Means of Improving the Provision of
Uniform and Consistent Medical and Dental Care to
Members of the Reserve Components

 

Report

To

Congress

Prepared by: Office of the Assistant Secretary of Defense For Reserve Affairs
Office of the Assistant Secretary of Defense For Health Affairs

 

 

INTRODUCTION

Section 746 of the National Defense Authorization Act (NDAA) for Fiscal Year 1997 directed the Department of Defense (DoD), in consultation with the Secretary of Transportation, to conduct a study and report to Congress on the means of improving the provision of uniform and consistent medical and dental care to members of the Reserve components (RCs). In response to this congressional requirement, two major areas were identified and evaluated: (1) reserve component health care and (2) force health protection. These topics encompass the circumstances under which medical and dental care may be provided to Reserve component service members and the means of meeting medical readiness standards for deploying those service members. To ensure a comprehensive review of the many issues related to the provision of medical care to reservists, the Department established a working summit, which included representatives from the Office of the Secretary of Defense, the Active and Reserve components and the DoD medical community. Additionally, to support this evaluation, the Department also contracted with Birch & Davis Associates, Inc. The following report is submitted in response to section 746 and reflects the departmentís assessments and recommendations. The report develops recommendations for ensuring that medical treatment, entitlements, and readiness for RC members are sufficient and in parity with those provided to Active component (AC) members. The recommendations will help ensure uniform and consistent health care and related benefits for RC members that correlate with duty status and risk of illness or injury.

BACKGROUND

During the Cold War, a reservist incurred limited exposure to potential hazards during periods of duty (active or inactive duty). The focus for the RC was on training for mobilization. The Reserve components consisted principally of a force whose use upon mobilization would be to provide augmentation and replacement manpower for the Active components. In contrast, the focus of the Active components was on fulfilling operational requirements.

Since the end of the Cold War, and with the drawdown of the force, the role of the Reserve components has changed, and the use of the RCs in the performance of operational missions has increased dramatically. Reservists are now providing daily support to military operations around the world. This increased use results in a significant increase in exposure to injury, illness, disease, and death in the line of duty. As shown in Exhibit 1, Reserve component man-day contributions to Total Force missions have increased ten-fold from a 1989 benchmark. At the same time, the overall strength of the Reserve forces has decreased by nearly one quarter. As a result, the average Reservistís exposure to injury and illness has increased significantly.

Secretary Cohenís goal for the 21st century is a seamless Total Force that integrates active and reserve components and provides the national command authority the flexibility and interoperability necessary for the full range of military operations. To achieve this goal, all residual barriers, structural and cultural, to integration of the Active and Reserve components of the force must be eliminated.

Current legislation and policy reflect the historic use of reservists by structuring medical and dental care, incapacitation, and disability entitlements according to length of assignment: 30 days or less or more than 30 days. However, it is the performance of duty, not the length of duty, that creates the risk for harm. Reservists now work side by side with AC members and perform the same missions as AC members. Yet, when a reservist is injured performing one of those missions, entitlement to health care, pay, and family support is different from that of the AC member. RC benefits currently are based on the length of duty rather than the performance of duty. The increased exposure to risk associated with increased reliance on the RC has resulted in an increasing number of line of duty injuries to reservists and has served to highlight the disparity between Active and Reserve component medical benefits and entitlements, despite exposure to similar levels of risk.

For example, on April 1, 1997, an Air Force Reserve C-130 aircraft crashed at Tegucigalpa, Honduras. Seven RC crew members survived this crash with incapacitating injuries. Although the survivors were entitled to incapacitation pay and medical treatment, prevailing restrictions precluded them from being retained on active duty for treatment of their injuries past the period of duty prescribed in their orders. Because length of duty status determines entitlements, their family members were not eligible for health care through the militaryís TRICARE system. An Active or Reserve service member on orders for more than 30 days would have received retirement credit, pay and allowances, medical treatment for line of duty (LOD) injuries, comprehensive medical care for non-LOD conditions, and comprehensive medical care for family members. One survivor, who is married with three children under age five, noted, "I never thought in a million years that my family and I would not be covered if an accident occurred while serving my country." He also stated that, "If the Reservist/Guardsman knows that in a time of need, neither he nor his family will be protected, retention will be a serious problemÖhow can I continue to put my family in this predicament?" This example illustrates both the anachronistic scheme for the provision of health care and related benefits to Reserve component service members and the importance of modernizing the benefit scheme as a quality of life, force protection and recruiting and retention tool.

Increased use of the RC also heightens the importance of maintaining the medical and dental readiness of each member. Medical readiness issues begin at the time of entrance into military service with the induction physical examination and continue with routine medical fitness requirements throughout a military career. There is currently no uniform, DoD-wide rule on accountability and responsibility for providing health care services to RC members, creating a risk of inconsistent treatment of similarly situated individuals.

As mission demands, participation and potential exposure of reservists to harm increase, it is important to reassess the requirements for medical readiness and health care entitlements for Reservists, and health care entitlements for family members. A comprehensive and uniform approach to the provision of health care, force health protection and medical readiness is needed for the Reserve component career professionals who serve their country less than full-time. This study strives to make feasible legislative recommendations toward improvements in these issue areas. The broad goals of this study are to improve the medical readiness of the Reserve components and the Total Force and to ensure that medical treatment and entitlements for RC members are sufficient and in parity with those provided to AC members. The laws and policy governing health care for reservists must be brought up to date to reflect the realities of the current role and use of the RC.

Exhibit 1

RESERVE COMPONENT HEALTH CARE

Medical and Dental Care for Reserve Component Members

The purpose of providing uniform medical and dental care for military members is to create and maintain readiness and high morale in the uniformed services. It is considered a vital element in maintaining a quality All Volunteer Force. The special character of military service, which is the basis for establishing a military healthcare system, also applies to members of the Reserve components when they are serving in a duty status.

A member of a Reserve component serving on active duty for more than 30 days is entitled to receive medical and dental care in any facility of any uniformed service as prescribed under section 1074 of title 10, United States Code (U.S.C.). This is the same coverage that is provided for members of the Active component. For members of the National Guard and Reserve serving shorter periods of active duty or performing inactive duty training, the situation is more complex.

Reserve component members who incur or aggravate an injury, illness or disease while performing a period of active duty that is 30 days or less, are entitled, under section 1074a of title 10, U.S.C., to the medical and dental care appropriate for the treatment of the injury, illness or disease. This section also applies to Reserve component members performing inactive duty training. In either case, the injury, illness or disease must be incurred or aggravated in the "line of duty" and must not be the result of gross negligence or misconduct by the member. Appropriate care is authorized until it is determined that further hospitalization or treatment cannot materially improve the disability that resulted from the injury, illness or disease. At this point, the member must be processed for disability retirement or separation if he or she can not be returned to full duty.

Portal-to-Portal Coverage

Section 1074a has been expanded over the years to provide what is often referred to as "portal-to-portal" coverage, that is, coverage from the time the Reserve component member leaves home for duty until his or her return. In 1983, appropriate medical and dental care was authorized for treatment of an injury incurred or aggravated while traveling to or from inactive duty training. In 1984, such care was authorized for members who contract diseases or become ill during inactive duty training.

In 1985, Congress plugged a significant gap in medical coverage for Reserve and Guard members by authorizing medical and dental care for Reserve component members who aggravate a disease or illness, to include a pre-existing disease, while in a duty status. Congress was especially concerned about members who suffered heart attacks or strokes during inactive duty training. This had become a greater problem with the heightened awareness of the need to ensure that members of the National Guard and Reserve meet physical fitness standards. In 1986, Congress further amended section 1074a to include hospitalization coverage for injuries and to provide more uniform medical and dental care for all National Guard and Reserve members.

More recently, medical coverage was extended to those members who overnight at or in the vicinity of the training site, prior to commencement of or in-between successive periods of inactive duty training. Ostensibly, this completed fairly comprehensive portal-to-portal coverage for Reserve component members when traveling to and performing, remaining overnight at, and returning home from training duty. However, some significant gaps in coverage remained.

Active Duty for 30 Days vs. 31 Days

Until recently, prevailing Comptroller General decisions precluded a Reserve component member from being continued on active duty in order to receive medical care. In decisions dating back to 1965 and 1975, members on active duty for 30 days or less, who were hospitalized or recovering from an injury in the line of duty, could not remain in an active military status beyond the last duty day prescribed by their original orders. The active duty could not be extended through a period of hospitalization. Another rule was that any subsequent injury during hospitalization could not be considered the result of active duty unless related to the original injury.

Like other aspects of reserve compensation, medical benefits and entitlements for Reserve component members and their dependents are based on the type and length of duty. The significant disparity between the medical benefits and protections afforded members on active duty for 30 days or less and those serving 31 days or more was highlighted by the increasing use of Reserve component members to perform operational mission support of short duration in the current post-Cold War period. These members were being exposed to the same type of hazardous risks as their Active component counterparts and Reserve members on longer tours of active duty. If disabled, the member was entitled to treatment for the injury or illness, but protection during the period of treatment or recovery, in the event of subsequent injury, illness or disease, was not provided for the member or his family.

Meanwhile, between 1996 and 1998, Reserve component support of day-to-day operations was more than double that provided from 1993 through 1995. The increase in required support was supplemented by greater flexibility to use Reserves operationally in a variety of duty statuses. The Department has never espoused healthcare for Reserve component members commensurate with that afforded the members of the Active force. However, Reserve members do expect to be covered in the event of becoming seriously disabled as a result of military service, such as in the crash of the C-130 in Honduras, when seven Reservists were injured and were recovering from their injuries for up to one year.

Correction of an Inequity

Both the Department and Congress recognized the potential for inequities in the coverage provided members on active duty for 30 days or less vice those serving 31 days or more. In the National Defense Authorization Act for FY 1998, medical coverage provided in section 1074a was expanded for members serving on active duty for 30 days or less, whose orders are modified or extended so as to result in active duty of more than 30 days. In such cases, the member is now entitled to medical and dental care on the same basis and to the same extent as members covered under section 1074 (Active component members).

This change applies to Reserve component members who are being treated for or recovering from an injury, illness or disease incurred or aggravated in the line of duty, while performing active duty for a period of 30 days or less. In addition, the dependents of a member whose orders are extended are entitled to medical and dental care provided under section 1076 while the member remains on active duty. This important change in Reserve component benefit protections does not address members who sustain a disabling injury or disease while performing inactive duty training.

Inactive Duty Training

Inactive duty training is defined in DoD regulations as "authorized training performed by members of a Reserve component not on active duty, and performed in connection with the prescribed activities of the Reserve component of which they are a member." It consists of regularly scheduled unit training periods, additional training periods and equivalent training. While the primary purpose is to provide individual and unit readiness training, it may also support Active component mission requirements concurrent with the performance of training.

This expanded use of inactive duty training provides increased flexibility for employment of Reserve forces in support of Total Force missions. It also creates the potential for a member in an inactive duty training status to serve alongside a member on active duty. In the event of serious injury, the difference in medical entitlements during the period of treatment and recovery for the two categories of members and their dependents, based on the member's respective duty status, becomes readily apparent. The member on inactive duty for training has no orders that can be extended or modified to entitle the member to the same care and benefits as a similarly affected Reserve component member on active duty. This also has a significant effect on the memberís dependents. Specifically, the member in the inactive duty training status is not eligible for health care for conditions other than the injury incurred in a duty status, and the dependents of the member are not entitled to health care in the military health system.

The dependents of a Reserve component member who dies from an injury, illness or disease incurred or aggravated while performing inactive duty training are entitled to continuing medical and dental care. However, the dependents of a member being treated for or recovering from a life threatening or other serious disability as a result of inactive duty training would not be entitled to medical or dental care under the military healthcare system.

Medical and Dental Care for Dependents of Reserve Component Members

Family members and other dependents of Reserve component personnel serving on active duty for more than 30 days are entitled, under section 1076 of title 10, U.S.C., to the medical and dental care prescribed by section 1077 of title 10, U.S.C. The latter section lists the specific types of health care authorized for eligible dependents. Entitlement is subject to the availability of space, facilities and the capabilities of the medical and dental staff. Such coverage also applies to a dependent of a member who dies while serving on active duty, regardless of the length of that duty, or who dies while traveling to or from the place at which duty was to be performed, to include inactive duty for training.

Transitional medical and dental care is provided for a member and his dependents under section 1074b of title 10, U.S.C., immediately following the memberís service on active duty in support of a contingency operation. Upon release from active duty, the member and his dependents are entitled to the health care available under section 1076 or the health benefits contracted under section 1079(a) of title 10, U.S.C., for up to 30 days or until the member and his dependents are covered by an employer-sponsored health plan, whichever is earlier. Care under the transition authority does not depend on establishing that an injury, illness or disease was incurred or aggravated in the line of duty.

With respect to dental care, the Secretary of Defense has the authority, under section 1076a of title 10, U.S.C., to establish basic dental benefits plans for eligible dependents of uniformed service members who are on active duty for more than 30 days. To assure adequate premium collections to cover program costs, the department requires that the sponsor have at least two years of service obligation remaining in order to enroll his or her dependents in the dental insurance program. Currently, about 1.7 million dependents are enrolled in the DoD dependentsí dental program, or 80% of those eligible for this contract program. The authority to establish a Selected Reserve dental insurance plan is provided under section 1076b. This plan is authorized only for members of the Selected Reserve, other than those ordered to active duty for more than 30 days. It is not available for dependents.

Dependents of Reserve component members serving in a duty status are in a unique situation. They are generally not accustomed to relying upon the military healthcare system, and most are not located near military treatment facilities. For these reasons, and in order to maintain the continuity in their health care, many dependents would prefer to retain their civilian medical providers, when their Reserve component sponsor is ordered to active duty. However, escalating costs in such circumstances can make it infeasible for members to retain their civilian health care program when serving on active duty.

Health Care Protection Under USERRA

A Reserve component member does have the option of continuing health coverage under his or her civilian employer-sponsored plan. The Uniformed Services Employment and Reemployment Rights Act (USERRA) enacted in 1994, now chapter 43 of title 38, U.S.C., provides for full health benefit continuation for persons who are absent from work to serve in the military. Health insurance coverage may be continued for the member and his or her dependents for up to 18 months during periods of military service. For a member who is ordered to active duty for 30 days or less, the employer may require the member to pay only his normal employee share. However, for longer tours, the Reserve employee may be required to pay the full premium cost. If the employer requires the Reservist employee to pay most or all of the premium cost, this may discourage the Reservist from remaining in the employer-sponsored health care plan.

If a member chooses not to continue his or her civilian health coverage during the period of military service, the member nevertheless retains the right to immediate reinstatement of the coverage upon returning to the civilian job. However, coverage does not extend to an injury, illness or disease determined by the Secretary of Veterans Affairs to have been incurred or aggravated during military service. If unable to report back to his or her civilian employer because of a service-connected injury, illness or disease, a Reserve member retains the right to reemployment for up to two years (may be extended), but may not have civilian health care reinstated until reporting back to the civilian employer.

In conjunction with the authorities in title 10 governing military health care for both the member and his dependents, USERRA provides a safety net. But that safety net still has some holes. These problems were alluded to in the discussion of health care for dependents. The first problem that may arise is the loss of medical coverage for the member and his dependents if the period required for recovery from an injury, illness or disease incurred while performing inactive duty training extends beyond 18 months. Even if the member elects to extend his civilian medical coverage under USERRA, he and his family would be without coverage after 18 months. The second problem relates to the potential cost of maintaining an employer sponsored health plan. Many reservists do not live close to a military medical treatment facility. They must depend on civilian health care. The cost of maintaining a civilian-sponsored health plan may be prohibitive if the member is required to pay the entire premium for maintaining that coverage. This could make continuing civilian coverage problematic for a Reserve component member.

DoD Summit on Reserve Component Health Care

To fully address the requirements contained in section 746 of the National Defense Authorization Act for FY 1997, the Department established the DoD Reserve Health Care Summit. One of the principal objectives of the DoD summit was to ensure that those who become ill or injured as a result of military service receive appropriate health care and medical benefits. The summit intended to dispel any lingering disparity in benefits based on length of duty by establishing as a basic premise that "the performance of duty, not the length or type of duty determines a service memberís risk and exposure to harm." This proposition recognizes that Reserve component members now work side by side with Active component members performing many of the same missions and accepting comparable risks.

The summit concluded that basing benefits on length of duty or duty status creates a disparity in benefits for Reserve component members. Even though an injury, illness, or disease was incurred or aggravated while performing duty, the benefits a member is entitled to could be different depending on the length of the duty. Military members serving on active duty for 31 days or more not only receive treatment for any injury, illness, or disease sustained, but are also entitled to comprehensive health care for themselves and their dependents for any other medical conditions that may arise. Reserve component members who are not continued on active duty beyond 30 days after sustaining an injury, or who sustained the injury while performing inactive duty training, may be entitled to treatment for the condition, but are not covered for any other unrelated health care problems that may arise for the member or the memberís family. The DoD summit on Reserve component healthcare attempted to address these discrepancies.

Moreover, the summit addressed medical readiness requirements for Reserve component members. They studied the statutory and policy requirements as well as the implementation of those requirements. The summit found that there were also disparities that inhibited the Reserve components from achieving full medical readiness. These will be discussed in the Health Protection section of this report.

Interpreting Statutory Language

The summit determined that certain inconsistencies in authorized medical care or treatment for Reserve component members stem from varying interpretations of the terminology contained in applicable provisions of law. The piecemeal nature of many of the amendments to section 1074a over the years has contributed to this result. The intent of specific language may not be entirely clear, which can lead to inequities for many Reserve component members.

For example: Is a Reserve component member who sustains an injury after stopping to pick up a child at the day care center while returning from inactive duty training considered to be injured while traveling "directly" from the place of duty? In establishing a comparable standard of reasonableness for veterans benefits, title 38, U.S.C. provides for taking into account such factors as the hours of travel involved, the method of travel employed, the itinerary, and the manner in which the travel was performed. No comparable standard has been provided for disabilities incurred during travel under applicable title 10 U.S.C. provisions.

Other examples include: Is a member remaining overnight between successive training periods covered if involved in an automobile accident while driving to dinner off base? Clearly, the member was not in a duty status; however, the member was between successive inactive duty training periods. Although 1985 legislation which provided medical care for aggravation of pre-existing disease was termed the "heart attack" provision, is a member covered if underlying atherosclerosis existed long before any possible aggravation resulting from training duty? The summit determined that these questions of interpretation and those in other situations arise from a lack of specificity in the law and DoD regulations.

Recommendation 1. There are no accompanying definitions in the law to describe specifically what constitutes "incurring" or "aggravating" an injury, illness or disease in the "line of duty." The summit recommended that these and other terms be clearly defined in statute or DoD regulation. Clearly defined statutory language will provide the basis for the Department to develop a standard of "reasonableness" in its policy interpretations. Also, health care benefits for members on full-time National Guard duty and Reserve component members in a non-pay status need to be clarified in law or DoD regulation.

Protecting Members on Inactive Duty for Training

Protecting Members on Inactive Duty for Training

The National Defense Authorization Act for FY 1998 provided the authority to modify or extend the orders of a Reserve component member, who is disabled in the line of duty while serving on orders to active duty of 30 days or less. If the extension, which covers the period of treatment or recovery, results in the modified orders exceeding 30 days, the Reserve component member would become entitled to the same medical and dental care as an Active component member. He or she would also be entitled to any other benefits that relate to active duty status.

Approximately 1,100 Reserve component members become incapacitated each year. About 15% of these cases occur while the member is in an inactive duty training status. Currently these members receive treatment only for the service-related injury, illness or disease. The total cost of this limited health care is about $100,000 per year. It is estimated that placing these incapacitated Reserve members on active duty to provide them with full benefits during the period of treatment and recovery would cost an additional $200,000 per year. This cost takes into consideration the amount of time the member will be incapacitated and the probability that the member has or will be able to continue other health insurance.

There is an average of 2.2 dependents per Reserve component member. Currently, the dependents of Reserve members who are incapacitated while serving on inactive duty for training are not entitled to medical care under the military healthcare system. Placing the incapacitated Reserve member on active duty during treatment and recovery would result in an additional DoD expense of approximately $500,000 per year to cover the estimated cost of providing health care for their dependents. The summit recommends that Reserve and Guard members on inactive duty for training and their dependents be provided full medical protection and other active duty benefits during the period they are being treated for or are recovering from a service-incurred or aggravated injury, illness or disease.

Recommendation 2. If a member of a Reserve component is injured, becomes ill or contracts disease in the line of duty while performing inactive duty training, there should be authority to place the member on active duty, during the period of treatment for or recovery from the injury, illness or disease. A legislative amendment that would achieve this recommendation is included in the National Defense Authorization Act for Fiscal Year 2000.

Recommendation 3. RC members are frequently required to remain overnight in the field in an Inactive Duty status. Consideration should be given to providing medical coverage for Reserve component members who are injured or become ill while remaining overnight at the site of inactive duty training between successive training periods, even if they reside within reasonable commuting distance. These members may be training late into the evening or performing duty early in the morning which could make commuting to and from their residence impractical. This requires new legislation.

Waiver of CHAMPUS (TRICARE) Deductible

When Reservists are ordered to active duty in support of a contingency operation, they often experience income and other economic loss along with the personal stress of activation and deployment. These latter stresses are exacerbated by family and employer concerns. When such pressures are coupled with concern for affordable health care for family members, who are left behind, it creates a burden on Reserve members that may be disproportionate even to that experienced by deploying active duty members.

In general, National Guard and Reserve members ordered to active duty for more than 30 days and their families are entitled to medical treatment on the same basis as other active duty members. Their family members are eligible for TRICARE Standard. However, the normal TRICARE deductible requirement, $100-300 per family per year, can present an inequity for Reserve component families.

Family members of Reservists and Guardsmen are often not located near military treatment facilities or other lower cost, military-managed health care programs. Additionally, family members of Reserve component members who are ordered to active duty for less than six months are not eligible for TRICARE Prime, the Departmentís HMO-like option which has no annual deductible and requires only nominal co-payments. It was felt that enrolling family members of individuals ordered to active duty for less than six months would add a costly administrative expense to TRICARE Prime. Thus, Reserve component members may find the health care options for their families restricted to TRICARE Standard, the most costly option for military members.

In addition to their TRICARE annual deductible, Reserve component members may have already satisfied or may be in the process of satisfying an annual deductible under their civilian health care coverage. It is anticipated that few Reservists would willingly drop their civilian health care coverage and their family membersí regular medical practitioners when they are placed on active duty, unless such coverage becomes too expensive to retain.

In 1996, in an effort to improve access to health care and to reduce out-of-pocket costs for Reserve component members ordered to active duty in support of a contingency operation, the Department of Defense developed a demonstration project. The demonstration project waived the annual deductible under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS/TRICARE) for the families of Guardsmen and Reservists ordered to active duty for more than 30 days in support of Operation Joint Endeavor conducted in and around the former Yugoslavia.

The annual cost of waiving the TRICARE deductible for dependents of Reserve component members serving on active duty in support of a contingency operation would be dependent upon the number of Reservists called to active duty, for less than one year, who have family members eligible for TRICARE. Based on the historical experience of the Bosnia call-up from 1996 through 1998, an average of 2,700 Reserve component dependent users filed claims annually. The cost of waiving the deductible for this size population is conservatively estimated at $800,000 per year. This estimate is based on a deductible of $300 per user, which does not take into consideration the lower deductible amounts for Reservists with one family member or those in the grade of E4 and below.

Recommendation 4. Provide the Secretary of Defense with the authority to waive or reduce TRICARE annual deductible amounts (currently $300 for most families) in the case of dependents whose Reserve component sponsor is ordered to active duty for less than one year. This discretionary authority would be applied to Reserve component personnel ordered to active duty in support of a contingency operation (as defined in section 101(a)(13) of title 10 United States Code). In addition to reducing potentially inequitable out-of-pocket expenses, such discretionary authority would enhance National Guard and Reserve membersí satisfaction with military service and the military healthcare system. The National Defense Authorization Act for Fiscal Year 2000 includes a provision to accomplish this recommendation.

Reserve Component Dental Care

A large number of Guardsmen and Reservists mobilized during the Persian Gulf War did not meet the dental readiness standards required for deployment. Reportedly, as many as one-quarter of those mobilized could not be deployed until they completed dental examinations and associated treatment. The effort to meet these dental requirements placed considerable strain on mobilization facilities and the military dental care system. Concern for maintaining dental readiness in the Reserve forces, prompted Congress, in the National Defense Authorization Act for FY 1996, to direct the Department to establish a dental insurance program for members of the Selected Reserve.

The TRICARE Selected Reserve Dental Program (TSRDP), authorized by section 1076(b) of title 10, U.S.C., has been in effect since October 1997. To enroll in the program, a Reservist must have at least one-year remaining of his or her commitment to serve in the Selected Reserve. While an estimated 640,000 Reserve members are eligible for the program, enrollment, as of March 1999, is about 27,000 National Guard and Reserve members, considerably lower than the 200,000 initially projected. These initial projections were based on survey data indicating that nearly one-third of all Reservists and Guardsmen had no civilian dental insurance.

The Department is continuing its extensive efforts to increase awareness of TSRDP and thereby increase enrollment in the program. A quick survey and focus groups, conducted to determine the reasons for low enrollment, identified several concerns that may limit Reserve component member participation in the program. Concerns with the current program include: the limited provider network, the lack of a family member option and the reduced benefits compared to comparable private sector dental programs.

Recommendation 5. The dental program for the Reserve components be expanded to include a more comprehensive benefits package, not just basic coverage as currently provided in the law. In addition, a family option needs to be offered, at no cost to the government. Merging the TSRDP into the TRICARE Family Member Dental Program may be a cost-effective option. Combining these programs would provide uniform dental benefits for Selected Reserve members and their dependents comparable to those provided for active duty dependents. The expanded benefits and family option would address the concerns expressed by National Guard and Reserve members. Without increased enrollment in the Selected Reserve dental program or merging it into the Active family member dental program, the cost of maintaining the current TSRDP as a separate program may become prohibitive. A provision to implement this recommendation is included in the National Defense Authorization Act for Fiscal Year 2000.

Medical Insurance Protection

Reserve members have a personal responsibility to ensure that they are able to meet the medical readiness standards for deployment established by their component. However, there is a perception, especially within the DoD military medical community, that many Reserve component members may lack civilian health care coverage. There are a number of Reserve component members who are unemployed, seasonally employed, who work for small firms or are full-time students. The only data currently available on the extent to which Reserve component members have medical insurance coverage was obtained as part of periodic, comprehensive surveys of members and their spouses.

Recommendation 6. The department should conduct a study designed to determine the overall medical readiness of Reserve component members in order to determine prospectively their fitness for duty as well as DoDís ability to monitor and access such information.

RESERVE COMPONENT FORCE HEALTH PROTECTION

Background

The 1997 report of the Departmentís Quadrennial Defense Review emphasizes that with the approach of the 21st century, the readiness of U.S. military forces to meet the full range of defense strategy demands has never been more important. In recent years, DoD policy and budget guidance have explicitly made readiness the top priority.

An essential component of overall military readiness is medical readiness. It ensures a fit and healthy force for deployment and employment. DoD policy specifies that all service members, Active, National Guard and Reserve must be physically and mentally fit to carry out their missions. Defense guidance requires that resource programming to support medical readiness provide for comprehensive force health protection.

In todayís post-Cold War, post-drawdown environment, considerable force structure and operational capability have been transferred to the Reserve components. Reserve forces are now critical to the successful conduct of military operations both in wartime and in peacetime. The medical readiness of the individual members comprising those forces is essential to ensuring the effective early use of Reserve forces in any operational scenario.

Historical Perspective

Prior to the Armed Forces Reserve Act of 1952, there was no clearly established priority for ensuring that Reserve component members were prepared for mobilization. From the end of World War II through the Korean and Vietnam conflicts, there was continued concern about the readiness of Reserves for immediate mobilization. The Vietnam Conflict was sustained for nearly a decade through conscription and without a large-scale call-up of Reserves. With the advent of the Total Force Policy and the All Volunteer Force in the decade of the 1970s, the scope, size and criticality of missions assigned to the Reserve components began to increase dramatically.

The Persian Gulf War was the first use of the Presidentís involuntary call-up authority, under which nearly 270,000 Reserve component members were mobilized and served an average of nearly six months active duty. The Persian Gulf War highlighted both successes and failures with respect to providing force protection. Despite few casualties, the Department was not adequately prepared to deal with health issues that arose upon completion of the conflict. The difficulty in addressing the health-related problems of many Gulf War veterans, including a large number of reservists, was compounded by the lack of pre and post-deployment medical assessment data collected and maintained on deploying members.

Another watershed event occurred with the call-up of several thousand Reservists possessing skills predominantly resident in the RC to support an operational commitment in Haiti. This reflected the first use of the Presidentís involuntary call-up authority to support a relatively small-scale contingency operation. Limited scale call-ups continued for operations in Bosnia. Roughly 20,000 Reservists have now served an average of 8 to 9 months in support of these operations since December 1995.

Today, smaller force levels, smaller budgets and less overseas presence present a challenge to our military forces. As a result, Reserves are used more often to meet peacetime mission requirements and help reduce Active component operational burdens. In each of the last three years, the Reserve components have provided the equivalent of nearly 13 million workdays in direct support of the Active forces. This direct support was in addition to training and other duty performed during those years. Increased use of the RC heightens the importance of maintaining the medical and dental readiness of each RC member.T

Statutory Requirements

The military services are required under chapter 1007 of title 10, U.S.C. to maintain adequate and current personnel records of each Reserve component memberís physical condition and availability for service. The kind of duty to which the RC member is being assigned must be considered in determining the physical qualifications required for active duty. The law also provides that each Reserve component member will be examined as to physical condition at least once every five years if not more often. Finally, RC members are required to submit an annual certificate of physical condition.

Additional requirements have been established under section 1074a of title 10, U.S.C., specifically for Reserve component members of the Army who are assigned to early deploying units. The Army must provide these early-deployers with an annual medical and dental screening and the dental care identified during the annual screening. Early-deploying members over age 40 also must complete a full physical exam at least every two years.

Individual members of the Reserve components have a personal responsibility to maintain a medical condition that meets requirements for deployment. Section 10205 of title 10 U.S.C. requires that each member notify the military service concerning any change in physical condition that would prevent the member from meeting the physical or mental standards prescribed for his or her armed force. The military services establish dental readiness standards, physical fitness standards and require certain immunizations to support the medical fitness of their respective Active and Reserve forces and to ensure they are fully deployable.

Section 1074f of title 10, U.S.C. directs the Department to establish a system to assess the medical condition of members of the armed forces (including members of the Reserve components) who are deployed outside the United States or its territories or possessions as part of a contingency operation. The system must include the use of pre-deployment and post-deployment medical examinations to accurately record the medical condition of members before their deployment and any changes in their medical condition during or subsequent to the deployment. The law also requires centralized recordkeeping and quality assurance that system requirements are met.

Force Health Protection

DoD is developing a force health protection strategy for members who are subject to deployment. That strategy ensures physical fitness, continued health, and medical treatment at the right time and right location so that national objectives and military missions can be achieved. It is designed to benefit the Total Force and to support Joint Vision 2010. Force health protection provides a conceptual framework for optimizing health readiness and protecting service members from all health and environmental hazards associated with military service.

Medical and dental readiness and health promotion are key elements of this comprehensive management strategy. Also important to improving force health protection are the provision of better health information, more effective medical recordkeeping and a robust health surveillance system. Joint medical surveillance policy establishes the Departmentís continuous responsibility to provide force health protection to all service members who are subject to deployment, who are deployed or who have completed a deployment. This policy ensures the collection, monitoring and assessment of information relating to the health status, health risks, and health consequences of deployments on individual service members and the military force as a whole.

Deployment health surveillance includes identifying the population at risk, recognizing and assessing hazardous exposures, employing specific countermeasures and monitoring health outcomes. Policies for the health surveillance of Reserve component members must be consistent with the policies established for the Active component. Medical information management is dependent upon an effective medical tracking system for retaining health and health-related data on all military members throughout their military service, and especially before, during and after deployments.

The Department is committed to improving its ability to assess and protect the health of military personnel during deployments. The health status, physical readiness and deployability of Reserve component members ordered to active duty during Operation Desert Storm were a subject of debate. While successful in supporting the overall military effort, mobilization operations revealed that some Reserve component personnel were not in proper medical or physical condition to deploy and perform wartime tasks.

Physical Exams

Although Reservists are career professionals serving on less than a full-time basis, the health and physical readiness demands placed on our Reserve forces are generally consistent with those of the Active force. Complying with the existing statutory requirement that a member be examined at least every five years means that approximately 270,000 Ready Reservists, including over 175,000 Selected Reserve members, require a physical examination each year. In addition, each of the nearly 1.4 million members of the Ready Reserve must submit an annual certificate of physical condition as prescribed in the existing statute.

The average cost to the military services of providing a physical exam ranges between $200 and $300 per examination. The estimated annual cost to the Department of meeting the requirement that each member of the Ready Reserve complete a physical exam every five years is $46 million. While Reserve component medical units may conduct these physical exams, this is often accomplished at the expense of essential mission-related training for these units. In addition, the medical force structure in the Reserve components has been substantially reduced, further straining the capability of medical units to meet examination requirements.

The benefits of a periodic physical exam have been a topic of discussion within the Department since Operation Desert Storm. The Army recently eliminated physical examinations for Active component members under age 30 with the exception of deployed members. The Air Force has implemented an extensive health assessment program in lieu of periodic physical exams. The value added by such exams is now considered marginal, nor do they promote health and wellness. Based on current research and medical practice, the focus of the Department for ensuring a ready force has shifted to the identification of risk factors and to health education.

Health risk behavior for Reservists is influenced by two distinctly different environments or culturesóone civilian and the other military. Since the mid-1980s, the Department has issued policy guidance encouraging military personnel and their families to adopt health promotion programs, including smoking prevention and cessation, physical fitness, nutrition, stress management, alcohol and drug abuse prevention and early identification of hypertension. The unique, part-time nature of Reserve service constitutes a challenge to providing preventative and health promotion programs for Reserve component members. Presently, there are few such military programs available to the reserve community. Also, research is needed to describe factors related to the health and physical fitness of Reservists compared with their Active component and civilian counterparts.

Physical Exam Recommendations

DoD medical programming guidance currently directs the military services to ensure that all RC personnel are required to have a periodic physical exam every five years. While there are no data to support the benefits of conducting periodic physical exams, the DoD Health Care Summit was reluctant to recommend a change to the statutory requirements at this time. The Summit suggested that additional research needs to be accomplished to identify the most cost-effective methods for ensuring Reserve component medical readiness.

Recommendation 7. The Department should conduct a phased study, in conjunction with Recommendation 6 above, to:

  1. Identify the potential health risks or problems that have a direct impact on deployability and retention of RC members;
  2. Develop a more cost effective, focused health assessment tool for use in conducting physical exams for Reserve component members;
  3. Conduct a pilot program employing the assessment tool to measure individual medical fitness and deployability; and
  4. Establish joint procedures, based on the results of the pilot program, that will ensure greater consistency and uniformity in determining the medical readiness of Reserve component members.

Individual Ready Reserve

The Summit concluded there is little return on investment for any program to conduct physical exams for the more than 450,000 members of the Individual Ready Reserve (IRR). The annual cost of ensuring that IRR members are examined as to physical condition at least every five years is approximately $2.3 million. This cost reflects approximately 10 percent of what the Department should be spending annually on physical exams for this population. However, DoD is able to provide only about 11,000 of the more than 100,000 required physical exams for IRR members each year. In this period of constrained resources, it would be far more cost-effective to conduct physical exams on these Reserve members at the time they are ordered to active duty.

Recommendation 8. Amend section 10206 of title 10, U.S.C., to eliminate any physical examination requirement for members of the IRR prior to activation. Instead, the Department should concentrate on developing a concise DoD annual physical condition certification questionnaire for IRR members of all the Services.

Army Early Deployers

The statutory requirement to provide physical exams every two years for members of the Selected Reserve of the Army who are over 40 years of age and are members of units scheduled to deploy within 75 days of a mobilization creates difficulties for the Department. This is a very fluid category with a relatively high turnover of individuals each year. Those Reserve component units and individual RC members identified as early-deploying change frequently.

Conducting physical examinations and certifying the health status of Reserve members is often difficult because of funding limitations. The annual cost to the Department of meeting this over-40 physical examination requirement for early deploying unit members, as established in section 1074a of title 10, U.S.C., is $3.8 million. This cost to provide a physical exam for these members every two years is over four times the annual cost (about $900,000) if an exam were provided every five years as required for other members of the Reserve force.

A requirement for a complete medical examination every two years exceeds the recommendations of the U.S. Preventive Services Task Force, a 20Ėmember non-federal panel commissioned by the Public Health Service in 1984 to develop recommendations for clinicians on the appropriate use of preventive measures. The Task Force does not consider such frequency of examinations cost effective in terms of identifying disease or determining deployability. The use of yearly health assessment questionnaires and appropriate age specific tests during the five-year periodic medical examination provide sufficient medical screening of the population over age 40.

Recommendation 9. Repeal section 1074a(d), to include the requirement for preferential dental care for these early deployers. Identify a more efficient and cost-effective health assessment program for ensuring the medical readiness of early-deploying RC members.

Cost Effective Alternatives

As previously noted, funding limitations make it extremely difficult to accomplish the number of physical exams required each year for the Ready Reserve. While it can be argued that it may be cheaper for Reserve component medical units to perform examinations for other RC units, it must not be overlooked that such duty is often performed at the expense of the unitís required medical sustainment and readiness training. It is DoD policy that any sustainment training for medical personnel should be related to the memberís operational billet and should maintain or enhance the skill proficiency of the individual.

Performing examinations routinely can have an adverse affect on the retention of health care personnel in the Reserve components. It is the challenge of training for and performing medical missions in a military environment and of doing something different than in civilian practice that attracts health care professionals into the RC. Therefore, in addition to detracting from mission-related training, performing routine physical examinations on other Reserve members can be detrimental to medical recruiting and retention efforts.

The Veterans Health Administration (VHA) and the Division of Federal Occupational Health (FOH) of the Department of Health and Human Services have expressed interest in providing reimbursable physical exams for military personnel. The US Army Medical Command has issued a statement of work for a contract to support the DoDís administration of immunizations and other health care-related requirements, to include physical exams. A network of multiple government providers would support reform initiatives to pursue greater opportunities for the sharing of medical assets. The development of a strategic federal health care alliance provides an exciting opportunity for accomplishing immunizations, physical exams, dental screenings and other DoD requirements in support of the Reserve components.

A recent memorandum of agreement between DoD, Federal Occupational Health and the Veterans Health Administration not only assures support to the DoD anthrax vaccination program, but is also designed to provide "an array of comprehensive occupational health services in medical, clinical, employee assistance, industrial hygiene, fitness, environmental and "other disciplines." The United States Military Entrance Processing Command (USMEPCOM) is also currently developing a statement of work to test the cost effectiveness, feasibility, and impact of contracting remote-site medical examinations with other health care systems, including the Veterans Affairs System.

Recommendation 10. Identify cost-effective alternatives that use other facilities. Potential alternatives include the Department of Veterans Affairs, Health and Human Services, civilian contractors or even private practitioners.

Dental Readiness

Dental emergencies can potentially impact the combat effectiveness of individuals and units. The loss of members due to any type of disease and nonbattle injuries (DNBI) can be detrimental to the ability of a unit to accomplish its wartime mission. Dental diseases have historically accounted for approximately 20 percent of DNBI. Dental readiness depends on the dental health of military personnel and is crucial to an effective fighting force.

The DoD dental classification system establishes four dental readiness categories that apply to both Active and Reserve component members. In order to maintain a high state of dental readiness, it is essential to be able to identify those members who require dental care or treatment. Military personnel will not be reassigned or deployed if they are in Dental Class 3 or 4, which means they have an oral condition that is likely to result in a dental emergency within the next 12 months or they are in need of a dental examination. It is important to be able to track member compliance with dental readiness standards and ensure members obtain required dental treatment. Historically, DoD has had difficulty monitoring the dental readiness of Reserve component members.

In 1998, the Department issued a policy requiring an annual dental examination for all active duty and Selected Reserve personnel to ensure fitness for duty and deployability. It was acknowledged at the time that this policy would not be "immediately attainable" in the Reserve components without mechanisms for screening Guardsmen and Reservists and without programming additional resources to accomplish this readiness requirement in the RC.

Reserve component members are not entitled to routine military dental treatment unless they are serving on active duty for more than 30 days. Members serving on a more limited basis are generally restricted to emergency care only. The Department does not have the dental staff to provide annual dental examinations and determine dental classification for all Reserve component members without overburdening military dental resources.

The congressionally-mandated, TRICARE Selected Reserve Dental Insurance Program provides one alternative to readiness-oriented dental care for insured members. It is a voluntary program that includes an annual examination by a civilian provider. It is relatively inexpensive, with members paying 40% and the Government 60% of the premium costs. While this alternative can improve dental readiness, it has not alleviated the strain on military dental resources in meeting the requirement to perform annual dental screenings. Thus far, the program has been under-subscribed. Civilian provider certification forms are presently under development.

Tracking RC Dental Readiness

The majority of Reserve component members receive their care from civilian dentists. However, information related to such care is not available to the Department. Currently, there is no means established to document the civilian dental care received by Reserve component members. For this reason, the Reserve components do not have an up-to-date status on the dental readiness of all their members. Moreover, if a dental problem is identified by a military dental provider, the member is often instructed to seek civilian dental care within a specified period of time. However, mechanisms for monitoring compliance with such instructions are limited. Also, it should be noted that Reservists in low income families may find it cost prohibitive to seek treatment from a civilian provider, if they lack personal or employer-sponsored dental insurance.

Just as in the case of their physical condition, RC members have a personal obligation to maintain a dental health status that does not preclude their mobilization and deployment. For the most part, the Department considers deployability a condition for retaining a member in the Reserve components. However, to enforce the requirement for members to maintain their dental health as a condition of retention, there must be a mechanism for RC commanders to track and record the dental readiness of unit members.

Recommendation 11. Develop and implement a standardized dental examination and classification form that can be completed by a military or a civilian dentist and that will satisfy the DoD annual dental examination and classification requirement. Such a tool must be consistent with established DoD dental classification standards. The Summit also recommended establishing the technical electronic support necessary to track dental classification and treatment compliance and to incorporate tracking information into existing automated information systems while ensuring that this information is easily accessible to all command levels, to include RC unit commanders.

Immunizations

Administering required immunizations is a vital element of individual health readiness for deployment and a critical pre-deployment, force health protection measure. Immunizations are intended to provide immunity against certain naturally occurring diseases and protection from certain chemical and biological weapons to which service members may be exposed as a result of a deployment. Some vaccinations are given to all new recruits, others are administered to personnel in high risk occupations or deploying to high risk areas. (See exhibit 2)

As with other force health protection measures, the inoculation of active duty personnel is accomplished by the military health care system and funded by the defense health program (DHP). The DHP also funds some vaccines for the Reserve components. However, the administration of the vaccine is normally the responsibility of the Reserve components. This can require the use of medical personnel and the provision of ancillary supplies not typically included in the RC budgets. The result is often a tiered and incomplete approach to inoculation of the Reserve force.

Problems with RC Immunizations

Access to immunizations, to include those specifically directed by commanders of combatant commands, which can impact the timely delivery and administration of a vaccine, is a major problem for the Reserve components. To inoculate RC personnel in large numbers would require medical teams to administer shots during monthly drill periods. Burdensome administrative requirements already compete for the limited availability of RC members. Accomplishing additional requirements further detracts from the time required for performance of mission or wartime related training. Also, using RC medical personnel to administer inoculations detracts from their medical mission or unit collective training.

A second major problem for the Reserve components is the lack of a system for documenting and tracking immunizations. The military services in general differ in the methods and tools used for tracking and documenting immunizations. These tools include medical records, shot forms, automated record systems and mass immunization rosters. Because of the potential for inconsistencies in data from these various tools, the Department is developing an automated system to record and track immunizations of service members.

VACCINATIONS FOR MILITARY PERSONNEL

Immunizing Agent

Army

Navy

Air Force

Marine Corps

Coast Guard

Adenovirus types 4 and 7

A

A

F

A

F

*Anthrax *

C

C

C

C

C

Cholera

D

D

D

D

D

Hepatitis A

A,R

A,R

A,R

A,R

A,R

Hepatitis B

E, F

E, F

E, F

E, F

E, F

Influenza

A, X

A, R

A, R

A, R

A, B, F

JE Vaccine

C

C

C

C

C

Measles

A, E

A, E

A, E

A, E

A, F

Meningococcal

(A, C, Y, W135)

A, C

A, C

A, C

A, C

A, F

Mumps

E, F

A, E, F

E, F

A, E, F

F

OPV

A, C, R

A, R

A, R

A, R

A

Plague

C, E

E

E

E

E

Rabies

E

E

E

E

F

Rubella

A, E

A, E

A, E

A, E

A

Tetanus-diphtheria

A, R

A, R

A, R

A, R

A

Typhoid

B, C

B, C

B, C

B, C

C

Varicella

E, F

E, F

E, F

F

E, F

Yellow fever

B, C

A, R

B, C

A, R

A, B, D

A ó All recruits

B ó Alert forces

C ó When deploying or traveling to high-risk areas

D ó Only when required by host country for entry

E ó High risk occupational groups

F ó As directed by applicable surgeon general or Commandant (G-K), Coast Guard

R ó RCs

X ó RC personnel on active duty for 30 days or more during the influenza season

Source: Joint Regulation on Immunizations and Chemoprophylaxis

*In addition to the requirement for anthrax vaccinations for personnel deploying or traveling to high risk areas, DoD is implementing in stages a total force Anthrax Vaccine Immunization Program.

Exhibit 2

New Approach with Anthrax

The advent of the DoD-wide anthrax inoculation program has forced the military services to seek efficient alternatives for administering immunizations, comparable to those discussed above for the accomplishment of physical exams. National Guard and Reserve units are located in over 4,400 communities nationwide. The challenge is to establish an expanded provider network that is at the same time cost-effective and that can serve to reduce interference with training. DoD is attempting to meet this challenge by contracting with other agencies such as the Department of Veterans Affairs, Federal Occupational Health and other organizations outside DoD.

The Veterans Health Administration offers a full range of health services at more than 1,000 locations across the nation. The Federal Occupational Health (FOH) organization provides immunizations, as well as physical exams and wellness services at more than 200 clinics and 200 wellness centers throughout the U.S. In addition, FOH contracts for medical services in areas where no Federal medical facility exists. Just as the previously discussed agreements with these agencies offer a cost effective alternative for providing physical exams, use of their facilities on a reimbursable basis would also assure a more comprehensive, accessible and flexible immunization program for members of the Reserve components. The annual cost to administer required vaccinations by means of such contracted agreements is estimated at $10 million.

Recommendation 12. To ensure that Reserve component members receive required immunizations, develop: (1) a more comprehensive approach to administration of inoculations for the Reserve components that includes maximum cost-effective use of other federal agencies and civilian facilities; and (2) an automated tracking system for monitoring the immunization readiness of Reserve component members in order that Reserve component commanders have immediate access to the health readiness status of their unit personnel.

Optical Readiness

Visual acuity is essential for combat effectiveness. Reservists who require spectacles to meet basic readiness requirements must have them prescribed during peacetime in order to be able to perform mission-related duties. Members requiring spectacles cannot effectively perform training or other duties in mission oriented protective posture (MOPP) gear without protective mask inserts (PMI). These members must have a PMI for realistic MOPP training in peacetime and for deployment. Providing PMIs and spectacles is another force health protection measure.

The Department funds spectacles and PMIs for RC members on active duty for more than 30 days from the Defense Health Program (DHP) or as part of contingency operation funds. The Reserve components reimburse the DHP for optical items issued to Reserve component members attending initial entry training. Part-time Reserve component members, who wear spectacles in their civilian environment, often are expected to use these same spectacles when training. The rigors of routine training in some units can result in harm to the civilian acquired spectacles or possible injury to the individual Reservist.

Commanders may authorize unit members to be fitted with military spectacles; however, the expense of spectacles and PMIs in such cases is funded from RC training accounts. The DHP is reimbursed for all PMIs issued to members other than those serving on active duty for more than 30 days. Typically, units order spectacles and PMI simultaneously. Currently, there is no system for individual accountability, active or reserve, in the event of negligent loss once the spectacles and PMIs are issued.

The estimated annual cost to provide protective mask inserts for each Reserve component member is $3.3 million. This cost takes into account annual accessions to the RC and replacements due to prescription changes every five years. This cost may be overstated if replacements due to prescription changes occur less frequently than every five years.

Recommendation 13. That optical readiness be considered as a DoD Total Force health protection measure. PMI requirements should be identified and funded in peacetime for the Total Force. Force health protection measures, including the purchase of spectacles and PMIs, should not be resourced from training funds. A mechanism should be established for members to reimburse the Department for the negligent loss of PMI.

Medical Readiness Responsibilities

DoD, the Services and individual Reservists share in the responsibility to ensure that each individual RC member meets readiness requirements for deployment. Although requirements may vary by Service, job classification and unit mission, each RC member is responsible for maintaining his or her medical and dental condition as required for deployment and retention. If members do not meet established standards for deployment, they not only jeopardize their careers, but they also compromise the mission readiness of their unit. It is essential that an individualís responsibility for satisfying medical readiness requirements be expressly communicated to each RC member.

While Reserve component members have a personal responsibility to monitor their medical readiness, the Department has a responsibility to ensure overall force health protection. Medical programming guidance directs the military services to ensure that any program associated with force health protection, such as health promotion, wellness, or fitness is provided to the Reserve components. However, funding for RC force health protection measures are not specifically earmarked within the Defense Health Program. It is not possible to identify in the DHP exactly how much money is being allocated or spent on force health protection for the RC. Active component readiness is a byproduct of the Defense Health Program. At this point, the DHP virtually excludes Reserve component readiness.

In 1991, DoD directed specific actions to strengthen its ability to perform the military medical mission. Section 1100 of title 10, U.S. Code, established the military health care account known as the DHP. Funds in this account are to be used to provide medical and dental care to eligible DoD beneficiaries. Funds may also be obligated for contracts, studies or demonstration projects for the delivery of health care. All funding for the DoD medical program, including operations and maintenance, procurement, some research and development, and CHAMPUS (TRICARE), was consolidated into this single defense medical appropriations account.

Recommendation 14. (1) All RC members be made aware of their rights and responsibilities with respect to their medical and dental readiness and that they are held accountable for meeting retention and deployment standards; (2) The most cost-effective and efficient methods to achieve Reserve component force health protection measures be determined and adequately funded.

CONCLUSION

Today the Reserve components are integrated into the total force and operate in conjunction with the Active force to support virtually all operations. The annual level of support provided over each of the past three years equates to about 1/3 the level of support provided by the Reserve components during the peak of Operation Desert Storm. To function in this more demanding, post-Cold War environment, National Guard and Reserve members must meet the same standards for physical condition and readiness as their Active counterparts.

Operational commanders should expect that assigned personnel have been subject to periodic medical assessments that assureóActive or Reserveóthey are fully capable of performing required operational duties. Commanders expect that when their personnel are deployed in areas where they are potentially more exposed to illness or disease they will have received appropriate immunizations and other protective measures. Commanders should not be placed in the position of having to consider the relative degree of risk associated with employing an individual, because of differences in coverage based on component, duty status or duration of orders. Correcting inequities related to medical and dental care for the servicemember and his dependents as well as providing the necessary force health protection measures are essential to achieving full utilization of the Reserve forces.

The medical mission of the Department of Defense is to provide medical services and support to the armed forces during military operations, and to members of the armed forces, their dependents, and others entitled to DoD medical care. The recently concluded DoD Reserve Component Health Care Summit acknowledged that Reserve component mission demands and potential exposure to harm are increasing.

Clearly, DoD has evolved from a Reserve component focused on training for mobilization to a Reserve component that is operationally relevant on a day-to-day basis. While Guard and Reserve members serve part-time, they maintain a full-time military commitment. They are available for immediate call to active duty. The recommendations contained in this report and listed separately below recognize the need to reassess the requirements for healthcare and medical readiness to ensure equitable protection for our Reserve component "full-time part-timers" in the event of service-incurred or aggravated injury, illness or disease, and health and environmental hazards associated with deployment or other military service.

RECOMMENDATIONS

Reserve Component Health Care

  1. Establish definitions in law or DoD regulation to describe specifically what constitutes "incurring" or "aggravating" an injury, illness or disease in the "line of duty."
  2. Allow DoD to place a Reserve component member who is injured, becomes ill or contracts disease in the line of duty while performing inactive duty training, on active duty during the period of treatment for or recovery from the injury, illness or disease.
  3. Allow DoD to provide medical coverage for Reserve component members who become injured or ill while remaining overnight at the site of inactive duty training between successive training periods, even if they reside within a reasonable commuting distance.
  4. Provide permanent statutory authority for the Secretary of Defense to waive or reduce CHAMPUS (TRICARE) annual deductible amounts (currently $300 per family) in the case of dependents of Reserve component members ordered to active duty for less than one year in support of a contingency operation.
  5. Authorize an expanded TRICARE dental program that provides for merging the Selected Reserve Dental Program into the Family Member Dental Program thereby ensuring a more comprehensive benefits package for Reserve component members and a family member option at no cost to the government.
  6. Conduct a study designed to determine the overall medical readiness of Reserve component members in order to determine prospectively their fitness for duty as well as DoDís ability to monitor and access such information.
  7. Reserve Component Force Health Protection

  8. Conduct a phased study, in conjunction with Recommendation 6 above, to:
    1. identify potential health risks or problems that have a direct impact on deployability and retention of RC members;
    2. develop a more cost effective, focused health assessment tool for use in conducting physical exams for RC members;
    3. establish a pilot program to measure individual medical fitness and deployability;
    4. establish joint procedures, based on the results of the pilot program, that will ensure greater consistency and uniformity in determining the medical readiness of Reserve component members.
  9. Amend section 10206 of title 10, United States Code, to eliminate any physical examination requirement for members of the IRR prior to activation,. if not previously examined during an activation within the past five years. Develop a more effective annual physical condition certification questionnaire for IRR members of all the Services.
  10. Eliminate sections 1074a(d), to include the requirement for preferential dental care for Army early deployers. Identify a more efficient and cost-effective health assessment program for ensuring the medical readiness of early-deploying RC members.
  11. Identify cost-effective alternatives for accomplishing medical readiness requirements that consider the use of other facilities, including those of the Department of Veterans Affairs, Health and Human Services, civilian contractors or private practitioners. DoD should continue to pursue ongoing efforts to establish memorandums of agreement with Veterans Affairs and Federal Occupational Health.
  12. Develop and implement a standardized dental examination and classification form that can be completed by a military or a civilian dentist and that will satisfy the DoD annual dental examination and classification requirement. Establish the technical electronic support necessary to track dental classification and treatment compliance and to incorporate tracking information into existing automated information systems while ensuring that this information is easily accessible to RC unit commanders.
  13. Develop a more comprehensive approach to administration of immunizations for the Reserve components that includes maximum cost-effective use of other federal agencies and civilian facilities. Develop Reserve component requirements for existing and proposed Total Force automated tracking systems to monitor the immunization readiness of Reserve component members and to ensure commanders have immediate access to the health readiness status of their unit personnel.
  14. Optical readiness should be considered a Total Force health protection measure with protective mask insert (PMI) requirements identified and funded in peacetime for the Total Force. Force health protection measures, including the purchase of spectacles and PMIs, should not be resourced from training funds. A mechanism should be established for members to reimburse the Department for the negligent loss of PMI.
  15. Ensure all RC members are made aware of their rights and responsibilities with respect to their medical and dental readiness and that they are held accountable for meeting retention and deployment standards. Determine the most cost-effective and efficient methods to achieve Reserve component force health protection measures and provide adequate funding.

The recommendations contained in this report have not been subjected to program analysis and evaluation by the Department nor evaluated under the Planning, Programming and Budgeting review process of the Department of Defense. Any legislative proposals that DoD develops pursuant to this report are subject to review by the Office of Management and Budget.