April 02, 2019

Helping Special Needs Families and Improving Military Readiness

The Department of Defense (DoD) is moving out on efforts to rebuild the warfighting readiness of the joint force with the objective of reducing the number of nondeployable service members to a maximum of 5 percent across all military services. As then–Defense Secretary Jim Mattis said, “you’re either deployable, or you need to find something else to do. I’m not going to have some people deploying constantly and then other people, who seem to not pay that price, in the U.S. military.” While commanders focus on the readiness of their active-duty service members, an often overlooked but equally important measure of readiness is providing medical and educational support for military families with special needs.

Currently, DoD assigns military personnel to new duty locations based upon military requirements and then medically screens family members for eligibility to accompany them. This process is inefficient; lacks sufficient oversight, standardization, and transparency; and is prone to mistakes. Frustrations navigating this complex process distract military personnel from their primary duties and prevent members from serving in duty locations of their family’s preference and their nation’s need.

As each of the military services works toward improving military readiness, it should also strive to improve programs intended to support our military families and their readiness.

Many families have been assigned to duty locations where they cannot obtain necessary medical care or educational support for their dependents. Other families are unnecessarily denied desirable assignments with their families because access to essential care is unknown and the military families are not empowered as decisionmakers. Military units are placed under increased strain when inbound assignments are cancelled or deferred, and critical positions are left vacant until future assignment cycles. These strains decrease military readiness, limit service member career opportunities, place unnecessary stress on military families trying to access needed care, and further burdens families who are willing to accept increased financial costs associated with unaccompanied assignments overseas without command sponsorship.

The DoD manages care for special needs family members through initial identification within the Exceptional Family Member Program (EFMP). EFMP is a mandatory enrollment program that is intended to work with other military and civilian agencies to provide a multi-agency approach for community support, housing, medical, educational, and personnel services to families with special needs. Both the 2012 and 2018 Government Accounting Office (GAO) investigations identify frustrations with support for special needs families and the EFMP process in general and recommend increased oversight and standardization across the services. The reviews also note a lack of common performance measures to properly assess the effectiveness of current EFMP programs. More recently, 35 military families submitted a formal complaint to the principal deputy inspector general for the Department of Defense, citing that “DoD’s continued failure to follow the law, its history of mismanagement of these critical programs, and the inconsistent approaches across the services warrants the in-depth type of review and oversight only your office can provide.”

This is a significant problem affecting thousands of military families: a 2018 GAO report documented that as of 2016 there were 104,677 active-duty family members (across all military services in the continental United States and excluding overseas forces) enrolled in EFMP and requiring special needs support. Additionally, according to the report “America’s Military Readiness and the Essential Role of Medicaid,” published by Tricare for Kids Coalition, 200,000 children of active-duty service members have health coverage through Medicaid, which often serves as an extended medical coverage for special needs children. The Congressional Research service reported, as of October 2018, approximately 8 percent (137,000) of military family members receive support from EFMP. These reports reveal a significant percentage of families are affected by EFMP and potentially limited in where the DoD can assign their families for military duty.

EFMP in Practice

When I was assigned to flying squadrons at Kadena AB, Japan, I had friends who were denied EFMP clearance and accepted unaccompanied assignments so that they could continue flying F-15s in the active-duty Air Force and continue their military career progression. While both officers had the option of leaving their families behind, they elected to keep their families together. These fighter pilots paid for their EFMP family members to travel overseas at their own cost, accepting the associated risk of not having access to the military treatment facility (MTF) and being responsible for seeking medical care in the host country for those family members denied EFMP clearance.

Later in my career, as a fighter squadron commander I frequently dealt with frustrations navigating the EFMP process with officer and enlisted personnel. In my first year of command, approximately 10 percent of our active-duty graduates were unable to accept assignment overseas with their special needs families and were diverted to stateside assignments. This is despite having the support of every commander in the chain of command to work within the existing system to find a solution that met the needs of the airmen and their family, as well as the needs of the Air Force.

There is a lack of oversight, standardization of services, and responsibility at the installation level.

One young lieutenant was finishing almost two years of intensive flying training – worth upward of $9 million – to graduate as an F-15C pilot and join the combat Air Force. He had an assignment to RAF Lakenheath, England, pending review because a family member had been identified as special needs and enrolled in EFMP. Because the MTF at RAF Lakenheath did not have adequate services to support the medical needs of the child, the assignment was ultimately denied. The airman was diverted to an assignment stateside with the Air National Guard. The airman and his family had no voice in the decision; they wanted to accept the assignment to England, understood the limited care available through the MTF, and could have accessed needed care within the host nation medical system. With the current pilot shortage, and the continuing efforts to increase pilot production and improve retention, the Air Force should jump at the chance to allow more service members the opportunities to serve in locations of their preference.

A common frustration voiced by my airmen was the lack of transparency in the EFMP process. Once a military service member is notified of a new assignment, they must complete a long checklist of training, out-processing, and overseas screening items before receiving orders authorizing their permanent change of station. All military personnel with families must also submit EFMP paperwork for review by medical personnel at the gaining base. After the paperwork is submitted, active-duty personnel have no ability to track the status of the review, and they wait an average of four to six weeks for a decision authorizing or denying accompanied travel of their dependents. According to Lt Col Matt Thomas, 550th Fighter Squadron Director of Operations, in the fall of 2018, pilot graduates caught in this process were waiting up to three months after graduation to learn of their follow-on assignment. This waiting period is another frustration for military families left in limbo while trying to make plans to relocate their families, as they are unable to terminate rental contracts or sell their homes, locate new housing, find new schools, coordinate household goods shipment, etc.

Colonel Scot Heathman, Vice Commander Fairchild AFB, shared with me his family’s frustrations with EFMP when past assignments were denied and official forms could not be provided. There was an overall lack of communication throughout the process. He believes the number one desire for EFMP families would be to create a “faster, more efficient, less burdensome PCS (permanent change of station) experience."

During a panel discussion hosted by Tricare for Kids Coalition, LCDR Anthony Putney (ret.) shared his experiences and frustrations, common to other military members, with securing special needs care for his daughter at multiple assignments. Navigating the complexities of insurance claims and medical coverages, which vary state to state, felt like a full-time job and made it difficult to focus on his role as an air traffic controller. LCDR Putney also shared that a requested stateside assignment was denied because medical care for their special needs’ child was not available at the base MTF, even though adequate medical care was available in the surrounding community. This denial violated EFMP standards because the surrounding community could provide adequate care.

An Unfulfilled Commitment to Military Families

In 2011, President Obama made the “care and support of military families a top national security policy priority” when signing Presidential Directive No. 9, titled “Strengthening Our Military Families: Meeting America’s Commitment.” The president committed to ensuring that “our active duty personnel, reservists, guardsman, veterans, caregivers, and their families … have the resources they need to be their best.” Unfortunately, an examination of the past ten years concerning support provided to military families with special needs is inconsistent and lamentable.

There is a lack of oversight, standardization of services, and responsibility at the installation level. With multiple offices in charge of different portions of EFMP, MTF organizations that manage important tasks – like ensuring needed medical and educational services are available prior to orders being issues – lack standardization between installations and the military services. This results in decreased support for EFMP families, delays in service, and extended timelines to process enrollments and assignments. Close coordination among MTF medical staff, EFMP family support, and assignment personnel is essential but inconsistent.

Despite DoD establishing the Office of Special Needs in 2010, the 2018 GAO report reveals that less than 6 percent of the 104,677 families with special need family members have service plans required by DoDM 1342.12. These fundamental service plans are intended to map out services special needs family members will receive and how and when these services will be administered. According to the GAO’s analysis, “the services have developed relatively few services plans, and there is wide variation in the number of family support providers employed, which raises questions about potential gaps in services for families with special needs.”

In order to identify shortfalls in the Air Force’s EFMP support, an Air Force Rapid Improvement event was held in August 2017. The participants identified a number of significant issues: lack of standardization, training, and accountability for base-level EFMP personnel; lack of education on EFMP reassignment and deferment process among stakeholders; lack of specialized legal assistance to assist EFMP families; lack of timely transfer of medical records; lack of Tricare coordination for continuity of care during transition; and a lack of training among EFMP Family Support staff to proactively promote and execute the EFMP. A year later, in August 2018, the Air Force held a summit at Joint Base San Antonio-Randolph to communicate directly with airmen and families to help address concerns and identify solutions to many of the shortfalls identified in 2017. The summit included briefings from organizational stakeholders on current initiatives to improve EFMP and provided information through online resources and social media, along with a new EFMP orientation course scheduled to debut in 2019. Also, in response to growing demands on the EFMP program, the Air Force announced family support coordinators will increase from 58 to 97 at 78 installations.

Stop Admiring the Problem and Provide Actionable Solutions

The Air Force 2018 EFMP summit represents an excellent first step initiating a productive dialogue and acknowledging many concerns of EFMP families. Future events need to include a much larger audience, improve webcast quality and access to briefing materials, and recognize and begin addressing the lack of standardization of EFMP across military services and installations. Effectiveness of current programs are based on the motivation and skill of individual EFMP staff personnel and their ability to collaborate with various EFMP offices. For on-line resources, good progress has also been made by establishing Military OneSource as the EFMP “go-to” resource providing a centralized, one-stop shop for EFMP-related information, resources, and support.

The DoD Office of Special Needs should conduct a comprehensive review of EFMP, capturing current best practices, establishing standards for services provided to EFMP families, and identifying common performance measures to properly assess the effectiveness of current EFMP programs. These standards should specify how many EFMP Family Support, Medical Special Need Coordinators, and Assignment personnel should be employed based upon the existing population of EFMP families within each military service and where resources could be shared at joint base installations.

One of the most significant challenges improving and streamlining the current assignment and screening process is protecting HIPAA privacy laws and complying with the Americans with Disability Act. New processes should be developed to protect HIPAA concerns while accommodating the needs of EFMP families. The Air Force is currently experimenting with a Talent Marketplace IT platform for officer assignments which allows officers and commanders to provide assignment preferences, career ambitions, and family considerations to their assignment functionals allowing for a transparent and flexible process. This technology should be provided for EFMP families to share their assignment preferences and special needs constraints while protecting HIPAA concerns.

When military personnel are Q-coded (identified for assignment limitations due to special needs requirements), families should be briefed on career considerations, available insurance options and resources, and which installations currently provide support for their special needs requirements and would be available for base of preference assignment. This would allow military families to have more control on career and family decisions and decrease the workload of EFMP medical and assignment personnel responsible for screening special needs family members during each assignment cycle.

Many families have been assigned to duty locations where they cannot obtain necessary medical care or educational support for their dependents.

Oversight and responsibility of EFMP programs should be reviewed and streamlined where possible; existing programs are complex, with multiple stakeholders and offices of responsibility. A better solution may be to consolidate EFMP responsibilities under a single commander. If something is important, put someone in charge, give them the resources to succeed, and hold them accountable. A consolidated EFMP work center would provide EFMP families a single point of contact and facilitate accurate and timely information for both their assignment coordination and family support needs. Examples of such programs include Joint Base McGuire-Dix-Lakehurst EFMP One Stop which provides EFMP families from all the services access to advocacy, recreational activities, resource directories, respite care information, support groups, system navigation, workshops and the Military Family Support 360 Project.

The Marine Corps has taken significant steps to improve and streamline support for their EFMP families. According to Jennifer Stewart, HQ Marine Corps Family Care Deputy Branch Head and EFMP Manager, in 2007 the Commandant directed a functional analysis of the EFMP program. From this study, resources and funding were provided to consolidate all EFMP functions under HQ Marine Corps Marine and Family Division. Family support, assignment coordination and enrollment are all the responsibility of one office. A new case management system was designed that provides all EFMP personnel access to documentation and case notes to increase communication and better understand each special needs case. At the installation level, EFMP families go to USMC EFMP Family Support Offices, which provides information on all their EFMP needs from one location.

In order to gain access to special needs care available in local communities, especially overseas, medical insurance coverage may need to be expanded for family members with special needs requirements, and medical referral processes should be streamlined where appropriate. Military families may also have the option to enroll in additional insurance coverage such as Medicaid, Tricare Prime Overseas, International SOS, or another third-party insurance that provides access to needed medical care beyond that available in the military network of care. In speaking with Jim Kaufman PhD, Vice President Public Policy for Children’s Hospital Association, he suggested that the DoD could work together with the current “Advancing Care for Exceptional Kids Act of 2017.” The program, which has strong bipartisan support in Congress, is designed to “improve care for children with medical complexity in Medicaid, while also reducing program spending.” The DoD could create a care coordination model between MTFs, children’s hospitals, community providers, and even international members like the children’s hospitals in England. This model would allow military personnel to serve with their families in more locations and provide appropriate medical support for their family members.

EFMP Family Support and Medical personnel need to be more knowledgeable of the services available in local communities and engage with EFMP families earlier in the assignment process to discuss special needs availability and options. Notably, the U.S. government already takes similar steps for embassy personnel and families assigned overseas where there are no military treatment facilities available. For example, Lt Col Colin Smith (USMC) shared with me his experience coordinating with embassy personnel in Latvia, the Regional Medical Officer, and Tricare Europe representatives when assigned as a foreign affairs officer. Together, they ensured medical care for his special needs child was available in the host nation and helped Lt Col Smith continue to serve in this highly desirable position with his family. In contrast, current EFMP processes implemented by the military services requires care to be available at the gaining installation, removes decision authority from affected service members and commanders, and leaves final travel recommendations with the gaining military treatment facility and special needs coordinators.

Most importantly, military members and EFMP personnel should engage collaboratively throughout the EFMP review process to increase transparency and communication among all parties. EFMP assignment and medical review should include input from military members and command teams to ensure the assignment is desired and provide a clear understanding of the limitations of medical care available at the next MTF and what support is available in the local community. The military member and their family, with mentorship from command teams and medical experts, should then be allowed the opportunity to accept or decline the accompanied assignment based upon the best interests of their family. The DoD always retains the option to assign the military member unaccompanied, but it may not retain that service member very long.

The nation trusts the solider, sailor, airman, and Marine to make daily life or death decisions with equipment worth millions of dollars. The nation also invests millions of dollars in their development and training to be the most lethal and ready force in the world. Yet our soldiers, sailors, airmen, and Marines are not afforded the responsibility or authority to make the best decisions for their families and where they may best serve the nation. As each of the military services works toward improving military readiness, it should also strive to improve programs intended to support our military families and their readiness. These efforts will help improve retention of our highly trained force and strengthen the resolve of our military families.

Brad Orgeron is a Lieutenant Colonel in the US Air Force and a military fellow at the Center for a New American Security.

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Air Force, Department of Defense, or the U.S. government.

Read more in the CNAS Military, Veterans and Society Program's "Supporting the Military Community" commentary series.

  1. Interview with Lt Col Matthew Thomas, 550FS Director of Operations, 26 November 2018.
  2. Interview with Colonel Scot Heathman, Vice Commander Fairchild AFB, WA. 10 Dec 2018.
  3. “Military Readiness and Medicaid Panel” and conversation with LCDR Anthony P. Putney hosted by Tricare for Kids Coalition, Reserve Officers Association, 15 November 2018.
  4. Interview with Jennifer Stewart, HQ Marine Corps Family Care Deputy Branch Head and EFMP Manager, 12 Dec 2018.
  5. Discussion with Jim Kaufman PhD, Vice President Public Policy for Children’s Hospital Association, 28 November 2018.
  6. Interview with Lt Col Colin Smith (USMC), Military Fellow Center for a New American Security, 26 Feb 2019.
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