Defense Health Care: Improved Monitoring Could Help Ensure Completion of Mandated Reforms
Fast Facts
Over the past 10 years, the Department of Defense has addressed 115 of 158 legally-required military health system reforms. For example, DOD created the TRICARE Select health plan—allowing beneficiaries to seek specialty care without referrals.
But DOD hasn't created a process to monitor its actions. Such a process would help DOD better oversee completion of the remaining requirements. This includes, for example, consolidating all military services' medical research and development under one new organization.
We recommended that DOD address this and other issues.
Highlights
What GAO Found
The National Defense Authorization Acts (NDAA) for fiscal year 2012 through 2022 contained 158 requirements—actions required for Department of Defense (DOD) to take—that GAO identified as reforms of the military health system. GAO placed each requirement into one of five reform categories.
DOD completed actions to address the majority (approximately 73 percent) of the requirements across the five categories (see figure).
Status of DOD Actions to Address NDAA Requirements
Note: GAO assigned each of the NDAAs' 158 requirements to a single category even when a requirement overlapped with another category. Four requirements were not counted because GAO could not determine DOD's past actions for various reasons, such as information posted online for a pilot program that ended.
Many of the requirements DOD addressed were from the NDAA for Fiscal Year 2017. For example, DOD established the TRICARE Select health plan (as required in section 701). Additional work remains for the department to complete actions to address the remaining requirements, which include several significant reforms. For example, GAO found that DOD partially addressed requirements from section 711 of the John S. McCain NDAA for Fiscal Year 2019 to establish public health and research and development organizations within the Defense Health Agency by September 30, 2022. As of April 2023, Defense Health Agency officials stated that the transfer of public health personnel was ongoing as DOD worked to complete Phase I of the transfer. Without finalizing implementation plans with timelines for completion and, although not required, providing them to Congress to improve oversight, DOD could be further delayed in addressing these requirements.
DOD has processes for delegating responsibility for addressing military health system reform requirements and identifying and tracking requirements for reports and briefings to Congress. However, DOD does not have a systematic process to comprehensively monitor actions to address reform requirements. By establishing such a process, DOD could improve oversight of its complex, multi-year reform initiatives, including performance of reforms in relation to the MHS goals of better health, better care, improved readiness, and lower costs.
Why GAO Did This Study
For the past decade, DOD has been taking actions to reform its health system. The military health system is a massive enterprise charged with maintaining a medically ready force and ready medical personnel. To achieve this mission, DOD estimated it will provide care to approximately 9.6 million beneficiaries at a cost of more than $55.8 billion in fiscal year 2023.
The NDAA for Fiscal Year 2022 includes a provision for GAO to study DOD's implementation of statutory requirements for military health system reform. This report examines (1) statutory requirements for reform of the military health system that GAO identified within each NDAA for fiscal years 2012 through 2022, and the extent to which DOD has (2) taken actions to address these requirements for military health system reform and assessed the effectiveness of certain reforms, and (3) monitored actions taken in response to the requirements. GAO analyzed NDAAs and DOD documentation, and interviewed DOD senior officials.
Recommendations
GAO is making four recommendations, including that DOD finalize implementation plans for the transfers of (1) public health and (2) research and development organizations, and establish a process to monitor actions taken to address statutory requirements for the military health system. DOD concurred with each of GAO's recommendations.
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Defense | The Secretary of Defense should ensure that the Secretary of the Air Force, in coordination with the Surgeon General of the Air Force and the Director of the DHA, completes a briefing to the House and Senate Armed Services Committees regarding the previous elimination of inpatient capabilities from its MTF at Aviano Air Force Base. (Recommendation 1) |
DOD concurred with this recommendation. The Air Force transmitted a report to the congressional committees in June 2023 explaining its transition of the MTF at Aviano Air Force Base to an outpatient clinic.
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| Department of Defense | The Secretary of Defense should ensure that the Director of the DHA, in coordination with the Surgeons General of the military departments, completes an implementation plan with related timelines for the remaining phases of the public health transfer and provides the plan to Congress. (Recommendation 2) |
DOD concurred with this recommendation. According to DOD, as of November 2023, the department was in the process of determining remaining phases of the public health transfer, including what functions the military departments will retain. DOD expects to complete its implementation plan by the end of fiscal year 2024. We will provide updated information about the final implementation plan and the status of this recommendation when it becomes available.
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| Department of Defense | The Secretary of Defense should ensure that the Director of the DHA, in coordination with the Surgeons General of the military departments, completes an implementation plan with related timelines for the transfer of research and development, and provides the plan to Congress. (Recommendation 3) |
DOD concurred with this recommendation. According to DOD, as of November 2023, the department was finalizing an implementation plan and expected to complete it by the end of 2023. We will provide updated information about the status of this recommendation when we receive the final implementation plan from DOD.
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| Department of Defense | The Secretary of Defense should ensure that the Assistant Secretary of Defense for Health Affairs establishes a systematic process to comprehensively monitor the actions taken to address statutory requirements for the MHS, and incorporates the information in its MHS evaluation activities. The process could include consolidating in a single data source the responsible leaders, actions taken, and time frames. (Recommendation 4) |
DOD concurred with this recommendation. According to DOD, as of November 2023, the department plans to create a repository of information about all reforms directed since fiscal year 2017. DOD expects to complete the repository by January 2024, and incorporate the information into its existing Military Health System Review and Analysis evaluation process by March 2024. We will update the status of this recommendation when further information is available from DOD.
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