Over one million U.S. military service members are members of the National Guard or reserves. These troops are being tested like never before, yet they do not receive the same physical and mental health care coverage provided to their active-duty counterparts, a gap that a recently introduced bipartisan bill seeks to address.
The year 2020 has been called "the year of the Guard," given nearly continuous activations for domestic missions supporting responses to the COVID-19 pandemic, several natural disasters, civil disturbances and unrest, and Department of Homeland Security activities at the southern border. As a result, 2020 required one of the highest mobilization levels of the National Guard since World War II. This may contribute to an increase in the use of health care benefits, particularly those associated with mental health care.
Referred to as the reserve component, members of the National Guard or reserves represent approximately one-third of all military personnel. The reserve component is strategically important within the U.S. armed forces, serving both international and domestic missions. Approximately one-quarter of U.S. military service members who deployed between 2001 and 2015 were in the reserve component. Reserves serve only on federal missions, while National Guard can be mobilized under state or federal orders.
Despite their essential role in the military, reserve component service members do not receive the same medical benefits as active component service members. Eligibility for military health insurance benefits under TRICARE changes over time based on whether a service member is “activated” for a particular mission and the length of the activation orders. When they are not on active-duty orders, reserve component service members might be covered by insurance provided through an employer or spouse. Thus, in a given year, a reserve component service member can receive health insurance from different types of TRICARE coverage, U.S. Department of Veterans Affairs coverage, and two or more sources of civilian coverage.
Members of the U.S. military must maintain good overall health to ensure peak performance, including mental health. During a recent visit to U.S. forces, Defense Secretary Lloyd Austin said, “mental health is health period. And we have to approach it with the same energy that we apply to…any other health issue, with compassion and professionalism and resources." For those with mental health concerns, having consistent access to high-quality treatment is not only essential to their own recovery and well-being but vitally important to military readiness.
Yet, there is a need to ensure that reserve component members receive consistent access to high-quality mental health care. A newly released RAND report found that reserve component members were often less likely to receive recommended mental health care compared to active component service members. The study assessed care delivered by the military to over 93,000 service members (active and reserve component) diagnosed with post-traumatic stress disorder, depression, or substance use disorder during 2016 and 2017. RAND researchers compared whether care differed for reserve compared to active components on whether servicemembers received recommended care for their diagnosis and found several differences.
For example, only 23% of reserve component personnel received adequate care – either psychotherapy or medication – when starting treatment for post-traumatic stress disorder, compared to 29% of active component service members. A more dramatic difference was found in rates of receiving timely outpatient follow-up care after discharge from psychiatric hospitalization. Upon discharge, patients are at increased risk for worsening symptoms, rehospitalization, and even dying by suicide. Timely follow-up care has been shown to reduce these risks, yet only 54% of reserve component personnel received follow-up care within 7 days of discharge, compared to 90% of active component service members.
Although RAND has not yet identified the reasons that might explain the observed differences in receiving recommended care between reserve and active component members, there are several possibilities. Contributing factors may include inconsistent insurance coverage, challenges associated with navigating changing coverage and providers, and the costs of maintaining coverage. Evidence following implementation of the Affordable Care Act showed that increased insurance coverage is associated with increased rates of receiving mental health care.
The role of the reserve component is being tested in historical ways, and the strain is being felt by those service members and their families. Efforts could be made to support the mental health needs of these service members. Army General Daniel Hokanson, chief of the National Guard Bureau, called delivering health care for all guardsmen a key legislative priority, recognizing that it is imperative to provide “access to the resources needed to maintain their resilience.” He noted that improving access to mental health care, in particular, could reduce suicide rates in the National Guard.
Consistent health care coverage for reserve component members is certainly one potential solution that could be explored. Given the differences that have been observed in rates of receiving recommended mental health care and its vital importance to the military, it may be time to explore policy solutions to ensure that reserve component personnel have access to high-quality mental health care.
Justin Hummer is an associate behavioral and social scientist at the nonprofit, nonpartisan RAND Corporation. Kimberly Hepner is a senior behavioral scientist and a licensed clinical psychologist at RAND.