If it wants to fix the appalling mess that medical care has become at Washington D.C.’s Walter Reed hospital, the Department of the Army might take a quick trip down Georgia Avenue to the Department of Veteran’s Affairs Washington, D.C. medical center. The VA hospital system, which once produced regular horror stories similar to Walter Reed’s, has emerged as one of the best-run federal agencies. The Department of Defense should look to imitate it while simultaneously freeing military health care from the constraints a VA-like system would almost certainly impose on those who have DOD pay for their health care.
The rational for this bifurcated approach lies in the major differences between the two military-related health systems. Quite simply, people receiving VA benefits get all their care from the same place. Universal electronic medical records follow VA health-system clients everywhere and give doctors access to complete clinical histories, diagnostic results, and nearly anything else they need to provide treatment. High-tech in-home monitoring equipment lets doctors help the chronically ill in real time. According to one study from the RAND Corporation, the VA’s care outperforms that private hospitals paid via Medicare while costing less. For all its good points, however, the VA system lacks in flexibility. VA enrollees who don’t like a VA hospital or doctor have few choices.
TriCare, the DOD’s primary system, functions much more like private insurance. Although initially a plan only for active duty military personnel and their dependents, it has recently expanded to cover reservists and their families. All TriCare participants can select doctors from among all those willing to accept the plan’s payment schedule. They make copayments and have broad choices inside and outside of military hospitals.
While American civilians would prefer a system more like TriCare, a VA-like system fits the military better. An integrated system could more closely focus on care of service-related injuries and keeping America’s fighting force in top shape. Having complete electronic medical records for every person in the military — something DOD is already working on — would improve readiness. Many of the highly prescriptive behavioral modifications that a more integrated system with better recordkeeping might encourage — think of at-home electronic scales to transmit the weight of soldiers ordered to go on a diet — would be an invasion of individual liberty in the private sector but make sense within the military. Finally, health problems ranging from combat injures to rare diseases that flourish in war zones exist only in the military.
Making the DOD system more like the VA’s would have implications for TriCare. Given obvious need to focus on the health care needs of active duty service members, this drive to improve the DOD’s own health care system should also mean an end to the expansion of those eligible for TriCare. While there’s no reason to drop any currently eligible person from TriCare, focusing the system on the health of those on active military duty could ultimately mean slower growth in spending for private DOD-paid care. In time, a refocused military health-care system might provide fewer on-plan doctors for TriCare participants.
Fairness to military dependents (and service members who desire private care) thus requires some thought about how to make the system more flexible. To do this, DOD could let all TriCare members open private, portable health-savings accounts while still receiving full TriCare benefits. These accounts, which individuals can carry with them from job to job, have caught on slowly in the private sector because, so far, they’re only available when paired with high deductible health plans that require large contributions from the HSA before insurance kicks in. For many people, this seems like a bad deal. For TriCare members, however, the HSAs would seem like an added benefit rather than a way of simply saving the employer money: HSA funds can be used for alternative medicine, over-the-counter drugs, and other things that almost no conventional health plan covers. Doctors unwilling to accept TriCare payments could also be paid out of the accounts. In short order, in fact, HSAs could relieve a bit of pressure on DOD hospitals and let them focus more closely on care for injured service members. In the long run, they could provide an example of how individuals can improve their health when they make their own choices. In the end, adding HSAs to TriCare could make everyone better off.