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December 6, 2012

COMMENTARY: In times of tight budgets, questions arise over what the Pentagon's Tricare Health-Care Program should cover

WASHINGTON — Who should pay for costly special treatment for autistic children in families of active and retired military service personnel?

This is no idle question. It relates to the Pentagon budget before Congress and, in a broader sense, to the "fiscal cliff" and Americans' view of government spending.

In May, the Republican-controlled House approved a bipartisan amendment to transfer $30 million from the Army research and development account in the fiscal 2013 defense authorization bill to create a new section under the Pentagon's Tricare health-care program. The section would broaden the availability of money for applied behavior analysis (ABA) treatment of autistic children when prescribed by a physician.

Until recently, the Defense Department considered ABA treatment an educational intervention, not a medical therapy, so it was not broadly covered under Tricare. It is an expensive treatment "generally begun by age 3 1/2 and consists of up to 40 hours per week of intensive therapy for two years or longer," according to the Congressional Research Service.

Tricare's Extended Health Care Option program, under which ABA was permitted, was limited to active-duty personnel and had an annual cap of $36,000 per enrollee. The American Academy of Pediatrics recommended at least 25 hours a week of intense therapy for children newly diagnosed with autism, but the Tricare cap permitted less than 20 hours a week for therapy.

During the House debate on the measure, Rep. John B. Larson, D-Conn., co-sponsor of the amendment, said the cap had to be removed and coverage needed to be expanded to include retired military personnel as well as those on active duty.

Also in May, the Senate Armed Services Committee voted down a similar amendment — sponsored by Sen. Kirsten Gillibrand, D-N.Y. — to the authorization bill. But after a Senate Armed Services subcommittee hearing in June, Gillibrand reintroduced the amendment when the bill came to the Senate floor.

On Thursday, the Democratic-controlled Senate voted overwhelmingly for the Gillibrand amendment, which would shift $45 million from the Defense Department operations and maintenance account in the fiscal 2013 authorization bill to pay for ABA treatment under Tricare. Her amendment would increase the House amount and also cover the Coast Guard, the Commissioned Corps of the National Oceanic and Atmospheric Administration, and the Commissioned Corps of the Public Health Service.

Gillibrand said she was speaking for "30,000 military families who have loved ones with disabilities, including those on the autism spectrum." She said that "military families with children on the autistic spectrum are receiving fewer services than their civilian governmental counterparts across the country," noting that "the Office of Personnel Management has determined that such treatments may be covered as medical therapies for federal civilian employees."

She also pointed out that "Guard and Reserve families receive intermittent care, and children of retirees can't even get coverage at all." One result is that some current and former service members turn to state Medicaid programs for help. But ABA and other services are often unavailable because of waiting lists — seven years long in Maryland and 10 years in Virginia — according to Gillibrand.

And remember, Medicaid is a program Congress is looking at cutting.

Sen. Tom Coburn, R-Okla., who has been critical of other types of Pentagon spending for medical health programs, praised Gillibrand for saying the Pentagon should offer ABA treatment. But he wanted to add one provision — that all the active and Reserve service members in Tricare prime pay $2 more per month — $24 a year — which would cover the cost of the additional therapies for autistic and other disabled children.

The Tricare Prime annual enrollment fee for retirees rose by $30 a year in fiscal 2012 for an individual, to $260, and $60 a year for family enrollments, to $520.

Those increases, the first since 1995, became sensitive issues. The Obama administration has tried to increase Tricare fees further, but Congress has balked. One irony is that health-care programs for other federal employees — some of which cover autism therapy — start at roughly seven times the cost of Tricare.

"One of the things we ought to do is . . . to bring Tricare standards up to make sure they meet the needs of everybody. I don't disagree with that," Coburn said. "But the other thing we ought to do is we ought to pay for it."

"All it would take is $24 a year by our Tricare Prime [beneficiaries] to pay to make sure that the people with disabilities and the people with autism have the appropriate therapies and they are covered under Tricare," Coburn said. Taking the money from operations and maintenance will mean "less flight time, less drill time, less shooting time, less preparation time to go out and be a war fighter," he said.

Gillibrand didn't work with Coburn last week on a payment amendment. Instead, she said, "This is $45 million for one year just to get the treatments in place for these families. In one year's time, we will have more accountability and transparency on what the real cost is. This is just an estimate."

In 1992, Sen. Tom Harkin, D-Iowa, introduced a $25 million amendment to have the Pentagon conduct breast cancer research. Twenty years later, it has become a more than $200 million-a-year program covering research on dozens of diseases.

We must consider how many more disease therapies Tricare will cover — and who will pay for them.

Pincus reports on intelligence, defense and foreign policy for The Washingon Post and writes the Fine Print column.

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