This is the accessible text file for GAO report number GAO-05-890R 
entitled 'Defense Health Care: DOD Has Established a Chiropractic 
Benefit for Active Duty Personnel' which was released on September 6, 
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September 6, 2005: 

The Honorable John Warner:
Chairman:
The Honorable Carl Levin:
Ranking Minority Member:
Committee on Armed Services:
United States Senate: 

The Honorable Duncan L. Hunter:
Chairman:
The Honorable Ike Skelton:
Ranking Minority Member:
Committee on Armed Services:
House of Representatives: 

Subject: Defense Health Care: DOD Has Established a Chiropractic 
Benefit for Active Duty Personnel: 

The Floyd D. Spence National Defense Authorization Act for Fiscal Year 
2001 (NDAA 2001) directed the Department of Defense (DOD) to develop 
and implement a plan to make a chiropractic benefit available to all 
active duty personnel in the U.S. armed forces.[Footnote 1] The 
practice of chiropractic focuses on the relationship between structure 
(primarily, the spine) and function (as coordinated by the nervous 
system) and how that relationship affects the preservation and 
restoration of health. In August 2001, DOD submitted to Congress an 
implementation plan that described how it planned to develop a 
chiropractic benefit within the military health system. The plan 
addressed patient eligibility, access to care, the location of 
chiropractic clinics, projected costs, staffing, and the marketing and 
monitoring of the benefit. 

The NDAA 2001 directed DOD to develop the implementation plan in 
consultation with the Oversight Advisory Committee (OAC), which was 
established by the National Defense Authorization Act for Fiscal Year 
1995 (NDAA 1995). The OAC was directed by the NDAA 1995 to oversee a 3- 
year DOD chiropractic demonstration project at no fewer than 10 
military treatment facilities (MTF).[Footnote 2] The NDAA 1995 directed 
that the OAC include the Assistant Secretary of Defense for Health 
Affairs; the Surgeons General of the Army, the Air Force, and the Navy; 
and at least four representatives of the chiropractic profession; and 
also directed that we serve as a member of the OAC.[Footnote 3] As a 
member of the OAC, we attended meetings of the OAC and provided 
technical input and advice. 

The NDAA 2001 also mandated that we monitor the development and 
implementation of DOD's chiropractic health care plan. As agreed with 
the committees of jurisdiction, we reviewed the implementation of DOD's 
chiropractic benefit.[Footnote 4]

To review the implementation of DOD's chiropractic benefit, we examined 
relevant legislation, statutes, and reports containing congressional 
directives to DOD for establishing and enhancing the chiropractic 
benefit as well as those directing earlier chiropractic demonstration 
projects. We reviewed DOD's February 2000 Final Chiropractic Health 
Care Demonstration Program Report and DOD's August 2001 Report on 
Chiropractic Health Care Implementation Plan (implementation plan). We 
also reviewed pertinent DOD policies and procedures, and communications 
between the services and the TRICARE Management Activity (TMA), the 
office responsible for ensuring that DOD's health policy is 
implemented. We collected workload, staffing, and financial data from 
fiscal year 2002 through fiscal 2004 from each of the MTFs that have 
established chiropractic clinics. Although we did not independently 
verify the data that we collected, we queried representatives from each 
of the services to review the systems used for collecting and 
maintaining the data. We determined that the data were adequate for our 
purpose. We interviewed officials from the TMA, the Offices of the 
Surgeons General of the Air Force, Army, and Navy; and officials and 
chiropractors from five MTFs that have chiropractic clinics. We also 
interviewed an official from Cherokee Nation, a company that contracts 
chiropractors to work in chiropractic clinics for the Army and Air 
Force. We conducted our review according to generally accepted 
government auditing standards from October 2004 through August 2005. 

Results in Brief: 

To implement its chiropractic benefit, DOD has opened chiropractic 
clinics at 42 of its 238 MTFs, worldwide, and does not plan to add any 
additional clinics at this time. All of DOD's 1.8 million active-duty 
personnel are eligible for the benefit. The 42 chiropractic clinics are 
located in the United States in areas with a high number of active-duty 
personnel. Approximately 969,000, or 54 percent, of active-duty 
personnel reside in the areas served by the MTFs with chiropractic 
clinics. To support the benefit, DOD provides annual allotments from 
its health care budget. In fiscal year 2004, the allotment increased to 
$11 million. An additional $203,000 was provided by the MTFs with 
chiropractic clinics in fiscal year 2004. DOD generally adhered to the 
priorities specified in its implementation plan in selecting the sites 
for the 42 clinics and in determining the clinics' staffing levels. DOD 
has not completed other actions described in the implementation plan. 
For example, DOD's implementation plan stated that a marketing and 
promotion program, which would include pamphlets and other materials, 
would be necessary to make active-duty personnel aware of the benefit. 
However, DOD did not provide active- duty personnel with such materials 
as specified in the plan. Instead, DOD relied on each MTF to determine 
whether and how to promote the benefit. The implementation plan also 
called for close monitoring of the benefit to determine whether the 
benefit meets current needs, but DOD officials said that they had not 
monitored whether the benefit meets current or future demand from 
active-duty personnel. 

In commenting on a draft of this report, DOD generally agreed with our 
findings. DOD noted that oversight of the chiropractic clinics is 
provided at the service level, which involves frequent communication 
with TMA regarding medical care, budget, and legislative issues that 
affect the chiropractic program across the military health system. 

Background: 

Military health care is provided by TRICARE, DOD's health provider 
network. TRICARE covers about 9.1 million beneficiaries, including 
active-duty and retired members of the armed services and their 
families. The military health system's primary mission is to maintain 
the health of 1.8 million military personnel engaged in active 
duty.[Footnote 5] Costing about $17.8 billion in fiscal year 2004, 
TRICARE is financed through DOD's Defense Health Program (DHP) budget. 
The services administer TRICARE through their respective MTFs and other 
providers. Worldwide, DOD has 238 MTFs. The Surgeon General of each 
service has authority over the MTFs for that branch of the service. 

Congress has directed that DOD consider implementing a chiropractic 
benefit in the military health system since the 1980s. The Department 
of Defense Authorization Act of 1985 mandated that DOD conduct a 
demonstration project to evaluate the cost-effectiveness of 
incorporating chiropractic services for active-duty service members, 
retirees, and their dependents, as part of the Civilian Health and 
Medical Program of the Uniformed Services (CHAMPUS) benefit, the 
military health system in place prior to TRICARE.[Footnote 6] In August 
1993, DOD prepared a report to Congress on the CHAMPUS Chiropractic 
Demonstration Project. The report stated that after a 2-year 
demonstration project conducted in two states, DOD did not favor 
establishing a permanent benefit because other types of care had higher 
priority for the DHP's limited funds. 

In the NDAA 1995, Congress directed the Secretary of Defense to 
establish another demonstration program at no fewer than 10 sites for 3 
years to evaluate the feasibility and advisability of expanding DOD's 
health system to include the chiropractic benefit.[Footnote 7] The NDAA 
1995 also directed the Secretary to convene the OAC to, among other 
things, submit to Congress a plan for evaluating the program. The 
Secretary, with assistance from the OAC, was required to produce a 
final report at the conclusion of the demonstration period. The 
National Defense Authorization Act for Fiscal Year 1998 directed that 
the demonstration be increased to include at least three additional 
clinics in the MTFs that were not already designated to participate in 
the program, and it also extended the program for 2 more years, to 
conclude at the end of fiscal year 1999.[Footnote 8]

DOD issued its Final Chiropractic Health Care Demonstration Program 
Report in February 2000. The report concluded that it was feasible to 
integrate chiropractic care services into DOD's health system because 
chiropractic services complemented traditional medical care for 
patients with back pain but that it was not advisable to do so because 
of the additional costs entailed. The report stated that chiropractic 
care posed an additional cost because it did not fully offset the costs 
of traditional, nonchiropractic, medical care. DOD estimated that the 
anticipated total cost of making chiropractic care available to all 
TRICARE beneficiaries could reach $70 million annually.[Footnote 9] The 
report also stated that because of fiscal limitations within the 
military health system, full implementation of the chiropractic benefit 
would necessitate reducing or eliminating other existing medical 
programs. 

In the NDAA 2001, Congress directed DOD to develop a plan to provide 
the chiropractic benefit for all active-duty members of the 
military.[Footnote 10] In August 2001, DOD issued its implementation 
plan, which served as an operational framework for DOD in implementing 
its chiropractic benefit. Enclosure I lists selected legislation 
directed toward establishing and increasing the availability of DOD's 
chiropractic benefit. 

DOD Has Made the Chiropractic Benefit Available at 42 MTFs in the 
United States: 

To implement its chiropractic benefit, DOD has opened chiropractic 
clinics in 42 of its 238 MTFs. DOD does not currently plan to open 
additional clinics, but DOD officials said they continue to assess 
additional need for the benefit. The benefit is provided for active- 
duty personnel at the MTFs with chiropractic clinics, all of which are 
located in the United States. The locations for clinics were selected 
because they are in areas that have a high number of active-duty 
personnel. Approximately 969,000, or 54 percent, of active-duty 
personnel, reside in the areas served by the MTFs with chiropractic 
clinics. DOD allocated $11 million to the benefit in fiscal year 2004, 
and an additional $203,000 was provided by the MTFs with chiropractic 
clinics. DOD generally followed its implementation plan in locating and 
staffing its chiropractic clinics, but it did not actively promote or 
closely monitor the benefit as described in the plan. 

DOD Has Opened Clinics at 42 MTFs and Does Not Plan to Open More: 

DOD has opened chiropractic clinics for active-duty members of the 
uniformed services at 42 of DOD's 238 MTFs and does not plan to open 
additional clinics. The NDAA 2001 mandated that DOD create a plan to 
fully implement the chiropractic benefit; DOD responded by developing 
and submitting an implementation plan in August 2001 and began 
implementing the program in October of that same year. By fiscal year 
2003, DOD had opened 31 chiropractic clinics. In a committee report for 
the National Defense Authorization Act for Fiscal Year 2004, the Senate 
Committee on Armed Services directed that DOD provide the benefit at no 
fewer than 45 sites by the end of fiscal year 2004.[Footnote 11] DOD 
officials said they have fulfilled the requirements of the law and do 
not have immediate plans to add any additional clinics. They also said 
they will continue to assess additional need for the benefit. 

The chiropractic clinics have been opened at the MTFs in the United 
States with large active-duty populations. As of June 2005, the Army 
had opened the most chiropractic clinics with 17, the Air Force had 
opened 14, and the Navy had opened 11. Each of the 42 chiropractic 
clinics accepts active-duty patients from the other services. Figure 1 
shows the locations of the MTFs that have chiropractic 
clinics.[Footnote 12]

Figure 1: Location of DOD's 42 Chiropractic Clinics (August 2005): 

[See PDF for image] 

Note: Specific locations are listed in enc. II. 

[End of figure]

Fifty-Four Percent of Active-Duty Personnel Are Served by the MTFs with 
Chiropractic Clinics: 

Approximately 969,000, or 54 percent, of active-duty personnel, reside 
in the areas served by the MTFs with chiropractic clinics. (See table 
1.) However, DOD officials said that the chiropractic benefit is 
available to all active-duty personnel because they can be referred by 
their primary care manager to a chiropractor located in one of DOD's 42 
chiropractic clinics. DOD officials said that personnel residing in 
remote and overseas locations or in locations that are not near an MTF 
with a chiropractic clinic can travel, if necessary, to receive the 
benefit. According to DOD data, 19 percent of active-duty personnel 
currently reside in remote or overseas areas. DOD defines a remote area 
as an area in the United States in which an active-duty member resides 
and works more than 50 miles from an MTF. An additional 28 percent of 
active-duty personnel reside in areas of the U.S. served by MTFs that 
do not have chiropractic clinics. Currently, there is no provision for 
active-duty personnel to receive chiropractic services in the civilian 
or purchased-care sector. 

Table 1: Proximity of Active Duty Personnel to Chiropractic Clinics 
(August 2005): 

Location of active-duty personnel: Residing in areas served by a 
chiropractic clinic; 
Active-duty population: 969,000; 
Percent of active-duty population: 54%. 

Location of active-duty personnel: Residing in locations not served by 
a chiropractic clinic: Living overseas; 
Active-duty population: 246,000; 
Percent of active-duty population: 14%. 

Location of active-duty personnel: Residing in locations not served by 
a chiropractic clinic: Living in remote areas; 
Active-duty population: 88,000; 
Percent of active-duty population: 5%. 

Location of active-duty personnel: Residing in locations not served by 
a chiropractic clinic: Living in areas of the United States served by 
MTFs with no chiropractic clinic; 
Active-duty population: 497,000; 
Percent of active-duty population: 28%.

Location of active-duty personnel: Residing in locations not served by 
a chiropractic clinic: Total; 
Active-duty population: 831,000; 
Percent of active-duty population: 46%. 

Location of active-duty personnel: Total; 
Active-duty population: 1,800,000; 
Percent of active-duty population: 100%. 

Sources: TMA and the Offices of the Surgeons General of the Air Force, 
Army, and Navy, DOD. 

[End of table]

DOD's Allotments for the Benefit Have Increased: 

Since 2002 the chiropractic benefit has been directly funded from the 
DHP with an annual allotment for each of the services. DOD's annual 
allotment to the chiropractic benefit has grown over time to $11 
million in fiscal year 2004. Table 2 shows the annual DHP allotments 
for the chiropractic benefit for fiscal years 2002 through 2004 as well 
as the number of clinics in operation by each service for the same 
period. 

Table 2: Annual DHP Allotments Directly for the Chiropractic Program 
and Number of Clinics, by Service, Fiscal Years 2002-2004: 

Dollars in millions. 

Service: Air Force; 
Fiscal year 2002: DHP allotment: $1.80; 
Fiscal year 2002: Number of clinics: 4; 
Fiscal year 2003: DHP allotment: $1.70; 
Fiscal year 2003: Number of clinics: 8; 
Fiscal year 2004: DHP allotment: $2.70; 
Fiscal year 2004: Number of clinics: 14. 

Service: Army; 
Fiscal year 2002: DHP allotment: $2.3; 
Fiscal year 2002: Number of clinics: 5; 
Fiscal year 2003: DHP allotment: $4.4; 
Fiscal year 2003: Number of clinics: 13; 
Fiscal year 2004: DHP allotment: $4.3; 
Fiscal year 2004: Number of clinics: 17. 

Service: Navy; 
Fiscal year 2002: DHP allotment: $1.8; 
Fiscal year 2002: Number of clinics: 5; 
Fiscal year 2003: DHP allotment: $3.6; 
Fiscal year 2003: Number of clinics: 10; 
Fiscal year 2004: DHP allotment: $4; 
Fiscal year 2004: Number of clinics: 11. 

Total; 
Fiscal year 2002: DHP allotment: $6.00; 
Fiscal year 2002: Number of clinics: 14; 
Fiscal year 2003: DHP allotment: $9.80; 
Fiscal year 2003: Number of clinics: 31; 
Fiscal year 2004: DHP allotment: $11; 
Fiscal year 2004: Number of clinics: 42. 

Source: DOD. 

Notes: DHP allotments are in millions of dollars. Totals may not add 
because of rounding. 

[End of table]

Most MTFs provide additional financial support for their respective 
chiropractic clinics from their own resources. Twenty-six of the 42 
MTFs that have chiropractic clinics have provided additional financial 
support from funds that the MTFs have received for their general use to 
cover supplies or incidental items. The amount of funding provided by 
MTFs for their respective clinics has varied from one MTF to another. 
Table 3 shows the amount of MTF funds provided for chiropractic 
clinics, as well as the number of clinics in operation, by service for 
fiscal years 2002 through 2004. 

Table 3: MTF Funds Provided for Chiropractic Clinics and Number of 
Clinics, by Service, Fiscal Years 2002-2004: 

Service: Air Force; 
Fiscal year 2002: MTF funds: $10,571; 
Fiscal year 2002: Number of clinics: 4; 
Fiscal year 2003: MTF funds: $40,642; 
Fiscal year 2003: Number of clinics: 8; 
Fiscal year 2004: MTF funds: $94,932; 
Fiscal year 2004: Number of clinics: 14. 

Service: Army; 
Fiscal year 2002: MTF funds: $25,768; 
Fiscal year 2002: Number of clinics: 5; 
Fiscal year 2003: MTF funds: $54,012; 
Fiscal year 2003: Number of clinics: 13; 
Fiscal year 2004: MTF funds: $44,222; 
Fiscal year 2004: Number of clinics: 17. 

Service: Navy; 
Fiscal year 2002: MTF funds: $111,317; 
Fiscal year 2002: Number of clinics: 5; 
Fiscal year 2003: MTF funds: $60,914; 
Fiscal year 2003: Number of clinics: 10; 
Fiscal year 2004: MTF funds: $63,674; 
Fiscal year 2004: Number of clinics: 11. 

Total; 
Fiscal year 2002: MTF funds: $147,656; 
Fiscal year 2002: Number of clinics: 14; 
Fiscal year 2003: MTF funds: $155,568; 
Fiscal year 2003: Number of clinics: 31; 
Fiscal year 2004: MTF funds: $202,828; 
Fiscal year 2004: Number of clinics: 42. 

Sources: Offices of the Surgeons General of the Air Force, Army, and 
Navy. 

Note: Funds contributed by MTFs were in addition to the DHP allotments 
provided to the services. 

[End of table]

DOD Generally Followed Its Implementation Plan in Establishing the 
Benefit: 

DOD generally followed its implementation plan in selecting sites and 
determining staffing levels for the chiropractic clinics that were 
opened after the conclusion of the demonstration project but did not 
complete other actions described in the implementation plan. In 
determining locations for chiropractic clinics, DOD noted in its 
implementation plan that chiropractic care would continue at the 13 
MTFs that had chiropractic clinics established for the demonstration 
project. For each service, the implementation plan included a list of 
MTFs considered for receiving chiropractic clinics, prioritized by 
projected demand on the basis of the size of the active duty population 
served by the MTFs. Decisions about opening chiropractic clinics at 
particular MTFs also were based upon criteria reflecting specific 
aspects of the areas served by the MTFs. DOD officials said that, in 
addition to the criteria used to develop the lists, other factors that 
were considered included the (1) proximity of other MTFs offering 
chiropractic services, (2) availability of space at the MTF, and (3) 
plans for future construction at the MTF. The implementation plan 
provided the services with guidance on the order for opening the 
clinics. However, DOD gave the services discretion in deciding which 
clinics to open on the basis of all of the factors. 

The locations of the clinics suggest that DOD generally opened clinics 
at the MTFs in the order in which they appear on the list in its 
implementation plan. (See enc. II.) The Army opened clinics at 17 of 
the first 18 MTFs appearing on the list, the Navy opened clinics at 11 
of the first 12, and the Air Force opened clinics at 14 of the first 
25. Officials from the Surgeons General's offices said that the lack of 
available space at an MTF was the most common reason that an MTF on the 
list would not have received a clinic but said that the services 
carefully evaluated each site on the list. 

DOD officials said they also generally followed the criteria stated in 
the implementation plan for staffing the clinics. According to DOD's 
implementation plan, staffing levels at each clinic would be based on 
the number of active-duty personnel and historical MTF workloads. DOD 
assumed that a single chiropractor with one assistant could treat 
approximately 1,000 patients and handle 4,200 visits a year from these 
patients. At the end of fiscal year 2004, DOD had staffed its 42 
clinics with 58 chiropractors. Most of the clinics are staffed with a 
single chiropractor. DOD's chiropractors are civilian contractors. The 
Army and Air Force use a third-party firm to hire their chiropractic 
contractors, while the Navy hires its entire chiropractic staff through 
the Navy Medical Logistics Command. Table 4 shows the number of 
chiropractors staffed in DOD chiropractic clinics, by service, since 
fiscal year 2002. 

Table 4: Number of Chiropractors Staffed in DOD Chiropractic Clinics, 
by Service, Fiscal Years 2002-2004: 

Service: Air Force; 
Fiscal Year 2002: 11; 
Fiscal Year 2003: 14; 
Fiscal Year 2004: 18.

Service: Army; 
Fiscal Year 2002: 13; 
Fiscal Year 2003: 19; 
Fiscal Year 2004: 21.

Service: Navy; 
Fiscal Year 2002: 9; 
Fiscal Year 2003: 18; 
Fiscal Year 2004: 19.

Total; 
Fiscal Year 2002: 33; 
Fiscal Year 2003: 51; 
Fiscal Year 2004: 58.

Sources: Offices of the Surgeons General of the Air Force, Army, and 
Navy. 

[End of table]

The implementation plan anticipated that staffing requirements would be 
recomputed according to demand as the chiropractic program matured and 
data were collected to evaluate the benefit. However, DOD has not 
conducted a formal assessment of staffing needs since October 2001, 
when the benefit was first established. Instead, service 
representatives said they have staffed clinics on the basis of input 
from the MTFs about how they are handling their workload and said that 
they communicate as needed with the MTF officials to assess the status 
of the chiropractic clinics and solve any staffing issues that might 
arise. 

DOD has not completed other actions described in the implementation 
plan. For example, DOD's implementation plan stated that a marketing 
and promotional program would be necessary to make personnel aware of 
the benefit, as well as to inform their physicians, case managers, and 
commanders about the benefit. Such a program was to include promotional 
materials such as handouts, posters, generic news items for post or 
base papers, or other similar materials. However, DOD's promotional 
activities have been limited. For example, DOD officials said that DOD 
had not provided materials for promoting the chiropractic benefit to 
the services but had instead left it to the services to promote the 
benefit. Service representatives said that they had not produced 
promotional materials about the chiropractic benefit and did not 
monitor the MTFs' promotional efforts. The MTF staff we interviewed 
said that they had not produced materials to promote the chiropractic 
benefit. We found that only 10 of the 42 MTFs with chiropractic clinics 
included the chiropractic benefit on their Web site. In addition, 
although the implementation plan stated that DOD would monitor the 
program to determine whether the benefit meets current needs and to 
identify future demand, DOD officials told us that they have not 
conducted such monitoring. 

Agency Comments: 

We requested comments on a draft of this report from DOD. DOD provided 
written comments that are reprinted in enclosure III. In its comments, 
DOD generally concurred with our findings, noting that oversight of the 
chiropractic clinics is provided at the service level, which involves 
frequent communication with TMA regarding medical care, budget, and 
legislative issues that affect the chiropractic program across the 
military health system. We incorporated technical comments provided by 
DOD as appropriate. 

We are sending copies of this report to the Secretary of Defense, 
appropriate congressional committees, and other interested parties. 
Copies will also be made available to others upon request. In addition, 
this report is available at no charge on GAO's Web site at 
http://www.gao.gov. If you or your staff have any questions regarding 
this report, please contact me at (202) 512-7101 or crossem@gao.gov. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. Contributions 
were made by Tom Conahan, Assistant Director; Martin Gahart; Cathleen 
Hamann, and Carolina Morgan. 

Signed by: 

Marcia Crosse: 
Director, Health Care: 

Enclosures - 3: 

Enclosure I: 

Selected Laws Pertaining to Development of DOD's Chiropractic Benefit: 

Law: Department of Defense Authorization Act, 1985, Pub. L. No. 98-525 
 632(b), 98 Stat. 2492, 2543 (1984); 
Description: Directed the Secretary of Defense to conduct demonstration 
projects to determine the cost-effectiveness of a chiropractic benefit 
for CHAMPUS-eligible beneficiaries. 

Law: National Defense Authorization Act for Fiscal Year 1995, Pub. L. 
No. 103-337,  731, 108 Stat. 2663, 2809 (1994); 
Description: Required that the Secretary of Defense establish a 3-year 
chiropractic demonstration program at no less than 10 military 
treatment facilities to evaluate the feasibility and advisability of 
providing chiropractic care through the medical care facilities of the 
Armed Forces. Provided for establishment of an Oversight Advisory 
Committee (OAC) to assist and advise in the development and conduct of 
the demonstration program. 

Law: National Defense Authorization Act for Fiscal Year 1998, Pub. L. 
No. 105-85,  739(a), (b), 111 Stat. 1629, 1815 (1997); 
Description: Extended the demonstration program for 2 years through 
fiscal year 1999. Mandated the expansion of the chiropractic health 
care demonstration program to at least three additional treatment 
facilities. 

Law: Floyd D. Spence National Defense Authorization Act for Fiscal Year 
2001, Pub. L. No. 106-398,  702, 114 Stat. 1654, App. A 1654A-173-174 
(2000); 
Description: Required the development and implementation of a plan to 
provide a permanent chiropractic care benefit for all active-duty 
personnel to be phased in over a 5-year period, beginning October 1, 
2001. Required that GAO monitor the development and implementation of 
the chiropractic plan.[A]. 

Law: National Defense Authorization Act for Fiscal Year 2004, Pub. L. 
No. 108-136,  711, 117 Stat. 1392, 1530 (2003); 
Description: Required the Secretary of Defense to accelerate the 
implementation of the plan to provide a chiropractic benefit for active-
duty personnel, with the goal of completing the implementation of the 
plan by October 1, 2005, rather than the original deadline of October 
1, 2006. 

Source: GAO. 

Note: CHAMPUS = Civilian Health and Medical Program of the Uniformed 
Services. 

[A] We did not evaluate the development of DOD's implementation plan 
because of our previous role as a member of the OAC in accordance with 
NDAA 1995. In our role, we participated in developing DOD's 
implementation plan by providing the OAC with a member. To maintain 
compliance with the independence requirements of generally accepted 
government auditing standards, we are unable to evaluate the 
development of that same plan. 

[End of table]

Enclosure II: 

Military Treatment Facilities Considered for Chiropractic Clinics, in 
Order of Projected Demand, by Service: 

Air Force: 

Military treatment facilities as listed in implementation plan: 59th 
Medical Wing, Lackland Air Force Base (AFB), Tex.[A]; 
Date opened: September 1998. 

Military treatment facilities as listed in implementation plan: 11th 
Medical Group, Bolling AFB, D.C; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 10th 
Medical Group, U.S. Air Force Academy, Colo; 
Date opened: October 2002. 

Military treatment facilities as listed in implementation plan: 1st 
Medical Group, Langley AFB, Va; 
Date opened: October 2002. 

Military treatment facilities as listed in implementation plan: 55th 
Medical Group, Offutt AFB, Nebr.a; 
Date opened: October 1995. 

Military treatment facilities as listed in implementation plan: 375th 
Medical Group, Scott AFB, Ill.a; 
Date opened: October 1995. 

Military treatment facilities as listed in implementation plan: 72nd 
Medical Group, Tinker AFB, Okla; 
Date opened: February 2004. 

Military treatment facilities as listed in implementation plan: 96th 
Medical Group, Eglin AFB, Fla; 
Date opened: October 2003. 

Military treatment facilities as listed in implementation plan: 6th 
Medical Group, MacDill AFB, Fla; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 74th 
Medical Group, Wright Patterson AFB, Ohio; 
Date opened: March 2004. 

Military treatment facilities as listed in implementation plan: 16th 
Medical Group, Hurlburt Field AFB, Fla; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 60th 
Medical Group, Travis AFB, Calif.a; 
Date opened: October 1995. 

Military treatment facilities as listed in implementation plan: 99th 
Medical Group, Nellis AFB, Nev; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 3rd Med 
Group, Elmendorf AFB, Alaska; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 56th 
Medical Group, Luke AFB, Ariz; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 42nd 
Medical Group, Maxwell AFB, Ala; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 355 
Medical Group, Davis Monthan AFB, Ariz; 
Date opened: January 2004. 

Military treatment facilities as listed in implementation plan: 89th 
Medical Group, Andrews AFB, Md; 
Date opened: October 2002. 

Military treatment facilities as listed in implementation plan: 12th 
Medical Group, Randolph AFB, Tex; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 78th 
Medical Group, Robins AFB, Ga; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 305th 
Medical Group, McGuire AFB, N.J; 
Date opened: February 2004. 

Military treatment facilities as listed in implementation plan: 377th 
Medical Group, Kirtland AFB, N. Mex; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 43rd 
Medical Group Pope AFB, N.C; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: 81st 
Medical Group, Keesler AFB, Miss; 
Date opened: October 2002. 

Military treatment facilities as listed in implementation plan: 2nd 
Medical Group, Barksdale AFB, La; 
Date opened: February 2004. 

Army: 

Military treatment facilities as listed in implementation plan: Womack 
Army Medical Center, Fort Bragg, N.C; 
Date opened: January 2003. 

Military treatment facilities as listed in implementation plan: Darnall 
Army Community Hospital, Fort Hood, Tex; 
Date opened: October 2002. 

Military treatment facilities as listed in implementation plan: Martin 
Army Community Hospital, Fort Benning, Ga.[A]; 
Date opened: October 1995. 

Military treatment facilities as listed in implementation plan: 
Blanchfield Army Community Hospital, Fort Campbell, Ky; 
Date opened: December 2003. 

Military treatment facilities as listed in implementation plan: Walter 
Reed Army Medical Center, D.C.[A]; 
Date opened: September 1998. 

Military treatment facilities as listed in implementation plan: 
Kimbrough Ambulatory Care Center, Fort Meade, Md; 
Date opened: October 2003. 

Military treatment facilities as listed in implementation plan: Winn 
Army Community Hospital, Fort Stewart, Ga; 
Date opened: May 2003. 

Military treatment facilities as listed in implementation plan: Madigan 
Army Medical Center, Fort Lewis,Wash; 
Date opened: April 2003. 

Military treatment facilities as listed in implementation plan: 
Reynolds Army Community Hospital, Fort Sill, Okla.[A]; 
Date opened: September 1995. 

Military treatment facilities as listed in implementation plan: Ireland 
Army Community Hospital, Fort Knox, Ky; 
Date opened: July 2003. 

Military treatment facilities as listed in implementation plan: Evans 
Army Community Hospital, Fort Carson, Colo.[A]; 
Date opened: September 1995. 

Military treatment facilities as listed in implementation plan: Tripler 
Army Medical Center, Fort Shafter, Hawaii; 
Date opened: May 2003. 

Military treatment facilities as listed in implementation plan: General 
Leonard Wood Army Community Hospital, Fort Leonard Wood, Mo; 
Date opened: October 2003. 

Military treatment facilities as listed in implementation plan: 
Moncrief Army Community Hospital, Fort Jackson, S.C.[A]; 
Date opened: September 1995. 

Military treatment facilities as listed in implementation plan: 
Eisenhower Army Medical Center, Fort Gordon, Ga; 
Date opened: July 2003. 

Military treatment facilities as listed in implementation plan: William 
Beaumont Army Medical Center, Fort Bliss, Tex; 
Date opened: April 2003. 

Military treatment facilities as listed in implementation plan: Dewitt 
Army Community Hospital, Fort Belvoir, Va; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: Guthrie 
Ambulatory Healthcare Clinic, Fort Drum, N.Y; 
Date opened: January 2004. 

Navy: 

Military treatment facilities as listed in implementation plan: Naval 
Medical Center, Portsmouth, Va; 
Date opened: January 2003. 

Military treatment facilities as listed in implementation plan: Naval 
Medical Center, San Diego, Calif; 
Date opened: September 2003. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Camp Pendleton, Calif.[A]; 
Date opened: October 1995. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Pensacola, Fla; 
Date opened: September 2003. 

Military treatment facilities as listed in implementation plan: 
National Naval Medical Center, Bethesda, Md.[A]; 
Date opened: August 1999. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Camp Lejeune, N.C.[A]; 
Date opened: September 1995. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Jacksonville, Fla.[A]; 
Date opened: September 1995. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Great Lakes, ll; 
Date opened: October 2003. 

Military treatment facilities as listed in implementation plan: Naval 
Medical Clinic, Pearl Harbor, Hawaii; 
Date opened: No clinic opened. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Bremerton, Wash; 
Date opened: September 2002. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Cherry Point, N.C; 
Date opened: January 2003. 

Military treatment facilities as listed in implementation plan: Naval 
Hospital, Beaufort, S.C; 
Date opened: October 2002. 

Sources: Report on Chiropractic Health Care Implementation Plan (August 
2001), and the Offices of the Surgeons General for the Air Force, Army, 
and Navy. 

Note: Military treatment facilities are arranged by projected demand 
based on population served by the Military Treatment Facility, within 
service. 

[A] Denotes clinics opened for the demonstration project, from fiscal 
year 1995 through fiscal 2000. 

[End of table]

Comments from the Department of Defense: 

THE ASSISTANT SECRETARY OF DEFENSE: 
HEALTH AFFAIRS:
WASHINGTON, D. C. 20301-1200: 

AUG 12 2005: 

Ms. Marcia Crosse: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street, N.W.
Washington, DC 20548: 

Dear Ms. Crosse: 

This is the Department of Defense (DoD) response to the Government 
Accountability Office (GAO) draft report, "DEFENSE HEALTH CARE: DoD Has 
Established a Chiropractic Benefit for Active Duty Personnel," dated 
July 21, 2005, (GAO Code 290253/GAO-05-890R). 

Thank you for the opportunity to review the draft report. The report 
makes no specific recommendations to the Department of Defense. We 
concur with the draft report, but offer the enclosed comments and 
suggestions to make it more technically accurate. 

My points of contact are Ms. Anne Giese (Functional) at (703) 681-0039 
and Mr. Gunther Zimmerman (Audit Liaison) at (703) 681-3492. 

Sincerely,

Signed by: 

William Winkenwerder, Jr., MD: 

Enclosure: As stated: 

GAO DRAFT REPORT - DATED July 21, 2005 GAO Code 290253/GAO-05-890R): 

"DEFENSE HEALTH CARE: DoD Has Established a Chiropractic Benefit for 
Active Duty Personnel"

DEPARTMENT OF DEFENSE COMMENTS: 

OVERALL COMMENTS: 

Oversight of the Chiropractic clinics is provided at the Service level. 
The individual Services collect and analyze metrics for the programs at 
their military treatment facilities. The Services have the 
responsibility for monitoring execution of the Chiropractic program at 
their facilities. The Services review the status of their sites on a 
regular basis in order to renew contracts with the Chiropractors, 
justify funding requests, and respond to legislative initiatives. TMA 
is in frequent communication with the Services regarding medical care, 
budget and legislative issues that impact the Chiropractic care program 
across the military health system. Data collected by the Services are 
most useful during the discussions with TMA on issues that affect the 
entire military health system. 

(290253): 

FOOTNOTES

[1] Pub. L. No. 106-398, App. A,  702, 114 Stat. 1654, 1654A-173-174 
(2000). 

[2] An MTF is a military hospital or clinic on or near a military base. 

[3] Pub. L. No. 103-337,  731, 108 Stat. 2663, 2809 (1994) (NDAA 
1995). 

[4] We did not evaluate the development of DOD's implementation plan 
because of our previous role as a member of the OAC in accordance with 
NDAA 1995. In our role, we participated in developing DOD's 
implementation plan by providing the OAC with a member. To maintain 
compliance with the independence requirements of generally accepted 
government auditing standards, we are unable to evaluate the 
development of that same plan. 

[5] In addition to members of the armed forces, "active-duty personnel" 
also include members of the Coast Guard, the Commissioned Corps of the 
National Oceanic and Atmospheric Administration, and the Public Health 
Service. Members of the Reserves and National Guard are also eligible 
for care in the military health system when they are in active-duty 
status for over 30 days. 

[6] Pub. L. No. 98-525,  632(b), 98 Stat. 2492, 2543 (1984). 

[7] Pub. L. No. 103-337,  731, 108 Stat. 2663, 2809 (1994). 

[8] Pub. L. No. 105-85,  739(a), (b), 111 Stat. 1629, 1815 (1997). 

[9] We did not adjust the $70 million figure to 2005 dollars. The 
figure is taken from DOD's February 2000 report and is in 2000 dollars. 

[10] Congress did not direct that DOD's plan include the provision of 
the benefit to military retirees and dependents. 

[11] S. Rep. No. 108-46 at 331-332 (2003). 

[12] On May 13, 2005, DOD made recommendations for base realignments 
and closures. Thirty-six bases that have MTFs with chiropractic clinics 
would be affected if these recommendations are implemented; 16 would be 
realigned and 20 would gain additional staff or functions. DOD defines 
"realignment" as any action that both reduces and relocates functions 
and civilian personnel positions. DOD has not determined how this would 
affect the chiropractic program.