CRS Insights
Defense Health Program Funding Shortfall for Fiscal Year 2015
Pat Towell, Coordinator, Specialist in U.S. Defense Policy and Budget (
ptowell@crs.loc.gov, 7-2122)
Don J. Jansen, Specialist in Defense Health Care Policy
(djansen@crs.loc.gov, 7-4769)
July 30, 2015 (IN10332)
As reported in an online article (behind subscription wall) dated July 27, 2015, by Austin Wright in Politico and a
Stars and Stripes online
article dated July 28, 2015, a letter from the Assistant Secretary of Defense for Health
Affairs and the service Surgeons General to the armed services and appropriations committee chairs dated July 16,
2015, states that the Defense Health Program (DHP) budget account faces a projected "shortfall of over $2 billion
in fiscal year (FY) 2015." The letter attributes the shortfall to three factors: (1) unexpected growth in retail
prescription drug spending, (2) more beneficiaries than expected, and (3) a general increase in the inflation rate of
medical costs. The letter asks for committee approval of various reprogramming requests as well as abstention
from reductions to the FY2016 DHP appropriation request. The article reports that the shortfall is being cited as an
argument in support of a provision in the Senate-passed defense authorization bill to increase TRICARE pharmacy
copayment. The copayment issue is one of several that have reportedly been holding up conferees' progress in
negotiating a final version of the FY2016 national defense authorization act (H.R. 1735).
What Is the Defense Health Program?
"Defense Health Program" is the title for the appropriation and budget account that funds, among other things, both
the in-house care provided through Department of Defense (DOD) facilities and personnel and the private sector
care (or "purchased care") portions of the TRICARE health insurance program that will be used by an estimated
9.3 million military service members, retirees, and family members worldwide in FY2015. Both in-house care and
private sector care are budget activity groups. Each includes the cost of prescription drugs provided to
beneficiaries through military pharmacies and treatment facilities in the case of in-house care or by mail order,
retail drug stores, and non-DOD medical facilities in the case of private sector care.
How Much Was Requested and Appropriated for DHP in FY2015?
The base (not including overseas contingency operation funding) DHP
FY2015 appropriation totaled
$32,069,772,000, of which $14,503,759,000 was for private sector care. The base DHP
request was for a total of
$31,994,918,000, of which $15,412,599,000 was for private sector care. The
explanatory statement stated that the
reduction of $908,840,000 to the in-house care request was accounted for in part by what was designated as
$855,000,000 in "historical under execution" and $200,000,000 in "excess growth in pharmaceutical drugs." The
2015 budget request assumed inflation of 3.7 percent for FY2015 for DHP purchases (excluding fuel and pay).
Table 1. Defense Health Program Appropriations, FY2015
Amounts are discretionary budget authority in thousands of dollars
FY2015 Budget
FY2015 Appropriation
Request
(
P.L. 113-235/H.R. 83)
Operation and Maintenance
In-House Care
8,799,086
8,680,970
Private Sector Care
15,412,599
14,503,759
historical underexecution
(-855,000)
pharmaceutical drugs—excess growth
(-200,000)
other congressional changes (net)
(+146,200)
Consolidated Health Support
2,462,096
2,360,696
historical underexecution
(-100,000)
other congressional changes (net)
(-2,000)
Base Operations and Communications
1,683,694
1,832,471
facilities maintenance and repair
(+150,000)
other congressional changes (net)
(-1,223)
Other O&M budget activities
2,674,436
2,652,754
Subtotal, O&M
31,031,911
30,030,650
Procurement
308,413
308,413
Research and Development
654,594
1,730,709
TOTAL, DHP
31,994,918
32,069,772
Note:
a. "Other O&M" budget activities include Information Management, Management Activities, and
Education and Training.
Historical DHP Underexecution
Although at one time DOD regularly requested supplemental funding for DHP, that has not been the case in recent
years. Appropriated amounts have been in excess of actual needs and DOD has requested and received prior-
approval from the relevant congressional committees to reprogram the excess amount to other DOD programs. In
response, appropriators have anticipated such "underexecution" and, as illustrated in Table 2, not appropriated the
full amount of the DHP budget requested in certain budget activity groups, primarily private sector care and
consolidated health support.
Table 2. Congressional Reductions to TRICARE "Private Sector Care" Budget
Requests on Grounds of "Underexecution" or "Pharmacy Cost Growth"
Amounts in millions of dollars
P.L. 112-10
2011
underexecution
-236.0
H.R. 1473
P.L. 112-74
2012
historical underexecution
-330.0
H.R. 2055
P.L. 113-6
2013
historical underexecution
-807.4
H.R. 933
unjustified growth in pharmacy
costs
-20.0
P.L. 113-76
2014
historical underexecution
-968.0
H.R. 3547
unjustified growth in pharmacy
costs
-150.0
P.L. 113-235
2015
historical underexecution
-855.0
H.R. 83
unjustified growth in pharmacy
costs
-200.0
S. 1558
2016
(Senate
committee
historical underexecution
-263.1
reported)
H.R. 2685
Funds in FY2016 request would
(House
restore cuts made to FY2015
-1,102.6
passed)
request
Why Were the 2015 DHP Budget Estimates Inaccurate?
Forecasting future year health expenditures requires making assumptions about a multitude of factors, all of which
may be subject to change. DOD officials state in personal communications that of the $2 billion shortfall,
compound pharmacy accounts for about $1.5 billion, a modest increase in TRICARE Mail Order Pharmacy
accounts for about $100 million (unrelated to compounds), and increased health care costs account for about $415
million. "Compound pharmacy" refers to a combination of two or more drugs prepared by a pharmacist for a
patient's individual needs. These drugs can be expensive. A DOD information paper dated July 10, 2015, indicates
that after new screening procedures were put in place for compound pharmacy prescriptions, the cost per
prescription was reduced from $6,889 in April 2015 to $254 for the post-implementation period of May 11 to 31.
DOD is doing additional research related to trends in pharmacy costs.