In a statement on health care issues to the Senate Armed Services Subcommittee on Personnel, TMC was blunt in its criticism of past, current, and proposed future reductions in care and increases in fees and other costs as part of DoD and VA attempts to deal with tight federal budgets.

“Retired service members, their families, and survivors have been no stranger to sacrifice. Nearly 600,000 of today’s retirees served on active duty during the current Iraq/Afghanistan wars. Hundreds of thousands more saw service in multiple hot and cold conflicts. Older retirees endured years when the government provided them no military health coverage and those retired between 1985 and 2005 have forfeited an average 10 percent of earned retired pay because they retired under pay tables depressed by decades of budget-driven capping of military raises below civilian pay growth,” the group told lawmakers.

“Pentagon leaders’ insensitivity to this situation is perfectly illustrated by Secretary [of Defense Leon E.] Panetta’s answer at a recent Senate Budget Committee hearing. When asked why the proposal focuses so much on raising fees for military retirees, he answered they would accept the changes because they’re used to doing what they’re told and used to a culture of sacrifice. In other words, they’re used to abuse so we can – and plan – to abuse them again.”

The VA, of course, has a decidedly different view of its budget priorities and plans for providing health care to the nation’s veterans. In its Medical Programs budget proposal for FY 13, the department said its funding request “is structured on a framework which reflects four major categorizations: Medical, Benefits, Corporate, and Inter-agency.” It was especially pointed in praising the VA Innovation Initiative (VAi2), part of the department’s effort “to accelerate the VA’s transformation into a 21st century organization that is Veteran-centric, results-oriented and forward-looking.”

“VAi2 provides a structured way for the department to identify and evaluate new solutions and technologies while allowing improved collaboration between VA leadership, frontline employees, the private sector and the veterans we serve,” according to the budget document.

“Through VAi2, the department demonstrates its commitment to continuous innovation and improvement to maximize access, quality, and performance for veterans while reducing costs, wherever possible, to taxpayers. VAi2 is built upon a belief that some of the best ideas can be found outside of Washington – from the VA clinician, nurse, and claims processor in the field to major academic centers and small veteran-owned start-up companies. VAi2 uses competitions to identify innovative new ideas from these multiple sources.”

“VAi2 will remain flexible and open to new opportunities for special projects that can have rapid and meaningful impact on VA’s quality, access, cost and performance,” the document added.

But not everyone is convinced, especially TMC, which sought to drive home one central point in their testimony to Congress on DoD and VA health care budgets: “History shows clearly that there are unacceptable retention and readiness consequences for shortsighted budget decisions that cause servicemembers to believe their steadfast commitment to protecting their nation’s interests is poorly reciprocated.”

That the changing demographics of the veteran population – from a growing percentage of female and aging veterans to where they live and the health issues they face – must be addressed by current and future VA budgets is undisputed.

“There will be bigger growth in the veterans population and health care issues coming that are out of proportion to the size of the general and even the military population,” Heritage Foundation analyst James Carafano, director of the Allison Center for Foreign Policy Studies, said. “The nature of the veteran population also will shift significantly in the future, including being far more mobile.

“The VA model is largely built on large hospitals in urban areas, where those volunteering now are increasingly white, rural high school graduates. Which means today’s incoming veterans are more likely to go back to their rural roots.”

How the VA deals with those changes – and how its actions are perceived by the veterans it serves – will be subject to all of the drivers that influence the federal government and its budget priorities: real needs, political issues, economic pressures, etc. Some of those also drive the health care needs of veterans, especially as new diagnoses and treatments become available even as the cost of services – and veterans’ ability to contribute to paying those costs – become more acute.

This story was first published in The Year in Veterans Affairs & Military Medicine 2012-2013 Edition.