The Coalition would like to thank the Subcommittee once again for sponsoring a wide range of legislation that is helping servicemembers, veterans, their family members and survivors.  We deeply appreciate the Subcommittee's continued leadership and commitment to those who are in uniform today and those who have served our nation in the past.

Force health protection, covers many areas: fitness and health, protection and prevention, and treatment. We would like to focus our attention today on deployment health policy, practices and procedures.  Critical to this effort is effective coordination and collaboration between the Defense Department (DoD) and the Department of Veterans Affairs (VA).  The Coalition believes both departments are working together better than in the past, though we believe more must be done.

Pre - and Post - Deployment Assessment. In April 2003, the Under Secretary of Defense for Personnel and Readiness, Dr. David Chu, endorsed a policy that now requires all commands to have an enhanced post-deployment health assessment process. The Coalition agrees with a GAO assessment that there has been significant improvement in compliance with DoD guidance.  Unfortunately, the war against terrorism was well underway before this guidance was finally enforced. 

DoD is to be commended for making headway in pre-deployment health assessment, continuous hazard and health monitoring in the field, and a post-deployment assessment.   Individual serum samples are collected and maintained in the DOD serum repository. Occupational and environmental health surveillance programs help monitor members' deployment health.

The pre- and post-assessment forms (DD Form 2795/2796) are self-administered documents and medical personnel review the forms with servicemembers. Any positive responses trigger additional review and referral for follow-up care. 

The Coalition has reviewed these documents and we have concerns about subjectivity and the human dimension of the evaluation process.

The Coalition recognizes that the men and women of the uniformed services are truly dedicated to their mission -- protecting the interests of our nation.  We fear the "zeal" to deploy may cause some individuals to overlook any physical aliments they believe may cause them to remain behind. Our men and women want to serve and go to great lengths to do so.  We can see that it would be easy to overlook or even deny a condition when completing self-reporting documents, especially with the pre-deployment form (DD 2795).

Subjectivity also can complicate the more thorough post-deployment assessment (DD 2796), since servicemembers are eager to "get out" or "get home."  They may overlook or deny conditions in their desire to return home or for fear that their return may be delayed in a medical hold status. 

Several recent GAO reports have addressed compliance with force health protection policies (September 2003, October 2003 and others).   While these investigations have dealt with the process, the Coalition asks the Subcommittee to provide oversight to evaluate the effectiveness of the content and the outcomes of a program that has a subjective self-assessment component coupled with some aspects of a "medical" review.  The problem is that these procedures and the resources to support them vary considerably among the Services and their Reserve components.

The Coalition urges the Subcommittee to direct a study of the effectiveness of the self-administered pre - and post - deployment assessment and continue providing oversight to ensure compliance with pre- and post-deployment policies and procedures. 

National Guard and Reserve Deployment and Post-Deployment Health Issues.  The Military Coalition is most appreciative to Congress for including the Temporary Reserve Health Care Program (Section 702) in the FY 2004 National Defense Authorization Act.  This program will provide temporary coverage, until December 2004, for National Guard and Reserve members who are uninsured or do not have employer-sponsored health care coverage.  TRICARE officials plan to build on existing TRICARE mechanisms to assist in implementation; however, TMA is not certain how long this will take.  Reserve Component members are anxious to enroll, and fear that the coverage period may be lost.  Immediate implementation is required.

The Coalition is also grateful to the Subcommittee for Sections 703 and 704 of the NDAA.  Section 703, Earlier Eligibility Date for TRICARE Benefits for Members of Reserve Components, provides TRICARE health care coverage for reservists and their family members starting on the date a "delayed-effective-date order for activation" is issued.

Section 704, Temporary Extension of Transitional Health Care Benefits, changes the period for receipt of transitional health care benefits from 60 or 120 days to 180 days for eligible beneficiaries.  These provisions should be easier to implement than the TRICARE buy-in provision of Section 702 and we understand that the technical fixes to the Defense Eligibility and Enrollment Reporting System (DEERS) are being made to implement the Section 704 benefits. We are concerned, however, that the latest word from DoD, a February 12, 2004 press release announcing the implementation of these benefits, provided few details about the implementation and continued to encourage beneficiaries to save their receipts for health care incurred in the demonstration period "in the event the sponsor is determined to be eligible and the care qualifies for retroactive TRICARE reimbursement once the 2004 Temporary Reserve Health Benefit Program begins."

Congress recognized the extraordinary sacrifices of our citizen-soldiers by extending this pre- and post-mobilization coverage.  Now it's time to recognize the changed nature of 21st century service in our nation's reserve forces by making these pilot programs permanent.

To support military readiness, recruitment / retention programs, deployment health, and reserve family morale, the Military Coalition strongly urges the Subcommittee to endorse permanent authorization of all provisions of the Temporary Reserve Health Care Program (Sec 702, 703, and 704 P.L. 108-136). 

President's Task Force Recommendations. The Coalition endorsed the final Report (May 2003) of the President's Task Force (PTF) to Improve Health Care Delivery for Our Nation's Veterans. 

A major PTF recommendation is a seamless transition to veteran status for separating and retiring servicemembers.  As soon as an individual enters the armed forces, DoD and VA should have a stake in monitoring and evaluating the member's health.  Force health protections, medical readiness, and research into occupational exposures are all important government interests in this collaboration.

Lessons learned from the first Gulf War taught us that a better job must be done to collect, track and analyze occupational exposure data.  Without this information, benefits determinations cannot be fairly adjudicated, nor can the causes of service-related disorders be better understood.  The enhanced post-deployment health assessment for servicemembers serving in Operation Iraqi Freedom is designed to capture occupational exposure information. The objective is to benchmark information for future reference and intervention as necessary. 

To do so, both departments must share exposure information and any other health status data electronically.  VA and DoD need to complete development of an interoperable bi-directional electronic medical record (EMR) -- the lynchpin to a seamless transition (PTF Recommendation 3.3). The technology exists but the will must be found to move forward to completion. 

Another important PTF recommendation is "the one-stop physical" upon separation or retirement. Offering one discharge physical, providing outreach and referrals for a VA Compensation and Pension examination (PTF Recommendation 3.4), as well as following up on claims adjudication and ratings is not just more cost effective in terms of capital and human resources, it is the right thing to do -- to ensure that servicemembers receive the benefits they have earned and deserve.

There is an ideal mechanism for this approach and that is the Department of Veterans Affairs Benefits Delivery at Discharge (BDD) program.  Presently, the various VA regional offices have ongoing BDD programs at 136 military installations in the United States and overseas in Korea and Germany to ensure that separating military members, who participate in the program, receive a VA Compensation and Pension examination leading to a disability compensation rating immediately upon separation. 

The BDD program has proven extremely successful but so far occurs only through local agreements between the regional office directors and installation commanders. 

TMC recommends a national Memorandum of Understanding between the Secretaries of Defense and Veterans Affairs is now critical to achieve the maximum efficiency and cohesive support for this exemplary program.

Finally, the government has been talking about developing an electronic DD 214 for years, yet the document remains in paper format.  Initial start-up costs would be paid back many times over in efficiencies gained. This is not just a matter of conserving resources.  It is essential to remove barriers that in the past have denied servicemembers and veterans proper medical care and benefits determinations.

Other commissions have worked toward the same goals in the past, only to have their recommendations sit on the shelf.  Successful implementation will require Congressional direction and additional funding. 

The Military Coalition asks the Subcommittee to work with the Veterans Affairs Committee and the Departments of Defense and Veterans Affairs to ensure action on the PTF recommendations including seamless transition, a bi-directional electronic medical record (EMR), enhanced post-deployment health assessment, and implementation of an electronic DD214. 

Tracking Occupational Exposure Data.  The PTF made additional recommendations regarding collecting and sharing comprehensive servicemember data to determine the effects of service on veteran health. Significant issues arise when attempting to assess the health of veterans whose condition may have resulted from exposures to occupational/environmental hazards during military service.  Agent Orange and Gulf War Undiagnosed Illnesses challenges were made more difficult by the inability to determine where members served, the environmental condition, and personal exposure. 

To put it simply, medical records must be tied to personnel records to effectively evaluate the cause and effect of exposures. The Coalition is grateful that this Subcommittee recognized this problem by enacting Section 767 (P.L.105-85), Tracking Service Member Location.

The issue is even more critical in light of the increased threat of biological or chemical warfare. The Coalition is mindful of the national security implications of this task, as stated in the PTF report: "Providing VA occupational exposure data, however, must be weighed against the potential security concerns of releasing these data, as in matters involving individual location for certain types of individuals, such as Special Forces, or assignment detail for sensitive areas."

However, not all orders are classified and much could be done to tie medical and personnel records for cases of exposures during routine operations. The Coalition notes that by 2006, the Defense Integrated Military Human Resources System (DIMHRS) is expected to consolidate the personnel and pay systems.  This will provide a single service record and service activities.  However, the PTF noted, ".many elements related to tracking an individual's specific location, activities and exposures will remain undocumented."

In a hearing before the Subcommittee on National Security, Emerging Threats and International Relations, House of Representatives Committee on Government Reform (March 25, 2003), Dr. William Winkenwerder, Jr., Assistant Secretary of Defense for Health Affairs, reported that since DIMHRS is still several years away, the department has offered a temporary solution -- an interim deployment medical surveillance system, the force health protection portal.  The Coalition is concerned whether this measure is adequate given the very high stakes posed by the war on terrorism.

The Coalition urges the Subcommittee to continue to monitor implementation of Section 767 of P.L. 105-85) and take steps to facilitate the PTF recommendation that the VA and DoD provide sharing of servicemembers' assignment history, location, occupational exposure, and injuries information.

Dental Readiness.  The number one deployment problem in the First Gulf War was dental  "un-readiness" and the same is true today.  Reserve Component members are required on their own to maintain a certain level of dental readiness, known as "Classification T-2" for mobilization purposes.  Classification T-2 means that no emergency dental procedures would be required for at least six months.

Unfortunately, the current DoD Selected Reserve dental program does not provide a benefits package that can assure participants would meet "Classification T-2" standards.  In addition, only five percent of eligible Guard and Reserve members are enrolled.  The program provides diagnostic and preventive care for a monthly premium, and other services including restorative, endodontic, periodontic and oral surgery services on a cost-share basis, with an annual maximum payment of $1,200 per enrollee per year. 

During this mobilization, soldiers with repairable dental problems had teeth pulled at mobilization stations to meet deployment timetables. Congress responded by passing legislation that allows DoD to provide medical and dental screening for Selected Reserve members who are assigned to a unit that has been alerted for mobilization. But, waiting for an alert to initiate screening is too late. For Operation Iraqi Freedom call-ups, the average time from alert to mobilization was less than 14 days, insufficient to address deployment dental standards.  In some cases, units were mobilized before receiving their alert orders. This lack of notice for mobilization continues, with many reservists getting notification days prior to call-up.

The Military Coalition recommends increasing the government subsidy under the Selected Reserve TRICARE Dental Plan and enhancing the benefit package to allow reservists to meet readiness and deployment dental standards. 

Other medical and family readiness issues of concern to TMC include the following:

• Optional Payment of Premiums for Employer or Personal Health Insurance.  Guard and Reserve family members are eligible for TRICARE if the member's orders to active duty are for more than thirty days; but some families would prefer to preserve the continuity of their own health insurance.  Being dropped from private sector coverage as a consequence of extended activation adversely affects family morale and military readiness and discourages some from reenlisting.  Many Guard and Reserve families live in locations where it is difficult or impossible to find providers who will accept new TRICARE patients. 

Recognizing these challenges for its own reservist-employees, the Department of Defense routinely pays the premiums for the Federal Employee Health Benefit Program (FEHBP) when activation occurs.  In addition, Congress authorized all other Federal departments and agencies to provide this benefit.  If this benefit is good for the roughly 10 percent of the Selected Reserve who are federal workers, it ought to be provided in kind to the rest of the Guard and Reserve as an option. 

The Military Coalition urges the Subcommittee to authorize payment of part or all of civilian health care premiums as an option for mobilized service members.   

• Inadequate Resources and Policy Gaps Cause Medical 'Holds".  The Coalition is grateful for the Subcommittee's leadership in drawing attention to and directing action on the medical hold backlogs.  While the Coalition appreciates the Subcommittee's efforts as well as those of the defense medical community, we believe that a root cause of medical holds is the lack of consistent and comprehensive screening protocols, and the resources to support them.

Reserve component members often must complete military medical exams in the private sector. The requirement for a medical examination (a "physical") varies by military specialty, but it is the Coalition's understanding that the general standard for active duty and reserve servicemembers is that one must be conducted every five years.  For reservists who do not have insurance there is an understandable reluctance to incur a personal expense that the government does not reimburse. Even for those with employer-sponsored insurance or insurance through others means, a routine physical is often not a covered benefit. (Routine physicals are not a TRICARE Standard benefit either). 

The Military Coalition recommends that Congress provide the Services and their reserve components with adequate resources to meet and maintain deployment medical standards prior to mobilization.    

• Coordination of TRICARE - VA Benefits During Post-Deployment Period.  In 2002, the VA established a policy permitting returning National Guard and Reserve combat theatre veterans to have two-years' access to VA care without regard to a VA disability rating (VHA Directive 2002-049).  Servicemembers are assigned to VA priority group '6' pending completion of their ratings.    While TMC applauds this effort to provide extended benefits, we have several concerns. 

During transition there will be an overlapping period when servicemembers will have both TRICARE and VA benefits.  The Coalition has concerns about "the handoff" of these individuals from one system to the other.  What kind of support is available to assist them to better understand which benefit to use and when?  How proactive are both departments in educating servicemembers?

Eventually, these new veterans will undergo medical evaluation and some may receive a VA disability compensation rating.  For those assigned to VA priority groups 1-6, the usual access rules will apply.  Unless they have been reliant on VA services those assigned to VA priority 7 or 8 could be disenrolled from VA health care.  That could defeat the objective of continuous health surveillance beyond the two-year window.

The Military Coalition is grateful for extended TRICARE and VA health benefit coverage for returning reservists and we recommend closer collaboration between DoD and VA to ensure servicemembers are educated on their coverage alternatives during transition.

Mental Health Care Services.  United Press International reported on February 18, 2004 that between 8 and 10 percent of the nearly 12,000 soldiers evacuated in the war on terror had mental problems, according to the commander of the Landstuhl Regional Medical Center in Germany, Colonel Rhonda Cornum, USA.  (COL Cornum is a decorated combat veteran and former-POW of the First Gulf War).  COL Cornum said the ill troops had "psychiatric or behavioral issues". 

As we noted earlier, acute physical injuries arising from combat receive world-class care. But TMC is also concerned about the growing number of returning troops who have scars that are not visible and may be overlooked -- the psychological conditions that inevitably arise from war, such as PTSD and other problems that have led to domestic violence. The demographics of the volunteer force today are vastly different than the largely conscripted forces of conflicts before the first Gulf War and more than 50% of the force is married, many with dependent children.  

While both the DoD and the VA have experience treating mental illness caused by war, our concern is also for the families who must adjust to servicemembers who return with the physical, emotional, and psychological scars of war.   Who will be there to help the family members whose lives will be changed forever? 

Reserve component members and their families - many of whom live far from the support services provided on military installation-may experience additional stressors as a result of the disruption from mobilization.   The Coalition is also concerned that some mental health issues may not emerge until sometime in the future, after these families' eligibility for TRICARE has ended. Where will these families find the help they may need?  How will deployment-related mental health issues that emerge among reserve component servicemembers and their families after the servicemembers' return to their civilian occupation and communities be identified and tracked in statistics of deployment-related health care issues.

The Coalition notes that all servicemembers and reserve component personnel and their families can now access the "One Source" 24-hour information and referral service previously available only for Marine Corps and Army personnel. One Source provides information and assistance in such areas as parenting and childcare, educational services, financial information and counseling, civilian legal advice, elder care, crisis support, and relocation information. The service is available via telephone, email, or the web and is designed to augment existing Service support activities and to link customers to key resources, web pages and call centers. It will also be available to family center staff.

The Coalition hopes that these assistance programs will serve as a useful augmentation and relieve the burden of counseling that traditionally has fallen on family service centers and Chaplains.  The Coalition believes that our families will need all available resources and more.

The Coalition recommends that the Subcommittee endorse the necessary resources to support robust psychological services for our nation's servicemembers and veterans so that they avoid becoming the next generation of our nation's homeless. 

Care and Transition Support for Less Acute Patients.  The Coalition believes that those who are acutely injured are getting "five star" care from the DoD with a smooth handoff to the VA for follow up care.  Collaboration in these efforts is unprecedented.  VA Social Workers, Disabilities Specialists and others are working in the military's direct care system to facilitate the transition of injured servicemembers to the VA system.  We are also pleased to note the development of a post-deployment health clinical practice guideline so that DoD and VA providers will use the same tool to provide effective and appropriate evaluation and response to the medical concerns of those servicemembers returning.

However, TMC is concerned over questions related to the care of those with less acute conditions who is not being cared for at major military medical centers.  We are less confident that the handoff between the DoD and VA at a smaller installation is as effective as that of the larger facilities. The Coalition believes that coordination activities for the less acutely disabled could be improved.  Currently 250,000 troops are being rotated in and out of Iraq - the largest peacetime rotation since WWII.  It is imperative that the VA and DoD build on their collaboration by improving outreach and transition services at all military hospitals, re-deployment sites and separation activities. 

TMC recommends that the Subcommittee oversee the transition process for less acute patients and ensure there are sufficient resources to support the needs of returning ill and wounded servicemembers, including the more than 350,000 members of the Guard and Reserve who have been mobilized since 9/11. 

CONCLUSION 

The Military Coalition reiterates its profound gratitude for the extraordinary progress this Subcommittee has made in the area of deployment health policy, practices and procedures as well as securing a wide range of personnel and health care initiatives for all uniformed services personnel and their families and survivors. The Coalition is eager to work with the Subcommittee in pursuit of these goals as outlined in our testimony.

Thank you very much for the opportunity to present the Coalition's views on these critically important topics.