Health-Care Realities

Feb. 1, 1997

In November, three days before he retired, Lt. Gen. (Dr.) Edgar R. Anderson, Jr., the USAF surgeon general, told Air Force News Service that the Air Force could no longer deliver on the promise of lifetime, no-cost health care at military medical facilities.

More than a third of the military hospitals that existed in the US in 1987 will be closed by 1997. Meanwhile, the retired military population has grown by leaps and bounds. The system can’t handle the patient load.

Years ago in simpler times, generations of military members were promised health-care benefits for the rest of their lives to offset the lower pay and other exigencies of career service. That promise became even more important as the cost of medical care rose to unprecedented levels. Today, it is regarded as the number one noncash benefit.

From the 1960s on, direct care in military medical facilities was supplemented by the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). Planners did not foresee the inversion and overload on military hospital facilities that lay ahead in the 1980s and 1990s when force cuts set up a decline in medical infrastructure just as the large Cold War force was reaching retirement age. More than half a million retired beneficiaries lost access to military hospitals and clinics because of base closures.

Older retirees are hit especially hard. Military health programs close abruptly for them when they move over to Medicare at age 65. Up to now, military hospitals have been treating Medicare eligibles on a space-available basis, but that is wearing thin.

A provision called “subvention” would allow Medicare to reimburse the Defense Department for care provided to these older retirees, but Congress adjourned last fall without approving such subvention. A new bill will be introduced this year. It would particularly help the 55 percent of the over-65, Medicare-eligible military retirees who live within 40 miles of one of the military hospitals that remain.

As the Military Coalition said in testimony to Congress last year, the perception that military retirees have better-than-average health-care benefits is a myth. According to a 1994 survey by Hay Associates, the majority of corporate employers provide at least some coverage in addition to Medicare for their retirees. Military retirees must buy their own Medigap policies. It is further telling that about two million of the 8.4 million persons eligible for military medical care have obtained private health insurance instead.

Two years ago, budgeteers floated the preposterous notion that medical care for retirees was a “contingent benefit” rather than an entitlement. They have since retreated from that position under a barrage of evidence to the contrary. Government officials no longer deny that the promise of lifetime health care was made, although they continue to hedge about whether it was “contractual” or only a “moral commitment.”

Either way, what the government says it will ultimately deliver for most retirees is some sort of civilian health-care program with enrollment fees and copayments. The centerpiece of the plan is Tricare, a series of managed-care options for active-duty and retired military families. Implementation is under way, and surveys say that those who have tried Tricare like it. Former Surgeon General Anderson said that one of the first things he was going to do after retirement was sign up for Tricare.

Under the option called Tricare Prime, patients are treated in military facilities when care is available there and by contract physicians when it isn’t. Enrollment is free for the active-duty force, $460 a year for retired military families. Retirees who do not live in a Tricare Prime service area near a military hospital get Tricare Standard–previously known as CHAMPUS–which involves burdensome paperwork and has costly deductibles and copayments.

Many retirees, especially those without access to Tricare Prime, would like to join the Federal Employees Health Benefits Program, which covers 4.1 million federal beneficiaries. It offers a wide choice of doctors and excellent medical coverage. (It also avoids some of the problems of Tricare, such as vague and uncertain reciprocity agreements among the 12 geographic regions.) FEHBP is the health-care plan that members of Congress chose for themselves. A variation is “FEHBP-65,” which would allow Medicare eligibles to enroll. The $1,377 premium for a family buys better coverage at less cost than Medicare supplements provide.

When the possibilities are arrayed, it is clear that one size does not fit all. The Air Force Association and the Military Coalition have taken the position that at least three options, supported and funded as necessary by the federal government, are required.

  • Continued access, via subvention funding, to military hospitals for retirees after age 65.
  • Tricare, for retirees who can take good advantage of it, for active-duty families who cannot afford enrollment fees in other programs, and because military doctors need patients other than healthy young people to maintain military readiness and medical proficiency.
  • FEHBP, for those, especially older retirees, whose needs are not well met by the other options.

This isn’t the way that either military members or the government thought 40 years ago that things would work out, but under the circumstances, it is the least–the very least–the government can do to redeem its obligation and to meet the health-care needs of those who served.