Issue Briefs

GAO has issued the latest in a series of reports on benefits and assistance to federal civilian employees working overseas in support of military operations, focusing this time on medical care. Following is an excerpt from the report.


Although DOD primarily provides both emergency life-saving medical care as well as routine medical care to U.S. military personnel in Iraq and Afghanistan, it is unclear what level of routine medical care deployed DOD civilian employees can expect in theater. DOD relies on its own deployed civilians to carry out or support a range of essential missions, including logistics support, maintenance, intelligence collection, criminal investigations, and weapon systems acquisition. About 2,600 DOD civilian employees were deployed to Iraq, and about 2,000 DOD civilian employees were deployed to Afghanistan according to DOD’s April 2010 report[Footnote 9] to Congress on medical care for injured or wounded deployed U.S. federal civilians. In response to congressional interest, DOD reviewed the department’s existing policies for medical care for DOD deployed civilians and federal civilian employees that might be injured or wounded in support of contingency operations and reported to Congress on the results in April 2010. DOD noted in its report that with each new mission, the need for new civilian skills has resulted in an increase in the number of deployed civilians and that these civilians are not immune to the dangers associated with contingency operations, since they too incur injuries or wounds in their efforts to support the missions in Iraq and Afghanistan.

Although DOD guidance clearly provides that deployed DOD civilians will receive life-saving emergency care, it is unclear to what extent DOD civilians can expect routine medical care in theater because a DOD directive and theater guidance differ with regard to their eligibility for routine medical care. Specifically, DOD Directive 1404.10[Footnote 10] states that the department’s civilian employees who become ill, are injured, or are wounded while deployed in support of U.S. military forces engaged in hostilities are eligible to receive health care treatment and services at the same level and scope provided to military personnel. However, theater guidance for Iraq and Afghanistan,[Footnote 11] which provides detailed information on medical care to deployed civilians, among others, states that DOD civilians are eligible for emergency care but most routine care for them is subject to availability. This differs from the DOD directive that states care should be at the same level and scope provided to military personnel. In addition, we found that the theater guidance document for care in Afghanistan[Footnote 12] provided additional guidance that is inconsistent with both the DOD directive and with guidance provided elsewhere in the document as to the level of care to be provided to DOD deployed civilians. Specifically, one section of the guidance stated routine care for all civilians was to be provided subject to availability while another section of the same guidance stated routine care was to be provided for deployed DOD civilians in accordance with a previous issuance of DOD Directive 1404.10. The previous version of DOD Directive 1404.10 indicated that civilians designated as emergency essential employees would be eligible for care at the same scope provided to military personnel, while the current January 2009 DOD directive extends the provision of routine medical care to a much wider group of DOD deployed civilians.

Medical officials in Afghanistan told us that they provide routine medical care to U.S. federal civilians on a space-available basis, and that they would not turn away any person with injuries that presented a danger to life, limb, or eyesight, regardless of the employment status of an individual. This issue has received continuing congressional interest. For example, in April 2008 the House Armed Services Committee Subcommittee on Oversight and Investigations issued a report on deploying federal civilians and addressed the medical care provided to them when they are wounded, ill, or injured while in a war zone.[Footnote 14] Furthermore, DOD’s report to Congress on deployed DOD civilians stated that the department believes it is imperative that each federal civilian understands where, when, and how they can receive medical treatment in theater. Although we did not learn of any deployed DOD civilians being turned away from receiving routine care in theater during the time of our review, officials in theater said it could be a concern if the number of DOD civilians that deploy increases, and that theater medical officials would assess the impact of any increase on the planning process for determining medical personnel requirements. However, if theater officials concluded that they needed more medical personnel due to increases in numbers of DOD deployed civilians, we recognize that an increase in medical resources would have to be balanced against other high-priority needed resources due to the force cap limiting the overall numbers of military personnel that can be in theater. For example, the former commander who oversaw military medical units in Afghanistan noted to us that while there is no medical-specific force cap, including a limit on the number of medical personnel within the larger force cap, any additional military personnel needed in theater must be balanced by the loss of other military personnel in other areas, such as a transportation unit, and that the force cap has played a role in their decisions in determining medical personnel requirements. Additionally, the current commander who oversees military medical units in Afghanistan stated that local base commanders can request additional medical personnel if they believe that the number of U.S. soldiers or civilians merits an increase. The official stated that an increase of about 800 to 1500 civilians would have to occur before they would consider revising military medical personnel requirements. At the conclusion of our audit, an Army official agreed that if there is an inconsistency between departmental guidance and theater guidance, it should be examined. As long as theater guidance differs from the requirements of departmental directives, uncertainty about deployed civilians’ eligibility for routine care in theater will remain and the military medical personnel requirements planning process may not be fully informed by department-level expectations.