Since 9/11 active duty members and their National Guard and Reserve peers have engaged in numerous duty assignments from homeland security to armed conflict. At the same time, members have continued to serve in various far-flung areas of the globe. The main message is, that they are gone! Separations produce economic strain, psychological strain and high levels of stress in the family. The lifeline of the military family, the military community, is also feeling the strain. Family services are important to an installation not pressured by high Perstempo or conflict-related deployments. They are a critical necessity when families are left behind. Family center personnel, military chaplains, installation mental health professions and Morale, Welfare and Recreation programs all provide needed assistance to families. When spouses find themselves as the sole head of the family and as the single parent, the services available to assist them and their children with these challenges are truly lifelines. E-mail, video teleconferencing centers, and special family activities ease the strains and pains of separation. But none of these services are without cost. Just as the deployed servicemember’s readiness is dependent on proper training, food, shelter, clothing and weapons systems, the readiness of the family is dependent on accessing needed services. Both must be adequately funded to assure a force ready to successfully carry out its assigned mission.
NMFA applauds the Office of Military Community and Family Policy in the Office of the Secretary of Defense (OSD) for its creation of a Joint Family Support Contingency Working Group to promote better information-sharing and planning among OSD and the military Service headquarters family support staff, including the Reserve Components. NMFA appreciates the invitation to participate in this working group, an innovative concept that grew out of the successful collaboration in the operation of the Pentagon family assistance center after the attack on the Pentagon. The working group recognized that most military families live off-base and is encouraging new ways of helping families that are not all centered on the installation. NMFA has long promoted additional outreach into the civilian community by installation personnel so that family members unable to get to an installation can still receive needed assistance. The possibility of further incidents, which could again restrict access to installations, makes this outreach even more imperative.
One new vehicle for communicating with family members and helping them access assistance when needed, wherever they are located, is being tested by the Marine Corps Community Services (MCCS). The new program, “MCCS One Source,” provides 24 hours a day, 7 days a week, telephone and online family information and referral, situational assistance, and links to military and community resources. Since February 1, this service has been available to active duty and Reserve Marines and their family members. The Army has also made this service available to solders and families at select installations. Employee Assistance Programs such as “One Source,” provide an accessible source of information for servicemembers and families and, if properly coordinated with other support services, should allow Service family support professionals to devote more time and attention to supporting unit volunteers and to assisting families with more complex problems.
A program offered by Army Chaplains, “Building Strong and Ready Families” is targeted at improving relationship skills and assisting initial-entry soldiers and their families with making the transition into the military culture. NMFA is very grateful that a clarification on the use of appropriated funds to pay the expenses of soldiers and their families to participate in these command-sponsored, chaplain-lead training opportunities was included in the FY 2003 Defense Appropriations Act and requests, that if permanent authority has not been granted, such clarification of the use of appropriated funds be included again in this year’s Act.
One very necessary improvement needed in the family support arena is closer collaboration between all the various helping individuals and agencies who assist in the development and maintenance of strong emotional and mental health in both individuals and families of the military community. As was seen in the Fort Bragg, North Carolina, domestic violence cases during the summer of 2002, not all military family members or servicemembers make use of the counseling and support services available to them. While the TRICARE mental health benefits are rich by the standards of many other plans, the program does not have a preventive care component. For TRICARE to pay for services, there must be a medical diagnosis, thus discouraging many family members from seeking care. Many members and their families also believe that seeking counseling services through military programs may harm their careers or that these services are only intended for families identified as having problems. The authors of the Fort Bragg Epidemiological Consultation Report who examined the domestic violence incidents, noted that the various agencies that could provide support to the service members and families do not often coordinate their activities. NMFA strongly believes that better coordination and communication among all installation “helping agencies” as well as with those in the civilian community is imperative to help families deal with stress and promote better mental health. NMFA also believes that TRICARE must cover preventive mental health services just as it covers medical preventive services such as well-baby checks, immunizations, PAP smears and mammograms. An emphasis on emotional health rather than treatment may also make beneficiaries more likely to seek appropriate services in a timely manner.
A significant element of family readiness is an educational system that provides a quality education to military children, recognizes the needs of these ever moving students and responds to situations where the military parent is deployed and/or in an armed conflict. Since approximately 80 percent of military children attend civilian public schools, the DoD Impact Aid supplement is vital to both these children and the school systems that educate them. No less than the stay at home spouse, children are affected by the absence of a parent and experience even higher levels of stress when their military parent is in a war zone shown constantly on television. Addressing the needs of these children and their classmates is imperative to lowering the overall family stress level, and to achieving an appropriate level of family readiness. But it does not come without cost to the local school system.
This Subcommittee has consistently supported the needs of the schools operated by the DoD Education Activity (DoDEA). These schools are located on military installations in the United States and in overseas locations. The commitment of this Subcommittee to the education of these military children has resulted in higher test scores, minority student achievement, parent involvement programs and partnership activities with the military community. It is significant to note that the Commander of USAREUR states that over half of the military members assigned to USAREUR are deployed away from their permanent duty sites. Imagine the challenges facing a school system in a foreign country where half of the student body has an absent parent! Your continued commitment to and support of these schools is strongly requested.
Military child care is another important element in family readiness. Sergeant Major of the Army Jack Tilley noted that during 2002, twenty-seven percent of enlisted soldier parents reported lost duty time due to a lack of child care. Deployments increase the need for child care. Families, where the parents were previously able to manage their work schedules to cover the care of their children, must now seek outside child care as one parent deploys. Guard and Reserve families most often do not live close enough to a military installation to take advantage of either the Child Development Center or Family Day Care homes. Since 2000, DoD has had the authority to increase the availability of child care and youth programs through partnerships with civilian agencies and other organizations. The Services set up pilot programs to take advantage of this authority and obtain more care for children off the installations; however, less than 10 percent of DoD child care is provided off-base. NMFA is concerned that current funding levels for the Military Child Development System may not be adequate to meet both the routine demands for child care and to meet the increased need due to deployments. We request additional funds to ensure the provision of the high quality child care servicemembers and their families need.
Finally, the ability of a military spouse to be employed and to have career progression affects both the family’s finances and the self-sufficiency of the spouse when the member deploys. Studies after the Persian Gulf War showed that spouses who were employed handled the stressors of the deployment better than those who were not employed. NMFA anxiously awaits the DoD report on the status of its spouse employment programs requested by Congress in the FY 2002 NDAA. While we do not expect DoD to create a jobs program for every military spouse, it does need to facilitate the transition of mobile military spouses into already existing opportunities and to target efforts where spouses are having the greatest difficulty accessing educational programs or employment. Sixty-three percent of military spouses are in the labor force. Eighty-seven percent of junior enlisted spouses (E-1 to E-5) are in the labor force. Very obviously, the financial health of the military family is significantly dependent upon the employment of the spouse. Family financial health is without question a family readiness issue.
NMFA applauds the various initiatives to meet the needs of families wherever they live and whenever they need them and requests adequate funding to ensure continuation of current programs and implementation of new ones. However, we are also very aware that the “bedrock” family support programs must not be shunted aside in order to fund only the new initiatives. Since there appears little chance that the increase in family separations will come to an end, the higher stress levels caused by such separations require a higher level of community support.
National Guard and Reserve Families
As of May 6th, 224,528 National Guard and Reserve members were on active duty. While many of the challenges faced by their families are similar to those of active component families, they must face them with a less-concentrated and mature support network and, in many cases, without prior experience with military life. Unlike active duty units located on one installation with families in close proximity, reserve component families are often miles from the servicemember’s unit. Therefore, unless they pay for their own travel expenses, families are often unable to attend unit pre-deployment briefings. NMFA constantly hears the frustrations family members experience when trying to access information and understand their benefits. The lack of accurate benefit information and unrelenting communication difficulties are common themes among Guard and Reserve families.
DoD has developed several key initiatives that address the needs of Guard and Reserve families. NMFA applauds this effort, but there is still much to be done. For example, the OSD Reserve Affairs office maintains an excellent website. Its Family Readiness Toolkit and Deployment Guide provide practical information; however, many families report it is difficult to use. Guard and Reserve families ask for standardized materials that are appropriate to all services, so that if an Army Reserve family happens to live close to a Navy installation they would understand how to access services there. The establishment of a joint Family Readiness program would facilitate the understanding and sharing of information between all military family members.
NMFA thanks the state family readiness coordinators and unit volunteers for helping to provide family members with basic information. Unfortunately, some units do not have adequate programs because of the lack of volunteers and paid family readiness coordinators, whose sole job is to support the family. Additional family readiness staffing and support for unit level volunteers could ensure information is forwarded to families who are unable to attend unit briefings. Guard and Reserve unit volunteers, even more than many of their active duty counterparts, are stressed because of the numbers of families they must assist and the demands placed upon them. At a minimum, NMFA requests funding for child care to enable these dedicated volunteers to more efficiently perform their expected tasks. Funding to enable families to attend pre-deployment briefings would help strengthen the ties between the units and the families and the families with each other and assist in assuring that accurate information is provided directly to the family members.
In addition to being geographically separated from the servicemember’s unit, families are often geographically separated from each other. NMFA suggests that DoD also strengthen and perhaps formalize partnerships with national organizations such as the American Red Cross and U.S. Chamber of Commerce to enlist their assistance through their local chapters in setting up community-based support groups for military family members. The groups could include not only spouses and significant others of all deployed members, no matter what unit or Service the member is attached to, but also the parents of servicemembers. Involving local community leaders in setting up these support groups would address two of the most common concerns expressed by some of these isolated families: the feeling that they are the only families in town going through the strain of deployment, and the sentiment that people not associated with the military do not appreciate their sacrifices.
Through our contact with Guard and Reserve families and family support personnel over the past year, NMFA has heard wonderful stories of individual states, units and families caring for and supporting each other. NMFA is aware of leadership involvement at all levels to help ease the challenges faced by servicemembers and families. NMFA is especially proud of the efforts of The National Committee for Employer Support of the Guard and Reserve (ESGR) as an advocate for the reserve component member facing employment issues. ESGR is encouraging employers to set up their own family support programs and provides information to employers and to their employees about the legal rights of reserve component members. By providing this information in the workplace, ESGR is helping civilian communities gain a better understanding of the valuable role the Guard and Reserve play in the defense of our nation.
Compensation issues continue to be of paramount concern among Guard and Reserve families. Many members have taken a significant pay cut upon activation. Families who initially financially prepared for a six month activation now are faced with the devastating monetary consequences of a one or two year loss in income. Some small business owners and single practice professionals are facing the loss of their businesses. NMFA is aware of the disaster the previous income replacement program created, but believes that attention must be directed to these problems or retention of these individuals may become extremely problematic. In addition, some Guard and Reserve members experienced problems with pay processing upon activation. This delay in receiving the paycheck led to overdue payments on bills, and occasional threats to foreclose on mortgages or to turn the family over to a collection agency. Pay and personnel systems for activated Guard and Reserve members must work in coordination so families do not have to deal with bill collectors.
The cost of meeting unique family readiness needs for National Guard and Reserve families must be calculated in Guard and Reserve operational budgets and additional resources provided. DoD should partner with other organizations and explore new means of communication and support to geographically dispersed Guard and Reserve families.
Health Care
After a rocky start over several years, the TRICARE system is providing most of the promised benefit for most families, particularly those enrolled in Prime. Changes made in the Prime Remote program for active duty families and ensuring access to Prime and Prime Remote for the families of Guard and Reserve members, who have orders for 30 days or more, have gone a long way to providing a truly uniform benefit for all families of those on active duty.
NMFA is also pleased to report the continuation of the partnership established between the DoD Office of Health Affairs, the TRICARE Management Activity (TMA) and the beneficiary associations. This collaboration benefits both beneficiaries and the Department. NMFA appreciates the information received in these meetings and the opportunity for dialogue with those responsible for managing DoD health care policies and programs. Through this medium, NMFA and other organizations have been able to raise areas of concern, provide feedback on the implementation of new programs and benefits and to help provide better information to beneficiaries about their health care benefit.
However, despite these improvements, NMFA remains apprehensive about several issues: funding, beneficiary access to health care, the implementation of a new generation of TRICARE contracts and the ability of National Guard and Reserve families to have reasonable access to care and continuity of care.
Funding
The FY 2004 budget request includes what DoD believes to be an accurate level of funding for the Defense Health Program. However, NMFA urges this Subcommittee to continue its efforts to ensure full funding of the entire Defense Health Program, to include meeting the needs for military readiness and of both the direct care and purchased care segments of TRICARE. NMFA is particularly pleased with the allocation of funds by TMA and the Services to support the new Family Centered Obstetrical Care initiative. While the increased funds for this program may well have been driven by the impending loss of DoD’s ability to force military family members to receive obstetrical care in Military Treatment Facilities (MTFs), it has nonetheless been a remarkable achievement. Many MTFs have instituted significant and substantial improvements to their obstetrical programs and more are constantly coming on line every day. NMFA assumes this initiative will continue to be funded in a robust manner and hopes that the spirit of Family Centered care, the innovations created by the program and the funding provided will move into other specialties within the MTFs.
Access
Although recent TRICARE surveys highlight improvements in beneficiary access to care, NMFA continues to field calls on almost a daily basis from beneficiaries with access issues. Servicemembers and families enrolled in Prime are promised certain standards for access to care in providing appointments, wait times at a provider’s office and geographic availability. Yet the calls we receive tell another story. Even servicemembers are told by the direct care system, “Call back next month, there are no more appointments this month.” Family members are routinely not informed that they can request an appointment with a provider in the civilian sector if access standards cannot be met in the direct care system. However, IF the member or family member mentions the words, “access standards,” appointments that fall within the guidelines magically appear. NMFA was also made aware that some in the direct care system were telling family members that accepting appointments outside of the access standards was a way for them to “support the war in Iraq” since medical personnel from the facility had been deployed. TRICARE was designed so that care could be provided in a timely manner within the civilian network when it was not available in the direct care system. There is no reason, including the deployment of medical personnel, that access standards should not always be met.
When family members enrolled in Prime attempt to access care within the civilian network they utilize the Managed Care Support Contractors web pages or the Prime Booklet’s list of providers. However, they often feel as if they are “letting their fingers walk through the yellow pages,” as they hear, telephone call after telephone call, “The doctor is not accepting any new TRICARE Prime patients.” Lists of providers must show who is and who is not accepting new patients. This information is of prime importance to families arriving at a new duty station. To their credit some, but not all, of the Managed Care Support Contractors are providing this information.
As TRICARE Prime has improved, those who have remained in TRICARE Standard often feel as if they are unwanted stepchildren. Managed Care Support Contractors are required in the current contracts to assist Standard beneficiaries in finding a provider who accepts TRICARE. However, most Standard beneficiaries are not aware of this provision, because no one is required to communicate with them. When new Managed Care Support contracts came on line, contractors mailed brochures to all eligible beneficiary households, but other than giving basic information on the various choices with the TRICARE program, the information was basically geared to enrollment in Prime. Contractors are required to communicate regularly with Prime enrollees, but not with Standard beneficiaries. In fact, most of the literature regarding Standard states that it is the same as the old CHAMPUS program. No mention is made of prior authorizations, which vary from Region to Region, or of other region specific “rules of the road.”
In many areas Standard beneficiaries have more difficulty than Prime enrollees in finding providers. While Standard beneficiaries can certainly utilize Prime network providers (if they know where to find such a list), many have remained in Standard because there is no Prime network where they live or they have elected to have a broader choice of providers. Managed Care Support Contractors on the other hand are, understandably, more interested in establishing and maintaining their Prime networks. Anecdotal evidence provided to NMFA appears to indicate that many providers are unaware that they may remain TRICARE providers even if they decline to become Prime network providers. In addition, many providers also complain of the “new rules of the road” on prior authorizations and paper work, which were not required when they were CHAMPUS providers. Low reimbursement rates and claims processing continue to be cited by providers as reasons they do not seek to become authorized TRICARE providers.
TRICARE Standard is an option in the TRICARE program and those who are forced or desire to use that option should be supported as fully as those who chose to enroll in Prime. Contractors must make significant efforts to recruit Standard providers.
DoD and the contractors must be ever vigilant in identifying areas where sufficient numbers of providers in certain specialties refuse to accept TRICARE because of the reimbursement rates. DoD has the authority (and has used it in Alaska and recently in Idaho) to increase reimbursement rates to ensure a proper mix and number of providers. Contractors must continue their strong effort to improve claims processing and education of providers and their support staffs on the unique requirements of the TRICARE claims process.
TNEX and other contracts
The next round of TRICARE Contracts (TNEX) would appear to place significantly new levels of authority and responsibility on local MTF Commanders. NMFA is concerned that this may actually increase the differences in how a beneficiary accesses care rather than make it more uniform. Currently, Managed Care Support Contractors in some Regions have total responsibility for making appointments, and in all Regions they have the responsibility for making appointments within the civilian network. The new contracts would appear to leave this responsibility to the local MTF Commander, either to arrange all of the appointments or to opt into an as yet unknown national appointment contract. All current Managed Care Support Contractors are required to have a health information line. The new contracts leave the decision to have one and/or which one to have up to the local MTF Commander.
TNEX also appears to blur lines of authority and accountability rather than strengthening them. Beneficiaries need a clear line of command and accountability for their problems with accessing care to be fixed and for their concerns about quality of care to be appropriately addressed.
If changes are made in how beneficiaries access care from the current method, beneficiaries need to be educated and informed BEFORE the fact.
Beneficiaries may not only face new ways of accessing care, but new “rules of the road” as a national contract is awarded for the retail pharmacy benefit. The implementation of the new TRICARE mail order pharmacy program contract (TMOP) was not without some significant problems. Fortunately, most were transitory and have been or are being addressed. However, a problem facing some beneficiaries could have been avoided with proper education and information. TMOP is now tied into both the retail pharmacies and the MTF pharmacies, so all pharmacy providers are aware of prescriptions being filled at all other venues in real time. Under the previous contractor such real time checking was not done. If a provider ordered a new medication for a beneficiary and wanted the medication started immediately, yet the beneficiary was to be on the medication for a long time, the beneficiary probably used both the retail and mail order pharmacy on the same or similar dates. Under TMOP the mail order request of the beneficiary will be denied until 75% of the retail prescription is consumed. This is not a problem with receiving the medication in a timely manner, nor is it a new DoD regulation, but it was a new wrinkle to beneficiaries that caused concern and could have been avoided.
Guard and Reserve Health Care
While the “rules of the road” for using TRICARE, particularly Prime, seem now to be well understood by most active duty and retired family members, it is another story for National Guard and Reserve families. Since many of these families do not live near an installation, most of their information comes in printed form, on the web or via telephone. In addition, many live in areas where providers are unaware of TRICARE, as there are few if any other uniformed service beneficiaries in the area. Lead Agents and TRICARE contractors routinely conduct TRICARE briefings for members of units about to mobilize; unfortunately, in most cases, families (those who will actually have to navigate the system) live too far away to attend. If the servicemember and family live in a different TRICARE Region from the one where the unit is located, the information provided in the unit setting may not be the same for the Region in which the family actually lives. Decisions to enroll in Prime, use Standard or remain with an employer provided plan need to be family decisions based on full and accurate information provided to servicemembers AND their families.
NMFA has long believed that the approach to meeting the health care needs of Guard and Reserve members and their families must be flexible enough to ensure access to care and continuity of care. We believe S. 852, recently introduced by Senators DeWine, Daschle, Smith and Leahy, addresses most of these issues. Provisions included in the legislation would authorize Guard and Reserve members to enroll in TRICARE when not on active duty and subsidize the cost of the program at approximately the same level as the Federal Employee Health Benefits Program (FEHBP) is for Federal Civilians. This would allow those who currently have no insurance in civilian life to have access to an affordable program and would provide continuity in both program and care when the member is activated. Alternatively, the legislation would authorize DoD to pay the premiums of an employer provided private sector plan up to the level of what TRICARE would cost DoD if it were provided to the member and his/her family. This would allow those with civilian provided coverage to continue with their current plan and providers.
Funding must be adequate to meet readiness needs, provide for both the purchased care segment of TRICARE and the direct care system to include the Family Centered Obstetrical Care initiative. Access standards were part of the promise DoD made to families when they enrolled in TRICARE Prime. These access standards must be met either in the MTF or the civilian network. Civilian networks must be robust enough to support MTFs in meeting the access standards. Recruitment of TRICARE Standard providers and education of Standard beneficiaries should be as much a part of the TRICARE program as are these endeavors for Prime providers and enrollees. The new round of contracts must provide standardized ways to access health care across all Regions and beneficiaries should have a clear picture of who can solve their access problems and quality of care concerns. Families of Guard and Reserve members should have flexible options for their health care coverage that address both access to care and continuity of care. In addition, accurate and timely information on their options and such things as transitional health care must be provided to the families as well as the servicemember.
NMFA thanks this Subcommittee and Congress for your advocacy for pay and benefit improvements necessary to retain the quality force that now protects our homeland and wages war against terror. Your actions have helped to rebuild military members’ trust and to ease the crisis in recruiting and retention. We ask you to remember that mission readiness is tied to servicemember readiness, which is tied to family readiness. The stability of the military family and community and their support for the forces rests on the Nation’s continued focus on the entire package of quality of life components. Military members and their families look to you for continued support for that quality of life. Please don’t let them down.
