– Executive Summary –
The National Guard operates under a unique dual status, alternating between state and federal activation authorities. National Guard service members (NGSMs) activated under state active duty (SAD) are considered state employees and perform critical domestic response missions, including, but not limited to, disaster relief, civil unrest support, and public health emergencies.[1] However, unlike their federally activated counterparts, NGSMs under SAD are not eligible for TRICARE healthcare coverage.[2] Instead, they must rely on variable state workers’ compensation programs, which often fail to provide comprehensive medical and mental healthcare.[3] The disparity in coverage creates significant challenges for NGSMs who serve in hazardous and high-stress environments under a SAD status, the same environments as federally activated peers performing defense support of civil authorities (DSCA) missions.[4] The lack of healthcare parity between SAD and federal activation statuses affects NGSMs’ well-being, readiness, and retention, leading to long-term consequences for both the individuals affected and the operational effectiveness of the National Guard.
This research examines the healthcare inequities between NGSMs under SAD and federally activated NGSMs providing DSCA, exploring legislative and policy factors contributing to this disparity. A qualitative case study approach is employed, analyzing historical policies, legislative gaps, and real-world case studies. These cases include responses to Hurricane Harvey, the COVID-19 pandemic, and the Return to Nature Funeral Home incident, each illustrating the critical gaps in mental health and medical support for NGSMs under SAD. The findings from these case studies emphasize the risks of leaving NGSMs without access to consistent and comprehensive healthcare, particularly in high-stress mission environments where trauma exposure is prevalent. Without adequate support systems in place, these NGSMs may experience long-term physical and psychological health issues that affect their ability to continue serving effectively.[5]
The research identifies key deficiencies in the healthcare structure for NGSMs under SAD. Inconsistent and inadequate coverage is a primary issue, as state workers’ compensation programs vary widely in quality and scope. Some states provide minimal mental health coverage, while others provide none, and still others impose significant bureaucratic hurdles that limit access to medical and mental healthcare resources.[6] Many of these programs fail to account for the unique nature of military service and what NGSMs under SAD may be exposed to during civil support responses, particularly cumulative trauma from repeated disaster response and homeland security operations.[7] The problem is further exacerbated by delayed treatment, as NGSMs under SAD face prolonged claim processing times or denied claims, struggling to obtain necessary treatment and leading to deteriorating health conditions and increased financial burdens.
The lack of healthcare parity has a direct impact on readiness. When NGSMs cannot access medical or mental healthcare as needed, their ability to recover from physical or psychological injuries is significantly compromised.[8] This situation reduces unit effectiveness and increases attrition rates, ultimately weakening the National Guard’s ability to respond to state and national emergencies, as well as support federal overseas contingency operations. NGSMs who have suffered or developed mental health conditions while serving under SAD may have difficulty obtaining treatment for these issues under workers’ compensation programs, forcing them either to pay out of pocket for necessary care or to forgo treatment altogether. Thus, NGSMs under SAD who serve in the most demanding and high-risk roles during civil support missions are left without the healthcare and resources they need to maintain their readiness, health, and well-being.
To address these challenges, this thesis proposes two primary reforms. The first recommendation is to implement conditional TRICARE eligibility for NGSMs under SAD. Under this proposal, NGSMs would receive TRICARE coverage when their state workers’ compensation program proves inadequate and its resources or capabilities have been exhausted. This reform would provide an essential safety net for NGSMs under SAD who cannot access necessary care through state programs, ensuring that they receive medical and mental health services comparable to their federally activated counterparts through TRICARE. By allowing TRICARE to supplement rather than replace state workers’ compensation systems, this reform maintains state autonomy while providing a more equitable healthcare solution for NGSMs serving under SAD.
The second recommendation is to integrate SAD into the Duty Status Reform (DSR) initiative.[9] This option seeks to align SAD healthcare coverage with federal activation statuses under Title 32 and Title 10, creating a standardized, streamlined system that ensures consistent benefits across all activation statuses for NGSMs. By incorporating SAD into the framework of the existing DSR initiative, this policy would simplify administrative processes, reduce bureaucratic obstacles, and ensure continuity of care for NGSMs transitioning between duty statuses. This option would address long-term systemic inequities in National Guard healthcare access and provide a more comprehensive approach to managing NGSMs’ medical and mental health needs.[10]
The implementation of these reforms requires coordinated efforts among state and federal agencies, policymakers, and National Guard leadership. A phased approach is recommended to ensure a smooth transition and minimize disruptions to existing systems. The first step involves establishing conditional TRICARE eligibility by defining specific criteria under which NGSMs qualify for coverage while preserving state autonomy. This process would require collaboration between state governments and federal agencies to determine eligibility thresholds and funding mechanisms. Legislative advocacy is also a critical component of this effort, as changes to existing policies must be approved through legislative action. Engaging with lawmakers and state officials will be essential in securing the necessary support to implement these reforms.
Long-term structural reforms should focus on developing an oversight framework to ensure NGSMs receive timely and adequate healthcare, regardless of activation status. This framework should include mechanisms for monitoring the effectiveness of state workers’ compensation programs, identifying gaps in coverage, and ensuring that NGSMs can access the care they need without unnecessary delays or burdens placed on individuals to acquire care. Additionally, efforts should be made to improve awareness and education among NGSMs regarding their healthcare options, ensuring that NGSMs are fully informed about the benefits available to them and how to navigate the system effectively. The current disparity in healthcare access for NGSMs under SAD represents a critical policy failure that has far-reaching consequences for both individual service members and the operational readiness of the National Guard. By implementing conditional TRICARE eligibility and incorporating SAD into the DSR initiative, the National Guard can address these inequities while maintaining the flexibility of state control over NGSMs under SAD. These reforms will ensure that all NGSMs, regardless of activation status, receive equitable healthcare coverage, improving both individual resilience and the National Guard’s overall effectiveness in responding to emergencies and supporting contingency operations. Without these changes, NGSMs will continue to face unnecessary hardships, undermining their ability to serve effectively and placing additional strain on the National Guard as an institution.[11] Addressing these disparities is a necessary step toward ensuring the long-term sustainability and success of the National Guard’s dual-status mission.
[1] Department of Defense, The Use of the National Guard for Defense Support of Civil Authorities, DoD Instruction 3025.22 (Washington, DC: Department of Defense, 2017).
[2] Bryce H. P. Mendez and Barbara Salazar Torreon, Limits on TRICARE for Reservists: Frequently Asked Questions, CRS Report No. R45968 (Washington, DC: Congressional Research Service, 2021).
[3] National Guard Bureau, National Guard Bureau Fact Sheet: National Guard Duty Statuses (Arlington, VA: National Guard Bureau, 2024).
[4] Bert B. Tussing and Robert McCreight, eds., Introduction to Homeland Defense and Defense Support of Civil Authorities (DSCA): The U.S. Military’s Role to Support and Defend (Boca Raton, FL: CRC Press, 2014).
[5] Justin Hummer and Kimberly A. Hepner, “Supporting the Mental Health Needs of National Guard and Reserve Members,” RAND Corporation, September 22, 2021, https://www.rand.org/pubs/commentary/2021/09/supporting-the-mental-health-needs-of-national-guard.html.
[6] Charlotte Rowe, Grazia Ceschi, and Abdel Halim Boudoukha, “Trauma Exposure and Mental Health Prevalence among First Aiders,” Frontiers in Psychology 13 (March 2022): 824549, https://doi.org/10.3389/fpsyg.2022.824549.
[7] Scott D. Szymendera, Workers’ Compensation: Overview and Issues, CRS Report No. R44580 (Washington, DC: Congressional Research Service, 2019).
[8] Charles R. Figley, ed., Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized (New York: Routledge, 1995), https://www.emdr.org.il/wp-content/uploads/2021/08/Figley1995CompassionFatiguebook.pdf; Rowe, Ceschi, and Boudoukha, “Trauma Exposure and Mental Health Prevalence among First Aiders.”
[9] Thomas J. Liuzzo, Reserve Component (RC) Duty Status Reform (DSR) (Office of the Under Secretary of Defense, Personnel & Readiness, October 27, 2023).
[10] National Guard Association of the United States, Protecting National Guard Equities in Duty Status Reform: Fiscal Year 2021 Fact Sheet (Washington, DC: National Guard Association of the United States, 2021), https://www.ngaus.org/sites/default/files/2020-09/FY21-DSR-Fact-Sheet.pdf.
[11] National Guard Association of the United States.
