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Tom Philpott
Fears of 'hollow force' unfounded, lawmakers told

The Congressional Research Service has a message for those who suggest planned defense budget cuts and military compensation curbs will return America to the "hollow force" era of the 1970s.
Such references, in light of current force quality and the amount of money used to modernize weapons, infrastructure and benefit programs over the past decade, might be deemed "inappropriate," CRS advises in a new report, "A Historical Perspective on 'Hollow Forces.'"
A delicate issue in preparing the report must have been whom to caution. The authors, defense specialists Andrew Feicket and Stephen Daggett, direct their advice to "military leaders." But the specter of a hollow force seems more often to be raised these days by lawmakers, particularly by Republicans who suggest the Obama administration is willing to allow readiness to fray. CRS exists to serve Congress, however, not to chastise it.
Five of seven suspected causes for the sorry state of the armed forces after the Vietnam War, while transitioning to an all-volunteer military, are "non-applicable" to today's military, the report says. The current force isn't buffeted by low public support, severe recruiting and retention challenges, lousy pay, obsolete equipment or inadequate maintenance dollars.
If there's an issue with troop morale today it's due mostly to frequent deployments, a problem that is easing, the report says. And while an era of smaller budgets has arrived, the current inventory of modernized equipment "appears relatively robust," the report says.
"Most of the conditions that existed in the 1970s do not exist today," it says. "It also is unlikely even in the case of drastically reduced military funding and a smaller military, (that) recruit quality would decline, pay and benefits would be drastically cut or U.S. public support for the military would significantly decline," all of which happened after Vietnam.
Republicans criticize the administration on two fronts regarding defense spending in the next decade. They don't like how $488 billion in cuts through 2021 are to be implemented, as outlined by Defense Secretary Leon Panetta in late January, though Congress did agree to the overall size of the these cuts in passing last year's Budget Control Act.
They also don't like Obama's holding lawmakers to an onerous deal struck last August: that if a bipartisan "super committee" couldn't reach agreement by last Christmas on cutting at least a trillion dollars more of the federal debt, then a "sequestration" of automatic cuts would begin in 2013. About half of that cut would be applied to defense over 10 years unless Congress agrees on a different response to the super committee debacle.
On Panetta's plan for the first set of cuts, to draw down ground forces by 100,000 and rely more on unmanned systems and Special Forces units, Rep. Howard P. "Buck" McKeon, (R-Calif., chairman of the House Armed Services Committee, said impact will be "far deeper than Congress envisioned in the Budget Control Act, because of strategic choices the President has made."
On the sequestration cuts, McKeon seeks to derail them. He backs the Down Payment to Protect National Security Act (HR 3662), which would protect military budgets by continuing to freeze federal salaries and cutting the workforce by 10 percent over 10 years by refusing to fill job vacancies.
"Last year, when the Super Committee failed, I pledged that I would not be the chairman who would preside over the hollowing out of our military. I renew that commitment today," McKeon said Jan. 26.
Five days later, CRS released its report suggesting "hollow force" is a hot-button term being used today inappropriately, at least by some.
"An informed discussion may be best served by military leaders avoiding reference to a 'hollow force' and adopting a more measured approach to inform Congress and other decision makers about their concerns for the future state of the U.S. military," the report says.
It notes that Gen. Edward C. Meyer, then Army chief of staff, introduced the term "hollow Army" during May 1980 testimony before the House Armed Services Committee. Pay and benefits had eroded so dramatically that the Army a year earlier had missed its recruiting target by 15,000 and the Navy was short 20,000 petty officers. Six of 10 Army divisions stateside were deemed "not combat ready."
Obama's 2013 budget request, to be released Feb. 13, will propose higher TRICARE fees for all military retirees. It also will assume full military pay raises in 2013 and 2014 but smaller increases starting in 2015.
CRS notes that basic pay has climbed by 35 percent since 2001.
"When increased housing allowances, subsistence allowances and enlistment and reenlistment bonuses are added, total take home pay has increased even more. And when increases in retirement benefits, due to TRICARE for Life medical benefits and concurrent receipt of military pay and veterans disability benefits, are considered, military compensation has grown more than 55 percent above inflation since fiscal year 1998," the report says.
Yet CRS cautions against reducing military compensation to address budget deficits.
"Congress might want to consider carefully how such changes would affect the quality of the force (if) the economy recovers and private employment prospects for potential military-age recruits improves, making the military a less attractive employment option," it says.
But a hollow force? Cultural and economic conditions facing today's military "bear little resemblance" to the post-Vietnam era, CRS concludes. So while significant budget cuts could "have a major impact on force structure and weapon programs," senior military leaders will determine how resources are allocated, and avoiding that hollow force "may be expected to remain an overarching priority."
The authors might have added that "hollow force" will continue to be heard, loudly and often, in the upcoming budget debates.

To comment, email milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111 or visit www.militaryupdate.com.

Tom Philpott 2Feb12

TRICARE For Retirees Targeted as Defense Budgets Fall

As defense budgets grew over the past decade, Congress shrugged off complaints of runaway military health costs and blocked every proposal from the Bush administration to raise TRICARE fees sharply on retirees.

Defense budgets have stopped rising, however, and Defense officials today are sounding more confident that Congress will follow last October's $5-a-month bump in TRICARE Prime enrollment fees for working-age retirees with more substantial fee increases for retirees of all ages.

Defense Secretary Leon Panetta and Arm Gen. Martin Dempsey, chairman of the Joint Chiefs, outlined plans Jan. 26 to lower defense budgets over the next 10 years by $487 billion in compliance with the Budget Control Act passed last spring to dampen growth in federal debt.

Though Panetta and Dempsey withheld full details on proposals to curb personnel costs, until President Obama presents his 2013 budget request to Congress Feb. 13, they said the personnel saving initiatives would include:

New enrollment fees, co-pays and deductibles on retirees under 65, phasing them in over five years and using a "tiered approach" so that senior-grade retirees pay higher fees than lower ranking retirees.
A new annual enrollment fee for the TRICARE for Life insurance supplement to Medicare, used by retirees 65 and older. This fee also would be tiered so retirees drawing smaller retirement checks pay less.
These changes, Defense leaders said, still would leave military retiree health care fees significantly below "comparable civilian equivalents."

TRICARE pharmacy co-payments would be increased again in ways to discourage use of the more convenient but more costly retail outlets and encourage greater use of base pharmacies and the home delivery program.
Persons medically-retired by their service, and surviving spouses of members who died on active duty, would be exempt from the higher fees.
On active duty pay raises, Panetta said starting in 2015 they would be capped in some unspecified way though no member would see a drop in pay.

The budget also will ask Congress to establish a "BRAC-like" commission to recommend cost-saving reforms to military retirement. Any retirement changes, however, would impact only future recruits, not the current force or retirees. BRAC refers to Base Realignment and Closure commissions. They were given broad authority to recommend base closings, which Congress could accept or reject but not modify. The retirement commission would have similar powers regarding compensation changes.

Coincidently, Panetta said the budget will seek two more rounds of base closings to help to trim infrastructure costs.

Defense background papers explained that personnel costs make up a third of defense spending today but the planned cuts to personnel accounts would represent only one ninth of total funding to be stripped from future budgets, a concession to the importance of keeping a quality force.

"This budget recognizes that [people], far more than any weapon system, far more than any technology, are the great strength of the United States military," Panetta said. "For that reason, we focus first on every other area of the defense enterprise for savings, in order to minimize any impact on the quality of the troops and their families."

Five days later, when the Military Healthcare System held its annual conference at National Harbor, Md., across the Potomac River from Washington D.C., the keynote speaker for 3000 attendees was Jonathan Woodson, assistant secretary of defense for health affairs.

He spoke about new "fiscal realities" impacting the health system but avoided mention of the planned fee increases. Woodson predicted, however, that smaller defense budgets "will shine an even brighter light on military health costs, which could exceed 10 percent of the Department of Defense budget if reforms are not made."

He noted too that, "for years, experts and non-experts have been saying that the growth of healthcare costs is unsustainable. Everyone nods their head and says 'Yes, we need to control healthcare costs.' And somehow, despite all this head nodding in solemn agreement that costs cannot keep rising, the costs nonetheless have continued to go up."

Explosive growth in military health costs from 2000 to 2005 eased, Woodson said, so that the pace now matches inflation for civilian health care at about five percent a year. "But that is dangerously higher than the overall inflation rate," he added. When defense budgets were growing, "this was a cause for concern but it still seemed manageable. Not anymore. In order to meet the overall military readiness imperatives, and our moral obligation to the American taxpayer, we must slow down our growth rate."

Woodson pointed not to TRICARE fees increases but to "a new commitment to collaboration between the servicesto reduce redundancy and waste." He listed four major initiatives to lower costs and improve population health including: a new patient safety campaign; renewed efforts to reduce smoking by service members and obesity among families including retirees; expansion of the Patient-Centered Medical Home concept to enhance delivery of preventive services and lower costly emergency room visits by patients who only need primary care; an effort to encourage greater innovation throughout the military health system.

On TRICARE fees, associations representing beneficiaries, particularly retirees, are preparing for a fight on Capitol Hill while waiting for fuller details on the TRICARE proposals. Opponents are sure to argue that TRICARE for Life beneficiaries were promised free lifetime health care, even though the courts ruled such promises, by recruiters and career counselors, are nonbinding because they were not backed by written law.

They will argue too that deeply discounted lifetime health care is a benefit earned by all retirees through unique hardships of military careers.

The daunting challenge for sympathetic lawmakers will be finding budget dollars to shield retirees from higher TRICARE fees as overall defense spending falls.

Let your elected officials know how you feel about these threats to your TRICARE benefits.

To comment, email milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA, 20120-1111 or visit: www.militaryupdate.com.

Tom Philpott
VA sees 'paperless' claims as critical to ending backlog

The only way to achieve VA Secretary Eric Shinseki's goal for 2015 that every disability compensation claim is processed within 125 days and with 98 percent accuracy is to shift to a paperless claims system. And that transformation has begun.
That was the testimony Tuesday by VA's top claim processing official before the House veteran affairs' subcommittee on disability assistance.
Tom Murphy, director of compensation service for the Veterans Benefits Administration (VBA), an agency for the Department of Veterans Affairs, acknowledged the claims backlog has grown in recent years.
Compensation and benefit claims pending at VA, as of Jan. 23, totaled 852,127, and 65 percent of them 557,460 had been filed by veterans more than 125 days ago, which means they are in "backlog" status.
Over the last year VA processed almost a million claims, but more than 1.3 million new claims were filed, some seeking compensation for the first time but most seeking an upgrade to current disability ratings. The number of veterans filing claims annually has more than doubled since 2000.
The surge is tied to the Iraq and Afghanistan wars and also to court decisions and to VA policy changes that made hundreds of thousands of Vietnam War veterans eligible for compensation for diseases linked to possible wartime exposure to herbicides, including Agent Orange.
Murphy didn't challenge subcommittee complaints that the backlog is rising. But he did challenge a lawmaker who suggested VA plans to move to electronic claim processing will only deepen the backlog, at least for a while.
Given projected claims growth, Murphy asked, "How do we take care of those veterans in less than 125 days, which the secretary has stated is our goal, and do it with the resources we have currently on board? ... The only way we're going to be able to do that is to get out of the paper world and into the digital world."
VA will introduce "very shortly" an electronic Claim for Disability. It will be available through VONAPP Direct Connect (VDC), VA's online e-benefits site. The VDC site currently allows veterans only to request changes online to listed dependents on their benefits profiles.
To understand what's coming, Murphy said, veterans should think "along the line of your TurboTax interview process," but rather than filing income tax returns electronically, they will be prompted to file compensation claims. The process for an average claim will take 30 to 45 minutes.
"At the same time the veteran has the opportunity to submit any private evidence they want considered in the case," Murphy said. "And just that little bit I just described to you (will take) months out of our process"
Most of the two-hour hearing, however, focused on VA's mammoth effort to apply current medical science and revise the VA Schedule for Rating Disabilities, or VASRD, by 2016. Disability evaluation boards have used the VASRD since the end of World War II to compensate veterans for average impairment in earning capacity caused by service-related conditions.
Over the last 60 years VA has adjusted the VASRD piecemeal to account for new illnesses or some developments in medical science. But this is the first comprehensive review to ensure that disability categories, rating percentages and compensation levels are accurate and equitable.
Representatives for several veterans' service organizations complained at the hearing that they have had few opportunities since the VASRD reform effort began two years ago to influence interim findings meaningfully.
Jeff Hall, assistant legislative director for Disabled American Veterans, acknowledged that the VBA has encouraged veterans groups to participate in initial public forums on how VASRD assigns ratings by diagnostic codes to conditions across 15 separate body systems. But apart the forums, Hall said, "VBA is not making any substantial efforts to include VSO input during the actual development of draft regulations for the updated rating schedule."
DAV also is concerned that VA will continue to compensate solely on how disabilities impact earning capacity, ignoring calls from past studies for additional compensation tied to reduced quality of life.
Frank Logalbo, national service director on benefits for the Wounded Warrior Project, said VASRD reform must support higher compensation for mental health disorders, including post-traumatic stress. He also said "deep flaws in both VA evaluation procedures and its rating criteria pose real problems for warriors bearing psychic combat wounds." Not only do current ratings fail to compensate properly for loss of earnings due to mental health disabilities but also the review process itself is woefully inadequate, he said.
"A one-time, 20-to-30-minute conversation in a hospital office simply will not tell the most knowledgeable, conscientious examiner how the veteran functions in the community," Logalbo said.
Retired Army Lt. Gen. James Terry Scott chaired the Veterans Disability Benefits Commission, which in 2007 concluded that veterans with mental health ailments are undercompensated. It also recommended that Congress increase disability compensation by as much as 25 percent to recognize that disabled vets suffered a reduced quality of life.
Scott now chairs VA's Advisory Committee on Disability Compensation, which has a major role in revising the VASRD. He said the compensation gap for mental health disorders is real and likely will be closed with a significant bump in VA ratings for ailments such as post-traumatic stress disorder.
"What I think you're going to see is that the degree of disability associated with PTSD is going to be recognized (with) a higher percentage disability rating assigned," Scott said. "In other words I think you will see more people suffering from more severe forms of PTSD rated at 100 percent."
Scott has lost some of his earlier enthusiasm for compensating disabled veterans' for reduced quality of life, saying it can argue the issue is addressed in part through other benefits, including the caregiver compensation law passed last year. And VA already pays Special Monthly Compensation to the most severely disabled, he noted. Any additional pay for loss of quality of life probably should build on that and continue to target only veterans with very serious disabilities, Scott said.

To comment, email milupdate@aol.com , write to Military Update, P.O. Box 231111, Centreville, VA 20120-1111 or visitwww.militaryupdate.com.

Tom Philpott 23Jan12
Review board to send letters to 75,000 disabled veterans

On combat patrol several years ago, a U.S. soldier suffered two attacks from improvised explosive devices in a 24-hour-period. The first one rattled him and killed his buddy. The second one blew him out of his vehicle and knocked him unconscious.
The Army would medically separate this soldier with a 10 percent disability rating, even though his medical records showed symptoms of traumatic brain injury and post-traumatic stress disorder.
This case, and many like it, occurred before Congress in 2008 ordered military branches to clean up their disability evaluation systems and end practices that had underrated medical conditions of ill and injured members.
Congress did something else to correct past wrongs. It directed the Department of Defense to establish the Physical Disability Review Board (PDRB) with authority to reexamine the files and, if appropriate, raise disability ratings of up to 77,000 veterans those medically separated with ratings less than 30 percent between Sept. 11, 2001, and Dec. 31, 2009.
A few weeks ago the soldier struck by those two IEDs year ago learned that the PDRB had recommended his disability rating be raised to 70 percent, well above the 30 percent threshold needed to qualify for disability retirement, and applied back to the date of the Army's first rating decision.
"We looked at the same exams," explained PDBR President Michael F. LoGrande in an interview. "He had post-traumatic stress legitimately. All the documentation was there. He had traumatic brain injury. All the documentation was there."
For all the good it can do, a big problem for the PDBR is this: It has been operating since June of 2009, and raising disability ratings on 45 percent of cases reviewed, but only 2,700 veterans from an eligibility pool of 77,000 have applied to have their ratings reviewed. LoGrande called the 3.5 percent response rate "shockingly small."
That is about to change, thanks to Sen. Mark Udall, D-Colo. At his urging, the Department of Veterans Affairs, coordinating closely with the PDBR, will begin a phased mailing this month of information packets on the PDBR to every qualified veteran with a current home address on file at VA.
The first batch of letters about the PDBR, including an application form, will be mailed to 15,031 veterans, all of them medically separated in 2001 (post-9/11), 2002 or 2003. The next batch of 20,000 will go out by late April to eligible vets separated in 2004 and 2005. A July mailing of 16,500 will target the years 2006 and 2007. Finally, an October mailing to 13,200 will reach out vets separated in 2008 and 2009.
But eligible veterans don't have to wait for the letter. They can apply now to the PDBR to have their ratings reviewed. All the information they need already is available online at: www.health.mil/pdbr.
No rating can be downgraded, but much is at stake for those seeking an upgrade. A rating below 30 percent resulted, at most, in a severance payment. A bump to 30 percent or higher changes a veteran's status to disabled "retiree." That means a lifetime annuity, access to military health care for the retiree and dependents, discount shopping on base and more.
They also will get annuity back pay to the date of the original disability evaluation board decision, less an amount that must be recouped equal to the value of severance pay provided at time of discharge.
Advocates for veterans given low-ball ratings since 9/11 had pushed for a direct mailing. LoGrande did so, too, as early as two years ago. Looking back, he said, the PDBR probably wasn't ready for the response now ahead.
"We neither had the resources nor the manpower at the time to do it. And frankly, I don't think everyone was ready for us to do that. Let's just put it that way," he said, alluding to resistance from on high to a direct mailing immediately after the PDBR began operating.
Last summer Udall's staff requested a briefing on the PDBR and the response rate from veterans. LoGrande explained that, to date, outreach efforts had focused on state directors of veterans' affairs in California, Colorado, Texas, Florida and Georgia, where more than half of the pool of eligible vets live. Udall decided that wasn't good enough.
The senator wrote to VA Secretary Eric Shinseki that the population that needed to be told about the PDRB was all veterans "no longer serving." He asked for VA's help in a direct mailing. Shinseki responded in October, asking Allison A. Hickey, his under secretary for benefits, to meet with LoGrande and begin working out details for a mass mailing.
Udall this week praised the interagency cooperation.
"Now that the VA and the PDBR have combined forces, we are a step closer to ensuring that disability and retirement benefits match the sacrifices this generation of veterans has made for our country," Udall said.
VA's initial idea was a single mass mailing. PDBR sought instead a phased mailing to avoiding swamping the board and frustrating applicants who already wait an average of 13 months for a PDBR decision. That's down from 18 months a year ago.
LoGrande said responses to the first mailing will tell the PDBR how it needs to beef up staff, particularly with more physicians who must be trained on the VA schedule of ratings and schooled on how to apply it to applicant files, many of which contain extensive medical histories.
The PDBR now has only five full-time physicians and eight contract physicians who have more limited duties involving preparation of files for board decisions. LoGrande knows he'll need more doctors, but not how many.
PDBR already has a backlog of 461 cases, defined as those taking longer to decide than the deadlines set in current regulations. The board expects to have to rely heavily on the services to provide more active or reserve physicians to be trained for PDBR case reviews and decisions.
Of the mass mailing, LoGrande said, it simply is "the right thing to do," regardless of the work ahead or cost to the government.
"If that veteran were my son or my daughter, my niece or nephew, or my brother or sister," he said,"I would want them to have that opportunity."

To comment, email milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA 20120-1111 or visit www.militaryupdate.com

Tom Philpott 9Jan12
Petraeus:Home loans force families apart

Many military homeowners who saw their homes plummet in value in the financial crisis still can't get relief from "under water" mortgages that leave families owing more to loan servicers than their homes are worth.
The situation is especially difficult for the military, whose families must move every two to four years. Some affected members, on receiving orders to new assignments, are leaving families behind in those homes to avoid a hard hit to family finances or loan defaults, which would harm credit ratings.
Holly Petraeus, head of the Office of Servicemember Affairs in the new Consumer Financial Protection Bureau (CFPB), explained in a phone interview that the burden of under water mortgages remains a major issue for families, as she discovered last year during visits to 15 military communities.
Petraeus, wife of retired Army Gen. David Petraeus, former commander of allied forces in Iraq and Afghanistan and current director of the Central Intelligence Agency, has spent her entire life in the military. Her father, William A. Knowlton, was a four-star Army general. Her son is a soldier, so Holly Petraeus also is a military mom.
She noted that many military bases are in states hardest hit by collapse of the housing market, including California, Nevada and Florida, so many members bought homes at prices that current markets won't support.
"I was in Florida recently and had about 300 people at the town halls I did," she said. "I asked informally how many were homeowners and about half of them raised their hands. I asked, 'How many of you now owe more than the home is worth?' And two-thirds of the hands stayed in the air."
Their biggest fear, she said, is permanent change-of-station orders.
"What then? There are no easy answers," she said. "They can't sell their house for enough money to pay off their mortgage. They have had trouble getting access to some assistance programs." Unless they are delinquent in paying mortgages, "they can't do a short sale or a loan modification."
Military folks who don't pay their mortgages and lose their homes to foreclosure put at risk their security clearances and possibly their careers.
"A number of them, we've heard anecdotally, have made the tough decision to just leave their family in the house and go alone to the new duty station," Petraeus said. "That is pretty tough, when you think a permanent change-of-station move is usually three years and there is no guarantee they'll get orders back to where their family is living when that's over."
Some military families were helped when Congress voted to modify the Housing Assistance Program (HAP), which was created the 1960s to protect military and federal civilian families who see home values drop because of base closures. In 2009, HAP was expanded help new categories of military homeowners, including personnel seriously wounded during Post-9/11 deployments; surviving spouses of members killed during deployments; and military members who bought homes before July 1, 2006, and have been reassigned between Feb. 1, 2006, and Sept. 30, 2010.
But the extra $550 million Congress appropriated to expand HAP has been used and no more military families are receiving that special help.
Urging Congress or the Department of Defense to support more funding for HAP is "not my decision to make," Petraeus explained. "But I can certainly raise awareness about the issue and of what I hear from military families about the impact of the situation on them."
The CFPB and its service members' affairs office were created under the Dodd-Frank Wall Street Reform and Consumer Protection Act, which attempts to address abuses behind the financial crisis.
Petraeus is tasked with educating and empowering military people to make better decisions on financial products and services. Her office also monitors military consumer complaints and the responses they receive from CFPB and government agencies. It also coordinates all federal and state consumer protection efforts on behalf of military personnel and their families.
Advice to military consumers can be found on the CFPB's website: www.consumerfinance.gov. Consumer may file complaints about credit cards or mortgages online or by calling (855) 411-CFPB (2372).
Petraeus said she has seen "some movement" to help families with under water mortgages, apart from HAP effort now out of money.
"Fannie Mae and Freddie Mac have now changed their guidance to servicers to say that a military move is a qualifying hardship that should allow people to access some of the assistance programs," she explained.
Treasury officials also changed criteria so some military people can qualify for incentives to conduct short sales or other alternatives to foreclosure under the Home Affordable Foreclosure Alternatives (HAFA) program. Military no longer need to show a drop in income to qualify.
Her office and the CFPB are still in startup mode. But spurred on by military people seeking greater consumer protection, Petraeus has spoken out on their biggest consumer concerns, including aggressive marketing by for-profit colleges, abuses by payday lenders and Internet-based loan sharks and product scammers, including those with bogus cars for sale.
"General indebtedness is a problem for the military," she said. "There will always be people looking for loans. One big concern is now they may be looking on the Internet where it's very hard to know who you're dealing with." Many websites promising easy loans actually exist only to create leads for unidentified persons with money to lend.
"In one case I heard about, a service couple was having issues with a loan they thought they had paid off ... Eventually they figured out the lender was in Croatia. On the Internet you just never know who you are dealing with," Petraeus said. Young people see it as "their hometown, in a way." But confidence navigating the Internet "doesn't mean you'll recognize a scam. And there are plenty of them out there."

To comment, email milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA 20120-1111 or visit www.militaryupdate.com.

Tom Philpott 2Jan2012
Lawmakers waste billions fumbling 'doc-rate fix'

Congress has known for a decade that the formula it set in 1997 for adjusting physician payments under Medicare and by extension the fees paid to civilian doctors under TRICARE, the military's health insurance program is seriously flawed and can't be allowed to take effect.
But rather than replace the formula, which the American Medical Association says would have cost $48 billion in 2005 but would exceed $300 billion today, Congress chooses year after year to delay its effect.
It dangles the flawed formula and the fee cuts it would trigger over the heads of physicians treating Medicare and TRICARE patients. Then, as the effective date nears, and patients worry their doctors will stop treating them, lawmakers vote to delay the formula's effect a while longer.
Meanwhile, the gap between what Medicare and TRICARE pay doctors, and what would be permissible under the 1997 formula, widens every year. For example, if Congress had not voted Dec. 23 to block use of the formula again, Medicare and TRICARE fees would have fallen in January by 27 percent. The size of threatened rate cuts was 25 percent last December and 21 percent early in 2010.
The vote this time delayed the cut in doctor fees a mere two months, until March 2012. The same package also delayed for two months a 2 percent scheduled increase in the federal payroll tax and a planned cutoff of unemployment benefits to several million out-of-work Americans.
"I've very nervous when I see a two-month patch like this," said Dr. Robert M. Wah, a reproductive endocrinologist and ob-gyn physician who chairs the American Medical Association's Board of Trustees. In 2010, Congress voted five separate patches to keep the flawed rate formula at bay.
"We may be starting another season of patches," said Wah, a retired Navy doctor who still practices and teaches at Walter Reed National Medical Center at Bethesda and at the National Institutes of Health. "The problem is we have a very leaky boat and we keep putting patches on it. What we really need is a new boat. And these patches are very expensive."
If lawmakers continue to dawdle over this issue, the cost of the fix will nearly double to $600 billion in five more years, Wah said. Included in that figure is the extra cost of making temporary patches, which will climb from $22 billion in 2012 to $92 billion in 2016, the AMA argues.
"I've told Congress there is a tumor in the (federal) budget that grows every day," Wah said. "It needs to be dealt with. And the longer they put it off, the more expensive and painful it's going to be to fix.
The problem began with the Balanced Budget Act of 1997, which sought to control Medicare costs using something called a Sustainable Growth Rate (SGR) formula to set spending targets on physician services. For years in which the annual SGR target is met, doctor fees are adjusted by the rate of medical inflation. But when spending exceeds the SGR target, the formula calls for lowering doctor reimbursements.
From the start, SGR targets were set too low, critics contend. They failed to take into account cost growth tied to factors such as advances in medical technology and an expanding number of physician services.
Health care providers already point to low reimbursement rates as the top reason they won't accept TRICARE users as patients, according to a June 2011 report on patient access by the Government Accountability Office
The AMA conducted a more detailed survey of physicians and Medicare fees in 2010. Two findings were striking, Wah said. One of every three primary care physicians said they were forced to limit the number of Medicare patients in their practices because of low payments. Among physicians overall, including specialists, one in five limited the number of Medicare patients because of current reimbursements.
Wah said those findings might not reflect physician attitudes toward TRICARE patients, who usually are a smaller part of their practice. Also, Wah said, most physicians he knows try "to do their part to take care of TRICARE patients out of a sense of duty and recognition of the sacrifices military members and their families have made."
"But there's a limit to that, right?" Wah added. "I mean, at some point the finances do come into play."
Even without the threat of a 27 percent cut in fees, Wah said, doctors believe Medicare and TRICARE reimbursements haven't kept pace with their costs of sustaining their practices.
"Rent has gone up; salaries go up; benefit costs go up; insurance goes up. But Medicare and TRICARE payments have not kept up," Wah said. "So now there's a 20 percent gap between ... the cost of running the office versus rate of payment for taking care of seniors and military families. That 20 percent gap is a huge challenge for physicians."
Sam Hutchison, office manager for Senior Health Services, a primary care and geriatric practice specializing in patients 60 and older, and located near Fort Bragg in Fayetteville, N.C., said a 27 percent cut fees would spur many private practice doctors to stop treating Medicare and TRICARE patients or to stop accept new ones.
But his clinic, which is associated with a local hospital, exists to treat Medicare and TRICARE for Life patients. Timely clinical care, even with fees cut, is seen as more cost effective than having patients ignore their health until catastrophic illnesses requires emergency care and hospitalization.
Hutchison said the fight in Congress appears to be between defenders of insurance companies and advocates for physicians, with patients caught between the battle lines. His physicians were delighted to see the Obama health reform law require Medicare to cover co-payments for preventive services like prostate exams, colonoscopies, bone density screens and mammograms.
"Giving our physicians the ability to turn a wellness check with a Medicare patient into a complete physical, and actually reimburse us for the time spent doing it, was moving in the right direction. And now they are doing the complete opposite," Hutchison said.

To comment, email milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA 20120-1111 or visit www.militaryupdate.com.

Tom Philpott 26DEC11
In post-Iraq era...raw down tools replace benefit boom

The end of the Iraq war also appears to end a golden age of growth in military pay and benefits, which lasted at least a decade and corrected many perceived or long-standing faults in military compensation.
Disabled retirees, reserve component members, surviving spouses and active forces all benefited from flush wartime budgets and a Congress attuned after 9/11 to America's deepening appreciation of current and past generations that risk life and limb in our nation's wars.
But amid a deepening debt crisis and return of all U.S. forces from Iraq, the 2012 defense authorization bill (HR 1540) approved last week shows priorities shifting, toward controlling defense spending and preparing to drawdown forces. Restored are some old authorities needed to "reduce end strength in a responsible manner," explained a House-Senate conference report on the bill. These include:
nTemporary Early Retirement Authority, TERA, to allow select members a reduced annuity if released after 15 years but less than 20;
nVoluntary Retirement Incentive Pay, payable to "no more than 675 officers" with 20 to 29 years of service, who can be encouraged to leave in return for payments of up to 12 months of basic pay;
nVoluntary Separation Pay and Benefits for select enlisted members or officers who have more than six years' service but fewer than 2; and
nExpansion from three months to one year the period that an enlisted member can be discharged early without incurring a loss of benefits. But no pay or allowances would be paid for obligated time not served.
The Army and Marine Corps saw the steepest force increases during the Iraq war and expect to make the deepest post-war cuts. Army end strength in 2012 will fall by 7,400 soldiers, to 562,000, by October. That's still up 77,000 from 2003. Marine strength will hold at 202,100, but plans are to cut the Corps to 186,800 or even lower as cost-cutting pressure intensifies.
The Navy is down 54,400 sailors since wartime strength peaked at 383,000 in 2002. It will lose 3,000 more to reach 325,700 by fall.
The Air Force is to gain 600 airmen for total active duty strength of 332,800. Though it is down 40,000 airmen since a wartime peak in 2004, the Air Force exceeded its authorized level by 1,200 last October.
The new defense bill authorizes the modest TRICARE Prime enrollment fee increases that took effect Oct. 1 for working-age retirees, the first bump since TRICARE began 16 years ago. It also directs retiree Prime fees be raised annually by the percentage hike in retired pay through annual cost-of-living adjustments or COLAs. Pharmacy co-payments will be allowed to rise.
Effective back to Oct. 1, 2011, the services must prorate imminent danger pay and hostile fire pay of $225 a month based on number of days spent in designated danger areas. Previously, any part of a day in a war zone qualified a member for the full monthly payment. Only if there's exposure to hostile fire will a day in theater now trigger full payment.
The Obama administration, military leaders, prominent lawmakers and various debt commissions have signaled deeper cost-sharing ahead for military beneficiaries, including a first-ever enrollment fee for TRICARE for Life and a dampened COLA formula for all federal entitlements. So beneficiaries have reason to be wary of the defense budget to be unveiled in February with all accounts, including personnel, facing spending cuts.
Killed during final negotiations between House-Senate conferees on this defense bill was a provision to end reductions in survivor benefit annuities for surviving spouses to match Dependency and Indemnity Compensation from the Department of Veterans Affairs. Also killed was a provision to ease the impact of this SBP-DIC offset by increasing amounts paid under the interim Special Survivor Indemnity Allowance.
Progress also has stalled on other entitlement reforms, including lifting the ban on concurrent receipt of both retired pay and VA disability compensation for all disabled retirees. Still being impacted by the ban are retirees with disability ratings of 40 percent or less and disabled veterans forced by health conditions to leave service short of 20 years. President Obama at one time endorsed those benefit expansions, but no more.
Military associations don't brag of gains over the past decade, probably to protect them and to the fight effectively for others. But even a partial list is impressive. Older retirees today have TRICARE for Life, a prized supplement to Medicare that didn't exist before. All beneficiaries have access to a mail-order drug program and a vast retail pharmacy network. Many thousands of retirees with serious or combat-related disabilities now draw full retired pay plus VA disability compensation because Congress ended for them the century-old ban on concurrent receipt.
The Survivor Benefit Plan is more valuable since Congress ended a deep reduction in annuities at age 62 when surviving spouses become eligible for Social Security. The gratuity for combat-related deaths was raised six-fold to $100,000 and maximum Servicemembers' Group Life Insurance coverage rose from $250,000 to $400,000. Congress also approved a lump sum Traumatic SGLI payment of up to $100,000 to assist the most severely wounded with immediate financial challenges.
A decade ago careerists faced a reduced retirement plan, Redux, and an anemic post-service education benefit. Congress restored for them the traditional retirement plan of "half" base pay at 20 years with full COLA or annual cost-of-living adjustments. In 2009, a far more valuable Post-9/11 GI Bill took effect for those with active service since Sept. 11, 2001.
A perceived military pay gap with the private sector was closed over a decade with a string of annual raises that exceeded private sector wage growth, and out-of-pocket housing costs fell sharply as Basic Allowance for Housing was raised enough to cover members' average rent and utility costs.
Reserve personnel also saw gains, including premium-based TRICARE coverage while in drill status and the lowering of the age-60 reserve retirement tied to length of wartime deployments after January 2008.
To comment, email milupdate@aol.com write to Military Update, P.O. Box 231111, Centreville, VA 20120-1111 or visit www.militaryupdate.com.

Tom Philpott 12DEC11
National Guard deeds at home and in war deliver Joint Chiefs seat

Congress is about to elevate the position of chief of the National Guard Bureau to full membership on the Joint Chiefs of Staff, joining the JSC chairman, vice chairman and four service branch chiefs as top military advisers to the president and his national security team.
It's a controversial bump in power and prestige that proponents argue honors all who have served in the Army and Air National Guard during a decade of war, expansion of the homeland security mission and raised expectations by the public for swift, effective responses to natural disasters.
Every current member of the Joint Chiefs opposes the move, finding no military reason for the elevation, and several potential problems. But National Guard representation on the JCS is hugely popular with state governors and adjutant generals, with 468,000 current Guard members and with many politicians. With defense budgets tightening, it is an inexpensive way to show fresh support and appreciation for home state militias.
"I really think momentum for this started with Katrina," said retired Maj. Gen. Gus L. Hargett Jr., president of the National Guard Association of the United States. Within days of that massive hurricane hitting the Gulf Coast in August 2005, almost 60,000 Guardsmen were deployed. Yet President Bush also ordered to New Orleans an active duty force of 5,000, the 82nd Airborne, a move that grabbed the spotlight and chapped Guard leaders.
If the National Guard chief at the time, Lt. Gen. Steve Blum, "had been a member of the Joint Chiefs we would have never sent the 82nd Airborne to Louisiana," Hargett said. The Guard "would have done all of that itself and it would have been a more of unified effort" versus "two chains of command working to do the same thing."
The House last May led Congress into making the Nation Guard Bureau chief a permanent member of the JCS, giving voice vote to this as part of a block of more obscure amendments to the fiscal 2012 defense authorization bill.
Senate approval came Nov. 28, also on a voice vote, in this case for a stand-alone amendment from Sen. Patrick Leahy, D-Vt., to the Senate version of the defense bill. But Leahy's amendment had 70 co-sponsors, including Sen. Jim Inhofe of Oklahoma.
Indeed, by early November, with the Joint Chiefs grumbling and Leahy's initiative gaining steam, the Senate Armed Services Committee called a hearing of historic significance. For the first time, all six four-star officers on the JCS appeared to testify and share their concerns.
The lone witness testifying in favor of putting the National Guard Bureau chief on the JCS was Gen. Craig R. McKinley, current National Guard Bureau chief.
The Defense Department's general counsel, Jeh Charles Johnson, also testified, advising that while the change would be legal it "could create legal confusion as to whether the Army and the Air Force chiefs of staff continue to represent their total force."
Gen. Martin E. Dempsey, JCS chairman, noted that he, like his predecessor, extended a standing invitation to Guard chief McKinley to attend JCS meetings. McKinley had enjoyed such access since becoming the first four-star officer to serve as NGB chief, the result of 2008 Guard reforms.
So, Dempsey said, "there is no compelling military need to support this historic change." He added that active and reserve component forces now are indistinguishable on the battlefield, in part because service chiefs of Army and Air Force "are the single voice for their respective branches ... The proposed change could undermine this unity of effort."
Dempsey also noted that only two of six reserve components would be represented so directly on the Joint Chiefs, "creating what could at least be the perception of inequity" for Reserve forces.
A more important concern, Dempsey said, involves accountability.
"Each of the Joint Chiefs is subject to the civilian oversight of a single appointed and confirmed secretary. The chief of the National Guard Bureau has no such oversight. Elevation to the JCS would make him equal to the service chiefs without commensurate accountability," Dempsey said.
But McKinley testified that, after three years on the job, he feels it is best for the nation that the National Guard chief be a full JCS member. Only full membership "will ensure that the responsibilities and capabilities" of Guard units in their nonfederalized role of supporting governors and states "are considered in a planned and deliberate manner."
His current effectiveness in getting resources and training for nonfederalized missions is "based upon ad hoc or personal relationships" and not firmly rooted in the law and national strategy. The Guard's domestic mission must receive more consideration in contingency planning, allocation of scarce resources, and advice to the president, secretary of defense and the national and homeland security councils, he added.
Threats to the homeland, he added, are more dangerous "than at any time in our history." With the Guard chief as a full JCS member, he said, mission "planning and resourcing would be vastly improved."
Many senators agreed.
"The citizen soldier's time has come," said Sen. Lindsey Graham, R-S.C., in a rapid-fire prosecutorial exchange with service chiefs and McKinley.
"General Dempsey, you're a very fine man. But if you got pissed off at (McKinley), could you tell him to get out of the room?"
"Yes, I could," the chairman said.
"Good, " Graham said, and to which McKinley added, "I think you need to be in the room with some weight behind you, not just an invitation."
Others opposed JCS expansion. Sen. James Webb , D-Va., a Marine in Vietnam and architect of the Post-9/11 GI Bill, said "anyone who's saying that citizen soldiers are not at the table right now is being unnecessarily divisive (and) unfair to the stewardship and leadership of the Army and the Air Force ... This legislation is unnecessary."
Sen. Carl Levin, D-Mich., committee chair, read reasons given by the Commission on the National Guard and Reserves in 2007 to oppose having the National Guard chief on the JCS. Topping the list was the fact that service chiefs have greater duties.
Hargett noted that the Joint Chiefs had opposed accepting the Marine Corps commandant in 1978 and passage of the Goldwater Nichols law in 1986, forcing the services to operate jointly. Both moves are now praised.
"So they are not always right," he said. "And they are very protective of their turf. That's what I believe this is about, more than anything else."

To comment, email milupdate@aol.com, write to Military Update, P.O. Box 231111, Centreville, VA 20120-1111 or visit www.militaryupdate.com.

VA staff shortages still impacting care says PTSD experts
Tom Philpott 5DEC2011

Despite adding billions of dollars for mental health care to Department of Veterans Affairs budgets the last four years, and the hiring of 7,000 more mental health professionals at VA clinics and hospitals, many veterans with severe combat-related stress still face long waits to get the care they need.
And some VA facilities might be "gaming" appointment dates so they appear to comply with a rule that veterans with post-traumatic stress disorder, or PTSD, begin treatment within 14 days of seeking care.
Those were just two of many complaints leveled at VA officials who oversee the department's burgeoning mental health care program during a hearing of the Senate Veterans Affairs Committee last week.
The most disturbing testimony came from Michelle Washington, coordinator of PTSD services and evidence-based psychotherapy at the VA medical center in Wilmington, Del. She said staff shortages are impacting patient care as needed therapy for severe PTSD cases is delayed by weeks or months, and scheduled appointments are sacrificed to management's higher goal of boosting new patient enrollment figures.
"Due to chronic short staffing at my facility, and the inability to manage my patient appointments based on their individual needs, I am frequently frustrated in my ability to provide that care," Washington said.
The evidence-based psychotherapy she uses for severe or complex PTSD cases, Washington said, involves 10 to 12 consecutive weekly sessions during which patients "re-experience" the trauma and address "erroneous beliefs" about the event so they "better process" trauma memory.
But scheduling patients for a series of weekly appointments "is very difficult at my facility," Washington said. Patients wait as long as six weeks for their first appointment. While waiting, some patients lose their motivation for treatment, while others see their PTSD worsen.
"Also, because scheduling clerks are under great pressure to bring new veterans in within 14 days, they may take one of my PTSD patient's regular appointments for a new patient appointment, which hurts the effectiveness of my patient's treatment," she said.
The Wilmington center appears on paper to schedule appointments for PTSD patients within the mandated 14 days. But the first visit often will involve paperwork and patient history and no therapy, allowing statistical records to indicate treatment has begun.
"As long as scheduling continues to be driven by clerks pressured by management to make the numbers look good, and as long as mental health providers have little or no say about where and when to best serve their patients," Washington said, "this will keep happening."
She also described a "pervasive shortage of primary care providers" that results in patients being referred erroneously to mental health care for lack of an initial comprehensive care assessment to diagnosis properly conditions that require medical care and not a mental health provider.
John Roberts, executive vice president for mental health at the Wounded Warrior Project, said many veterans still can't get timely mental health appointments because staff hiring isn't keeping pace with the needs of veterans, particularly those returning from Iraq and Afghanistan.
"Why, after 10 years, do warriors have to struggle to get effective care for the signature wound in this war?" Roberts asked. "Why isn't the under secretary for health ... moving beyond measuring baseline access to initial mental health evaluations to systematically tracking access to sustained follow-up care? If leaders spent more time speaking with the veterans, and their own clinicians, they would realize that the problems with VA mental health system run far deeper than even their data suggests."
VA mental health care staffs have increased by 48 percent since 2006 while the number of veterans using mental health service has climbed 34 percent to reach 1.2 million in fiscal 2010.
Roberts urged the VA to enhance mental health by using its authority to refer patients to civilian providers when VA resources don't allow timely care, and by expanding peer support programs so PTSD patients get mentoring and encouragement from veterans successfully treated.
The veterans affairs committee held its last hearing on mental health staff shortages in July with testimony of two veterans with PTSD who had attempted suicide and still couldn't get denied timely appointments.
At the time, Sen. Patty Murray, D-Wash., committee chairman, directed VA to survey some frontline mental health care providers to determine whether they had sufficient resources to give timely care. At Wednesday's hearing Murray announced that the results "were not good."
Forty percent of providers said they could not schedule an appointment in their clinic within the VA-mandated 14-day window and 70 percent said they did not have adequate staff or space to deliver timely care.
Yet VA officials in July told Congress that 95 percent of veterans were getting appointments within the 14-day window. Murray asked Mary Schohn, director of VA mental health operations, to explain the "disconnect."
Schohn conceded that Washington might have hit on the reason "that patients are not having access to the evidenced-based therapies in the way that we expect they should be."
The query of VA mental health care providers did indicate, Schohn said, that "there's access to the system, but not necessarily access to the specific therapies in the time they should occur. And we are working on ensuring that that happens." Schohn said clarifying guidance on the 14-day rule has gone out to hospitals and clinics, and site visits are planned "to find ways to solve the issues that Dr. Washington presented here today."
Sen. Richard Burr of North Carolina, the committee's ranking Republican, noted that VA's mental health budget jumped by 25 percent in 2011 to $5.7 billion. He demanded that Schohn provide a full accounting of how that was spent.
Schohn conceded some "variability" in access to care across the VA system. But overall, VA leads the private sector, and any other health system in the world, in delivering quality mental health care.
"I am personally concerned when I hear these stories about that not happening," she said.

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Amid battles to protect benefits while gays seek equality
Tom Philpott 28Nov2011

The dismal failure by the congressional "super committee" to deal with the nation's debt crisis leaves the Department of Defense facing automatic $55-billion-a-year spending cuts from 2013 through 2021. That is in addition to defense cuts of near-equal size already planned across the same decade.
President Obama promised before Thanksgiving to veto any attempt to block the automatic cuts unless Republicans agree to replace them with a "balanced" debt reduction package, one that includes tax increases on the wealthy and the closing of corporate loopholes as well as Democrat concessions to curb some popular federal entitlement programs.
With most Republicans having pledged to a powerful lobbyist, Grover Norquist and his Americans for Tax Reform group, not to allow tax increases of any kind, military associations fear pay and benefits particularly the TRICARE health program for military retirees are in the cross-hairs of both parties.
It is against this backdrop of threats to current benefits that gays and lesbians in uniform have begun to press for equality in benefits. Advocates are lobbying the department for regulation changes, filing challenges in federal court and pressing Congress to repeal the 1996 Defense of Marriage Act that prohibits extension of federal benefits, including military allowances, travel costs and health care, to spouses in same-sex marriages.
Military gays and lesbians have been able to serve openly since Sept. 20 when repeal of the "Don't Ask, Don't Tell" law took effect. A social research center at UCLA, the Miller Institute, estimates that 66,000 homosexuals serve on active duty and in the National Guard and Reserve.
Defense officials recently released a list of 14 military benefit programs that allow service members to designate "beneficiaries of their choosing, regardless of sexual orientation."
These include Service Members Group Life Insurance; Veterans' Group Life Insurance; Post Vietnam-era Veterans Assistance Program; the All-volunteer Force Educational Assistance Program (active duty death benefit); military death gratuity; final settlement of accounts; wounded warrior designated caregiver; thrift savings plan; casualty notification; escort for dependents of deceased or missing; designation as "person having interest in status of a missing member; persons eligible to receive effects of deceased persons; and travel allowance to attend Yellow Ribbon Reintegration events.
And, under the military's Survivor Benefits Plan, members can designate anyone to be a beneficiary under an "insurable interest" category of SBP. For such coverage, retirees pay a monthly premium equal to 10 percent of covered retired pay versus 6.5 percent for spousal coverage. Same-sex partners, even if armed with a marriage license from a state that recognizes homosexual unions, remain ineligible for spousal SBP.
Zeke Stokes, communications director for Servicemembers Legal Defense Network, a gay and lesbian advocacy group, said the list is a helpful resource. But every program listed was available to gay members before repeal of Don't Ask, Don't Tell (DADT), even if many hesitated to list same-sex partners for these programs or notifications for fear of revealing too much while DADT was in effect.
Eileen Lainez, a Defense Department spokeswoman, said officials continue "a careful and deliberate review" of programs with an eye toward revising eligibility for additional benefits "if legally permitted."
The day before the list was released, the Servicemembers Legal Defense Network filed a lawsuit in federal court in Boston on behalf of six married homosexual couples on active duty, and two who are retired, seeking full military benefits. The lawsuit challenges the constitutionality of the Defense of Marriage Act and other statutes that prohibit same-sex married couples from getting all benefits and family support that straight couples get.
Benefits illegally denied, the suit contends, include housing, health care, full survivor benefits, identification cards, and access to base stores as well as other morale, welfare and recreation programs.
"If one of our plaintiffs deployed and died in combat, the same level of survivor benefits that accrue naturally to a spouse would not accrue to their spouse because they are not recognized by the federal government," said Stokes.
Alexander Nicholson, executive director of Servicemembers United, the largest organization of gay and lesbian troops and veterans, said DoD doesn't have to wait for courts or Congress to extend more benefits to gay and lesbian members. For example, the law allows base shopping and ID cards for military "dependents." DoD through regulation simply could broaden the definition of dependent to include same-sex spouses.
Defense officials said those issues are, in fact, being studied.
The services are getting a lot of questions from gay members on benefits, particularly access to health care and base facilities such as commissaries, exchanges, housing and education services. Members are encouraged to direct these questions to their personnel office. A DoD website with general information is www.defense.gov/dadt_repeal.
Support groups are strengthening. One Nicolson helped to launch is American Military Partners Association at www.militarypartners.org.
Believing the Defense of Marriage Act (DOMA) to be unconstitutional, President Obama's Justice Department announced in February that the department no longer would defend the law in federal court. That has left opponents of gay marriage, including the Family Research Council (www.frc.org) looking toward the Republican-led House of Representatives to provide attorneys to defend DOMA against the new lawsuit.
Nicholson said that, besides the benefits disparity, gay service members have reported very few problems so far with repeal of DADT.
"We haven't hear many complaints at all," he said. Gay members who have revealed their status to peers, subordinates or commanders "are really expressing a lot of surprise at how well they are received," Nicholson said.
"Certainly not everybody is coming out. People are making judgments based on their environment and surroundings. It's an individual judgment call, but it's just like any other conservative workplace," he said.

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