Federal Report

Congress nudges DoD toward fixing serious health care shortfalls in Japan

DoD has gone some way toward easing the health care access problems employees in Japan have faced. But Congress is paying attention to ongoing challenges.

Jared Serbu@jserbuWFED

July 17, 2023 5:06 pm

6 min read

Provisions in a pair of must-pass pieces of legislation making their way through the House of Representatives could go some way toward addressing what advocates say is a lingering crisis in access to health care for DoD employees in Japan — particularly for the more than 6,000 members of the department’s civilian workforce who serve there.

One of the provisions, part of the 2024 defense authorization bill the House approved on Friday, would order U.S. Indo-Pacific Command, the geographic combatant command responsible for military forces in the region, to conduct a study on whether the personnel who support its missions are getting the health care they need to keep doing everything they do.

The study would be specific to personnel assigned to United States Forces Japan and Joint Region Marianas, and would need to be conducted in fairly short order: INDOPACOM would have to let Congress know at least its preliminary views on the care the Defense Health Agency is delivering within 60 days after the bill’s passage. A final report along with any potential recommendations for added funding to improve those services and hire more health care personnel would be due within a year.

Although access to health care has always been somewhat challenging for DoD civilians in Japan, as Federal News Network reported in February, the problems began to escalate significantly last fall.

Technically, civilians have always been treated on a “space available” basis in military treatment facilities (MTFs). But in September, the Defense Health Agency’s regional director adopted a new, narrower reading of that principle, which had the effect of restricting civilians’ care at MTFs to only acute, non-recurring health problems. The change also made it impossible for civilians to make medical appointments until the day they wanted to be seen — and only if appointments were available on that day.

Following a listening tour in Japan by Gil Cisneros, DoD’s top personnel official, DHA partially reversed that policy in March, letting civilian employees make primary and specialty care appointments in advance, including for non-acute health conditions.

But the changes did not go far enough, according to Japan Civilian Medical Advocacy, a volunteer organization of DoD civilian employees, because they didn’t fully restore access to emergency care, nor did they address the underlying shortage of medical personnel and appointments — an issue that also affects active duty military members and their families.

The House version of the NDAA asks INDOPACOM to use that latest DHA policy as a baseline to assess how its missions and costs would impacted by its military and civilian workforce’s access to health care. It also asks for “mission risk assessments” under theoretical alternative scenarios in which the military health system would be directly responsible for also caring for civilians and their families – not just on a space available basis – and for “entities who have entered into agreements” with DoD, like contractor employees.

And recent events since the March policy reversal have shown some additional evidence that the Military Health System’s posture in Japan isn’t just affecting its space available patients.

Last month, expectant moms who’d planned to deliver their babies at Naval Hospital Okinawa between August and and December of this year were told they’d need to plan to be put into a “Stork Nesting” program that would have required them to fly to an MTF in the continental U.S. to deliver their babies there instead, because of a shortage of practitioners at that facility.

A few days after the “Stork Nesting” plan gained some media attention, the Defense Health Agency added a notice to its website saying it had figured a way out of the problem:

“Through a collaborative effort on the part of DHA and the medical departments of all military services, Okinawa will continue to provide full labor and delivery services for all beneficiaries within the INDOPACOM area of responsibility.”

Meanwhile, the House’s Defense appropriations bill also asks the department for answers about health care access, but without directly referencing Japan.

In directive language accompanying the bill, appropriators said they had broader concerns about reforms that have been underway since 2017, when Congress first ordered the military services to turn the management of their hospitals and clinics over to DHA.

“The committee remains concerned that reforms to the Military Health System have been implemented in a manner that has resulted in a more fractured healthcare system for servicemembers and beneficiaries,” appropriators wrote. “Specifically, the committee is concerned about continued issues in medical readiness, medical manpower, and access to care. In order to achieve a more unified medical enterprise and integrated healthcare system that best supports servicemembers and beneficiaries, the committee directs the secretary of Defense to develop a strategy to address deficiencies within the MHS enterprise and brief the congressional defense committees on the strategy not later than 180 days after the enactment of this act.”

In a separate provision of the appropriations bill – which would still need to be reconciled with its Senate counterpart and signed by the president before it became law – the House committee expressed concern about understaffing issues in MTFs, and included a provision that would order DHA to deliver a report on how it could rearrange its current health care market structure and revamp its hiring processes for health care practitioners.

“The committee acknowledges DHA’s difficulties in attracting and hiring qualified medical personnel, particularly nurses,” lawmakers wrote. “The committee believes that current hiring practices leave the department at a disadvantage when recruiting personnel. The committee directs the director of the DHA to examine the hiring policies for nurses, related specifically to required professional experience, and provide a briefing … describing potential solutions to this impediment and the feasibility of providing market directors greater hiring flexibility.”

Although the current markup season for the 2024 DoD authorization and appropriations bills represents the first time lawmakers have expressed concern about the access problems in Japan via legislation, members of Congress have raised flags about the issue prior to now in other ways.

In an April 21 letter to Defense Secretary Lloyd Austin, 11 members of Congress led by New Jersey Rep. Frank Pallone said the department needed to take “immediate action” to provide access to health care for the entire DoD population serving in Japan.

“Civilians and contractors perform vital services for the United States’ mission to protect our national security and interests overseas. They and their families deserve access to adequate medical care,” the lawmakers wrote. “If guaranteed access to primary and emergency care is not made available to all Total Force patients by the DoD, civilian personnel will be forced to leave Japan. The very real possibility of a mass exodus of civilians would severely weaken military operations at a time when tensions are rising in a strategic region.”