Defense Health Primer: U.S. Coast Guard Health Services

Established in 1790, the U.S. Coast Guard (USCG) is a military service in the Department of Homeland Security (DHS) and a branch of the armed forces of the United States. The role of USCG is to provide security, maritime safety, and environmental stewardship on the high seas and in the ports, inland waterways, and maritime economic zones of the United States. To support these tasks, 14 U.S.C. §504 authorizes USCG to administer a Health Services program to sustain the medical readiness of approximately 50,000 active duty and reserve servicemembers of the Coast Guard. The USCG program also collaborates with the Military Health System (MHS) of the Department of Defense (DOD) to offer health care services to 9.6 million beneficiaries eligible for the TRICARE program.

Mission

The USCG Health, Safety, and Work-Life (HSWL) Directorate (CG-11) administers the USCG Health Services program; it

• provides health care to active duty and reserve servicemembers supporting USCG missions;
• "ensure[s] the medical and dental readiness" of servicemembers for "world-wide deployment;" and
• ensures the availability of quality, cost-effective health care for all eligible Coast Guard beneficiaries (i.e., active and reserve servicemembers, retirees, and family members).

Organization

The CG-11 Director is typically a U.S. Public Health Service (USPHS) flag officer (O-8) assigned to USCG Headquarters and serves as the chief medical advisor (i.e., Surgeon General) to the USCG Commandant. The CG-11 Director also works under the immediate supervision of the Assistant Commandant for Human Resources, who reports to the Deputy Commandant for Mission Support.

The CG-11 Director delegates day-to-day oversight and administration of the program to the Chief of Health Services, who also functions as the Deputy Surgeon General of the Coast Guard. The HSWL Service Center administers the various health programs under its purview, which include 14 Regional Practice offices that provide technical assistance and administrative oversight for all USCG clinics and shipboard medical assets.

Budget

Most USCG health-related spending is organized into several Program, Project, and Activity categories of the Coast Guard's Operations and Support account in the annual DHS appropriation. The fiscal year (FY) 2024 USCG budget request included $1.2 billion in discretionary funds for health-related spending and $250.5 million in mandatory funds that pay for USCG retiree health care. These funds are separate from DOD's Defense Health Program account that funds the MHS.

USCG Health Services Personnel

A variety of medical professionals staff the USCG Health Services program, including physicians, dentists, advanced practice providers, nurses, corpsmen, and administrators. At the end of FY2023, 1,343 personnel were assigned to the USCG Health Services program. This included a mix of USCG officers and enlisted servicemembers (67%), USPHS officers (14%), civil servants (5%), and contractors (14%).

USPHS Support to USCG

USPHS has historically provided health care support to USCG, originally through its now-decommissioned Marine Hospital Service. By law (42 U.S.C. §253), USCG is entitled to USPHS support for "medical, surgical, and dental treatment and hospitalization." A 2019 Memorandum of Understanding (MOU) formalizes this medical support relationship, which assigns USPHS officers to fill certain USCG personnel requirements on a reimbursable-basis. USPHS officers may be assigned to a clinic or a ship and can deploy with certain USCG units.

USCG Health Services

USCG offers a limited range of outpatient medical and dental care (e.g., primary care; occupational health; flight medicine; optometry; mental health; physical therapy; dentistry; and basic laboratory, radiology, and pharmacy services). USCG delivers these health care services in fixed U.S. health care facilities, ships, and certain deployed environments. USCG operates 44 shore-based outpatient clinics in the United States (see Figure 1) and no inpatient facilities. The clinics function similarly to DOD's military treatment facilities (MTFs).

Figure 1. USCG Shore-Based Clinics

Source: CRS graphic based on data provided by USCG officials, August 2020. Note: USCG clinics in Guam and Puerto Rico are not depicted on this map.

Additionally, most USCG ships are equipped with a sickbay staffed with at least one health care provider. Shipboard health services are generally limited to primary care and first-responder care; however, some ships may be equipped and staffed to conduct certain emergency surgical procedures. Typically, when a patient's medical needs exceed the medical capabilities of a USCG clinic or sickbay, they can be referred or medically evacuated to a DOD MTF or civilian medical facility participating in TRICARE. Approximately 60% of all active duty USCG servicemembers obtain their health care primarily at a USCG clinic, while others (including Coast Guard retirees and family members) receive their health care at a DOD MTF or TRICARE provider.

Interaction with TRICARE

Chapter 55 of Title 10, U.S. Code, entitles all active duty members, retirees, and family members of the uniformed services (including USCG) to the benefits offered by the TRICARE program, including care in DOD MTFs. Statute (14 U.S.C. §506) requires DHS to reimburse DOD for MTF care provided to Coast Guard beneficiaries. Non-USCG beneficiaries may receive primary care in USCG clinics under certain conditions established by the HSWL Service Center and on a space-available basis. In general, USCG health services policies on quality and access to care mirror or defer to DOD's policies.

Current Challenges

There are a number of perceived challenges facing the USCG Health Services program, many of which have attracted congressional attention and ongoing oversight.

USCG Health Services Strategy

Since at least 2021, Congress has expressed interest in understanding the current state of USCG Health Services and how the service's medical capabilities are used to support operations and medical readiness of the force. In 2022, the USCG Commandant published the service's strategy, which includes actions to "generate a modern and ready workforce" through the delivery of "point-of-need healthcare." These actions include modernization of health service policies and procedures, development and diversification of technologies to deliver high-quality health care, and strengthening "organic Coast Guard medical capability" through innovation and workforce training initiatives.

Congress enacted several provisions in the Don Young Coast Guard Authorization Act of 2022, as part of the James M. Inhofe National Defense Authorization Act for 2023 (FY2023 NDAA; P.L. 117-263), to require review, study, or implementation of certain health services-related reforms. Section 11407 of the FY2023 NDAA directed the USCG Commandant to conduct a "comprehensive review" and develop a strategic plan that improves and modernizes the health services program "to ensure access to high-quality, timely healthcare" for USCG beneficiaries. The provision requires a report to Congress on the review's findings and recommendations, strategic plan, and a description of how the Commandant would implement the recommendations.

USCG Health Services Staffing Needs

USCG has typically based its health services staffing requirements on "historical staffing levels" at individual clinics and units. In 2022, the Government Accountability Office (GAO) found that USCG "cannot ensure it has the right number and type of medical and dental staff to keep its personnel ready to meet its mission." Section 11406 of FY2023 NDAA directed USCG to develop medical staffing standards that take into consideration current and future DHS missions, requirements for certain clinical specialties, workforce mix (uniformed, civilian, and contract personnel), and staffing at remote USCG clinics. The provision required USCG to have developed these standards by June 2023 and to provide a report to Congress not later than 180 days after developing the standards.

Disability Evaluation System

USCG utilizes a legacy Disability Evaluation System (DES) process to evaluate a servicemember's fitness for duty and make a determination on retention or separation from military service. In comparison, DOD used to use a similar legacy DES process that GAO found to have long delays, duplicate DOD and VA processes, and confuse servicemembers. DOD transitioned to a more streamlined process called the Integrated Disability Evaluation System (IDES) in 2012, while USCG continues to primarily use a legacy DES process. In March 2020, USCG began a five-site pilot program to replace its legacy DES with IDES. USCG has not yet announced plans to implement IDES across all installations.

Section 11243 of the FY2023 NDAA required GAO to conduct a study and provide a report to Congress on USCG's DES and make recommendations to improve the overall process. The law also required USCG to develop a temporary, then permanent policy that improves the "timeliness, communication, and outcomes" and affords maximum career and separation transition benefits for servicemembers going through the DES process.