In May 2022, the American Legion passed Resolution Number 26 to little fanfare. The resolution announced The Legion’s support for legislation that would mandate making Tricare Prime — the government sponsored healthcare benefit offered to uniformed service members, their dependents, and retirees — available to all veterans residing in any United States territory, just as if they lived in the 50 states or Washington, D.C.
In other words, the American Legion supported ending an institutionalized health inequity that disproportionately affects people of color. This inequity is not required by law and there is no indication that Congress ever intended to give the Department of Defense authority to discriminate against one set of U.S. veterans over another.
Peer reviewed academic literature supports the claim that this inequity in access could result in poorer health outcomes for veterans living in the territories. To understand why, a short primer on Tricare itself is helpful. Tricare is a universal insurance program for uniformed service members in the Department of Defense service branches, Coast Guard, and the United States Public Health Service Commissioned Corps, or USPHS.
In most circumstances, all active duty service members in the DoD are mandatorily enrolled in Tricare Prime. Prime — a healthcare maintenance organization, or HMO — provides beneficiaries with the ability to access medical care at a Military Treatment Facility, or MTF, which includes military hospitals and clinics like Walter Reed National Military Medical Center. If the local facility cannot meet the demand, Prime allows the beneficiaries to access a network of civilian providers. This network is established around MTFs in what is called a Prime Service Area.
Tricare Select is the preferred provider option, or PPO. Beneficiaries, either retirees or active duty family members, may elect to enroll in Select if they prefer the PPO, or could be required to enroll if, for example, they live too far away from a Prime Service Area. But in the territories there is no option to enroll in Prime for retirees and their families. Instead, they can only enroll in Select.
Numerous scientific studies have shown that the choice between Prime and Select is associated with a wide range of health outcomes. Treatment at MTFs — only available through Prime — is associated with lower rates of maternal mortality, breast cancer transitions, the use of invasive gynecological procedures like open hysterectomies, and spinal fusions. Although not a universal finding, much of the reviewed literature indicates that Prime, the HMO, results in equal or better care.
Yet veterans living in the territories don’t get to choose the option that works best for them — unless they move to the 50 states or Washington, D.C. While it is true that the ability to access care at MTFs in some territories (notably Puerto Rico) would likely not change, this does not mean that extending equitable access to Prime would not help retirees living in the territories. They would have lower copays and fewer out-of-pocket costs, the Prime Service Areas would be required to expand their network to meet the needs of the retiree population, and most importantly, the veterans who served our country would finally know that their service is not less than that of their stateside peers.
The Biden Administration has the authority to end this discriminatory practice without Congressional intervention. In fact, although Congress never defined the territories as part of the United States for the purposes of Tricare, DoD has defined them as states in the Tricare portion of the Code for Federal Regulations. The Code — albeit not our practice — acknowledges the value and dignity of those who serve wherever they live. Our nation has been made stronger by this diversity in our forces, and we — as a country — are obligated to provide the benefits to which service members are entitled. Right now, we are breaking those promises and it is possible, even probable, that these broken promises are hurting those who served us.
The last racially segregated unit to serve our nation was the 65th Infantry Division from Puerto Rico, nicknamed “The Borinqueneers” after the Taino name for Puerto Rico. Both the Army Chief of Staff Gen. James McConville and Veterans Affairs Secretary Denis McDonough honored the heroism of the Borinqueneers last year during the first National Borinqueneers Day. Gen. McConville thanked attendees for fighting to ensure the Borinqueeners “got [their] due.” Secretary McDonough said the Borinqueneeers “fought for our freedoms when they did not fully enjoy those freedoms themselves.” Without full access to Tricare, the Borinqueneers have still not gotten their due, and they still do not enjoy the full promise of freedom for which they fought. In this year’s National Defense Authorization Act, Congress should right this historic wrong and bring equity to the service members who gave themselves equally.
Frankie Perez is a 42-year-old veteran who was medically retired from the Army National Guard and he is currently living in Puerto Rico without access to Tricare Prime. He is the founding CEO of the Post-Traumatic Arts Foundation and is a volunteer leader with multiple veteran service organizations. Frankie was selected as one of the six ambassadors for a 1,000 mile Walk of America expedition.
Blake Hite is a student at Georgetown University Law Center. He formerly worked for the Resident Commissioner of Puerto Rico as legislative aide for military and veterans affairs issues; the opinions in this article do not reflect those of the Resident Commissioner. Hite is a veteran of the Navy. Neither authors are current or past members of the American Legion.
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