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[C. Todd, “Biden Moves to Improve Opportunities for Military Spouses,” DoD News, June 9, 2023, https://www.defense.gov/News/News-Stories/Article/Article/3423902/biden-moves-to-improve-opportunities-for-military-spouses/, accessed June 22, 2023, GDS-LL]

At Fort Liberty, North Carolina, today, President Joe Biden signed an executive order designed to strengthen economic opportunities for military and veteran spouses, caregivers and survivors.

The Dobbs v. Jackson (U.S. Supreme Court, 2022) decision overturned the provision of a constitutional right to an abortion. Since the decision, there has been much discussion about the effects of the ruling on American soci-ety, and especially the disproportionate effect that it will have on women (Ahmed, 2022; Barbaro, 2022, Fawcett, 2022; Hesse, 2022; Leonhardt, 2022).1Women in the military, who are charged with defending and protecting the United States, are an important group that deserve special consideration in this discussion. For the military, the Dobbs ruling is a matter of national security. Women are an integral part of the military. They comprise 17.2 percent of the active-duty force. They are the fastest-growing subpopulation in the military (U.S. Department of Defense [DoD], 2022). For the past several years, the military ser-vices have been deliberately recruiting women, both to fulfill specialized positions and discrete operational needs and because they represent a higher percentage of the recruitable population than their male counterparts (Hunter, 2021; Office of People Analytics, 2018). Although there has been focus on allowing women to serve KYLEANNE M. HUNTER, SARAH O. MEADOWS, REBECCA L. COLLINS, ISABELLE GONZÁLEZHow the Dobbs Decision Could Affect U.S. National SecurityCORPORATIONPerspectiveEXPERT INSIGHTS ON A TIMELY POLICY ISSUESeptember 2022 2in previously closed positions (such as infantry), women have been and are serving in other roles that also are essen-tial to our military readiness. Women in the military play a significant role in health care occupations, electrical and mechanical equipment repair, functional support (such as payroll and supply), and administrative roles. These occu-pations are foundational for the effective functioning of the military (Brooks and Stanley, 2007; Meadows et al., 2022, Table 2.4). Women also are essential to the DoD civilian work-force. Women make up nearly one-third of the civilian workforce and hold positions from child care providers to senior executives. In the civilian sector, women play a sig-nificant role in administrative and educational roles (U.S. Office of Personnel Management, 2022), which are essen-tial for the day-to-day operations of the U.S. military. The recent Supreme Court ruling in Dobbs v. Jack-son will limit service women’s and DoD civilian women’s access to the full scope of reproductive health care and will have a direct effect on the health of these critical popula-tions. Understanding the scope of these effects is essential to understanding how Dobbs could affect military readi-ness and therefore national security. Unfortunately, data in this area are limited. For example, there is no single source that tells us how many military service members or DoD civilians have sought abortions as part of their reproduc-tive health care. To better understand the size and scope of the impact of the Dobbs decision on these important populations, we integrate data from several sources, includ-ing publicly available data and two representative surveys of active-duty service members developed and adminis-tered by the RAND Corporation for DoD. We estimate how many military-employed women’s reproductive health options have been or might soon be limited, and we iden-tify force readiness–related concerns, such as effects on the military health care, education, and child care systems, as well as on military recruiting and retention. Abortion Care in the Department of DefenseSince well before Dobbs, 10 U.S.C. 1093, a Hyde Amend-ment–like statute,2 prohibited TRICARE, DoD’s health care program, from paying for abortions with three excep-tions: When the life of the mother would be endangered if the pregnancy were carried to term, if the pregnancy arises from rape, or if the pregnancy arises from incest (we refer to these cases as covered abortions) (Burrelli, 2013). The statute also prohibits DoD facilities, including military hospitals and clinics (military treatment facilities, also known as MTFs) from performing noncovered abortions. Insurance as part of the Federal Employee Health Ben-efits (FEHB) Program, which would include DoD federal AbbreviationsDHAPIDefense Health Agency Procedural InstructionDoDU.S. Department of DefenseFEHBFederal Employee Health BenefitsHRBSDoD Survey of Health-Related BehaviorsIUDintrauterine deviceMHSMilitary Health SystemMTFmilitary treatment facilityPHAperiodic health assessmentWRHSDoD Women’s Reproductive Health Survey bro

TRICARE works with Medicare to help reduce your medical expenses. The exact way TRICARE coordinates benefits with Medicare depends upon the TRICARE program you are currently enrolled in.

This briefly highlights the Medicare and TRICARE coordination of benefits:

TRICARE For Life offers secondary coverage to Medicare for all beneficiaries who have both Medicare Part A and B. TRICARE For Life is available worldwide. Medicare provides coverage in the U.S. and U.S. Territories. In all other overseas locations, TRICARE is the primary payer. You may visit any authorized provider. Your provider will file your claims with Medicare. Medicare pays its portion and electronically forwards the claim to TRICARE For Life claims processor. TRICARE For Life then pays the provider directly for TRICARE-covered services. For services covered by both Medicare and TRICARE, Medicare pays first and TRICARE For Life pays your remaining coinsurance for TRICARE-covered services. For services covered by TRICARE but not by Medicare, TRICARE For Life pays first and Medicare pays nothing. You must pay the TRICARE fiscal year deductible and cost shares. For service covered by Medicare but not by TRICARE, Medicare pays first and TRICARE For Life pays nothing. You must pay the Medicare deductible and coinsurance. For services not covered by Medicare or TRICARE, Medicare and TRICARE pay nothing and you must pay the entire bill.

The United States military is facing hardship in recruiting new members, which has elicited worry about the nation's security should the U.S. find itself at war.

Last month, U.S. Army Secretary Christine Wormuth said during a discussion at George Washington University that the Army fell short of its recruiting target last year by about 15,000. Due to the Army projecting that it would again not meet its recruitment goals for 2023, Wormuth and Chief of Staff General James McConville recently said $1.2 billion would be shifted to initiatives related to enlistments.

A new study from the Pentagon shows that 77% of young Americans would not qualify for military service without a waiver due to being overweight, using drugs or having mental and physical health problems.

A slide detailing the findings from the Pentagon's 2020 Qualified Military Available Study shared with Military.com shows a 6% increase from the latest 2017 Department of Defense research that showed 71% of Americans would be ineligible for service.

[Roxana, “US Army Is Facing ‘War for Talent,’ Courting Gen Z With Benefits,” Bloomberg Government, June 1, 2022, https://about.bgov.com/news/us-army-is-facing-war-for-talent-courting-gen-z-with-benefits/, accessed June 22, 2023, GDS-LL]

National Security Handicap

Here’s Why the TRICARE Pharmacy Cuts Could Threaten All Beneficiaries By: Karen Ruedisueli MARCH 22, 2023 Here’s Why the TRICARE Pharmacy Cuts Could Threaten All Beneficiaries MJ_Prototype/Getty Images 2023-aia-small-bug-logo.pngMOAA continues efforts to restore the TRICARE pharmacy network by including the issue as part of our spring Advocacy in Action (AiA) event, where more than 200 MOAA members will visit congressional offices to generate support for MOAA’s legislative priorities. With the new TPharm5 contract, the TRICARE pharmacy network has been reduced by nearly 25% – from about 55,000 locations last year to 42,000 locations as of February 2023. The cut was driven by reduced network requirements within the contract – a cost-savings measure. [NEW ADVOCACY IN ACTION REQUEST: Help MOAA Fight Cuts to the TRICARE Pharmacy Network] Many independent pharmacies report contract terms that would not even cover their costs to procure medications, forcing them to choose between leaving the network or serving TRICARE beneficiaries at a financial loss. Most beneficiaries won’t be immediately impacted by this cut – healthy families in metro areas still have plenty of options for occasional medication needs and common maintenance medications, including the TRICARE Home Delivery program. However, the narrowed pharmacy network diminishes TRICARE protections in the event of serious illness or injury or more complex needs needs due to aging – in this way, it presents a threat to all beneficiaries. There are approximately 66,000 retail pharmacies in the U.S. Less than a year ago, there was an 83% chance a beneficiary’s pharmacy would be in the network. Now, that sits at 64%, and it could drop to 53% based on minimum contract requirements. [SHARE YOUR STORY: Have the TRICARE Pharmacy Cuts Affected Your Care?] Network cuts also disproportionately impact rural communities, which tend to have a lower presence of large chain drug stores and are more often served by independent pharmacies and Walmart, which left the network in December 2021. Many rural residents must drive past Walmart and their community pharmacies to get to a network pharmacy for acute medication needs. TRICARE’s narrowed network also falls short of a key benchmark – FEP Blue, the Blue Cross Blue Shield plan that covers two-thirds of Federal Employee Health Benefit Program (FEHBP) participants. FEP Blue boasts more than 55,000 pharmacies in its national network, and TRICARE benefits should be on par with the benchmark set for civilians who serve in the federal government. Advocacy in Action messaging will present the pharmacy network reduction in the context of a series of TRICARE cuts that have eroded the benefit in recent years, including an unprecedented TRICARE Select enrollment fee, a higher catastrophic cap, medical encounter copays that have doubled in many instances, and a new pharmacy formulary Tier 4 that eliminates coverage for certain drugs approved by the Food and Drug Administration (FDA). The military health care benefit is an obligation our nation has incurred to sustain the all-volunteer force. Fulfilling this obligation is particularly important during the current recruiting crisis when our nation needs key influencers, including current and former servicemembers and their families, to endorse military service. Cutting the TRICARE benefit for those who have served for decades not only betrays uniformed services retirees, it also risks reducing their likelihood of recommending service to the next generation. Take part in MOAA’s Advocacy in Action campaign by contacting your lawmakers today -- even if you've already contacted them on this issue using previous links to our Legislative Action Center, you can still click to add your voice again as part of AiA efforts. Keep up with new details on this and other legislative efforts at MOAA’s Advocacy News page.

Many U.S. military veterans lack health insurance and are ineligible for care in Veterans Administration health care facilities. Using two recently released national government surveys--the 2004 Current Population Survey and the 2002 National Health Interview Survey--the authors examined how many veterans are uninsured (lacking health insurance coverage and not receiving care from the VA) and whether uninsured veterans have problems in access to care. In 2003, 1.69 million military veterans neither had health insurance nor received ongoing care at Veterans Health Administration (VHA) hospitals or clinics; the number of uninsured veterans increased by 235,159 since 2000. The proportion of nonelderly veterans who were uninsured rose from 9.9 percent in 2000 to 11.9 percent in 2003. An additional 3.90 million members of veterans' households were also uninsured and ineligible for VHA care. Medicare covered virtually all Korean War and World War II veterans, but 681,808 Vietnam-era veterans were uninsured (8.7 percent of the 7.85 million Vietnam-era vets). Among the 8.27 million veterans who served during "other eras" (including the Persian Gulf War), 12.1 percent (999,548) lacked health coverage. A disturbingly high number of veterans reported problems in obtaining needed medical care. By almost any measure, uninsured veterans had as much trouble getting medical care as other uninsured persons. Thus millions of U.S. veterans and their family members are uninsured and face grave difficulties in gaining access to even the most basic medical care.

In developing the Single-payer Healthcare Delivery System, the focus must not only be on the previous failed efforts, health interventions, and unequal and disparaging outcomes of the current system. We must focus on the processes of the existing healthcare systems fragmented, complex, and multi-payer structures and their impacts. We must also consider how services are aligned and distributed as well as who and who does not benefit. In analyzing our present model, it is essential to understand its underlying power and structures. In the United States, the tri-economy structures—non-profit, private, and public entities—comprise our economic system that governs our communal affairs. These structures function within the financial policy guidelines to produce goods and services, all of which encompass providing health insurance coverage, upon which we heavily rely. However, our economic system comprises several types of government-sponsored healthcare coverage for the unemployed, the disabled, the elderly, the military, and the federally defined poor populations. These health plans are known as Medicaid, Medicare, and Tricare, which provide limited medical services. Each serves a specific community. Each has its own set of internal and external challenges built into its policies and practices, which influences the delivery of services, patient outcomes, health status, 4 and patient satisfaction levels. Military Tricare plans are exclusive memberships designed only for military individuals and their families and managed by veteran administrators. Its challenges present themselves as patient grievances involving untimely services, long waiting periods, misleading information, administrative errors, and patient delays in processing authorization referrals. Patients also complain about problems and concerns around the poor quality of care services, reflecting staff and providers' behavior and attitudes, patient safety, improper care, insufficient care, and poor results.

[Roxana, “US Army Is Facing ‘War for Talent,’ Courting Gen Z With Benefits,” Bloomberg Government, June 1, 2022, https://about.bgov.com/news/us-army-is-facing-war-for-talent-courting-gen-z-with-benefits/, accessed June 22, 2023, GDS-LL]

National Survey

[Roxana, “US Army Is Facing ‘War for Talent,’ Courting Gen Z With Benefits,” Bloomberg Government, June 1, 2022, https://about.bgov.com/news/us-army-is-facing-war-for-talent-courting-gen-z-with-benefits/, accessed June 22, 2023, GDS-LL]

Social Media Reach

[Roxana, “US Army Is Facing ‘War for Talent,’ Courting Gen Z With Benefits,” Bloomberg Government, June 1, 2022, https://about.bgov.com/news/us-army-is-facing-war-for-talent-courting-gen-z-with-benefits/, accessed June 22, 2023, GDS-LL]

The US Army—facing a potential recruiting crisis not seen since the all-volunteer force was created almost five decades ago—is stepping up its efforts to get Generation Z to sign up.

General Ediger. Chairman Heck, Ranking Member Davis, and distinguished members of the subcommittee, thank you for inviting us to appear before you today. The Air Eorce is truly grateful for the hard work of the Military Compensation and Retirement Modernization Commission. Many parts of the Commission’s recommendations will enhance and facilitate programs that serve our airmen, their families, and our veterans. Today I will speak to impacts in two areas of primary importance for the Air Eorce based upon our analysis of the Commission’s recommendations. I will begin with the impacts on the readiness of our medical force. We appreciate the Commission’s focus on the linkage between care provided in our hospitals and the readiness of our medical force. We found their proposal to identify and quantify readiness related essential medical capabilities helpful to focus efforts on the capture of specialty care for our hospitals. That concept builds upon the Readiness Skills Verification Program we have utilized in the Air Eorce for over 15 years to set clinical standards for the readiness of our medical force. However, we do not see the need for a joint readiness command, as existing processes jointly utilized by the services enable us to measure and assess the readiness of our force. We have significant concern about the impact the Commission’s health plan recommendations would have on the readiness of our force. We believe the proposal would shift family member and retiree care significantly to the private sector and thereby move care essential to our readiness out of our medical facilities. We also believe the proposal to place our medical facilities into competition with the private sector would drive up administrative costs and significantly detract from the focus on the operational mission in our medical facilities. The second area of primary concern centers on our support to Active Duty families. We believe resilient families with excellent health service support greatly enhance the resilience of all of our airmen. We support changes in the President’s budget to improve TRICARE while enhancing our readiness. Additionally, significant progress in the strategic line of efforts referenced by Dr. Woodson has occurred, and we are a progressive system of health and readiness as a result. 7 We are concerned that the Commission’s proposed change to the health plan would increase stress on airmen and families by requiring them to navigate a complex insurance marketplace on a recurring basis. We are concerned that the Commission’s proposal would shift family care significantly into the private sector, thereby creating a hole in the safety net commanders depend upon for Active Duty families under stress. Proper balance in the mix of our medical force is important to maintaining a ready medical force while providing safe and highquality health services. The National Defense Authorization Act of 2010 permanently prohibited the services from converting non-military essential Active Duty medical positions to civilian positions. Relief from this prohibition would enable the Air Force to judiciously increase the proportion of civilians in its force mix. I thank the committee for your continued support for Air Force medicine and the opportunity to answer your questions today. Dr. Heck. Thank you. Admiral Faison.

Following the release of the Commission’s final report in Janu- ary, Navy Medicine participated in the DOD-led rapid and com- prehensive review of the healthcare recommendations. While there is general support for the underlying objectives of the recommenda- tions, I will briefly highlight some of our perspectives and concerns regarding them. In relation to medical readiness, we do support establishing com- mon and service-specific essential medical capabilities, or EMCs, as they could be an effective means to monitor readiness and guide resourcing decisions. We note, however, that EMCs must be developed for more than just surgical trauma skills. Military medicine supports a wide range of operations, including treating disease and non-battle inju- ries during military operations as well as providing humanitarian assistance and disaster relief when called upon in crisis. While there is general agreement to the Commission’s objective to provide an affordable health benefit with additional choice, we must recognize that our medical centers, hospitals, and clinics are our most important readiness training platforms for our military medical personnel and critical to sustaining vital skills and clinical competencies of them. The availability of case mix, volume, com- plexity, and diversity is vital to having a trained and ready medical force. 8 In this regard, care of our beneficiaries is inextricably linked to our readiness mission. Patient enrollment is fundamental to our approach to maintaining the health of our patients. The Military Health System is working hard to recapture workload into our di- rect care system and leveraging initiatives like our Patient Cen- tered Medical Home program to improve access and care. Navy Medicine is leading forward in these areas as they continue to show progress. We believe that the Commission’s approach to offer greater choice through the use of commercial insurance plans presents risk by reducing patient volume and case mix in our sys- tem and positioning MTFs [military treatment facilities] at a sig- nificant disadvantage in attracting patients when competing against commercial insurance plans.

[Brittany, “The Status of Military Recruiting and Retention Efforts Across the Department of Defense,” Veterans of Foreign Wars, September 21, 2022, https://www.vfw.org/advocacy/national-legislative-service/congressional-testimony/2022/9/the-status-of-military-recruiting-and-retention-efforts-across-the-department-of-defense, accessed June 21, 2023, gds-LL]

The DOD Fall 2021 Propensity Update data show that the inclination to serve among the nation’s youth is at a low not seen since 2007. Survey respondents indicated that the top three of ten reasons to serve are monetary compensation, having future education paid for, and travel opportunities. Conversely, the lowest reported factor was the desire to impact one’s community. Overall, eight out of the ten primary reasons to serve were individual, predominantly tangible benefits, while the remaining two reasons were intangible benefits rooted in altruism. Accordingly, while an ideal recruit might be drawn to the military out of a sense of duty and selfless service, most are attracted by the benefits of service that enable self-development and sustainment.

Military hospitals to seek more challenging patient mix By DAILY PRESS | dailypress@dailypress.com | PUBLISHED: July 12, 2015 at 3:00 a.m. | UPDATED: July 27, 2019 at 2:39 p.m. The Department of Defense will ask Congress for new authorities to funnel more challenging cases into military treatment facilities, a move aimed at sustaining wartime specialty skills and overall medical readiness, said Jonathan Woodson, assistant secretary of defense for health affairs. The effort to enrich the patient mix, particularly for inpatient care, will focus on treating more elderly patients, more veterans with complex conditions who might otherwise be ineligible for on-base care, and more military retirees who also are DoD civilian employees. Woodson and the surgeon generals of the Army, Navy and Air Force appeared before a House panel in June and largely rejected the sweeping reforms to military health care and the TRICARE benefit recommended by the Military Compensation and Retirement Modernization Commission. But the commission’s report had Woodson and the uniformed medical leaders defending the effectiveness of military treatment facilities as wartime training platforms, and discussing new ways to attract a more demanding case mix and to expand the workloads of physicians at base hospitals. “There are going to be some new authorities we’ll need, to allow patients to flow from the market to the MTFs [military treatment facilities] to ensure we have the proper case mix,” Woodson told the House armed services subcommittee on military personnel. “This is to include new ways of attracting Medicare-aged patients” and perhaps to “actually define a sort of Medicare Advantage within the MTFs. We [also] need to be given broader authorities that relate to taking care of veterans,” Woodson said. “There’s even an opportunity for us to take care of DoD civilians [because] we have a lot of dual-eligible folks who work for the federal government and they have TRICARE benefits. So why not allow them to use their TRICARE benefits within MTFs?” These steps, he said, “would lead to a proper utilization of the MTFs, proper market management [for] the case-mix, skill-mix issue” that worries commissioners, and “extraordinary service to the beneficiary population.” Asked when he will seek these authorities, Woodson told us Wednesday that internal discussions to “optimize” use of MTFs continue. He said DoD would work closely and transparently with Congress to give the military health system “greater agility to shape the delivery of healthcare in today’s evolving and fast-moving market place.” However, any action taken to enhance case mix also would preserve “timely access to care for our existing beneficiaries and enrollees,” he said. As to which facilities would use new authorities to corral more challenging cases, Woodson said the service medical departments would decide that “based on specific readiness requirements, capabilities and capacity. All decisions will need to be tailored to the geographic locality of the MTF and what those local needs and requirements are.” The compensation reform commission had urged creation of a four-star Joint Readiness Command to be responsible for preserving medical readiness gains after 14 years of war. In arguing for the four-star command, commissioners sited data from the health system’s self-analysis during an ongoing modernization study that show many military physicians have light inpatient workloads compared to civilian peers and a mundane case mix when measured against what’s needed to stay ready for war. The commission’s other major health reform idea is to replace the triple-option TRICARE benefit with TRICARE Choice, a menu of private sector health insurance offerings for military families and retirees to pick their desired coverage. Premiums and co-payments of mid-range plans would be covered for active duty families by a new monthly health allowance. Woodson and the surgeons general rejected the readiness command as unnecessary and TRICARE Choice as potentially stressful for families and harmful to readiness. By forcing base hospitals to compete with civilian insurers for patients, they said, TRICARE Choice could result in military doctors seeing even fewer patients, aggravating the readiness challenge. Greater choice through commercial insurance would leave military treatment facilities “at a significant disadvantage in attracting patients,” Rear Adm. C. Forrest Faison, Navy deputy surgeon general, told the House panel. Army supports “increased choice” for beneficiaries,” said Lt. Gen. Patricia D. Horoho, Army surgeon general. But the TRICARE Choice plan “would negatively impact readiness of our entire health care team and present financial challenges to both active duty families and retirees.” The surgeons general concurred with commissioners that the military health care system should set training and resource levels so as to preserve essential medical capabilities or EMCs. But the list of EMCs should be more comprehensive than commission’s targeting of combat casualty clinicians and logistical capabilities. “Those EMCs must address the whole spectrum of health rather than focus solely on combat trauma and surgical capabilities,” said Horoho. She noted that less than one of every five service members evacuated from Iraq or Afghanistan were wounded. Most had diseases or non-battle injuries. It is true clinical skills needed for wartime deployment “don’t always exactly match up with our day to day practices at home station,” conceded Lt. Gen. Mark A. Ediger, Air Force surgeon general. But the services have known that and have processes in place to track and to augment that experience through partnerships with VA and civilian trauma centers. The Air Force, for example, for each of its medical specialties, defines the “case volume and mix and skills that translate into the deployed environment,” Ediger said. “Then we keep records and we track the extent to which we are able to meet those requirements and keep clinicians ready.” For this year at least, Congress opted not to adopt the commission’s major health reform recommendations. Rep. Tom MacArthur (R-N.J.) is one lawmaker who said his opinion was changed by department testimony. “I started as an advocate for change,” MacArthur said as the hearing came to a close. “But sometimes the cure can be worse than the illness.” To comment, write Military Update, P.O. Box 231111, Centreville, VA, 20120 or email milupdate@aol.com or twitter: @Military_Update

[Terri, Carrie, “The US Military Health System: Promoting Readiness And Providing Health Care,” Health Affairs vol 38, no. 8: Military Health Systems, August 2019, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00239, accessed June 19, 2023, GDS-LL]

Governance And Funding

[Terri, Carrie, “The US Military Health System: Promoting Readiness And Providing Health Care,” Health Affairs vol 38, no. 8: Military Health Systems, August 2019, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00239, accessed June 19, 2023, GDS-LL]

The US Military Health System (MHS) is charged with simultaneously ensuring the health-related readiness of US armed forces and providing for the health care needs of eligible military personnel and their dependents. This dual mission is complex and requires a sophisticated, agile system that can both sustain the health of the force to meet national security objectives and care for service-related injuries and illnesses and deliver a health care benefit to personnel and their families. These missions are typically referred to as the “readiness mission” and the “benefits mission.” To fulfill these missions, the MHS has a diverse set of assets, including fixed facilities, deployable medical providers and equipment, and a benefit program that delivers services through a mix of care provided at military treatment facilities and via a network of providers in the private sector. In this article we provide a brief history and overview of the MHS, describe its configuration in more detail, and discuss how transformations within the MHS and across the broader US health care system have influenced and shaped this large federal health care system.

The Dept. of Defense is crowing about its recruiting success in fiscal year '09, and chalking it up -- at least in part -- to the weak economy. From the Washington Post:

The Pentagon, which made the announcement Tuesday, said the economic downturn and rising joblessness, as well as bonuses and other factors, had led more qualified youths to enlist.