In January, the Military Compensation and Retirement Modernization Commission proposed replacing the current triple option Tricare benefit with a menu of commercial insurance options similar to those offered to federal civilians, but with a break on premiums except for working age retirees.
As the military community studied those details, the Obama administration released its latest defense budget, which continued a pattern, adopted during the George W. Bush administration, of proposing hefty Tricare fee increases, particularly for the younger and non-disabled retirees.
After months of consideration, Congress rejected both paths for the 9.5 million military health care beneficiaries.
Instead, the big legislative lift for 2015 was an overhaul of military retirement for future generations.
Now eyeing 2016, the chairmen of the House and Senate armed services committees promise to begin to reform the $50 billion military health system.
Their staffs already are doing groundwork.
Beneficiary associations, recognizing the serious intent of the two powerful committees, are urging they keep as a priority the needs of military families, retirees and Reserve and Guard members as well as sacrifices made daily by active duty forces.
Rep. Mac Thornberry, R-Texas, chairman of the House committee, said reforms will begin not with the commission's recommendations but with its findings -- what it learned of weaknesses and inefficiencies in the system.
"Part of where we begin is with their concerns about access (and) about the way Tricare functions," Thornberry said. But "the first purpose of the military health care system is to have service members able to fight and win our wars, and to take care of them as they do."
In this first year as chairman, Thornberry not only tackled retirement but took first steps to overhaul the defense acquisition system.
He suggested health reform, like fixing acquisition, might occur in stages.
"I don't know that we're going to come in with some sweeping package and overhaul the whole system," Thornberry said. "I want to be careful that we don't do unintended damage."
Thornberry said he can and will rely on the military health care expertise of personnel subcommittee chairman Rep. Joe Heck, R-Nev., a career Army Reserve physician who "lives and works in that system."
What Thornberry knows is that problems with access and quality of care vary by location, with rural areas particularly challenged.
He also has met "at least some Tricare providers who believe they can provide significantly better service if they can bring some of what they're doing in private sector into Tricare. That's something we want to explore."
Tricare regulations "might be limiting their ability to offer the access to service, maybe even quality, that they are able to offer other places."
On whether beneficiaries should pay more for their health benefit, Thornberry said that would be decided as part of a wider reform focus.
"The Pentagon keeps sending over these proposals, year after year, to take more money out of folks' paychecks, and that's it," Thornberry said. "That's not right. We need to look at the broader Tricare system, see how it might be improved. Perhaps that might involve some higher fee or premiums; I don't know.
"But we need to look at it in broader context: the purpose of the military health care system, the role it plays in pay and benefits, in recruitment and retention, over the long term."
He added, "There may well be some higher fees, but there ought to be greater benefit that goes with it."
For example, he said, a better system of scheduling initial health care appointments and timely referrals.
'Major subject of emphasis'
He and Sen. John McCain, R-Ariz., chairman of the Senate Armed Services Committee, "have agreed that Tricare reform will be a major subject of emphasis for us in the coming year," Thornberry said.
The House committee has held a roundtable discussion with the military surgeons general and informal talks with beneficiary organizations.
The National Military Family Association sponsored a panel discussion on Capitol Hill last week, where Thornberry made opening remarks.
The Military Officers Association of America is polling its members on health care issues.
More beneficiary groups are to testify before Heck's subcommittee next Thursday.
The Military Coalition, an umbrella group of 34 military associations and veterans groups, has prepared principles and goals to consider for health care reform in the coming year.
Most associations reject the commission's Tricare Choice Plan as going too far to replace current Tricare offerings.
However, there's agreement that continuity of care is a problem for Guard and Reserve members.
So the Reserve Officers Association is urging adoption of the commission's Tricare Reserve Choice plan if alternative fixes to reserve component health care fail to advance soon.
Some advocates argue Tricare beneficiaries simply need to be better educated on the value of using Tricare Standard, the fee-for-service option, in areas where managed care in Tricare Prime networks is limited.
Retired Vice Adm. Michael Cowan, former Navy surgeon general and current executive director of the Association of Military Surgeons of the United States, recently was invited to share his views on Tricare reform with House committee staff.
Cowan told them Tricare works, he said, and rejected the commission's claim that the current system is broken.
Military direct care, Cowan said, is sized to support war plans.
It is not big enough to take care of all families, retirees and other beneficiaries. So it purchases care via Tricare networks and programs.
When military doctors need more patients for training, they pull more back into direct care.
As proof the concept works, Cowan pointed to military medicine's performance in recent wars, including a "90-percent-plus survival rates from some of the most horrible war wounds mankind has ever seen."
The system can be made to operate more efficiently, to see more patients and provide more timely care, Cowan said.
But he doesn't feel replacing current Tricare with commercial insurance plans is the solution.
The commissioners shaped its recommendations "through only the prism of the disaffected. If you only look for problems, you only see problems."
In doing so it missed what's working well, including the new Defense Health Agency, which is implementing system-wide efficiencies.
"It's been, in my view, spectacularly successful," Cowan said.
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