TRICARE provides coverage for medical services, medications, and dental care for military families and retirees and their survivors. President Barack Obama’s FY 14 budget proposal called for across-the-board increases in fees and deductibles, “phased in over a five-year period,” for veterans, while exempting active-duty service members from some hikes, such as prescription co-pays.

The VSOs also argue the civilian healthcare system has neither the experience nor the infrastructure to deal with military-unique health issues, even those with related non-military causes, such as gunshot or blast trauma, TBI, or post-traumatic stress disorder (PTSD) stemming from civilian life.

“Our integrated transition plan of care, from military treatment facilities to our Polytrauma Rehabilitation Centers and into the community, is paramount to the success of our wounded heroes and their families,” he added. “The system set up throughout VA is world class and has no equal for those suffering from TBI.”

Homer S. Townsend, Jr., executive director of Paralyzed Veterans of America (PVA), maintains “there is nothing in private practice that compares at any level with the VA’s [five] polytrauma centers,” 22 associated polytrauma network sites, and 87 Polytrauma Support Clinic Teams, nor its 24 Spinal Cord Injury Centers. Even so, he added, neither DoD nor the VA was fully prepared for the level of polytrauma and spinal cord injuries coming out of OIF/OEF, something civilian medical care could not begin to handle.

The VA defines polytrauma as complex, multiple injuries – at least one of which is life-threatening – to multiple body parts and organs stemming from a single event and resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. TBI frequently occurs in polytrauma in combination with other disabling conditions, such as amputation, auditory and visual impairments, spinal cord injury, PTSD, and other medical problems.

The VA’s Chief Consultant for Rehabilitation Services Dr. Lucille Beck said the Polytrauma System of Care was created in response to the “need to establish a new system and new models of care to treat the most severely wounded and injured soldiers from the ongoing conflicts in the Middle East.”

At the same time, Chief of Physical Medicine & Rehabilitation Services Dr. Shane McNamee, at the VA Medical Center in Richmond, Va., said the VA’s “highly coordinated, effective system is unparalleled in this nation’s medical system for those who have suffered a traumatic brain injury.”

“Our integrated transition plan of care, from military treatment facilities to our Polytrauma Rehabilitation Centers and into the community, is paramount to the success of our wounded heroes and their families,” he added. “The system set up throughout VA is world class and has no equal for those suffering from TBI.”

The severity and complexity of such injuries require an extraordinary level of coordination and integration of clinical and other support services on a scale beyond the experience of civilian healthcare, according to Beck, even as the VA system adds to the evolution of civilian polytrauma care.

“The recovery process, to achieve a new level of ‘normal,’ requires a determined patient, who is backed by a strong support network and a committed team of highly skilled rehabilitation specialists. The recovery of every patient has its advancements and setbacks, joys and challenges, and this journey can be long. Yet our experience with every patient advances medical knowledge, producing improvements in the care delivery and rehabilitation for all who are recovering from polytrauma,” she said.

It is just such extraordinary efforts – equally reflected in quantum leaps in prosthetic technology and rehabilitation, facial reconstruction, psychological diagnosis and care, etc. – veterans groups fear may suffer in the ongoing budget crisis, whether through cuts to DoD programs or future reductions or changes in R&D and care for veterans or their families.

“The only times the all-volunteer force has been jeopardized have been due to budget-driven benefit cuts that failed to offset the extraordinary demands and sacrifices of a service career,” TMC warned the Senate. “For all of these reasons, TMC does not support the additional array of proposed TRICARE fee increases proposed in the FY2014 defense budget. In view of fee increases and statutory and policy benefit limitations already imposed in 2011 and 2012, TMC believes it is time to hold defense officials accountable to implement efficiencies that don’t affect fees or care.”

An advocacy group of veterans from all services and eras, formed in 2012 – Concerned Veterans for America (CVA) – argues the problem is not spending, which it agrees is out of control, but the VA itself.

“Our veterans return from war only to be greeted by utter dysfunction at the Department of Veterans Affairs. Roughly 500,000 veterans are stuck in a disability claims ‘backlog,’ waiting almost a year for a response – and even longer for resolution. This is a national disgrace and must be fixed,” CVA proclaims on its website. “Throwing more money at the problem has not worked. Instead, VA needs serious reform – transforming a bloated bureaucracy into a modern and efficient organization focused on serving veterans rather than making them wait in line for benefits they’ve earned.”

In its most recent presentation to Congress, TMC would seem to agree – but includes DoD, as well.

“TMC believes strongly that active DoD and VA collaboration is not only essential to achieving seamless transition, such cooperation is also critical to the long-term sustainability of our defense strategy, the health and wellness of the all-volunteer force and the acknowledgment of our country’s commitment and moral obligation to the long-term care and support for those who served,” the VSO consortium maintained. “As the military begins implementing its exit strategy in Afghanistan, the coalition worries about the stability and viability of the policies, programs and services over the long haul intended to care for and support our wounded, ill and injured and their families – caregivers.

“We believe greater progress can be made if the departments more aggressively pursue collaborative partnerships with other government agencies and non-government entities to drive down costs, support seamless transition efforts and improve continuity of medical care. Both agencies have stated repeatedly that ‘they can’t meet the needs of our recovering warriors without the help of outside organizations’ – yet, DoD and VA continue to remain isolated and closed systems, not drawing on or leveraging the very public-private partnerships they say they want and need.”

On Sept. 25, the Defense Advisory Committee – a Stimson Center panel of 17 retired defense leaders and corporate officials – took an opposing approach to trimming defense spending. One of many controversial proposals in its “Strategic Agility: Strong National Defense for Today’s Global and Fiscal Realities” report is a call for a multibillion dollar “reform” of military health benefits.

“As with the rest of the country, the Department of Defense faces staggering and growing healthcare costs. Unlike the rest of the country, that burden is distributed disproportionately. Military retirees and their dependents pay only a fraction of what their civilian counterparts pay, producing incentives for non-essential medical care that overloads the system. Reforms have been proposed that could achieve savings without affecting the health care of any serving servicemember,” the panel reported.

“We recommend increasing means-tested beneficiary cost-sharing requirements for ‘TRICARE for Life,’ which provides secondary coverage for Medicare-eligible retirees, and TRICARE, the standard health plan for retirees and dependents, as well as higher cost-sharing for pharmaceuticals for dependents and retirees. Greater out-of-pocket costs would encourage beneficiaries to exercise more judicious use of healthcare services and promote use of less expensive, but equally effective, care options. These changes would produce $5 billion in savings by fiscal year 2015; annual savings would continue to grow over time.”

The future of military and veterans healthcare now faces a “perfect storm” – an unpopular Congress about to enter a new election year, a military struggling to deal with more than a trillion dollars in mandated budget cuts through the rest of this decade, a president under increasing pressure to resolve the nation’s economic woes, and an aging, growing population of veterans. How that will resolve is impossible to predict.

The future of military and veterans healthcare now faces a “perfect storm” – an unpopular Congress about to enter a new election year, a military struggling to deal with more than a trillion dollars in mandated budget cuts through the rest of this decade, a president under increasing pressure to resolve the nation’s economic woes, and an aging, growing population of veterans. How that will resolve is impossible to predict.

“The real problem is the balance between what the government is spending on military versus non-military,” Baker concluded. “Sequestration imposes 50 percent of its cuts on the defense budget, even though defense is only 20 percent of federal spending. The defense budget was the sole bill-payer for the so-called ‘peace dividend’ of the 1990s and remains the bill-payer today.”

This article first appeared in the The Year in Veterans Affairs & Military Medicine 2013-2014 Edition