Section Contents

1. Eligibility
2. Department of Defense
3. Veterans Health Administration
4. Private Sector
5. Nonprofit and Volunteer Organizations

As service members move from pre-enlistment, enlistment, deployment, post deployment, and separation from the military, they face a variety of health care systems including the Department of Defense, the Veterans Health Administration, as well as public and private insurance in the civilian sector. In order to address the needs of all service members and veterans, policy makers must address gaps in all the systems. This section provides a brief overview of the eligibility criteria for each system and the PTSD and TBI services available.

1.   Eligibility

Service members (active duty and Guards/Reserves) move through multiple payers and multiple service systems before, during, and after their deployment. At different times they may be covered by Civilian insurance (Medicare, Medicaid, or private insurance), VA, DoD/TRICARE, or they may, at times be uninsured (Exhibit 1).

Exhibit 1: Health Care Coverage for Service Members and Veterans

*Guard and Reserve members are considered “activated” when they are called or ordered to duty for more than 30 consecutive days.

A.   Active Duty

All active duty service members and active Guard and Reserve are eligible for health care through DoD. This includes direct services provided in Military Treatment Facilities (MTFs) as well as a managed care plan (TRICARE) that uses civilian sector providers.

B.   Veterans

OEF/OIF veterans are automatically eligible for enhanced enrollment in VA health care services for 5 years with no copayments. National Guard and Reserve members who have left active duty and have returned to their units also receive this enhanced enrollment eligibility. At the end of the five years, these veterans can continue to use VA services, but depending on their income and disability status, they may be required to make applicable copayments.

C.   Civilian Systems

Among OEF/OIF veterans who are eligible for VA health care, 35 percent used that care as of December 2007 (Veterans for Common Sense 2008). No information exists on the 65 percent that did not use VA services. Some likely relied on civilian coverage and others may have experienced no perceived need for care. Some may have tried to access VA care, but encountered barriers to accessing services. Others may be unaware of the services that are available. The actual number of eligible OEF/OIF veterans that will use VA services after the 5 year presumptive eligibility period will be determined by service-connected disability ratings and other factors. However, based on an analysis of veterans under 65, it is likely that a significant majority will rely on private insurance and some will be uninsured (Exhibit 2).

Exhibit 2: Health Insurance Status of Veterans Under age 65, 2007

Source: Author’s Analysis of the Current Population Survey

Description: Pie chart showing that among veterans under age 65, 17 percent are enrolled with VA (7 percent use VA only, 10 percent use VA in conjunction with other insurance). Most veterans (66 percent) are privately insured and do not use VA, 5 percent are enrolled in Medicare or Medicaid, and 13 percent are uninsured.

2.   Department of Defense

DoD provides health care to over eight million beneficiaries, including active duty personnel, and retirees and their dependents. DoD medical health system (MHS) has two missions—readiness and benefits. The readiness mission ensures that personnel are ready to deploy, provides medical services and support to the armed forces during military operations, and involves deploying medical personnel and equipment to support military forces throughout the world. The benefits mission provides medical services and support to members of the armed forces, their family members, and others entitled to DoD health care. (US GAO 2007).

DoD’s dual health care mission is carried out through a direct care system that comprises 530 Army, Navy, and Air Force Military Treatment Facilities (MTFs) worldwide. Within the direct care system, each military branch is responsible for managing its MTFs and other activities. Historically, these separate systems are not well coordinated. The services generally fail to cooperate with each other and resist efforts to consolidate their medical departments (US GAO 2007)

DoD also operates a purchased care system that uses civilian managed care support contractors (TRICARE) to develop networks of civilian primary and specialty care providers and to provide other customer service functions, such as claims processing.

Prevention Programs: The Army’s signature prevention program is the mandatory Battlemind training program, which is provided in a large group setting to all Army personnel prior to deployment, and immediately upon return. In the 45-minute pre-deployment program, soldiers about to deploy are told what they are likely to see, hear, think, and feel. The post-deployment program explains the possible impact of deployment on psychological, social-emotional, and behavioral functioning. It explains what is “normal” and provides information about available mental health resources available should service members have difficulties readjusting. The Battlemind program highlights the problems that can occur when the skills needed for effective combat are carried over into the home environment (Exhibit 3).

Exhibit 3: Combat Skills that Can Cause Problems if Not Adapted to the Home Front

Source: Walter Reed Army Institute of Research 2007

Battlemind has shown some success. The Army’s most recent survey of deployed soldiers found that soldiers who received training were less likely to screen positive for mental health problems while in Iraq (12 percent compared to 21 percent). Soldiers that did not screen positive were significantly more likely to agree that (a) the training in managing the stress of deployment was adequate, and (b) the training to identify service members at risk for suicide was sufficient. However, even with Battlemind training, one-third of soldiers were not confident in their ability to help service members get mental health assistance, and 40 percent were not confident in their ability to identify service members at risk of suicide (US Army Surgeon General 2008)

Mandatory Behavioral Health Screenings for PTSD: Beginning in 1998, DoD has required service members to complete a Pre-Deployment Health Assessment (PHA) shortly before deployment and the Post-Deployment Health Assessment (PDHA) immediately after deployment. Recognizing that a service member’s symptoms may change over time, DoD recently mandated that the Post-Deployment Health Re-Assessment (PDHRA) be completed six months after the service member returns home.

Military members complete a brief set of screening questions, which are reviewed by a mental health professional. The service member is supposed to be referred for additional services as needed. Although the screenings potentially can identify individuals who need, but do not seek, services, they have significant limitations.

• Implementation of this program varies among military installations, and the reviewing providers may lack the necessary training to detect and address pathology (US GAO May, 2006).
• Referrals are inconsistent. A GAO report found that, four of five returning troops potentially at risk for PTSD, were not referred for further mental health evaluation. Half of those eventually got help on their own, but less than 10 percent were referred through the military (US GAO May, 2006).
• Service members may not accurately report their mental health concerns.

TBI Screenings: DoD admits that it lacks a system-wide approach for proper identification, management, and surveillance of individuals who sustain mild to moderate TBI (English 2007). However, quality pilot programs have been in existence for some time and efforts are underway to make screening universal.

Treatment:  In addition to services available through TRICARE (described in detail below), DoD has a variety of programs designed to maintain the psychological readiness of the forces that are administered both within and outside the confines of the Defense Health Program including, for example:

• Military Treatment Facility: Installation-level military medical treatment facilities and the larger military medical centers and clinics each develop and implement programs focusing on deployment issues. While there are a number of excellent programs, the availability, coherence, and quality of such programs varies across the system, depending upon the number of mental health professionals assigned to the unit, their training and experience, and command support for behavioral health programs (US DoD Task Force on Mental Health 2007).
• Military OneSource: This initiative offers a 24-hour, 7-day-a-week, confidential nonmedical information and referral system that can be accessed through the telephone, Internet, and e-mail. It also offers confidential short-term (up to six sessions per year per problem), face-to-face counseling for nonclinical problems. If care is sought for a clinical problem for which TRICARE provides reimbursement, Military OneSource refers the individual to TRICARE or the nearest MTF.
• Chaplains: Military mental health services often are delivered in partnership with services provided by military chaplains. This is especially true in deployed environments where mental health and pastoral services constitute an essential component of deployment support. Outside of the deployed environment, military chaplains provide marital and individual counseling, and service members may seek out chaplains because issues of stigma may be lessened, and greater assurances of confidentiality may be offered.
• Substance Abuse Prevention and Treatment: Each military service has substance abuse prevention and treatment programs.
• Other Organizations: A number of other organizations provide direct or indirect support for the psychological health of military members and their families, including Health Promotions Offices, Sexual Assault Prevention and Response Offices, Exceptional Family Member Programs, Suicide Prevention Programs, and Combat Operational Stress Control programs.

This multiplicity of programs, policies, and funding streams provides many points of access to support for psychological health. However, the multiplicity may also lead to confusion about benefits and services, fragmented delivery of care, and gaps in service provision (US DoD Task Force on Mental Health 2007) and cause considerable variation in mental health service delivery among the different bases and military services.

In addition, the military has a shortage of uniformed behavioral health professionals. This shortage is exacerbated by the need to spread these providers between deployed and nondeployed settings, the high turnover rate, and the limited ability to rely on civilian professionals (American Psychological Association 2007). Several commissions and studies—including the DoD Task Force on Mental Health—have concluded that the number of mental health care professionals in the military health care system is too low to meet current needs.

The military is trying to meet this demand for mental health by offering financial incentives to recruit and retain existing psychologists, psychiatrists and other mental health professionals, and by offering expanding internship opportunities for training. Besides bringing on more professionals to active duty, the Army, Navy and Air Force are all hiring professionals as civilian contractors or federal employees.

Psychological Health Services in Theater: Recognizing that isolating mental health professionals in offices or clinics may discourage service members with concerns about the stigma from seeking care, the military has been embedding mental health providers in units. Each branch has developed a slightly different approach but all are based on the theory that keeping service members with their units helps in the recovery process.

The Army has three tiers of care. The first tier is provided by fellow service members or uniformed mental health professionals and chaplains embedded with the troops. In the next tier, the soldier is taken to a “combat stress control unit” for one to three days of rest, hot food, hot showers, clean uniforms and medication if needed. The stress control unit is near the combat unit and can relocate if the combat unit relocates. Soldiers are treated with the expectation that they will feel better in a couple of days and go back to work. An advantage of this approach is that soldiers maintain their identity with their combat unit and leadership. The third tier is a combat support hospital that provides more intensive services. If the issue cannot be resolved in these settings, the soldier is evacuated to Germany or the United States.

The Marines’ Operational Stress Control and Readiness (OSCAR) program matches psychologists, psychiatrists and mental health technicians with Marine regiments in the months before a deployment, continuing during a rotation in Iraq, then back home. The Navy has the “Psychologists at Sea” program that puts Navy psychologists aboard aircraft carriers.

Despite these new programs, access to behavioral health services in theater is limited. Compared to 2006, soldiers reported more difficulty accessing services in 2007. The Army advisory team cites a shortage of behavioral health personnel in Iraq, with one behavioral health provider for every 734 soldiers (US Army Surgeon General 2008).

TRICARE: TRICARE Prime, the health care plan available to active duty service members and activated guard and reserve troops, is similar to a civilian maintenance organization (HMO), where each enrollee is assigned a “gatekeeper” who provides primary care and authorizes referrals for specialty care. Beneficiaries receive care from a Military Treatment Facility (MTF) when available. If services are not available at the MTF, or the enrollee does not live near an MTF, he or she may seek care from a provider in the TRICARE network—a network of civilian health professionals. A point of service option is also available for care received without a referral, but results in higher out-of-pocket costs.

Although the TRICARE benefit covers outpatient mental health, service members who rely on the TRICARE network often have limited access to services. The DoD Task Force on Mental Health found that many providers on the TRICARE network provider list were not accepting TRICARE patients. A recent GAO survey of Reservists, most of whom had prior experience with private insurance coverage, also highlighted the paucity of available TRICARE network providers. Although the survey did not focus on mental health providers specifically, it found that only 12 percent of Reservists felt that the availability of providers and specialists was better in TRICARE than in the private sector, compared to 50 percent who felt that availability was better in the private sector (US GAO Feb 2007).

While there are some areas where TRICARE seems to be providing an accessible continuum of mental health services, this is not generally the case. With increased deployments of National Guard and Reserve members who have time limited TRICARE coverage for themselves and their families, combined with increasing demand for services from families and retirees and the deployment of mental health professionals who would otherwise be providing services on base, the networks are stretched to their limit. TRICARE has difficulty expanding the network because of low reimbursement rates and fragmented rules (US DoD Task Force on Mental Health 2007).

The DoD Mental Health Task Force determined that the TRICARE continuum of care for mental health services is severely deficient. Intensive outpatient care, one of the most frequently utilized services in private and VA care is not covered at all, substance abuse treatment options are limited, characterized by very poor access, and well below the level offered even by Medicaid. Crucial early intervention services including marital/family counseling and early intervention for hazardous substance misuse are not covered (US DoD Task Force on Mental Health 2007).

Based on recommendations from the DoD Mental Health Task Force, the Secretary of Defense has undertaken efforts to increase staffing, increase recruitment and improve the continuum of TRICARE services.

3.   Veterans Health Administration

VA operates the nation’s largest integrated health care system with over 210,000 employees and a budget of $37.3 billion. In fiscal year 2007, VA provided health care to approximately 5.6 million veterans at 157 VA Medical Centers and 875 community-based outpatient clinics nationwide (US Department of Veterans Affairs 2008). As of April 2007, over one-third (35 percent) of the 717,000 OEF/OIF veterans, who were eligible for VA services, sought VA care, most commonly for musculoskeletal injuries and mental health issues.

VA has undergone significant positive changes in the past 10-15 years. It has become an integrated system that is, by many measures, producing the highest quality care in the country (Longman 2005).

This improvement can be credited at least partially to the system being decentralized, with treatment being shifted to more outpatient settings. The system is now divided into 21 regional “Veterans Integrated Service Networks” that administer health services and tailor service delivery to local needs and conditions. In addition to decentralization, VA also developed an electronic medical record system (VISTA) heralded as a model for other providers (Frist 2005). These significant improvements notwithstanding, VA continues to face challenges in adapting the current health care delivery to meet the unparalleled incidence of PTSD and TBI in the returning OEF/OIF veteran population.

There is concern that VA is not geographically accessible to all veterans. Approximately 39 percent of veterans reside in rural areas. Although according to VA, over 92 percent of enrollees reside within one hour of a VA facility, and 98.5 percent are within 90 minutes, this includes small community based outpatient clinics, which offer very limited or no mental health services (Cross 2007). Some argue that VA should consider itself the healthcare provider for all veterans and provide services both through VA staffed clinics and where necessary, due to travel time or other factors, through contractual arrangements with local providers.

Vet Centers: In addition to the medical centers and clinics, VA has 209 Veterans Readjustment Centers known as “Vet Centers.” They have a considerable degree of autonomy and thus can tailor services and staffing to meet the specific cultural and psychological needs of the veterans they serve. Although the centers get some support from VA health centers, they are separate entities and guarantee that anything said at the Vet Center stays at the Vet Center. VA is implementing plans to expand the number of Vet Centers to 232 within the next two years.

Every Vet Center has at least one VA qualified mental health professional on staff. In FY 2006, the Vet Center program had 1,066 assigned staff positions of which 159 were outreach specialists and 876 were authorized counseling staff (58 percent of whom were licensed mental health professionals). Vet Centers are generally small, storefront buildings with four or five staff members, two-thirds of whom are veterans (Batres 2007).

One of the distinguishing features of the Vet Center program is its authority to provide services to veterans’ immediate family members. As noted earlier, family participation can be critical to the success of treatment. Therefore, family members are included in the counseling process, to the extent necessary to treat the veterans’ readjustment issues. Veterans' immediate family members are also eligible for care at Vet Centers. In addition, Vet Centers offer bereavement counseling to surviving family members.

Outreach for OIF/OEF veterans: VA has invested new resources to reach out to OIF/OEF veterans. Hundreds of outreach workers, mostly OIF/OEF veterans have been hired by both the VA medical centers and Vet Centers. These outreach workers and other VA staff members attend all demobilization activities for National Guard and Reserve Units, and attempt to in general make OIF/OEF veterans aware of services and facilitate their use of services.

Screening and Assessment:  VA provides screening for mental health issues, including depression, PTSD, and substance abuse in all primary care clinics. Recently VA implemented universal screening for TBI for all OIF/OEF veterans. Patients screening positive on any of the mental health or TBI screens are further evaluated and triaged to treatment as indicated.

Treatment: VA offers a continuum of care for patients with mental disorders but not all types of care may be available to each client. For PTSD each medical center has at least one therapist who specializes in the care of patients with stress disorders. Most have an interdisciplinary PTSD team, and at selected medical centers intensive outpatient, residential or impatient programming is available. A few medical centers have programs specifically dedicated to female veterans or veterans with comorbid substance abuse. A few of the largest Community Outpatient Clinics offer specialized PTSD care, but most offer only general mental health care, and smaller clinics may offer only primary care.

As noted earlier in this report, analyses of the effectiveness of PTSD treatments including the most recent Institute of Medicine report indicate that the treatments with proven efficacy are intensive and time consuming to administer. They require specialized training for staff and the availability of time to provide them to veterans. VA has struggled to translate the results of these effectiveness studies to widespread clinical practice across the system. Efforts are ongoing, and VA has created a special office to try to improve the translation of evidence based approaches, but they are still unavailable in many locations.

Some locations, particularly smaller clinics rely on “telemental” therapy, in which clients receive treatment from a remote mental health professional using video conferencing. While preliminary research clearly has established that a variety of telemental health modalities are feasible, reliable, and satisfactory for general clinical assessments and care, much less is known about the clinical application and general effectiveness of telemental health modalities employed in the assessment or treatment of PTSD (Morland et al. u.d)

Waiting lists and waiting times: VA recently completed an analysis of gaps in mental health care throughout the system. This analysis underscored the reality that access to services is still unacceptably variable across the VA system, despite considerable augmentation of programming in the past few years. In response VA is beginning to fund additional initiatives to fill these gaps. For example in September 2008 VA announced it was adding substance use disorder clinicians to PTSD teams at a cost of $13.3 million per year and that it will provide approximately $17 million per year to establish Intensive Outpatient Substance Use Disorder Programs at 28 additional medical centers, bringing the total number of facilities with these programs to 105.

4.   Private Sector

A large percentage of veterans, Guard members, and Reservists rely on TRICARE or private insurance provided by their own, or their spouse’s, employer. As a result, many providers treating these service members are not part of the military or VA system, and may not be familiar with the unique needs of the population.

Relative to active duty families, members of the National Guard and Reserves and their families have limited access to military chaplains, family support programs, and all other parts of the military landscape designed to support psychological health. Unfortunately, community providers may not be sufficiently aware of or sufficiently trained to fulfill their needs (US DoD Task Force on Mental Health 2007).

The military service branches and VA have undertaken efforts to disseminate knowledge and best practices to civilian health professionals. For example, the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences developed a two-week intensive training course and a series of seminars, and is planning to reach out to both military and civilian psychologists, psychology interns and residents.

Private insurance does not guarantee access to quality mental health services. The President’s New Freedom Commission on Mental Health identified several obstacles that prevent insured consumers from getting appropriate care in the private sector. These obstacles include unfair treatment limitations and cost-sharing requirements placed on mental health benefits, and a fragmented mental health delivery system (President’s New Freedom Commission on Mental Health 2003). As the Institute of Medicine points out in Improving the Quality of Care for Mental and Substance-use Conditions: Quality Chasm Series (2006), mental health care is frequently delivered in ways that are not consistent with scientific evidence, and often delivered in isolation from general health care, despite the fact that mental illnesses and general health problems are frequently intertwined. Patients receive care from multiple physicians, across multiple sites, and in multiple delivery systems. These different entities often fail to coordinate care or share information. This failure to collaborate jeopardizes patients’ health and recovery. Collaboration is especially difficult because mental health substance-use problems are often addressed by public-sector programs apart from private-sector general health care.

5.   Nonprofit and Volunteer Organizations

Numerous nonprofit and volunteer organizations provide creative approaches to reducing PTSD symptoms and helping service members and veterans reintegrate into society. These types of programs could play an important role in encouraging veterans to seek longer-term professional care or in supplementing traditional therapies. For example:

• Organizations such as Give an Hour, Operation Comfort, Strategic Outreach to Families of All Reservists (SOFAR), the Colorado Psychological Association, and The Returning Veterans Project NW provide free counseling services.
• The Wounded Warrior Project has a weeklong adventure program including ropes courses, water sports, and a Native American healing ritual.
• The Valley Forge Return to Honor Workshop offers complimentary three-day intensive cognitive and experiential reintegration workshops.
• The Merritt Center offers complimentary retreat programs that include walks in the woods, sweat lodge ceremony, therapeutic massage, release exercises of body and mind and other relaxation strategies.

Some programs serve a small geographic area, while others are nationwide. Each program performs its own outreach based on its available resources. These programs have no national registry.