARE is relatively inexpensive to TRICARE users, they use it more.

Utilization could be curbed by increasing emphasis on wellness and disease prevention, and keeping chronic diseases under better control, the commission said. It could also be curbed by increasing fees.

Lawmakers disagreed.

WILLIAM MATTHEWS is a Springfield, Virginia-based freelance writer who specializes in military matters. He can be contacted at magazine@ngaus.org.


OUR TAKE

Access to affordable, high-quality, uninterrupted medical care has long been a NGAUS priority. It’s a personnel readiness issue. It’s a quality-of-life issue for National Guardsmen and their families. And it’s a retention issue. The association led the lengthy struggle to create TRICARE Reserve Select (TRS), which provides traditional Guardsmen and Reservists with a low-cost option for medical coverage. Today, NGAUS is focused on giving Guardsmen more choices for quality care and better continuity of that care. The association urges Congress to allow Guard military technicians to purchase TRS. As federal employees, they are currently prohibited from doing so. In addition, employers should be provided incentives to cover the cost of TRS for their Guard and Reserve employees. There should also be an option for Guardsmen and Reservists to receive government stipends to cover the purchase of commercial health coverage.